Quality Improvement Efforts in Pediatric Oral Health.

Quality improvement (QI) and measurement are increasingly used in health care to improve patient care and outcomes. Despite current barriers in oral health measurement, there are nascent QI and measurement efforts emerging. This paper describes the role that QI and measurement can play in improving oral health care delivery in clinical practice by presenting a QI initiative that aimed to test and implement a chronic disease management approach to address early childhood caries.

Dental Hygienist-Led Chronic Disease Management System to Control Early Childhood Caries.

UNLABELLED: Management of the complex chronic disease of early childhood caries requires a system of coordinated health care interventions which can be led by a dental hygienist and where patient self-care efforts are paramount. BACKGROUND AND PURPOSE: Even after receiving costly surgical treatment under general anesthesia in the operating room, many children develop new and recurrent caries after only 6-12 months, a sequela that can be prevented. This article describes the chronic disease management (CDM) of dental caries, a science-based approach that can prevent and control caries. METHODS: In this article, we (1) introduce the concept of CDM of dental caries, (2) provide evidence that CDM improves oral health outcomes, and (3) propose a dental hygienist-led team-based oral health care approach to CDM. Although we will be describing the CDM approach for early childhood caries, CDM of caries is applicable in children, adolescents, and adults. CONCLUSIONS: Early childhood caries disease control requires meaningful engagement of patients and parents by the oral health care team to assist them with making behavioral changes in the unique context of their families and communities. The traditional dentist/hygienist/assistant model needs to evolve to a collaborative partnership between care providers and patients/families. This partnership will be focused on systematic risk assessment and behaviorally based management of the disease itself, with sensitivity toward the familial environment. Early pilot study results demonstrate reductions in the rates of new caries, dental pain, and referral to the operating room compared with baseline rates. Dental hygienists are the appropriate team members to lead this approach because of their expertise in behavior change and prevention.

Developing content for American Board of Pediatric Dentistry certification examinations using practice analysis.

BACKGROUND: The American Board of Pediatric Dentistry (ABPD) conducted a practice analysis to guide the development of its certification examination outlines for assessing the knowledge, skills, and abilities of pediatric dentists. This article describes the systematic approach used by the ABPD. METHODS: The ABPD conducted its practice analysis in 4 phases: (1) preparation, (2) focus group meetings, (3) survey, and (4) examination blueprint development. RESULTS: Phase 2 resulted in 150 job tasks relevant to entry-level pediatric dental practice, organized into 10 domains. In Phase 3, 8,730 pediatric dentists received an electronic survey, with 10% returning a completed survey. Respondents rated tasks in terms of frequency and risk, which were analyzed to determine the combined relevance of each task. Phase 4 organized a final list of tasks within each domain and the recommended weighting of domains by certifying examination. CONCLUSIONS: The ABPD practice analysis created a comprehensive outline of the job tasks an entry-level pediatric dentist is expected to perform. The ABPD plans to use the results to help develop the examination content for continuing certification and will use a similar process every 5 through 7 years to update the examination content blueprints to ensure their continued relevance to the practice of pediatric dentistry. PRACTICAL IMPLICATIONS: The ABPD used a process known as practice analysis to ensure that its examinations and continued competency assessments measure the knowledge, skills, and abilities required for safe and effective clinical practice.

Infant oral health is the current standard of care.

Despite professional recommendations calling for earlier first dental visits, Massachusetts children, on average, have their first dental visit at 3 years of age. This article will discuss the age-one dental visit and early establishment of a dental home. The components of an infant oral health visit will be outlined, including how to efficiently and effectively perform a caries risk assessment and a successful knee-to-knee exam. All dentists are challenged to improve their collective standard of care by incorporating infant oral health into their practices.

Into the future: keeping healthy teeth caries free: pediatric CAMBRA protocols.

Early childhood caries prevalence has increased significantly in children ages 2-5 years. ECC disproportionately affects lower socioeconomic and minority groups, is a predictor for future decay, but is preventable and manageable. Caries risk assessment systematically derives a patient's caries risk and is important during an infant oral health visit beginning at age 1. Information obtained through a risk assessment can guide a disease management care path tailored to an individual's age and risk to effectively treat and manage one's caries disease process.

Pit-and-fissure sealants on primary molars are a cost savings.

BACKGROUND: In this study, the authors examine the cost-effectiveness of light-polymerized resin-based fluoride sealants on primary molars in high caries risk children younger than 6 years. METHODS: The authors examined the cost-effectiveness of pit-and-fissure sealant (PFS) treatment on primary molars by comparing sealed and unsealed molars treated in the outpatient clinic or operating room. Using 1,884 primary molars followed over a 5-year period, the authors used a mixed-effects regression model to estimate the probability of caries development. They used restricted means to estimate years free of caries for carious molars. They used a decision tree to address uncertainty due to PFS treatment failure, predict the expected value associated with each strategy, and estimate the incremental cost-effectiveness ratio using a 3% discount rate to adjust future cost and outcomes to present value. RESULTS: Over 5 years, the cost of care was $90 for unsealed molars and $75 for sealed molars. Unsealed molars remained caries free for 4.32 years compared with 4.85 years in sealed molars. The cost-effectiveness of PFS treatment was dominant, leading to a savings of $25 for each caries-free year gained and overall savings of $742 million for the United States dental health system over a 5-year period. CONCLUSIONS: PFS treatment is associated with cost savings and a delay in caries development and should be considered in children with high caries risk. PRACTICAL IMPLICATIONS: Policy makers should consider reimbursement of PFS treatment on primary molars in high caries risk children.

Effectiveness of Nutritional Advice for Community-Dwelling Obese Older Adults With Frailty: A Systematic Review and Meta-Analysis.

Objectives: This systematic review was aimed to examine the effectiveness of nutritional advise interventions compared with usual care, or exercise, or exercise combined with nutritional advice as a means of improving the body weight, body composition, physical function, and psychosocial well-being of frail, obese older adults. Methods: CINAHL, Cochrane Library, Embase, MEDLINE, PsycINFO, and Scopus databases were searched to identify relevant studies. The quality of the included studies was assessed using Cochrane's risk of bias tool 2. Meta-analysis was performed with respect to body weight and fat mass. Other outcomes were synthesized narratively. Results: Eight articles (from two studies) with a total of 137 participants were included in the review. The results revealed that nutritional advice was more effective than exercise in reducing body weight and fat mass. The nutritional advice was also beneficial in enhancing physical function and psychosocial well-being. However, it was less effective than exercise or combined interventions in increasing muscle strength and preventing lean mass loss. Conclusions: Nutritional advice is an essential intervention for reducing body weight and fat mass, for enhancing physical function, and for improving the psychosocial well-being of obese older adults experiencing frailty. The limited number of studies included in this review suggests that there is a need for more well-designed interventional studies in order to confirm these findings.

Caries risk assessment, prevention, and management in pediatric dental care.

The recent increase in the prevalence of dental caries among young children has highlighted the need for a new approach to prevent caries in children at a younger age. New disease prevention management models call for children to have their first visit to the dentist at age 1 or when their first tooth erupts. This article addresses early childhood caries risk assessment, prevention, and management strategies in young children using the concept of the "dental home" and a simple six-step protocol to conduct an effective and comprehensive infant oral care visit.

Pediatric dental care: prevention and management protocols based on caries risk assessment.

Recent increases in caries prevalence in young children, especially among minorities and the economically disadvantaged, highlight the need for early establishment of dental homes and simple, effective infant oral care preventive programs for all children as part of a medical disease prevention management model. This article presents an updated approach and practical tools for pediatric dental caries management by risk assessment in an effort to stimulate greater adoption of infant oral care programs among clinicians and early establishment of dental homes for young children. [corrected]

Sealed primary molars are less likely to develop caries.

BACKGROUND: The authors examined the association between light-polymerized resin-based fluoride-releasing sealants and the development of pit-and-fissure caries on primary molars. METHODS: In this 3-year retrospective study, the authors reviewed the dental records of 297 children (1,352 teeth) younger than 6 years who were at high caries risk. Sealant placement or nonplacement on primary molars in the outpatient clinic and operating room setting was recorded, and random-effects logistic regression analysis accounting for the effect of data clustering was performed to measure caries incidence over time. RESULTS: The odds of developing pit-and-fissure carious lesions on sealed primary molars were 0.055 times (95% confidence interval [CI], 0.011 to 0.285; P = .001) and 0.013 times (95% CI, 0.001 to 0.159; P = .001) the odds of that on nonsealed primary molars in the outpatient clinic and in the operating room, respectively. In molars that became carious, those sealed were associated with longer time to caries development in both the outpatient clinic (2.69 years, 95% CI, 2.08 to 3.29) and operating room (1.97 years, 95% CI, 1.45 to 2.48). CONCLUSIONS: Sealed primary molars were less likely to develop pit-and-fissure caries when placed in both the clinic and operating room settings. PRACTICAL IMPLICATIONS: Dental sealants on primary molars should be considered for children at high caries risk.

How useful are current caries risk assessment tools in informing the oral health care decision-making process?

BACKGROUND: Caries risk assessment (CRA) tools could address oral health disparities and enhance the efficiency of the oral health care system. The authors aimed to explore the feasibility and limitations of using clinical CRA tools in informing oral health care policy-making processes. METHODS: The authors used the National Health and Nutrition Examination Survey to construct 10 CRA models from a sample of clinical CRA tools identified from the literature. They used these models to estimate the proportion of publicly insured people aged 1 through 20 years categorized as at low, moderate, and high risk, and they projected their oral health care costs. RESULTS: The authors found substantial variation among the selected models in assigning risk levels. The weighted average proportions (range) of people categorized as at low, moderate, and high risk were 25% (0%-66%), 14% (0%-50%), and 61% (11%-100%), respectively. Depending on the CRA model, the projected annual cost of covering this population ranged from $18 billion to $127 billion. CONCLUSIONS AND PRACTICAL IMPLICATIONS: Developing a valid, evidence-based, accurate, and reliable population-based CRA model could address the variability among clinical CRA tools, improve estimates of dental disease burden, help design targeted oral public health programs, and enable comparative effectiveness analyses among oral health care interventions.

Changes in Oral Health Behaviors Associated With a Nursing Intervention in Primary Care.

Objective. To describe changes in oral health behaviors following implementation of a nursing intervention targeting children at risk for early childhood caries at an urban 2-site primary care practice. Methods. Nurses used a proprietary Nursing Caries Assessment Tool (N-CAT) to identify behaviors associated with early childhood caries risk, then provided brief focused dental education, fluoride varnish applications, and dental referrals to children without a dental home. We used generalized estimating equation logistic regression models, adjusted for age at visit, to analyze changes in oral health behaviors over time including the following: (1) tooth brushing frequency, (2) use of fluoride toothpaste, and (3) adult help with brushing among children younger than 5 years of age who had at least 2 N-CATs documented during well care visits between April 2013 and June 2015. We also evaluated dietary habits including going to bed with a bottle or sippy cup and sugar-sweetened beverage consumption, as secondary study outcomes during the same time frame. Results. A total of 2097 children with a mean age of 15.8 (SD 7.6) months at the initial visit were included in the analysis; 51% were boys; 28% were black, 36% Hispanic/Latino, 5% white, 2% Asian, and 19% other; 75% were publicly insured. During the study period, significant (P < .05) improvements were noted across the 3 oral health behaviors studied among children younger than 18 months. Conclusion. Nursing interventions show promise for promoting preventive dental care in primary care settings and deserve further study.

Trends in Pediatric Dental Care Use.

This article explores trends in 3 areas of dental services use for children less than 21 years of age. First, it examines the change in access to prevention, diagnostic, and treatment services over time among Medicaid-enrolled children and how access to care is affected by state-level factors. Second, it evaluates trends and health care costs associated with the treatment of oral health conditions in the operating room of pediatric hospitals. Third, it examines the trends in use of emergency departments for dental needs among children in the United States.

The association of RANTES polymorphism with severe acute respiratory syndrome in Hong Kong and Beijing Chinese.

BACKGROUND: Chemokines play important roles in inflammation and antiviral action. We examined whether polymorphisms of RANTES, IP-10 and Mig affect the susceptibility to and outcome of severe acute respiratory syndrome (SARS). METHODS: We tested the polymorphisms of RANTES, IP-10 and Mig for their associations with SARS in 495 Hong Kong Chinese SARS patients and 578 controls. Then we tried to confirm the results in 356 Beijing Chinese SARS patients and 367 controls. RESULTS: RANTES -28 G allele was associated with SARS susceptibility in Hong Kong Chinese (P < 0.0001, OR = 2.80, 95%CI:2.11-3.71). Individuals with RANTES -28 CG and GG genotypes had a 3.28-fold (95%CI:2.32-4.64) and 3.06-fold (95%CI:1.47-6.39) increased risk of developing SARS respectively (P < 0.0001). This -28 G allele conferred risk of death in a gene-dosage dependent manner (P = 0.014) with CG and GG individuals having a 2.12-fold (95% CI: 1.11-4.06) and 4.01-fold (95% CI: 1.30-12.4) increased risk. For the replication of RANTES data in Beijing Chinese, the -28 G allele was not associated with susceptibility to SARS. However, -28 CG (OR = 4.27, 95%CI:1.64-11.1) and GG (OR = 3.34, 95%CI:0.37-30.7) were associated with admission to intensive care units or death due to SARS (P = 0.011). CONCLUSION: RANTES -28 G allele plays a role in the pathogenesis of SARS.

The interferon gamma gene polymorphism +874 A/T is associated with severe acute respiratory syndrome.

BACKGROUND: Cytokines play important roles in antiviral action. We examined whether polymorphisms of IFN-gamma,TNF-alpha and IL-10 affect the susceptibility to and outcome of severe acute respiratory syndrome (SARS). METHODS: A case-control study was carried out in 476 Chinese SARS patients and 449 healthy controls. We tested the polymorphisms of IFN-gamma,TNF-alpha and IL-10 for their associations with SARS. RESULTS: IFN-gamma +874A allele was associated with susceptibility to SARS in a dose-dependent manner (P < 0.001). Individuals with IFN-gamma +874 AA and AT genotype had a 5.19-fold (95% Confidence Interval [CI], 2.78-9.68) and 2.57-fold (95% CI, 1.35-4.88) increased risk of developing SARS respectively. The polymorphisms of IL-10 and TNF-alpha were not associated with SARS susceptibility. CONCLUSION: IFN-gamma +874A allele was shown to be a risk factor in SARS susceptibility.

Chronic Disease Management Strategies of Early Childhood Caries: Support from the Medical and Dental Literature.

An Institute of Medicine report places chronic disease management (CDM) as an intervention on a treatment spectrum between prevention and acute care. CDM commonly focuses on conditions in which patient self-care efforts are significant. Framing early childhood caries (ECC) as such a chronic condition invites dentistry to reconsider its approach to caries management and shift gears from a strictly surgical approach to one that also incorporates a medical approach. This paper's purpose was to explore the definition of and concepts inherent in CDM. An explanatory model is introduced to describe the multiple factors that influence ECC-CDM strategies. Reviewed literature suggests that early evidence from ECC-CDM interventions, along with results of pediatric asthma and diabetes CDM, supports CDM of ECC as a valid approach that is independent of both prevention and repair. Early results of ECC-CDM endeavors have demonstrated a reduction in rates of new cavitation, dental pain, and referral to the operating room compared to baseline rates. ECC-CDM strategies hold strong promise to curtail caries activity while complementing dental repair when needed, thereby reducing disease progression and cavity recurrence. Institutionalizing ECC-CDM will both require and benefit from evolving health care delivery and financing systems that reward positive health outcomes.

Cost-effectiveness of a disease management program for early childhood caries.

OBJECTIVES: To assess the cost-effectiveness of a pilot disease management (DM) program aimed at preventing early childhood caries among children younger than 5 years. METHODS: The DM program was implemented in the Boston Children's Hospital-based dental practice in 2008. Health care costs were obtained from the hospital finance department and non-health care costs were estimated through a parent survey. The measure of effectiveness was avoided hospital-based visits for restorative treatment or extractions. Incremental costs (2011 US$) and effectiveness were estimated from a health care system, societal, and public payer perspectives over 3, 6, and 12 months, by comparing DM participants (n = 395) to a historical comparison group (n = 123) using generalized linear models. Bootstrapping and other sensitivity analyses were used to incorporate uncertainty in the analyses. RESULTS: The DM program was associated with a reduction in societal costs of $20 (p = 0.85), $215 (p = 0.24), and $669 (p < 0.01) per patient and a reduction in the number of hospital-based visits for restorative treatment or extractions by 0.44 (p < 0.01), 0.42 (p < 0.01), and 0.45 (p < 0.01) per patient over 3, 6, and 12 months, respectively. The probability of it being less costly and more effective was 61.5 percent, 81.9 percent, and 98.6 percent over 3, 6, and 12 months, respectively. Consistent results were observed from a health care system and public payer perspectives. CONCLUSIONS: The DM program appears cost-effective and has the potential to reduce health care costs. Our results justify a multicenter trial to evaluate the DM program on a larger scale.

Progress in Early Childhood Caries and Opportunities in Research, Policy, and Clinical Management.

The 2014 Early Childhood Caries Conference encompassed evidence-based reviews on the state of the science regarding early childhood carries (ECC) epidemiology, etiology, prevention, and disease management. The purpose of this paper was to discuss the work presented at the conference and identify opportunities in research, policy, and clinical management that may improve early childhood caries outcomes and lower costs of care. While great progress has been made since the 1997 ECC Conference, there remains a paucity of high-quality evidence from randomized controlled trials on what are the most effective means to prevent and manage ECC. Analyses of studies indicate that some approaches, such as chlorhexidine, iodine, and remineralizing agents, have not shown consistent findings in preventing ECC. However, evidence exists to yield recommendations in some areas. There are useful risk assessment indicators to identify preschool children at risk for caries. Fluoridated toothpaste and fluoride varnish currently are the most effective chemotherapeutic strategies to prevent ECC. Motivational interviewing, a form of patient-centered counseling, is effective for motivating oral health behaviors and shows promise for reducing caries. Additionally, evidence is emerging that shows the value of chronic disease management approaches and integrating ECC oral health care within medical care settings. Recommendations for future directions in ECC research and policy were also key outcomes of the conference.