Paycheck Protection Program (PPP) COVID-19 relief funding for veteran-, minority-, and women- owned dental businesses: A cross-sectional study.

Background: The Covid-19 pandemic exacerbated dental staffing shortages, which impact care delivery and ultimately oral health equity. Federal funding efforts like the Paycheck Protection Program (PPP) sought to aid traditionally underserved businesses including those owned by veterans, minority racial and ethnic groups, and women. Objectives: (1) To examine differences in PPP funding between veteran- and nonveteran-owned dental care delivery businesses and organizations and (2) to analyze other relevant factors associated with variation in PPP funding levels for dental businesses. Methods: Using publicly available PPP data, we ran unadjusted bivariable and adjusted multivariable linear regression models to estimate associations between loan approval amount and forgiveness amount, veteran status, and relevant covariates. Results: Minority racial and ethnic groups and women received less PPP funding and less loan forgiveness, on average, compared with non-minority groups. In the adjusted model with no missing self-reported demographic observations at p < 0.10, veterans received more PPP funding and loan forgiveness, on average, compared to non-veterans. Conclusion: To our knowledge, this is the first comprehensive analysis of all dental recipients of PPP funding throughout the United States. Despite PPP program intentions and strategies, traditionally underserved dental businesses did not receive increased funding to support employment.

A cross-sectional analysis of oral health care spending over the life span in commercial- and Medicaid-insured populations.

BACKGROUND: Life course theory creates a better framework to understand how oral health care needs and challenges align with specific phases of the life span, care models, social programs, and changes in policy. METHODS: The authors obtained data from the 2018 IBM Watson Multi-State Medicaid MarketScan Database (31 million claims) and the 2018 IBM Watson Dental Commercial and Medicare Supplemental Claims Database (45 million claims). The authors conducted analysis comparing per enrollee spending on fee-for-service dental claims and medical spending on oral health care for patients from ages 0 through 89 years. RESULTS: Oral health care use rate and spending are lower during the first 4 years of life and in young adulthood than in other periods of life. Stark differences in the timing, impact, and severity of caries, periodontal disease, and oral cancer are seen between those enrolled in Medicaid and commercial dental plans. Early childhood caries and oral cancer occur more frequently and at younger ages in Medicaid populations. CONCLUSIONS: This life span analysis of the US multipayer oral health care system shows the complexities of the current dental service environment and a lack of equitable access to oral health care. PRACTICAL IMPLICATIONS: Health policies should be focused on optimizing care delivery to provide effective preventive care at specific stages of the life span.

Survival of silver diamine fluoride among patients treated in community dental clinics: a naturalistic study.

BACKGROUND: Silver diamine fluoride (SDF) is a minimally-invasive preventive service used in the U.S. to avert and arrest caries since 2014. No studies document survival outcomes based in real world delivery. We analyzed 12-month survival outcomes of SDF applied independently or concurrently with other restorative procedures among a population receiving community dental care. METHODS: We analyzed data on SDF applications from de-identified dental claims on Oregon Health Plan patients served by Advantage Dental in 2016, who had been seen in 2015 (patient n = 2269; teeth n = 7787). We compared survival rates of SDF alone, SDF applied with a sedative filling, and SDF with a same-day restoration. Failure was defined as a restoration or extraction of the tooth 7 to 365 days after initial application. Survival was defined as a patient returning 180 or more days after application whose tooth did not have a restoration or extraction. Differences were assessed through Wilcoxon equality of survivor function tests and log-rank equality of survivor tests to compare failure rates, Cox Proportional Hazards models to assess factors associated with survival of SDF, and Kaplan-Meier survival estimate to calculate the probability of survival over time. RESULTS: SDF alone had an overall survival rate of 76%. SDF placed with sedative filling and with a same-day restoration had survival rates of 50% and 84% respectively, likely reflecting treatment intent. SDF alone survived exceptionally well on primary cuspids, permanent molars, and permanent bicuspids and among patients aged 10 to 20 years, with modest variation across caries risk assessment categories. A single annual application of SDF was successful in 75% of cases. Among SDF failures on permanent dentition, more than two-thirds of teeth received a minor restoration. CONCLUSION: SDF is a minimally invasive non-aerosolizing option that prevented non-cavitated lesions and arrested early decay among community dentistry patients when applied independently or concurrently with restorative procedures. Professional organizations, policy makers, providers, and payors should broaden optional SDF use by informing clinical guidelines, reimbursement policies, and treatment decisions. Future research should address clinical, social, service delivery, workforce, and economic outcomes using diverse population-based samples, and the mechanisms underlying single application success and caries prevention potential.

Understanding value in oral health: the oral health value-based care symposium.

OBJECTIVE: There are both opportunities and challenges with the implementation of oral health value-based care (OHVBC). To tackle concerns and advance conversation, a symposium was convened with subject matter experts to develop a gap analysis and capture insights into professional readiness for value-based care design. METHODS: The symposium was convened as a private event for 46 participants over the course of one and a half days in December 2019. Thematic analyses utilized the OHVBC Readiness Framework (DentaQuest Partnership, 2019) to further codify conversations as part of the gap-analysis process. Poll Everywhere, a text messaging application that allows participants to answer questions in real time, was also employed to solicit responses. RESULTS: Attendees of the symposium felt that OHVBC would have a large portion of market share within the next 10 years. A qualitative assessment of multiple table discussions determined that the participants developed more consensus around themes for the current state and the future-desired state than the action-planning needed to close the gap between the two. This may relate to individual ideology, and the siloed environment is still prevalent in the oral health realm. In a postsymposium survey, respondent attendees did not perceive that COVID-19 would delay or negatively impact the adoption of OHVBC and may result in accelerating its utilization. CONCLUSION: The oral health community is experiencing multiple drivers to adopt more OHVBC within business and care models. However, there is still a lack of uniformity on how to execute this delivery model.

MORE Care: an evaluation of an interprofessional oral health quality improvement initiative.

OBJECTIVE: This evaluation assesses the Medical Oral Expanded Care (MORE Care) initiative in four states that focused on oral health integration into primary care practices located in dental shortage areas. METHODS: This analysis is conducted using self-reported primary data collected from each of the participating MORE Care clinics in South Carolina, Pennsylvania, Colorado and Oregon. Three measures: the percentage of pediatric patients with a) fluoride varnish applied, b) self-management goals reviewed, and c) risk assessed, were evaluated to compare the impact and timing of change tactics on participating teams. An engagement dashboard tool was also hand coded with inductive codes using an adapted grounded theory approach common in applied health services research, to iteratively identify themes that could illuminate or explain quantitative findings. RESULTS: The average proportion of pediatric patients receiving fluoride varnish increased from 25 percent after the first collaborative learning session to 40 percent after the third collaborative learning session. The proportion of pediatric patients with self-management goals reviewed also improved, increasing from 25 percent to 62 percent. There was more variation in the proportion of pediatric patients with oral health risk assessments completed increasing from 47 percent to 77 percent. Qualitative analysis of MORE Care open text data produced three themes related to facilitators and barriers of project implementation and criteria for project success. CONCLUSIONS: The results of this analysis demonstrated that MORE Care is effective in creating an operational structure for integrating oral health care into primary care practices and most successful when participating clinics meet success criteria.

Person-centered care model in dentistry.

BACKGROUND: To achieve optimal health and oral health, the system of care must place a person and their social well-being at the center of decision making and understand factors spent outside the clinical settings, including individual behavior, context and lifestyle. MAIN TEXT: Person-centered care offers a unique and compelling opportunity for dentistry, and its practitioners, to improve quality of care and overall health outcomes. For decades, the dominant treatment modalities within dentistry primarily focused on a surgical, treatment-oriented approach as opposed to health promotion and improvement. However, new business and care models are disrupting the dental care system, and transforming it into one that is focused on disease management and prevention-oriented primary care that considers overall health and well-being. We proposed a person-centered care model to improve oral health as an integral part of overall health. The model identified three key players who act as change agents with their respective roles and responsibilities: Person, provider, and health care system designer. CONCLUSIONS: While previous person-centered models in dentistry focused on the role of providers within the clinical setting, this work emphasizes the role of the care designer in creating an environment where both person and provider are able to communicate effectively and achieve improved health outcomes.

An Assessment of Participant-Described Interprofessional Oral Health Referral Systems Across Rurality.

PURPOSE: As a means to identify and quantify oral health interprofessional collaborative practice (IPP), we examined participant-described medical-to-dental (M2D) referral networks and how they function across rurality. METHODS: We conducted a cross-sectional survey on the appraisal of IPP referral systems in 2016. Secondarily, we examined if rural health clinics (RHCs) have different experiences with M2D referrals compared to other practice types. Independent variables included geographic and organizational indicators, referral system attributes, and respondent characteristics. Data were coded by Census region and state Medicaid expansion status. Bivariable and multivariable analyses were conducted using SAS. FINDINGS: A convenience cohort (n = 559) from 44 states was examined. Nearly, half (48.7%) reported dependable M2D referral systems. In bivariate analysis, all independent variables were significant except for state Medicaid expansion status. In multivariable analysis, Census region retained significance (P = .0093). Organization type and practice issues with no shows/missed appointments continued to have significance (P < .001 and .002, respectively). Accountable care organizations were over 5 times (5.72, P = .001) more likely than RHCs to report dependable M2D referral systems. Federally qualified health clinics were slightly over 3 times more likely than RHCs to report dependable M2D referral (3.04, P < .001). No differences between RHCs and other private practices were observed. CONCLUSIONS: The importance of IPP continues to be promoted in the current health care environment. Our study demonstrates that, in this motivated study population, M2D referrals can work well, even in rural areas. Organization type, directionality of referral, broken appointment rates, and electronic health information management were all found to significantly impact the respondents' rating on the dependability of an M2D referral process.

Dentists' and Parents' Attitude Toward Nitrous Oxide Use in Kuwait.

The aim of this study was to investigate the attitude of dentists in Kuwait toward the use of nitrous oxide sedation as a behavior management technique (BMT) for pediatric patients and assess their training in nitrous oxide sedation. In addition, we assessed parents' knowledge of and attitude toward the use of nitrous oxide as a BMT for their children. The objective was to determine if nitrous oxide sedation is being provided and utilized as a means to enhance dental care for pediatric patients. A cross-sectional survey was randomly distributed to both groups of interest: parents accompanying their children to the dentist and licensed dentists in Kuwait. Participants had to meet certain inclusion criteria to be included in the survey and had to complete the entire questionnaire to be part of the analysis. A total of 381 parents completed the questionnaires. The majority of parents responded that they were unaware of nitrous oxide sedation and were not aware of it as a BMT (79%). Two thirds of the parent would accept nitrous oxide sedation if recommended by a dentist treating their children. Two hundred and one dentists completed the survey and met the inclusion criteria. The majority (74.5%) of dentists were willing to use nitrous oxide as a BMT. However, only 6% were utilizing nitrous oxide sedation and providing it to their child patient if indicated. The main reasons for this huge gap are lack of facilities/equipment and lack of training as indicated by the dentists. This study showed that parents are accepting nitrous oxide sedation as a BMT for their children. It also showed the willingness of the dentists to provide such BMT to their patients. The lack of training and lack of equipment are the main barriers to providing such service to the patients. More training courses and more facilities should be provided to eliminate such barriers.

Evaluating the advances and use of hypodermic needles in dentistry.

Different injection techniques and patient management methodologies have been proposed to decrease the fear patients may have concerning dental needles. Dental providers should have an understanding of the technological advances, changes in techniques, and patient perceptions associated with the hypodermic needle. This article provides an overview of the pain perception process associated with dental injections. It reviews the two main sensory nerve fibers associated with injection pain and discusses needle properties as well as complications and adverse occurrences.

Evaluating complications during intraoral administration of local anesthetics in a rural, portable special needs dental clinic.

The aim of this study was to identify and quantify complications with local anesthetic administration on consecutive patients seen for dental care in a portable dental clinic providing care to patients with special needs. This prospective study includes data on the patients seen by the portable dental team. A standardized form is used to determine complications and associated information for 172 dental visits in which local anesthetic is administered. After statistical analysis of 172 consecutive cases, the overall complication rate is 8.1%. All of the complications are considered to be mild or moderate; there are no reports of severe events. The complications encountered most frequently are associated with self-inflicted soft tissue injury or inadequate anesthesia. Comprehensive care with local anesthesia delivered by a portable dental clinic has a low risk of complication. The administration of an inferior alveolar nerve block or body-mass status appears to affect the incidence of complications.

Evaluating complications of local anesthesia administration and reversal with phentolamine mesylate in a portable pediatric dental clinic.

This study sought to identify and quantify complications with local anesthetic administration and reversal on consecutive patients seen for comprehensive dental care in a school-based, portable dental clinic, and includes data on the patients seen by the participating portable dental providers. In 923 dental visits where local anesthetic was administered, a standardized form was used to gain further information and identify any complications; this was accompanied by a questionnaire for the student's teacher, in order to quantify the student's distraction and disruption ratings following the dental visit. After statistical analysis of the 923 consecutive cases, the overall complication rate was 5.3%. All of the complications were considered to be mild or moderate, and there were no severe event reports. The complications encountered most frequently (n = 49) were associated with self-inflicted soft tissue injury. The results of this study indicate that comprehensive care with local anesthesia delivered by a school-based portable dental clinic has a low risk of complications. Whereas safe administration of dental care is achievable with or without phentolamine mesylate as a local anesthetic reversal agent, its use was determined to improve safety outcomes. Three factors appeared to directly increase the incidence of complications: the administration of an inferior alveolar nerve block, attention deficit disorder, and obesity. Teacher evaluations demonstrated that children receiving care by a portable dental team were able to reorient back to classwork and were not disruptive to classmates.

An evaluation of 10 percent and 20 percent benzocaine gels in patients with acute toothaches: efficacy, tolerability and compliance with label dose administration directions.

BACKGROUND: The authors evaluated the efficacy and tolerability of 10 percent and 20 percent benzocaine gels compared with those of a vehicle (placebo) gel for the temporary relief of toothache pain. They also assessed the compliance with the label dose administration directions on the part of participants with toothache pain. METHODS: Under double-masked conditions, 576 participants self-applied study gel to an open tooth cavity and surrounding oral tissues. Participants evaluated their pain intensity and pain relief for 120 minutes. The authors determined the amount of gel the participants applied. RESULTS: The responders' rates (the primary efficacy parameter), defined as the percentage of participants who had an improvement in pain intensity as exhibited by a pain score reduction of at least one unit on the dental pain scale from baseline for two consecutive assessments any time between the five- and 20-minute points, were 87.3 percent, 80.7 percent and 70.4 percent, respectively, for 20 percent benzocaine gel, 10 percent benzocaine gel and vehicle gel. Both benzocaine gels were significantly (P ≤ .05) better than vehicle gel; the 20 percent benzocaine gel also was significantly (P ≤ .05) better than the 10 percent benzocaine gel. The mean amount of gel applied was 235.6 milligrams, with 88.2 percent of participants applying 400 mg or less. CONCLUSIONS: Both 10 percent and 20 percent benzocaine gels were more efficacious than the vehicle gel, and the 20 percent benzocaine gel was more efficacious than the 10 percent benzocaine gel. All treatments were well tolerated by participants. Practical Implications. Patients can use 10 percent and 20 percent benzocaine gels to temporarily treat toothache pain safely.

Dental hygienists' evaluation of local anesthesia education and administration in the United States.

PURPOSE: The goal of this project was to investigate the educational experiences and the use of local anesthesia by dental hygiene providers in the U.S. METHODS: Approved by the Institutional Review Board at the University of Pittsburgh and undertaken from February to May 2009, this study was designed using a questionnaire-based survey. Using a randomized list obtained via the American Dental Hygienists' Association (ADHA), the survey questionnaires were sent via mail to 1,200 dental hygienists in the U.S. Quantitative evaluations were confined to descriptive statistics including standard summation, an estimation of means and a valid percent for identified variables. RESULTS: A total of 432 (n=432) of the 1,200 survey questionnaires were returned, which represents a 36% response rate. The respondents represented a total of 296 dental hygiene educational programs, and included practice sites that span all 50 states. Findings indicate that the majority of responding dental hygienists perceive a need for the use of this pain control modality in their practice and administer local anesthetic injections. Additionally, the majority of respondents that administer local anesthetic injections reported that they perform local anesthetic administration for cases in which the dentist provides total care. Furthermore, the results revealed that the hygienists that received training in the administration of local anesthesia injections reported a higher rate of educational preparedness in 6 of the 7 educational topics listed in this survey: local anesthesia related topics (local anesthesia administration, local anesthetic pharmacology and local anesthetic complications), basic pharmacology, medical emergency management and special needs care. CONCLUSION: This examination parallels the results presented in previous studies, while offering new data relating to local anesthesia administration by dental hygienists. With the majority of dental hygienists reporting a perceived need and the use of this method of pain control, this practice appears to be a significant addition to overall dental care and dental hygiene education.

Assessing the need for anesthesia and sedation services in Kuwaiti dental practice.

The objective of this study was to examine the public health relevance of the prevalence of dental fear in Kuwait and the resultant barrier that it creates regarding access to dental care. The study analysis demonstrated a high prevalence of dental fear and anxiety in the Kuwaiti population and a perceived need for anesthesia services by dental care providers. The telephone survey of the general population showed nearly 35% of respondents reported being somewhat nervous, very nervous, or terrified about going to the dentist. In addition, about 36% of the population postponed their dental treatment because of fear. Respondents showed a preference to receive sedation and anesthesia services as a means of anxiety relief, and they were willing to go to the dentist more often when such services were available. People with high fear and anxiety preferred to receive some type of medication to relieve their anxiety. In conclusion, the significance and importance of the need for anesthesia services to enhance the public health of dental patients in Kuwait has been demonstrated, and improvements are needed in anesthesia and sedation training of Kuwaiti dental care providers.

Allergic reactions to local anesthetic formulations.

True allergic reactions to local anesthetics are rare adverse reactions. At the most, they represent less than 1% of all adverse local anesthetic reactions. When true allergic reactions have been confirmed, the reactions are most commonly the type I anaphylactic and type IV delayed hypersensitivity responses. The type I immediate hypersensitivity reactions are the most severe and may be life-threatening. In the event a potential allergic reaction occurs in a dental office, the dentist needs to properly evaluate the events leading up to the reaction and provide a differential diagnosis. A referral should be given to any patient when an allergic reaction cannot be ruled out as an intravascular injection, toxic overdose, psychogenic reaction, or an idiosyncratic event.

Ocular complications associated with local anesthesia administration in dentistry.

The most widely used method for controlling pain during dental procedures is the intraoral administration of local anesthetics in close proximity to a specific nerve or fiber to obtund nerve conduction. The most commonly anesthetized nerves in dentistry are branches or nerve trunks associated with the maxillary and mandibular divisions of the trigeminal nerve (cranial nerve V). However, other nerves may be inadvertently affected by intraoral local anesthesia injections, resulting in anesthetic complications of structures far from the oral cavity. Practitioners should be aware of potential ocular complications following intraoral injections in dentistry. These complications include oculomotor paralysis and vision loss. The knowledge of these conditions and their potential cause should alert the dentist to the importance of appropriate injection techniques and an understanding of management protocol.

Needle phobia: etiology, adverse consequences, and patient management.

Needle phobia has profound health, dental, societal, and legal implications, and severe psychological, social, and physiologic consequences. There is genetic evidence for the physiologic response to needle puncture, and a significant familial psychological component, showing evidence of inheritance. Needle phobia is also a learned behavior. The dental practitioner must recognize patients with needle phobia before the administration of local anesthetics to identify patients who are potentially reactive and to prevent untoward sequelae. Needle phobia is highly associated with avoidance behavior, and the dentist must exhibit compassion and respect. To avoid bradycardia, hypotension, unconsciousness, convulsions, and possibly asystole, oral premedication with benzodiazepines or other antianxiety agents must be considered for patients who are needle phobic. Management of needle phobiaeinduced syncope includes perioperative monitoring, oxygen administration, positioning, atropine, and vasopressors.