Income-Based Disparities in a Yearly Dental Visit in United States Adults and Children: Trend Analysis 1997 to 2016.

OBJECTIVE: To determine how income-based disparities in a yearly dental visit (the Healthy People 2020 Leading Health Indicator for Oral Health) changed since legislation to expand dental coverage and to compare disparity trends in children and adults. METHODS: We analyzed Medical Expenditure Panel Survey 1997 to 2016 to determine yearly dental visit rates for US children and adults by family income. We determined measures of income disparity, including the Slope Index of Inequality and the Relative Index of Inequality and examined trends in yearly dental visit, Slope Index of Inequality, and Relative Index of Inequality using joinpoint regression. RESULTS: Income-based disparities, absolute and relative, narrowed over time for children. Steady upward trends in yearly dental visit rates were observed for poor and low-income/poor children and no joinpoint was identified that corresponded to legislation expanding dental care coverage for lower income children. Relative income-based disparities in yearly dental visit rates widened for adults over 20 years. After declining for 14 years, yearly dental visit rate increased for poor adults from 2013 to 2016 suggesting a possible positive effect in adult dental care use trends following enactment of the Affordable Care Act. CONCLUSIONS: In 1997, US children and adults had similar levels of income-based disparity in yearly dental visits, but by 2016, they differed markedly. Trends in income-based disparities in yearly dental visit rate narrowed for children but widened for adults. There are lessons from the expansion of dental care coverage for children that could be applied to improve access to dental care for adults.

Teeth: Small but Mighty and Mighty Important. A Comprehensive Review of Children's Dental Health for Primary Care Clinicians.

Healthy teeth allow us to eat and stay well-nourished. Although primary care clinicians receive limited training about teeth, given the common nature of dental problems, it is important that they understand and recognize normal and abnormal dental conditions and can implement primary and secondary prevention of dental conditions in their practice. PubMed has been used to search the scientific literature for evidence on the following topics: normal dental development, dental abnormalities, malocclusion, teething, dental caries and related epidemiology and prevention, fluoride, dental injury and its management and prevention; and identification, prevention and treatment of gingivitis and periodontal disease. Literature review relied on randomized controlled trials, meta-analyses, systematic reviews, and Cochrane reviews when relevant and available. Other sources of evidence included cohort and case-control studies. Consensus statements and expert opinion were used when there was a paucity of high-quality research studies. The literature has been synthesized on these topics to make them relevant to pediatric primary care clinicians, and as available, the strength of evidence has been characterized when making clinical recommendations.

Infant Oral Health.

It may be easy to discount oral health in infancy because most infants are not born with teeth and only a few teeth erupt during the first year of life. Infancy, however, is a critical time for formation of habits. Positive habits, such as twice-daily brushing with fluoride toothpaste starting at first teeth eruption, provides topical fluoride, which is important for remineralization of the tooth and helps establish a lifelong healthy practice. Negative habits, such as bottle propping and frequent juice consumption, reinforce behaviors that promote caries and obesity. This article reviews normal dental development and eruption. Congenital anomalies affecting the mouth as well as acquired conditions, primarily dental caries, are reviewed. Oral health preventive modalities, including professionally applied products and home-based strategies, are discussed.

The Primary Care Pediatrician and the Care of Children With Cleft Lip and/or Cleft Palate.

Orofacial clefts, specifically cleft lip and/or cleft palate (CL/P), are among the most common congenital anomalies. CL/P vary in their location and severity and comprise 3 overarching groups: cleft lip (CL), cleft lip with cleft palate (CLP), and cleft palate alone (CP). CL/P may be associated with one of many syndromes that could further complicate a child's needs. Care of patients with CL/P spans prenatal diagnosis into adulthood. The appropriate timing and order of specific cleft-related care are important factors for optimizing outcomes; however, care should be individualized to meet the specific needs of each patient and family. Children with CL/P should receive their specialty cleft-related care from a multidisciplinary cleft or craniofacial team with sufficient patient and surgical volume to promote successful outcomes. The primary care pediatrician at the child's medical home has an essential role in making a timely diagnosis and referral; providing ongoing health care maintenance, anticipatory guidance, and acute care; and functioning as an advocate for the patient and a liaison between the family and the craniofacial/cleft team. This document provides background on CL/P and multidisciplinary team care, information about typical timing and order of cleft-related care, and recommendations for cleft/craniofacial teams and primary care pediatricians in the care of children with CL/P.

Visits to US emergency departments by 20- to 29-year-olds with toothache during 2001-2010.

BACKGROUND: Visits to emergency departments (EDs) for dental symptoms are on the rise, yet reliance on EDs for dental care is far from ideal. ED toothache visits represent opportunities to improve access to professional dental care. METHODS: This research focuses on 20- to 29-year-olds, who account for more ED toothache visits than do other age groups. The authors analyzed publicly available ED visit data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2001 through 2010. They assessed trends in ED toothache visit rates compared with back pain and all cause ED visits during the past decade. The authors used NHAMCS data for years 2009 and 2010 to characterize the more recent magnitude, relative frequency, and independent risk factors for ED toothache visits. Statistical analyses accounted for the complex sampling design. RESULTS: The average annual increase in ED visit rates among 20- to 29-year-olds during 2001-2010 was 6.1% for toothache, 0.3% for back pain, and 0.8% for all causes of ED visits. In 2009 and 2010, 20- to 29-year-olds made an estimated 1.27 million ED visits for toothaches and accounted for 42% of all ED toothache visits. Toothache was the fifth most common reason for any ED visit and third most common for uninsured ED visits by 20- to 29-year-olds. Independent risk factors for ED toothache visits were being uninsured or Medicaid-insured. CONCLUSIONS: Younger adults increasingly rely on EDs for toothaches-likely because of barriers to accessing professional dental care. Expanding dental coverage and access to affordable dental care could increase options for timely dental care and decrease ED use for dental symptoms. PRACTICAL IMPLICATIONS: Though additional research is needed to better understand why younger adults disproportionately use the ED for toothaches, findings from this study suggest the importance of maintaining access to a dental home from childhood through adolescence and subsequently into early adulthood.

Predictors of unmet dental need in children with autism spectrum disorder: results from a national sample.

OBJECTIVE: Unmet dental need in children with autism spectrum disorder (ASD) is common. We tested hypotheses that lacking a medical home or having characteristics of more severe ASD is positively associated with having unmet dental need among children with ASD. METHODS: Using data from the 2009 to 2010 National Survey of Children with Special Health Care Needs, we analyzed 2772 children 5 to 17 years old with ASD. We theorized that unmet dental need would be positively associated with not having a medical home and having characteristics of more severe ASD (eg, parent reported severe ASD, an intellectual disability, communication, or behavior difficulties). Prevalence of unmet dental need was estimated, and unadjusted and adjusted odds ratios, 95% confidence intervals, and P values were computed using survey methods for logistic regression. RESULTS: Nationally, 15.1% of children with ASD had unmet dental need. Among children with ASD, those without a medical home were more apt to have unmet dental need than those with a medical home (adjusted odds ratio, 4.46; 95% confidence interval, 2.59-7.69). Children with ASD with intellectual disability or greater communication or behavioral difficulties had greater odds of unmet dental need than those with ASD without these characteristics. Parent-reported ASD severity was not associated with unmet dental need. CONCLUSIONS: Children with ASD without a medical home and with characteristics suggestive of increased ASD-related difficulties were more apt to have unmet dental need. Pediatricians might use these findings to aid in identifying children with ASD who might not receive all needed dental care.

Oral health opinions and practices of pediatricians: updated results from a national survey.

BACKGROUND: Professional guidelines and state Medicaid policies encourage pediatricians to provide oral health screening, anticipatory guidance, and fluoride varnish application to young patients. Because oral health activities are becoming more common in medical offices, the objective of this study was to assess pediatricians' attitudes and practices related to oral health and examine changes since 2008. METHODS: As part of the 2012 Periodic Survey of Fellows, a random sample of 1638 members of the American Academy of Pediatrics was surveyed on their participation in oral health promotion activities. Univariate statistics were used to examine pediatricians' attitudes, practices, and barriers related to screening, risk assessment, counseling, and topical fluoride application among patients from birth to 3 years of age. Bivariate statistics were used to examine changes since 2008. RESULTS: Analyses were limited to 402 pediatricians who provided preventive care (51% of all respondents). Most respondents supported providing oral health activities in medical offices, but fewer reported engaging in these activities with most patients. Significantly more respondents agreed they should apply fluoride varnish (2008, 19%; 2012, 41%), but only 7% report doing so with >75% of patients. Although significantly more respondents reported receiving oral health training, limited time, lack of training and billing remain barriers to delivering these services. CONCLUSIONS: Pediatricians continue to have widespread support for, but less direct involvement with oral health activities in clinical practice. Existing methods of training should be examined to identify methods effective at increasing pediatricians' participation in oral health activities.

Chapter Oral Health Advocates: A Nationwide Model for Pediatrician Peer Education and Advocacy about Oral Health.

Objective. (1) To describe an innovative program training US pediatricians to be Chapter Oral Health Advocates (COHAs). (2) To provide insight into COHAs' experiences disseminating oral health knowledge to fellow pediatricians. Patients and Methods. Interviews with 40 COHAs who responded to an email request, from a total of 64 (62% response). Transcripts were analyzed for common themes about COHA activities, facilitators, and barriers. Results. COHAs reported positive experiences at the AAP oral health training program. A subset of academic COHAs focused on legislative activity and another on resident education about oral health. Residents had an easier time adopting oral health activities while practicing pediatricians cited time constraints. COHAs provided insights into policy, barriers, and facilitators for incorporating oral health into practice. Conclusions. This report identifies factors influencing pediatricians' adoption of oral health care into practice. COHAs reported successes in training peers on integrating oral health into pediatric practice, identified opportunities and challenges to oral health implementation in primary care, and reported issues about the state of children's oral health in their communities. With ongoing support, the COHA program has a potential to improve access to preventive oral health services in the Medical Home and to increase referrals to a Dental Home.

Visiting the emergency department for dental problems: trends in utilization, 2001 to 2008.

OBJECTIVES: We tested the hypothesis that between 2001 and 2008, Americans increasingly relied upon emergency departments (EDs) for dental care. METHODS: Data from 2001 through 2008 were collected from the National Hospital Ambulatory Medical Care Survey (NHAMCS). Population-based visit rates for dental problems, and, for comparison, asthma, were calculated using annual US Census Bureau estimates. As part of the analysis, we described patient characteristics associated with large increases in ED dental utilization. RESULTS: Dental visit rates increased most dramatically for the following subpopulations: those aged 18 to 44 years (7.2-12.2 per 1000, P < .01); Blacks (6.0-10.4 per 1000, P < .01); and the uninsured (9.5-13.2 per 1000, P < .01). Asthma visit rates did not change although dental visit rates increased 59% from 2001 to 2008. CONCLUSIONS: There is an increasing trend in ED visits for dental issues, which was most pronounced among those aged 18 to 44 years, the uninsured, and Blacks. Dental visit rates increased significantly although there was no overall change in asthma visit rates. This suggests that community access to dental care compared with medical care is worsening over time.

Utility of a summative scale based on the Children with Special Health Care Needs (CSHCN) Screener to identify CSHCN with special dental care needs.

Our objective was to determine if a summative scale reflecting the number of positive criteria on the Children with Special Health Care Needs (CSHCN) Screener is useful in identifying subgroups of CSHCN at risk for poorer oral health and unmet dental care needs and who should be considered to have special dental care needs. Data were analyzed for a population-based sample of 91,642 US children <18 years from the 2007 National Survey of Children's Health. The independent variable of interest was the summative number of positive CSHCN Screener criteria. Dependent variables were parent-perceived condition of child's teeth, toothache, cavities, broken teeth, bleeding gums in the previous 6 months, and unmet dental care needs in the past 12 months. Descriptive and multivariable logistic regression analyses were performed for each outcome using the survey command in Stata to account for the sampling design. A summative scale based on the number of positive CSHCN Screener criteria was independently associated with various parent-perceived poorer oral health outcomes in children. CSHCN who met 4 or 5 screener criteria had 4 and 4.5 times, respectively, the odds of having fair-poor condition of teeth and bleeding gums relative to non-CSHCN. They also had 87% higher odds for parent-perceived toothache and 2 and 2.5 times the odds of having recent broken teeth and unmet dental care needs relative to non-CSHCN, respectively. There was no dose-dependent association between summative number of positive CSHCN Screener criteria and reported cavities in children. Application of a summative score based on the CSHCN Screener has utility in identifying the CSHCN subgroup with special dental care needs.

Wanting better: a qualitative study of low-income parents about their children's oral health.

PURPOSE: Using qualitative methods, the purpose of this study was to understand low-income parents' experiences and how these influenced their oral health-related behavior toward their children. METHODS: Twenty-eight parents were recruited from 7 sites that serve low-income families. Interviews, which were audiotaped and transcribed, were comprised of mostly open-ended questions. Transcripts were analyzed for common themes. RESULTS: Parents' experiences influenced their oral health-related beliefs, intentions, and behaviors. Finding dentists who accept Medicaid was the greatest barrier to realizing intended preventive dental care. Physicians appeared to have relatively little impact on these families' oral health care, even though parents believed that oral health is part of overall health care. WIC (the Supplemental Nutrition Program for Women, Infants and Children) played an important role in facilitating oral health knowledge and access to dental care. CONCLUSIONS: Most low-income parents had received little attention to their own oral health, yet wanted better for their children. This motivated the high value placed on their children's preventive oral health. Parents faced challenges finding dental care for their children. Difficulty finding a regular source of dental care for low-income adults, however, was nearly universal. The authors identified strategies, which emerged from their interviews, to improve the oral health knowledge and dental care access for these low-income families.

Dental care and children with special health care needs: a population-based perspective.

This paper grew out of a project reviewing progress in children's oral health after Oral Health in America: A Report of the Surgeon General was published in 2000. It includes a summary of advances in national surveillance of children with special health care needs (CSHCN), and presents more recent data on unmet dental care need among CSHCN. To that end, we used the 2006 National Survey of Children with Special Health Care Needs to determine the prevalence of unmet dental care need among CSHCN and to compare this within subgroups of CSHCN, as well as to children without special health care needs, and to results from the previous iteration of this survey. Dental care remains the most frequently cited unmet health need for CSHCN. More CSHCN had unmet needs for nonpreventive than preventive dental care. CSHCN who are teens, poorer, uninsured, had insurance lapses, or are more severely affected by their condition had higher adjusted odds of unmet dental care needs. CSHCN who were both low income and severely affected had 13.4 times the adjusted odds of unmet dental care need. In summary, CSHCN are more likely to be insured and to receive preventive dental care at equal or higher rates than children without special health care needs. Nevertheless, CSHCN, particularly lower income and severely affected, are more likely to report unmet dental care need compared with unaffected children. Despite advances in knowledge about dental care among CSHCN, unanswered questions remain. Recommendations are provided toward obtaining additional data and facilitating dental care access for this vulnerable population.

Oral health and pediatricians: results of a national survey.

OBJECTIVE: Pediatricians have regular opportunities to perform screening dental examinations on young children and to educate families on preventive oral health. We sought to assess pediatricians' current attitudes and practices related to oral health of children 0-3 years old. METHODS: A Periodic Survey of Fellows, focused on oral health in pediatricians' office settings, was sent to 1618 postresidency fellows of the American Academy of Pediatrics. RESULTS: The response rate was 68%. More than 90% of pediatricians said that they should examine their patients' teeth for caries and educate families about preventive oral health. However, in practice, only 54% of pediatricians reported examining the teeth of more than half of their 0-3-year-old patients. Four percent of pediatricians regularly apply fluoride varnish. The most common barrier to participation in oral health-related activities in their practices was lack of training, which was cited by 41%. Less than 25% of pediatricians had received oral health education in medical school, residency, or continuing education. Most pediatricians (74%) reported that availability of dentists who accept Medicaid posed a moderate to severe barrier for 0-3-year-old Medicaid-insured patients to obtain dental care. CONCLUSIONS: Pediatricians see it within their purview to educate families about preventive oral health and to assess for dental caries. However, many pediatricians reported barriers to fully implementing preventive oral health activities into their practices. Pediatricians and dentists need to work together to improve the quality of preventive oral health care available to all young children.

Bupivacaine administration and postoperative pain following anterior iliac crest bone graft for alveolar cleft repair.

OBJECTIVE: To determine whether placement of a bupivacaine-soaked absorbable sponge (BAS) in addition to bupivacaine infiltration at the anterior iliac crest (AIC) donor site alters postoperative pain for children undergoing alveolar bone grafting (ABG) for cleft lip with or without cleft palate (CL+/-P). The comparison group received only bupivacaine infiltration (NO BAS) at the AIC. DESIGN: Retrospective cohort. Medical records were abstracted by one investigator, blinded to BAS versus NO BAS use. SETTING AND PATIENTS: Consecutive patients with CL+/-P who underwent ABG between 2000 and 2006 at one large U.S. craniofacial center. INTERVENTION: BAS was used in 118 procedures and NO BAS in 89. OUTCOME MEASURES: Postoperative pain score, total and opioid pain medication requirement, length of hospital stay (LOS), and time to initial ambulation. RESULTS: One hundred eighty-two patients underwent 207 ABG procedures. Mean pain scores were significantly lower when BAS was used compared with NO BAS (1.3 versus 1.8; p = .01). Patients who received BAS required significantly less pain medication than NO BAS patients: opioids (0.14 versus 0.20 mg/kg; p = .01) and total (0.60 versus 0.71 mg/kg; p = .02). Relative to the NO BAS group, those who received BAS had a shorter LOS (30.9 versus 42.4 hours; p < .0001) and less time to initial ambulation following surgery (14.4 versus 20.6 hours; p < .0001). CONCLUSION: Use of BAS at the AIC donor site significantly reduced postoperative pain score, pain medication requirement, LOS, and time to ambulation relative to children who did not receive BAS following ABG.

Pediatric primary care providers and adolescent depression: a qualitative study of barriers to treatment and the effect of the black box warning.

PURPOSE: The recent black box warning on antidepressants has drawn attention to controversies regarding the treatment of adolescent depression in primary care settings, but little is known about how providers decide to treat depressed youth and what resources are employed. METHODS: We conducted focus groups with 35 providers and staff in nine community-based pediatric practices in rural and urban settings of western Washington State. Discussion topics included perceived barriers to the treatment of depression in youth, how providers addressed these barriers, and the impact of the recent Federal Drug Administration (FDA) black-box warning. Focus groups were audiotaped and professionally transcribed. Qualitative content analysis was conducted using Atlas ti software and differences in coding were resolved via discussion by three independent reviewers. RESULTS: Based on analysis of interviews, a conceptual model was developed detailing factors influencing primary care providers' (PCP) decisions about depression treatment. The three key themes that influenced doctors' decisions about treating depression were lack of availability of mental health resources in the community, feeling responsible for helping based on long-standing relationships with patients and families, and patient and family beliefs and preferences regarding treatment. Most of the approaches to address barriers were not systemized and were physician dependent. Most providers expressed concern about recent antidepressant warnings, but many continued to treat and none had developed new strategies for closer monitoring of youth initiating treatment with antidepressants. CONCLUSION: The decision of when and how PCPs decide to treat adolescent depression is strongly influenced by PCP perceptions of their role in treatment, availability of other treatment resources, and family and patient preferences and resources. Few practices have developed changes in the approach to practice needed to meet FDA black-box recommendations regarding close monitoring of response to medications.

Preventive dental care for children in the United States: a national perspective.

OBJECTIVE: Preventive dental care is a cornerstone of optimal oral health. However, in 1996, only 38% of US children received preventive dental care. We used the National Survey of Children's Health to (1) describe the proportion of US children with > or = 1 preventive dental visit within the previous year, (2) identify factors that were associated with preventive dental care use, and (3) test the hypothesis that preventive dental care use by near-poor children is associated with State Child Health Insurance Program policies for covering dental care. METHODS: The National Survey of Children's Health includes data from 102,353 children, weighted to represent 72.7 million children, nationally. Our outcome of interest was > or = 1 preventive dental visit in the past year. We conducted multivariate regression analysis to identify factors that were associated significantly with this outcome using Stata survey capabilities. RESULTS: In 2003, 72% of US children had a reported preventive dental care visit in the previous year. On multivariable analysis, we found that being young, black or multiracial relative to white, lower income, and lacking a personal doctor were variables with a significantly lower likelihood of a preventive dental visit. Children in states with State Child Health Insurance Program dental coverage and broadest income eligibility had a 24% higher likelihood of a preventive dental visit when compared with children in states with limited or no State Child Health Insurance Program coverage for dental services, on adjusted analysis. CONCLUSIONS: Although the proportion of US children with a preventive dental visit now is higher than previously reported, children who are at highest risk for dental problems still are those who are least likely to receive preventive dental care. When states cover preventive dental care at income eligibility levels > or = 200% of the federal poverty level, there is a greater likelihood that near-poor children will receive preventive dental care.

A comparison of nasendoscopy and multiview videofluoroscopy in assessing velopharyngeal insufficiency.

OBJECTIVES: 1) To compare nasendoscopy (NE) and multiview fluoroscopy (MVF) in assessing velopharyngeal gap size; and 2) to determine the relationship between these assessments and velopharyngeal insufficiency (VPI) severity. STUDY DESIGN AND SETTING: Retrospective review of consecutive patients with VPI at a tertiary care children's hospital, assessed with NE and MVF between 1996 and 2003. RESULTS: 177 subjects. NE and MVF gap areas were correlated (R = 0.34, 95% CI 0.26-0.41). In adjusted analysis, VPI severity was associated with: 1) NE gap area (OR = 2.78, 95% CI 1.96-3.95), 2) MVF gap area (OR 1.64, 95% CI 1.37-1.95), 3) age <5 years (OR 3.30, 95% CI 1.47-7.38), and 4) previously repaired cleft palate (OR 0.48, 95% CI 0.25-0.94). CONCLUSIONS AND SIGNIFICANCE: NE and MVF assessments provide complementary information and are correlated. Both are associated with VPI severity. However, the "bird's-eye view" provided by NE has a stronger correlation with VPI severity than MVF. EBM RATING: B-2b.

Community orthodontists and craniofacial care: results of a Washington state survey.

BACKGROUND: Little is known about community orthodontists' previous training in, experience with, or receptivity to caring for children with craniofacial disorders. OBJECTIVES: (1) To characterize the current level of participation by Washington state orthodontists in craniofacial care; and (2) to identify factors that promote or impede community orthodontists' involvement in caring for children with craniofacial conditions. DESIGN: Mail survey. METHODS: A 26-item questionnaire was designed and mailed to all active orthodontists in Washington state (N = 230). Question topics included practice characteristics, training and experience with craniofacial conditions, concerns related to public and private insurance, and communication with craniofacial teams. RESULTS: Of eligible respondents, 68% completed the survey. Most orthodontists' patient panels were made up of patients who either have private insurance or pay cash for services. On average, 2% of respondents' patients were Medicaid beneficiaries. Only 20% of respondents had seen more than three patients with cleft lip and/or palate in the past 3 years. Although a minority of orthodontists receive referrals from (27%) or are affiliated with (11%) craniofacial teams, most orthodontists perceived craniofacial care positively and were interested to learn more about craniofacial care and to accept additional patients with these conditions. CONCLUSIONS: Results of this survey can inform potential strategies to increase access to orthodontic care for children with craniofacial disorders. These would include developing an organized training, referral, and communication system between community orthodontists and state craniofacial teams and considering a case-management approach to facilitate this process.