Developing Children's Oral Health Assessment Toolkits Using Machine Learning Algorithm.

OBJECTIVES: Evaluating children's oral health status and treatment needs is challenging. We aim to build oral health assessment toolkits to predict Children's Oral Health Status Index (COHSI) score and referral for treatment needs (RFTN) of oral health. Parent and Child toolkits consist of short-form survey items (12 for children and 8 for parents) with and without children's demographic information (7 questions) to predict the child's oral health status and need for treatment. METHODS: Data were collected from 12 dental practices in Los Angeles County from 2015 to 2016. We predicted COHSI score and RFTN using random Bootstrap samples with manually introduced Gaussian noise together with machine learning algorithms, such as Extreme Gradient Boosting and Naive Bayesian algorithms (using R). The toolkits predicted the probability of treatment needs and the COHSI score with percentile (ranking). The performance of the toolkits was evaluated internally and externally by residual mean square error (RMSE), correlation, sensitivity and specificity. RESULTS: The toolkits were developed based on survey responses from 545 families with children aged 2 to 17 y. The sensitivity and specificity for predicting RFTN were 93% and 49% respectively with the external data. The correlation(s) between predicted and clinically determined COHSI was 0.88 (and 0.91 for its percentile). The RMSEs of the COHSI toolkit were 4.2 for COHSI (and 1.3 for its percentile). CONCLUSIONS: Survey responses from children and their parents/guardians are predictive for clinical outcomes. The toolkits can be used by oral health programs at baseline among school populations. The toolkits can also be used to quantify differences between pre- and post-dental care program implementation. The toolkits' predicted oral health scores can be used to stratify samples in oral health research. KNOWLEDGE TRANSFER STATEMENT: This study creates the oral health toolkits that combine self- and proxy- reported short forms with children's demographic characteristics to predict children's oral health and treatment needs using Machine Learning algorithms. The toolkits can be used by oral health programs at baseline among school populations to quantify differences between pre and post dental care program implementation. The toolkits can also be used to stratify samples according to the treatment needs and oral health status.

Child and Parent Demographic Characteristics and Oral Health Perceptions Associated with Clinically Measured Oral Health.

OBJECTIVE: To examine child and parent reports about the child's oral health and assess the associations of these reports with clinical assessments of oral health status by dental examiners. METHODS: Surveys with 139 items for children and 133 items for parents were administered by Audio Computer-Assisted Self-Interview Software. In addition, the Children's Oral Health Status Index (COHSI) was computed from a dental examination. RESULTS: A total of 334 families with children ages 8 to 17 y participated at 12 dental practices in Los Angeles County. Ordinary least squares regression models were estimated separately for child and parent surveys to identify items uniquely associated with the COHSI. Ten of 139 items the children reported regarding their oral health were associated with the COHSI. The strongest associations were found for child's age, aesthetic factors (straight teeth and pleased with teeth), and cognitive factors related to perception of dental appearance (pleased/happy with the look of the child's mouth, teeth, and jaws). Nine of 133 parent items about the child's oral health were associated with the COHSI in the parent model, notably being a single parent, parent's gender, parent born in the United States, pleased or happy with the look of their child's teeth, and accessing the Internet. CONCLUSION: These child and parent survey items have potential to be used to assess oral health status for groups of children in programs and practices in lieu of dental screenings. KNOWLEDGE TRANSLATION STATEMENT: The paper's results inform the development of a toolkit that can be used by schools, public health agencies, and dental programs to identify children with low oral health status based on parents' and children's responses to survey items across demographic, physical, mental, and social domains. These survey items can be used to inform parents of the desirability of proactively addressing inadequacies in their child's oral health status, enabling them to more rationally address dental needs.

Evidence-based clinical practice guideline for the use of pit-and-fissure sealants: a report of the American Dental Association and the American Academy of Pediatric Dentistry

BACKGROUND: This article presents evidence-based clinical recommendations for the use of pit-and-fissure sealants on the occlusal surfaces of primary and permanent molars in children and adolescents. A guideline panel convened by the American Dental Association (ADA) Council on Scientific Affairs and the American Academy of Pediatric Dentistry conducted a systematic review and formulated recommendations to address clinical questions in relation to the efficacy, retention, and potential side effects of sealants to prevent dental caries; their efficacy compared with fluoride varnishes; and a head-to-head comparison of the different types of sealant material used to prevent caries on pits and fissures of occlusal surfaces. TYPES OF STUDIES REVIEWED: This is an update of the ADA 2008 recommendations on the use of pit-and-fissure sealants on the occlusal surfaces of primary and permanent molars. The authors conducted a systematic search in MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and other sources to identify randomized controlled trials reporting on the effect of sealants (available on the US market) when applied to the occlusal surfaces of primary and permanent molars. The authors used the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the quality of the evidence and to move from the evidence to the decisions. RESULTS: The guideline panel formulated 3 main recommendations. They concluded that sealants are effective in preventing and arresting pit-and-fissure occlusal carious lesions of primary and permanent molars in children and adolescents compared with the nonuse of sealants or use of fluoride varnishes. They also concluded that sealants could minimize the progression of noncavitated occlusal carious lesions (also referred to as initial lesions) that receive a sealant. Finally, based on the available limited evidence, the panel was unable to provide specific recommendations on the relative merits of 1 type of sealant material over the others. CONCLUSIONS AND PRACTICAL IMPLICATIONS: These recommendations are designed to inform practitioners during the clinical decision-making process in relation to the prevention of occlusal carious lesions in children and adolescents. Clinicians are encouraged to discuss the information in this guideline with patients or the parents of patients. The authors recommend that clinicians reorient their efforts toward increasing the use of sealants on the occlusal surfaces of primary and permanent molars in children and adolescents.(AU)

Disparities in children's oral health and access to dental care.

Dental caries can be prevented by a combination of community, professional, and individual measures including water fluoridation, professionally applied topical fluorides and dental sealants, and use of fluoride toothpastes. Yet, tooth decay is the most common chronic disease of childhood. Dental care is the most prevalent unmet health need in US children with wide disparities existing in oral health and access to care. Only 1 in 5 children covered by Medicaid received preventive oral care for which they are eligible. Children from low income and minority families have poorer oral health outcomes, fewer dental visits, and fewer protective sealants. Water fluoridation is the most effective measure in preventing caries, but only 62% of water supplies are fluoridated, and lack of fluoridation may disproportionately affect poor and minority children. Childhood oral disease has significant medical and financial consequences that may not be appreciated because of the separation of medicine and dentistry. The infectious nature of dental caries, its early onset, and the potential of early interventions require an emphasis on preventive oral care in primary pediatric care to complement existing dental services. However, many pediatricians lack critical knowledge to promote oral health. We recommend financial incentives for prioritizing Medicaid Early and Periodic Screening, Diagnostic, and Treatment dental services; managed care accountability; integration of medical and dental professional training, clinical care, and research; and national leadership. JAMA. 2000;284:2625-2631.

Pediatric oral health performance measurement: current capabilities and future directions.

This paper offers an overview of performance measurement in health care, provides a synopsis of the findings and recommendations of an Oral Health Expert Panel organized by the National Committee for Quality Assurance (NCQA) under contract with the Health Care Financing Administration (HCFA), and discusses challenges and possible future directions for pediatric oral health care performance measures development. Existing performance measures for pediatric oral health care are extremely limited; however, several new measures have been proposed and are in various stages of development and testing. Measures capable of being implemented in the short-term focus on access and use of services, rely on administrative data sources, and represent refinements and enhancements of current measures. Measures proposed for future implementation focus more on the effectiveness of care, consumer assessments of care and plan performance, and the value of services provided to enrolled children. Recommendations are targeted toward high-risk children who, for the most part, are covered by public programs (e.g., Medicaid and the Children's Health Insurance Program). Nevertheless, the entire set of recommended measures is considered to be relevant to all pediatric populations and applicable to all forms of dental care coverage, including state-administered programs and commercial third party arrangements.

Sociodemographic distribution of pediatric dental caries: NHANES III, 1988-1994.

This article examines the extent to which caries prevalence and untreated caries vary in children by ethnicity and household income level. Data from the Third National Health and Nutrition Examination Survey, 1988-1994, for 10,332 children 2 to 18 years of age indicate that lower-income children and Mexican-American and African-American children are more likely to have a higher prevalence of caries and more unmet treatment needs than their higher-income and non-Hispanic white counterparts.

Oral health component of child health services research.

The June 11 JAMA article outlines a rationale for developing a focus on child health services research and offers several strategies for facilitating the process. Developing a child health research agenda is essential to advancing dental care and professional education and, thus, is relevant to educators as well as researchers and policy makers. Oral health considerations are not likely to have high visibility or priority within that agenda unless dental health services researchers and dental schools become involved. An obvious question that is bound to be raised is "does it make sense to attempt to direct some portion of the already scarce resources available for dental health services research to children's issues?" Many individuals in leadership positions will probably think not; however, with an appropriate strategy, a small number of organized individuals and institutions can make a significant difference. Given the nature of dental diseases and the historical values of the profession, what better place to start?

Variation in the use of crowns and their alternatives.

The use of crowns and their alternatives for the restoration of compromised posterior teeth is of interest to educators, purchasers, and patients. Considerable curricular time is devoted to learning these techniques, substantial amounts of money are spent on these procedures, and differences in the outcomes of these treatments may have consequences for tooth survival. To begin to understand more about the actual use of these procedures, the provision rates of these services in a sample of U.S. dental practices were examined. This study reports on the extent to which utilization patterns and subsequent costs of crowns and their alternatives were associated with certain patient and practice characteristics. Insurance claims for dental services submitted by general dental practices through an electronic claims clearinghouse were used. Crown ratios (crowns/crowns plus alternatives) were calculated for dental practices to evaluate relationships with available explanatory variables. Findings indicated that older patients were significantly more likely to receive crowns than those in younger groups, resulting in as much as a 33 percent increase in the mean per tooth cost of treatment in the oldest group. Regional variation existed in the provision of crowns and resulted in up to a 31 percent difference in the mean per tooth treatment cost between regions. Crown ratios exhibited variation beyond that accounted for by patient and practice factors, thus raising questions about the consistency of treatment recommendations among dentists. These findings support the need to examine further the consistency of crown use among general dentists and to modify current approaches for teaching treatment planning in predoctoral restorative curricula.

Caries experience in inner-city preschoolers at the time of their initial dental visit.

This retrospective study examined caries experience in a population of inner-city preschoolers at their initial dental visit. Clinical and sociodemographic data for 103 patients aged five years and under at the time of their first dental visit were obtained from the dental records of an inner-city community health center clinic located in a fluoridated area. The sample consisted of fifty-eight males and forty-five females who were seen during a continuous six-month period in 1991. The mean age of the subjects was 44.1 months (S.D. +/- 10.5 months). Sixty-seven percent of the children in the sample were found to have caries. The mean number of decayed surfaces (ds) was 6.54 (+/- 7.16), with the following distribution by surface type: occlusal--2.89 (+/- 3.15); proximal--1.75 (+/- 2.91); buccal/lingual--1.90 (+/- 2.73). Caries prevalence and severity increased with age. Findings from this sample demonstrate that dental caries remains a significant problem in inner-city preschoolers, thereby underscoring the importance of early intervention programs.

Delivery systems for preschool children.

The United States dental care delivery system generally performs well for those who gain access and can afford necessary care; however, many segments of the population with significant levels of dental disease find it difficult or impossible to avail themselves of the potential benefits that the system has to offer. Preschool children are no exception, and they often receive little or no consideration in epidemiologic studies or policy development. Increasing awareness and improving preschooler's access to needed services will require fundamental changes in attitudes, policies, and behaviors on the part of the public, public officials, and health care professionals, including those within the dental profession.

Child patient behavior: a new perspective.

All behavior depends on responses of the nervous system (Shepherd 1988). Alkon demonstrated physical changes in the nervous systems of Hermissenda crassicornis and rabbits at the molecular level following behavioral conditioning. This physical change resulted in a reduced flow of potassium ions across the neuronal cell membrane for some time, with resultant enhanced excitability during this period. It is suggested that behavioral deterioration in children during sequential dental visits might be the result of a reduced potassium ion flow across the neuronal cell membrane, with resultant enhanced excitability during this period. Alkon also reported that in a "conditioned" stimulus, information flows along a "collateral pathway" formed in the course of the learning experience. It is hypothesized that behavioral improvement in children following positive dental experiences (model learning and desensitization) may be due to the information of the "conditioned" dental stimulus flowing along a "collateral pathway" formed in the course of the learning experience.

Informatics futures in dental education and research: quality assurance.

Traditional methods for quality assurance are increasingly being questioned on the grounds of costs and effectiveness. Quality assurance in dentistry has suffered from many of the same problems that have impeded development of the field outside the hospital sector: inadequate data sources, a paucity of broad-based research demonstrating the effects of various treatment approaches on patient outcomes, and a lack of cost-effective methods by which to monitor and evaluate care. Informatics holds considerable promise for dealing with those problems in a comprehensive, reliable and efficient manner. Although a considerable shared commitment on the art of academic dentistry will be needed, the anticipated advantages to be gained in terms of advancing the quality of dental education, research and patient care are substantial. The initiatives being undertaken by the AADS Special Committee on Information Technology are most timely. Parallel informatics efforts are being mounted at the national and international level in numerous health care disciplines. The dental academic community should be prepared to take advantage of the opportunities that the field of informatics is expected to yield in the near future so that it can provide leadership in promoting positive changes within the profession.

Relationship of microbiological, social, and environmental variables to caries status in young children.

This study was undertaken to investigate the significance of social, environmental, and biological variables in relation to caries status in a group of young children, and to determine whether incorporating data on social and environmental variables into a multivariate model could improve the accuracy of a screening approach that relies solely on quantifying levels of salivary Streptococcus mutans. Data regarding fluoride status and sociodemographic characteristics were collected from the dental records of 89 children who ranged in age from 10-71 months, and who had been screened previously for S. mutans. Multivariate analyses (logit) revealed that the probability of having clinically or radiographically detectable caries was associated with 1) higher levels of salivary S. mutans, 2) residing in a single-parent household, 3) having suboptimal levels of fluoride in the drinking water and 4) not being covered by a dental insurance plan. The findings attest to the importance of considering social and environmental factors, in addition to biological variables, when evaluating caries status in young children.

Evaluations of effectiveness and quality of care.

Although technical competency continues to be viewed as an essential prerequisite for practicing dentistry, it is no longer felt to be a sufficient indicator of the effectiveness or quality of care that will be or is provided by a practitioner. Consistent with a broader definition of quality that includes timeliness and appropriateness of treatment, continuity of care, emphasis on prevention, and adequate documentation of services provided, initiatives are being mounted to develop improved methods for evaluating the effectiveness of treatment approaches and quality of care provided for patients. Fundamental to these evaluations are hypotheses relating aspects of the structure, process, and outcome dimensions of dental practice. Evidence for interrelationships among elements of these dimensions generally is weak or lacking entirely. If dentistry is to keep apace with other segments of the health care community, efficient methods must be developed to collect valid and reliable data from practice settings that will facilitate the evaluation of the impact of treatments, providers, and organizational arrangements on the oral health status and general welfare of patients.

Relationships between price and two components of quality of dental services.

Failure to account for differences in service attributes can lead to biased estimates and erroneous inferences regarding relationships between price and quality in studies of the dental care delivery system. This study examined relationships between prices of several common dental procedures and two components of the structure and process dimensions used in quality of care assessments. Results from ordinary least squares regression analysis demonstrated a significant positive relationship between price and an index of technical quality for two restorative services provided by general practitioners, even when controlling for market area characteristics. Additional analyses revealed that prices charged by general practitioners for specific services typically were lower on average and demonstrated greater variation than those charged by specialists for the same procedures. These findings highlight the need to consider service differentiation, including quality variation, in empirical studies involving the pricing of dental services.

Relationships among structure, process, and outcome scores derived from evaluations of 300 general dental practices.

Analyses were undertaken to examine relationships among measures of structure, process, and outcome using data obtained during field testing of the Development of Evaluation Methods and Computer Applications in Dentistry (DEMCAD) office assessment instrument in 300 general dental practices. Correlation coefficients between scores for the structure dimension and scores for the process/outcome dimensions were 0.50 and 0.40, respectively, while process and outcome dimension scores were correlated at an even higher level (r = 0.79). Thus the DEMCAD instrument demonstrated a relatively high degree of interrelationship among these three major dimensions compared to other reports in the health care evaluation literature. Additional analyses were conducted to compare relationships between structure and process measures and various components of outcome, and to compare results across different types of practices (urban group, rural and urban nongroup). Correlations between the patient satisfaction component of outcome and scores for the structure/process dimensions were considerably lower than the corresponding correlations involving outcome components other than patient satisfaction. Ordinary least squares regression models demonstrated that structure scores were not significantly related to outcomes when controlling for process and that relationships were quite consistent across practice types.