Charlotte W. Lewis

Unmet dental care needs among children with special health care needs: implications for the medical home.

Background. Little is known about the characteristics of children with special health care needs (CSHCN) who have unmet dental care needs. Objective. We sought to describe the magnitude of unmet needs for dental care among CSHCN and to characterize those with unmet dental care needs. Design, Setting, and Subjects. We used data from the National Survey of Children with Special Health Care Needs, which used a telephone survey to identify 750 CSHCN from each of the 50 states and the District of Columbia. Families of 38 866 CSHCN were interviewed, and the data were weighted to represent 9.32 million CSHCN nationally. Outcome. Our primary outcome of interest was unmet dental care need, defined as whether CSHCN were said to have needed dental care but were unable to obtain it. We also considered reasons why a child had an unmet dental care need and compared other categories of health care service needs and unmet needs with dental care. Bivariate and multivariate analyses were conducted to determine factors associated with unmet dental care needs. Results. Overall, 78% of CSHCN were reported as needing dental care in the past 12 months, which was second only to prescription medications in the frequency of need. Of those who reported a dental care need, an estimated 755 581 or 10.4% of CSHCN did not receive all of the dental care they needed. Relative to all other health care service categories, unmet dental care needs affected the most children. Poorer children, uninsured children, children with lapses in insurance, and children with greater limitations attributable to disability had significantly greater odds of unmet dental care needs in multivariate analyses. Children with a personal doctor or nurse were significantly less likely to have unmet dental care needs. Conclusions. Dental care is the most prevalent unmet health care need for CSHCN, affecting substantially more children than any other health care need category. Moreover, the perceived need for dental care for CSHCN exceeds the need for either preventive or specialty medical care. Given these findings, dental care should be an integral and explicitly stated part of the comprehensive coordinated services that the medical home aims to provide for CSHCN. Greater efforts to improve access to dental care for poor and more disabled CSHCN are needed.

Furlow palatoplasty for management of velopharyngeal insufficiency: a prospective study of 148 consecutive patients.

Background: The objectives of the study were to describe speech outcomes in a large series of patients undergoing Furlow palatoplasty for management of velopharyngeal insufficiency and to test whether preoperative velopharyngeal gap size and other patient characteristics significantly affect those outcomes. Methods: Data collected included age at the time of surgery, surgeon, type of cleft, syndrome diagnosis, preoperative velopharyngeal gap size as determined by videonasendoscopy, and preoperative and postoperative perceptual speech assessments. Descriptive statistics were generated and ordinal logistic regression on the outcome variable, postoperative velopharyngeal insufficiency severity score, was performed. Results: In this series of 154 patients, 148 had complete perceptual speech data. Of these 148 patients, 72 percent had improvement in velopharyngeal insufficiency severity after the procedure and 56 percent had complete resolution of velopharyngeal insufficiency. Postoperative insufficiency was scored as none or minimal (i.e., resolution) in 38 of 52 patients (73 percent) with a small preoperative velopharyngeal gap, 26 of 51 patients (51 percent) with a moderate preoperative gap, and four of 21 patients (19 percent) with a large preoperative gap. Preoperative velopharyngeal gap size was significantly associated (p < 0.0001) with postoperative insufficiency on ordinal multivariate logistic regression after controlling for preoperative insufficiency and other covariates. There was not a significant association between syndrome diagnosis, age at Furlow palatoplasty (younger than 5 years versus older), gender, surgeon, or presence of submucous cleft palate and postoperative speech outcome, in either the unadjusted or adjusted analyses. Conclusions: Preoperative velopharyngeal gap size, as determined with nasendoscopy, was significantly associated with postoperative velopharyngeal insufficiency severity after Furlow palatoplasty. Small gap size is associated with a greater likelihood of resolution.

Dental Care and Children with Special Health Care Needs: A Population-Based Perspective

This paper grew out of a project reviewing progress in childrens 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.

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.

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 childrens 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 “birds-eye view” provided by NE has a stronger correlation with VPI severity than MVF.

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 Childrens Health to (1) describe the proportion of US children with ≥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 Childrens Health includes data from 102353 children, weighted to represent 72.7 million children, nationally. Our outcome of interest was ≥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 ≥200% of the federal poverty level, there is a greater likelihood that near-poor children will receive preventive dental care.

Recent Epidemiology of Pediatric Cochlear Implantation in the United States: Disparity Among Children of Different Ethnicity and Socioeconomic Status†

Objectives/Hypothesis: Congenital severe to profound sensorineural hearing loss (SNHL) is found in higher proportions of children with minority and/or lower socioeconomic status (SES). Cochlear implants were approved by the U.S. Food and Drug Administration for use in children with bilateral severe to profound SNHL in 1990. The objectives of the study were as follows: 1) to study the epidemiology of pediatric cochlear implantation, assessing whether cochlear implant technology is provided to children with severe to profound SNHL in proportion to their racial/ethnic or SES, and 2) to compare data provided by a national health care database with data provided by cochlear implant manufacturers.

Toothache in US Children

OBJECTIVES To describe the prevalence of and risk factors for recent toothache among US children and to estimate frequency of contact between children with toothache and their pediatric primary care providers (PPCP). DESIGN Cross-sectional analysis of nationally representative data. SETTING The 2007 National Survey of Childrens Health. PARTICIPANTS Population-based sample of parents/guardians of 86 730 children aged 1 through 17 years from 50 states and the District of Columbia. OUTCOME MEASURE Parent-reported toothache in the last 6 months. RESULTS A total of 10.7% of US children and 14% of children aged 6 to 12 years experienced toothache in the last 6 months. Poor and low-income minority children and those with special needs were significantly more likely to have had a toothache on multivariable analysis. Most children with toothache in the last 6 months had their own physician (88.9%) and had a preventive medical visit in the last year (88.1%), pointing to opportunities for PPCP to identify and intervene with children who have untreated dental decay and toothache. CONCLUSIONS Toothache is not the universal experience it was before the advent of modern dentistry. Nevertheless, a substantial number of US children recently had a toothache, with noteworthy variability between states. There are opportunities for PPCP to address oral health prevention, assess for dental decay and toothache, and treat complications. We propose toothache as a potential quality indicator reflecting disparities in oral health for a population.

A New Oral Health Elective for Medical Students at the University of Washington

Background: Oral health is an important but inadequately addressed area in medical school curricula. Primary care practitioners are in an ideal position to help prevent oral disease but lack the knowledge to do so. Purposes: We developed an oral health elective that targeted 1st- and 2nd-year medical students as part of a previously described oral health initiative and oral health curriculum. Methods: To promote interprofessional collaboration, we utilized medical–dental faculty teams for lectures and hands-on peer instruction by dental students for clinical skills. Results: Evaluations revealed positive shifts in attitudes toward oral health and significant gains in oral health knowledge and self-confidence. Students rated the course highly and advocated for further integration of oral health into required medical curricula. Conclusions: We describe the elective including curriculum development, course evaluation results, and steps for implementing a successful oral health elective into medical education. We highlight interprofessional collaboration and constituency building among medical and dental faculty and administrators.

Fluoride Varnish Use in Primary Care: What Do Providers Think?

Objective. A number of state Medicaid programs, including Washington, reimburse pediatricians and other pediatric health care providers to apply fluoride varnish, a caries preventive agent, to eligible patients’ teeth. Little is known about the factors that encourage or impede diffusion of fluoride varnish into primary care physicians’ (PCPs’) offices. The objective of this study was to perform an in-depth case study of fluoride varnish diffusion in 12 pediatric, family medicine, and nurse practitioner offices that underwent fluoride varnish training. Methods. We conducted focus groups with providers and staff in 12 community-based medical practices that had undergone fluoride varnish training within the previous 18 months. Topics of discussion included how the office staff learned about and sought fluoride varnish training, the perceived role of PCPs in oral health, oral health problems within the practice, specific details about the training, and organizational and logistic factors that promoted or impeded adoption. Focus groups were audiotaped and professionally transcribed; content analyses of the transcripts were conducted by the 3 authors. Results. Three major themes emerged about the fluoride varnish diffusion process; these were preexisting factors, communication, and logistics. Within preexisting factors, PCPs learned about fluoride varnish through their involvement in public health-related activities and were influenced to participate in the training by their concerns for their patients’ oral health and difficulty gaining access to professional dental care. Among communication factors identified as important were qualities of the training session and the communication that occurred within the practice about fluoride varnish. When staff were included in the fluoride varnish decision-making and planning process, the practice was more likely to be successful in implementing fluoride varnish. Logistic factors included systems used to identify and capture eligible patients for fluoride varnish application. Other important logistic factors that were considered included division of labor and timing of the fluoride varnish application during the visit. Access to dental care was a persistent theme throughout the focus group discussions that had an impact on the other 3 major themes. Conclusions. Fluoride varnish can be adopted successfully into medical practice given PCP and staff commitment and openness, training that leaves participants motivated, appropriate systems, and resources for professional dental care referral. In addition, PCP involvement with fluoride varnish provided opportunities to discuss preventive oral health with families. Specific recommendations to encourage fluoride varnish diffusion in other settings are offered for program planners and PCP offices.