Leslie P. Zeldin

Barriers to the adoption and implementation of preventive dental services in primary medical care.

OBJECTIVE: To determine the barriers to adopting preventive oral health procedures in medical primary care. METHODS: Medical providers who participated in a Medicaid demonstration in North Carolina completed questionnaires reporting their experiences with providing preventive dental services for children from birth to 3 years of age. Eleven factors were established as possible obstacles to the adoption of an oral health program. After 12 months of participation in the Into the Mouths of Babes training program, providers (N = 231) from 49 pediatric practices and 28 family physician practices reported if any of the 11 factors had been an obstacle to adoption and, if so, whether these obstacles were overcome. Program adoption and implementation, defined as providing all of the services on a regular basis, were predicted by using logistic regression to analyze the responses from providers who reported 1 or more barriers, the number of barriers identified (knowledge, attitudes, and external factors), and the number that were overcome. RESULTS: Program-adoption rates were high, with 70.3% of the participants providing dental services on a routine basis. Attitude and external factors were positively associated with adoption, particularly with difficulty in applying the varnish, integration of the dental procedures into practice, resistance among staff and colleagues, and dentist referral difficulties. From 40.4% to 61.5% of providers overcame these 4 most common barriers. Those who reported external barriers and were unable to overcome them were less likely to provide the services, compared with those providers who reported no barriers (odds ratio: 0.08 [95% confidence interval: 0.01–0.44]). CONCLUSIONS: The number of barriers to adopting preventive dental procedures in primary care medical practices is associated with implementation. A large proportion of these barriers can be overcome, leading to high adoption rates in a short amount of time. The barriers to adoption are similar to those identified in the literature on changing patient care, with the unique aspects of fluoride application to teeth. Interventions to promote preventive dental care in medical settings should rely heavily on empirical literature. Training physicians in preventive dentistry should identify and target potential barriers with information and options for introducing office-based systems to improve the chances of adoption.

Oral Health of Early Head Start Children: A Qualitative Study of Staff, Parents, and Pregnant Women

OBJECTIVES We explored the oral health knowledge, attitudes, and activities of Early Head Start (EHS) staff members, parents, and pregnant women, along with their suggestions related to future oral health educational interventions targeting EHS children. METHODS Nine focus groups were conducted with EHS staff, parents, and pregnant women. Audiotapes of sessions were transcribed and entered into ATLAS.ti 5.0 for coding and analysis. RESULTS Attitudes about the importance of childrens oral health among parents and pregnant women were mixed. Staff members voiced responsibility for childrens oral health but frustration in their inability to communicate effectively with parents. Parents in turn perceived staff criticism regarding how they cared for their childrens oral health. Gaps were noted in the oral health activities of EHS programs. Participants expressed confusion regarding the application of Head Start oral health performance standards to EHS. The need for culturally sensitive, hands-on oral health education was highlighted. CONCLUSIONS Tailored, theory-based interventions are needed to improve communication between EHS staff and families. Clear policies on the application of Head Start oral health performance standards to EHS are warranted. Educational activities should address the needs and suggestions of EHS participants.

Training pediatric health care providers in prevention of dental decay: results from a randomized controlled trial

BackgroundPhysicians report willingness to provide preventive dental care, but optimal methods for their training and support in such procedures are not known. This study aimed to evaluate the effect of three forms of continuing medical education (CME) on provision of preventive dental services to Medicaid-enrolled children by medical personnel in primary care physician offices.MethodsPractice-based, randomized controlled trial. Setting: 1,400 pediatric and family physician practices in North Carolina providing care to an estimated 240,000 Medicaid-eligible children aged 0–3 years. Interventions: Group A practices (n = 39) received didactic training and course materials in oral health screening, referral, counseling and application of fluoride varnish. Group B practices (n = 41) received the same as Group A and were offered weekly conference calls providing advice and support. Group C practices (n = 41) received the same as Group B and were offered in-office visit providing hands-on advice and support. In all groups, physicians were reimbursed

Oral Health Literacy Assessment: development of an oral health literacy instrument for Spanish speakers

38–

Oral Health Activities of Early Head Start and Migrant and Seasonal Head Start Programs

43 per preventive dental visit. Outcome measures were computed from reimbursement claims submitted to NC Division of Medical Assistance. Primary outcome measure: rate of preventive dental services provision per 100 well-child visits. Secondary outcome measure: % of practices providing 20 or more preventive dental visits.Results121 practices were randomized, and 107 provided data for analysis. Only one half of Group B and C practices took part in conference calls or in-office visits. Using intention-to-treat analysis, rates of preventive dental visits did not differ significantly among CME groups: GroupA = 9.4, GroupB = 12.9 and GroupC = 8.5 (P = 0.32). Twenty or more preventive dental visits were provided by 38–49% of practices in the three study groups (P = 0.64).ConclusionA relatively high proportion of medical practices appear capable of adopting these preventive dental services within a one year period regardless of the methods used to train primary health care providers.Trial RegistrationClinicalTrials.gov NCT00464009

Framing young childrens oral health: a participatory action research project

OBJECTIVE To develop an oral health literacy instrument for Spanish-speaking adults, evaluate its psychometric properties, and determine its comparability to an English version. METHODS The Oral Health Literacy Assessment in Spanish (OHLA-S) and English (OHLA-E) are designed with a word recognition section and a comprehension section using the multiple-choice format developed by an expert panel. Validation of OHLA-S and OHLA-E involved comparing the instrument with other health literacy instruments in a sample of 201 Spanish-speaking and 204 English-speaking subjects. Comparability between Spanish and English versions was assessed by testing for differential item functioning (DIF) using item response theory. RESULTS We considered three OHLA-S scoring systems. Based on validity and reliability comparisons, 24 items were retained in the OHLA-S instrument. OHLA-S was correlated with another health literacy instrument, Spanish Test of Functional Health Literacy in Adults (P < 0.05). Significant correlations were also found between OHLA-S and years of schooling, oral health knowledge, overall health, and an understanding of written health-care materials (P < 0.05). OHLA-S displayed satisfactory reliability with a Cronbach Alpha of 0.70-0.80. DIF results suggested that OHLA-S and OHLA-E scores were not comparable at a given level of oral health literacy. CONCLUSIONS OHLA-S has acceptable reliability and validity. OHLA-S and OHLA-E are two different measurement tools and should not be used to compare oral health literacy between English- and Spanish-speaking populations.

Exploring the genomic basis of early childhood caries: a pilot study

Guidelines recommend that Migrant and Seasonal Head Start programs (MSHS) address the dental needs of children of migrant and seasonal farmworkers. This study describes parent- and child-oriented oral health activities of North Carolina’s MSHS programs and compares them with non-migrant Early Head Start (EHS) programs using data collected from a questionnaire completed by teachers and family services staff. Migrant and Seasonal Head Start staff reported engaging in more oral health activities than EHS staff, which was confirmed by results of logit and ordered logit regression models. Despite promising findings about the engagement of MSHS staff, participation in oral health activities is lower than recommended. Differences between EHS and MSHS programs might be due to differing needs of enrolled children and families or to different approaches to meeting the needs of families.

Dental Care for Pregnant Women

Background and Objectives Despite the widespread acknowledgement of the importance of childhood oral health, little progress has been made in preventing early childhood caries. Limited information exists regarding specific daily-life and community-related factors that impede optimal oral hygiene, diet, care, and ultimately oral health for children. We sought to understand what parents of young children consider important and potentially modifiable factors and resources influencing their children’s oral health, within the contexts of the family and the community. Methods This qualitative study employed Photovoice among 10 English-speaking parents of infants and toddlers who were clients of an urban WIC clinic in North Carolina. The primary research question was: “What do you consider as important behaviors, as well as family and community resources to prevent cavities among young children?” Five group sessions were conducted and they were recorded, transcribed verbatim and analyzed using qualitative research methodology. Inductive analyses were based on analytical summaries, double-coding, and summary matrices and were done using Atlas.ti.7.5.9 software. Findings Good oral health was associated with avoidance of problems or restorations for the participants. Financial constraints affected healthy food and beverage choices, as well as access to oral health care. Time constraints and occasional frustration related to children’s oral hygiene emerged as additional barriers. Establishment of rules/routines and commitment to them was a successful strategy to promote their children’s oral health, as well as modeling of older siblings, cooperation among caregivers and peer support. Community programs and organizations, social hubs including playgrounds, grocery stores and social media emerged as promising avenues for gaining support and sharing resources. Conclusions Low-income parents of young children are faced with daily life struggles that interfere with oral health and care. Financial constraints are pervasive, but parents identified several strategies involving home care and community agents that can be helpful. Future interventions aimed to improve children’s oral health must take into consideration the role of families and the communities in which they live.

Oral health activities of Early Head Start teachers directed toward children and parents

Objective A genetic component in early childhood caries (ECC) is theorized, but no genome‐wide investigations of ECC have been conducted. This pilot study is part of a long‐term research program aimed to: (1) determine the proportion of ECC variance attributable to the human genome and (2) identify ECC‐associated genetic loci. Methods The studys community‐based sample comprised 212 children (mean age=39 months; range = 30–52 months; males = 55%; Hispanic/Latino = 35%, African‐American = 32%; American Academy of Pediatric Dentistry definition of ECC prevalence = 38%). Approximately 2.4 million single nucleotide polymorphisms (SNPs) were genotyped using DNA purified from saliva. A P < 5 × 10−8 criterion was used for genome‐wide significance. SNPs with P < 5 × 10−5 were followed‐up in three independent cohorts of 921 preschool‐age children with similar ECC prevalence. Results SNPs with minor allele frequency ≥5% explained 52% (standard error = 54%) of ECC variance (one‐sided P = 0.03). Unsurprisingly, given the pilots small sample size, no genome‐wide significant associations were found. An intergenic locus on 4q32 (rs4690994) displayed the strongest association with ECC [P = 2.3 × 10−6; odds ratio (OR) = 3.5; 95% confidence interval (CI) = 2.1–5.9]. Thirteen loci with suggestive associations were followed‐up – none showed evidence of association in the replication samples. Conclusion This studys findings support a heritable component of ECC and demonstrate the feasibility of conducting genomics studies among preschool‐age children.