Michelle M. Henshaw

Dental Caries of Refugee Children Compared With US Children

Objective. Dental care is a major unmet health need of refugee children. Many refugee children have never received oral health care or been exposed to common preventive oral health measures, such as a toothbrush, fluoridated toothpaste, or fluoridated water. Oral health problems among refugee children are most likely to be detected first by pediatricians and family practitioners. Given the increased influx of refugees into the United States, particularly children, it is important for the pediatric community to be aware of potential oral health problems among refugee children and be able to make referrals for treatment and recommendations for the prevention of future oral diseases. The purpose of this study was to describe the prevalence of caries experience and untreated decay among newly arrived refugee children stratified by their region of origin and compared with US children. Methods. Oral health assessments were conducted within 1 month of arrival to the United States as part of the Refugee Health Assessment Program of the Massachusetts Department of Public Health. The outcome variables include caries experience and untreated decay. Caries experience is determined by the presence of an untreated caries lesion, a restoration, or a permanent molar tooth that is missing because it has been extracted as a result of dental caries. Untreated caries is detected when 0.5 mm of tooth structure is lost and there is brown coloration of the walls of the cavity. Comparisons of the refugee children with US children in Third National Health and Nutrition Examination Survey data were made using χ2 test of independence and multiple logistic regression. Results. Oral health screenings were performed on 224 newly arrived refugees who ranged in age from 6 months to 18 years and had a mean age of 10.6 years (SD: 4.82; median: 10.7 years). African refugees represented 53.6%, with the majority from Somalia, Liberia, and Sudan. Eastern European refugees composed 26.8% of the study sample. The remaining 19.6% come from a number of countries, such as Afghanistan, Pakistan, and the Middle East. Refugee children had 51.3% caries experience and 48.7% with untreated decay. Caries experience in refugees varied by region of origin, with 38% from Africa exhibiting a history of caries compared with 79.7% of Eastern Europeans. The highest proportion of children with no obvious dental problems was from Africa (40.5%) compared with 16.9% from Eastern Europe. US children had caries experience similar to that of refugees (49.3%) but significantly lower risk of untreated decay (22.8%). Comparisons between refugee children and US children found significant differences for treatment urgency, untreated caries, extent of dental caries, and presence of oral pain. White refugee children, primarily from Eastern Europe, were 2.8 times as likely to have caries experience compared with white US children, with 9.4 times the risk of untreated decay compared with white US children. In contrast, African refugee children were only half as likely to have caries experience compared with white US children (95% confidence interval: 0.3-0.7) and African American children (95% confidence interval: 0.3-0.7). However, African refugee children were similar to African American children in risk of untreated decay (odds ratio: 0.94). Conclusion. African refugee children had significantly lower dental caries experience as well as fewer untreated caries as compared with similarly aged Eastern European refugee children. They were also less likely to have ever been to a dentist. Possible reasons for these findings may include differences in exposure to natural fluoride in the drinking water, dietary differences, access to professional care, and cultural beliefs and practices. The prevalence of caries experience and untreated caries differed significantly between refugee children and US children. These differences varied significantly by race. When refugee children were compared with US children, the African refugee children had only half the caries experience of either white or African American children. However, African refugee children had similar likelihood of having untreated caries as compared with African American children, despite that very few African children had previous access to professional dental care. These findings are consistent with previous studies on health disparities in the United States. White refugee children, primarily from Eastern Europe, were also 3 times as likely to have caries experience compared with either white or African American children and were 9.4 times as likely to have untreated caries as white US children. Refugee children are more likely to establish primary medical care before seeking dental treatment. With the limited access to dental care among refugees, pediatricians should be particularly alert to the risk of oral diseases among refugee children.

Recruitment for Health Disparities Preventive Intervention Trials: The Early Childhood Caries Collaborating Centers

Background Four trials of interventions designed to prevent early childhood caries are using community-engagement strategies to improve recruitment of low-income, racial/ethnic minority participants. The trials are being implemented by 3 centers funded by the National Institute of Dental and Craniofacial Research and known as the Early Childhood Caries Collaborating Centers (EC4): the Center for Native Oral Health Research at the University of Colorado, the Center to Address Disparities in Children’s Oral Health at the University of California San Francisco, and the Center for Research to Evaluate and Eliminate Dental Disparities at Boston University. Community Context The community contexts for the EC4 trials include urban public housing developments, Hispanic communities near the US–Mexican border, and rural American Indian reservations. These communities have a high prevalence of early childhood caries, suggesting the need for effective, culturally acceptable interventions. Methods Each center’s intervention(s) used community-based participatory research approaches, identified community partners, engaged the community through various means, and developed communication strategies to enhance recruitment. Outcome All 3 centers have completed recruitment. Each center implemented several new strategies and approaches to enhance recruitment efforts, such as introducing new communication techniques, using media such as radio and newspapers to spread awareness about the studies, and hosting community gatherings. Interpretation Using multiple strategies that build trust in the community, are sensitive to cultural norms, and are adaptable to the community environment can enhance recruitment in underserved communities.

Healthy Eating Index Is a Predictor of Early Childhood Caries

Early childhood caries (ECC) is a preventable form of dental caries that affects very young children, particularly among low-income families and certain racial/ethnic minorities. The current study examined the relationship of dietary quality, as measured by the Healthy Eating Index (HEI), to the prevalence of ECC in 2- to 5-year-old children. Data from the Third National Health and Nutrition Examination Survey (NHANES III) were used for the study. We used logistic regression to compute adjusted odds ratios (OR) for ECC and 95% confidence intervals (CI). Children with the best dietary practices (uppermost tertile of the HEI) were 44% less likely to exhibit severe ECC compared with children with the worst dietary practices (lowest tertile of the HEI). A healthy eating pattern geared for promotion of optimal child development and prevention of chronic disease in later life may also reduce the risk of early childhood caries, particularly severe early childhood caries.

Multicultural Issues in Oral Health

Demographic changes over the coming decades will heighten the challenges to both the dental profession and the nation. The expected growth in the numbers of racial and ethnic minorities and the concomitant growth of immigrant populations are likely to lead to worsening of oral health disparities. Their consequences are becoming increasingly evident, as the profession strives to improve the oral health of all Americans. The increasing diversity of the population, together with the importance of cultural beliefs and behaviors that affect health outcomes, will require ways to enhance provider-patient communications and oral health literacy. One important means by which to promote oral health in diverse populations is to develop a dental workforce that is both culturally and linguistically competent, as well as one that is as culturally diverse as the American population.

The Impact of Functional Health Literacy and Acculturation on the Oral Health Status of Somali Refugees Living in Massachusetts

OBJECTIVES We assessed the impact of health literacy and acculturation on oral health status of Somali refugees in Massachusetts. METHODS Between December 2009 and June 2011, we surveyed 439 adult Somalis who had lived in the United States 10 years or less. Assessments included oral examinations with decayed, missing, and filled teeth (DMFT) counts and measurement of spoken English and health literacy. We tested associations with generalized linear regression models. RESULTS Participants had means of 1.4 decayed, 2.8 missing, and 1.3 filled teeth. Among participants who had been in the United States 0 to 4 years, lower health literacy scores correlated with lower DMFT (rate ratio [RR] = 0.78; P = .016). Among participants who had been in the country 5 to 10 years, lower literacy scores correlated with higher DMFT (RR = 1.37; P = .012). Literacy was not significantly associated with decayed teeth. Lower literacy scores correlated marginally with lower risk of periodontal disease (odds ratio = 0.22; P = .047). CONCLUSIONS Worsening oral health of Somali refugees over time may be linked to less access to preventive care and less utilization of beneficial oral hygiene practices.

Oral Health and Interprofessional Collaborative Practice: Examples of the Team Approach to Geriatric Care.

Oral health for the older adult patient is vital for function, comfort, and communication and is a critical component of overall health. Oral diseases such as dental caries, periodontal disease, and oral cancer may lead to pain, functional limitations, and decreased quality of life. Optimal oral health outcomes are often owing to effective interprofessional collaboration between and among health care providers, in conjunction with patient family members and caregivers. This article highlights 2 cases illustrating how interprofessional team dynamics can affect patient outcomes.

The basic research factors questionnaire for studying early childhood caries

BackgroundWe describe development of the Early Childhood Caries (ECC) Basic Research Factors Questionnaire (BRFQ), a battery of measures assessing common potential predictors, mediators, and moderators of ECC. Individual-, family-, and community-level factors that are linked to oral health outcomes across at-risk populations are included. Developing standard measures of factors implicated in ECC has the potential to enhance our ability to understand mechanisms underlying successful prevention and to develop more effective interventions.MethodsThe Early Childhood Caries Collaborating Centers (EC4), funded by National Institute of Dental and Craniofacial Research, developed the BRFQ, which was used across four randomized trials to develop and test interventions for reducing ECC in at-risk populations. Forty-five investigators from across the centers and NIDCR were involved in the development process. Eight “measures working groups” identified relevant constructs and effective measurement approaches, which were then categorized as “essential” or “optional” common data elements (CDEs) for the EC4 projects.ResultsEssential CDEs include 88 items, with an additional 177 measures categorized as optional CDEs. Essential CDEs fell under the following domains: oral health knowledge, oral health behavior, utilization/insurance and cost, parent/caregiver dental self-efficacy, quality of life, caregiver and family characteristics, and child characteristics.ConclusionsThe BRFQ makes available a battery of measures that support efforts to understand population risk factors for ECC and to compare oral health outcomes across populations at risk. The BRFQ development process may be useful to other clinical research networks and consortia developing CDEs in other health research fields.Trial registrationAll the trial that used the BRFQ were registered at Clinicaltrial.gov NCT01116726, April 29, 2010; NCT01116739, May 3, 2010; NCT01129440, May 21, 2010; and NCT01205971, September 19, 2010.

Oral microbiota of children in a school-based dental clinic

OBJECTIVES Dental caries disproportionately affects disadvantaged subjects. This study hypothesized that there were greater caries extent and higher levels of caries-associated and anaerobic subgingival bacterial species in oral samples of Hispanic and immigrant children compared with non-Hispanic and US born children. METHODS Children from a school-based dental clinic serving a community with a large Hispanic component were examined, and the extent of caries was recorded. Microbial samples were taken from teeth and the tongues of children. Samples were analyzed using DNA probes to 18 oral bacterial species. RESULTS Seventy five children were examined. Extent of caries increased with child age in immigrant, but not in US born or Hispanic children. There were no differences in the microbiota based on ethnicity or whether the child was born in US or not. There was a higher species detection frequency from teeth than tongue samples. Levels of Streptococcus mutans and other Streptococcus spp increased with caries extent. Prevotella intermedia, Tannerella forsythia and Selenomonas spp were detected at low levels in these children. CONCLUSIONS We conclude that, while there was a high rate of dental caries in disadvantaged school children, there were no differences in the caries-associated microbiota, including S. mutans, based on ethnicity or immigration status. Furthermore, while anaerobic subgingival, periodontal pathogens were also detected in children, there was no difference in species detection based on ethnicity or immigration status. Increased levels of streptococci, including S. mutans, however, were detected with high caries levels. This suggested that while it is beneficial to target preventive and treatment programs to disadvantaged populations, there is likely no additional benefit to focus on subgroups within a population already at high risk for dental disease.

Oral cancer and precancer screening studies have high discriminatory ability

Objective Systematic review and meta-analysis of the performance of screening measures for oral cancer and precancer.Data sources PubMed (Medline), SCISEARCH and the Cochrane Library up to December 2000, hand-searching of relevant journals, and discussions with relevant authors.Study selection Prospective field studies which related specifically to validation of oral cancer or precancer screening using at least a ‘soft’ gold-standard. Studies estimating parameters of screening performance, response to screening invitation and compliance in follow-up.Data extraction and synthesis Global estimates for sensitivity and specificity were obtained from the selected studies using the summary receiver operator characteristic (SROC) curve meta-analytical technique.Results Six studies were included, and weighted pooled averages for sensitivity, specificity and likelihood ratios were calculated (See Table 1).Conclusions There was considerable heterogeneity with respect to location, population and screening personnel in the studies but this had only a moderate effect on sensitivity and specificity. The discriminatory ability demonstrated by the screening personnel, irrespective of their grade and training, was generally of a fairly high order.

Randomized Trial of Motivational Interviewing to Prevent Early Childhood Caries in Public Housing

Introduction: Caries experience among preschool-age children has remained relatively unchanged for the past 2 decades, despite recently documented decreases in untreated decay. Objectives: In a community-based cluster-randomized controlled trial, a motivational interviewing (MI) intervention administered to primary caregivers was hypothesized to reduce caries increment over 2 y as compared with controls, among children aged 0 to 5 y at baseline living in public housing. Methods: Public housing residents, who served as interventionists, were trained in MI with a focus on early childhood caries prevention. All 26 eligible public housing developments were randomized to either control (quarterly clinical examinations, fluoride varnish applications, toothbrush/toothpaste, and educational brochures) or intervention (same procedures as control plus MI counseling). Quarterly MI sessions were delivered in English or Spanish over 2 y, audio recorded, and assessed for treatment fidelity. The primary outcome was the increment in dmfs (decayed, missing, and filled tooth surfaces) as assessed by clinical examination at baseline, 12 mo, and 24 mo. Secondary outcomes included caregiver oral health knowledge and child oral health behaviors (child toothbrushing and sugar-sweetened beverage intake). Baseline characteristics were compared between groups and adjusted for housing-site clusters. Longitudinal outcomes were analyzed with mixed models. Results: A total of 1,065 children (49% female, 55% non-White, 61% Hispanic, 89% below poverty level, n = 686 control) and their caregivers were enrolled. During 2 y of follow-up, the mean dmfs increment increased in both groups; however, there were no statistically significant group differences at 24 mo or group × time interactions. The mean increase in intervention caregivers’ knowledge was significantly greater than that of control, F(2, 1,593) = 3.48, P = 0.0310, but there were no significant intervention effects on caregiver-reported child sugar-sweetened beverage intake or child toothbrushing. Conclusion: MI counseling plus intensive caries prevention activities resulted in knowledge increases but did not improve oral health behaviors or caries increment (ClinicalTrials.gov NCT01205971). Knowledge Transfer Statement: When viewed in light of the findings from the companion Pine Ridge study and other recent MI studies, the results of this study suggest that when the complex disease of early childhood caries is addressed in high-risk populations, MI is not effective, and alternative approaches are warranted.