R. Gary Rozier

Parental perceptions of children's oral health: The Early Childhood Oral Health Impact Scale (ECOHIS)

BackgroundDental disease and treatment experience can negatively affect the oral health related quality of life (OHRQL) of preschool aged children and their caregivers. Currently no valid and reliable instrument is available to measure these negative influences in very young children. The objective of this research was to develop the Early Childhood Oral Health Impact Scale (ECOHIS) to measure the OHRQL of preschool children and their families.MethodsTwenty-two health professionals evaluated a pool of 45 items that assess the impact of oral health problems on 6-14-year-old children and their families. The health professionals identified 36 items as relevant to preschool children. Thirty parents rated the importance of these 36 items to preschool children; 13 (9 child and 4 family) items were considered important. The 13-item ECOHIS was administered to 295 parents of 5-year-old children to assess construct validity and internal consistency reliability (using Cronbachs alpha). Test-retest reliability was evaluated among another sample of parents (N = 46) using the intraclass correlation coefficient (ICC).ResultsECOHIS scores on the child and parent sections indicating worse quality of life were significantly associated with fair or poor parental ratings of their childs general and oral health, and the presence of dental disease in the child. Cronbachs alphas for the child and family sections were 0.91 and 0.95 respectively, and the ICC for test-retest reliability was 0.84.ConclusionThe ECOHIS performed well in assessing OHRQL among children and their families. Studies in other populations are needed to further establish the instruments technical properties.

Problems With Access to Dental Care for Medicaid-Insured Children: What Caregivers Think

OBJECTIVES This study aimed to gain insight into the experiences, attitudes, and perceptions of a racially and ethnically diverse group of caregivers regarding barriers to dental care for their Medicaid-insured children. METHODS Criterion-purposive sampling was used to select participants for 11 focus groups, which were conducted in North Carolina. Seventy-seven caregivers of diverse ethnic and racial backgrounds participated. Full recordings of sessions were obtained and transcribed. A comprehensive content review of all data, including line-by-line analysis, was conducted. RESULTS Negative experiences with the dental care system discouraged many caregivers in the focus groups from obtaining dental services for their Medicaid-insured children. Searching for providers, arranging an appointment where choices were severely limited, and finding transportation left caregivers describing themselves as discouraged and exhausted. Caregivers who successfully negotiated these barriers felt that they encountered additional barriers in the dental care setting, including long waiting times and judgmental, disrespectful, and discriminatory behavior from staff and providers because of their race and public assistance status. CONCLUSIONS Current proposals to solve the dental access problem probably will be insufficient until barriers identified by caregivers are addressed.

Comorbidity and survival of elderly head and neck carcinoma patients

Alcohol and tobacco, the primary etiologic agents for head and neck carcinoma (HNCA), cause other chronic diseases and may contribute to the high prevalence of comorbid conditions and generally poor survival of persons with HNCA.

Effect of crown margins on periodontal conditions in regularly attending patients

Subgingival margins of cast restorations have been associated with increased gingival inflammation and probing depth, but it is not known if such effects would be seen among patients receiving regular professional care. In this study, 831 regularly attending patients in 35 North Carolina dental practices were examined. Plaque, gingival inflammation, calculus, and probing depth were assessed on facial and mesiofacial surfaces of the Ramfjord teeth. Surface-specific analyses showed significantly greater (p less than 0.05) gingival inflammation and deeper probing depths with subgingival cast restoration margins for nearly all surfaces examined. Less frequently, decreases in plaque and calculus were associated with the presence of crowns. Intact surfaces in patients with cast restorations were not significantly different from the same surfaces in patients without cast restorations. Even among patients receiving regular preventive dental care, subgingival margins are associated with unfavorable periodontal reactions.

Effectiveness of Preventive Dental Treatments by Physicians for Young Medicaid Enrollees

OBJECTIVE: To estimate the effectiveness of a medical office–based preventive dental program (Into the Mouths of Babes [IMB]), which included fluoride varnish application, in reducing treatments related to dental caries. METHODS: We used longitudinal claims and enrollment data for all children aged 72 months or younger enrolled in North Carolina Medicaid from 2000 through 2006. Regression analyses compared subgroups of children who received up to 6 IMB visits at ages 6 to 35 months with children who received no IMB visits. Analyses were adjusted for child and area characteristics. RESULTS: Children enrolled in North Carolina Medicaid with ≥4 IMB visits experienced, on average, a 17% reduction in dental-caries–related treatments up to 6 years of age compared with children with no IMB visits. When we simulated data for initial IMB visits at 12 and 15 months of age, there was a cumulative 49% reduction in caries-related treatments at 17 months of age. The cumulative effectiveness declined because of an increase in treatments from 24 to 36 months, an increase in referrals for dental caries occurred with increasing time since fluoride application, and emergence of teeth not initially treated with fluoride. CONCLUSIONS: North Carolinas IMB program was effective in reducing caries-related treatments for children with ≥4 IMB visits. Multiple applications of fluoride at the time of primary tooth emergence seem to be most beneficial. Referrals to dentists for treatment of existing disease detected by physicians during IMB implementation limited the cumulative reductions in caries-related treatments, but also contributed to improved oral health.

Short Assessment of Health Literacy—Spanish and English: A Comparable Test of Health Literacy for Spanish and English Speakers

OBJECTIVE The intent of the study was to develop and validate a comparable health literacy test for Spanish-speaking and English-speaking populations. STUDY DESIGN The design of the instrument, named the Short Assessment of Health Literacy-Spanish and English (SAHL-S&E), combined a word recognition test, as appearing in the Rapid Estimate of Adult Literacy in Medicine (REALM), and a comprehension test using multiple-choice questions designed by an expert panel. We used the item response theory (IRT) in developing and validating the instrument. DATA COLLECTION Validation of SAHL-S&E involved testing and comparing the instrument with other health literacy instruments in a sample of 201 Spanish-speaking and 202 English-speaking subjects recruited from the Ambulatory Care Center at the University of North Carolina Healthcare System. PRINCIPAL FINDINGS Based on IRT analysis, 18 items were retained in the comparable test. The Spanish version of the test, SAHL-S, was highly correlated with other Spanish health literacy instruments, Short Assessment of Health Literacy for Spanish-Speaking Adults (r=0.88, p<.05) and the Spanish Test of Functional Health Literacy in Adults (TOFHLA) (r=0.62, p<.05). The English version, SAHL-E, had high correlations with REALM (r=0.94, p<.05) and the English TOFHLA (r=0.68, p<.05). Significant correlations were found between SAHL-S&E and years of schooling in both Spanish- and English-speaking samples (r=0.15 and 0.39, respectively). SAHL-S&E displayed satisfactory reliability of 0.80 and 0.89 in the Spanish- and English-speaking samples, respectively. IRT analysis indicated that the SAHL-S&E score was highly reliable for individuals with a low level of health literacy. CONCLUSIONS The new instrument, SAHL-S&E, has good reliability and validity. It is particularly useful for identifying individuals with low health literacy and could be used to screen for low health literacy among Spanish and English speakers.It is hardly news anymore that a significant proportion of adults in the United States have difficulty navigating the health care system and managing personal health issues because of inadequate health literacy or limited “capacity to obtain, process, and understand health information and services needed to make appropriate health decisions” (Seldon, Zorn, Ratzan, & Parker, 2000). Inadequate health literacy, as a growing body of research has shown, is a risk factor for patients’ difficulties in understand health information and following medical instructions (Cho, Lee, Arozullah, & Crittenden, 2008; Davis et al., 2006; Gazmararian, Williams, Peel, & Baker, 2003; Parker, Ratzan, & Lurie, 2003), poor disease/self-management knowledge (Gazmararian et al., 2003), underuse of preventive services and routine physician and dental visits (Baker et al., 2004; Jones, Lee, & Rozier, 2007; Lindau, Basu, & Leitsch, 2006; Lindau et al., 2002; Rogers, Wallace, & Weiss, 2006; Scott, Gazmararian, Williams, & Baker, 2002), increased hospitalizations and medical costs (Baker et al., 2002; Howard, Gazmararian, & Parker, 2005), and high mortality rates (Sudore et al., 2006). Identifying individuals with inadequate health literacy is difficult because information such as age, educational attainment (i.e., years of schooling), and self-reported literacy skills do not reliably reflect an individual’s health literacy level (Bass, Wilson, Griffith, & Barnett, 2002; Davis, Jackson, George, et al., 1993; Davis, Arnold, Berkel, et al., 1996; Nurss, el-Kebbi, Gallina, et al., 1997). Over the years, several instruments, including the Test of Functional Health Literacy in Adults (TOFHLA), the Rapid Estimate of Adult Literacy in Medicine (REALM), and the Newest Vital Sign (NVS), have been developed to assess health literacy in the U.S. (Davis et al., 1993; Murphy, Davis, Long, Jackson, & Decker, 1993; Parker, Baker, Williams, & Nurss, 1995; Weiss et al., 2005). Most of the instruments, however, have a strong focus on the English-speaking populations and are inappropriate for assessing the health literacy level of Spanish-speakers. In the case of REALM, an attempt to develop a Spanish version failed because of the phonetic structure of the Spanish language (Nurss, Baker, David, Parker, & Williams, 1995).1 Where a Spanish version is available, e.g., TOFHLA-Spanish, the Spanish instrument is usually developed using a rudimentary translation-and-back-translation technique and is not validated psychometrically. A recent study comparing the psychometric properties of the English and Spanish versions of shortened TOFHLA raised a significant concern about their comparability (Aguirre, Ebrahim, & Shea, 2005). Our research team developed an easy-to-use health literacy test, the Short Assessment of Health Literacy for Spanish-speaking Adults (SAHLSA), for Spanish-speakers (Lee, Bender, Ruiz, & Cho, 2006). The SAHLSA contains 50 test items and has good psychometric qualities. It has been adopted in research and clinical practice in the U.S. (Keselman et al., 2007; Rosembla & Tse, 2006) and is being validated for use in Latin American countries (Huaman-Calderon, Quiliano-Terreros, & Vilchez-Roman, 2009). Since the publication of SAHLSA, many users have expressed the need for an English version to allow comparisons of health literacy level between Spanish and English speakers for research and clinical purposes. In this paper, we report our subsequent effort to develop a comparable test for Spanish and English-speakers, named Short Assessment of Health Literacy-Spanish & English or SAHL-S&E, based on the same methods used in developing SAHLSA. The test contains 18 items and is easy to administer. In taking the test, examinees are asked to read aloud each of the 18 medical terms and then associate each term to another word similar in meaning to demonstrate comprehension. The following sections describe the development of the SAHL-S&E, the methods employed to validate the instrument, results of the validation, and recommendations for use of the instrument.

The Relationship of Oral Health Literacy and Self-Efficacy With Oral Health Status and Dental Neglect

OBJECTIVES We examined the associations of oral health literacy (OHL) with oral health status (OHS) and dental neglect (DN), and we explored whether self-efficacy mediated or modified these associations. METHODS We used interview data collected from 1280 female clients of the Special Supplemental Nutrition Program for Women, Infants and Children from 2007 to 2009 as part of the Carolina Oral Health Literacy Project. We measured OHL with a validated word recognition test (REALD-30), and we measured OHS with the self-reported National Health and Nutrition Examination Survey item. Analyses used descriptive, bivariate, and multivariate methods. RESULTS Less than one third of participants rated their OHS as very good or excellent. Higher OHL was associated with better OHS (for a 10-unit REALD increase: multivariate prevalence ratio = 1.29; 95% confidence interval = 1.08, 1.54). OHL was not correlated with DN, but self-efficacy showed a strong negative correlation with DN. Self-efficacy remained significantly associated with DN in a fully adjusted model that included OHL. CONCLUSIONS Increased OHL was associated with better OHS but not with DN. Self-efficacy was a strong correlate of DN and may mediate the effects of literacy on OHS.

Treatment Outcomes and Costs of Dental Sealants Among Children Enrolled in Medicaid

OBJECTIVES This retrospective cohort analysis of children enrolled in the North Carolina Medicaid program compared the likelihood of restorative treatments and associated cumulative Medicaid expenditures for teeth with or without dental sealants. METHODS We assessed the dental experience of the cohort of 15 438 children from 1985 to 1992 on the basis of enrollment and claims files. We conducted regression analyses for outcomes (caries-related services involving the occlusal surface [CRSOs] of permanent first molars) and cumulative expenditures, controlling for characteristics of the child, the treating dentist, and the childs county of residence. RESULTS Overall, 23% of children received at least 1 sealant and 33% at least 1 CRSO. Sealants were effective in preventing CRSOs, although the degree of effectiveness was highest for children with the greater levels of CRSOs before sealant placement. Estimated cumulative Medicaid expenditures indicated expenditure savings from sealants within 2 years of application for children with 2 or more prior CRSOs. CONCLUSIONS Sealant placement was associated with expenditure savings to Medicaid for certain high-risk children, so Medicaid and, more broadly, society will benefit by providing for sealant placement in these children.

Effects of enrollment in medicaid versus the state children's health insurance program on kindergarten children's untreated dental caries.

OBJECTIVES We compared levels of untreated dental caries in children enrolled in public insurance programs with those in nonenrolled children to determine the impact of public dental insurance and the type of plan (Medicaid vs State Childrens Health Insurance Program [SCHIP]) on untreated dental caries in children. METHODS Dental health outcomes were obtained through a calibrated oral screening of kindergarten children (enrolled in the 2000-2001 school year). We obtained eligibility and claims data for children enrolled in Medicaid and SCHIP who were eligible for dental services during 1999 to 2000. We developed logistic regression models to compare childrens likelihood and extent of untreated dental caries according to enrollment. RESULTS Children enrolled in Medicaid or SCHIP were 1.7 times (95% confidence interval [CI] = 1.65, 1.77) more likely to have untreated dental caries than were nonenrolled children. SCHIP-enrolled children were significantly less likely to have untreated dental caries than were Medicaid-enrolled children (odds ratio [OR]=0.74; 95% CI=0.67, 0.82). According to a 2-part regression model, children enrolled in Medicaid or SCHIP have 17% more untreated dental caries than do nonenrolled children, whereas those in SCHIP had 16% fewer untreated dental caries than did those in Medicaid. CONCLUSIONS Untreated tooth decay continues to be a significant problem for children with public insurance coverage. Children who participated in a separate SCHIP program had fewer untreated dental caries than did children enrolled in Medicaid.

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.