Susan A. Fisher-Owens

Influences on Children's Oral Health: A Conceptual Model

OBJECTIVES. Despite marked improvements over the past century, oral health in America is a significant problem: caries is the most common chronic disease of childhood. Much oral health research examines influences primarily in the oral cavity or focuses on a limited number of individual-level factors. The purpose of this article was to present a more encompassing conceptual model of the influences on childrens oral health. METHODS. The conceptual model presented here was derived from the population health and social epidemiology fields, which have moved toward multilevel, holistic approaches to analyze the complex and interactive causes of childrens health problems. It is based on a comprehensive review of major population and oral health literatures. RESULTS. A multilevel conceptual model is described, with the individual, family, and community levels of influence on oral health outcomes. This model incorporates the 5 key domains of determinants of health as identified in the population health literature: genetic and biological factors, the social environment, the physical environment, health behaviors, and dental and medical care. The model recognizes the presence of a complex interplay of causal factors. Last, the model incorporates the aspect of time, recognizing the evolution of oral health diseases (eg, caries) and influences on the child-host over time. CONCLUSIONS. This conceptual model represents a starting point for thinking about childrens oral health. The model incorporates many of the important breakthroughs by social epidemiologists over the past 25 years by including a broad range of genetic, social, and environmental risk factors; multiple pathways by which they operate; a time dimension; the notion of differential susceptibility and resilience; and a multilevel approach. The study of childrens oral health from a global perspective remains largely in its infancy and is poised for additional development. This work can help inform how best to approach and improve childrens oral health.

Assessing a multilevel model of young children's oral health with national survey data.

OBJECTIVES To empirically test a multilevel conceptual model of childrens oral health incorporating 22 domains of childrens oral health across four levels: child, family, neighborhood and state. DATA SOURCE The 2003 National Survey of Childrens Health, a module of the State and Local Area Integrated Telephone Survey conducted by the Centers for Disease Control and Preventions National Center for Health Statistics, is a nationally representative telephone survey of caregivers of children. STUDY DESIGN We examined child-, family-, neighborhood-, and state-level factors influencing parents report of childrens oral health using a multilevel logistic regression model, estimated for 26 736 children ages 1-5 years. PRINCIPAL FINDINGS Factors operating at all four levels were associated with the likelihood that parents rated their childrens oral health as fair or poor, although most significant correlates are represented at the child or family level. Of 22 domains identified in our conceptual model, 15 domains contained factors significantly associated with young childrens oral health. At the state level, access to fluoridated water was significantly associated with favorable oral health for children. CONCLUSIONS Our results suggest that efforts to understand or improve childrens oral health should consider a multilevel approach that goes beyond solely child-level factors.

Giving Policy Some Teeth: Routes To Reducing Disparities In Oral Health

Despite improvements in oral health status and clear links between oral and systemic health, oral health is not accorded the same importance in health care policy as is general health. This review of oral health disparities over the life span documents the results of this inequity. Dental concerns and unmet dental treatment needs, especially among vulnerable populations, are not well addressed in oral health policies. We offer examples of discrepancies between policy and needs and examples of successful interventions that integrate oral health care with informed policy.

An examination of racial/ethnic disparities in children's oral health in the United States

OBJECTIVE To assess the extent factors other than race/ethnicity explain apparent racial/ethnic disparities in childrens oral health and oral health care. METHODS Data were from the 2007 National Survey of Childrens Health, for children 2-17 years (n=82,020). Outcomes included parental reports of childs oral health status, receiving preventive dental care, and delayed dental care/unmet need. Model-based survey-data-analysis examined racial/ethnic disparities, controlling for child, family, and community/state (contextual) factors. RESULTS Unadjusted results show large racial/ethnic oral health disparities. Compared with non-Hispanic White people, Hispanic and non-Hispanic-Black people were markedly more likely to be reported in only fair/poor oral health [odds ratios (ORs) (95% confidence intervals) 4.3 (4.0-4.6), 2.2 (2.0-2.4), respectively], lack preventive care [ORs 1.9 (1.8-2.0), 1.4 (1.3-1.5)], and experience delayed care/unmet need [ORs 1.5 (1.3-1.7), 1.4 (1.3-1.5)]. Adjusting for child, family, and community/state factors reduced racial/ethnic disparities. Adjusted ORs (AORs) for Hispanics and non-Hispanic Blacks attenuated for fair/poor oral health, to 1.6 (1.5-1.8) and 1.2 (1.1-1.4), respectively. Adjustment eliminated disparities for lacking preventive care [AORs 1.0 (0.9-1.1), 1.1 (1.1-1.2)] and in Hispanics for delayed care/unmet need (AOR 1.0). Among non-Hispanic Blacks, adjustment reversed the disparity for delayed care/unmet need [AOR 0.6 (0.6-0.7)]. CONCLUSIONS Racial/ethnic disparities in childrens oral health status and access were attributable largely to socioeconomic and health insurance factors. Efforts to decrease disparities may be more efficacious if targeted at social, economic, and other factors associated with minority racial/ethnic status and may have positive effects on all who share similar social, economic, and cultural characteristics.

Most pregnant women in California do not receive dental care: findings from a population-based study.

Objectives. We examined the prevalence of dental care during pregnancy and reasons for lack of care. Methods. Using a population-based survey of 21,732 postpartum women in California during 2002–2007, we calculated prevalence of dental problems, receipt of care, and reasons for non-receipt of care. We used logistic regression to estimate odds of non-receipt of care by maternal characteristics. Results. Overall, 65% of women had no dental visit during pregnancy; 52% reported a dental problem prenatally, with 62% of those women not receiving care. After adjustment, factors associated with non-receipt of care included non-European American race/ethnicity, lack of a college degree, lack of private prenatal insurance, no first-trimester prenatal insurance coverage, lower income, language other than English spoken at home, and no usual source of pre-pregnancy medical care. The primary reason stated for non-receipt of dental care was lack of perceived need, followed by financial barriers. Conclusions. Most pregnant women in this study received insufficient dental care. Odds were elevated not only among the poorest, least educated mothers, but also among those with moderate incomes or some college education. The need for dental care during pregnancy must be promoted widely among both the public and providers, and financial barriers to dental care should be addressed.

Evidence Suggests There Was Not a “Resurgence” of Kernicterus in the 1990s

BACKGROUND: Although some have suggested that kernicterus disappeared in the United States in the 1970s to 1980s and dramatically reappeared in the 1990s, population-based data to support such a resurgence are lacking. METHODS: We used diagnosis codes on data collection forms from the California Department of Developmental Services (DDS) to identify kernicterus cases among children born from 1988 to 1997. We examined kernicterus mortality trends in the United States from 1979 to 2006 using death certificate data from the National Center for Health Statistics. RESULTS: We identified 25 cases of physician-diagnosed kernicterus. This figure was augmented to reflect estimates of cases lost to infant mortality, yielding incidence estimates of 1 in 200 000 California live births, 1 in 2500 among children who received services from DDS, and 1 in 400 children with cerebral palsy. There was no significant trend in kernicterus incidence from 1988 to 1997 (P = .77). Incidence before and after the 1994 publication of the AAP practice parameter for hyperbilirubinemia in healthy term infants was not significantly different (P = .92). Nationally, there were 3 reported infant deaths from kernicterus in 1994 and 2 or fewer in the other 28 years from 1979 to 2006 (0.28 deaths per million live births): there was no significant increase in kernicterus mortality over this period. CONCLUSION: Data from California do not support a resurgence of kernicterus in the 1990s. Deaths from kernicterus in the United States have remained rare, with no apparent increase during the last 25 years.

Racial Disparity Trends in Children’s Dental Visits: US National Health Interview Survey, 1964–2010

BACKGROUND AND OBJECTIVE: Research that has repeatedly documented marked racial/ethnic disparities in US children’s receipt of dental care at single time points or brief periods has lacked a historical policy perspective, which provides insight into how these disparities have evolved over time. Our objective was to examine the im-pact of national health policies on African American and white children’s receipt of dental care from 1964 to 2010. METHODS: We analyzed data on race and dental care utilization for children aged 2 to 17 years from the 1964, 1976, 1989, 1999, and 2010 National Health Interview Survey. Dependent variables were as follows: child’s receipt of a dental visit in the previous 12 months and child’s history of never having had a dental visit. Primary independent variable was race (African American/white). We calculated sample prevalences, and χ2 tests compared African American/white prevalences by year. We age-standardized estimates to the 2000 US Census. RESULTS: The percentage of African American and white children in the United States without a dental visit in the previous 12 months declined significantly from 52.4% in 1964 to 21.7% in 2010, whereas the percentage of children who had never had a dental visit declined significantly (P < .01) from 33.6% to 10.6%. Pronounced African American/white disparities in children’s dental utilization rates, whereas large and statistically significant in 1964, attenuated and became nonsignificant by 2010. CONCLUSIONS: We demonstrate a dramatic narrowing of African American/white disparities in 2 measures of children’s receipt of dental services from 1964 to 2010. Yet, much more needs to be done before persistent racial disparities in children’s oral health status are eliminated.

The complexities of home visitation for children with asthma in underserved communities

To the Editor The recent article by Postma et al. (1) raised several important issues related to home visitation as a component of pediatric asthma care in underserved communities. The Yes We Can Urban Asthma Partnership, which has been providing comprehensive asthma care in the clinic and community setting for 10 years, originally focused on home visits as a mechanism of adding culturally and linguistically appropriate social support to clinical asthma care (2). Similar to Postma et al., in a controlled trial designed to assess the additive effects of home visits, we noted that only 45% (26/56) of our patients who randomized to home visits completed the goal of three visits over a 6-month period; 16% (9/56) never completed any home visits, despite agreeing to participate. Both the control group (who received only clinic-based care) and the home visit group (who received clinic-based care and home visits) experienced improvements in clinical outcomes, including improved use of controller medications and decreased nighttime symptoms and urgent visits for asthma. Additionally, both groups showed improvement in the use of mattress covers to decrease dust exposure in the home. We found no statistical difference between intervention and control groups in these areas, suggesting that a clinic visit alone may be suitable for many areas of asthma management, particularly when clinicians and community health workers partner in asthma care. Although home visits have tremendous potential to help in asthma care, they are expensive and time consuming. Our experience reflects that of Postma et al.,

Increased public reimbursement for prophylactic visits with dentists associated with increased receipt of preventive dental services in children: Increased public reimbursement for prophylactic visits

OBJECTIVE To determine whether higher reimbursement for childrens preventive dentistry correlates with greater utilization of preventive dental care. METHODS A cross-sectional analysis of National Survey of Childrens Health 2011/2012 was conducted, combined with state Medicaid reimbursement rates for preventive dentistry. Analyses included prevalence, unadjusted odds ratios, and multivariable logistic regression for receipt of preventive dental services. RESULTS Of all surveyed American children 1-17 years, almost 20 percent had not received preventive dental care in prior year; this percentage is even higher in those with public insurance. Each

Telephone case management for asthma: an acceptable and effective intervention within a diverse pediatric population.

10 increase in state reimbursement was associated with a 17 percent decrease in odds of children not receiving preventive services. CONCLUSIONS Higher state reimbursement for preventive services may increase childrens receipt of preventive dental care.