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1.  Population-centered Risk- and Evidence-based Dental Interprofessional Care Team (PREDICT): study protocol for a randomized controlled trial 
Trials  2015;16:278.
To improve the oral health of low-income children, innovations in dental delivery systems are needed, including community-based care, the use of expanded duty auxiliary dental personnel, capitation payments, and global budgets. This paper describes the protocol for PREDICT (Population-centered Risk- and Evidence-based Dental Interprofessional Care Team), an evaluation project to test the effectiveness of new delivery and payment systems for improving dental care and oral health.
This is a parallel-group cluster randomized controlled trial. Fourteen rural Oregon counties with a publicly insured (Medicaid) population of 82,000 children (0 to 21 years old) and pregnant women served by a managed dental care organization are randomized into test and control counties. In the test intervention (PREDICT), allied dental personnel provide screening and preventive services in community settings and case managers serve as patient navigators to arrange referrals of children who need dentist services. The delivery system intervention is paired with a compensation system for high performance (pay-for-performance) with efficient performance monitoring. PREDICT focuses on the following: 1) identifying eligible children and gaining caregiver consent for services in community settings (for example, schools); 2) providing risk-based preventive and caries stabilization services efficiently at these settings; 3) providing curative care in dental clinics; and 4) incentivizing local delivery teams to meet performance benchmarks. In the control intervention, care is delivered in dental offices without performance incentives. The primary outcome is the prevalence of untreated dental caries. Other outcomes are related to process, structure and cost. Data are collected through patient and staff surveys, clinical examinations, and the review of health and administrative records.
If effective, PREDICT is expected to substantially reduce disparities in dental care and oral health. PREDICT can be disseminated to other care organizations as publicly insured clients are increasingly served by large practice organizations.
Trial registration NCT02312921 6 December 2014. The Robert Wood Johnson Foundation and Advantage Dental Services, LLC, are supporting the evaluation.
PMCID: PMC4475615  PMID: 26091669
Dental care; Dental care utilization; Medicaid; Oral health; Children; Pay-for-performance; Randomized controlled trial
2.  “Everybody Brush!”: Protocol for a Parallel-Group Randomized Controlled Trial of a Family-Focused Primary Prevention Program With Distribution of Oral Hygiene Products and Education to Increase Frequency of Toothbrushing 
JMIR Research Protocols  2015;4(2):e58.
Twice daily toothbrushing with fluoridated toothpaste is the most widely advocated preventive strategy for dental caries (tooth decay) and is recommended by professional dental associations. Not all parents, children, or adolescents follow this recommendation. This protocol describes the methods for the implementation and evaluation of a quality improvement health promotion program.
The objective of the study is to show a theory-informed, evidence-based program to improve twice daily toothbrushing and oral health-related quality of life that may reduce dental caries, dental treatment need, and costs.
The design is a parallel-group, pragmatic randomized controlled trial. Families of Medicaid-insured children and adolescents within a large dental care organization in central Oregon will participate in the trial (n=21,743). Families will be assigned to one of three groups: a test intervention, an active control, or a passive control condition. The intervention aims to address barriers and support for twice-daily toothbrushing. Families in the test condition will receive toothpaste and toothbrushes by mail for all family members every three months. In addition, they will receive education and social support to encourage toothbrushing via postcards, recorded telephone messages, and an optional participant-initiated telephone helpline. Families in the active control condition will receive the kit of supplies by mail, but no additional instructional information or telephone support. Families assigned to the passive control will be on a waiting list. The primary outcomes are restorative dental care received and, only for children younger than 36 months old at baseline, the frequency of twice-daily toothbrushing. Data will be collected through dental claims records and, for children younger than 36 months old at baseline, parent interviews and clinical exams.
Enrollment of participants and baseline interviews have been completed. Final results are expected in early summer, 2017.
If proven effective, this simple intervention can be sustained by the dental care organization and replicated by other organizations and government.
Trial Registration
Trial Registration: NCT02327507; (Archived by WebCite at
PMCID: PMC4457936  PMID: 26002091
oral hygiene; toothbrushing; dental devices, home care; dental care; communication; social support
3.  Multilevel factors associated with dentists’ counseling of pregnant women about periodontal health 
To identify the factors associated with dentists’ counseling of pregnant patients about periodontal health.
Survey data from Oregon general dentists (N=771) were linked to county-level data from the U.S. Area Resource Files and analyzed using two-level hierarchical linear models.
Dentists who believed there is an important relationship between periodontal disease and adverse pregnancy outcomes counseled significantly larger proportions of pregnant patients (P<.0001). Female dentists (P<.05) and those who saw a greater number of pregnant patients (P<.05) were more likely to counsel. County-level health workforce characteristics (e.g., percent female physicians, obstetricians or gynecologists, female dentists) were not significantly associated with dentists’ counseling.
Dentists who were knowledgeable about periodontal disease were more likely to counsel pregnant patients. Future interventions should improve the oral health knowledge of dentists and other healthcare professionals regarding the importance of comprehensive dental care, including periodontal treatment when needed, for all pregnant patients.
PMCID: PMC3879956  PMID: 24382365
Dentists practice patterns; counseling; periodontal disease; pregnancy; multilevel analysis
4.  Cluster-randomized xylitol toothpaste trial for early childhood caries prevention 
We assessed the efficacy of supervised toothbrushing with xylitol toothpaste to prevent early childhood caries (ECC) and to reduce mutans streptococci (MS).
In this cluster-randomized efficacy trial, 4 Head Start classrooms in the Marshall Islands were randomly assigned to supervised toothbrushing with 1,400ppm/31% fluoride-xylitol (Epic Dental, Provo, UT) or 1,450ppm fluoride-sorbitol toothpaste (Colgate-Palmolive, New York, NY) (N=196 children, ages 4–5 yrs). We hypothesized no difference in efficacy between the two types of toothpaste. The primary outcome was primary molar d2-3mfs increment after 6 mos. A single examiner was blinded to classroom assignments. Two classrooms were assigned to the fluoride-xylitol group (85 children) and 2 classrooms to the fluoride-sorbitol group (83 children). The child-level analyses accounted for clustering.
There was no difference between the two groups in baseline or end-of-trial mean d2-3mfs. The mean d2-3mfs increment was greater in the fluoride-xylitol group compared to the fluoride-sorbitol group (2.5 and 1.4 d2-3mfs, respectively), but the difference was not significant (95% CI:−0.17, 2.37;P=0.07). No adverse effects were reported.
After 6 mos, brushing with a low strength xylitol/fluoride toothpaste is no more efficacious in reducing ECC than a fluoride only toothpaste in a high caries risk child population.
PMCID: PMC4000539  PMID: 24709430
5.  Trends in Death Associated with Pediatric Dental Sedation and General Anesthesia 
Paediatric anaesthesia  2013;23(8):741-746.
Inadequate access to oral health care places children at risk for caries. Disease severity and inability to cooperate often result in treatment with general anesthesia (GA). Sedation is increasingly popular and viewed as lower risk than GA in community settings. Currently, few data are available to quantify pediatric morbidity and mortality related to dental anesthesia.
Summarize dental anesthesia-related pediatric deaths described in media reports.
Review of media reports in the Lexis-Nexis Academic database and a private foundation website.
Dental offices, ambulatory surgery centers, and hospitals.
U.S.-based children (≤ 21 y.o.) who died subsequent to receiving anesthesia for a dental procedure between 1980–2011.
Most deaths occurred among 2 –5 year-olds (n=21/44); in an office setting (n=21/44), and with a general/pediatric dentist (n=25/44) as the anesthesia provider. In this latter group, 17/25 deaths were linked with a sedation anesthetic.
This series of media reports likely represent only a fraction of the overall morbidity and mortality related to dental anesthesia. These data may indicate an association between mortality and pediatric dental procedures under sedation, particularly in office settings. However, these relationships are difficult to test in the absence of a database that could provide an estimate of incidence and prevalence of morbidity and mortality. With growing numbers of children receiving anesthesia for dental procedures from providers with variable training, it is imperative to be able to track anesthesia-related adverse outcomes. Creating a national database of adverse outcomes will enable future research to advance patient safety and quality.
PMCID: PMC3712625  PMID: 23763673
Anesthesia; Patient safety; Child; Conscious Sedation/adverse effects; Dental Anxiety/drug therapy; Treatment Outcome
SAAD digest  2012;28:23-30.
Dental fear is a barrier to receiving dental care, particularly for those patients who also suffer from mental illnesses. The current study examined United States dental professionals’ perceptions of dental fear experienced by patients with mental illness, and frequency of sedation of patients with and without mental illness. Dentists and dental staff members (n = 187) completed a survey about their experiences in treating patients with mental illness. More participants agreed (79.8%) than disagreed (20.2%) that patients with mental illness have more anxiety regarding dental treatment (p < .001) than dental patients without mental illness. Further, significantly more participants reported mentally ill patients’ anxiety is “possibly” or “definitely” a barrier to both receiving (96.8%; p < .001) and providing (76.9%; p < .01) dental treatment. Despite reporting more fear in these patients, there were no significant differences in frequency of sedation procedures between those with and without mental illness, regardless of type of sedation (p’s > .05). This lack of difference in sedation for mentally ill patients suggests hesitancy on the part of dental providers to sedate patients with mental illness and highlights a lack of clinical guidelines for this population in the US. Suggestions are given for the assessment and clinical management of patients with mental illness.
PMCID: PMC4033904  PMID: 24876662
7.  Unmet dental need in community-dwelling adults with mental illness: Results from the 2007 Medical Expenditure Panel Survey 
Mental illness (MI) affects approximately one in five US adults, and is associated with oral disease and poor dental treatment outcomes. Little is known about dental utilization or unmet dental need in this population.
This study examined dental visits and unmet dental need in community-dwelling adults with MI in 2007 Medical Expenditure Panel Survey (MEPS) data. Differences between adults with and without MI were tested using multivariate logistic regression.
Eighteen percent of adults (N=19,368) had MI; 5.5 percent had unmet dental need. Although individuals with MI were not significantly more likely to have a dental visit (46.3 percent) than those without MI (42.2 percent; OR=1.09, 95 percent CI=.97–1.23), they were significantly more likely to report unmet need (11.0 versus 5.3 percent; OR=2.00, 95 percent CI=1.67–2.41). Those with mood or anxiety disorders were most likely to report unmet need (Ps<.001).
While individuals with MI did not visit the dentist significantly more than adults without MI, their higher level of unmet need suggests current dental service use is not addressing their needs adequately.
Clinical Implications
Dentists should be familiar with MI conditions as these patients may have greater unmet dental need.
PMCID: PMC3613122  PMID: 23449910
Mental illness; dental need; utilization
8.  Treatment fidelity of brief motivational interviewing and health education in a randomized clinical trial to promote dental attendance of low-income mothers and children: Community-Based Intergenerational Oral Health Study “Baby Smiles” 
BMC Oral Health  2014;14:15.
Fidelity assessments are integral to intervention research but few published trials report these processes in detail. We included plans for fidelity monitoring in the design of a community-based intervention trial.
The study design was a randomized clinical trial of an intervention provided to low-income women to increase utilization of dental care during pregnancy (mother) or the postpartum (child) period. Group assignment followed a 2 × 2 factorial design in which participants were randomly assigned to receive either brief Motivational Interviewing (MI) or Health Education (HE) during pregnancy (prenatal) and then randomly reassigned to one of these groups for the postpartum intervention. The study setting was four county health departments in rural Oregon State, USA. Counseling was standardized using a step-by-step manual. Counselors were trained to criteria prior to delivering the intervention and fidelity monitoring continued throughout the implementation period based on audio recordings of counselor-participant sessions. The Yale Adherence and Competence Scale (YACS), modified for this study, was used to code the audio recordings of the counselors’ delivery of both the MI and HE interventions. Using Interclass Correlation Coefficients totaling the occurrences of specific MI counseling behaviors, ICC for prenatal was .93, for postpartum the ICC was .75. Participants provided a second source of fidelity data. As a second source of fidelity data, the participants completed the Feedback Questionnaire that included ratings of their satisfaction with the counselors at the completion of the prenatal and post-partum interventions.
Coding indicated counselor adherence to MI protocol and variation among counselors in the use of MI skills in the MI condition. Almost no MI behaviors were found in the HE condition. Differences in the length of time to deliver intervention were found; as expected, the HE intervention took less time. There were no differences between the overall participants’ satisfaction ratings of the HE and MI sessions by individual counselor or overall (p > .05).
Trial design, protocol specification, training, and continuous supervision led to a high degree of treatment fidelity for the counseling interventions in this randomized clinical trial and will increase confidence in the interpretation of the trial findings.
Trial registration NCT01120041
PMCID: PMC3996055  PMID: 24559035
Dental health; Motivational interviewing; Clinical competence; Postpartum care; Prenatal care
9.  Cross-cultural validity of a dietary questionnaire for studies of dental caries risk in Japanese 
BMC Oral Health  2014;14:1.
Diet is a major modifiable contributing factor in the etiology of dental caries. The purpose of this paper is to examine the reliability and cross-cultural validity of the Japanese version of the Food Frequency Questionnaire to assess dietary intake in relation to dental caries risk in Japanese.
The 38-item Food Frequency Questionnaire, in which Japanese food items were added to increase content validity, was translated into Japanese, and administered to two samples. The first sample comprised 355 pregnant women with mean age of 29.2 ± 4.2 years for the internal consistency and criterion validity analyses. Factor analysis (principal components with Varimax rotation) was used to determine dimensionality. The dietary cariogenicity score was calculated from the Food Frequency Questionnaire and used for the analyses. Salivary mutans streptococci level was used as a semi-quantitative assessment of dental caries risk and measured by Dentocult SM. Dentocult SM scores were compared with the dietary cariogenicity score computed from the Food Frequency Questionnaire to examine criterion validity, and assessed by Spearman’s correlation coefficient (rs) and Kruskal-Wallis test. Test-retest reliability of the Food Frequency Questionnaire was assessed with a second sample of 25 adults with mean age of 34.0 ± 3.0 years by using the intraclass correlation coefficient analysis.
The Japanese language version of the Food Frequency Questionnaire showed high test-retest reliability (ICC = 0.70) and good criterion validity assessed by relationship with salivary mutans streptococci levels (rs = 0.22; p < 0.001). Factor analysis revealed four subscales that construct the questionnaire (solid sugars, solid and starchy sugars, liquid and semisolid sugars, sticky and slowly dissolving sugars). Internal consistency were low to acceptable (Cronbach’s alpha = 0.67 for the total scale, 0.46-0.61 for each subscale). Mean dietary cariogenicity scores were 50.8 ± 19.5 in the first sample, 47.4 ± 14.1, and 40.6 ± 11.3 for the first and second administrations in the second sample. The distribution of Dentocult SM score was 6.8% (score = 0), 34.4% (score = 1), 39.4% (score = 2), and 19.4% (score = 3). Participants with higher scores were more likely to have higher dietary cariogenicity scores (p < 0.001; Kruskal-Wallis test).
These results provide the preliminary evidence for the reliability and validity of the Japanese language Food Frequency Questionnaire.
PMCID: PMC3898231  PMID: 24383547
Food frequency questionnaire; Cariogenic food; Diet; Reliability; Validity; Mutans streptococci
10.  Less counseling on Early Childhood Caries transmission by dentists 
Journal of public health dentistry  2012;73(2):10.1111/j.1752-7325.2012.00356.x.
High levels of Streptococcus mutans on teeth of young children are predictive of Early Childhood Caries (ECC). Transmission from mother-to-child is common and studies have demonstrated treatment of the mother results in less ECC. The objective of this study was to determine how dentists have adopted the practice of counseling about ECC.
In 2006 as part of a larger study on dental care for pregnant women, we surveyed 829 general dentists in Oregon. The questionnaire contained questions to capture the extent to which general dentists have adopted counseling pregnant women about ECC transmission, to describe personal and practice characteristics, and examine how dentists' views on the ease of adopting of new procedures related to ECC counseling. Multivariate logistic regression was used to identify separate and additive effects of demographic and practice characteristics, attitudes, and beliefs.
The adjusted odds of a dentist who strongly believed in the link between mothers and babies and provided ECC counseling were 1.60 (95% CI 1.3-2.0, P<0.01). The odds of a dentist who reported discussing ECC with staff members and provided counseling were 2.7 (95% CI 1.7-4.3, P<0.01). Male dentists were less likely to counsel patients than female dentists (Adjusted OR = 0.5, 95% CI 0.3-1.0, p<0.05).
The strongest predictors of counseling patients about ECC were dentists' belief in the evidence of caries transmission and dentists' discussion of ECC during staff meetings.
PMCID: PMC3855324  PMID: 22970775
dental caries; prevention; infant; pregnant woman
11.  Who is Referred for Sedation for Dentistry and Why? 
British dental journal  2009;206(6):10.1038/sj.bdj.2009.251.
To assess referrals to sedation examining dental anxiety and background of patients and compare these characteristics to those referred to a restorative dentistry clinic.
Descriptive, cross sectional survey and chart review.
Subjects and Methods
Subjects were 100 consecutive new patients in Sedation and Special Care and 50 new patients in Restorative Dentistry at Guy’s and St Thomas NHS Foundation Trust. A questionnaire included demographics, self-reported oral health and dental attendance, and dental fear. Information from the patient’s record was taken: ASA Classification, previous sedation or general anaesthesia, and alcohol and tobacco use, and medications.
The best predictors of referral were dental anxiety level and an irregular attendance. The most important fears were seeing, hearing and feeling the vibrations of the dental drill, and the perception of an accelerated heart rate. Other factors, such as general, mental and dental health, and alcohol use were related to referral but less important.
Referral is consistent with the goal of the Sedation Clinic to see anxious patients. Referring general practitioners are able to identify these patients.
PMCID: PMC3812064  PMID: 19329945
12.  What Happens After Referral For Sedation? 
British dental journal  2010;208(11):10.1038/sj.bdj.2010.502.
To follow up 100 referrals to the sedation clinic examining dental anxiety and background of patients and assess how many patients attended for treatment planning, initial treatment, and completed treatment and describe their characteristics. Among those who attended for initial treatment, which type of sedation they received at initial treatment and what level of clinician they saw.
Descriptive, cross sectional survey and review of case notes.
Subjects and Methods
Subjects were 100 consecutive new patients in Sedation and Special Care Guy’s and St Thomas NHS Foundation Trust. The notes were analysed by an experienced member of staff (CAB) and data entered into an Excel spreadsheet and an SPSS datafile created. These data were merged with a dataset containing their responses to the intake questionnaire and medical history for analysis.
Of the 100 patients initially referred, 72 attended the treatment planning session, 66 of the 72 (92%) attended for initial dental treatment, and 33 of 66 (50%) completed treatment. Dental Fear Survey (DFS) scores were related to attendance at the initial treatment visit but not to completion of treatment. Patients with mental health problems encountered more barriers. Only 33 of 100 patients referred completed treatment.
Attendance for treatment planning and initial treatment was high. Attendance is related to fear and mental health. Overall completion of treatment from referral was 33 percent.
PMCID: PMC3812067  PMID: 20512107
13.  Medicaid Reforms In Oregon And Suboptimal Utilization Of Dental Care by Women of Childbearing Age 
The authors studied dental services used by women of childbearing age who were in Medicaid in Oregon during the early 2000’s, a period of reforms to expand coverage. They compared claims for pregnant women, non-pregnant women with children, and non-pregnant women without children. They compared differences in claims for women enrolled in managed care and fee-for-service plans.
The authors computed the proportion of women for whom a dental claim was submitted in 6-month spans for 2000, 2001, 2002 (before reform) and 2005 (after reform).
Before and after reforms, average utilization of pregnant women, adjusted for proportion of the period covered, dropped from .36 (SD=.025) to .22 (SD=.028). Among non-pregnant women with children, average adjusted rates dropped from .49 (SD=.201) to .21 (SD=.078). The pattern was similar among women with no children: rates dropped from .50 (SD=.028) to .19 (SD=.078). Claims for diagnostic services were most frequent. No difference was found between women enrolled in managed care or fee-for-service.
Contrary to the intention, reforms were detrimental to the vulnerable populations Medicaid is intended to serve.
Clinical Implications
Dental care is important for maternal and child health. Utilization is unlikely to improve without changes in Medicaid and care delivery.
PMCID: PMC3808863  PMID: 20516101
Access to care; dental care utilization; pregnancy; women’s health; vulnerable populations
14.  Estimating Determinants of Dentist Productivity: New Evidence 
Journal of public health dentistry  2010;70(4):10.1111/j.1752-7325.2010.00180.x.
Productivity (output per unit of input) is a major driver of dental service capacity. This study uses 2006-2007 data to update available knowledge on dentist productivity.
In 2006-2007 the authors surveyed 1,604 Oregon general dentists regarding. hours worked, practice size, payment and patient mix, prices, dentist visits, and dentist characteristics. Effects of practice inputs and other independent variables on productivity were estimated by multiple regression and path analysis.
The survey response rate was 55.2 percent. Dentists responding to the productivity-related questions were similar to dentists in the overall sampling frame and nationwide. Visits per week are significantly positively related to dentist hours worked, number of assistants, hygienists, and number of operatories. Dentist ownership status, years of experience, and % Medicaid patients are significantly positively related to practice output. The contributions of dentist chairside time and assistants to additional output are smaller for owners, but the number of additional dentist visits enabled by more hygienists is larger for owners.
As in earlier studies of dental productivity, the key determinant of dentist output is the dentist’s own chairside time. The incremental contributions of dentist time, auxiliaries, and operatories to production of dentist visits have not changed substantially over the past three decades. Future studies should focus on ultimate measures of output -- oral health -- and should develop more precise measures of the practice’s actual utilization of auxiliaries, their skill and use of technology.
PMCID: PMC3808865  PMID: 20545830
15.  Areca use among adolescents in Yap and Pohnpei, the Federated States of Micronesia 
Areca (Betel Nut) is the fourth most commonly used psychoactive drug throughout the world and is legal in U.S. It is carcinogenic. Within a health program in the Federated States of Micronesia we surveyed use among adolescents.
One hundred 7th and 8th graders in Yap and Pohnpei were surveyed and clinical oral examinations conducted. The questionnaire included items on Areca: age first used Areca, whether peers or family members used Areca, frequency of use, whether tobacco was used, and source of Areca. Questions also assessed anxiety and depression. Two scales assessed getting along with other kids and adaptation to school.
61.5-71.4% of adolescents had ever used Areca and 54.7-68.6% used it at least once in the last month.
Most adolescents surveyed in Yap and Pohnpei used Areca, which may place these youth at increased risk for cancer and health disparities.
PMCID: PMC3854772  PMID: 24134714
Areca; Betel; Adolescent; Oral mucosa; Micronesia; Substance-related disorders
16.  School screening and parental reminders in increasing dental care for children in need: a retrospective cohort study 
To assess follow-up dental care received by children given baseline screening and referrals as part of an ongoing clinical trial.
A retrospective study with two cohorts of kindergarten children who had baseline and follow-up (nine months later) dental exams was used. The parents/caregivers of children with routine restorative or urgent needs at baseline received a referral letter and telephone reminders to seek care for their child. Children with referrals were evaluated at follow-up exam for the receipt of care. A baseline caregiver questionnaire provided information on the individual and family characteristics of the children.
A total of 303 children had dental exams at both time periods. At baseline, 42% (126/303) received referrals and among the referred group19% (24/126) received follow-up care. A greater proportion with urgent referrals (10/30, 33%) received care than those with routine referrals (14/96, 15%). Baseline dmft and DMFT was similar between children who did/did not receive follow-up care (P=0.178 and 0.491 respectively). Children receiving referrals had caregivers with less education, higher Medicaid participation, fewer routine care visits, poorer self-rating of teeth, and a higher proportion of children reporting tooth pain. Children without receipt of follow-up care had caregivers who were more likely to report not visiting a dentist within the last five years and a greater number of missed days from work due to tooth problems.
The rate of dental utilization was low even with school screening, referral and parental reminders among poor, largely minority inner-city kindergarten children.
PMCID: PMC3737569  PMID: 22316214
school children; dental caries; referrals; follow-up care
17.  Design of a community-based intergenerational oral health study: “Baby Smiles” 
BMC Oral Health  2013;13:38.
Rural, low-income pregnant women and their children are at high risk for poor oral health and have low utilization rates of dental care. The Baby Smiles study was designed to increase low-income pregnant women’s utilization of dental care, increase young children’s dental care utilization, and improve home oral health care practices.
Baby Smiles was a five-year, four-site randomized intervention trial with a 2 × 2 factorial design. Four hundred participants were randomly assigned to one of four treatment arms in which they received either brief Motivational Interviewing (MI) or health education (HE) delivered during pregnancy and after the baby was born. In the prenatal study phase, the interventions were designed to encourage dental utilization during pregnancy. After childbirth, the focus was to utilize dental care for the infant by age one. The two primary outcome measures were dental utilization during pregnancy or up to two months postpartum for the mother, and preventive dental utilization by 18 months of age for the child. Medicaid claims data will be used to assess the primary outcomes. Questionnaires were administered at enrollment and 3, 9 and 18 months postpartum (study end) to assess mediating and moderating factors.
This trial can help define the most effective way to provide one-on-one counseling to pregnant women and new mothers regarding visits to the dentist during pregnancy and after the child is born. It supports previous work demonstrating the potential of reducing mother-to-child transmission of Streptococcus mutans and the initiation of dental caries prevention in early childhood.
Trial registration Identifier NCT01120041
PMCID: PMC3751087  PMID: 23914908
Counseling; Motivation; Dental caries; Early childhood caries; Health Education; Dental; Mothers; Infant
18.  County-level characteristics as predictors of dentists’ ECC counseling in the USA: a survey study 
BMC Oral Health  2013;13:23.
Transmission of Streptococcus mutans from mother-to-child can lead to Early Childhood Caries. A previous study identified characteristics and beliefs of general dentists about counseling pregnant women to reduce risk of infection and Early Childhood Caries. This study extends those findings with an analysis of county level factors.
In 2006, we surveyed 732 general dentists in Oregon, USA about dental care for pregnant women. Survey items asked about individual and practice characteristics. In the present study we matched those data to county level factors and used multinomial logistic regression to test the effects of the factors (i.e., dentist to population ratio, percentage of female dentists, percentage of females of childbearing age, and percentage of individuals living in poverty) on counseling behavior.
County level factors were unrelated to counseling behavior when the models controlled for dentists' individual attitudes, beliefs, and practice level characteristics. The adjusted odds ratios for no counseling of pregnant patients (versus 100 percent counseling) were 1.1 (95% CI .8-1.7), 1.0 (1.0-1.1), 1.2 (.9-1.5), and 1.1 (1.0-1.2) for dentist/population ratio, percent female dentists, percent females of childbearing age, and percent in poverty, respectively Similar results were obtained when dentists who counseled some patients were compared to those counseling 100 percent of patients.
Community level factors do not appear to impact the individual counseling behavior of general dentists in Oregon, USA regarding the risk of maternal transmission of Early Childhood Caries.
PMCID: PMC3679951  PMID: 23688178
Early Childhood Caries; Prevention; Pregnant woman; County factors; Area Resource File
19.  A Community-based Randomized Trial of Postcard Mailings to Increase Dental Utilization Among Low-income Children 
Increasing awareness about the importance of preventive dental care among low-income families has been considered to be key to overcoming nonfinancial access to care barriers for children. The purpose of this randomized, controlled trial was to measure the impact of postcard mailings on dental utilization by low-income children through a dental society program designed to increase access to dental care.
Five thousand eight hundred and seven low-income 2- to 4-year-olds were randomly assigned to 1 of 3 groups: (1) Group 1 (N=2,014) received postcards containing information on how to enroll in the Yakima County Access to Baby and Child Dentistry program; (2) Group 2 (N=2,014) received the enrollment information as well as additional information on the availability of fluoride varnish and the need to visit the dentist by the age of 1-year-old; and (3) Group 3 (N=1,779) did not receive postcards.
Preventive services utilization rates were not different among the groups: 61% for Group 1, 62% for Group 2, and 60% for Group 3, although rates were high for a Medicaid population.
Postcard mailings did not significantly increase utilization of preventive dental services. Other strategies to increase utilization of preventive oral health measures are needed.
PMCID: PMC3587972  PMID: 23433618
access to dental care; Medicaid; child; RCT
20.  Preventive Dental Service Utilization for Medicaid-Enrolled Children in New Hampshire: A Comparison of Care Provided by Pediatric Dentists and General Dentists 
In this study, we compared preventive dental utilization through visits to a pediatric dentist (PD) vs. visits to a general dentist (GD) among Medicaid-enrolled children in New Hampshire (n=12,964). Dental claims were analyzed using conditional logistic regression models. After adjusting for covariates, children seen by a PD were 51% more likely to have received fluoride treatment, 26% more likely to have had at least two dental examinations, and 19% more likely to have received a sealant than children seen by a GD. Overall, our results suggest that children seen by a PD were more likely to have received preventive services than those seen by a GD. Because Medicaid-enrolled children are at increased risk for poor oral health, policies should be enacted to ensure that high-risk children receive appropriate and regular prevention-oriented dental care.
PMCID: PMC3564013  PMID: 19395842
dental Medicaid program; health care disparities; dental care for children; preventive dentistry; access to health care; pediatric dentistry; utilization
21.  Minority Participation in a School-Based Randomized Clinical Trial of Tooth Decay Prevention in the United States 
Contemporary Clinical Trials  2011;33(1):60-66.
To describe the strategies--based on the social triad concept of a partnership of researchers, school personnel and community-- employed to recruit low-income, minority parent/caregivers of kindergarten children into a school-based tooth decay prevention trial in the United States.
The study site was an urban school district with five elementary schools. Recruitment was carried out once each year for three years. Recruitment involved strategies at the school district, school, classroom, and student-parent level. A coalition of researchers, school personnel and community individuals was established for communication and recruitment. Outreach workers from the community were hired to promote, recruit, and disseminate oral health information. Study promotion included both print materials (logos, flyers, pictorial story boards) and presentations at school and community events.
The School District Superintendent and administrators approved the study, and all five school principals and kindergarten teachers participated. All children within the classrooms were eligible: the overall participation rate of was 86% (580/672). Community outreach workers actively facilitated the recruitment and participants were recruited at open house for parent-teacher meeting (37% of all participants), sending letters and consent forms home (31%), at a prearranged convenient time during drop off and pick up of the child at their respective schools (30%), curriculum nights and health fairs (2%).
Utilizing the social triad concept led to success in planning and carrying out the recruitment of predominantly minority school children with high participation rates.
PMCID: PMC3253938  PMID: 21986390
randomized clinical trial (RCT); recruitment; school children; minority participation
22.  Short term serum pharmacokinetics of diammine silver fluoride after oral application 
BMC Oral Health  2012;12:60.
There is growing interest in the use of diammine silver fluoride (DSF) as a topical agent to treat dentin hypersensitivity and dental caries as gauged by increasing published research from many parts of the world. While DSF has been available in various formulations for many years, most of its pharmacokinetic aspects within the therapeutic concentration range have never been fully characterized.
This preliminary study determined the applied doses (3 teeth treated), maximum serum concentrations, and time to maximum serum concentration for fluoride and silver in 6 adults over 4 h. Fluoride was determined using the indirect diffusion method with a fluoride selective electrode, and silver was determined using inductively coupled plasma-mass spectrometry. The mean amount of DSF solution applied to the 3 teeth was 7.57 mg (6.04 μL).
Over the 4 hour observation period, the mean maximum serum concentrations were 1.86 μmol/L for fluoride and 206 nmol/L for silver. These maximums were reached 3.0 h and 2.5 h for fluoride and silver, respectively.
Fluoride exposure was below the U.S. Environmental Protection Agency (EPA) oral reference dose. Silver exposure exceeded the EPA oral reference dose for cumulative daily exposure over a lifetime, but for occasional use was well below concentrations associated with toxicity. This preliminary study suggests that serum concentrations of fluoride and silver after topical application of DSF should pose little toxicity risk when used in adults.
Clinical trials registration
PMCID: PMC3538059  PMID: 23272643
Acute pain; Tooth; Medical device; Topical agent; Pharmacology; Toxicology
23.  Determinants of receiving intravenous sedation in a sample of dentally-fearful patients in the USA 
SAAD digest  2012;28:52-60.
Dental fear may be the most common reason for referral for intravenous sedation. Intravenous sedation offers many patients an opportunity to obtain needed dental care. However, intravenous sedation also has costs and may not help patients overcome their fear. Given a sample of 518 dentally-fearful patients in the USA presenting for dental care, this study examined the variables which predicted receiving intravenous sedation or not. About one-fifth of the patients received intravenous sedation, while the others received only cognitive behavioural therapy. Having more carious teeth, higher dental fear, more negative beliefs about dentists, lifetime diagnoses of panic disorder and/or generalized anxiety disorder, fewer existing coping skills, and a lower desire to cope with the dental situation were each predictive of having intravenous sedation. When the variables were considered simultaneously, only lower desire to cope contributed uniquely to the prediction. In a setting where psychological treatment for dental fear is available, patients’ desire to cope with their fear was the most important factor in determining whether they received intravenous sedation or not.
PMCID: PMC3526014  PMID: 23264704
24.  Referrals for Dental Care During Pregnancy 
Oral health is essential to overall health in the prenatal period. Pregnancy is not a time to delay dental care. Several studies have shown an association between periodontal disease and poor pregnancy outcomes including preterm birth. Interventions to provide periodontal treatment to pregnant women yield inconsistent results regarding preterm birth but have established the safety of periodontal therapy during pregnancy. Postpartum, women in poor dental health readily transmit the tooth decay pathogen Streptococcus mutans from their saliva to their infants resulting in increased risk of early childhood caries. Preventive services and treatment for acute problems should be recommended, fears allayed, and women referred. Dental x-rays may be performed safely with the use of appropriate shielding. Non-emergent interventions are best provided between 14 and 20 weeks of gestation for comfort and optimal fetal safety. Most gravid women do not seek dental care. Increased interprofessional communication to encourage dentists to treat pregnant women will reduce the number of women without care. In states where it is available, Medicaid coverage of dental services for pregnant women is typically allowed during pregnancy and for two months postpartum. Women’s health providers should understand the importance of protecting oral health during pregnancy and educate their patients accordingly.
PMCID: PMC3074205  PMID: 21429074
25.  Empowering Head Start to Improve Access to Good Oral Health for Children from Low Income Families 
Maternal and child health journal  2008;15(7):876-882.
Surveys over 20 years have documented worsening in the dental health of preschoolers. Healthy People 2010 Midcourse Review reports the country moving away from oral health goals for young children; the slip is 57%. Exacerbating this is the inability of Medicaid to provide for those in need. Most children receive examinations only: few receive comprehensive care. We urge Head Start grantees to adopt a new approach to oral health goals and in this paper offer: (1) a review of the problem and premises preventing a solution; (2) a proposal that Head Start adopt a public health perspective; and (3) specific roles staff and dental personnel can take to mount aggressive strategies to arrest tooth decay at the grantee site.
PMCID: PMC2914140  PMID: 18246416
oral health; preschool children; Head Start; tooth decay

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