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1.  Reducing Oral Health Disparities: A Focus on Social and Cultural Determinants 
BMC Oral Health  2006;6(Suppl 1):S4.
Oral health is essential to the general health and well-being of individuals and the population. Yet significant oral health disparities persist in the U.S. population because of a web of influences that include complex cultural and social processes that affect both oral health and access to effective dental health care.
This paper introduces an organizing framework for addressing oral health disparities. We present and discuss how the multiple influences on oral health and oral health disparities operate using this framework. Interventions targeted at different causal pathways bring new directions and implications for research and policy in reducing oral health disparities.
PMCID: PMC2147600  PMID: 16934121
2.  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
3.  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
4.  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
5.  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
6.  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
7.  Xylitol gummy bear snacks: a school-based randomized clinical trial 
BMC Oral Health  2008;8:20.
Habitual consumption of xylitol reduces mutans streptococci (MS) levels but the effect on Lactobacillus spp. is less clear. Reduction is dependent on daily dose and frequency of consumption. For xylitol to be successfully used in prevention programs to reduce MS and prevent caries, effective xylitol delivery methods must be identified. This study examines the response of MS, specifically S. mutans/sobrinus and Lactobacillus spp., levels to xylitol delivered via gummy bears at optimal exposures.
Children, first to fifth grade (n = 154), from two elementary schools in rural Washington State, USA, were randomized to xylitol 15.6 g/day (X16, n = 53) or 11.7 g/day (X12, n = 49), or maltitol 44.7 g/day (M45, n = 52). Gummy bear snacks were pre-packaged in unit-doses, labeled with ID numbers, and distributed three times/day during school hours. No snacks were sent home. Plaque was sampled at baseline and six weeks and cultured on modified Mitis Salivarius agar for S. mutans/sobrinus and Rogosa SL agar for Lactobacillus spp. enumeration.
There were no differences in S. mutans/sobrinus and Lactobacillus spp. levels in plaque between the groups at baseline. At six weeks, log10 S. mutans/sobrinus levels showed significant reductions for all groups (p = 0.0001): X16 = 1.13 (SD = 1.65); X12 = 0.89 (SD = 1.11); M45 = 0.91 (SD = 1.46). Reductions were not statistically different between groups. Results for Lactobacillus spp. were mixed. Group X16 and M45 showed 0.31 (SD = 2.35), and 0.52 (SD = 2.41) log10 reductions, respectively, while X12 showed a 0.11 (SD = 2.26) log10 increase. These changes were not significant. Post-study discussions with school staff indicated that it is feasible to implement an in-classroom gummy bear snack program. Parents are accepting and children willing to consume gummy bear snacks daily.
Reductions in S. mutans/sobrinus levels were observed after six weeks of gummy bear snack consumption containing xylitol at 11.7 or 15.6 g/day or maltitol at 44.7 g/day divided in three exposures. Lactobacillus spp. levels were essentially unchanged in all groups. These results suggest that a xylitol gummy bear snack may be an alternative to xylitol chewing gum for dental caries prevention. Positive results with high dose maltitol limit the validity of xylitol findings. A larger clinical trial is needed to confirm the xylitol results.
Trial registration
PMCID: PMC2527560  PMID: 18657266
8.  A surrogate method for comparison analysis of salivary concentrations of Xylitol-containing products 
BMC Oral Health  2008;8:5.
Xylitol chewing gum has been shown to reduce Streptococcus mutans levels and decay. Two studies examined the presence and time course of salivary xylitol concentrations delivered via xylitol-containing pellet gum and compared them to other xylitol-containing products.
A within-subjects design was used for both studies. Study 1, adults (N = 15) received three xylitol-containing products (pellet gum (2.6 g), gummy bears (2.6 g), and commercially available stick gum (Koolerz, 3.0 g)); Study 2, a second group of adults (N = 15) received three xylitol-containing products (pellet gum, gummy bears, and a 33% xylitol syrup (2.67 g). For both studies subjects consumed one xylitol product per visit with a 7-day washout between each product. A standardized protocol was followed for each product visit. Product order was randomly determined at the initial visit. Saliva samples (0.5 mL to 1.0 mL) were collected at baseline and up to 10 time points (~16 min in length) after product consumption initiated. Concentration of xylitol in saliva samples was analyzed using high-performance liquid chromatography. Area under the curve (AUC) for determining the average xylitol concentration in saliva over the total sampling period was calculated for each product.
In both studies all three xylitol products (Study 1: pellet gum, gummy bears, and stick gum; Study 2: pellet gum, gummy bears, and syrup) had similar time curves with two xylitol concentration peaks during the sampling period. Study 1 had its highest mean peaks at the 4 min sampling point while Study 2 had its highest mean peaks between 13 to 16 minutes. Salivary xylitol levels returned to baseline at about 18 minutes for all forms tested. Additionally, for both studies the total AUC for the xylitol products were similar compared to the pellet gum (Study 1: pellet gum – 51.3 μg.min/mL, gummy bears – 59.6 μg.min/mL, and stick gum – 46.4 μg.min/mL; Study 2: pellet gum – 63.0 μg.min/mL, gummy bears – 55.9 μg.min/mL, and syrup – 59.0 μg.min/mL).
The comparison method demonstrated high reliability and validity. In both studies other xylitol-containing products had time curves and mean xylitol concentration peaks similar to xylitol pellet gum suggesting this test may be a surrogate for longer studies comparing various products.
PMCID: PMC2267452  PMID: 18267030
9.  Reliability and cross-cultural validity of a Japanese version of the Dental Fear Survey 
BMC Oral Health  2009;9:17.
This study established the reliability and cross-cultural validity of a Japanese version of the Dental Fear Survey (DFS).
Two studies were carried out in separate populations. The first involved 166 Japanese dental and nursing students and assessed internal consistency and test-retest reliability. The second involved 2,095 Japanese parents or guardians of school children and tested the hypothesis that the conceptual structure of the Japanese translation was consistent with the U.S. version using Structural Equation Modeling (SEM).
In the first study Cronbach alpha ranged from .94 to .96 and test-retest reliability (Spearman correlation) ranged from .89 to .92. The intra-class correlation coefficients (ICC) was 0.919 (95%CI: 0.892 – 0.940). In the second study SEM was used on the covariance matrix of the 20 questions in a random sample of 600 questionnaires to evaluate the goodness of fit of the theoretical model; and then, in an exploratory manner corrected for specification errors until a model that fit the data well was achieved.
The Japanese version of the DFS appears reliable and demonstrates cross-cultural validity. The modeling confirms the three factors on which the English language version was based.
PMCID: PMC2718877  PMID: 19591677
10.  Linear response of mutans streptococci to increasing frequency of xylitol chewing gum use: a randomized controlled trial [ISRCTN43479664] 
BMC Oral Health  2006;6:6.
Xylitol is a naturally occurring sugar substitute that has been shown to reduce the level of mutans streptococci in plaque and saliva and to reduce tooth decay. It has been suggested that the degree of reduction is dependent on both the amount and the frequency of xylitol consumption. For xylitol to be successfully and cost-effectively used in public health prevention strategies dosing and frequency guidelines should be established. This study determined the reduction in mutans streptococci levels in plaque and unstimulated saliva to increasing frequency of xylitol gum use at a fixed total daily dose of 10.32 g over five weeks.
Participants (n = 132) were randomized to either active groups (10.32 g xylitol/day) or a placebo control (9.828 g sorbitol and 0.7 g maltitol/day). All groups chewed 12 pieces of gum per day. The control group chewed 4 times/day and active groups chewed xylitol gum at a frequency of 2 times/day, 3 times/day, or 4 times/day. The 12 gum pieces were evenly divided into the frequency assigned to each group. Plaque and unstimulated saliva samples were taken at baseline and five-weeks and were cultured on modified Mitis Salivarius agar for mutans streptococci enumeration.
There were no significant differences in mutans streptococci level among the groups at baseline. At five-weeks, mutans streptococci levels in plaque and unstimulated saliva showed a linear reduction with increasing frequency of xylitol chewing gum use at the constant daily dose. Although the difference observed for the group that chewed xylitol 2 times/day was consistent with the linear model, the difference was not significant.
There was a linear reduction in mutans streptococci levels in plaque and saliva with increasing frequency of xylitol gum use at a constant daily dose. Reduction at a consumption frequency of 2 times per day was small and consistent with the linear-response line but was not statistically significant.
PMCID: PMC1482697  PMID: 16556326
11.  Biotech and Biomaterials Research to Reduce the Caries Epidemic 
BMC Oral Health  2006;6(Suppl 1):S1.
The goal of this workshop is to develop a consensus within the biomaterials/bioengineering community for a research agenda focused on creating technologies that will address the current dental caries pandemic. The workshop will bring together expertise from academia, industry, and the NIH institutes in the areas of oral biofilm microbiology and innovative biomaterials. The rationale for the workshop is that science and technology have not produced sufficient practical tools for public health practitioners and the private delivery system to address the pandemic in dental caries that exists for children and adults from families with low incomes and for numerous ethnic minority and racial groups. Moreover, it is unclear whether the barriers are remediable bioengineering and technical problems or fundamental science questions. Nevertheless, the obligation to address the gap between scientific research and practical application is especially relevant today. The U.S. and state governments bear the majority of the cost of trying to control this pandemic through Medicaid, the Public Health Service, Indian Health Service and other similar programs. These costs continue to escalate as continued applications of existing technology are unlikely to markedly reduce disparities. The mainstays of caries prevention, topical and systemic fluorides and pit and fissure sealants, are technologies developed in the 1950s and 1960s.
PMCID: PMC2147601  PMID: 16934110
12.  Children's acceptance of milk with xylitol or sorbitol for dental caries prevention 
BMC Oral Health  2005;5:6.
Xylitol, a polyol sugar, has been shown to reduce dental caries when mixed with food or chewing gum. This study examines the taste acceptability of xylitol in milk as a first step toward measuring the effectiveness of xylitol in milk for the reduction of dental caries in a public health program.
Three different types of milk (Ultra High Temperature (UHT), powder and evaporated) were tested for acceptability by 75 Peruvian children (25 per milk group, ages 4 to 7 years). Each group evaluated xylitol and sorbitol in one type of milk. In the first phase, each child was presented with a tray of four plastic cups containing 50 ml of milk with 0.021 g/ml xylitol, 0.042 g/ml xylitol, 0.042 g/ml sorbitol or no sugar. Each child was asked to taste the samples in a self-selected order. After tasting each sample, the child placed the milk cup in front of one of three cartoon faces (smile, frown or neutral) representing the child's response to the taste of each sample. In the second phase, the child was asked to rank order the milk samples within each category (smile, frown or neutral). Ranks within categories were then combined to obtain a rank ordering for all the test samples.
The ranking from best to worst for the samples across categories (UHT, powder, evaporated) was xylitol (0.0.042 g/ml), sorbitol (0.042 g/ml), xylitol (0.021 g/ml) and milk alone (Friedman's ANOVA). Xylitol and sorbitol were preferred over milk alone, and xylitol (0.042 g/ml) was preferred to sorbitol (0.042 g/ml)(p < .05 sign test).
Milk sweetened with xylitol is well accepted by Peruvian children ages 4–7 years.
PMCID: PMC1183221  PMID: 16042782

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