Prospective study of 5-year caries increment among children receiving comprehensive dental care in the New England children's amalgam trial

Abstract – Objective: To measure the 5‐year caries increment among high‐risk children during their participation in the New England Children’s Amalgam Trial (NECAT), and to evaluate sociodemographic factors that may account for any observed disparities. Methods: NECAT recruited 534 children aged 6–10 with at least two decayed posterior occlusal surfaces from urban Boston and rural Maine. After restoration of baseline caries and application of sealants to sound surfaces, NECAT continued to provide free comprehensive semiannual dental care to participants. The net caries increment of children who completed the 5‐year follow‐up (n = 429) was calculated and predictors of caries increment were investigated using multivariate negative binomial models. Results: The majority of children (89%) experienced new caries by the end of the 5‐year follow‐up. Almost half (45%) had at least one newly decayed surface by the first annual visit. At year 5, the mean number of new decayed teeth was 4.5 ± 3.6 (range 0–25) and surfaces was 6.9 ± 6.5 (range 0–48). Time trends showed a noticeably higher increment rate among older children and young teenagers. Multivariate models showed that age (P < 0.001), number of baseline carious surfaces (P < 0.001), and toothbrushing frequency (<1/day versus ≥2/day, P = 0.04) were associated with caries increment. Only 48 children (11%) did not develop new caries. Conclusions: Despite the receipt of comprehensive semiannual dental care, the vast majority of these high‐risk children continued to develop new caries within 5 years. While disparities were observed by age, extent of prior decay, and toothbrushing frequency, no other sociodemographic factors were associated with caries increment, suggesting that the dental care provided during the trial reduced sociodemographic disparities in prior caries experience that were observed at baseline.     

Prevalence and severity of dental caries among American Indian and Alaska Native preschool children

Objectives: To describe the Indian Health Service (IHS) oral health surveillance system and the oral health status of American Indian and Alaska Native (AI/AN) children aged 1‐5 years. Methods: A stratified probability sample of IHS/tribal sites was selected. Children were screened by trained examiners at community‐based locations including medical clinics, Head Start, preschools, kindergarten, and Women, Infants, and Children (WIC). Data collection was limited to the primary dentition and included number of teeth present plus number of teeth with cavitated lesions, restorations, and extracted because of decay. Number of molars with sealants and urgency of need for dental care data were also obtained. Statistical analyses were performed with SAS (SAS Institute Inc., Cary, NC, USA). Sample weights were used to produce population estimates based on selection probabilities. Results: A total of 8,461 AI/AN children 12‐71 months of age were screened at 63 IHS/tribal sites, approximately 7 percent of the estimated IHS user population of the same age. Overall, 54 percent of the children had decay experience, 39 percent had untreated decay, 7 percent had primary molar sealants, 36 percent needed early or urgent dental care, and 6 percent needed urgent dental care. The mean of decayed, missing, or filled teeth was 3.5 (95 percent confidence interval, 3.1‐3.9). The prevalence of decay experience increased with age; 21 percent of 1‐year‐olds and 75 percent of 5‐year‐olds had a history of caries. When stratified by IHS area, there were substantial differences in the oral health of preschool children. Conclusions: The results confirm that in the United States, AI/AN children served by IHS/tribal programs are one of the racial/ethnic groups at highest risk of caries.     

Oral health status and dental needs of autistic children and young adults

Aim: Children with autism might need more dental care than non‐autistic, healthy children. The aims of this study were: (a) to describe the caries experience and treatment needs of autistic children aged 6–16 years in the United Arab Emirates; and (b) to provide baseline data at national and regional levels to enable comparisons and future planning of dental services for children with autism. Methods: All children attending a day centre in Sharjah, United Arab Emirates, for autism were selected for the study. Sixty‐one autistic children aged 6–16 years (45 males and 16 females) were included in the study. Each patient received a complete oral and periodontal examination using codes and criteria as described by the World Health Organization. Results: The overall mean for Decayed, Missing, and Filled Teeth/decayed, missing, and filled teeth was 2.4. Female autistic children had significantly higher mean Decayed, Missing, and Filled Teeth/decayed, missing, and filled teeth scores (4.4) than males (1.63). The percentage of decayed, missing, and filled teeth increased with increasing age. The restorative index and met need index for the autistic children aged 11–15 years were 0.02 and 0.10, respectively. Conclusion: Effective oral health promotion strategies need to be implemented to improve the oral health status of autistic children.     

Oral health status of New Hampshire Head Start children, 2007‐2008

Objectives: We report on the baseline prevalence and severity of dental caries of children enrolled in the New Hampshire Head Start program during the 2007‐2008 school year. Methods: We selected a random cluster sample of 607 children aged 3‐5 years attending 27 Head Start centers across the state. Four volunteer dentists provided oral examinations and determined the presence of untreated dental caries, caries experience, and treatment urgency. Results: Overall, 40 percent of the participating children had experienced dental caries, and 31 percent had at least one untreated decayed tooth. Approximately 22 percent of the children had evidence of maxillary anterior caries, 23 percent were in need of dental care, and <1 percent needed urgent care. Conclusions: The prevalence of dental caries is comparable with that reported by Head Start programs elsewhere. The prevalence of caries affecting maxillary anterior teeth is higher. Further studies should examine state‐specific barriers to dental care among this population.     

Primary Language Spoken at Home and Children's Dental Service Utilization in the United States

Objective: Language barriers have been well documented as a contributing factor to disparities in the receipt of medical services, especially for Hispanic children. However, there is a paucity of information on the effect of language barriers on children's dental service utilization. We examined the association of primary language spoken at home with the receipt of preventive and routine dental care for children in the United States. Methods: We analyzed data from the Medical Expenditure Panel Survey (2002‐2004), which contains data on 21,049 children weighted to represent 75.8 million children nationally. Results: Among children aged 1‐18 years, 13 percent spoke a language other than English at home. Whites, females, children between the ages of 7 and 12 years, and those whose parents spoke English at home had the highest marginal rates of preventive and routine dental visits. However, the large marginal effect of language, even among Hispanics, was not significant after adjusting for other covariates. Parental education and having a primary provider were the strongest predictors of preventive and routine dental visits. Conclusion: Children that did not speak English at home were less likely to receive preventive or routine dental care. However, after adjusting for other socio‐economic factors, our study suggests that language barriers may not play as pronounced a role in the receipt of dental care as that documented for medical services.     

Increasing dental care utilization by Medicaid-eligible children: a dental care coordinator intervention

Objectives: The aim of this study was to determine the effect of a dental care coordinator intervention on increasing dental utilization by Medicaid-eligible children compared with a control group.
Methods: One hundred and thirty-six children enrolled in Medicaid aged 4 to 15 years at baseline in 2004 who had not had Medicaid claims for 2 years, were randomly assigned to intervention or control groups for 12 months. Children and caregivers in the intervention group received education, assistance in finding a dentist if the child did not have one, and assistance and support in scheduling and keeping dental appointments. All children continued to receive routine member services from the dental plan administrator, including newsletters and benefit updates during the study.
Results: Dental utilization during the study period was significantly higher in the intervention group (43 percent) than in the control group (26 percent). The effect was even more significant among children living in households well below the Federal Poverty Level. The intervention was effective regardless of whether the coordinator was able to provide services in person or via telephone and mail.
Conclusion: The dental care coordinator intervention significantly increased dental utilization compared with similar children who received routine Medicaid member services. Public health programs and communities endeavoring to reduce oral health disparities may want to consider incorporating a dental care coordinator along with other initiatives to increase dental utilization by disadvantaged children.     

A model for extending the reach of the traditional dental practice: the ForsythKids program

BACKGROUND: The authors describe and evaluate the short-term effectiveness of a community-based program for dental caries prevention in children. METHODS: The authors enrolled pupils in the ForsythKids program after receiving informed consent. They targeted children at six Massachusetts elementary schools, grades 1 through 3, with pupil populations at high risk of developing caries. The children underwent examination by dentists using calibrated technique and received comprehensive preventive care from dental hygienists. The authors determined effectiveness by means of comparing results of the initial examination with those of a second examination performed six months later. RESULTS: At baseline, 70 percent of the 1,196 participating children had decayed or filled teeth. More troublingly, 42.1 percent of the primary teeth and 31.1 percent of the permanent teeth had untreated decay. Six months after preventive intervention, the proportion of teeth with new decay was reduced 52 percent in primary teeth and 39 percent in permanent teeth. Furthermore, the percentage of children with newly decayed or restored primary and permanent teeth was reduced by 25.4 percent and 53.2 percent, respectively. CONCLUSIONS: These results indicate that this care model relatively quickly can overcome multiple barriers to care and improve children's oral health. CLINICAL IMPLICATIONS: If widely implemented, comprehensive caries prevention programs such as ForsythKids could accomplish national health goals and reduce the need for new care providers and clinics.     

Individualizing recall intervals in child dental care

Abstract Individualizing and extending recall intervals for children have been recommended in Norway to target resources efficiently. Recall intervals were changed for children aged 3–18 years in Drammen from 1991. Clinical time spent by dentists and dental hygienists, dental health status and length of recall intervals were registered from 1990 to 1993. For the child population, the mean recall interval changed from 12.5 to 13.7 months and the annual time spent per child was reduced by 14% from 1990–91 to 1992–93. Adjusted for the decline in number of new decayed teeth, the reduction in time spent was 11%. Children with intervals of 17 to 20 months had fewer new decayed teeth and their care required less personnel time than other children. For children with new decayed teeth, time spent for dental care was not associated with recall interval, while for children without new decayed teeth, longer recall intervals were associated with shorter time for dental care. The variation in number of decayed teeth and time spent for dental care was substantial at all intervals. Individualizing and extending recall intervals to some extent targeted resources at children with more dental disease. However, in the short run, inequality in dental health persisted. Limited extension of recall intervals did not interrupt the long-term trend toward better dental health in the children and substantial resources were saved in the dental services.     

Income gradients in oral health according to child age

This study aimed to confirm whether the well‐known income disparities in oral health seen over the life course are indeed absent in 9‐ to 11‐yr‐old children, and to explore the role of access to dental care in explaining the age‐profile of the income gradient in child oral health. We used data from the 2007 United States National Survey of Children's Health. Income gradients in parental reports of children's decayed teeth or cavities, toothache, broken teeth, bleeding gums, and fair/poor condition of teeth were assessed in stratified analyses according to age of child (1–5, 6–8, 9–11, 12–14, and 15–17 yr), using survey logistic regression to control for family‐, parental‐, and child‐level covariates. Health insurance status and use of preventive dental care were the indicators for children's access to dental care. The adjusted ORs for the effect of family income on having decayed teeth or cavities, toothache, and fair/poor condition of teeth were not significant in 9‐ to 11‐yr‐old children. Different age‐patterns were found for broken teeth and bleeding gums. The attenuation of the income gradients in having decayed teeth or cavities, toothache, and fair/poor condition of teeth, previously seen in 9‐ to 11‐yr‐old children, was also seen in 15‐ to 17‐, 12‐ to 14‐, and 6‐ to 8‐yr‐old children, respectively, after controlling for children's access to dental care. This study supports the attenuation of income inequalities in oral health in 9‐ to 11‐yr‐old children. Access to dental care could attenuate income gradients in oral health in other age groups.     

Maximum bite force and related dental status in children with deciduous dentition

Six hundred seventy-six Taiwanese children with deciduous dentition were sampled for maximum bite force and related dental status. Sixty-seven percent of children had at least one decayed tooth. The mean number of decayed teeth of all children was 2.97+/-3.58, and the mean plaque index of the right maxillary central incisor was 2.00+/-0.75. Twenty-seven percent of children had occlusal anomalies. Boys had a statistically significantly larger maximum bite force than did girls. Children with normal occlusion had statistically significantly larger maximum bite forces than did children with malocclusion. A statistically positive correlation was found between the number of decayed teeth and the plaque index. However, a statistically negative correlation was found between the number of decayed teeth and the maximum bite force and between the plaque index and the maximum bite force.     

Factors associated with access to dental care for children with special health care needs

BACKGROUND: The authors examined the relationship between receipt of routine medical care and receipt of dental care among children with special health care needs (CSHCN) who resided in the American Dental Association's Fifth Trustee District, which includes Alabama, Georgia and Mississippi. METHODS: The authors conducted a cross-sectional study using data from the 2001 National Survey of Children with Special Health Care Needs, a module of that year's State and Local Area Integrated Telephone Survey (sponsored by the U.S. Department of Health and Human Services' Maternal and Child Health Bureau of the Health Resources and Service Administration, Rockville, Md., and conducted by the Centers for Disease Control and Prevention, Atlanta). The authors used bivariate and logistic regression analyses to explore the relationships (n = 2,092) between predisposing, enabling and need factors and receipt of dental care. RESULTS: The parents of an estimated 76 percent of CSHCN in the district reported that their child had a need for dental care in the previous 12 months. Of these, 13.1 percent did not receive care. Failure to obtain needed dental care was associated with failure to obtain routine medical care, as was having a lower income. CONCLUSIONS: Failure to obtain routine medical care may be a risk factor for failure to obtain dental care. Any income below 400 percent of the federal poverty guidelines appears to be a barrier to receiving dental care for CSHCN. PRACTICE IMPLICATIONS: Providers of routine medical care may play an important role in linking CSHCN to dental care. Investigators need to examine other barriers to dental care for CSHCN. Strategies to optimize access to dental care for CSHCN at all income levels are needed.     

Patient-level and practice-level characteristics associated with receipt of preventive dental services: 48-month incidence

Objectives: This study aims to: a) quantify the incidence of preventive dental services [in‐office fluoride application and dental cleaning (prophylaxis)]; b) determine if these services are effectively targeted to patients with the highest need; and c) quantify the role of practice characteristics and patient‐level factors in service receipt. Methods: A population‐based prospective cohort study was conducted with 873 adults who had at least one tooth at baseline, 743 of whom provided 48‐month data. In‐person interviews and clinical examinations were conducted biennially for 48 months, with 6‐monthly telephone interviews in between. Dental records were abstracted afterward, and practices that served participants completed questionnaires. Analysis was limited to persons with at least one dental visit of any type during follow‐up (87 percent of the sample). Results: Only 9 percent of the persons received at least one fluoride application; 75 percent received a dental cleaning. Persons with high need were actually less likely to have received preventive services. In multivariable regression analyses, characteristics of the practice in which the subject received care were very strongly related to fluoride receipt, independent of patient‐specific characteristics. Conclusions: One preventive procedure was common; the other was uncommon. However, practices did not effectively target high‐risk patients for either procedure. Instead, both services were typically received by persons with the least need for them. These findings are consistent with the conclusion that practitioners greatly influenced the delivery of fluoride services, with substantial contributions also made by patient‐level predisposing and enabling factors for both preventive services.     

Determinants of dental care visits among low-income African-American children

BACKGROUND: The objective of the authors' analysis was to investigate the determinants of dental care visits among young, low-income African-American children. METHODS: Trained researchers interviewed a representative sample of low-income black families (caregivers and children aged 0 through 5 years) in Detroit to assess their dental visit history, dental insurance status and oral health behaviors. Dental examinations were conducted using the International Caries Diagnosis Assessment System (ICDAS). Of the 1,021 families who completed an interview and examination, a subset of the 552 children aged 3 to 5 years (and their primary caregivers) was the focus of this analysis. RESULTS: Children with private dental insurance had four times higher odds of having visited a dentist compared with those who had no dental insurance, and the odds for children receiving Medicaid were about 1.5 times higher. A child's age and a caregiver's educational attainment were positive and significant determinants of child dental visits. Caregivers who visited a dentist for preventive reasons were five times more likely to have taken their children to visit the dentist. Visiting a dentist was associated with an increased mean number of filled or missing tooth surfaces, but it was not significantly associated with the mean number of untreated decayed teeth. CONCLUSION: Children's dental insurance status was a significant determinant of their having visited a dentist. Even after the authors accounted for insurance status and other risk indicators, they found that children of caregivers who reported visiting a dentist for preventive care had a higher number of dental care visits. Determinants of caregivers' preventive dental visits must be identified and encouraged to improve the percentage of low-income children who visit dentists.     

Oral health status and access-to-care concerns of Suffolk County Head Start children

This study was undertaken to establish the caries prevalence in Head Start/Early Head Start children among the non-fluoridate community of Suffolk County, Long Island, and to elicit access-to-oral-health-care issues that are present for these children. Three hundred five parents completed questionnaire surveys about access-to-care issues at Suffolk County Head Start centers. Two hundred sixteen Suffolk County Head Start children ages 2 to 5 were screened for this study. The average DMFT (decayed, missing, filled teeth) across all children screened was 2.01. Fifty-four percent of parents reported that their children received dental care in the last two years. Twenty-four percent of children who received dental care reported having access-to-care issues. Of the parents who encountered such issues, the most prevalent one stated was, "We could not find a dentist to accept our insurance." The authors concluded that there is a heightened prevalence of early childhood caries in the Head Start/Early Head Start population of Suffolk County, Long Island. There are high levels of underutilized dental care in this population. The parents in this community have reported there are access-to-care issues present that may result in high levels of dental disease.     

Cost‐effectiveness of an experimental caries‐control regimen in a 3.4‐yr randomized clinical trial among 11–12‐yr‐old Finnish schoolchildren

The aim of this study was to assess the cost‐effectiveness of an experimental caries‐control regimen in a randomized clinical trial (RCT) conducted in Pori, Finland, in 2001–2005. Children (n = 497) who were 11–12 yr of age and had at least one active initial caries lesion at baseline were studied. The children in the experimental group (n = 250) were offered an individually designed patient‐centered regimen for caries control. The children in the control group (n = 247) received standard dental care. Furthermore, the whole population was exposed to continuous community‐level oral health promotion. Individual costs of treatment procedures and outcomes (DMFS increment score) for the follow‐up period of 3.4 yr were calculated for each child in both groups. The incremental cost‐effectiveness ratio was €34.07 per averted DMF surface. The experimental regimen was more effective, and also more costly. However, the total costs decreased year after year, and for the last 2 yr the experimental regimen was less expensive than the standard dental care. The experimental regimen would probably have been more cost‐effective than standard dental care if the follow‐up period had been longer, the regimen less comprehensive, and/or if dental nurses had conducted the preventive procedures.     

Longitudinal evaluation of the impact of dental caries treatment on oral health‐related quality of life among schoolchildren

This study aimed to evaluate the impact of dental caries treatment on oral health‐related quality of life (OHRQoL) among schoolchildren and the responsiveness of the Child Perceptions Questionnaire (CPQ_8‐10) instrument. Brazilian schoolchildren, 8–10 yr of age, were randomly selected and assigned to two groups – dental caries treatment (DCT) and caries‐free (CF) – according to their caries experience [decayed, missing, or filled primary teeth (dmft) and decayed, missing or filled secondary teeth (DMFT) values of ≥0]. The CPQ_8‐10 instrument was administered at baseline and at 4 wk of follow‐up (i.e. 4 wk after completion of dental treatment). In the DCT group, increases in CPQ_8‐10 scores were observed between the baseline and follow‐up results. However, longitudinal evaluation of the CF group demonstrated no statistically significant difference in CPQ_8‐10 scores. Responsiveness of the CPQ_8‐10 instrument (magnitude of change in CPQ_8‐10 scores) in the DCT group was greater (effect size >0.7) than in the CF group. The findings of this study show that dental caries treatment has an important impact on OHRQoL of children. The CPQ_8‐10 was considered an acceptable instrument for longitudinal measurement of changes in OHRQoL.     

Cariogenicity of soft drinks, milk and fruit juice in low-income african-american children: a longitudinal study

BACKGROUND: The authors conducted a study to test the hypothesis that high consumption of soft drinks, relative to milk and 100 percent fruit juice, is a risk factor for dental caries in low-income African-American children in Detroit. METHODS: Trained dentists and interviewers examined a representative sample of 369 children, aged 3 to 5 years, in 2002-2003 and again two years later. The authors used the 2000 Block Kids Food Frequency Questionnaire (NutritionQuest, Berkeley, Calif.) to collect dietary information. They assessed caries by using the International Caries Detection and Assessment System. RESULTS: Soft drinks, 100 percent fruit juice and milk represented the sugared beverages consumed by the cohort. A cluster analysis of the relative proportion of each drink at baseline and follow-up revealed four consumption patterns. Using zero-inflated negative binomial models, the authors found that children who changed from being low consumers of soft drinks at baseline to high consumers after two years had a 1.75 times higher mean number of new decayed, missing and filled tooth surfaces compared with low consumers of soft drinks at both time points. CONCLUSION: Children who consumed more soft drinks, relative to milk and 100 percent fruit juice, as they grew older were at a greater risk of developing dental caries. CLINICAL IMPLICATIONS: Health promotion programs and health care providers should emphasize to patients and caregivers the caries risk associated with consumption of soft drinks.     

Dental insurance and the oral health of preschool children

Using data from the Rand Health Insurance Experiment, the effects of cost-sharing plans on the health of the primary teeth in 264 children aged 3 to 5 years were investigated. From six areas in the United States, families were assigned at random to different dental and medical insurance plans. The plans varied in the amount of required cost sharing. Families participated in the study for 3 (70%) or 5 (30%) years. Children covered by the plan (requiring no cost sharing) had significantly fewer decayed teeth and deft (decayed, extracted, and filled teeth) at the end of the study than did children covered by the cost-sharing plans. No differences existed among plans in the number of extracted and restored teeth. Children of middle- and low-income families benefited most from having access to free dental care.