Service quality implications of dental undergraduate outreach teaching for Primary Care Trusts in England, UK

OBJECTIVE: Primary Care Trusts (PCTs) assumed new responsibilities for dentistry in 2005. In dental education it has been suggested that more emphasis is made of primary care outreach schemes. The paper considers the service quality implications of dental outreach teaching for PCTs with particular reference to access and acceptability. RESEARCH DESIGN AND CLINICAL SETTING: A pilot of outreach teaching for Manchester undergraduates in relation to adult dental care began in 2001. Six groups of eight students, working in pairs, spent one day per week in one of three community dental clinics in socially deprived areas. The evaluation of the first year used data from 908 patient treatment summaries, 139 patient questionnaires, and records of patient attendance. MAIN OUTCOME MEASURES: Access and acceptability measured by patients' demographic characteristics, patients' attendance at the clinics; patients' reasons for attendance, use of services and satisfaction with the service. RESULTS: In terms of access, the new service was used by local patients. Their main reasons for attending were convenience, a dental problem, free treatment, lack of access to a dentist, and lay referral. Some 41 percent attended initially because of an emergency, 30 percent said that if they had not attended the clinic they would have gone nowhere or did not know where they would have gone, and 49 percent had not attended a dentist for more than two years. In terms of acceptability most patients were positive about being treated by a student, 96 percent thought the quality of care excellent or good, and the same percentage said they would return to the clinic. The main areas of criticism were waiting times and appointments. CONCLUSIONS: Students can provide an accessible and acceptable local primary care dental service for adult patients in socially deprived areas as part of their undergraduate learning, and in a way that complements the existing services.     

School screening and parental reminders in increasing dental care for children in need: a retrospective cohort study

Objective: The objective of this study is to assess follow‐up dental care received by children given baseline screening and referrals as part of an ongoing clinical trial. Methods: A retrospective study with two cohorts of kindergarten children who had baseline and follow‐up (9 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. Results: A total of 303 children had dental exams at both time periods. At baseline, 42 percent (126/303) received referrals and among the referred group19 percent (24/126) received follow‐up care. A greater proportion with urgent referrals (10/30, 33 percent) received care than those with routine referrals (14/96, 15 percent). Baseline dmft decayed, missing, filled primary teeth and DMFT decayed, missing, filled permanent teeth 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 5 years and a greater number of missed days from work because of tooth problems. Conclusion: The rate of dental utilization was low even with school screening, referral and parental reminders among poor, largely minority inner‐city kindergarten children.     

Financing clinical dental education

Many reports have documented the growing financial challenges faced by dental schools. This article examines the financial implications of two new models of dental education: 1) seniors spend 70 percent of their time in community clinics and practices, providing general dental care to underserved patients, and 2) schools develop patient-centered clinics where teams of faculty, residents, and senior students provide care to patients. We estimate that the average dental school will generate new net revenues of about $2.7 million per year from the community-based educational programs for senior students and about $14 million per year from patient-centered care clinics. These are upper boundary estimates and vary greatly by school. The organizational and financial challenges of moving to these new educational models are discussed.     

Medicaid costs associated with the hospitalization of young children for restorative dental treatment under general anesthesia

OBJECTIVE: This paper examines the cost to the Iowa Medicaid program of hospitalizing young children for restorative dental care under general anesthesia, and describes the dental services received in this setting. METHODS: Medicaid dental claims for young children receiving restorative dental care under general anesthesia during fiscal year 1994 were matched with corresponding hospital and anesthesia claims. RESULTS: The total cost to the Medicaid program of treating a child in the hospital under general anesthesia was $2,009 per case. Less than 2 percent of Medicaid-enrolled children under 6 years of age who received any dental service accounted for 25 percent of all dollars spent on dental services for this age group, including hospital and anesthesia care. The most frequent type of procedure was stainless steel crowns (SSCs), with an average of almost six per case. CONCLUSIONS: Early identification, prevention, and intervention are critically important to prevent the costly treatment of children with ECC in hospital operating rooms.     

Community socioeconomic status and children's dental health

BACKGROUND: Although a substantial decline in dental caries has occurred among U.S. children, not everyone has benefited equally. The first-ever surgeon general's report on oral health in America indicates that the burden of oral diseases is found in poor Americans. This study investigates the relationship between community socioeconomic status, or SES, and dental health of children. METHODS: An oral health survey of 17,256 children, representing 93 percent of children residing in 62 Tennessee communities, was conducted in public elementary schools during the 1996-1997 school year. Portable dental equipment was used for examinations, and data from each examination were entered directly into a laptop computer. The authors performed analyses of covariance to examine the relationship between community SES (low/medium/high) and dental health, controlling for community fluoridation. RESULTS: Community SES was significantly related to caries experience in the primary teeth, the proportion of untreated caries in the primary and permanent teeth, dental treatment needs, dental sealants and incisor trauma. Overall, dental health was significantly worse for low-SES communities than for medium- and high-SES communities. CONCLUSION: The authors conclude that all specific dental indexes used to measure children's dental health in this study, with the exceptions of caries experience in the permanent teeth and sealant presence, were inversely related to the communities' SES. The percentage of children with dental sealants was directly related to the community's SES. PRACTICE IMPLICATIONS: Further improvements in oral health will necessitate that community-based preventive programs and access to quality dental care be made available to children who are identified as being at highest risk of experiencing oral disease.     

Associations between dental anxiety,dental treatment due to toothache,and missed dental appointments among six to eight-year-old Danish children: a cross-sectional study

The aims of this study were to estimate the prevalence of missed dental appointments among Danish children at 6 to 8 years of age and to examine the association between dental anxiety, dental treatment due to toothache, and missed dental appointments in a population-based cross-sectional study. The study was conducted in four municipalities in the County of North Jutland, Denmark, and included a total of 1235 children (response rate 74.1%). Data on missed dental appointments and toothache were obtained from dental records, and data on dental anxiety from the Children's Fear Survey Schedule–Dental Subscale. Overall, 37.7% of children missed one or more dental appointments, while 17.7% missed two or more appointments. These proportions did not differ by age or gender. Among children with dental anxiety, the adjusted OR for an association with two or more missed dental appointments was 1.32 (95% CI: 0.72–2.40), and among children who had dental treatment due to toothache, the adjusted OR of two or more missed dental appointments was 2.61 (95% CI: 1.63–4.18).     

Associations between dental anxiety, dental treatment due to toothache, and missed dental appointments among six to eight-year-old Danish children: a cross-sectional study

The aims of this study were to estimate the prevalence of missed dental appointments among Danish children at 6 to 8 years of age and to examine the association between dental anxiety, dental treatment due to toothache, and missed dental appointments in a population-based cross-sectional study. The study was conducted in four municipalities in the County of North Jutland, Denmark, and included a total of 1,235 children (response rate 74.1%). Data on missed dental appointments and toothache were obtained from dental records, and data on dental anxiety from the Children's Fear Survey Schedule-Dental Subscale. Overall, 37.7% of children missed one or more dental appointments, while 17.7% missed two or more appointments. These proportions did not differ by age or gender. Among children with dental anxiety, the adjusted OR for an association with two or more missed dental appointments was 1.32 (95% CI: 0.72-2.40), and among children who had dental treatment due to toothache, the adjusted OR of two or more missed dental appointments was 2.61 (95% CI: 1.63-4.18).     

Characteristics and study motivation of clinical dental students in Nigerian universities

A cross-sectional study of a cohort of 197 clinical dental students in the four accredited dental schools in Nigeria was conducted to determine the sociodemographic characteristics of these dental students and their motives for the choice of dentistry. The results indicate that the number of female dental students in Nigeria is increasing, which reflects a trend well established in virtually all other nations. The vast majority of Nigerian dental students (97 percent) qualified for school based on their performance on the University Matriculation Examination. About one-third, 32.5 percent, indicated that dentistry was their first choice for a career. This choice was greatly influenced by family in 50 percent of this group of students. There were several factors that strongly influenced career choice among students who indicated that dentistry was their first choice: interest, prestige, good employment opportunity abroad, and regular work hours. The need to go into a prestigious and financially lucrative profession similar to medicine were the commonest reasons identified by the group of students for whom dentistry was not the first career choice. The motives for choosing dentistry as a career in this group of students seem to relate to an image of dentistry as a vehicle for the achievement of personal goals. It is recommended that high school students be encouraged to see dentistry first hand. This is because in countries such as Nigeria it is not unusual for a potential dental student to have never visited the dentist.     

Mobile dental vans: planning considerations and productivity

OBJECTIVES: Many children, especially those from lower socio-economic families, have limited access to dental care, transportation problems and poor appointment attendance. Mobile dental clinics have been implemented in many communities to address these issues. METHODS: Structured surveys were sent to the three mobile programs in Connecticut to collect information on the age of the program, issues encountered in planning and implementation, and ongoing costs and productivity. RESULTS: Each mobile clinic had two operatories and operated 140-200 days per year. Programs provided 2921-3417 diagnostic and preventive procedures and 359-721 treatment procedures per year for an average daily production of 18-24 procedures. All programs required external funding to remain financially solvent. CONCLUSION: Implementation and management of these programs is complicated. However, they provide an innovative solution to bringing dental care to underserved children and when operated in conjunction with schools can eliminate transportation problems and missed appointments.     

Characteristics of publicly insured children with high dental expenses

BACKGROUND: Dental coverage is provided for all children with Medicaid in Washington State. The goal of this study was to illuminate the characteristics of a sample of Medicaid-enrolled children with high dental expenses. METHODS: Dental care utilization data for a 33-month period were obtained from Washington State's Medicaid database. For children, 0 to 6 years, these data were linked with a parent survey addressing oral health behaviors, knowledge, family history of caries, snacking patterns, and access to dental care. Children with dental expenses of $1,000 or more were classified as the "high-expense" group. Risk factors for the high-expense group were evaluated using multiple logistic regression. RESULTS: 345 children had at least one dental procedure including preventive and diagnostic care. Among these, 30 children (9 percent) incurred 64 percent of total dental expenses for the entire group. Parent perception of lack of dental coverage was associated with incurring high dental expenses. Children of Asian or Pacific Islander heritage were at disproportionately high risk compared to White children. Age of child and family history of caries were also associated with increased risk for high expenses. CONCLUSIONS: Not all low-income children on Medicaid are at high risk for caries. A combination of factors, including family history of caries and parent's perception of lack of dental insurance coverage, can potentially increase a child's likelihood for high-expense dental treatment. This study highlighted a small group of children with disproportionately high dental expenses. For some, earlier knowledge of coverage may have resulted in more timely access to preventive and diagnostic care, reducing the subsequent need for expensive restorative treatment.     

State case studies: improving access to dental care for the underserved

Introduction: This article, a supplement to the work of the Institute of Medicine's Committee on Oral Health Access, examines dental access disparities, reviews societal strategies for reducing disparities, explores the relationship between state level public health and dental safety net efforts and utilization/oral health outcomes, and describes selected public health and safety net programs with special promise. Methods: Data were obtained from interviews with state dental directors and safety net leaders and a review of the literature. Findings: There is a two-fold difference in utilization rates between low- (<30 percent) and high- (56 percent) income families. The three societal strategies for reducing disparities - Medicaid, dental safety net system, and increasing the supply of dentists - all have significant limitations. The primary factor positively related to oral health is per capita income. Five promising programs for reducing access disparities include a dental home initiative for young children; a virtual dental home for school children and nursing home residents; a women, infants, and children early oral education and prevention intervention program; an enhanced Medicaid reimbursement program for educational institutions in North Carolina; and a school-based dental care system run by Connecticut Federally Qualified Health Centers. Conclusions: There are wide disparities in access to dental care, and current societal strategies to reduce disparities have significant limitations. At the state level, the primary determinant of oral health status is per capita income. Several states have promising programs to reduce disparities but most are still at the demonstration level and have not been adequately evaluated.     

The impact of a state children's health insurance program on access to dental care

BACKGROUND: Access to dental care for low-income children is limited. The authors examined the impact of a new state children's health insurance program, or SCHIP, in North Carolina on children's access to dental care. METHODS: Parents of 639 school-aged children responded to two surveys that asked about their child's access to dental services before enrollment and one year after enrollment in the new program. The authors used two-tailed McNemar tests to detect statistically significant changes within subjects. RESULTS: The percentage of school-aged children with a visit to a dentist in the previous year increased from 48 percent at baseline to 65 percent after one year in the program. Reported unmet dental need decreased from 43 percent at baseline to 18 percent after one year of enrollment. The proportion of children reported to have a usual source of dental care improved after enrollment in the program. CONCLUSION: The SCHIP model in North Carolina is an innovative program that has made a significant impact on access to dental care for school-aged children. PRACTICE IMPLICATIONS: SCHIP dental programs that resemble private insurance models and reimburse dentists at rates close to market rates hold the potential to address problems associated with dental access for low-income children.     

Enrichment and recruitment programs at dental schools: impact on enrollment of underrepresented minority students

Dental schools have created summer enrichment and recruitment programs to increase enrollment of underrepresented and disadvantaged students. Enrichment programs strengthen students' academic skills in the areas of basic medical sciences, communications, test taking, and other learning strategies. The purpose of this study was to identify program characteristics of summer enrichment and recruitment programs and to determine which characteristics predicted participant enrollment in dental school. Twenty-three schools received a survey, and seventeen responded for a response rate of 74 percent. The majority of program participants were underrepresented minority (URM) students (program median=99 percent). The leading program goals were to increase minority enrollment (47 percent) and URM competitiveness (35 percent). The median program length was seven weeks and forty hours per week. Programs offered the following components: basic sciences (thirty-two median hours). DAT review/preparation (thirty median hours), introduction to dentistry (sixteen median hours), preclinical laboratory activities (sixteen median hours), and learning strategies (nine median hours). The length of program time in existence was a significant predictor of participant enrollment into dental school (R square=.320; p=.035). The overall median percentage for dental school enrollment in the study was 52.3 percent. The directors of six programs who place more than 60 percent of their students in dental school were interviewed. They reported that mentorship, institutional support, program structure, and admission policies were key factors contributing to success. It is concluded that recruitment and enrichment programs are a viable option to increase URM dental school enrollment.     

Exposures to blood and body fluids among dental school-based dental health care workers.

A survey of United States dental schools was conducted to determine the annual incidence of reported percutaneous and mucosal exposures to blood and other body fluids among dental school-based dental health care workers (DHCW). A response rate of 51.9 percent provided information on 10,433 DHCW and 1.6 million student clinic and 169,836 school-based faculty practice patient visits. This response represents approximately half of all DHCW and student clinic visits in U.S. dental schools in AY 1996/1997. A total of 652 exposures were reported, of which 629 occurred in student clinics. Dental schools averaged twenty-three reported exposures per year, and the overall annual reported exposure rate in student clinics was 4.0/10,000 patient visits and 1.3/10,000 in faculty practice. Dental students accounted for 62.5 percent of all reported exposures, a rate of 106.3/1000 students per year. The exposure rate for dental students was significantly greater that any other category of DHCW. Expressed in terms of person years, an exposure rate of 0.17 was comparable to that reported for dental schools but considerably less than found in other dental care settings. A second survey directed to individual DHCW drew responses from only 8.3 percent of the 10,433 DHCW. Among these respondents, 31 percent of those acknowledging an exposure reported it. A judgment that the injury was not serious, the time necessary to report an exposure, and a belief that the patient was healthy were the primary reasons for not reporting. The results of this study provide dental schools with benchmarks for comparing their reported exposure experience and assessing programs intended to prevent and manage exposures.     

Hypertension in a dental school patient population

Patient records were retrospectively reviewed to investigate the incidence of hypertensive patients seen at a U.S. dental school. This research was conducted to create an awareness of the current problems in diagnosing and treating hypertensive patients in the dental environment. Nine hundred and seventy-six records of patients seen between January 1, 1999 and January 1, 2000 were reviewed. Five hundred records that met specific study criteria related to health history, medications used, recorded blood pressure, and other criteria were selected for the study. Factors examined included demographic data consisting of age, sex, and ethnicity; history of hypertension; Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure classification; control of hypertension; and medications used. The data demonstrated that 32 percent of the patients were hypertensive, 49 percent of whom were unaware of their high blood pressure prior to their dental visit. Nearly 9 percent of the hypertensive patients with elevated blood pressure had to be immediately sent for medical consult before they could receive dental treatment. The average blood pressure of the hypertensive patients was systolic 145.6 and diastolic 87.9 with a range of 110 to 240 systolic, 60 to 135 diastolic. Of the diagnosed patients, 41.9 percent were taking antihypertensive medication for their condition, and 13 percent were taking two or more medications. Nearly one third of a sample of 500 dental school clinic patients had high blood pressure in this retrospective study. This study demonstrates that it is crucial that dental providers take blood pressure readings for screening, monitoring of hypertensive patients, and appropriate dental care.     

Public dental service utilization among adults in South Australia

Background:  Longitudinal patterns of public dental service use may reflect access issues to public dental care services. Therefore, patterns of dental service use among South Australian adult public dental patients over a 3½-year period were examined.
Methods:  Public dental patients (n = 898) initially receiving a course of emergency dental care (EDC) or general dental care (GDC) at baseline were followed for up to 3½ years. Patient clinical records were accessed electronically to obtain information on dental visits and treatment received at those visits.
Results:  Some 70.7 per cent of EDC and 51.3 per cent of GDC patients returned for dental treatment post-baseline. EDC patients returned within a significantly shorter time period post-baseline, received significantly more courses of care and were visiting more frequently than GDC patients. A greater proportion of EDC patients received oral surgery, restorative, endodontic and prosthodontic services, but fewer received periodontic services. EDC patients received significantly more oral surgery and fewer preventive services per follow-up year, on average, than GDC patients. Large proportions of EDC (52.4 per cent) and GDC (63.8 per cent) patients who returned sought emergency care post-baseline.
Conclusions:  Patients appeared to be cycling through emergency dental care because of lack of access to general care services, highlighting access problems to public dental care.     

Oral health status and access to dental care for ohio head start children

PURPOSE: The purpose of this survey were to assess the dental caries prevalence rate among children enrolled in Ohio's Head Start programs and assess factors relating to their dental care access. METHODS: Oral screenings were conducted on 2,555 children, ages 3 through 5 years, at 50 Ohio Head Start centers using probability-proportional-to-size sampling. In addition, parental responses to 6 access-oriented questions on the consent form were analyzed. RESULTS: Overall, 38% of 3- to 5-year-old Head Start children screened had experienced dental caries, and 28% had at least 1 untreated decayed tooth. Of the children with caries experience, 73% had decayed teeth, while the remaining 27% had restorations only. Among children, there were no statistically significant differences associated with race or payment method. With regard to dental care access, 11% of Head Start parents reported they could not get wanted dental care for their children during the previous 12 months, most often due to cost of care/lack of insurance. Nine percent of children had a toothache in the previous 6 months. Although 85% of Head Start children had visited a dentist in the previous 12 months, another 10% had never visited a dentist. CONCLUSIONS: The significant prevalence rate of dental caries among Ohio Head Start children is consistent with other states' reports. Although almost 9 of 10 children visited a dentist during the year, three fourths of children with dental caries did not have their care completed by the time they were screened during the second half of the school year. Oral health disparities according to race and payment source were not found among Ohio Head Start children.     

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.