Associations between Dentition Status and Nutritional Status in Community-Dwelling Older Adults

Background/Objective: Older adults are at higher risk of malnutrition. The aim of this study was to explore associations between nutritional status and dentition status among older adults seeking care in a dental clinic. Methods: This was a cross-sectional study of data from older adults (65–89 y) who received care at a northeastern US urban dental school clinic between June 2015 and June 2020 (N = 305). Clinical and demographic data were obtained from the electronic health record; nutritional status was determined using the Self–Mini Nutritional Assessment (Self-MNA), and odontograms and digital radiography were used to determine dental data. Adjusted multivariable models were used to explore associations between variables. Results: The sample was 53.8% female with a median age of 72.0 y. The median Self-MNA score was 13, reflective of normal nutritional status; 29.5% were at risk of or had malnutrition. Median numbers of teeth and posterior and anterior occluding pairs of teeth (POP, AOP) were 18.0, 2.0, and 5.0, respectively. Those with normal nutritional status had significantly more teeth, POPs, and AOPs than those at risk of or with malnutrition (P = 0.015, P = 0.015, and P = 0.039, respectively). Every additional unit increase in the number of natural or restored teeth or POP was associated with significantly lower odds of being at risk of or with malnutrition (3% and 13%, respectively). Having functional dentition was associated with 46% lower odds of being at risk of or with malnutrition. Conclusion: This study demonstrated that older adults who had more teeth, better occlusion, and functional dentition were more likely to be of normal nutritional status than those who had less teeth, had poorer occlusion, and lacked functional dentition. Further research with larger, more diverse samples and varied measures of dentition are needed to better understand the associations between nutritional status and dentition status. Knowledge Transfer Statement: The findings from this study suggest that older adults with fewer teeth and therefore less efficient occlusion are at higher risk for malnutrition than those with more teeth and better occlusion. Health care professionals should include screening for dentition and malnutrition as part of their routine practice to identify patients who may have tooth loss and be at risk of malnutrition and refer them accordingly for interventions to optimize oral health and nutritional status.

Opposition to Early Dental Visit by Dentists: A Qualitative Study on Mothers’ Social Networks

Objectives: To examine whether information that mothers received from dentists in their social network was consistent with professional recommendations for the first dental visit at age 1 y. Methods: We performed a cross-sectional qualitative study on mothers in Pennsylvania and West Virginia from 2018 to 2020 to explore how their social networks influence their children’s dental service utilization. In-person, semistructured interviews were conducted with 126 mothers of children ages 3 to 5 y. Qualitative data were transcribed, coded, and analyzed using NVivo 12. Two investigators analyzed data using grounded theory and the constant comparative method. Results: Over half of mothers reported a professional relationship with a dentist as part of their social network on children’s oral health. Mothers described the following themes: 1) mothers contacted dentists in their social network for child dental information and to schedule their child’s first dental visit, 2) mothers described dentists’ justifications for the timing of the first dental visit older than age 1 y, 3) mothers described the impact of the dentist declining to see her child, and 4) after the dentist declined to see her child, some mothers did not comply with the dentist’s recommendation of delayed child dental visits because they were given alternative information that encouraged early dental visits. Conclusions: Our findings indicate a need for dentists to reinforce mothers’ dental-seeking behavior for young children and adhere to recommendations on the age 1 dental visit. Knowledge Transfer Statement: Qualitative data on mothers’ social networks show that dentists play a key role in access to early dental visits, particularly when dentists decline to see the mother’s child for visits.

Age of First Oral Health Examination and Dental Treatment Needs of Medicaid-Enrolled Children

Introduction: Early childhood caries (ECC), despite being preventable, remains the most prevalent disease of childhood, particularly in children between the ages of 2 and 5 y. The association between the type of health care provider completing initial oral health examinations and subsequent dental caries in children under 6 y of age is unclear. Objective: The objective of the current study is to longitudinally assess the association between age at first oral health examination and provider type at first oral health examination on dental treatment for children under 6 y of age. Methods: Deidentified administrative claims data were used from the IBM Marketscan Multi-State Medicaid Database (n = 2.41 million Medicaid-enrolled children younger than 6 y in 13 states from 2012 to 2017). A Kaplan–Meier survival analysis was used to examine the association between age at first oral health examination and provider type with first treatment of dental caries at follow-up. Results: The adjusted hazard ratio (HR) of dental caries for children whose first oral health examination at 4 y of age is 5.425 times higher than for children whose first oral health examination was before 1 y of age (95% confidence interval [CI], 5.371–5.479). The adjusted HR of dental caries for children seen by pediatric dentists (HR = 1.215; 95% CI, 1.207–1.223) and physicians (HR = 2.618; 95% CI, 2.601–2.635) was higher than those seen by a general dentist. Conclusions: Findings from this study highlight the importance of children having their first oral health examination no later than 12 mo of age in accordance with existing guidelines and referrals from physicians to prevent the need for invasive treatment. Knowledge of Transfer Statement: Results of this study emphasize the need for a child’s first oral health examination to be completed no later than 12 mo of age to prevent dental caries. Reinforcement and referrals by physicians based on this recommendation facilitate early establishment of a dental home in young children.

DEEP Study: Modeling Outcomes and Costs of Persistent Orofacial Pain

Persistent orofacial pain (POFP) affects patients’ daily lives and can lead to significant costs for them and/or the health service provider. This partial economic evaluation examined costs and utilities experienced by individuals with POFP over a 24-mo period and used these data to populate the life course Markov model used to estimate costs and quality-adjusted life years (QALYs) from pain onset over an individual’s life course while receiving usual health care. A total of 202 people receiving care for POFP were followed for 24 mo. Data were collected every 6 mo on pain-related disability (Graded Chronic Pain Scale dichotomized to low [0–IIa] or high [IIb–IV] pain-related disability states), health service utilization, and health-related quality of life measured by QALYs derived from the EQ-5D-5L. Unbalanced regressions were used to demonstrate how costs and QALYs varied according to participant characteristics with the results used to parameterize a Markov model. This probabilistic Markov model was used to estimate the outcomes for a cohort of POFP patients from age 25 y until death as determined by age- and sex-specific mortality rates. Across all time points, complete data were available from 129 participants. A high pain-related disability state led to significantly increased health care cost (£221; 95% confidence interval [CI], 87–355; P < 0.01) and a significant decrease in quality of life (mean difference, –0.08; 95% CI, –0.11 to −0.05; P < 0.0001) over a 24-mo period. The Markov model estimated that the average cost was £27,317 (95% CI, 26,558–28,046) and the average lifetime QALYs were 17.54 (95% CI, 17.38–17.71). The modeling suggests that a cohort of POFP patients from age 25 y would only accrue 18 QALYs per person before death. POFP therefore exerts a considerable impact on health, and it is likely more effective care (pathways) could realize substantial gains in terms of both treatment outcomes and health care utilization. Knowledge of Transfer Statement: Despite a substantial number of consultations, individuals experiencing the care pathways in this study continued to have far from perfect health over their life course. The modeling suggests they would only experience 18 y in “perfect health.” There is considerable scope to improve current care/outcomes and patient experience.

Resource Allocation in a National Dental Service Using Program Budgeting Marginal Analysis

Introduction: In any health system, choices must be made about the allocation of resources (budget), which are often scarce. Economics has defined frameworks to aid resource allocation, and program budgeting marginal analysis (PBMA) is one such framework. In principle, patient and public values can be incorporated into these frameworks, using techniques such as willingness to pay (WTP). However, this has not been done before, and few formal resource allocation processes have been undertaken in dentistry. This study aimed to undertake a PBMA with embedded WTP values in a national dental setting. Methods: The PBMA process was undertaken by a panel of participant-researchers representing commissioners, dentists, dental public health staff, and academics. The panel reviewed current allocations and generated a set of weighted criteria to evaluate services against. Services to be considered for removal and investment were determined by the panel and wider discussion and then scored against the criteria. Values from a nationally representative WTP survey of the public contributed to the scores for interventions. Final decisions on removal and investment were taken after panel discussion using individual anonymous electronic voting. Results: The PBMA process resulted in recommendations to invest in new program components to improve access to general dentists, care home dentistry, and extra support for dental public health input into local government decisions. Disinvestments were recommended in orthodontics and to remove routine scaling and polishing of teeth. Discussion: The PBMA process was successful in raising awareness of resource allocation issues. Implementation of findings will depend on the ability of decision makers to find ways of operationalizing the decisions. The process illustrates practical aspects of the process that future dental PBMAs could learn from. Knowledge Transfer Statement: This study illustrates a framework for resource allocation in dental health services and will aid decision makers in implementing their own resource allocation systems.

Dentists’ Attitudes Toward Dental Implant Maintenance in Thailand

Introduction: As implant therapy is a widely applied treatment modality, general dentists are in the frontline of maintaining health in patients with implants. It is however unknown to what extent general dentists are competent and feel prepared to deliver maintenance of implants to patients. Objectives: The aim of this study was to investigate the attitudes and self-reported and objectively assessed competences of general dentists with maintenance of dental implants in patients. Methods: A questionnaire designed and validated for the purpose of the study, including attitudes and self-reported and objectively assessed competences, was distributed by means of an online platform. Results: Data from 429 questionnaires were included in the study. Half of the participants were 28 to 33 y old and 78% had been working <10 y. Seventy-eight percent believed that dental implant maintenance should be performed by general dentists, but only 51% were prepared to do this, citing obstacles such as insufficient knowledge and limitations of their working environment. The mean ± SD objectively assessed competence score was 8.97 ± 2.74 of 17. There were significant differences (P < 0.001, 1-way analysis of variance) in the scores among dentists who offered the full range of maintenance and management of complications (10.83 ± 2.45) with those willing to provide comprehensive oral examination and implant maintenance only (9.31 ± 2.73), those offering comprehensive examination but unwilling to conduct maintenance (8.22 ± 2.28), and those who refer all dental implant patients elsewhere (7.2 ± 2.66). Around half of the dentists believed that implants last for life. Conclusions: While general dentists appeared to largely acknowledge the importance of providing implant maintenance care and present with positive attitudes, a large portion was unwilling to engage with maintenance of implants in patients and appeared to lack essential competences to this end. The main obstacles for providing implant maintenance care included insufficient knowledge and lack of a properly equipped clinical environment. Knowledge Transfer Statement: The results of this study can identify deficiencies in the currently available maintenance competences and schemes for patients with implants. These results can also help dental professionals, scientific bodies, and associations to design appropriate education and professional development strategies that can strengthen the confidence and competences of general dentists, thus offering better service to the public.

Child Sexual Abuse—Challenging Conditions for Adult Oral Health: A Qualitative Study

The aim was to analyze perceptions of oral health in adults who have been exposed to child sexual abuse. Eleven participants (10 women), 19 to 56 y of age, who had experienced sexual abuse as children were purposively selected and interviewed in-depth. The participants were encouraged to describe how they perceived the effect of the sexual abuse on their oral health as adults. The interviews were recorded digitally and transcribed verbatim. The collected material was analyzed according to qualitative content analysis. The theme “challenging conditions for maintaining oral health” was identified, comprising 2 categories: first, “the emotional significance,” with the subcategories 1) emotional barriers and 2) powerful relief, and second, “the obstacles to oral health,” with the subcategories 1) daily self-care with complications and 2) dental appointments with difficulties. The findings indicate that the experience of sexual abuse during childhood can have a negative impact on oral care in adulthood. The informants stated that oral health was of utmost importance but also associated with strong emotions. There were obstacles to maintenance of oral health that were difficult to surmount. Knowledge Transfer Statement:The study provides access to the attitudes of survivors of child sexual abuse regarding oral health and the needs and obstacles that they experience. This is important knowledge for dental professionals to optimize dental care.

Oral Health Status and Oral Health–Related Quality of Life of First Nations and Metis Children

Objectives: To assess the oral health status and oral health–related quality of life (OHRQoL) of young First Nations and Metis children. Methods: This cross-sectional study assessed the oral health status of Indigenous children <72 mo of age while their parents/caregivers completed a questionnaire, including the Early Childhood Oral Health Impact Scale (ECOHIS), to assess OHRQoL. Analysis included descriptive statistics, bivariate analyses, and multiple regression. A P value ≤0.05 was considered significant. Results: Overall, 146 children were recruited with a mean age of 40.1 ± 21.2 (SD) months, and 49% were male. Among First Nations children, 65.4% had early childhood caries (ECC) as compared with 45.2% among Metis children (P = 0.025). However, there was no statistically significant difference in the prevalence of severe ECC (S-ECC) between First Nations and Metis children (60.6% v. 42.9%, P = 0.051). The mean decayed, missing, and filled primary teeth (dmft) score was 4.9 ± 5.3 (range 0–20), and the mean decayed, missing, and filled surfaces (dmfs) score was 14.5 ± 20.4 (range 0–80). The total mean ECOHIS score was 4.4 ± 5.9 (range 0–25), while the mean Child Impact Section and Family Impact Section scores were 2.6 ± 4.0 (range 0–10) and 1.8 ± 2.8 (range 0–8), respectively. Multiple linear regression showed S-ECC was associated with total mean ECOHIS scores (P = 0.02). Higher total mean ECOHIS scores (which indicates poorer OHRQoL) were observed in children with ECC compared with caries-free children (5.8 v. 2.4, P = 0.0001). Conclusion: Oral health disparities such as ECC and reduced OHRQoL exist among many First Nations and Metis children in Manitoba. This is the first Canadian study exploring the OHRQoL of Indigenous children in addition to their oral health status. Knowledge Transfer Statement: This study is the first to report on the oral health–related quality of life and its relationship to early childhood caries (ECC) among young Canadian First Nations and Metis children. Metis children are just as likely to suffer from severe ECC than First Nations children. The findings of this study have informed community-based and community-developed oral health promotion and ECC prevention activities.

Physical Constraint in Pediatric Dentistry: The Lived Experience of Parents

Background: The use of physical constraint in pediatric dentistry is highly controversial. Papoose boards in particular, which envelop and immobilize children during treatment procedures, have been described as barbaric devices even though their goal is to protect the patient. In this debate, the voice of parents is important but still missing in the scientific literature. Aim: To understand how parents or caregivers experienced physical constraint and the use of the papoose board on their children during regular dental treatment. Design: We conducted qualitative research rooted in interpretive phenomenology. Accordingly, we performed in-depth individual interviews with a purposive sample of 7 parents or caregivers. The interviews took place in Montréal, Canada, after the children had been treated with a papoose board for nonemergency dental treatments. The discussions were audio recorded, transcribed, and thematically analyzed. Results: Two perspectives emerged among participants. Some explained that the papoose board calmed their children, helped the dentist to complete the procedures, and made their experience less stressful. For others, the papoose board was a horrible and traumatizing experience, leading to feelings of guilt toward their children. They expressed anger toward the dentists for not allowing them enough time to decide and for imposing use of the device. Conclusion Our study raises serious ethical concerns about this practice. We believe that using a papoose board should remain an extraordinary measure and, more generally, that dental professionals should reflect on the place of children and their families in clinical encounters. Knowledge Transfer Statement: The findings of this study should encourage policy makers, dental professionals and ethicists to consider the following points: 1) the traumatizing experiences described by parents raise serious ethical concerns about the use of papoose boards; 2) the dental profession should reflect on the place of children and their families in the clinical encounter and grapple with the importance of consent and how to ensure consent in encounters involving children and their parents.

Dental Erosion: Effect of Diet Drink Consumption on Permanent Dentition

Objective: The aim of this study is to examine the effect of diet drinks on dental erosion among a representative sample of US adults. Methods: Adult dietary and dental data were analyzed from the 2003–2004 cycle of the National Health and Nutrition Examination Survey. Erosion was measured with a modified tooth wear index and was analyzed as a dichotomous variable. Cluster analysis was performed, and the cluster number was based on having a separate diet drink cluster and the R2 values. Survey procedure and sample weights were used. Results: Most of the population (80%) had some form of dental erosive lesions. When compared with the total sample, people with erosion were more likely to be male (52.5%) and older. People with no erosive lesions were younger (42.3%) and non-Hispanic Black (21.2%). Cluster analysis resulted in 4 distinct clusters: high water, high diet drinks, high coffee/tea, and high soda. The respective percentage of individuals in each cluster who had erosion was 78.9%, 85%, 83.9%, and 76.2%, where the “high diet drinks” cluster showed the highest erosion ( P = 0.28). Logistic regression modeling showed that the “high diet drinks” cluster had increased odds of erosion (odds ratio = 1.27; 95% CI = 0.58 to 2.77) when compared with the “high water” cluster, but the relationship was not statistically significant. Conclusion: High diet drinks consumption slightly increased the odds of dental erosion among US adults, although this relationship was not statistically significant. It is thus not yet clear that dentists should recommend diet drinks, as they might be linked to systemic diseases. Further research is needed to explore more about risk factors of erosion. Knowledge Transfer Statement: The findings of this study are suggestive, though not significantly, that diet drinks may increase risk for dental erosion. While further research is needed, it is not clear that dentists should recommend these drinks as healthy substitutes for sugary drinks.