Faculty Bibliography

BACKGROUND:Dental care utilization for low income pregnant women is met with challenges in the traditional dentist-centered model of care. County-level measures provide insights for policy and roles for stakeholders that extend beyond the dentist-patient relationship. We examined county-level data to generate hypotheses about factors that influence utilization of dental services in North Carolina's Medicaid for Pregnant Women (MPW) program. METHODS:County-level Medicaid utilization data for dental services for 2014-2016 were pooled to get mean county estimates of dental utilization in the MPW program. Descriptive statistics and multivariate regression models of dental utilization and county-level measures are presented. Data used were collected by NC Child and the Robert Wood Johnson Foundation's County Health Rankings Reports. USDA Economic Research Service data were used to categorize counties in terms of Farming, Recreation, Persistent Poverty, and metro/non-metro status using Rural Urban Continuum Codes. RESULTS:Dental utilization ranged from 1-26% with a median of 8.5% across the 100 counties of North Carolina. Strong patterns linking utilization of dental services in the MPW program to contextual social measures of well-being emerged, specifically, increased reporting of child abuse and neglect, elevated infant mortality, poor quality of life, and worse ranking in years of potential life lost. Counties with persistent poverty had lower rates of dental utilization. CONCLUSIONS:Utilization of dental services in the MPW program is generally low. Patterns identify the potential for enhancing community-clinical linkages to improve birth outcomes and care coordination for pregnant women to enhance dental utilization in this population. Dental coverage in the Medicaid program in most states is administered separately from medical coverage. The separation of the funding mechanisms adds a further layer of complexity to care integration. Efforts to enhance dental care for pregnant women in the Medicaid program may benefit from policy that aligns incentives for care coordination within the community. Policy that extends the window of eligibility for dental benefits to 24 months after the birth of the child will help women complete the dental treatment that is needed. This also leverages the value of care coordination for community stakeholders from diverse child health sectors.

BACKGROUND:Spontaneous abortion, or miscarriage, is a complication of pregnancy which can severely affect women both physically and psychologically. We investigated the associations of periodontitis and periodontopathic bacteria with spontaneous abortion. METHODS:We conducted a matched case-control study in two tertiary hospitals in Khon Kaen, Thailand. Cases were 85 women with spontaneous abortion at < 20 weeks gestation matched to 85 controls on age, gestational age, and hospital. Full mouth periodontal examinations were performed. Periodontitis was defined as at least 1 site with probing depth ≥5 mm and clinical attachment level ≥2 mm at the same site. Subgingival plaque samples were collected to determine the levels of Porphyromonas gingivalis, Tannerella forsythia and Fusobacterium nucleatum using real time PCR. RESULTS:The cases were significantly more likely to have periodontitis (50.6%) than the controls (21.2%; p = 0.007). Conditional logistic regression revealed a crude odds ratio [OR] of 4.1 for the association between periodontitis and spontaneous abortion (95% confidence interval [CI] = 1.9-8.9, p = 0.001). The OR decreased, but was still significant, after controlling for previous miscarriage (OR = 3.3, 95%CI = 1.4-7.8, p = 0.006). There was no significant association between the levels of periodontopathic bacteria and spontaneous abortion. Increased levels of P. gingivalis and F. nucleatum were associated with periodontitis in both case and control groups. Association between increased T. forsythia levels and periodontitis was observed only in the case women. CONCLUSION/CONCLUSIONS:Periodontitis was more common in women with spontaneous abortions as compared to matched controls. Levels of periodontopathic bacteria was not associated with spontaneous abortion in this population.

Background/UNASSIGNED:The Obstetrics and Periodontal Therapy (OPT) study, a randomized controlled trial, reported no effect of periodontal treatment on preterm birth. Even though there were more spontaneous abortions or stillbirths in the control group, sensitivity analyses using conventional approaches did not change the results. The development of newer epidemiological methods to assess bias caused by the truncated outcome, and the availability of OPT study data in the public domain, allowed us to reanalyse these data. Methods/UNASSIGNED:We used the survivor average causal effect (SACE), also known as the principal strata effect, to correct potential bias resulting from unequal survival of fetuses in the treatment and control arms of the OPT study. Results/UNASSIGNED:The risks of preterm and spontaneous abortions or stillbirths were respectively 49/413 (11.86%) and 5/413 (1.21%) in the periodontal treatment group, and 52/410 (12.68%) and 14/410 (3.33%) respectively in the control group. The risk differences (%) comparing periodontal treatment and control groups were -0.82%: 95% confidence interval (CI) -5.30% to 3.67% for preterm birth, and -2.12%: 95% CI -4.14% to -0.11% for spontaneous abortions or stillbirths before correction. Risk differences for preterm birth comparing periodontal treatment and control groups increased in magnitude, reached statistical significance and showed a beneficial effect of periodontal treatment after correction for bias using SACE. Conclusions/UNASSIGNED:Periodontal treatment provided to mothers with mild to moderate periodontal disease before 21 weeks of gestation may prevent preterm births.

Purpose: The study objectives were to investigate the effect of silver diamine fluoride (SDF) on the microtensile bond strength between glass ionomer cement and carious primary dentin and evaluate the mode of restoration failure. Methods: Forty carious primary molars were sectioned in half through the middle of the carious lesion and randomly allocated to test and control groups. The test specimens were treated with 38 percent SDF, and the control, deionized water. The samples were stored in artificial saliva for 14 days at 37 degrees Celsius, and the dentin surfaces were conditioned and restored with Fuji IX GP Extra. After 24 hours in artificial saliva, the specimens were prepared for microtensile bond strength testing and stressed in tension at one mm per minute until failure. Mean bond strengths were compared using the paired t test. The failure mode was assessed with a stereomicroscope under 40X magnification. Results: The mean microtensile strength for the test group was 7.4 MPa (SD=±5.1) and 6.3 (±4.6) for the control group (P>0.05). Most common failure mode was the mixed failure mode in both groups. Conclusion: Silver diamine fluoride does not adversely affect the bond strength between glass ionomer cement and carious primary dentin in vitro.

Objectives/UNASSIGNED:To compare the glycemic control in non-smoking patients with type 2 diabetes according to their periodontal and dental status. Research design and methods/UNASSIGNED:This cross-sectional study investigated patients previously diagnosed with type 2 diabetes and under antidiabetic medication. Clinical data and fasting blood glucose (FBG) levels were collected from medical and dental records. Patients were divided into three groups according to dental and periodontal diagnosis: no or mild periodontitis (NO/MILD, n=96), moderate or severe periodontitis (MOD/SEV, n=74) and edentulous (n=141). FBG levels were compared between groups. Logistic regression was also applied to estimate the OR of presenting hyperglycemia. Results/UNASSIGNED:Edentulous patients had significantly higher FBG levels of 155.7±70.9 (mean±SD mg/dL) than those in the MOD/SEV (136.6±33.8) and the NO/MILD (123.1±36.7) groups. Differences between the latter two groups were also significant. Edentulous patients had adjusted ORs of 4.53, 4.27 and 3.95 of having FBG≥126, ≥150 and ≥180 mg/dL, respectively, in comparison with NO/MILD group. The MOD/SEV group also presented significant odds of having FBG≥126 mg/dL (OR=2.66) and ≥150 mg/dL (OR=2.45) than the NO/MILD group. Conclusions/UNASSIGNED:Patients in the MOD/SEV group had worse glycemic control than the ones in the NO/MILD group. However, edentulous patients presented higher glycemic levels than both dentate groups, and also presented with higher odds of having hyperglycemia.

OBJECTIVES: Caries in the primary dentition (CIPD) has a high prevalence in U.S. children compared to other diseases, with substantial disparities among different population groups. Few reports correlate CIPD prevalence with clinical impairment of children's quality of life, such as tooth pain, speech delay or trauma to the child from operative restorations, which we collectively term morbidity. Likewise, current case definitions (ECC, S-ECC) and disease metrics (mean dmfs/dmft) are not helpful in assessing morbidity for individual or groups of children. We describe a construct to stage caries severity for children ages 0 -5, called "CIPD Levels." This metric is based on small interval age-group dmft scores, and has a direct link to current and predicted morbidity for the child. It is modeled after staging systems for medical diseases in which the various stages or levels are correlated with the probability of morbidity or mortality. METHODS: We created a matrix in which CIPD Levels 0-4 are assigned for dmft scores 0-7 depending on a child's age. CIPD Level-4 is the highest level, and frequently results in clinical adverse outcomes, including pain and extensive restorations. We next tested this matrix with data from a high-risk population. RESULTS: Among children with any cavitated caries at age <24 months, 82.8% reached the adverse outcomes threshold (CIPD Level-4) at age 36 months. For children with dmft = 0 at 24 months, 71.4% did not reach CIPD Level-4 at age 36 months. CONCLUSION: Our new metric is useful for quantifying disease burden from caries for high-risk children.

Purpose: Randomized Controlled Trials (RCTs) are often subject to selection bias due to censoring, or loss to follow-up (LTF). The inverse probability weighting (IPW) method can be applied toRCT data with censoring to correct for selection bias and obtain an unbiased estimate of the effect of the randomized treatment on the outcome of interest. In this case study, IPW is applied to an RCT examining the effect of periodontal treatment on preterm birth among pregnant women with periodontal disease. Methods: Public-use data from the Obstetrics and Periodontal Therapy (OPT) Study (n-823), which is a RCT examining the effect of periodontal treatment on preterm birth among pregnant women with periodontal disease, were used. Authors concluded that periodontal treatment did not affect preterm birth. However, 5 women in the treatment group and 14 women in the control group experienced stillbirths, and thus were considered censored. In order to correct for selection bias due to censoring, IPW was utilized to create a pseudo-population where all participants were uncensored. Utilizing this pseudo-population, weighted Cox proportional hazards models were conducted to examine the effect of periodontal treatment on preterm birth had all participants been uncensored. Results: The unadjusted, unweighted hazard ratio for the effect of periodontal treatment on preterm birth was 1.04(95% CI-.90, 1.90), whereas the weighted hazard ratio was 1.02(95% CI-.88, 1.18). Although the new analysis yielded different estimates, the overall Conclusion remained unchanged. Conclusions: Periodontal treatment did not affect preterm birth after accounting for LTF during pregnancy using IPW. In this case study of the application of IPW to RCT data, the unweighted and weighted estimates for the effect of periodontal treatment on preterm birth did not differ. Nevertheless, IPW is an appropriate method to adjust for censoring in clinical trials to obtain an unbiased estimate of the randomized treatment effect

This paper describes an innovative public health intervention, called 'Smile Grenada', targeting the oral health of children in Grenada utilizing the resources of a US dental school, several oral health care companies, local governmental and public health authorities, and Grenadian school personnel. METHODS: Preintervention visual/tactile caries examinations were collected from 1,092 schoolchildren (mean age 9.9 years, standard deviation, SD = 3.7) in 2010. The intervention included: (1) classroom-based toothbrushing with fluoridated toothpaste, (2) fluoride varnish applied by trained dental students, teachers and local providers 3 times a year and (3) glass ionomer sealants placed on first permanent molars in children aged 6-8 years. Postintervention data were collected in May, 2013 (n = 2,301, mean age 9.8 years, SD = 3.7). Decayed and demineralized surfaces were examined for the whole sample and decay/demineralization and sealant retention on 6-year molars were examined separately (ages 6-8 in 2013 cohort). RESULTS: The number of decayed/demineralized surfaces declined across all age groups. The average number of decayed surfaces dropped from 9 at baseline to just over 6 (F1, 3,393 = 69.8, p < 0.0001) and the average number of demineralized surfaces dropped from 6 to less than 2 (1.8 surfaces; F1, 3,393 = 819.0, p < 0.0001). For children aged 6-8 years, there were statistically significantly fewer decayed surfaces (t1, 2,086 = 12.40, p < 0.0001; mean baseline 0.93, SD = 1.75; mean follow-up 0.23, SD = 0.83) and demineralized surfaces (t1, 2,086 = 19.7, p < 0.0001; mean baseline 2.11, SD = 2.74; mean follow-up 0.50, SD = 0.97) on 6-year molars. The Smile Grenada program successfully demonstrated a locally sustainable model for improving oral health in children in a developing country.

BACKGROUND: The authors tested hypotheses that more noxious family environments are associated with poorer adult and child oral health. METHODS: A community sample of married or cohabiting couples (N = 135) and their elementary school-aged children participated. Dental hygienists determined the number of decayed, missing and filled surfaces via oral examination. Subjective oral health impacts were measured by means of questionnaires completed by the parents and children. The parents completed questionnaires about interparental and parent-to-child physical aggression (for example, pushing) and emotional aggression (for example, derision), as well as harsh discipline. Observers rated the couples' hostile behavior in laboratory interactions. RESULTS: The extent of women's and men's caries experience was associated positively with their partners' levels of overall noxious behavior toward them. The extent of children's caries experience was associated positively with the level of their mothers' emotional aggression toward their partners. CONCLUSIONS: Noxious family environments may be implicated in compromised oral health. Future research that replicates and extends these findings can provide the foundation to translate them into preventive interventions. PRACTICAL IMPLICATIONS: Noxious family environments may help explain the limitations of routine oral health preventive strategies. Interprofessional strategies that also address the family environment ultimately may prove to be more effective than are single modality approaches.