Faculty Bibliography

INTRODUCTION/UNASSIGNED:Current economic evaluations of school-based caries prevention programs (SCPPs) do not compare multiple types of SCPPs against each other and do not consider teeth beyond permanent first molars. OBJECTIVES/UNASSIGNED:To assess the cost-effectiveness of a comprehensive SCPP relative to an SCPP focused on delivering sealants for permanent first molars only and to a default of no SCPP. Based on a societal perspective, a simulation model was used that compared the health and cost impacts on 1) permanent first molars only and 2) all posterior teeth. METHODS/UNASSIGNED:To calibrate the model, we used data from CariedAway, a comprehensive SCPP that used glass ionomer to prevent and arrest active decay among children. We then evaluated the incremental cost-effectiveness of implementing 3 alternate school-based approaches (comprehensive, sealant only, and no program) on only first molars and all posterior teeth. Probabilistic, 1-, and 2-way sensitivity analyses are included for robustness. Cost-effectiveness is assessed with a threshold of $54,639 per averted disability-adjusted life year (DALY). RESULTS/UNASSIGNED:We first compared the 3 programs under the assumption of treating only first molars. This assessment indicated that CariedAway was less cost-effective than school-based sealant programs (SSPs): the resulting incremental cost-effectiveness ratio (ICER) for CariedAway versus SSPs was $283,455 per averted DALY. However, when the model was extended to include CariedAway's treatment of all posterior teeth, CariedAway was not only cost-effective but also cost-saving relative to SSPs (ICER, -$943,460.88 per averted DALY; net cost, -$261.45) and no SCPP (ICER, -$400,645.52 per averted DALY; net cost, -$239.77). CONCLUSIONS/UNASSIGNED:This study finds that economic evaluations assessing only cost and health impacts on permanent first molars may underestimate the cost-effectiveness of comprehensive SCPPs 1) preventing and arresting decay and 2) treating all teeth. Hence, there is an urgent need for economic evaluations of SCPPs to assess cost and health impacts across teeth beyond only permanent first molars. KNOWLEDGE TRANSFER STATEMENT/UNASSIGNED:The results of this study can be used by policy makers to understand how to evaluate economic evaluations of school-based caries prevention programs and what factors to consider when deciding on what types of programs to implement.

BACKGROUND:The authors conducted a systematic review and meta-analysis to provide a summary estimate of the association between oral health and academic performance. TYPES OF STUDIES REVIEWED/METHODS:The authors conducted a systematic search of PubMed, Embase, and Google Scholar for studies on oral health, school absence, and academic achievement published in English from January 1945 through December 2017. Exposures included subjectively or objectively measured caries, oral pain, and periodontitis. Outcomes included school absence and school achievement. RESULTS:The authors screened a total of 2,041 studies, from which they extracted data from 14 studies of 139,989 children (12 cross-sectional studies, 1 case-control study, and 1 longitudinal study). Five studies had school absence as the primary outcome, and 7 studies had student achievement as the primary outcome. Three studies included both outcomes. The authors found no studies for periodontitis. The average modified Newcastle-Ottawa Scale score was 3.93. The authors rated 10 studies as having a low risk of bias and 4 as having a high risk of bias. Qualitative synthesis suggested that poor oral health may have negative effects on student absenteeism and achievement, but study quality was highly variable. Results from meta-analyses indicated that poor oral health was significantly associated with increased odds of poor academic performance (pooled odds ratio, 1.52; 95% confidence interval, 1.20 to 1.83) and absenteeism (pooled odds ratio, 1.43; 95% confidence interval, 1.24 to 1.63). CONCLUSIONS AND PRACTICAL IMPLICATIONS/UNASSIGNED:Increased focus on the broader implications of improvements in oral health for children, such as educational or socioemotional development, is of further interest to practicing dentists owing to the greater connection between oral health and general health. The authors of this study found that caries or tooth pain had a negative association with academic achievement and school absenteeism. However, study quality was limited by inconsistent exposure and outcome definitions and a predominance of cross-sectional designs. Thus, causal conclusions are not supported.

Following the 1983 A Nation at Risk report and culminating in No Child Left Behind (NCLB), states designed and implemented accountability policies to evaluate student achievement. External assessments of these policies identified substantial variability in the level of stakes associated with each system. This paper presents a comparative analysis of accountability policy prior to and during implementation of NCLB. Using the Virginia Standards of Learning and the Nebraska School-based Teacher-led Assessment and Reporting System, it explores the role of the historical and political context in shaping assessment policy through the lenses of the processes, conditions, and consequences of the policy process. It concludes that the influence of Nebraskan historical culture embedded the role of local action in the design and interpretation of accountability policy, which when combined with the collaborative efforts of the board of education, legislature, and executive branch, resulted in an atypical assessment model involving actors across the policy process. The Virginia experience was characterized by a strong political identity of centralization, yielding a top-down accountability system that constrained resources and opportunities for transforming policy at local levels. Findings demonstrate how comparable policy intentions for accountability are transformed due to existing state-level conditions and local policy culture.

BACKGROUND:Dental caries is the most prominent childhood disease in the world. In the United States, more than 50% of children have experienced caries. Untreated caries can have negative impacts on quality of life, academic performance, and school attendance. To reduce oral health disparities, multiple organizations recommend school-based caries prevention. METHODS/DESIGN/METHODS:A longitudinal, cluster randomized, non-inferiority trial will be conducted in low-income children from primarily Hispanic/Latino backgrounds currently enrolled in public elementary schools in New York City, New York, United States, from 2018 to 2023. The primary objective is to compare the non-inferiority of silver diamine fluoride and fluoride varnish versus glass ionomer therapeutic sealants and fluoride varnish in the arrest and prevention of dental caries. Secondary objectives are to evaluate differences in effectiveness when care is provided by nurses versus dental hygienists and assess the impact of prevention on oral health-related quality of life and educational outcomes. Caries arrest will be evaluated after 2 years, and caries prevention and secondary outcomes will be assessed at the completion of the study. Data analysis will follow intent-to-treat, and statistical analyses will be conducted using a two-sided significance level of 0.05. DISCUSSION/CONCLUSIONS:The comparative effectiveness of alternative caries prevention delivery models is considered to be one of the highest research priorities in the United States. Many treatments are currently available to prevent and arrest dental caries. The simplicity and affordability of silver diamine fluoride may be a viable alternative for the prevention of dental caries in high-risk children. TRIAL REGISTRATION/BACKGROUND:U.S. National Library of Medicine, www.clinicaltrials.gov , ID: NCT03442309 . Registered on 22 February 2018.

OBJECTIVES/OBJECTIVE:To compare common measures for dental caries in longitudinal caries research in support of a new measure, the Total Observed Caries Experience (TOCE). METHODS:TOCE was calculated as the total number of decayed or filled teeth ever observed. TOCE was compared to dmft, DMFT, and the prevalence of untreated decay using data from a 4-year, cluster randomized community-based caries prevention program. Outcomes were analyzed using generalized estimating equations and assessed change over time and effects across treatment groups. RESULTS:For TOCE and DMFT, the risk of caries over time increased. In contrast, risks decreased for dmft and the prevalence of untreated decay, driven largely by decayed primary teeth being exfoliated. Effects across treatment groups showed increased risk for some outcomes and attenuated risks in others; however, treatment effects for TOCE were more in line with expected results when compared with controls. CONCLUSIONS:TOCE accounts for caries on primary and permanent dentition and is not subject to bias due to exfoliation. It can be used as a robust measure to evaluate community-based caries prevention programs.

INTRODUCTION/BACKGROUND:Dental caries is the most prevalent childhood disease in the world and can lead to infection, pain and reduced quality of life. Multiple prevention agents are available to arrest and prevent dental caries; however, little is known of the comparative effectiveness of combined treatments when applied in pragmatic settings. The aim of the presented study is to compare the benefit of silver diamine fluoride and fluoride varnish versus fluoride varnish and glass ionomer therapeutic sealants in the arrest and prevention of dental caries. METHODS AND ANALYSIS/UNASSIGNED:A longitudinal, pragmatic, cluster randomised, single-blind, non-inferiority trial will be conducted in low-income rural children enrolled in public elementary schools in New Hampshire, USA, from 2018 to 2023. The primary objective is to compare the non-inferiority of alternative agents in the arrest and prevention of dental caries. The secondary objective is to compare cost-effectiveness of both interventions. Caries arrest will be evaluated after 2 years, and caries prevention will be assessed at the completion of the study. Data analysis will follow intent to treat, and statistical analyses will be conducted using a significance level of 0.05. ETHICS AND DISSEMINATION/UNASSIGNED:The standard of care for dental caries is office-based surgery, which presents multiple barriers to care including cost, fear and geographic isolation. The common intervention used in school-based caries prevention is dental sealants. The simplicity and affordability of silver diamine fluoride may be a viable alternative for the prevention of dental caries in high-risk children. Results can be used to inform policy for best practices in school-based oral healthcare. TRIAL REGISTRATION/BACKGROUND:NCT03448107. Pre-results.

Background/Purpose: Quality of life (QoL) is an integral parameter in understanding, assessing, and improving children's well-being across health conditions. Assessing oral health-related quality of life (OHRQoL) is crucial to evaluating patient well-being and measuring treatment efficacy in those with oral-facial conditions. The Child Oral Health Impact Profile (COHIP) is a validated instrument created to measure the OHRQoL of school-aged children (ages 8-18), yet no measure of OHRQoL exists for preschool children. The purpose of this study was to develop and validate a preschool version of the COHIP (COHIP-PS) for children aged 2 to 5. Methods/Description: A standard multistage process consisting of item selection, face validity testing, item impact testing, reliability and validity testing, and confirmatory factor analysis was used to develop the COHIP-PS. A cross-sectional convenience sample of caregivers with children 2 to 5 years old from 4 groups at varying locations completed the item clarity and impact forms. Groups were recruited from pediatric health clinics or preschools/day care centers, speech clinics, dental clinics, or cleft/craniofacial centers. Participants' children had a variety of oral health-related conditions, including caries, cleft lip and/or palate, or speech/language disorders.
Result(s): A total of 327 caregivers were included in the sample. Participants included caregivers from the cleft group (n = 81), speech group (n = 69), community group (n = 75), and dental group (n = 102). Approximately 84% of the overall caregiver sample were female, whereas 48% of the children were female. For children, 43% were white, followed by 33% Latino, 11% black, 7% Pacific Islander, 4.7% Other, and 1.5% Indian. For the cleft sample, children had cleft lip and palate (62%), cleft palate only (29%), or cleft lip only (9%). The COHIP-PS was found to have acceptable internal validity (= 0.71) and high test-retest reliability (0.87). Although discriminant validity results indicated significant differences across study groups, the overall magnitude of differences was modest. Results from confirmatory factor analyses support the use of a 4-factor model consisting of 12 items across oral health, functional well-being, socialemotional well-being, and self-image domains.
Conclusion(s): QoL is integral factor in understanding and assessing children's well-being. The COHIP-PS is a validated OHRQoL measure for preschool children with cleft or other oral conditions

The school and community context can contribute to inequity in child oral health. Whether the school and community affect the effectiveness of school-based caries prevention is unknown. The association between the school and community environment and dental caries, as well as their moderating effects with school-based caries prevention, was assessed using multilevel mixed-effects regression. Data were derived from a 6-y prospective cohort study of children participating in a school-based caries prevention program. For the school and community, living in a dental-shortage area and the proportion of children receiving free or reduced lunch were significantly related to an increased risk of dental caries at baseline. Caries prevention was associated with a significant per-visit decrease in the risk of untreated caries, but the rate of total caries experience increased over time. Caries prevention was more effective in children who had prior dental care at baseline and in schools with a higher proportion of low socioeconomic status students. There was significant variation across schools in the baseline prevalence of dental caries and the effect of prevention over time, although effects were modest. The school and community environment have a direct impact on oral health and moderate the association between school-based caries prevention and dental caries.Knowledge Transfer Statement:School-based caries prevention can be an effective means to reduce oral health inequity by embedding dental care within schools. However, the socioeconomic makeup of schools and characteristics of the surrounding community can affect the impact of school-based care.

BACKGROUND:Dental caries is the world's most prevalent childhood disease. School-based caries prevention can reduce the risk of childhood caries by increasing access to care. However, the optimal mix of treatment services, intensity, and frequency of care is unknown. METHODS:Data were derived from two prospective cohorts of US children participating in two caries prevention programs with different treatment intensities. One program provided primary and secondary prevention (glass ionomer sealants and interim therapeutic restorations) and one primary prevention only (glass ionomer sealants), both given twice yearly in six-month intervals. Primary study outcomes included untreated decay and the total observed caries experience. Analysis used generalized additive models to estimate nonlinear effects and trends over time. Results were compared to those estimated using generalized estimating equations and mixed-effects multilevel Poisson regression. RESULTS:Primary and secondary prevention combined did not significantly reduce total caries experience compared to primary prevention alone, but did reduce the risk of untreated decay on permanent dentition. Additionally, the rate of new caries experience was slower in the primary and secondary prevention group. Nonlinear trends for dental caries across both programs were statistically significant from zero (p < .001). CONCLUSION/CONCLUSIONS:Caries prevention consisting of primary and secondary prevention agents may be more effective than primary prevention alone in reducing the risk of tooth decay over time. Results suggest that the impact of caries prevention may not be constant over the medium- and long-term, suggesting reduced effectiveness with continued treatments.

OBJECTIVE:To explore factors related to completion of surgery recommendations among children with cleft lip and palate (CLP) or cleft palate only (CPO). DESIGN/METHODS:Multicenter prospective longitudinal cohort study (2009-2015). SETTING/METHODS:Six cleft centers in the United States. PATIENTS/PARTICIPANTS/METHODS:A diverse sample of 1186 youth aged 7.5 to 18.5 years with CLP or CPO and a caregiver. RESULTS:Data were collected from child-caregiver dyads at baseline and up to 3 follow-up visits. Of the 765 surgeries recommended during the study period, 83 were postponed and 597 were completed; this represents a completion rate of 78%. There were multiple reasons identified by patients for why the remaining 85 recommended surgeries were not completed. Children with nonprivate insurance were more likely to postpone recommended surgeries. Hispanic/Latino and Asian children had fewer surgeries compared to whites/Caucasians. Greater severity in rated speech differences was associated with more surgeries. Among participants who had completed all recommended surgeries, providers rated over 86% as having normal or mildly different facial appearance and 83% as having a normal or mild speech intelligibility rating. Similarly, caregivers rated 80% of facial appearance and 78% of speech positively. Approximately 25% of children had an additional surgical recommendation at the end of the study. CONCLUSIONS:The majority of surgical recommendations were completed with positive outcomes in facial appearance and speech intelligibility by provider and caregiver ratings. Several factors contributed to surgical recommendations not being completed and the results underscore the importance of examining socioeconomic and demographic disparities in surgical care.