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Efforts to improve pediatric oral health are underway in the Evergreen State, but work still needs to be done, according to the Washington State Department of Health’s 2015-2016 Smile Survey. For example, 53% of today’s third graders have had a caries experience, compared to 60% in 2005. Also, only 13% of third graders had decay in their permanent teeth, while the total was 24% in 2005. However, large gaps remain based on income, race, ethnicity, and language spoken at home.  

More than 13,000 kindergarten and second and third grade children in 76 public elementary schools participated in the Smile Survey, as well as more than 1,400 preschool children ages 3 to 5 years from 47 Head Start and Early Childhood Education and Assistance Programs. Each child received a dental screening completed by licensed dental hygienists and one dentist following the standardized protocol set by the Association of State and Territorial Dental Directors, and specific indicators for dental decay and dental sealants were noted. 

Overall, the survey shows that Washington is meeting or exceeding all of the federal Healthy People 2020 Oral Health Objectives for children ages 6 to 9 years. Also, 88% of these children were getting needed dental treatment, with a 12% rate of untreated decay for kindergarteners and second and third graders. Additionally, 14% of kindergartners had dental sealants, compared to 5% in 2010, and the 54% tally of third graders with sealants exceeds the Healthy People 2020 target of 28% and the national average of 32%.

The Department of Health attributes these improvements to initiatives like the Access to Baby and Child Dentistry Program, which connects low-income families with dentists who know how to care for young children, preventing tooth decay early and educating parents about how to take care of their children’s teeth. School-based dental sealant programs, community water fluoridation, preventive oral healthcare in pediatricians’ offices, and oral health education in early learning programs also were cited as drivers of this improvement.

By the third grade, however, children from low-income households still had at least 60% higher rates of decay experience and needed treatment at a 60% higher rate than their more affluent peers. Children of color in second and third grades had significantly higher rates of decay experience and 40% to 180% higher rates of treatment need than white children. Plus, kindergartners and third graders whose primary language spoken in the home was not English had more than a 50% higher rate of treatment need than English-only speakers. 

The preschoolers who were surveyed had a 17% rate of untreated tooth decay, which was lower than 2005’s rate of 26% but no different from 2010’s results. Also, their 13% rate of unmet treatment needs was lower than the 25% national average and Healthy People 2020 objective of 21%. Still, 45% had experienced tooth decay. And of those with decay, 21% had rampant decay, with 7 or more teeth affected. Washington is not meeting the Healthy People 2020 objective of 30% for caries experience in children ages 3 to 5. 

“The biggest challenge is that Washington has limited resources at the state and local levels to address oral health disparities for underserved populations,” said David Hudson of Community-Based Prevention at the Department of Health, who also noted that dentists have a role to play in improving the state’s oral health. “Dentists can provide care to underinsured and uninsured populations, including Medicaid patients, and encourage pregnant women to seek dental care before and during pregnancy.”

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The budget passed by the Arizona State Legislature and signed by Governor Doug Ducey on May 12 restores emergency dental benefits to adults in the state’s Medicaid program. The adult dental benefit was eliminated from the Arizona Health Care Cost Containment System (AHCCCS) during the Great Recession, prompting those in need of dental care to turn to emergency rooms for help.

“We can’t thank the governor and the legislature enough for recognizing this need. We’ve heard a lot about lack of access to dental care,” said Eric Curtis, DDS, president of the Arizona Dental Association (AzDA). “The best way to increase access is to break down barriers, which is what this budget item does. It’s the right diagnosis and solution.”

Emergency rooms aren’t staffed by dentists, so all doctors there could do to treat patients with toothaches or oral disease was triage the infection or ease the pain. The underlying problem would remain, ensuring repeat visits to the emergency room. The AzDA wanted the benefit restored so these patients could get appropriate, effective, and fiscally responsible care.

“We’d like to see more comprehensive benefits added for adult AHCCCS patients, but one step at a time,” said Curtis. “This is a major improvement that will help lower-income adults take care of serious health issues that can stand in the way of them getting employment.”

SB1527 sets a $1,000 cap for emergency dental care and extractions. The cost to the state is expected to be offset by reduced emergency room bills. The restoration of adult dental benefits is one of a number of initiatives that the AzDA has promoted to increase access to dental care. For example, the AzDA supported legislative changes approved 2 years ago to enable the use of teledentistry, extending a dentist’s reach into remote areas.

Also, legislation originated by the AzDA allows advanced practice hygienists and expanded function dental assistants with proper experience and training to perform additional duties for patients in the office and in remote or rural areas. Combined with teledentistry, these professionals are expected to greatly expand dentists’ reach into areas in need.

The AzDA also supports work to get more low-income children to dentists. Children have full dental coverage under AHCCCS, but fewer than half use the benefit. The AzDA is working with its partners on outreach to parents.

And, the AzDA supports community dental health coordinators, who come from the communities they serve and understand their cultures. These coordinators emphasize preventive services, helping families take control of their oral health while connecting them with dentists and hygienists.

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Pediatric severe obstructive sleep apnea (OSA) is most common among inner-city African-American children from low-income families in the Washington, DC, metropolitan area, according to the Children’s National Health System (CNHS). The organization’s researchers also have found that these children were most likely to have delayed diagnosis of severe OSA. 

“Earlier studies have shown that OSA is more prevalent among inner-city children,” said lead author Sasikumar Kilaikode, MD. “We wanted to see if this was the case in Washington, DC, as we have a large inner-city minority population. We also wanted to address the lack of data on the characteristics of severe OSA in inner-city children and adolescents.” 

OSA affects 3% of all children in the United States, impairing their ability to function in school and potentially leading to other significant health issues such as high blood pressure, heart disease, and diabetes. Severe OSA is defined as 10 or more events per hour in which the patient stops breathing, as measured in an initial sleep study.

The researchers looked at the medical records of 150 severe OSA patients seen in the CNHS Pediatric Sleep Center as well as their demographic variables, including where they live, their race and ethnicity, and their socioeconomic status. The vast majority of severe OSA patients were identified as African-American.

Also, African-American children had a 2-year median duration of symptoms before being diagnosed, or double that of white children. The regions with the most severe cases of OSA were those with the largest proportion of low-income and minority children: Prince George County, Md, and neighborhoods of Washington, DC, with the highest poverty levels.

“We have demonstrated that there is a critical need to focus care, resources, and education to identify and treat pediatric OSA in minority communities of inner-city areas. These children may be at the highest risk for severe OSA due to premature birth and a high prevalence of asthma and allergies. Lack of awareness at the family level delays reporting of symptoms and ultimately leads to delayed diagnosis,” said Kilaikode.

Pediatric dentists have a role in improving diagnosis and treatment, and they are an important part of the team in managing OSA in children, Kilaikode explained. For example, dentists can screen for symptoms such as snoring, gasping arousals, and observed apnea. Also, they can perform careful physical examinations of the oral and facial areas of children with positive symptoms.

“Our study and previous studies report that craniofacial abnormalities are an important cause of sleep apnea in children. So, dentists have an important role in identifying any structural abnormalities causing obstructions to breathing during sleep,” Kilaikode said. “Also, studies have been in progress about the use of dental appliances in the treatment of sleep apnea in children with dental or facial abnormalities contributing to the obstruction.”

Furthermore, dentists can encourage families to observe their children for sleep disordered breathing and report them early, she said. When positive symptoms are found, dentists can refer these children to a pediatric sleep center, where they can be evaluated and diagnosed with an overnight polysomnography, or sleep study. Early diagnosis and treatment may prevent unwanted complications in children, including neuro-cognitive impairment. 

“Our future directions include identifying barriers to timely diagnosis and early referral. We envision area-focused education and awareness for observing and reporting symptoms of OSA in children,” she said. “Our future plans also include providing awareness at the primary health provider level and reinforcing mandatory screening for symptoms of OSA during well-child visits. In addition, we plan to develop school and community based education initiatives.”

The results of the study were presented at the 2017 American Thoracic Society International Conference in Washington, DC.

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Errors happen in dentistry and across medicine, with the worst mistakes causing as many as 250,000 fatalities each year. Guidelines to normalize and encourage error disclosure are available to improve patient safety and healthcare outcomes, though they don’t address the psychology that influences how and when practitioners disclose errors and manage their consequences. Researchers now are calling for better education and training focused on these psychological challenges to reduce the number and severity of these errors. 

“We must transform the culture of error disclosure in the medical community from one that is often punitive to one that is restorative and supportive,” said Neha Vapiwala, MD, an associate professor of radiation oncology, vice chair of education at the Perelman School of Medicine at the University of Pennsylvania, and co-author of the study. “And to do that, we must tend to the psychological challenges that medical professionals wrestle with when they face the possibility of disclosing an error.” 

Initiatives such as the Disclosure, Apology, and Offer model have helped make moderate gains in creating a culture of transparency in health systems, according to the researchers. But these efforts primarily focus on the legal and financial aspects of error closure and do not address other barriers, such as the fear, shame, and guilt that come with error disclosure.

“Arguably, these psychological factors are harder to overcome, especially in this modern age of social media where healthcare providers can be reviewed and scrutinized in very public forums,” said Vapiwala. “There is real concern that any little slipup can live on the Internet for the rest of someone’s career.”

The researchers identified a pair of main cognitive biases that often hinder error disclosure: Fundamental Attribution Error, which is the tendency to overestimate one’s own role in a situation, and Forecasting Error, which is the tendency to overestimate the impact and duration of negative consequences while underestimating the ability to recover from those circumstances.

For example, if an error led to a patient injury, the physician might initially overstate his own role in that error rather than examine any systematic reasons for why that error occurred. The physician may then also overestimate the long-term consequences or recovery time for the patient, leading to feelings of both self-blame and exaggerated doom, both of which damage the physician-patient relationship and may impede a care provider from reporting the error.

“Overcoming these biases is akin to suppressing a reflex. It requires self-awareness, practice, and, most importantly, education and training,” Vapiwala said.

The authors offer several strategies to overcome these patterns, utilizing elements of social psychology to transform the current culture of error disclosure. Recommendations include incorporating standardized patients (SPs), actors who simulate patients not only to “practice” difficult patient encounters but also to help model interactions with family members, peers, and administrators to teach various behavior and coping mechanisms. SPs can effectively mimic the psychological elements of error disclosure, including profound guilt, feelings of ineptitude, and fear of repercussions, the researchers said. 

Virtual reality (VR) also can offer an immersive and realistic experience to supplement traditional curricula while providing tremendous scalability at a lower cost than SPs, the researchers said. For example, one recent VR exercise allowed viewers to experience the perspective of a 12-year-old Syrian refugee to incite more compassion and understanding. While similar VR medical content doesn’t currently exist, it is on the horizon for many medical trainees and professions. Still, SP and VR are limited, as users know they are using simulations. 

“Standardized patients and other simulated scenarios provide an excellent foundation. But until you are put into a real-world situation and forced to confront your mistake and its potential consequences, you can’t truly understand the psychosocial challenges,” said Jason Han, a fourth-year student at the Perelman School of Medicine and co-author of the study.

Finally, the researchers recommend implementing a professional standard for trainees, including a formal evaluation of the skills needed to disclose and cope with medical errors. This standard would further normalize error disclosure and make it a common practice among physicians and trainees, they said. The researchers conclude that the primary change will need to be cultural, not just among trainees but at every level of medical practice to successfully pivot away from the current stigma related to error disclosure.

“Administrators must make a shift from asking who is at fault to asking why and how did a situation occur, creating a culture that embraces error disclosure and seeks to solve the many systematic factors that led to an error in the first place,” Vapiwala said. “This approach will not only normalize error disclosures but also help us better understand why they happen so we can prevent more of them in the future.”

The study, “Applying Lessons from Social Psychology to Transform the Culture of Error Disclosure,” was published by Medical Education.

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The WannaCry ransomware attack hit more than 150 countries, locking up more than 300,000 computers and demanding a $300 payment before files could be restored. But that was only one incident, as the number of ransomware attacks increased more than 6,000% in 2016, according to IBM. Today, there are more than 9 million ransomware variants now active on the Internet. To help practices protect themselves, DDS Rescue offers a 12-step data security assessment. It includes: 

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Orthodontic treatment before the age of 18 years moderately improves oral health-related quality of life (OHRQoL), with the most improvement in emotional and social well-being, reports the University of Sheffield School of Clinical Dentistry. These findings are significant, according to the researchers, because there has been little evidence that orthodontic treatment improves OHRQoL until now.

“As practicing orthodontists, we are constantly being told by our patients that they are pleased they had their teeth straightened and that they are no longer embarrassed to smile or to be photographed. We wanted to find all the research that has tried to measure this effect with young people,” said Philip Benson, PhD, FDS, professor of orthodontics at the university and director of research of the British Orthodontic Society (BOS).

“We did a thorough search and found 13 studies that were relevant. Four of these studies used similar questionnaires to measure what young people thought about their teeth and how their dental appearance affects their life, before and after orthodontic treatment. We combined the data from these 4 studies to show that the improvement was measurable and moderately large in the areas of emotional and social well-being,” Benson said. 

The overall number of young people included in the research was relatively small, Benson added, so further research is needed. Hanieh Javidi, BDS, one of the study’s co-authors and who has just received the 2017 joint Faculty of Dental Surgery Royal College of Surgeons BOS Research Fellowship, will investigate OHRQoL in youth age 18 years and younger for her PhD research project.

Meanwhile, the British Orthodontic Society has launched “The BOS Guide: Better Teeth for Life,” an online resource that highlights the positive impact that orthodontic treatment can have on oral health and emotional well-being. It also provides patients with practical tips for achieving excellent results, all supported by the university’s study of orthodontics and OHRQoL in adolescents.

“The new BOS Guide demonstrates how life-enhancing orthodontic treatment can be,” said BOS president Alison Murray, BDS, MSc. “We know that patients in braces are encouraged to keep their mouths really clean, and there is evidence that once treatment has been completed, patients continue to look after their teeth. Orthodontics should be the start of a lifetime of excellent dental health.”

The study, “Does Orthodontic Treatment Before the Age of 18 Years Improve Oral Health-Related Quality of Life? A Systematic Review and Meta-Analysis,” was published by the American Journal of Orthodontics and Dentofacial Orthopedics.

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Dental anxiety is universal. According to a survey conducted by the Oral Health Foundation and Procter & Gamble in honor of National Smile Month, 67% of British adults are apprehensive about visiting a dental professional. Of those who worry, 33% are anxious about the discomfort of the treatment, while 26% worry about its costs.

Perhaps the anxiety is the result of poor oral health habits, the Oral Health Foundation and Procter & Gamble suggest. The survey found that 28% of those polled attempt to fix or improve their oral health just days before their visit to the dentist. Also, 50% had weakened enamel and 30% had tooth decay, likely caused by diets rich in sugar and acid.

“Cake culture and unhealthy options of high-sugar foods and drinks in vending machines and canteens are not only contributing to oral health problems but major issues with health overall, with increased levels of diabetes and obesity,” said Dr. Nigel Carter, CEO of the Oral Health Foundation.  

The Oral Health Foundation aims to turn these attitudes around with its National Smile Month campaign, May 15 through June 15. It encourages people to brush their teeth right before they go to sleep and at least one other time during the day with a fluoride toothpaste, reduce the number of sugary foods in their diet, and visit the dentist as often as recommended.

“Too often our oral health takes a backseat when we think about our overall health and well-being. This simply shouldn’t be the case,” said Carter. “National Smile Month is all about re-engaging the nation about the importance of a healthy mouth and the benefits our smile can have.” 

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If current consumers of sugar-free chewing gum increase their consumption by just one piece per day, $4.1 billion could be saved worldwide on dental expenditures from treating tooth decay each year, according to the Institute of Empirical Health Economics (IEHE). These savings would include $2.07 billion in the United States, $1.1 billion in Europe, and $149 million in China.

Chewing increases salivary flow, which helps remove leftover food debris while neutralizing and washing away the acids that are produced when food is broken down by the bacteria in plaque on teeth. This acid can break down tooth enamel. Also, the increased saliva provides more calcium and phosphate to help strengthen the enamel.

According to the ADA, chewing sugarless gum for 20 minutes after a meal can help prevent tooth decay. While sugarless gum should not replace brushing and flossing with a fluoride toothpaste twice a day and flossing once a day, the ADA reports, it can be an effective adjunct to oral care.

“In addition to the well-established clinical benefits, for the first time, this study models the reduction in the relative risk of tooth decay and subsequent cost savings for dental care as a result of increased consumption of sugar-free gum as part of a complete oral hygiene routine,” said Michael Dodds, BDS, PhD, lead oral health scientist with Wrigley, which funded the study and produces a range of sugar-free gum brands.

The study modeled the potential decrease in dental health costs from caries for 25 industrial countries. According to the researchers, 60% of dental service costs around the world are related to tooth decay, while 60% of all children and 90% of all adults have tooth decay. The IEHE and Wrigley both call for the inclusion of sugar-free gum in national oral healthcare advice, alongside other proven oral hygiene behaviors.

“While further studies are needed, these are exciting new insights that add to the extensive body of evidence on the benefits of sugar-free gum in oral care,” said Dodds.

The study, “A Global Approach to Assess the Economic Benefits of Increased Consumption of Sugar-Free Chewing Gum,” was published by the American Journal of Dentistry.

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