OBJECTIVES: The Rocky Mountain Network for Oral Health (RoMoNOH) promotes the delivery of preventive oral health services (POHS) to children receiving care at community health centers (CHCs) in Arizona, Colorado, Montana, and Wyoming. One POHS is oral health goal setting (OHGS). This study aimed to evaluate the effect of OHGS during medical visits on parent/caregiver-reported oral health behaviors (OHBs). METHODS: The RoMoNOH implementation team trained CHC healthcare providers in POHS, including caries risk assessment, oral health education, fluoride varnish application, dental referrals, and parent/caregiver oral health engagement. To promote parents' oral health engagement, healthcare providers were trained in motivational interviewing (MI) with OHGS at medical visits. To evaluate the impact of MI with OHGS on parent/caregiver OHBs, a healthcare team member invited parents/caregivers to complete a baseline survey after their medical visits. The evaluation team sent a follow-up survey after 10-14 days. The surveys measured parents/caregivers' goals, confidence in goal attainment, OHBs, and sociodemographics; the follow-up survey also measured OHGS attainment. Improvement in parent/caregiver-reported OHBs was tested with a paired t-test and unadjusted and adjusted multiple linear regression. RESULTS: In total, 426 parents/caregivers completed the baseline survey; 184 completed both surveys. OHBs, including toothbrushing frequency, stopping bed bottles, drinking tap water, and brushing with fluoride toothpaste improved over the evaluation interval. After adjusting for covariates, brushing with fluoride toothpaste (p = 0.01), drinking tap water (p = 0.03), and removing bed bottles (p = 0.03) improved significantly. CONCLUSION: MI with OHGS with parents/caregivers during medical visits has potential to improve OHBs on behalf of their children.

PROBLEM: Interprofessional education (IPE) is valued but difficult to deliver, given logistical and other barriers. Centering IPE around patients and grounding it in authentic practice settings are challenging within early undergraduate medical education.

APPROACH: This intervention facilitated student-patient conversations to elicit patient reflections on the health care professionals who keep them healthy and care for them when they are unwell. After being introduced to the Interprofessional Education Collaborative (IPEC) core competencies, first-year medical (n = 127) and dental (n = 34) students conducted a brief semistructured patient interview, using an interview card with guiding questions, during a precepted outpatient clinic session in March-May 2021. Students transcribed patients' stories and wrote their own reflections on the interview card. These reflections were used as a stimulus for a class IPE discussion. The authors employed a pragmatic qualitative research approach to explore what students learned about interprofessional collaboration from reflecting on patients' stories.

OUTCOMES: Of the 161 students, 158 (98%) completed an interview card. Sixteen health professions were represented in patients' stories. The patients' stories prompted students to recognize and expand their understanding of the IPEC competencies. Students' responses reflected synthesis of the competencies into 3 themes: students value patient-centered holistic care as the goal of interprofessional collaboration; students reflect emerging professional and interprofessional identities in relating to patients, teams, and systems; and students appreciate interprofessional care is complex and challenging, requiring sustained effort and commitment.

NEXT STEPS: Next steps include continuing to integrate patient voices through structured conversations across the undergraduate and graduate medical education spectrum and adapting the model to support conversations with other health professionals engaged in shared patient care. These experiences could foster ongoing deliberate reflection by students on their professional and interprofessional identity development but would require investments in student time and faculty development.

OBJECTIVE: This study completed the development of a standardized patient-centered dental home (PCDH) framework to align and integrate with the patient-centered medical home. This study identified measure concepts and specific measures and standards to complete the 4-level measurement framework to implement and evaluate a PCDH. This study built on prior model development, which identified the PCDH definition and characteristics and the components nested within those characteristics.

METHODS: An environmental scan identified existing oral health care quality measure concepts, measures, and standards for rating by the project's National Advisory Committee (NAC). A modified Delphi process, adapted from the RAND appropriateness method, was used to obtain structured feedback from the NAC. NAC members rated measure concepts on importance and, subsequently, specific measures and standards on feasibility, validity, and actionability using a 1 to 9 rating scale. Criteria for model inclusion were based on median ratings and rating dispersion. Open-ended comments were elicited to inform model inclusion as well as identify additional concepts.

RESULTS: We identified more than 500 existing oral health care measures and standards. A structured process was used to identify a subset that best aligned with a PCDH for rating by the NAC. Four Delphi rounds were completed, with 2 rounds to rate measure concepts and 2 rounds to rate measures and standards. NAC quantitative ratings and qualitative comments resulted in a total of 61 measure concepts and 47 measures and standards retained for inclusion in the framework.

CONCLUSIONS: The NAC ratings of measure concepts, and specific measures and standards nested within those concepts, completed the 4-level PCDH measurement framework. The resulting framework allows for the development and implementation of core measure sets to identify and evaluate a PCDH, facilitating quality improvement and dental-medical integration.

KNOWLEDGE TRANSFER STATEMENT: Clinicians, payers, health care systems, and policy makers can use the results of this study to guide and assess implementation of the various components of a patient-centered dental home and to support dental-medical integration.

Poor oral health is associated with cardiovascular disease and dementia. Potential pathways include sepsis from oral bacteria, systemic inflammation, and nutritional deficiencies. However, in post-industrialized populations, links between oral health and chronic disease may be confounded because the lower socioeconomic exposome (poor diet, pollution, low physical activity) often entails insufficient dental care. We assessed tooth loss, caries, and damaged teeth, in relation to cardiovascular and brain aging among the Tsimane, a subsistence population living a relatively traditional forager-horticulturalist lifestyle with poor dental health, but minimal cardiovascular disease and dementia. Dental health was assessed by a physician in 739 participants aged 40-92 years with cardiac and brain health measured by chest computed tomography (CT) (n=728) and brain CT (n=605). A subset of 356 individuals aged 60+ were also assessed for dementia and mild cognitive impairment (n=33 impaired). Tooth loss was highly prevalent, with 2.2 teeth lost per decade and a 2-fold greater loss in women. The number of teeth with exposed pulp was associated with higher inflammation, as measured by cytokine levels and white blood cell counts, and lower body mass index. Coronary artery calcium and thoracic aortic calcium were not associated with tooth loss or damaged teeth. However, aortic valve calcification and brain tissue loss were higher in those that had more teeth with exposed pulp. Overall, these results suggest that dental health is associated with indicators of chronic diseases in the absence of typical confounds, even in a population with low cardiovascular and dementia risk factors.

Cross-sector collaborations are alliances among partners from various sectors, including health, education, and business, working together to address complex issues. These alliances are key to addressing inequities in maternal health outcomes. The seven chapters in this section outline examples of successful collaborations, provide information on barriers to, and facilitators of, successful collaboration, or describe opportunities to engage with traditional or nontraditional stakeholders invested in maternal health. Community engagement is also important in building cross-sector collaborations aimed at addressing inequities. The chapters of this section will give readers a better understanding of models for collaborations and community engagement that can be adapted and employed to address inequities in maternal health.

Introduction : This is the first study to use the Common-Sense Model of Self-Regulation (CSM) theory for oral health (OH) interventions in pediatric practices. The objective of this qualitative study was to assess adoption and implementation of theory-based multi-level OH interventions, by clinicians (pediatricians and nurse practitioners) participating in a cluster-randomized clinical trial (cRCT), to create an OH toolkit for widespread dissemination into pediatric practices. Methods : Semi-structured interviews were conducted at the conclusion of the cRCT with 21 clinicians from 9 practices participating in the intervention arm. Clinicians in this arm received CSM theory-based education and resources to deliver OH interventions to parents/caregivers and document in EMR. Semi-structured interview questions were based on the Diffusion of Innovations Theory, assessing adoption and implementation. The interviews were coded using NVivo (QRS International) software. Main themes were identified using a thematic analysis approach. Results : Five themes identified from the interviews included: strengths of theory-based OH training for clinicians, OH resources to improve quality of care, considerations for efficient future implementation, financial considerations, and parent benefits and challenges. Clinicians found that the theory-based training and resources increased knowledge and confidence when addressing OH with parents and required only ≤ 2 minutes in their workflow with no financial consequences. Clinicians reported an increase in OH awareness among parents but suggested an overall need for more pediatric dentists. Conclusions : The CSM theory-based education and resources were well received by clinicians and perceived to be beneficial without adverse impact on workflow or practice finances. An online toolkit is planned, as these OH interventions can be successfully implemented and delivered in medical settings.

PURPOSE: The annual teaching oral-systemic health (TOSH) virtual clinical simulation and case study activity exposes interprofessional teams of nurse practitioner, nurse midwifery, dental, medical, and pharmacy students to a virtual clinical simulation experience that uses oral-systemic health as a clinical exemplar for promoting interprofessional core competencies. The present study examines changes in participating students' self-reported interprofessional competencies following participation in virtual TOSH from 2020 to 2022. These findings are also compared to those from in-person TOSH (2019) to examine the equivalence of student outcomes of both the in-person and virtual programs. METHODS: A pre- and post-test evaluation design was used to examine the effectiveness of exposure to the TOSH program on self-reported attainment of interprofessional competencies for participating students using the interprofessional collaborative competency attainment scale. RESULTS: Analysis of pre- and post-surveys demonstrated statistically significant improvement in students' self-rated interprofessional experience competencies following the virtual TOSH program, which aligns with results from the in-person cohorts. Similar findings between the in-person and virtual cohorts indicated no statistically significant difference between the two formats. CONCLUSION: These findings demonstrate the success of TOSH in promoting attainment of interprofessional competencies among future health professionals. We encourage administrators and faculty who lead health professional programs to take advantage of using virtual simulations as an integral component of interprofessional oral health clinical experiences where students from different health professions learn from and about each other in assessing and treating patients across the lifespan.

PURPOSE: Oral health (OH) has significant effects on pregnancy and infant outcomes. This study assesses the perspectives of obstetrical clinicians about OH education and promotion. METHODS: A fifteen-item survey was developed and circulated to obstetrics and gynecology (OBGYN) and family medicine (FM) physicians, and other prenatal health clinicians in Massachusetts (MA). Additionally, eight physicians were purposively sampled for in-depth interviews to discuss their experience with prenatal OH training and practice. Bivariate relationships between outcome variables from the survey (e.g., previous OH training, awareness of OH guidelines, asking about OH during prenatal visits) were analyzed along with coding and analysis of the qualitative interview data. RESULTS: The majority (77%) of the 86 survey respondents did not feel well-trained in OH. We found significant associations between being well-trained in OH and: (1) awareness of state guidelines (X(2) = 11.85, p < 0.001); (2) asking about OH during prenatal visits (X(2) = 9.21, p = 0.002); and (3) routinely referring patients for dental care (X(2) = 15.35, p < 0.001). Lack of access to dental insurance and dental professionals were found to be major perceived barriers to care. Responses from the interviews reinforced these findings.

Dental caries affect 97% of the world's population during their lifetime. Early childhood caries are the number one chronic disease affecting young children, and it disproportionately affects children of low-income families. American Academy of Pediatrics recommends fluoridated toothpaste to all children starting at tooth eruption, regardless of caries risk. In addition, fluoride varnish is recommended in all children every 3 to 6 months from tooth emergence until they have an established dental home. The health disparities that are most apparent in the rural communities are inadequate prenatal care, low birth weight, cancer, chronic respiratory disease, heart disease, unintentional injury, and stroke. When it comes to oral health, water fluoridation is one of the most cost-effective strategies in preventing dental caries. The need for oral health education in physician assistant/associate (PA) programs is well documented. Implementation has largely been performed using interprofessional education. This article describes an interprofessional education program that teaches PA students to apply fluoride varnish so that they are practice-ready when they graduate and practice medicine.

The Oral Health Nursing Education and Practice Program (OHNEP), a core partner of the National Interprofessional Initiative on Oral Health, is a national initiative focused on implementing an interprofessional oral health workforce innovation to influence change in clinical education, practice, and policy. OHNEP aims to address oral health disparities by enhancing the nursing profession's role in integrating oral health and its links to overall health in both academic and clinical settings. Leveraging the opportunity to cultivate faculty, preceptors, and clinicians as oral health champions, OHNEP aims to integrate interprofessional oral health clinical content and competencies in undergraduate and graduate nursing programs through faculty and preceptor development, curriculum integration, and establishing oral health as a standard of care in clinical settings. Outcomes include widespread dissemination of OHNEP virtual products and resources used by a significant number of undergraduate and graduate programs nationwide. OHNEP has a notable impact on policy related to integrating oral health and its links to overall health in undergraduate and graduate nursing programs, thereby increasing interprofessional oral health workforce capacity and aiming to improve oral health equity.

Importance  Process-based quality measures are generally intended to promote evidence-based practices that have been proven to improve outcomes. However, due to lack of standardized implementation of diagnostic codes in dentistry, assessing the association between process and oral health outcomes has been challenging.

Objective  To estimate the association of adhering to dental quality measures with patient oral health outcomes.

Design, Setting, and Participants  Using a target trial emulation, a causal inference framework, this retrospective cohort study estimated the difference in the risk of developing tooth decay between US children who adhered to process-based dental quality measures (receiving topical fluoride and sealant [treated groups]) and those who did not (control groups). Electronic health records of US children and adolescents aged 0 to 18 years from January 1, 2014, to December 31, 2020, were used. To emulate random treatment assignment based on baseline confounders, coarsened exact matching was used to produce covariate balance between the treated and control groups. A time-to-event regression model produced effect estimates, adjusting for time-varying covariates. Near-far matching was used to account for unmeasured confounders as a sensitivity analysis. Data were analyzed from May 1 to August 7, 2023.

Exposures  Adherence to dental quality measures.

Main Outcomes and Measures  Incidence of tooth decay.

Results  Among 69 212 US children aged between 0 and 18 years (mean [SD] age, 10.2 [5.0] years; 49.5% male, 50.4% female, and 0.1% unknown or transgender), 1930 (2.8%) were Asian, 2038 (2.9%) were Black, 8667 (12.5%) were Hispanic, 33 632 (48.6%) were White, and 22 945 (33.2%) were multiracial, other, or missing racial and ethnic group identification. Relative to control individuals, treated individuals were more likely to be at elevated risk of caries (fluoride measure: 16 453 [76.5%] vs 15 236 [39.8%]; sealant measure: 2264 [54.6%] vs 997 [44.0%]) and have regular dental visits (fluoride measure: 21 498 [100%] vs 13 741 [35.9%]; sealant measure: 1623 [39.2%] vs 871 [38.4%]). Adherence to quality measures was associated with reduced risk of tooth decay with adjusted hazard ratios of 0.82 (95% CI, 0.78- 0.86) for fluoride and 0.86 (95% CI, 0.76-0.97) for sealant in the matched cohort. Benefits of adhering to quality measures were greater among children at elevated vs low risk and with public vs commercial insurance for both measures.

Conclusions  In this cohort study, adhering to dental quality measures was associated with reduced risk of tooth decay, and benefits were greater among children at elevated risk and with public insurance. These findings provide insights in facilitating targeted application of quality measures or developing more tailored quality improvement initiatives.

DATA SOURCES AND SEARCH STRATEGY: Seven databases (MEDLINE, CINAHL, Embase, Scopus, ProQuest, Cochrane and Google Scholar) were searched up to the third week in June 2022. Keyword search terms were based on four key concepts: oral health, primary health, strategies, and integration.

STUDY SELECTION: Peer-reviewed studies that evaluated any strategies to integrate oral health into primary care (e.g., guidelines, policies, workforce programmes) were included in the review. Eligibility was restricted to papers written in English language. Papers in non-primary care settings or which did not describe an evaluation were excluded. Two reviewers independently screened titles and abstracts and thereafter full texts. Disagreements were resolved by consulting a third reviewer.

DATA EXTRACTION AND SYNTHESIS: Data were extracted by one reviewer; a second person verified accuracy. Covidence was used for data extraction. Two independent reviewers critically appraised the papers using the relevant tools (e.g. Critical Appraisal Skills Programme, Cochrane Collaboration, and STrengthening the Reporting of Observational studies in Epidemiology). PRISMA flow diagram was used to present the study selection process. Review findings were reported using a narrative synthesis approach. The Health System Building Blocks (HSBB) was used as a basis for structuring the results/discussion. Heterogeneity among the included studies was high and therefore no meta-analysis was conducted.

RESULTS: Forty-nine studies were included, of which two were RCTs. Most studies described oral healthcare delivered by non-dental primary care professionals within primary care services. Other settings included community, schools, and care homes. Outcomes of interest included: access to oral healthcare, knowledge/attitudes/perceptions, change in dental caries estimates. Almost all studies, except two studies which found no difference in the outcomes measured, favoured an integration strategy. Integration was achieved by enhancing competency (e.g. oral health promotion-trained educators), re-orientating responsibilities of health professionals at an organisation level and/or policy changes (e.g. expanded health insurance policy coverage to include oral health). Integration strategies enhanced access through improved referral pathways, documentation processes, operating efficiency, the number of health staff on hand, increased visits for oral health issues, higher fluoride varnish application rates for children, and more visits to dental health professionals.

CONCLUSIONS: In this review, promoting an integrated approach for oral health was associated with improvements across a range of outcomes. Integrating oral health into primary care is complex but holds promise for reducing the burden of dental diseases. Identifying the best practice models of service integration requires further research and evaluation.

OBJECTIVES: Federally Qualified Health Centers (FQHCs) may be well positioned to facilitate dental visits during pregnancy for low-income women. We sought to compare receipt of dental visits during pregnancy for women who received prenatal care at an FQHC versus a non-FQHC setting.

METHODS: We analyzed Michigan Medicaid administrative data for all live birth deliveries between April 2018 and December 2020. We used billing data to categorize the predominant setting for prenatal care as occurring at a FQHC or a non-FQHC and claims data to identify dental visits during pregnancy (in the 9 months prior to delivery). We employed bivariate and multivariate analyses to explore the relationship between setting for prenatal care and dental visits during pregnancy.

RESULTS: Women who received prenatal care at an FQHC versus non-FQHC had a higher proportion of dental visits during pregnancy (31.85% vs. 19.37%, p < 0.0001). In multivariate analyses, the strongest predictors of having a dental visit during pregnancy were FQHC prenatal care setting, having a dental emergency visit, having ≥3 prenatal visits, and having Medicaid coverage throughout pregnancy. Hispanic or Black race/ethnicity and 2020 delivery year were predictors of a lower likelihood of a dental visit. These predictors were consistent for the overall population and for the subset who had no dental visits pre-pregnancy.

CONCLUSION: Medicaid-enrolled women who receive prenatal care at an FQHC are more likely to have a dental visit during pregnancy than their counterparts who receive prenatal care in a non-FQHC setting.

Importance  Hospital-acquired pneumonia (HAP) is the most common and morbid health care–associated infection, but limited data on effective prevention strategies are available.

Objective  To determine whether daily toothbrushing is associated with lower rates of HAP and other patient-relevant outcomes.

Data Sources  A search of PubMed, Embase, Cumulative Index to Nursing and Allied Health, Cochrane Central Register of Controlled Trials, Web of Science, Scopus, and 3 trial registries was performed from inception through March 9, 2023.

Study Selection  Randomized clinical trials of hospitalized adults comparing daily oral care with toothbrushing vs regimens without toothbrushing.

Data Extraction and Synthesis  Data extraction and risk of bias assessments were performed in duplicate. Meta-analysis was performed using random-effects models.

Main Outcomes and Measures  The primary outcome of this systematic review and meta-analysis was HAP. Secondary outcomes included hospital and intensive care unit (ICU) mortality, duration of mechanical ventilation, ICU and hospital lengths of stay, and use of antibiotics. Subgroups included patients who received invasive mechanical ventilation vs those who did not, toothbrushing twice daily vs more frequently, toothbrushing provided by dental professionals vs general nursing staff, electric vs manual toothbrushing, and studies at low vs high risk of bias.

Results  A total of 15 trials met inclusion criteria, including 10 742 patients (2033 in the ICU and 8709 in non-ICU departments; effective population size was 2786 after shrinking the population to account for 1 cluster randomized trial in non-ICU patients). Toothbrushing was associated with significantly lower risk for HAP (risk ratio [RR], 0.67 [95% CI, 0.56-0.81]) and ICU mortality (RR, 0.81 [95% CI, 0.69-0.95]). Reduction in pneumonia incidence was significant for patients receiving invasive mechanical ventilation (RR, 0.68 [95% CI, 0.57-0.82) but not for patients who were not receiving invasive mechanical ventilation (RR, 0.32 [95% CI, 0.05-2.02]). Toothbrushing for patients in the ICU was associated with fewer days of mechanical ventilation (mean difference, −1.24 [95% CI, −2.42 to −0.06] days) and a shorter ICU length of stay (mean difference, −1.78 [95% CI, −2.85 to −0.70] days). Brushing twice a day vs more frequent intervals was associated with similar effect estimates. Results were consistent in a sensitivity analysis restricted to 7 studies at low risk of bias (1367 patients). Non-ICU hospital length of stay and use of antibiotics were not associated with toothbrushing.

Conclusions  The findings of this systematic review and meta-analysis suggest that daily toothbrushing may be associated with significantly lower rates of HAP, particularly in patients receiving mechanical ventilation, lower rates of ICU mortality, shorter duration of mechanical ventilation, and shorter ICU length of stay. Policies and programs encouraging more widespread and consistent toothbrushing are warranted.

Abstract

Tooth decay is the most common chronic disease in children, and children often see their primary care practitioners more frequently than dentists (Adjaye-Gbewonyo and Black 2019-2020; National Center for Health Statistics 2019-2020). This Infant Oral Health Education Program included two online training sessions for trainees in social work, nursing, medicine, and dentistry. Trainees were assessed on anticipated changes to their practice related to children's oral health. During the first training session, trainees received a lecture on infant oral health, and then discussed a case study in interprofessional groups to reinforce the content. Trainees in medicine and nursing completed training to receive Medicaid reimbursement for performing preventive oral health services. The second training session was profession specific with tailored instructions in the form of videos, as well as a demonstration on fluoride varnish application. Of the 78 trainees (22 social work, 4 pediatric nurse practitioner, 38 pediatric medicine residents, and 14 pediatric dentistry residents), 91% (n=70) reported that they were introduced to at least one new health information resource or tool. Four-fifths of the eligible trainees (n=16/20, 80%) who completed the evaluation had fulfilled the State's requirements to receive Medicaid reimbursement for performing preventive oral health services. Three-fourths of trainees (n=22/29, 75%) reported that they are likely to promote children's oral health in future clinical practice. Trainees from all four professions provided positive feedback about the content.

Abstract

Objectives: The Rocky Mountain Network for Oral Health (RoMoNOH) promotes the delivery of preventive oral health services (POHS) to children receiving care at community health centers (CHCs) in Arizona, Colorado, Montana, and Wyoming. One POHS is oral health goal setting (OHGS). This study aimed to evaluate the effect of OHGS during medical visits on parent/caregiver-reported oral health behaviors (OHBs).

Methods: The RoMoNOH implementation team trained CHC healthcare providers in POHS, including caries risk assessment, oral health education, fluoride varnish application, dental referrals, and parent/caregiver oral health engagement. To promote parents' oral health engagement, healthcare providers were trained in motivational interviewing (MI) with OHGS at medical visits. To evaluate the impact of MI with OHGS on parent/caregiver OHBs, a healthcare team member invited parents/caregivers to complete a baseline survey after their medical visits. The evaluation team sent a follow-up survey after 10-14 days. The surveys measured parents/caregivers' goals, confidence in goal attainment, OHBs, and sociodemographics; the follow-up survey also measured OHGS attainment. Improvement in parent/caregiver-reported OHBs was tested with a paired t-test and unadjusted and adjusted multiple linear regression.

Results: In total, 426 parents/caregivers completed the baseline survey; 184 completed both surveys. OHBs, including toothbrushing frequency, stopping bed bottles, drinking tap water, and brushing with fluoride toothpaste improved over the evaluation interval. After adjusting for covariates, brushing with fluoride toothpaste (p = 0.01), drinking tap water (p = 0.03), and removing bed bottles (p = 0.03) improved significantly.

Conclusion: MI with OHGS with parents/caregivers during medical visits has potential to improve OHBs on behalf of their children.

Medical-dental integration is recognized as a promising, whole-health approach to preventing disease and addressing the unmet dental needs of vulnerable populations. However, what exactly does this approach entail and what work is being done to make it more of a reality? As more and more providers continue to acknowledge the benefits of medical-dental integration, have we reached a tipping point where this model will inevitably become the standard of care?

IMPORTANCE: Dental caries and periodontal disease are common adult oral health conditions and potentially amenable to primary care screening and prevention.

OBJECTIVE: To systematically review the evidence on primary care screening and prevention of dental caries and periodontal disease in adults to inform the US Preventive Services Task Force.

DATA SOURCES: MEDLINE, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews (to October 3, 2022); surveillance through July 21, 2023.

STUDY SELECTION: Diagnostic accuracy studies of primary care screening instruments and oral examination; randomized and nonrandomized trials of screening and preventive interventions; cohort studies on primary care oral health screening and preventive intervention harms.

DATA EXTRACTION AND SYNTHESIS: One investigator abstracted data; a second checked accuracy. Two investigators independently rated study quality. Diagnostic accuracy data were pooled using a bivariate mixed-effects binary regression model.

MAIN OUTCOMES AND MEASURES: Dental caries, periodontal disease, morbidity, quality of life, harms; and diagnostic test accuracy.

RESULTS: Five randomized clinical trials, 5 nonrandomized trials, and 6 observational studies (total 3300 participants) were included. One poor-quality trial (n = 477) found no difference between oral health screening during pregnancy vs no screening in caries, periodontal disease, or birth outcomes. One study (n = 86) found oral health examination by 2 primary care clinicians associated with low sensitivity (0.42 and 0.56) and high specificity (0.84 and 0.87) for periodontal disease and with variable sensitivity (0.33 and 0.83) and high specificity (0.80 and 0.93) for dental caries. Four studies (n = 965) found screening questionnaires associated with a pooled sensitivity of 0.72 (95% CI, 0.57-0.83) and specificity of 0.74 (95% CI, 0.66-0.82) for periodontal disease. For preventive interventions no study evaluated primary care counseling or dental referral, and evidence from 2 poor-quality trials (n = 178) of sealants, and 1 fair-quality and 4 poor-quality trials (n = 971) of topical fluorides, was insufficient. Three fair-quality trials (n = 590) of persons with mean age 72 to 80 years found silver diamine fluoride solution associated with fewer new root caries lesions or fillings vs placebo (mean reduction, -0.33 to -1.3) and decreased likelihood of new root caries lesion (2 trials; adjusted odds ratio, 0.4 [95% CI, 0.3-0.7]). No trial evaluated primary care-administered preventive interventions.

CONCLUSIONS AND RELEVANCE: Screening questionnaires were associated with moderate diagnostic accuracy for periodontal disease. Research is needed to determine benefits and harms of oral health primary care screening and preventive interventions.

IMPORTANCE: Oral health is fundamental to health and well-being across the life span. Dental caries (cavities) and periodontal disease (gum disease) are common and often untreated oral health conditions that affect eating, speaking, learning, smiling, and employment potential. Untreated oral health conditions can lead to tooth loss, irreversible tooth damage, and other serious adverse health outcomes.

OBJECTIVE: The US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate screening and preventive interventions for oral health conditions in adults.

POPULATION: Asymptomatic adults 18 years or older.

EVIDENCE ASSESSMENT: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for oral health conditions (eg, dental caries or periodontal disease) performed by primary care clinicians in asymptomatic adults. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of preventive interventions for oral health conditions (eg, dental caries or periodontal disease) performed by primary care clinicians in asymptomatic adults.

RECOMMENDATIONS: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of routine screening performed by primary care clinicians for oral health conditions, including dental caries or periodontal-related disease, in adults. (I statement) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of preventive interventions performed by primary care clinicians for oral health conditions, including dental caries or periodontal-related disease, in adults. (I statement).

IMPORTANCE: Fluoride varnish reduces children's tooth decay, yet few clinicians provide it. Most state Medicaid programs have covered this service during medical visits for children aged 1 to 5 years, but private insurers began covering it only in 2015 due to the Patient Protection and Affordable Care Act (ACA) mandate that they cover a set of recommended preventive services without cost-sharing. Evidence on clinicians' behavior change postmandate is limited.

OBJECTIVE: To examine monthly changes in fluoride varnish applications among pediatric clinicians following the ACA mandate.

DESIGN, SETTING, AND PARTICIPANTS: Using all-payer claims data from Massachusetts, this cohort study applied an interrupted time-series approach with linear regression models comparing changes in monthly clinician-level outcomes before and after the mandate. Participants included clinicians who billed at least 5 well-child visits for patients aged 1 to 5 years and were observed at least once premandate. Adjusted for clinician fixed effects, models were assessed overall and separately for clinicians categorized by their monthly share of well-child visits paid by private insurers before the mandate: mostly private (>66% of visits paid by private insurers), mostly public (<33% of visits paid by private insurers), or mixed (33%-66% of visits paid by private insurers) insurance types. Analysis was performed from June 1, 2022, to July 31, 2023.

EXPOSURE: Preenactment and postenactment of the ACA mandate for private insurers to cover fluoride varnish applications without cost-sharing.

MAIN OUTCOMES AND MEASURES: Clinician-month measures of whether fluoride varnish was provided during at least 1 well-child visit and the share of such visits, analyzed separately for clinicians who did and did not apply fluoride varnish premandate.

RESULTS: The sample included 2405 clinicians, with 107 841 clinician-months. Premandate, 10.48% of the visits included fluoride varnish applications. Two years postmandate, the likelihood of ever applying fluoride varnish was 13.64 (95% CI, 10.97-16.32) percentage points higher. For clinicians providing fluoride varnish premandate, the share of visits with fluoride varnish increased by 9.22 (95% CI, 5.41-13.02) percentage points. This increase was observed in clinicians who treated children with insurance that was mostly mixed and mostly private; no substantial change was observed among those treating children with mostly public insurance.

CONCLUSIONS AND RELEVANCE: In this cohort study of pediatric primary care clinicians, an association between the ACA mandate and an increase in fluoride varnish application was observed, especially among clinicians primarily treating privately insured patients and those applying it premandate. However, application remains infrequent, suggesting persistent barriers.

Dental caries affect 97% of the world's population during their lifetime. Early childhood caries are the number one chronic disease affecting young children, and it disproportionately affects children of low-income families. American Academy of Pediatrics recommends fluoridated toothpaste to all children starting at tooth eruption, regardless of caries risk. In addition, fluoride varnish is recommended in all children every 3 to 6 months from tooth emergence until they have an established dental home. The health disparities that are most apparent in the rural communities are inadequate prenatal care, low birth weight, cancer, chronic respiratory disease, heart disease, unintentional injury, and stroke. When it comes to oral health, water fluoridation is one of the most cost-effective strategies in preventing dental caries. The need for oral health education in physician assistant/associate (PA) programs is well documented. Implementation has largely been performed using interprofessional education. This article describes an interprofessional education program that teaches PA students to apply fluoride varnish so that they are practice-ready when they graduate and practice medicine.

PROBLEM: Interprofessional education (IPE) is valued but difficult to deliver, given logistical and other barriers. Centering IPE around patients and grounding it in authentic practice settings is challenging within early undergraduate medical education.

APPROACH: This intervention facilitated student-patient conversations to elicit patient reflections on the health care professionals who keep them healthy and care for them when they are unwell. After being introduced to the Interprofessional Education Collaborative (IPEC) core competencies, first-year medical (n = 127) and dental (n = 34) students conducted a brief semi-structured patient interview, using an interview card with guiding questions, during a precepted outpatient clinic session in March-May 2021. Students transcribed patients' stories and wrote their own reflections on the interview card. These reflections were used as a stimulus for a class IPE discussion. The authors employed a pragmatic qualitative research approach to explore what students learned about interprofessional collaboration from reflecting on patients' stories.

OUTCOMES: Of the 161 students, 158 (98%) completed an interview card. Sixteen health professions were represented in patients' stories. The patients' stories prompted students to recognize and expand their understanding of the IPEC competencies. Students' responses reflected synthesis of the competencies into 3 themes: students value patient-centered holistic care as the goal of interprofessional collaboration; students reflect emerging professional and interprofessional identities in relating to patients, teams, and systems; and students appreciate interprofessional care is complex and challenging, requiring sustained effort and commitment.

NEXT STEPS: Next steps include continuing to integrate patient voices through structured conversations across the undergraduate and graduate medical education spectrum and adapting the model to support conversations with other health professionals engaged in shared patient care. These experiences could foster ongoing deliberate reflection by students on their professional and interprofessional identity development but would require investments in student time and faculty development.

Oral health is a vital component of overall health. In a pair of Recommendation Statements published by JAMA on November 7, 2023, the US Preventive Services Task Force (USPSTF) announced that current evidence is insufficient to assess the balance of benefits and harms of screening for oral health conditions and providing preventive interventions by primary care clinicians for children aged 5 to 17 years and in adults. The current state of scientific knowledge is reflected by the USPSTF’s I statements (“insufficient evidence” to support the recommendation) in each Recommendation Statement. This demonstrates the need for further research to better understand the effect of these services on health outcomes. The lack of data should not unduly influence primary care clinicians to stop considering oral health during routine medical examinations or checkups.

BACKGROUND: Poor oral health during pregnancy has significant implications across the life course, including increased risk for adverse pregnancy, birth outcomes, and the development of early childhood caries. In efforts to improve perinatal oral health in the United States, a set of national interprofessional guidelines were developed that include recommended practice behaviors for both oral health providers and prenatal providers. The purpose of this study was to examine guideline awareness, familiarity, beliefs, and practice behaviors among both provider types.

METHODS: Prenatal providers and oral health providers in Florida were recruited via random and convenience sampling to complete an online survey guided by the Consolidated Framework for Implementation Research (CFIR) and the Cabana Framework. The present analysis focused on the Individuals Involved domain (CFIR), awareness and familiarity with the guidelines (Cabana Framework), confidence, and practice behaviors as recommended by prenatal oral health guidelines (assess, advise, refer, share/coordinate). Data were analyzed using chi-square tests, independent samples t-tests, Pearson correlation coefficients, and one-way analysis of variance (ANOVA) and analyses were conducted in SPSS.

RESULTS: Prenatal and oral health providers did not differ significantly in their awareness of the guidelines, but awareness was significantly associated with three of the four practice behaviors for prenatal providers. Familiarity with the guidelines was significantly higher among oral health providers and was associated with all four practice behaviors for both provider types. Five out of ten oral health belief items were significantly associated with practicing the guidelines among prenatal providers, but only two among oral health providers. Confidence in performing the practice behaviors was significantly associated with guideline implementation among both groups. Years in practice was significantly associated with performing practice behaviors for prenatal providers, but not for oral health providers.

CONCLUSIONS: Our findings highlight the importance of professional organizations and the role of clinical guidelines on practice behaviors. Although provider education is a key implementation strategy, organizational and policy-level system changes could also be critical in supporting practice behaviors.

OBJECTIVES: Safety net clinics (SNC) provide healthcare to vulnerable populations and SNC websites are an important information source. In North Carolina (NC), all 100 counties are Dental Health Professional Shortage Areas, yet 91 of 317 SNCs are non-dental (ND-SNC). Our goals were to: (1) assess the presence and type of oral health (OH) information on ND-SNC websites; (2) develop and distribute an OH education webpage to ND-SNCs and track its use.

METHODS: The website search function was used with common dental terms to evaluate the presence of OH content on each ND-SNC website. Key representatives from ND-SNCs were surveyed to assess patient care and willingness to implement an OH webpage. Webpage topics included oral hygiene and a map of NC dentists that provide services to low-income patients. Google Analytics was used to track consumer webpage engagement including acquisition source (AS), average time on page (AT), and unique page views (UPV).

RESULTS: Of the 91 ND-SNCs websites, none contained OH education; 15% had information about nearby dental providers. For the 40 ND-SNCs using our webpage, January-December 2022, the primary AS for new webpage users was referrals; 72.5% of users visited directly from ND-SNC websites. Statewide AT was 2 min and 30 s (SD = 58 s), 2.88 times longer than the 52-s threshold marketing experts use to establish genuine user engagement. There were 1364 UPVs statewide for 2022.

CONCLUSION: Our results suggest a need for OH education content on ND-SNC websites, as users are searching for and engaging with this information.

BACKGROUND: Oral health is an important aspect of overall health and should be maintained during pregnancy. Due to complex physiological changes during pregnancy, the pregnant woman is at risk for developing periodontal disease and dental caries which are associated with poor birth outcomes including preterm births and low birthweight infants. Evidence-based guidelines developed by several professional organizations recommend oral screening be included in the first prenatal visit. The purpose of this quality improvement project was to implement a dental screening tool during prenatal care to identify pregnant patients with oral health needs and provide subsequent referrals to a dentist.

METHODS: The project was implemented over a 14-week period and included an oral health screening using a valid and reliable tool to identify oral health needs. Patients were screened and received a referral for dental care.

RESULTS: N = 826 pregnant women were screened. Of those screened 36.3% (n = 300) had not had their teeth cleaned in the past 12 months. More than 30% of pregnant patients (n = 316) reported some type of dental problem, 29.5% (n = 244) were screened during the first prenatal visit, and 36.7% (n = 303) were enrolled in Medicaid. At project completion, 74.6% (n = 616) of patients received dental referrals.

CONCLUSION: Conducting oral health screenings during the first prenatal visit is important for identifying pregnant women at risk for oral health problems and improving birth outcomes and allows the patient time to visit the dentist prior to birth. Integration of an oral health screening and referral process can be successfully implemented during prenatal care to meet the needs of childbearing women.

OBJECTIVE: National guidelines recommend that all children under age six receive fluoride varnish (FV) in medical settings. However, application rates remain low. This study aimed to update understanding of barriers and facilitators to guideline concordant FV application.

METHODS: We conducted virtual semi-structured interviews with a purposive sample (e.g., FV application rates, geographic location, practice size and type) of pediatric primary care clinicians and medical assistants in Massachusetts between February 1 and June 30, 2022. The Consolidated Framework for Implementation Research served as the study's theoretical framework and data were analyzed using a modified grounded theory approach.

RESULTS: Of the 31 participants, 90% identified as White and 81% as female. Major themes, which linked to four CFIR domains, included: Variation in perceived adequacy of reimbursement; Differences in FV application across practice types; Variation in processes, protocols, and priorities; External accountability for quality of care; and Potential levers for change. Important subthemes included challenges for small practices; role of quality measures in delivering guideline-concordant preventive oral healthcare; and desire for preventive care coordination with dentists.

CONCLUSIONS: This study suggests that potential barriers and facilitators to guideline concordant FV application exist at multiple levels that may warrant further study. Examples include testing the effectiveness of quality measures for FV application and testing strategies for implementing consistent processes and protocols for improving FV application rates.

OBJECTIVES: To evaluate the impact of an oral health integration training program on children's receipt of oral health and dental services in Southern Oregon.

METHODS: Children under 19 years with at least 6 months of Medicaid enrolment and at least one healthcare visit from 2014 to 2018 were included. The treatment group included children with at least one visit with a trained provider (n = 5541); children with no visits with trained providers (n = 8273) were the control group. The percentage of the treatment group who received oral health assessments was calculated, and regression models were developed to estimate the difference in likelihood of receiving fluoride varnish and dental services between treatment and control groups.

RESULTS: The percentage of children receiving oral health assessments increased over time. Visiting a trained provider was consistently associated, each year, with a greater likelihood of receipt of fluoride varnish and preventive and diagnostic dental services but was not associated with treatment dental services or dental sealants.

CONCLUSIONS: This study reports evidence for the overall impact of an oral health integration training on children's receipt of oral and dental services. Health systems implementing these types of training strategies should consider how to reach specific underserved subgroups, increase paediatric dentists, and expand efforts to include older children.