Donald L. Chi

To evaluate associations between state-level socioeconomic vulnerability and community water fluoridation (CWF) in the U.S. Data from calendar year 2022 were drawn from the U.S. Census Bureau to develop four state-level markers of socioeconomic vulnerability (percentages non-white, Hispanic/Latino, below federal poverty level, and <high school education) and the U.S. Centers for Disease Control and Prevention’s Water Fluoridation Reporting System to assess mean state-level CWF percent. Fractional logit regression models with robust standard errors, weighted by state population, were used to assess non-adjusted associations between each socioeconomic vulnerability marker and CWF (α < 0.05). Poverty-adjusted models were also run. The mean state-level CWF was 72.8% (SD = 20.0%; range:8.5%−100%). In the non-adjusted models, only state-level percentages of non-white and Hispanic/Latino individuals were significantly associated with lower state-level CWF percent. In the poverty-adjusted models, higher percentages of non-whites, Hispanic/Latinos, and individuals who did not complete high school at the state-level were associated with a significantly lower state-level CWF percent (p = 0.01, p < 0.01, and p < 0.01, respectively). Individuals living in more socioeconomically vulnerable states in the U.S. may face inequities in CWF access.

Introduction: Poor oral health among U.S. veterans remains a significant public health issue. Compared with non-veterans, veterans experience higher rates of oral disease and unmet dental care needs, contributing to substantial oral health disparities. Most U.S. veterans are ineligible for dental care through the Veterans Affairs (VA) dental care system because of the requirement for a 100% service-connected disability rating. This pilot study evaluated the association between veterans’ disability rating and dental care utilization for low-income veterans with disability ratings below 100% who sought care through Everyone for Veterans (E4V). E4V is a U.S. non-profit organization that provides dental care to low-income veterans ineligible for VA dental care. Materials and Methods: The analysis was based on 2014-20 data for veterans across 30 states with complete disability rating data and who utilized dental treatment during their enrollment in E4V (N = 140). Logistic regression models were used to generate odds ratios (OR) and 95% confidence intervals (CIs) to assess the relationships between disability rating and dental care utilization, which was categorized as basic restorative care, complex restorative care, or both. Results: The mean age of veterans was 49.0 years (standard deviation [SD] ± 17.6) and 87.6% were male. The mean disability rating was 38.7% (SD ± 33.6, range = 0%-90%). About 62.9% of veterans (n = 88) utilized basic restorative dental care, 76.4% (n = 107) utilized complex restorative dental care, and 40.0% utilized both (n = 56). In the confounder-adjusted model, disability rating was not significantly associated with any type of dental care utilization (basic restorative: P = .83; complex restorative: P = .51; both: P = .74). Conclusions: Although this study failed to observe significant associations between disability rating and restorative dental care utilization, the findings highlight the need for additional research on barriers to comprehensive dental care for veterans ineligible for VA dental care.

Neighborhood-based social capital – defined as resources within neighborhood social networks – is a potential contributor to adolescent oral health, but mechanisms that link the two are not well elucidated. We evaluated the potential mediating role of neighborhood, household, and individual oral health risk factors in the neighborhood social capital-tooth decay relationship. We collected cross-sectional data from 331 Medicaid-enrolled adolescents (ages 12–18 years) and one of their caregivers from 73 census tracts (neighborhoods) in three counties in Oregon, U.S.A in 2015 and 2016. Medicaid is a public insurance program in the U.S. providing no-cost dental insurance to low-income children. We measured four neighborhood social capital constructs: social support, social leverage, informal social control, and neighborhood organization participation. Oral health risk factors included worrying about food money, poor access to vegetables and fruits, inconsistent family and oral health routines, and adolescent stress. The outcome was number of untreated decayed tooth surfaces. Causal mediation analyses with mixed effect models were used to examine associations. Neighborhoods with higher social support had a lower prevalence of worrying about food money (prevalence ratio [PR] 0.74;95% CI: 0.56, 0.96;p = .02) as did neighborhoods with higher informal social control (PR 0.75;95% CI:0.58, 0.97;p = .03). All oral health risk factors were strongly associated with untreated decayed tooth surfaces. No form of neighborhood social capital was significantly associated with tooth decay. Natural indirect effects of neighborhood social support and informal social control operating through worrying about food money were not statistically significant. Future longitudinal studies that include robust measures of neighborhood social capital and adequate sample sizes are needed to enable neighborhood-based interventions that promote adolescent oral health.

Aim: To identify the behavioral correlates of caregiver‐reported oral health of individuals with Joubert Syndrome (JS). Methods: This cross‐sectional study included 302 caregivers of individuals with JS from the JS registry who responded to a 56‐item REDCap survey, and a purposive subset of 30 participants with JS for which a dental screening was completed. The primary outcome was caregiver‐reported oral health of individuals with JS (good/very good vs. fair/poor). Logistic regression models were used to generate confounder‐adjusted odds ratios (OR) and evaluate associations between oral health behaviors and caregiver‐reported oral health of individuals with JS ( p < 0.05). Results: The mean age of individuals with JS was 14.6 years (SD: 10.3). Most caregivers were female (84.1%), White (87.4%), non‐Hispanic (91.1%), and reported annual household incomes above $100 000 (53.7%). Behaviors significantly associated with poorer oral health included not eating or drinking by mouth (OR = 4.52, p = 0.005), not toothbrushing daily (OR = 5.29, p < 0.001), and infrequent toothpaste use (OR = 3.68, p = 0.003). Screenings showed 40.0% had poor hygiene, 23.3% had untreated caries, and 46.7% had gingivitis. Conclusions: Future efforts should focus on improving oral health behaviors to prevent dental disease in individuals with JS.

The goal of this study was to evaluate the associations between topical fluoride hesitancy and opposition to determine if hesitancy is a potential precursor to opposition. We administered an 85-item survey (11/2020-09/2021) to 1,135 caregivers that included the 20-item, 5-domain Fluoride Hesitancy Identification Tool (FHIT), from which we created five domain-specific scores of topical fluoride hesitancy (none/moderate/high for each domain); a score reflecting any topical fluoride hesitancy (moderate/high on any of the five domains); and a topical fluoride hesitancy severity score (total number of moderate/high responses to the five domains; range 0–5). The survey measured degree of topical fluoride opposition (0–10 with no = 0 and yes ≥ 1). We ran confounder-adjusted logistic regression models to evaluate associations between topical fluoride hesitancy scores and opposition. The analyses included 1,042 caregivers; mean age was 42.0 years (SD: 8.3), 78.7% were woman, and 58.3% were white. General hesitancy was reported by 82.9% of surveyed caregivers. Domain-specific hesitancy prevalence (moderate/high) was 81.3% for the necessity domain, 31.3% for chemicals, 19.5% for harm, 30.1% for uncertainty, and 25.2% for distrust. For severity, 14.7% of caregivers reported moderate/high hesitancy for all 5 domains, 7.7% for 4, 6.8% for 3, 9.3% for 2, and 43.9% for 1 domain. Opposition was reported by 39.1%. In the regression models, every hesitancy measure had a statistically significant (p < 0.01), positive association with opposition. In conclusion, topical fluoride hesitancy and opposition are positively associated but not identical. Additional work should elucidate the relationship between the two to inform strategies to address topical fluoride hesitancy and opposition.

Objective: Alaska Native children may be at increased risk for dental caries because of added sugar intake from sugar‐sweetened fruit drinks. This study describes development of a questionnaire to (a) assess Alaska Native caregivers' beliefs, knowledge, and behaviors regarding sugar‐sweetened fruit drinks, and (b) describe behavior changes within a community‐based intervention.Methods: Questionnaire development was conducted in three phases with Yup'ik Alaska Native caregivers in Southwest Alaska: (1) initial selection and adaptation of questionnaire items; (2) cognitive testing; and (3) data collection. The Sugar‐Sweetened Fruit Drink Questionnaire (SFDQ) contains 31 culturally‐tailored items across six areas: beliefs/values, environment/skills, knowledge, motivation, self‐efficacy, and behaviors.Results: Eighty‐one percent of caregivers gave their children sugar‐sweetened fruit drinks. Motivations included: what they grew up with (52%), few other options (46%), makes child happy (46%), healthier than soda (45%), and others in community drink them (42%). On average, 93% of caregivers believed drinking a lot of sugar‐sweetened fruit drinks leads to cavities in children and caregivers agreed (mean 4.1 on 5‐point scale, 5 = strongly agree) it is important to limit sugar‐sweetened fruit drinks. Among a sub‐sample of respondents (n = 20), we found low to moderate temporal stability in some SFDQ items over a 10–14 day period, indicating respondent ambivalence and/or uncertainty.Conclusions: Using community‐based participatory research methods, we developed a culturally tailored exploratory questionnaire that will be used to describe changes in caregiver knowledge, beliefs, attitudes, self‐efficacy, and behavior within a planned intervention to reduce sugar‐sweetened fruit drink intake in Alaska Native children.

The goal of this study was to describe medical providers’ fluoride-related beliefs and practices, experiences with fluoride-hesitant caregivers, and barriers to incorporating oral health activities into their practice. In this cross-sectional study, we specifically tested the hypothesis of whether these factors differed between pediatric and family medicine providers. A 39-item online survey was administered to a convenience sample of pediatric and family medicine providers in Washington state and Ohio (U.S.A.). Responses to the fluoride survey were compared between pediatric and family medicine providers with a chi-square test (α = 0.05). Of the 354 study participants, 45% were pediatric providers and 55% were family medicine providers. About 61.9% of providers believed fluoridated water was highly effective at preventing tooth decay while only 29.1% believed prescription fluoride supplements were highly effective. Nearly all providers recommend over-the-counter fluoride toothpaste (87.3%), 44.1% apply topical fluoride in clinic, and 30.8% prescribe fluoride supplements. Most providers reported fluoride hesitancy was a small problem or not a problem (82.5%) and the most common concerns patients raise about fluoride were similar to those raised about vaccines. Lack of time was the most commonly reported barrier to incorporating oral health into practice, which was more commonly reported by family medicine providers than pediatric providers (65.6% vs. 50.3%; p = .005). Pediatric and family medicine providers have early and frequent access to children before children visit a dentist. Improving the use of fluorides through children’s medical visits could improve pediatric oral health and reduce oral health inequities, especially for vulnerable populations at increased risk for tooth decay.