JDR Clinical & Translational Research最新文献

Introduction: Existing models of medical-dental integration, as well as those from behavioral health care integrated with primary medical treatment, provide a basis for a truly synthesized and expanded model incorporating medical, dental, and behavioral components. Such a comprehensive model allows for collaborative health care serving patients seamlessly without disciplinary silos, promoting optimal whole-person health. This innovative approach is consistent with recent developments in the behavioral and social oral health sciences that include an imperative for their full inclusion in dental health care, research, and education.

Methods: Existing models of medical-dental integration are described, along with current models from integrated primary medical and behavioral health care. Using these existing approaches as a basis, a new multilevel model is proposed to include social and cultural determinants of health.

Results: Contemporary approaches to providing health care across disciplines include referral to a geographically separate entity, co-location of services, and integrated, side-by-side care. Integration of electronic health records and interoperability are necessary (but not sufficient) factors that affect transdisciplinary health care. Effective communication among health care providers and the need for interprofessional education, comprehensive training, and ongoing cross-disciplinary consultation also are noted as crucial factors in truly collaborative care. Evidence for existing models varies greatly depending on the target population and type of services provided.

Conclusions: A fully integrated, transdisciplinary model of health care is possible, theoretically and practically. Combining aspects of extant integrated models and extending them provides opportunity for a greater focus on systemic factors and more emphasis on prevention. Consistent with this new model, medical and dental home concepts can be expanded to that of a person-centered health care home that includes interprofessional practice. This transdisciplinary approach contributes to greater health equity given the multilevel approach. Multidirectional integration of diverse disciplines representing the various realms of medicine, dentistry, and behavioral health care is essential for optimal health of all.

Knowledge transfer statement: This article can be used by clinicians, scientists, administrators, and policy makers in developing and implementing integrated systems of care that provide for patients' medical, dental, and behavioral health needs.

Introduction: Adolescents have experienced increasing levels of anxiety (AD) and depressive disorders (DD) in recent years. This study assessed the current attitudes of pediatric dentists and orthodontists on incorporating screenings for mental health disorders for their adolescent patients.

Methods: A sequential mixed-methods approach was used. A 35-item survey was sent to 5,538 pediatric dentists and orthodontists that included questions about attitudes and current screening practices for AD and DD. Multivariate logistic regression analysis was performed to examine factors associated with dentists' willingness to incorporate screening and discuss results with patients for AD and DD. Subsequently, we interviewed 16 orthodontists and pediatric dentists, conducted thematic analysis, and identified themes and subthemes.

Results: Based on 305 responses, >80% of respondents viewed screening for AD and DD as important, but <15% conducted screenings for them. Moreover, for those not screening, the odds of future screening for AD (odds ratio [OR]: 0.18, confidence interval [CI]: 0.08-0.43) and DD (OR: 0.23; CI: 0.09-0.56) were lower as the perceived importance of screening increased. Their willingness to screen for both AD (OR: 0.26, CI: 0.08-0.82) and DD (OR: 0.18, CI: 0.05-0.71) was also lower if they perceived this to negatively affect their patients' perception of them. The thematic analysis identified 3 main themes: (1) provider attitudes around mental health, (2) barriers to incorporating mental health screening, and (3) opportunities to integrate screening. Barriers included lack of training, access to mental health resources, and provider and patient stigma.

Conclusions: Our study showed that while most pediatric dentists and orthodontists understand the importance of screening their adolescent patients for AD and DD, many are unlikely to conduct screenings in the future. Obstacles such as inadequate training and stigma must be addressed for wider adoption. Further research and initiatives are crucial to tackle these challenges.

Knowledge transfer statement: The findings of this study offer insights to clinicians and policy makers into the attitudes, barriers, and facilitators among dentists-specifically pediatric dentists and orthodontists-who regularly treat adolescent patients, regarding mental health screenings for these individuals. This information can guide the development of initiatives, policy changes, and future research aimed at creating a more integrated dental care system that emphasizes the overall health of adolescent patients.

Introduction: The number of surgical extractions performed in hospitals in England remains unclear. This study reports the volume of surgical extractions conducted in hospitals and change in activity during the COVID-19 pandemic.

Methods: We conducted a nationwide observational cohort study using Hospital Episode Statistics (HES) in England for patients undergoing surgical removal of a tooth (defined using OPSC-4 code F09) between April 1, 2015, and December 31, 2020. Procedures were stratified by age, gender, and urgency (elective or nonelective), reported using descriptive statistics, number, and percentage. We conducted post hoc modeling to predict surgical activity to December 2023. In addition, we contrasted this with aggregate national data on simple dental extraction procedures and drainage of dental abscesses in hospital as well as dental activity in general practice.

Results: We identified a total of 569,938 episodes for the surgical removal of a tooth (females 57%). Of these, 493,056/569,938 (87%) were for adults and 76,882/569,938 (13%) children ≤18 years. Surgical extractions were most frequent in adult females. Elective cases accounted for 96% (n = 548,805/569,938) of procedures. The median number of procedures carried out per quarter was 27,256, dropping to 12,003 during the COVID-19 pandemic, representing a 56% reduction in activity. This amounted to around 61,058 cancelled procedures. Modeling predicts that this activity has not returned to prepandemic levels.

Conclusions: The number of surgical extractions taking place in hospitals during the pandemic fell by 56%. The true impact of this reduction is unknown, but delayed treatment increases the risk of complications, including life-threatening infections.

Knowledge transfer statement: The result of this study provides an evidence-based overview of the trends relating to surgical extractions of teeth in England taking place in hospitals. This information can be used to inform service and workforce planning to meet the needs of patients requiring surgical extractions. The data also provide an insight into the oral health needs of the population in England.

Background: People with alcohol dependence (AD) frequently experience oral health problems, but their dental attendance is poor, with limited evidence to the reasons why from their perspective.

Objective: To explore perceived barriers, motivators, and facilitators to accessing primary dental care in people with AD.

Methods: Qualitative study consisting of remote one-to-one and group semistructured interviews with a convenience sample of adults with lived experience of AD in northern England. Data were audio-recorded, transcribed, and coded. A reflexive thematic analysis method was used; use of COM-B model informed data interpretation.

Results: Twenty adults with lived experience of AD participated in 18 one-to-one interviews and 1 group interview (of 3 participants). Barriers to access were fear and physical, social, and environmental factors (physical effects of AD, financial barriers, nonprioritization of oral health). Motivators to access were pain and prioritization of oral health. Facilitators to access were patterns of alcohol use (i.e., sobriety) and dental service provision within recovery services.

Conclusions: Fear of "the dentist" is a major barrier to accessing dental care, and pain is the primary motivator, among people with AD, although neither are unique to this population. Fear and physical, social, and environmental barriers to access contribute to problem-oriented attendance, which negatively affect oral health outcomes. Opportunity to facilitate attendance increases when a person is in remission from AD through their physical capabilities improving. Increasing capability and opportunity can influence attendance beyond the automatic motivation of pain. Provision of dental care within recovery services could facilitate access to care. Understanding the "web of causation" is key to developing any intervention to improve dental access in people with AD. Further research is needed from the perspective of other adult populations with lived experience of AD, as well as of dental professionals, to gain deeper insight into barriers, facilitators, and possible solutions.

Knowledge transfer statement: The results of this study can help dental professionals understand factors affecting access to primary care in people with alcohol dependence to provide knowledge that may reduce stigma surrounding the disease. Results also demonstrate areas for intervention development for public policy.

Knowledge transfer statement: The goal of this editorial and following supplement articles is to present different perspectives on the implementation of medical-dental-behavioral integration to provide comprehensive, whole-person care. Through a discussion of barriers to and opportunities that emerge from this type of integrated care, this editorial and supplement provide strong evidence for the importance, feasibility, and necessity of integrated health care and concept of overall health.

Knowledge transfer statement: Our proposed estimate of periodontitis susceptibility cases addresses the issue of missing teeth, offering an innovative solution through a generative missing data imputation model. The implications of our findings extend to fostering more robust investigations into the relationships between periodontal health and systemic diseases, thereby offering valuable insights to clinicians for informed decision-making. Moreover, the study's capacity to shape clinical practices and interventions in public health will further fortify health policy strategies.

Introduction: Emerging studies on the links between suboptimal oral health and multimorbidity (MM), or the co-existence of multiple chronic conditions, have raised controversy as to whether enhancing access to dental care may mitigate MM in those with suboptimal oral health. In this study, we aim to assess the extent of the association between suboptimal oral health and MM and whether access to dental care can modify this association.

Methods: We conducted a cross-sectional analysis using data from the Canadian Longitudinal Study on Aging (CLSA) (N = 44,815, 45 to 84 y old). Edentulism, self-reported oral health (SROH), and other oral health problems (e.g., toothache, bleeding gums) were used as indicators of suboptimal oral health. MM was defined according to the Public Health Agency of Canada as having 2 or more of the following chronic conditions: cancer, cardiovascular diseases, chronic respiratory diseases, diabetes, and mental illnesses. For robustness, we also used a cutoff of having 3 or more of these chronic conditions. Variables for access to dental care included (1) dental visits within the past year, (2) availability of dental insurance, and (3) cost barriers to dental care. We constructed robust Poisson regression models to estimate the association between suboptimal oral health and MM and then assessed the effect measure modification by indicators of access to dental care on a multiplicative scale. We also calculated the relative excess risk due to interaction for prevalence ratio (PR) on an additive scale.

Results: Indicators of suboptimal oral health were significantly associated with MM (edentulism PR 1.17, 95% confidence interval [CI] 1.08, 1.27; poor SROH PR 1.44, 95% CI 1.33, 1.54; other oral health problems PR 1.52, 95% CI 1.44, 1.78). The magnitude of this association was higher in individuals who reported fewer dental visits within the past year, lacked dental insurance, and avoided dental care due to costs.

Conclusion: The association between suboptimal oral health and MM may be exacerbated by barriers to accessing dental care. Policies aiming to enhance access to dental care may help mitigate MM in middle-aged and older Canadians with suboptimal oral health.

Knowledge transfer statement: This study offers insights into the connection among suboptimal oral health, multimorbidity, and access to dental care factors in middle-aged and older Canadians. The findings can be of value for clinicians and policy makers aiming to enhance medical-dental integration and improve accessibility to dental care and to patients seeking information about the connections between oral health and chronic conditions. Implementation has the potential to enhance individual well-being and drive systemic improvements in health care.

Introduction: There are minimal evidence-based outcomes from clinical trials for medical-dental integration. This formative work and pilot study is a precursor to a larger cluster-randomized clinical trial in adult primary care practices to test an electronic health record (EHR) structured workflow for primary care providers (physicians/nurse practitioners [NPs]) and medical staff (medical assistants [MAs] and nurses) with oral health (OH) screening and referral for Medicaid-enrolled adults ≥55 years.

Methods: This study was conducted in 2 practices with providers, medical staff, and older adults. Focus groups preceded the pilot study to gain stakeholder insights prior to the multilevel interventions of systems changes and provider education. The system-level EHR changes for medical staff included ask (OH screening), advise (visit dentist soon/annually), assess (need for referral: eReferral to co-located dentists or structured referral to community dentists), and connect (referral; resources). Provider education (didactic and skills) was based on the Common-Sense Model of Self-Regulation (CSM) to deliver OH facts to older adults at primary care visits. Descriptive analysis was used to report on process outcomes of reach, adoption, and implementation/fidelity.

Results: After stakeholder input, the CSM-based didactic and skills curriculum was developed, and 4 physicians were trained. Changes in the Epic EHR were implemented, and 19 medical staff were trained in this new structured workflow together with physicians. In terms of reach, 83% (N = 80) of older adults were enrolled out of 96 approached (female: 66%; non-Hispanic: 83%; Caucasian: 43%). Workflow adoption was 100% of MAs completing the EHR questions and 89% of providers documenting giving OH facts. About 94% of older adults reported their physician giving them OH facts indicating implementation/fidelity of the intervention. About 60% of older adults reported no dental visits in the past year, and 66% requested eReferrals.

Conclusion: This study presents an innovative systems-based multilevel intervention for medical-dental integration.

Knowledge transfer statement: The results of this study can be used by practice leadership and clinicians when incorporating oral health into primary care for older adults. Considering adoption and implementation costs, this information could lead to a more complete approach to address oral health with patients.

Introduction: In 2011, the Institute of Medicine (IOM) recommended a minimum of 4 clinical oral health competencies for nondental professionals to promote optimal oral health, including (1) recognizing risk for oral disease through competent oral examinations and (2) making and tracking referrals.

Objectives: We determined whether California school nurses (SNs) knew about specific components of the 2 IOM competencies mentioned above using 3 clinical case scenarios following the Association of State and Territorial Dental Directors Basic Screening Survey Methodology.

Methods: In this cross-sectional study, a 23-item pilot-tested online survey was completed by 358 active California School Nurses Organization members between April and June 2023. We conducted univariate, bivariate, and multivariable linear regression analyses.

Results: For the first scenario, 61% of SNs correctly identified the condition as "root tips," with 93% indicating correctly that such a case should be referred immediately. In the second scenario, almost 77% of SNs correctly identified "untreated tooth decay," with 50% correctly suggesting that a child with untreated tooth decay without dental pain should visit a dental office within several weeks. In the third scenario, almost 50% correctly identified an abscessed tooth, with 75% indicating that a child with this condition should be referred immediately. Multivariable adjusted linear regression analysis showed that SNs with a bachelor's degree or lower had significantly lower overall knowledge in accurately identifying dental conditions and choosing appropriate dental referrals (P = 0.02).

Conclusions: At least half of the participating SNs accurately identified the dental conditions and chose the appropriate dental referrals. The educational status of SNs was a strong predictor of SNs' overall knowledge of identifying oral health conditions and appropriate dental referrals. SNs, when adequately trained, can assess oral health needs and make appropriate dental referrals as part of school-linked dental programs.

Knowledge transfer statement: SNs can identify common dental conditions in children and appropriately refer them to a dental professional. When adequately trained, they can be a valuable resource in implementing school-linked dental programs.

Introduction: Persistent, painful temporomandibular disorders (TMDs) are challenging to manage and usually require the active engagement of patients. To achieve this, it is necessary to understand the complex and multifactorial nature of persistent pain. Many dental professionals have little education about persistent pain and may prefer to offer structural management and advice. This research aims to explore how people understand their persistent TMD and how this understanding has been influenced by their treatment providers.

Methods: Twenty-one people were recruited to represent a diversity of experience with persistent TMD. Interviews followed a semistructured topic guide. Themes were constructed through reflexive thematic analysis to represent how people made sense of their symptoms and the messages that they had picked up through their treatment journey.

Results: Participants described examples of conflicting opinions and inconsistent management recommendations. They rarely recalled collaborative discussions about the nature and complexity of their symptoms and different options for treatment. This experience is represented by a single theme, "a medical merry-go-round." Subthemes of "a medical journey to nowhere-participants' frustrated attempts to find medical management that will end their pain" and "is it me?-participants' questioning their role in persisting pain" kept participants on the merry-go-round, while symptom resolution and participants' emerging development of a holistic understanding of their TMD pain provided exit points. Understanding pain holistically tended to be helpful and typically occurred despite rather than because of the advice given in routine treatment settings.

Conclusion: Participants in this study had not typically found their pain management within dental and medical settings to have helped them to construct meaning and understand their experiences of painful TMD. However, understanding symptoms holistically was experienced as beneficial. This study suggests that improved communication and signposting within services for persistent TMD may be beneficial to patients with TMD pain.

Knowledge transfer statement: Results of this study confirm that being offered a series of anatomically based, singular-cause explanations for persisting pain symptoms had been experienced as unhelpful by the participants who had sought help for their TMD. Participants highlighted the importance of accurate and collaborative communication and of dental professionals explicitly adopting and communicating a biopsychosocial understanding of pain to their patients who have TMD. Results highlight that some people can struggle to manage persisting pain with minimal support. Signposting patients to appropriate services and resources may help them to understand more about the nature of persistent pain and methods of managing it.