First Smiles Final Evaluation Report

FIRST 5 CALIFORNIA

Oral Health Education and Training Project

FINAL EVALUATION REPORT

March 2008

BARBARA AVED ASSOCIATES

BARBARA AVED ASSOCIATES Page 2 of 137

TABLE OF CONTENTS

EXECUTIVE SUMMARY....................................................................................................................4

INTRODUCTION..............................................................................................................................9

Background.....................................................................................................................................9 Project Goals and Strategies ................................................................................................... 10 Project Oversight....................................................................................................................... 10 Evaluation Outcomes ................................................................................................................ 11 Acknowledgements ................................................................................................................... 11

DATA SOURCES AND METHODS ........................................................................................... 12

FINDINGS ......................................................................................................................................... 17

THE STUDY POPULATION.................................................................................................... 18

Dental Providers ................................................................................................................... 19 Medical Providers.................................................................................................................. 24 Community Organizations.................................................................................................. 28

OUTCOME: Knowledge Gain and Retention ..................................................................... 29


OUTCOME: Increase in Self-Perceived Skills...................................................................... 43 Dental Providers ................................................................................................................... 43 Medical Providers.................................................................................................................. 50 Community Organizations.................................................................................................. 54

OUTCOME: Adoption of Desired Behaviors/Practices..................................................... 59


OUTCOME: Improvement in Access/Systems Change .................................................... 86

Access Problems and Systems Barriers .......................................................................... 86 Perceptions of Impact by Key Stakeholder Groups..................................................... 90 Extent of Local First 5 Involvement in Oral Health/First Smiles............................... 96 Changes in the Field of Dentistry Attributable to Project ......................................... 99 Integration/Coordination ................................................................................................. 105 Changes in Reimbursement............................................................................................. 106 Technical Assistance Provided........................................................................................ 106

OUTCOMES RELATED TO PARENT EDUCATION..................................................... 108


TRAINER EVALUATION............................................................................................................. 123

DISCUSSION AND CONCLUSIONS...................................................................................... 124

RECOMMENDATIONS ............................................................................................................... 131

APPENDICES .................................................................................................................................. 134

Grid of Study Instruments....................................................................................................... 134 Glossary of Terms and Acronyms......................................................................................... 135


March 2008

EXECUTIVE SUMMARY

“My child doesn’t need to see the dentist; I’m waiting until his teeth

finish coming in.” -- Parent attending a WIC oral health education session

Dental caries (tooth decay) is the most prevalent chronic infectious disease of children.1 Severe dental caries is a particular problem in young children because of the difficulty in managing them in a dental office—or requiring expensive treatment in operating rooms—as well as the multiple visits necessary to treat them. Child health professionals can play a significant role in reducing the burden of this disease provided they have the training and support to do so. This report summarizes findings from the evaluation of California’s $7 million, 4-year “First Smiles” program, an education and training project funded by First 5 California. The long-term goal of this workforce initiative investment was to create greater access statewide to preventive oral health services for children aged 0-5, including children with disabilities and other special needs, by training more dental and primary care professionals and staff from community agencies that typically serve families with highest risk for oral disease. The program was co-implemented by the California Dental Association Foundation (CDAF) and the Dental Health Foundation (DHF) in 2004-2008. BARBARA AVED ASSOCIATES was the evaluator. First Smiles achieved its process and outcome objectives to a great extent, providing evidence of the value of this investment, and was well received by the groups it reached.

HIGHLIGHTS OF FINDINGS

Providers and Their Practice Characteristics At the time of this report, a total of 15,230 (90% of the overall goal) California dental and

medical providers attended a First Smiles training, and an additional 883 staff from community service organizations received training in children’s oral health.2

The program drew a more diverse population of dentists and physicians in race/ethnicity, gender and years in practice compared to those professionals in active practice in California.

1 U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD. May 2000. 2 The evaluation dataset represents about 35% of the total number of professionals trained; not all participants took the course during the data collection period or returned evaluation surveys/posttests at the courses they attended.

First 5 Oral Health Education and Training Program Final Evaluation Report


Two-fifths (40%) of the practices of medical providers were located in areas served by the First 5 School Readiness Initiative; approximately half (22%) that proportion of the dental practices were located in SR zip codes.

Children from agricultural/ farmworker families, a First 5 priority interest area, represented an average of 13% in the practice settings of the total provider sample.

Knowledge Gain and Retention

All training participants exhibited a great deal of knowledge in most areas of the curriculum content (80% average correct posttest scores). Both dental and medical providers did least well in understanding that there is no general difference in the behavioral issues of children aged 0-5 with special needs versus all children 0-5.

The type of training was significant for the dental providers’ knowledge gain: participants did less well overall in the 2-hour than the 4-hour course. For medical training participants there was no difference between the shorter and longer training courses.

There was a general trend overall for course participants to lose information learned from the course over the 6-month follow-up period regardless of length of course.

More than 90% of providers who took a First Smiles course reported being satisfied with the training, learning new information and skills and believing they could apply the information in their practices; 57% of dental providers and 45% of medical providers had recommended the course to a colleague 6 months later.

One-third of dental professionals and one-quarter of medical professionals cited the project website as a source for maintaining knowledge about children’s oral health, although reading professional journals on the topic was the most commonly mentioned source for both groups, 75% and 69%, respectively.

Parents demonstrated a fair amount of knowledge (73% average correct score on posttest) after receiving education about children’s oral health, and retained it 6 months later (matched sample follow-up posttest).

Self-Perceived Skill Level Increase The highest self-perceived increase in skill level for dental and medical providers was the

ability to communicate with parents and provide education and anticipatory guidance. Dental providers next reported increased clinical skills in learning how to perform a knee-to-knee exam, and medical providers in assessing dental caries risk and protective factors.

Medical providers maintained the same perceived level of skill increase due to the training six

months later as they did right after taking the course; dental providers reported a slightly lower level at the time of follow up.


Adoption of Desired Provider and Consumer Behaviors

Six months after the training, 16% (25 of 156) of general dentists reached at follow up said they were seeing more children aged 0-5 in their practices; close to 80% reported having the capacity to accommodate requests for appointments for this age group.

The main barriers dentists cited to taking more 0-5 children were managing this age group in a dental office is difficult (e.g., crying/behavior issues) and having too-full or limited-hours practices.

Female general dentists were significantly more likely than male general dentists to start

seeing children at younger ages.

Six months after the training, dental providers significantly increased the frequency of performing the following procedures: for children 0-5, application of fluoride varnish and discussion of an infant’s bottle or breast feeding practices. For pregnant patients, discussion of breast feeding practices and recommendations to chew �ylitol gum more often.

As a result of what they learned at the course, six months later dentists increased by 8.3% and 8.7%, respectively, delegation of two procedures to other dental professionals: placing sealants and applying topical fluoride.

More staff and training for providing parent education and managing young children’s behavior are what medical and dental providers said it would take to see more children aged 0-5.

At the time of the course, medical providers reported more frequently than dental providers “always” conducting formal oral health risk assessments on new patients aged 0-5. This did not change at the time of follow-up: 29% of general dentists said they “always or almost always” performed a formal risk assessment compared to 42% of primary care providers.

Six months after the training, 51.7% of the primary care providers reported “always or almost always” referring pregnant patients to a dentist, up from 18.5%. They also increased from 12% to 20% their frequency of coordinating care with a pregnant patient’s dental provider.

With regard to children aged 0-5, 24% of the medical providers initially said they “never or almost never” inquired about the oral health of the child’s caregiver, but six months after training, only 9.9% reported such low frequency.

Typically, about a fourth of the community agency staff who participated in the program made referrals of children to a dentist by the recommended age of 1 and two-thirds by age 3; the proportion essentially did not change six months after the training.

Community agency staff anticipated being able to apply what they learned from the training to a greater extent than they were actually able to six months later. An inability to integrate a new program component into the agency’s programming, and inadequate time for staff to deliver oral health education to parents, were the main barriers they identified.


60.8% of parents had taken their child to a dentist in the last year when initially asked the question; 6 months after receiving oral health education from the program 64.1% reported doing so, an important though not statistically significant increase in utilization of dental services.

Parents’ reasons for not taking their child to a dentist in the last year, (when the child was at least 1 year old) were primarily because of not having dental insurance, not knowing how or where to find an available dental service and believing a child aged 1-5 was too young to need a dentist. The percent who reported not knowing how to find a dentist as the reason dropped to 10% 6 months later, however.

The number of parents wiping or brushing their children’s teeth after every meal increased significantly 6 months after receiving oral health education, from14% to 21%.

Access/Systems Change

All primary care providers and community agency staff experienced some difficulty in finding dentists willing to see children who were low-income, uninsured, had a disability or other special needs or needed anesthesia. These access issues were still a problem 6 months later.

Medical providers believe “the main reasons more of my colleagues don’t get involved in young children’s oral health” is colleagues’ perceptions that parents have low motivation and values about baby teeth—and that oral health should be the responsibility of dentists. The perceptions about parents were not borne out by the parents in this study; they rated oral health similarly in importance to other common health-related services they might seek for their child, such as immunizations.

The amount and type of local collaboration about children’s oral health increased as a result of the First Smiles program. The provision of technical assistance by project staff and dental experts also contributed to systems improvement and capacity building.

Effective June 1, 2006, Medi-Cal began reimbursing medical providers for fluoride varnish application for children under age 6. While the new benefit should be a major incentive for increasing physician willingness to offer the procedure, ambiguity about reimbursement—how to bill/whether it is part of managed care capitation rates—is largely accountable for primary care providers’ lack of follow through to provide it.

The exposure dental students get to the 0-5 age group, particularly children with special needs, is still relatively small compared to their exposure to older children and adult patients.

Key dental and medical leaders cited important policy and practice changes in California

attributable or contributable to First Smiles. These changes included increased awareness by the legislature of oral health problems and potential solutions, integration of Caries Management by Risk Assessment (CAMBRA) into the dental schools and dedicated school nurse time and materials by some school districts for application of fluoride varnish.


KEY RECOMMENDATIONS∗

Strengthen the First Smiles curriculum in areas where posttest results for each group

indicated the need for more emphasis. For example, that managing the behavior of children 0-5 with special needs is generally the same as for all children of that age.

Continue funding support for keeping the First Smiles curriculum updated will result in the course having a longer shelf life and maximizing the First 5 investment.

Fund more opportunities for training of dental professionals concerning children with disabilities and other special needs.

Provide support for more joint training of medical and dental providers, incorporating a hands-on component in fluoride varnish application for medical providers.

Deliver more training to primary care providers, particularly OB-GYN and rural practices, using the in-office training and technical assistance strategy.

Work with Healthy Families to ensure fluoride varnish is covered as a medical procedure by its health plans, and that both Healthy Families and Medi-Cal cover anticipatory guidance in both its medical and dental plans.

Support advocacy and education efforts that help inform primary care providers of the Medi-Cal benefit of reimbursement for fluoride varnish application. If the reimbursement rate is considerably out of line with the cost for providing it, it should be raised or providers will have little incentive to participate.

Provide funding and other assistance to WIC and Head Start agencies to increase their capacity for integrating the parent oral health curriculum into their client education services.

Support appropriate ways of helping California dental schools to update and increase the proportion of didactic and clinical curricula focused on children aged 0-5.

∗ The full list of 18 recommendations and supporting text is contained in the body of the report.


“This [project] is really all about changing the paradigm of children’s oral health in California.” –Jared Fine, DDS, MPH, Chair, First Smiles Scientific Advisory Committee

INTRODUCTION It is well documented that dental caries is the most prevalent chronic disease of children—especially among low-income families—despite the fact that tooth decay is largely preventable through regular dental checkups, the use of fluoride and sealants and appropriate diet and oral health care. In this report we summarize findings from our four-year evaluation examining the impact of the First 5 California (Children and Families Commission) statewide Oral Health Education and Training Initiative called “First Smiles.” BACKGROUND First 5 California, funded from a voter-approved tax on the sale of tobacco products, supports selected statewide initiatives and all 58 county commissions throughout the state to improve the lives of children from the prenatal period to the time they enter kindergarten. First 5 California’s programs are designed to meet the goal of ensuring more children are born healthy, raised in nurturing homes and ready to succeed in school. One of those programs, the Early Childhood Oral Health Initiative, was launched in 2004 in recognition of the link between a child’s oral health and their overall health, and the critical gap in access faced by many low-income families to preventive and treatment services based in part on provider and parent knowledge, attitudes and involvement. First Smiles, one of the Initiative’s two components, was a 4-year, $7M statewide education and training program conducted in 2004-2008 and co-administered by the California Dental Association Foundation (CDAF) and Dental Health Foundation (DHF). First Smiles’ goal was to deliver provider education and training targeted to medical and dental professionals, and consumer education targeted to community-based organizations such as WIC and Head Start that have significant early interaction with parents and other caregivers of children 0-5. Because First 5 California viewed the initiative as “a workforce enhancement,” the objective of the investment was to broaden the number of providers willing to provide quality oral health education and preventive services for young children, particularly low-income and children with


disabilities and other special health care needs, ultimately leading to greater access to services statewide.

TARGET GOALS AND STRATEGIES

The CDAF and DHF were contracted to reach 75% of California’s dental providers and 50% of the state’s primary care providers with education; and 30% of the dental and 20% of the medical providers with training as shown in the following chart:

Project Targets and Goals for Provider Training

Medical Professionals

Dental Professionals

Dentists, dental hygienists, and dental

assistants

Primary care providers (pediatricians, family practice, OB-GYNs,

pediatric nurse practitioners)

Medical residents

Education*

75% (34,097) 50% (7,174) 50% (1,238)

Training 30% (13,683)

(84% reached as of December 2007)

20% (2,900) (100% reached as of

December 2007)

50% (495) (100% reached as of

December 2007) *The evaluation was not tasked with measuring distribution of educational materials (brochures, journal articles, etc.) as CDAF and DHF reported on these process objectives directly to First 5.

Program Strategies The First Smiles program offered education and training in a variety of formats, including 1- and 2-hour in-person training (e.g., onsite in provider offices, at local dental society dinners), full-day training (e.g., at major meetings and conferences), 2-hour web-cast training sessions hosted by Vodium, a Washington, D.C.-based provider of webcast software and webcast services, and modules for distance learning. Educational strategies included dissemination of journal articles—some commissioned by this program—and newsletters. Partner agencies such as the California Primary Care Association, Anderson Dental, Kaiser and Molina Healthcare participated to deliver the provider trainings. Subcontracting statewide associations for WIC and Head Start and the UCSF Early Childhood Education Program offered training to staff of their organizations. The project also served as a resource for disseminating new and emerging research with capacity on the website for posting the latest scientific information. PROJECT OVERSIGHT A multi-disciplinary Scientific Advisory Committee (SAC) of 15 experts in children’s oral health, including children with special needs, was created by the joint venture to guide and inform the work of the project. The SAC met approximately 10 times and addressed issues ranging from risk assessment to complicated scientific discussions on chlorhexidine in obstetrical care. An evaluation subcommittee was created from this group that reviewed and provided feedback on


the Evaluation Plan and survey instruments. Additionally, First 5 appointed an Oversight Committee comprised of representatives from First 5 County Commissions and others, who met once in the project’s first year. EVALUATION OUTCOMES A comprehensive Evaluation Plan, driven by California First 5 requirements, was developed and approved and addressed both process and impact results. The primary study questions included the following: How many providers were reached by the program and what were their characteristics?

What was the extent of knowledge gain and retention among those attending a training?

To what extent was there an increase in self-perceived skills and confidence among dentists and physicians in serving children age 0-5, including children with special needs?

To what extent were dental and primary care professionals who attended a training providing preventive oral health services to young children, and what changes occurred in their practices as a result of participating?

To what extent did course participants value the training courses?

What system and policy improvements occurred in the field of dentistry, including California dental schools, that this program influenced?

To what extent did community organizations implement the oral health curriculum into their agencies’ programs for parents as a result of participating in training?

To what extent did parents learn about, value and adopt desired behaviors as a result of receiving education from the participating community organizations?

The Evaluation Team The evaluation team consisted of Barbara Aved, R.N., Ph.D., M.B.A.; Larry S. Meyers, Ph.D.; Elita Burmas, M.A.; Jude Hudson, B.A. and Anita Garcia-Fante, B.A. In addition to program evaluation, Dr. Aved’s expertise is in public health and health care policy. She is president of BARBARA AVED ASSOCIATES, a Sacramento-based consulting firm. Dr. Meyers is professor of psychology at California State University, Sacramento, and a researcher in the area of human services. Ms. Burmas is a private sector researcher and along with Dr. Meyers is an expert in statistical methods. Ms. Hudson, president of Hudson + Associates, and Ms. Garcia-Fante, who is bicultural/bilingual, are communications consultants focusing on health and human services. BAA support staff Deedra Withers, B.S., Philip Avedschmidt, B.B.A., and Erika Scheideman, B.S., provided data entry and research assistance. ACKNOWLEDGEMENTS We are grateful to Dr. Cindy Weideman and the Weideman Pediatric Dental practice in Citrus Heights, California, for allowing us to photograph patients and families, and to Joe Burull Photography and Gina Kuest, R.N., for additional photographs. Staff from the WIC agency in Los Angeles graciously offered to translate our parent survey into Spanish. And, Robert Isman, DDS, MPH, of the California Department of Health Care Services, kindly facilitated the request to Delta Dental for claims analysis.


DATA SOURCES AND METHODS The data described in this report came primarily from written surveys uniquely created for this evaluation. All data sources that informed the evaluation are summarized in Attachment 1, copies of which are available from First 5 California. SURVEY INSTRUMENTATION AND ADMINISTRATION Written Surveys To standardize the training, key messages the Scientific Advisory Committee reached consensus on were piloted among a group of 300 dentists in May 2004 as the curriculum was being developed. The curriculum was completed over the next 6 months and calibrated along with the evaluation posttest on December 3, 2004 with the 51dental and medical professionals selected as the initial trainer group. We fine-tuned the evaluation instruments following feedback from the calibration training. The training participants—dental and medical providers and early childhood education professionals from contracted community organizations serving children aged 0-5, e.g., WIC, Head Start—completed a survey/posttest (“survey”) immediately after participating in a training session (called “the initial survey”).3 They completed a similar survey/posttest approximately 6 months later (called the “follow-up survey/posttest).”4 The initial surveys were distributed and collected onsite by program trainers according to our protocols and mailed to us in self-addressed, prepaid mailers. While trainers were responsible for making sure the forms were distributed they could not be certain that each participant actually returned a completed survey before leaving the session. We received batches of surveys regularly between January 2005 and October 2007, and these constitute the primary dataset for this evaluation. We sent 6-month follow-up surveys to the training participants who had given readable fax numbers or e-mail addresses in their initial surveys. For those without either type of contact information but with telephone numbers, we made calls and attempted to obtain fax numbers. About one-third of the initial surveys from the medical and dental providers were missing all contact information and no follow-up was possible. (Within the medical and dental provider groups, physicians and dentists had about the same proportion of missing contact information. Community service organization staff were more likely than either of the other provider groups to supply contact information.) About one-third of the contact information that was provided 3 While Kaiser provided training to its physicians under this program it declined to participate in the evaluation. 4 The posttest was included in the survey instrument. While the surveys/posttests had some unique items for each target group, they were mostly similar, and were the same for each group regardless of the length of their course or the type of delivery.


was impossible to decipher, contained wrong or disconnected telephone and fax numbers, non-working email addresses, or missing area codes. The fact that there were students participating in the training courses (in many cases without practice contact information) also decreased the opportunity to obtain follow-up information, contributing to the small sample of matched initial/follow-up surveys.. The 6-month follow-up surveys were sent only one time. Because of the volume of questionnaires involved in this study, there was no attempt to follow up with those who did not respond. The majority of the respondents to the follow-up survey returned the survey via fax; very few used email.5 We worked with Vodium, the software and webcast service company that hosted the project website, to create a mechanism for online course takers to also participate in the evaluation. Evaluation data from the website were downloaded and analyzed for participants who had accessed the online course and completed a posttest survey during the reporting period. To facilitate distance learning opportunities, particularly for rural providers, a First Smiles correspondence course was also developed by CDAF and mailed to over 18,000 dentists, dental hygienists and dental assistants in counties where there were fewer than two “live” trainings (e.g., Mono, Del Norte). The home-study course was published in its entirety in journals of the California chapters of various dental organizations; readers pulled out the one-page posttest evaluation survey, completed it and mailed or faxed it to CDAF where it was then transmitted to us. For purposes of analyzing knowledge and knowledge retention outcomes, it was decided with CDAF that home-study course takers would be considered in the same training format category as online course takers. Initial and 6-month follow-up surveys/posttests were also administered to parents/caregivers of children aged 0-5. The respondents represent a convenience sample of parents/caregivers of WIC and Head Start-enrolled children who attended an oral health education session at those subcontracted organizations. Surveys were also developed and sent to groups such as local dental societies whose perspectives about various aspects of the program were important to inform the outcome evaluation. The same survey developed for the First Smiles Scientific Advisory Committee was also sent to 8-10 key informants (selected with input from CDAF and DHF) who represented medical and dental leadership in California. Another survey was developed and emailed to the 32 California local (county, bi-county, regional) dental society executive directors in April 2007. The purpose was to see how familiar dental societies were with First Smiles and the extent of their participation. The 40 trainers who ended up delivering the dental, medical and early childhood educator trainings also were sent a survey about their experience. Second attempts were made by email as necessary to increase the response rate for all of these surveys. In March 2005, we queried the state’s five dental schools—UCSF, USC, UOP, UCLA, Loma Linda University—to determine at baseline the type and extent of the current dental school curricula and clinical experience requirements concerning children age 0-5. (Examination of curricula from allied dental, postgraduate, medical, allied medical, nursing schools and child care training 5 We tested the possibility that there could be a higher email return rate if the recipient received the survey directly from a professionally-recognized organization such as the CDA. However, when this method was tested the CDA-emailed surveys did not result in a better response, and this distribution method was not used further.


institutions was not within the scope of this evaluation.) We also surveyed a representative sample of U.S. dental schools for comparative purposes. The U.S. sample was selected systematically from the 47 non-California dental schools in sequences separated by an interval of one with the following additional considerations: additional schools selected based on previous contact with this project; familiarity of the evaluator with the school; and availability of complete contact information on website. Names of schools were drawn until a sample size of half (23) of the non-California schools was selected. A total of 21(91%) completed surveys were received, representing 45% of the U.S. dental schools outside of California. 6 The 21 dental schools in the initial survey sample were sent the follow-up survey in November 2007 and 20 (95%) responded. Finally, we queried the local First 5 Commissions regarding the extent of their awareness and participation in First Smiles and perception of impact. We also collected information about their spending for oral health at baseline (FY 2003-04) and at follow up (FY 2007-08), mailing surveys in January 2005 and October 2007. TELEPHONE INTERVIEWS Telephone interviews were conducted with a sample of 102 dentists 12-16 months after the course to obtain more in-depth information primarily about the number of children 0-5 in their practice due to taking a First Smiles training,. The sample was drawn randomly from a proportionate sample of trainings by region and was representative of gender, years in practice and location of the dentists who participated in an in-person training. DENTI-CAL CLAIMS ANALYSIS Two data reports were requested from Delta Dental of California (Delta). The first was a comparison of claims at baseline from the first half of Calendar Year (CY) 2004 (January 1 – June 30) with claims from the first half of CY 2007. The purpose of the request was to determine if there had been an increase in the number of children age 0-5 seen by Denti-Cal providers who took a First Smiles course, and an increase in the number of preventive dental services provided. Delta was provided with an Excel file of the license numbers of enrolled Denti-Cal dentists trained through First Smiles to match with those who were enrolled as Denti-Cal providers during both periods. The Delta data were run but at the time of this report, they were not considered reliable and could not be included in the report. The second data report from Delta (which is included in this evaluation report) was the number of fluoride varnish applications and number of children under age 6 who received them from medical providers between June 2006—when fluoride varnish first became a medical benefit—through December 2007. The control period was before varnish became a covered benefit, during which time the number of paid applications was zero. The data are from Medi-Cal fee-for-service claims and do not include managed care. 6 The respondents included: Baylor College; Oregon Health and Science University; University of North Carolina at Chapel Hill; Columbia University; New York University; Marquette University; Temple University; University of Medicine and Dentistry of New Jersey; University of Pittsburgh; Ohio State University; University of Florida; University of Iowa; University of Mississippi; University of Washington; University of Oklahoma; Arizona School of Dentistry and Oral Health; University of Kentucky; Tufts University; West Virginia University; Medical College of Georgia; and University of Michigan.


FOCUS GROUPS To gain additional insight into the results of parent education, we conducted focus groups with a sample of parents and other caregivers between March and August 2006. Ten focus groups (two per site) were held in Los Angeles, Shasta, Contra Costa, Solano and Sacramento counties. Participants were recruited by local WIC and Head Start from among those agencies that participated in the program. Selection of parents was done in a non-random purposive manner to probe particular issues; in this case, to follow up a deliberate selection of parent survey respondents. Structured questions, which were sent to the host organizations ahead of time for comment, were used to guide the discussion. To ensure an adequate number of participants, we generally piggybacked the session to a service visit, event, class or meeting parents were already required or likely to attend. Three of the focus groups were conducted in Spanish by a bilingual facilitator. The focus group sessions lasted from 45-60 minutes and addressed the following issues:

Knowledge about children’s oral health Use of oral health services by caregivers and children 0-5 Difficulties encountered when accessing oral health services for children Current oral health practices in the home

At the end of the session, parents were given colorful gift bags containing oral health-related items (various types of toothpaste, adult and child toothbrushes, floss, �ylitol gum, etc.) in appreciation for their participation. LITERATURE REVIEW To inform the evaluation and benefit from other related studies, a review of the published literature was undertaken in summer 2004. Only articles and reports with research findings or policy or practice implications similar to the goals of this initiative were included. Most of the surveys cited in these studies were directly related to the purpose of the First 5 project, but a couple of questionnaires were obtained and reviewed and adapted with permission for this evaluation. STUDY LIMITATIONS The study used a posttest-only design to demonstrate knowledge gain (as opposed to knowledge increase), a suitable design when there is no available comparison group and no pretest data. The design requires identification of items on a posttest that were included in the curriculum. Pretests can add to project expense and cost valuable instructional time. Trainers and the SAC were concerned that taking additional time away from delivering the course (especially the 1-hour course) to require participants to complete a pretest was impractical and would have limited value-added information about knowledge gain that wasn’t already intuitively known. State First 5 staff agreed that while the posttest-only design was non-experimental and had limitations, the course posttest results would be the indicator for knowledge gain, and 6 months later used as the indicator for knowledge retention.


DATA ENTRY AND ANALYSIS Detailed coding schemes and Excel spreadsheets for data entry were created for the surveys and data entry staff were trained in their use. The standard data security measures were taken. The written provider surveys were logged in as they arrived and the data were entered into the spreadsheets for analysis. The data were cleaned and statistical analysis performed using SPSS Version 15.0.∗ Written summaries of findings from the telephone interviews, trainer and First 5 surveys and parent focus groups were prepared in structured formats from notes recorded during the session by the interviewer or facilitator, coded and analyzed for content.

∗ A note on the use of the Bonferroni correction. Statistical significance is traditionally evaluated by adopting a

“significance” or probability level (referred to as “the alpha level”) of .05. In essence, this means the conclusion drawn would be verified 95% of the time if the study was to be repeated ad infinitum. Another way to state this is that the chances (probability) of being wrong when we claim to have uncovered a statistically significant effect are less than 5%, expressed as p < .05.

Whether a given statistical outcome meets this alpha level is determined by locating the outcome of the analysis

on mathematical functions. Such functions or tables of values are currently incorporated into major statistical analysis software such as SPSS. These functions were developed by assuming that just one independent, stand-alone statistical analysis was performed, and serve us well under that condition. When several statistical outcomes are generated in either a single large analysis or in a related set of analyses, however, the aggregation of these procedures has the effect of adversely affecting the alpha level of any single outcome in the set. Thus, we may believe we are evaluating the outcome at a probability of .05 but the unintended actual probability may be closer to .25 or .40 or even higher. As a result, we may improperly identify an effect as statistically significant believing that we may be wrong only 5% of the time, but in reality our risk of being wrong could be closer to 50%. What has happened in such a scenario is that we have unintentionally inflated our alpha level (i.e., we have inflated our criterion used in knowing when we can legitimately assert that an effect is statistically significant).

To avoid alpha level inflation, it is appropriate to adjust the alpha level for a set of related analyses. The strategy

that is used in the present report is known as a Bonferroni correction or adjustment. To accomplish it, the traditional probability level to determine statistical significance of .05 is divided by the number of statistical tests being performed. For example, if 7 statistical tests are conducted on a set of survey items, the alpha (probability) level required to reach statistical significance would be .05/7 or .007. When we have utilized a Bonferroni correction of the alpha level, we have noted the adjusted statistical significance level when reporting the results.

Further, because we are comparing pairs of means and a given mean could differ from some means and not

others, placing footnotes by each mean to denote a statistically significant difference is not feasible. Therefore, any significant mean differences are described in the narrative accompanying the table or figure.


FINDINGS

“Parents should be encouraged to bring in their children at an earlier age. But, when I tell them their kids should have a check-up by age 1 they usually don’t believe me; they say they’ll bring them in ‘when the child is ready.’ “”

– A San Diego dentist

This section of the report is organized into chapters by the five project outcomes the evaluation was expected to address:

Knowledge Gain Knowledge Retention Self-Perceived Skill Level Increase Adoption of Desired Behaviors Access/Systems Change.

Additionally, a chapter on findings related to parent education provided by contracting community agencies was added to take advantage of available data and enrich the evaluation. The questions addressed in each of the outcome areas were developed as part of the comprehensive Evaluation Plan submitted to First 5 California and described in our Year 1 evaluation report. The findings for each provider group that received training (i.e., dental, medical and early childhood educators/other professionals at contracting community organizations) are described separately under each outcome area as readers may have a special interest in the impact of the program for a particular professional group. Findings for each group are headed with a color-coded bar as shown below.

DENTAL PROVIDERS [orange color] 1

MEDICAL PROVIDERS [green color]

CONTRACTING COMMUNITY ORGANIZATIONS [yellow color]


“Medical-dental collaborations, although they take time, need to be promoted and can result in important clinical care outcomes for children.”—Martha Molina-Bernadett, MD, MBA, Molina Healthcare

As of December 2007, First Smiles directly reached 15,230 dental and primary care providers with training, and indirectly reached many more with education through the distribution of journal articles, newsletters and other educational means. In addition, 883 staff from community organizations received training through this program.∗ The dental and primary care professionals (alternately referred to as “providers”) and community organization staff attended a conference-style, in-office, online or home study First Smiles training. The dataset for this evaluation includes 5,570 of those professionals who attending a training session between January 2005 and October 2007 and returned a usable initial evaluation survey; 3,369 (60%) of these respondents were dental professionals, 1,646 (30%) were medical professionals and 555 (10%) were staff from contracting community organizations, primarily WIC and Head Start, serving parents of children 0-5. Follow-up surveys were obtained at six months from 682 (12%) of the training participants. Community agency staff returned the greatest proportion (21%) of the follow-up surveys, followed by medical professionals (13%) and dental professionals (10%).7 The reverse order was true for the proportion of follow-up surveys that could be matched to an existing initial survey: 90% of dental professionals, 71% of medical professionals and 53% of community agency staffs’ 6-month surveys were able to be matched to their initial survey. The dataset also includes 1,318 initial and 658 follow-up surveys from the WIC and Head Start parents/caregivers, and a subsample of 117 of them who attended a focus group.

∗ In addition, there were 421,012 visits to the First Smiles Web site (approximately14, 000 per month since its launch in August 2004), and 1,037,000 copies of the consumer brochures distributed to providers, subcontractors and First 5 County Commissions. 7 Despite best efforts, response rates are declining for all types and manner of surveys as the U.S. population is being over-surveyed. For example, response rates to e-mail surveys have significantly decreased, reflecting the likelihood of viewing these as “spam.” Moreover, high response rates to surveys of physicians and other busy healthcare providers are difficult to achieve. Published research has shown the full range of response rates, from a low of 5% to 100%. (See, for example, “Web-based and mail surveys: a comparison of response, data and Cost. Griffis SE et al. Journal of Business Logistics, 2003, and “Encouraging physicians to respond to surveys through the use of fax technology.” Shelley Y. Lansing et al. Evaluation and the Health Professions, 2000.)

THE STUDY POPULATION


HOW MANY DENTAL PROVIDERS WERE REACHED BY THE PROGRAM AND WHAT WERE THEIR CHARACTERISTICS? A total of 11,476 California dental professionals (5,171 DDSs, 2,497 DHs, 3,717 Das)∗ attended a First Smiles training through December 2007, reaching at that time about 85% of the target goal. The program offered 135 live trainings across the state, delivered by 35 trainers or co-trainers of the 55 professionals who were calibrated as trainers for this program. Of the total trained, 1,364 dental professionals (482 DDSs, 405 DHs, 477 Das) received training through the home-study course CDAF introduced in March 2007. In total, 3,369 dental professionals who participated in a training course returned initial surveys, representing 60% of all providers in the dataset. Approximately 44%, 38% and 18% were from the in-person shorter, longer and online courses respectively. Of those who specified their profession, about a third were dentists followed by dental assistants (24%) and dental hygienists (20%). About 13% of the participants did not identify type of profession. For those returning a follow-up survey, over half were dentists. As dentists were more likely to supply a fax number (hygienists and assistants may have practiced in multiple offices and not had a consistent fax number to provide; they also tended to provide home and not office contact information), as a group they would have been sent a greater proportion of follow-up surveys. Hence, the longer-term information about dental providers is disproportionately influenced by the dentist group. Characteristics of the dental providers are on the following page in Table 1.

∗ DDS=Dentist; DH=Dental Hygienist; DA=Dental Assistant (terms used in the survey for profession type).

DENTAL PROVIDERS


Table 1. Dental Providers Characteristics and Type of Training

Initial Survey (N = 3369)

Follow-up Survey (N = 346)* Characteristics

n % n % Type of Profession

Dentist 1168 34.7 182 52.6 Hygienist 669 19.9 34 9.8 Dental Assistant 811 24.1 69 19.9 Dental Student / Resident 138 4.1 2 0.6 Other (e.g., dental office manager) 154 4.6 14 4.0 More Than One Selected 1 0.0 - - No Response / Missing Data 428 12.7 45 13.0

What is the nature of/your role in this practice? General Dentistry 1265 37.5 169 48.8 Pediatric Dentistry 181 5.4 30 8.7 Other Dental Specialty 152 4.5 13 3.8 Dental Hygiene 758 22.5 34 9.8 Dental Assisting 685 20.3 51 14.7 More Than One Selected 15 0.4 1 0.3 No Response / Missing Data 313 9.3 48 13.9

What is your gender? Female 2433 72.2 209 60.4 Male 795 23.6 98 28.3 No Response / Missing Data 141 4.2 39 11.3

What is your race / ethnicity? African American 52 1.5 3 0.9 American Indian 27 0.8 4 1.2 Asian 787 23.4 75 21.7 Hispanic 437 13.0 30 8.7 White, non-Hispanic 1663 49.4 177 51.2 Other 170 5.0 12 3.5 More Than One Selected 16 0.5 1 0.3 No Response / Missing Data 217 6.4 44 12.7

What is the zip code of your primary practice location? Zip code within areas participating in School Readiness

695 20.6 72 20.8

Zip code not within areas participating in School Readiness

1855 55.1 189 54.6

No Response / Missing Data 819 24.3 85 24.6 What type of Training?

In-Person 2-Hour 1470 43.6 107 30.9 In-Person 4-Hour 1291 38.3 113 32.7 Online/Correspondence 599 17.8 90 26.0 No Response / Missing Data 9 0.3 36 10.4

*Of these 346 follow-up surveys, only 311 (89.9%) could be matched to an existing initial survey.


Approximately three-quarters of the respondents were female. Close to half (49.4%) of the sample was composed of non-Hispanic Whites, 23.4% were Asian, 13.0% were Hispanic, and 1.5% were African American (Figure 1).

Figure 1. Race/Ethnicity of Participating Dental Professionals

1%

2%6%1%

5% 24%

15%46%

African AmericanAmerican IndianAsianHispanicWhite, Non-HispanicOtherMore Than One SelectedNo Response

When we examined the dentist-only respondents to see how reflective they were of overall California dentists8 for the characteristics of gender and race/ethnicity, there were major differences. According to California health professions workforce data,9 85% of the 23,000 active dentists in the state in 1998 were male while participants in the training program were nearly evenly split between male and female dentists. The First Smiles program also drew a more diverse participation ethnically and racially (probably reflecting the wide reach the program attempted to achieve). While somewhat the same proportion of African American dentists attended a training as practice in California, there were nearly twice the proportion of Hispanic and more than twice the proportion of Asian dentist participants than are represented among the state’s dentist population (Table 2). Compared to the physician respondents, dentists were much more likely to identify their gender and race/ethnicity.

8 We recognize that “all California dentists” includes dental specialties not likely to be represented among the First 5 dentist training participants. Of all California dentists, approximately 81% are in general practice. 9 The Center for the Health Professions. Center for California Health Workforce Studies, UCSF. Fact Sheet California Dentists. 1998.


Table 2. Training Participant Dentists and California Dentists by Gender and Race/Ethnicity

Characteristics All Training Participant

Dentists All California Dentists

(1998)

Gender n % n % Female 535 45.8 3,450 15.0 Male 614 52.6 19,550 85.0 No response/Missing Data 19 1.6 Total 1168 100.0 23,000 100.0

Race/Ethnicity African American 16 1.4 460 2.0 American Indian 3 0.3 * * Asian 482 41.3 4,140 18.0 Hispanic 78 6.7 920 4.0 White, non Hispanic 494 42.3 17,480 76.0 Other 55 4.7 * * More than one selected 3 0.3 * * No Response / Missing Data 37 3.2 * *

Total 1168 100.0 23,000 100.0

*Unavailable. Source: Survey respondents and UCSF Center for California Health Workforce Studies data, 1998. Note: The California figures have not been updated by UCSF nor were they aware of the availability of any updated data.

We were asked to examine the extent to which the program reached providers in areas benefiting from the First 5 California School Readiness Initiative. The SR program consists of programs in low-performing schools that improve the transition from early care settings to elementary school and increase the schools’ and communities’ capacity to promote the success of young children. About one-fifth (20.6%) of the dental practices were located within zip code areas participating in School Readiness (Figure 2), a lower percentage than medical providers’ practice locations (40.2%).

Figure 2. Dental Providers' Location in Relation to School Readiness Program

(n = 3369)

Within Areas Participating in

School Readiness20.6%

Not Within Areas Participating in


No Response24.3%


A broad range of years (less than one year to 56 years) of practice was represented in the sample, with those professionals practicing for relatively fewer years outnumbering those who had been in practice for relatively more years. Close to half (44.6%) of the dental respondents were in practice for 10 years or less, with the remainder about equally divided between 11-20 years and more than 21 years in practice (Figure 3). There was little difference between the dentists and the other types of dental professionals. The median number of years in practice for the total sample was 13 years. Using the CDA database (members and non-members) as the comparison group and years in practice as a proxy measure for age, the training participant dentists were younger and practicing relatively fewer years than overall California dentists (Table 3).

42.1% 45.0% 44.6%

27.0%25.0% 25.3%30.9% 30.1% 30.1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% o

f Par

ticip

ants

(w

ithin

that

gro

up)

0 -10 years 11 - 20 years 21 years plusNumber of Years of Practice

Figure 3. Dental Providers' Years in Practice

Dentists (n = 1130)Non-Dentists (n = 1587)

Total Sample (N = 2984)

Note: Non-dentists are the Dental Hygienist and Dental Assistant training participants.

Table 3. Years in Practice, Participant Dentists and CDA Member Dentists

Years in Practice Training Participants CDA Database

0-10 Years 42.1% 29.2% 11-20 Years 27.0% 30.5% 21 + Years 30.9% 40.3%

Source: First 5 Evaluation Survey data and California Dental Association Membership Database 2006.


HOW MANY MEDICAL PROVIDERS WERE REACHED BY THE PROGRAM AND WHAT WERE THEIR CHARACTERISTICS? Physicians, physician assistants, nurse practitioners and other nurses can play a significant role in reducing the burden of early childhood caries provided they have the training and support to do so. A total of 3,754 primary care medical professionals (2,915 MDs—exceeding the project target—490 medical residents and 349 NPs/PAs)∗ in California attended a 1- or 2-hour in-person training. The program offered 1,700 trainings across the state (1,591 office visits, 62 hospital trainings, 47 community-based trainings), delivered by 20 trainers or co-trainers (10 of whom were consistently used) of the 60 professionals calibrated as trainers for this program. During the study period, 1,646 medical professionals returned initial surveys, representing 30% of the providers in the dataset. Ninety-five percent were from the shorter course, predominantly offered as in-office trainings. As Table 4 on the next page shows, the majority (59.3%) of the sample was composed of licensed physicians; physicians also made up the greatest proportion (49.1%) of the follow-up sample although there was a high percentage (29.8%) among the follow-up respondents who did not disclose their profession. About 17% of the sample was divided between nurse practitioners, physician assistants, RNs and medical students or residents. Pediatric and family practice providers, in equal proportions, made up 81% of the practice area types. Another 5% were OB-GYN practices, and about 4% represented other healthcare areas such as internal medicine, neurology, pharmacy, school nursing, and case management.

∗ NP=Nurse Practitioner; PA=Physician Assistant (terms used in the survey for profession type).

MEDICAL PROVIDERS


Table 4. Medical Providers Characteristics and Type of Training


Follow-up Survey

(N = 218)* Characteristics

n % n % Type of Profession

MD / DO 976 59.3 107 49.1 NP / PA 138 8.4 23 10.6 RN 101 6.1 15 6.9 Medical Student / Resident 47 2.9 - - Other 74 4.5 5 2.3 More Than One Selected 7 0.4 3 1.4 No Response / Missing Data 303 18.4 65 29.8

What is your specialty or practice area? OB-GYN 79 4.8 3 1.4 Pediatrics 670 40.7 81 37.2 Family Practice (including community/public health) 661 40.2 54 24.8 Dental Professional** 96 5.8 7 3.2 Other 65 3.9 4 1.8

What is your gender? Female 894 54.3 94 43.1 Male 615 37.4 52 23.9 No Response / Missing Data 137 8.3 72 33.0

What is your race / ethnicity? African American 78 4.7 5 2.3 American Indian 4 0.2 - - Asian 464 28.2 39 17.9 Hispanic 236 14.3 19 8.7 White, non-Hispanic 507 30.8 67 30.7 Other 159 9.7 14 6.4 More Than One Selected 17 1.0 1 0.5 No Response / Missing Data 181 11.0 73 33.5

What is the zip code of your primary practice location? Zip code is within areas participating in School Readiness Initiative

661 40.2 68 31.2

Zip code is not within areas participating in School Readiness Initiative

706 42.9 71 32.6

No Response / Missing Data 279 17.0 79 36.2 What type of training was this?

In-Person 1-Hour 1564 95.0 144 66.1 In-Person 4-Hour 76 4.6 11 5.0 No Response / Missing Data 6 0.4 63 28.9

A little more than half (54.3%) of the total medical provider respondents were females. Asian and non-Hispanic Whites each comprised about 28.2% and 30.8%, respectively, of the sample. Hispanics were the next most well represented group at about 14% and African Americans made


up about 4.7% of the sample. Nearly ten percent (9.7%) identified themselves as “other,” and 11% declined to state their race/ethnicity. The large percentage (33.5%) that did not identify race/ethnicity in the follow-up survey prevents us from knowing whether the matched follow-up sample is generally reflective of the total sample of training participants. When we examined physician-only respondents to see how reflective they were of all California physicians10 there were major differences. Similar to the dentists, the First Smiles program clearly attracted a more diverse participation of physicians. Compared to 2002 California physician workforce data,11 one-quarter (24%) of the state’s professionally active, non resident patient care physicians are female while 41% of the physician participants in the training program were females. Race/ethnicity among the training sample was also more diverse. There were more than twice the proportion of Hispanic physician training participants, and one and a half times the proportion of African American and Asian physician participants than are represented among the California physician population. While whites make up about two-thirds of the state’s physicians they comprised only one-quarter of the training sample (Table 5).12 Because approximately 9% - 12% of the participants failed to identify their gender and/or race/ethnicity, we do not know the extent to which missing data might affect these comparisons. Table 5. Training Participant Physicians and California Physicians, Selected Demographics

Characteristics Training Participants

All Years All California Physicians

2002 Gender n % n %

Female 404 41.4 16,620 24.0 Male 482 49.4 52,631 76.0 No response/Missing Data 90 9.2 Total 976 100.0 69,252 100.0

Race/Ethnicity African American 52 5.3 2,078 3.0 American Indian 2 0.2 69 0.1 Asian 339 34.7 15,305 22.1 Hispanic 104 10.7 3,047 4.4 White, non Hispanic 233 23.9 45,568 65.8 Other 119 12.2 2,632 3.8 More than one selected 7 0.7 NA NA No Response / Missing Data 120 12.3 485 0.7 Total 976 100.0 69,252 100.0

Source: Survey respondents and California Physician Workforce: Supply and Demand Through 2015. Center for Health Workforce Studies, University at Albany, State University of New York, December 2004. NA=not available.

10 “All active California physicians” includes specialties not likely to be represented among the First 5 physician training participants. 11 California Physician Workforce: Supply and Demand through 2015, December 2004. The Center for Health Workforce Studies, University of Albany, State University of New York. American Medical Association Physician Masterfile, December 2002. 12 Because the majority of MDs in the sample were trained by Molina Healthcare, the physician profile disproportionately reflects their provider network.


About two-fifths (40.2%) of the practices represented by these medical providers were located in zip codes within the First 5 California School Readiness program area (Figure 4), about twice the proportion of the dental provider locations in School Readiness areas.

Figure 4. Medical Providers' Locations in Relation to School Readiness Initiative

(n = 1646)

Within Areas Participating in


Not Within Areas Participating in


No Response17.0%

A broad range of years (less than one year to 52 years) of practice was represented in the medical sample, with professionals practicing for relatively fewer years outnumbering those who have been in practice for relatively more years. About a third of the respondents were in practice for 5 years or less, and about half of the respondents were in practice for 10 years or less. (Figure 5). The median number of years in practice was 10 years.

Figure 5. Medical Providers' Years in Practice

8 6

468

238

179151

123 121

39 250

100

200

300

400

500

600

0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46+

Years

# o

f Par

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s


WHAT TYPE OF STAFF AND OTHER HEALTH AND SOCIAL SERVICE PROFESSIONALS PARTICIPATED IN TRAINING? First Smiles was also contracted to address consumers. The Initiative was designed to do this by training staff of community organizations that delivered children’s oral health education to pregnant women and parents of children age 0-5. For the most part, these organizations used a train-the-trainer approach to train other staff. WIC also delivered trainings directly at annual statewide conferences. Through train-the-trainer sessions, 883 community agency staff—484 from Head Start, 254 from WIC agencies and 145 through UC San Francisco Early Childhood Education program—received oral health training through this Initiative. A total of 555 of these individuals returned initial surveys and 118 (21.3%) returned a 6-month matched follow-up survey. Respondents who selected Other (23%) under job category represented the largest subset of the sample. The next largest subsets were individuals involved in Head Start (21.2% when job categories were combined) and nurses/other healthcare professionals, accounting for 18.2% of the sample. Because half of the respondents did not report their job type at follow-up it was not possible to determine their representation across the various job categories.

Table 6. Community Organization Professionals Participating in the Training Initial Survey

(N = 555) Follow-up Survey

(N = 118)* Characteristics n % n %

Job Category

Head Start Teacher 52 9.4 2 1.7 Head Start Family Advocate 48 8.6 2 1.7 Head Start Trainer 18 3.2 4 3.4 Community Health / Outreach Worker 23 4.1 7 5.9 Nutritionist 41 7.4 13 11.0 WIC Nutrition Assistant 39 7.0 5 4.2 Nurse / Other Healthcare Professional 101 18.2 7 5.9 Early Care and Education Professional 32 5.8 - - Social Worker 14 2.5 - - Other 124 22.3 17 14.4 More Than One Selected 18 3.2 1 0.8 No Response / Missing Data 45 8.1 60 50.8

*Of these 118 surveys, only 63 (53%) could be matched to an existing initial survey.

COMMUNITY ORGANIZATIONS


TO WHAT EXTENT DID KNOWLEDGE GAIN AND RETENTION OCCUR AMONG DENTAL PROVIDERS, AND DID IT DIFFER BASED ON LENGTH OF TRAINING?

The core curriculum for all providers addressed all of the key messages approved by the project’s Scientific Advisory Committee. A slight variation was tailored for dental professionals. The in-person training was offered three ways: as either a “short” or “long” course, depending on the depth of the information provided, and online. For the in-person trainings, dental providers could attend either a 2-hour or a 4-hour session. The overall (multivariate) effect of type of training was significant indicating that the three groups of participants performed differently on the individual test questions. Considering the posttest as a whole with all of the test items combined, the 4-Hour and Online groups performed significantly better than the 2-hour group. Only for the multiple choice (MC) items were the differences significant. The In-Person 2-hour group performed more poorly on the following MC items: for question 1, they performed significantly worse than the Online group but for questions 2, 3, and 4 they performed significantly worse than the In-Person 4-Hour group. In terms of differences in performance on other posttest items, and summarizing over all three training groups, it is possible to distinguish three items sets. Generally, respondents performed well on T/F items a, d, e, and MC item 4; they performed moderately well on T/F item c, and MC items 1, 2, and 3; and they performed very poorly on T/F item b (behavioral issues in treating children with special needs).

OUTCOME: KNOWLEDGE GAIN AND RETENTION

DENTAL PROVIDERS


Table 7. Initial Posttest Results of All Dental Providers

% Correct on Initial Survey

Survey Question In-Person 2-Hour

(n = 1410*)

In-Person 4-Hour

(n = 1258*)

Online (n = 123*)

TRUE / FALSE

a) Age for infant’s first dental visit 91.4 93.1 91.9

b) Behavioral issues in treating children with special needs 42.1 44.9 39.0 c) Medi-Cal/Healthy Families reimbursement 80.2 82.8 84.6 d) Role of �ylitol gum 92.6 92.5 95.9 e) Remineralization with fluoride varnish 96.2 94.6 95.9

Total Average Score for True/False 80.5 81.6 81.5 Average # of True/False Items Correct 4.0 4.1 4.1 MULTIPLE-CHOICE 1. Risk factors associated with early childhood caries 77.9 80.2 86.9 2. Pathological factors in caries balance equation 75.7 81.1 81.3 3. Protective factors in caries balance equation 68.1 76.6 70.7 4. Most prevalent unmet need in children with special needs 92.3 95.2 97.6

Total Average Score for Multiple Choice 78.5 83.3 84.2 Average # of Multiple Choice Items Correct 3.1 3.3 3.4

Total Test Score (all items combined) 79.6 82.3 82.7

*Sample size is after excluding those cases with 8 or more blank posttest responses on the initial survey. These excluded cases were not included in the computation; they were defined as not responding to enough questions to presume that they had challenged all of the test items and could therefore allow us to code a failure to answer a question as an incorrect answer. P = < .005. Note: Because we are comparing pairs of means and a given mean could differ from some means and not others, placing footnotes by each mean to denote a statistically significant difference is not feasible. Therefore, any significant mean differences are described in the narrative accompanying the table.

The data in Table 8 below represent those participants completing both the initial and follow-up surveys. Only the 2-hour and 4-hour training programs were included in this analysis; the on-line training sample size was too small to justify inclusion in the analysis. A Bonferroni corrected statistical significance level of .005 was used in the analysis. As expected, there was a general trend for participants to lose some information over the 6 month period. Of the nine test questions, five (T/F questions b, d, e, and MC 3) showed statistically significant declines in test performance, i.e., knowledge retention, over the 6-month period. The overall T/F score and the overall MC score also were significantly lower at the time of the follow-up survey. There were no significant differences between the 2-hour and the 4-hour training programs for the matched surveys.


P < .005. Note: Because we are comparing pairs of means and a given mean could differ from some means and not others, placing footnotes by each mean to denote a statistically significant difference is not feasible. Therefore, any significant mean differences are described in the narrative accompanying the table.

The different professions differed significantly on total test performance (Figure 6). Hygienists and dentists did not differ from each other but they performed better on the test than dental assistants and others (these latter two groups did not differ from each other). Across the professions, there was a statistically significant decline in overall test performance from the initial to the follow-up survey.

Table 8. Initial and Follow-up Posttest Results of Dental Providers

In-Person 2-Hour Training

% Correct (n = 104)*


% Correct (n = 112)*

Online Training

% Correct (n = 12)*

Survey Question

Initial 6-

Month %

Change Initial

6-Month

% Change

Initial 6-

Month %

Change

TRUE / FALSE

a) Age for infant’s first dental visit 95.2 92.3 -3.0 91.9 87.5 -4.8 100.0 91.7 -8.3

b) Behavioral issues in treating children with special needs 50.0 32.7 -34.6 52.7 44.6 -15.4 41.7 33.3 -20.1

c) Medi-Cal/Healthy Families reimbursement 84.6 78.9 -6.7 86.6 83.0 -4.2 83.3 66.7 -20.0

d) Role of �ylitol gum 97.1 86.5 -10.9 97.3 86.6 -11.0 91.7 100.0 +9.0

e) Remineralization with fluoride varnish 96.2 83.7 -13.0 96.4 86.6 -10.2 100.0 91.7 -8.3

Total T/F Correct 84.6 74.8 -11.6 85.0 77.7 -8.6 83.3 76.7 -7.9

# of T/F Items Correct 4.2 3.7 -11.9 4.3 3.9 -9.3 4.2 3.8 +9.5

MULTIPLE-CHOICE

1. Risk factors associated with early childhood caries 83.7 76.9 -8.1 83.0 72.3 -12.9 91.7 91.7 none

2. Pathological factors in caries balance equation 74.0 74.0 none 81.3 73.2 -10.0 83.3 66.7 -20.0

3. Protective factors in caries balance equation 74.0 52.9 -28.5 75.0 58.9 -21.5 83.3 66.7 -20.0

4. Most prevalent unmet need in children with special needs 100.0 98.1 -1.9 97.3 95.5 -1.8 100.0 100.0 None

Total M/C Correct 82.9 75.5 -8.9 84.2 75.0 -10.9 89.6 81.3 -9.3

# of M/C Items Correct 3.3 3.0 -9.1 3.4 3.0 -11.8 3.6 3.3 -8.3

*Sample size is after excluding those cases with 8 or more blank posttest responses on the initial and follow-up survey. These excluded cases were defined as not responding to enough questions to presume that they had challenged all of the test items (and could therefore allow us to code a failure to answer a question as an incorrect answer).


84.4%

75.7%

86.1%

77.7%

87.8%

76.4% 79.9%

70.5%74.6%

71.4%

0%10%20%30%40%50%60%70%80%90%

100%

Per

cent

age

Cor

rect

Full Sample (N = 294)

Dentist (n = 177)

DentalHygienist

(n = 32)

DentalAssistant

(n = 67)

Other (n = 14)

Sample Group

Figure 6. Dental Posttest Questions, Initially and at 6-Month

Initial Follow-up

Note: in some figures/tables, the full sample total is not equal to the sum of all the different subcategories due to missing responses. In Figure 6, for example, the full sample of dental participants was broken down further into subcategories based on profession or specialty, but participants who did not report their profession were excluded in the subsample analysis.

WHAT DID DENTAL PROVIDERS SAY ABOUT THE TRAINING? Overall, the dental participants appeared to be very satisfied with the course (Table 9). In their initial feedback they reported being likely to recommend the course to colleagues and anticipated being able to apply information they learned in their practices. They also expected to use the course materials. Six months later more than half (56.5%) reported that they had recommended the course to a colleague (follow-up data not shown). Because some respondents stated they already had certain skills prior to taking the course, the slightly lower agreement level relative to learning information and skills that were new is to be expected. The value of the course instructors, curricula content and materials was echoed by the sample of 102 dentists who participated in the follow-up telephone interviews.

Table 9. Dental Participants’ Feedback about the Course

Survey Question M SD n

To what extent do you agree with the following statements about the course you took today?

a) I would recommend the course to my colleagues 3.63 .55 3195

b) I learned information and skills that were new to me 3.36 .66 3115 c) I expect the course references and materials will be useful to me 3.55 .57 3120

d) I can apply the information I learned 3.61 .55 3126

Note. Item mean scores reflect the following response choices: 1 = strongly disagree, 2 = disagree or mostly disagree, 3 = agree or mostly agree, and 4 = strongly agree.


Additional feedback obtained from telephone interviews with a representative sample of general dentists included the following; practice changes are evident by their comments:

Dentists’ Feedback About the Training 6 Months Later

“The course helped me a lot with technique” “I’ve implemented the fluoride varnish procedure described at the training” “I was already seeing young kids but the course definitely improved the quality of care I provide” “I feel so much more comfortable with being able to see younger children” “I learned that kids need to come in at a younger age than I previously thought” “I now use my female hygienists to relate to little kids so when I come in to do the check-up the

kids are calmer and quieter” “The information about disabilities and special needs made me more comfortable with being able to

see these children” “Now I can explain to parents why it’s important to bring them in early” “I don’t see any new children in my older practice but I opened a new practice where I accept

children 0-5”

Source: DDS telephone interviews.

WHAT OTHER RESOURCES DID DENTAL PROVIDERS USE TO MAINTAIN KNOWLEDGE? Dental professionals who took the training made use of a variety of resources to stay current on issues related to young children’s oral health. The most common methods utilized were reading journal articles (74% of the respondents) and attending conferences and workshops on the topics. Dental professionals also used web-based resources for information, and accessing information posted on the First Smiles website (www.first5oralhealth.org) was reported by a third (32%) of the individuals.

Table10. Type of Resources Utilized by Dental Providers Since Training

Survey Question n

What resources have you utilized in the last 6 months to stay updated on oral health issues related to children 0 – 5?

Read professional journals on the topic 226 Attend conference or workshop on the topic 124 First Smiles (this project’s) website 96 Other web-based educational sites and materials 74 Other (what?) 22

Discussion/consults with other dentists 5 By training or being in residency training 4 Los Angeles POHAP (Pediatric Oral Health Assessment Project) 2 Unable to determine 2

Note. Because survey question allowed for the respondent to check more than one choice, no percentages were computed because the “total” would be greater than 100%).

http://www.first5oralhealth.org/�


“I thought the lecture series was very helpful. We do not get enough teaching on dental health in residency, so I found them valuable. They should be given every year so the new pediatric residents can be exposed to the material and the old ones get reinforcement.” – Bay Area Physician

TO WHAT EXTENT DID KNOWLEDGE GAIN AND RETENTION OCCUR AMONG PRIMARY CARE MEDICAL PROVIDERS? DID IT DIFFER BASED ON LENGTH OF TRAINING?

The core curriculum, which addressed all of the key messages, contained slight variations tailored for medical professionals. The training was offered as either a “short” or “long” course depending on the depth of the information provided. The short course, the most commonly delivered, was a 1-hour in-office presentation to physicians and their staff. The overall (multivariate) effect of type of training was significant indicating that the two groups of participants performed differently on individual posttest questions. However, when all posttest questions were combined, there was no statistically significant difference between the two lengths of training of the medical provider participants. Analyses of the data indicated that the groups differed significantly on questions T/F b and MC 1 (see Table 11 for a description of the posttest items). The 1-hour group performed significantly better than the 4-hour group on question T/F b (behavioral issues in treating children with special needs) but performed significantly more poorly on question MC 1 (risk factors associated with early childhood caries). In terms of differences in performance on other test items, and summarizing over both training groups, it is possible to distinguish three items sets. Generally, respondents performed well on T/F items a, d, e, and MC item 4; they performed moderately well on T/F items c, and MC items 2, and 3; and they performed very poorly on T/F item b.

MEDICAL PROVIDERS


The data in Table 12 on the following page represent those participants who answered the posttest questions on both the initial and follow-up surveys.∗ Only the 1-hour training program was included in this analysis; the 4-hour training did not have a large enough sample size to justify inclusion in the analysis. Similar to the dental participants, there was a general trend for participants to lose quite a bit of information over the 6-month period (see table for these posttest items). Of the nine test questions, five (questions T/F a and e and MC 1, 2, and 3) showed statistically significant declines in test performance of knowledge retention over the 6-month period. The overall T/F score and the overall MC score also were significantly lower at the time of the follow-up survey. It should be noted that knowledge retention of MC posttest questions 1, 2, and 3—risk factors associated with early childhood caries, pathological factors in caries balance equation, protective factors in caries balance equation—showed an extremely large decline over time.

∗ After first excluding cases with 8 or more blank responses and then those participants who had marked other or more than one profession, only 3 professions were represented in the follow-up surveys (physicians, NP/PAs, and RNs).

Table 11. Medical Providers’ Posttest Results

% Correct Initial Survey

Survey Question In-Person 1-Hour

(n = 1508*)

In-Person 4-Hour

(n = 76*) TRUE / FALSE

a) Age for infant’s first dental visit 90.6 90.8 b) Behavioral issues in treating children with special needs 54.8 32.9 c) Medi-Cal/Healthy Families reimbursement 78.5 90.8 d) Role of �ylitol gum 95.0 93.4 e) Remineralization with fluoride varnish 93.9 97.4

Total Average Score for True/False 82.6 81.1 Average # of T/F Items Correct 4.1 4.1 MULTIPLE-CHOICE 1. Risk factors associated with early childhood caries 63.9 80.3 2. Pathological factors in caries balance equation 74.0 80.3 3. Protective factors in caries balance equation 76.1 81.6 4. Most prevalent unmet need in children with special needs 95.1 96.1

Total Average Score for Multiple Choice 77.3 84.5 Average # of M/C Items Correct 3.1 3.4

Total Test Score (all items combined) 80.2 82.6

*Sample size is after excluding those cases with 8 or more blank posttest responses on the initial survey. These excluded cases were not included in the computation; they were defined as not responding to enough questions to presume that they had challenged all of the test items (and to therefore allow us to code a failure to answer a question as an incorrect answer).


Table 12. Initial and Follow-up Posttest Results for Medical Providers

*Sample size is after excluding those cases with 8 or more blank posttest responses on the initial survey. These excluded cases were not included in the computation; they were defined as not responding to enough questions to presume that they had challenged all of the test items and could therefore allow us to code a failure to answer a question as an incorrect answer. P < .005. Note: Because we are comparing pairs of means and a given mean could differ from some means and not others, placing footnotes by each mean to denote a statistically significant difference is not feasible. Therefore, any significant mean differences are described in the narrative accompanying the table.

Overall, each of the three groups represented in the follow-up surveys (physicians, NP/PAs and RNs) scored significantly lower on the follow-up posttest than they did on the initial posttest (Figure 7). There were no significant differences between the groups in their scores.


% Correct (n = 136*)


% Correct (n = 11*)

Survey Question

Initial 6-Month % Change Initial 6-Month % Change

TRUE/FALSE

a) Age for infant’s first dental visit 91.9 80.9 -12.0 100.0 72.7 -27.3 b) Behavioral issues in treating children

with special needs 46.3 34.6 -25.3 18.2 36.4 +100.0

c) Medi-Cal/Healthy Families reimbursement

86.8 83.1 -4.3 100.0 72.7 -27.3

d) Role of �ylitol gum 94.1 83.8 -10.9 100.0 72.7 -27.3 e) Remineralization with fluoride varnish 96.3 70.6 -26.7 100.0 81.8 -18.2 Total T/F Correct 83.1 70.6 -15.0 83.6 67.3 -19.5 # of T/F Items Correct 4.2 3.5 -16.7 4.2 3.4 -19.0

MULTIPLE-CHOICE

1. Risk factors associated with early childhood caries

64.7 46.3 -28.4 90.9 36.4 -60.0

2. Pathological factors in caries balance equation

75.0 42.7 -43.1 90.9 45.5 -49.9

3. Protective factors in caries balance equation

79.4 29.4 -63.0 100.0 36.4 -63.6

4. Most prevalent unmet need in children with special needs

96.3 89.0 -7.6 100.0 100.0 None

Total M/C Correct 78.9 51.8 -34.3 95.5 54.6 -42.8 # of M/C Items Correct 3.2 2.1 -34.4 3.8 2.2 -42.1


81.8%

62.2%

81.5%

59.5%

81.8%

66.7%

81.8%

68.3%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Per

cent

age

Co

rrec

t

Full Sample (N = 147)

MD/DO (n = 102) NP/PA (n = 22) RN (n = 14)

Sample Group

Figure 7. Medical Posttest Questions, Initially and at 6-Month

InitialFollow-up

WHAT DID MEDICAL PROVIDERS SAY ABOUT THE TRAINING? Overall, the medical participants were very satisfied with the course (Table 13). While most reported being likely to recommend the course to colleagues, fewer than half (44.9%) had actually done so 6-months later (data not shown). The medical provider participants also strongly agreed they would be able to apply information they learned in their practices, and expected to use the course references and materials. Table 13. Medical Participants’ Feedback about the Course


To what extent do you agree with the following statements about this course?

a) I would recommend the course to my colleagues 3.60 .56 1493

b) I learned information and skills that were new to me 3.49 .61 1469 c) I expect the course references and materials will be useful to me 3.56 .55 1469 d) I can apply the information I learned 3.58 .55 1467



WHAT OTHER RESOURCES DID MEDICAL PROVIDERS USE TO MAINTAIN KNOWLEDGE? Healthcare professionals who took the training made use of a variety of resources to stay current on issues related to young children’s oral health. The most common method utilized was reading journal articles on the topic, cited by 69% of respondents. Accessing information posted on the First Smiles website was reported by about one-quarter (28%) of the medical providers.

Table 14. Type of Resources Utilized by Medical Providers Since Training

Survey Question n

What resources have you utilized in the last 6 months to stay updated on oral health issues related to children 0 – 5?

Read professional journals on the topic 116 First Smiles (this project’s) website 48 Other web-based educational sites and materials 36 Attend conference or workshop on the topic 28 Other (what?) 26

Discussion with dentists/ other health colleagues 6 Miscellaneous 7

Note. Survey question allowed for the respondent to check more than one choice (and so no percentages were computed because the “total” would be greater than 100%).


“The biggest barrier to implementing what I learned today [at training] is finding the time to present this information to parents.” – WIC Nutritionist, Fresno

TO WHAT EXTENT DID KNOWLEDGE GAIN AND RETENTION OCCUR AMONG EARLY CHILDHOOD EDUCATORS AND OTHER PROFESSIONALS? Generally, the early childhood educators and other community agency staff did quite well on most of the posttest questions regarding ways to prevent dental decay and promote oral health (Table 15). The average total correct score of 81.2% for the true/false question set and 90.4% for the multiple choice question set were quite favorable. However, the staff appeared to have a little more trouble with T/F questions c and f than with the others, and these differences were statistically significant. Forty percent believed fluoride varnish to be a vaccine and answered item c incorrectly. The lower score on the question of frequent, prolonged breastfeeding as a risk factor for early childhood caries (T/F item f) is consistent with concerns that were raised about this issue during the trainings. Some agency staff felt the data on the association between nighttime nursing and risk of caries is not strong enough to make this association; further, they were concerned about the potential for such a message to negate efforts in encouraging women to breastfeed. Table15. Posttest Results of Community Organization Staff

Survey Question

Total Sample

% Correct (n = 554*)

TRUE/FALSE a) Dental decay is infectious transmissible disease 87.0 b) When infant should make first dental visit 85.2 c) Fluoride varnish is a vaccine 61.0 d) Tooth brushes should be stored separately 91.3 e) Pregnant women should wait to see a dentist 88.3 f) Frequent/prolonged breastfeeding is risk factor 61.9 g) Proportion of preschoolers with dental disease 93.9

Total Average Score for True/False Items 81.2 Average # of T/F Items Correct (out of 7) 5.7 MULTIPLE-CHOICE 1. Age when children can brush without help from adult 87.0 2. Preferred snacks for young children 92.6 3. Most prevalent unmet among children with special needs 91.5 Total Average Score for Multiple Choice Items 90.4 Average # of M/C Items Correct (out of 3) 2.7

*Sample size is after excluding those cases with 8 or more blank posttest responses on the initial survey. These excluded cases were defined as not responding to enough questions to presume that they had challenged all of the test items (and could therefore allow us to code a failure to answer a question as an incorrect answer).



Although the respondents scored well on the initial survey on the question of when a child should make its first dental visit, a number of staff had expressed the belief during the trainings that “this may be too early as most babies will have very few teeth.” The data in Table 16 below represent the participants in the matched initial and follow-up surveys. A Bonferroni corrected statistical significance level of .005 revealed no significant differences between the initial and follow-up responses for any of the questions. The largest apparent gain in performance was generally on T/F question c (an item the total sample answered less favorably in the initial posttest) and the largest apparent loss of information was generally on T/F question b.

Table 16. Initial and Follow-up Posttest Results for Community Staff

Survey Question

Initial Survey

% Correct (n = 63)

6-Month Survey

% Correct (n = 63)

% Change

TRUE/FALSE

a) Dental decay is infectious transmissible disease 90.5 88.9 -1.6 b) When infant should make first dental visit 95.2 84.1 -11.1 c) Fluoride varnish is a vaccine 57.1 65.1 +8.0 d) Tooth brushes should be stored separately 92.1 95.2 +3.1 e) Pregnant women should wait to see a dentist 96.8 95.2 -1.6 f) Frequent/prolonged breastfeeding is risk factor 61.9 55.6 -6.3 g) Proportion of preschoolers with dental disease 95.2 95.2 none

Total Average Score for True/False Items 84.1 82.8 -1.3

Average # of T/F Items Correct (out of 7) 5.9 5.8 -1.6

MULTIPLE-CHOICE 1) Age when children can brush without help from adult

100.0 90.5 -9.5

2) Preferred snacks for young children 95.2 98.4 +3.2 3) Most prevalent unmet among children with special needs

93.7 92.1 -1.6

Total Average Score for Multiple Choice Items 96.3 93.7 -2.6 Average # of M/C Items Correct (out of 3) 2.9 2.8 -3.4

*Sample size is after excluding those cases with 8 or more blank posttest responses on the initial and follow-up survey. These excluded cases were not included in the computation; they were defined as not responding to enough questions to presume that they had challenged all of the test items and could therefore allow us to code a failure to answer a question as an incorrect answer. Overall, there appeared to be relatively little difference in knowledge retention between the various job categories and the differences were not significant (Figure 8).


88%86% 85% 85%

75%

85%93%

80%

86%83%

92% 88%84%

78%

87% 91%88% 88%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Per

cent

age

Co

rrec

t

Full Sample (N

= 63)

Head Start Teacher (n

= 2)

Head Start Family Advocate (n

= 2)

Head Start Trainer (n

= 4)

Community Health

/Outre

ach Worker (n

= 7)

Nutritionist

(n = 13)

WIC Nutrit

ion Assistant (n

= 5)

Nurse/Other H

ealthcare Professio

nal (n = 7)

Other (n = 17)

Sample Group

Figure 8. Community Organizations' Staff Posttest Questions, Initially and at 6-months

InitialFollow-up

WHAT DID COMMUNITY ORGANIZATION PARTICIPANTS SAY ABOUT THE TRAINING? Overall, the early childhood educators were very positive about the training (Table 17) they received. There was high agreement that the course materials would be useful and participants expected to be able to apply what they learned when delivering oral health education classes to parents. The least endorsed item concerned learning about community resources, but even here they were quite positive. It is possible that the staff were well aware of such resources already and so had less to learn in this area.

Table 17. Community Organization Staff Feedback about the Course


To what extent do you agree with the following statements? a) The course content was relevant for staff in my position 3.74 .49 549 b) I learned information and skills that were new to me 3.53 .62 552 c) I learned about helpful community resources 3.22 .73 538 d) The course materials will be useful to me in my job 3.74 .48 549 e) I can apply what I learned when doing parent education 3.80 .45 549 f) (For early childhood educators only) I can apply what I learned when doing classroom activities with children

3.93 .27 27



Although participants who returned a follow-up survey still had relatively high agreement about the value of the training, there was a statistically significant difference between the responses obtained on the initial and follow-up surveys. Respondents indicated that the course materials were less useful and that they were less able to apply what they learned than anticipated when asked about these on the 6-month follow-up survey (Table 18). It should be noted, however, that the initial survey responses were so positive that any change would occur in the downward direction. Table 18. Community Organization Staff Feedback Initially and at 6-Months

Initial Survey (n=63)

Follow-up Survey (n=63) Survey Question

M SD M SD

n

What is your opinion about the following statements concerning the oral health training you participated in?

The course materials have been useful to me in my job. 3.76 .43 3.33 .65 63 I’ve been able to apply what I learned when doing parent education. 3.76 .43 3.32 .70 62

(For early care and education professional only) I’ve been able to apply what I learned when doing classroom activities with children.

Results not calculated because there were no follow-up surveys from anyone identifying as an “Early Care and Education Professional”



“Ever since taking the course as a dental student I have enrolled in a pediatric dental residency program in the state of New

York, and still find the information I gained in the CDA course training a great start for my career. Thank you.” – A pediatric dental resident from California

HOW DID DENTAL PROVIDERS PERCEIVE THEIR SKILL LEVEL AFTER TRAINING? We asked training participants to assess how much they believed their skills increased in specified areas. One limitation in interpreting the responses was that it was possible those who entered the training with a high skill level may have had less room to build their skill level whereas those having somewhat lower skills levels at the outset might have had more room for improvement. Some of these participants could have taken the training even though they possessed one or more of the skills that were taught (for instance, to receive continuing education units). To prevent misinterpreting the results, those individuals (roughly 10% of the total dental sample) who reported already possessing the various skills were identified and excluded from the analysis of self-perceived skills increase. Overall, dental providers agreed that the course increased their skills after training (Table 19). The highest degree of perceived increase was in communicating with parents, followed by performing a knee-to-knee exam; the lowest increase reported was in learning how to bill and get reimbursed for procedures. As would be expected, a higher percentage of dental providers than medical providers on average reported already having some of the skills prior to taking the course.

OUTCOME: INCREASE IN SELF-PERCEIVED SKILLS

DENTAL PROVIDERS


Table 19. Increase in Self-Perceived Skill Level Among Dental Providers

Initial Survey (n = 3369)

Survey Question

M SD n* Already

Had Skill n**

Specifically with regard to children 0-5, to what extent did this course increase your skills in:

a) Performing a knee-to-knee exam 2.52 .62 2790 333

(10.7%)

b) Knowing when to treat and when to refer an oral health problem 2.40 .65 2780 318

(10.3%)

c) Knowing how to treat a problem I identify 2.39 .63 2821 271

(8.8%)

d) Managing behavior of very young children 2.34 .66 2791 311

(10.0%)

e) Providing education and other anticipatory guidance to parents 2.56 .58 2883 222

(7.1%)

f) Learning how to bill and get reimbursed for procedures 2.09 .77 2778 185

(6.2%)

g) Organizing the dental office for success 2.22 .70 2787 224

(7.4%) Note. Item mean scores reflect the following response choices: 1 = very little, 2 = some, and 3 = a great deal. * Those who indicated “very little because I already had this skill” (a choice on the original survey) were excluded from the computation of means and standard deviations; only those who responded with “very little,” “some,” and “a great deal” were included in the computations. ** These ns and percentages are based on the total number of valid (non-missing) responses in the initial survey for that question. Because different participants responded to each question, the sample sizes will be somewhat different.

Gender differences in the ability of general dentists to handle very young children (skill item d in the table below) were analyzed. Based on responses from the initial surveys, female and male general dentists did not differ significantly in how they perceived their skill level in managing the behavior of young children as a result of taking the course.

The data in Table 20 on the next page represent those participants who answered these self-perceived skill level questions on both the initial and follow-up surveys. The questions were analyzed separately to preserve the sample size available for each. A Bonferroni corrected statistical significance level of .007 was used. Except for question b (knowing when to treat and when to refer an oral health problem), an analysis of variance revealed that participants indicated significantly lower levels of self-perceived skills at the end of the 6-month period.


Table 20. Increase in Self-Perceived Skill Level among Dental Providers, Initial and 6-Mos.

Initial Survey Follow-up Survey

Survey Question M SD n*

Already Had Skill

n** M SD n*

Already Had Skill

n**

Specifically with regard to children 0-5, to what extent did this course increase your skills in: a) Performing a knee-to-

knee exam 2.48 .62 209

61 (20.7%)

2.21 .70 209 62

(20.4%) b) Knowing when to

treat and when to refer an oral health problem

2.35 .67 196 61

(20.7%) 2.25 .64 196

65 (21.5%)

c) Knowing how to treat a problem I identify

2.31 .66 208 46

(15.6%) 2.13 .64 208

62 (20.5%)

d) Managing behavior of very young children

2.26 .70 210 55

(18.6%) 2.10 .67 210

54 (17.8%)

e) Providing education and other anticipatory guidance to parents

2.49 .58 221 42

(14.5%) 2.36 .66 221

44 (14.5%)

f) Learning how to bill and get reimbursed for procedures

2.12 .76 223 33

(11.6%) 1.71 .69 223

36 (12.0%)

g) Organizing the dental office for success

2.16 .71 212 39

(13.8%) 1.90 .64 212

40 (13.6%)

Note. Item mean scores reflect the following response choices: 1 = very little, 2 = some and 3 = a great deal. * The total number of participants providing follow-up surveys that could be matched to the initial survey was 311. However, the sample size for valid (non-missing) responses will vary from question to question. Those who indicated “very little because I already had this skill” (a choice on the original survey) were withheld from the computation of means and standard deviations; only those who responded with “very little,” “some,” and “a great deal” were included in the computations. ** These ns and percentages are based on the total number of valid (non-missing) responses in the initial and follow-up surveys. Because different participants are responding to each question, the sample sizes will be somewhat different.

Because we are comparing pairs of means and a given mean could differ from some means and not others, placing footnotes by each mean to denote a statistically significant difference is not feasible. Therefore, any significant mean differences are described in the narrative accompanying the table.

Figures 9.a. – g. on the following pages illustrate the frequency data with bar graphs to show the extent of change among dental professionals for each of the self-perceived skills.


8.1

16.5

37.6

47.154.3

36.4

0

10

20

30

40

50

60

70

80

90

100

Per

cent

age

Rep

ort

ing

very little some a great deal

Perceived Skill Level

Figure 9.a. Performing Knee-to-Knee Exam, Dental Providers

Initial (n = 234)Follow-up (n = 242)

12.416.8

43.2

52.1

44.4

31.1

0

10

20

30

40

50

60

70

80

90

100

Per

cent

age

Rep

ort

ing



Figure 9.b. Knowing When to Treat and Refer Oral Health Problems, Dental Providers



11.617.1

47.0

57.1

41.4

25.8

0

10

20

30

40

50

60

70

80

90

100

Per

cent

age

Rep

ort

ing



Figure 9.c. Knowing How to Treat Problem Identified by Self, Dental Providers


16.7 18.5

42.9

56.2

40.4

25.3

0

10

20

30

40

50

60

70

80

90

100

Per

cent

age

Rep

ort

ing



Figure 9.d. Managing Young Children's Behavior, Dental Providers



5.210.8

42.3 46.252.4

43.1

0

10

20

30

40

50

60

70

80

90

100

Per

cent

age

Rep

ort

ing



Figure 9.e. Providing Education/Guidance to Parents, Dental Providers


24.0

43.0 41.6 44.9

34.4

12.2

0

10

20

30

40

50

60

70

80

90

100

Per

cent

age

Rep

ort

ing



Figure 9.f. Learning How to Bill/Get Reimbursed for Procedures, Dental Providers



19.728.2

45.5

56.9

34.8

14.9

0

10

20

30

40

50

60

70

80

90

100

Per

cent

age

Rep

ort

ing



Figure 9.g. Organizing the Office for Success, Dental Providers



HOW DID MEDICAL PROVIDERS PERCEIVE THEIR SKILL LEVEL AFTER TRAINING? Medical providers were also asked to assess the degree to which they perceived that their skills increased in specified areas relevant to their practice settings. As with the dental professionals, the limitation in interpreting the responses was that it was possible those who entered the training with a high skill level may have had less room to build their skill level whereas those having somewhat lower skills levels at the outset might have had more room for improvement. To prevent misinterpreting the results of the surveys, those individuals were identified prior to the data analysis for this item, and the data were then analyzed for only those respondents who did not possess these skills prior to training. Overall, the medical providers reported that the course increased their skills after training. Similar to the dental providers, the highest degree of self-perceived increase among medical providers was in communicating with parents (Table 21), although all skill areas assessed were self-rated highly. On the whole, the medical providers reported a slightly higher increase in their skill level after training than the dental providers.

Table 21. Increase in Perceived Skill Level Among Medical Providers


Survey Question

M SD n* Already

Had Skill n**

To what extent did this course increase your skills in: a) Recognizing signs and symptoms of oral pathology and dental

decay 2.47 .59 1436 45 (3.0%)

b) Knowing how, when, and who to refer children to vs. knowing when and how to manage the problem myself

2.47 .60 1428 41 (2.8%)

c) Assessing caries risk and protective factors 2.52 .59 1443 34 (2.3%)

d) Providing education and other anticipatory guidance to parents 2.54 .56 1430 40 (2.7%)

Note. Item mean scores reflect the following response choices: 1 = very little, 2 = some, and 3 = a great deal. * Those who indicated “very little because I already had this skill” (a choice on the original survey) were withheld from the computation of means and standard deviations; only those who responded with “very little,” “some,” and “a great deal” were included in the computations. ** These ns and percentages are based on the total number of valid (non-missing) responses in the initial survey for that question. Because different participants are responding to each question, the sample sizes will be somewhat different.

MEDICAL PROVIDERS


The data in Table 22 represent those participants who answered the self-perceived skill level items on both the initial and follow-up surveys. A Bonferroni corrected statistical significance level of .013 was used. There was no statistically significant change in self-perceived skill level as a result of training between the two time periods: medical providers reported maintaining the same level of skills 6 months later.

Table 22. Increase in Perceived Skill Level among Medical Providers, Initial and 6 Mos.



Already Had Skill n**

M SD n*

Already Had Skill n**

To what extent did this course increase your skills in: a) Recognizing signs and

symptoms of oral pathology / dental decay

2.47 .61 86 6

(6.1%) 2.45 .57 86

8 (8.1%)

b) Knowing to refer children vs. knowing to manage the problem myself

2.43 .59 80 7

(7.3%) 2.30 .64 80

7 (7.3%)

c) Assessing caries risk and protective factors

2.49 .57 85 5

(5.2%) 2.42 .56 85

6 (6.2%)

d) Providing education and other anticipatory guidance to parents

2.61 .58 84 5

(5.2%) 2.56 .55 84

7 (7.2%)

Note. Item mean scores reflect the following response choices: 1 = very little, 2 = some, and 3 = a great deal. * The total number of participants providing follow-up surveys that could be matched to the initial survey was 101. However, the sample size for valid (non-missing) responses will vary from question to question. Those who indicated “very little because I already had this skill” (a choice on the original survey) were withheld from the computation of means and standard deviations; only those who responded with “very little,” “some,” and “a great deal” were included in the computations. ** These ns and percentages are based on the total number of valid (non-missing) responses in the initial and follow-up surveys. Because different participants are responding to each question, the sample sizes will be somewhat different. Figures 10.a. – d. on the next two pages illustrate the frequency distributions with bar graphs to show the extent of change for each of the self-perceived skills among medical providers.


8.0 7.0

42.0 45.150.0 47.9

0

10

20

30

40

50

60

70

80

90

100P

erce

ntag

e R

epo

rtin

g



Figure 10.a. Recognizing Signs and Symptoms of Oral Pathology, Medical Providers


6.09.3

45.550.7 48.5

40.0

0

10

20

30

40

50

60

70

80

90

100

Per

cent

age

Rep

ort

ing



Figure 10.b. Knowing How, When and Who to Refer to vs. When and How to Manage Problem by Self, Medical Providers



4.4 5.0

42.6 45.0

52.950.0

0

10

20

30

40

50

60

70

80

90

100P

erce

ntag

e R

epo

rtin

g



Figure 10.c. Assessing Caries Risk and Protective Factors, Medical Providers


4.58.5

31.3 34.8

64.2

56.7

0

10

20

30

40

50

60

70

80

90

100

Per

cent

age

Rep

ort

ing



Figure 10.d. Providing Parent Education/Anticipatory Guidance, Medical Providers



HOW DID EARLY CHILDHOOD EDUCATORS AND OTHER HEALTH AND SOCIAL SERVICE PROFESSIONALS PERCEIVE THEIR SKILL LEVEL AFTER TRAINING? To prevent misinterpreting the results of the surveys, similar to medical and dental providers the responses of early childhood education professionals who said they already possessed one or more of the skills that were taught—as few as 21 and as many as 61 individuals claimed this—were removed for the skill-level questions and the data were analyzed for the remaining respondents. Overall, the community agency staff reported that the course increased their skills after training. The highest degree of self-perceived increase was in the area of communicating with parents—a similar finding to the medical and dental providers (Table 23).

Table 23. Increase in Perceived Skill Level Among Community Organization Staff



Already Had Skill

n** As a result of this training, how much do you believe you increased your skills in:

a) Recognizing signs and symptoms of oral health issues 2.54 .59 514 37

(6.7%) b) Providing oral health education and demonstration to

parents 2.66 .51 525

21 (3.8%)

c) Deciding if a child needs referral to a dental provider 2.50 .63 500 46

(8.4%)

d) Learning how to brush a young child’s teeth 2.54 .65 482 61

(11.2%) Note. Item mean scores reflect the following response choices: 1 = very little, 2 = some, and 3 = a great deal. * Those who indicated “very little because I already had this skill” (a choice on the original survey) were withheld from the computation of means and standard deviations. ** These ns and percentages are based on the total number of valid (non-missing) responses in the initial survey for that question. Because different participants are responding to each question, the sample sizes will be somewhat different.

The data in Table 24 on the next page represent those participants who answered the self-perceived skill level items on both the initial and follow-up surveys. A Bonferroni corrected statistical significance level of .013 was used. The statistical analysis revealed that there was no significant change in self-perceived skill level as a result of the trainings observed between the two time periods; staff reported maintaining the same perceived skill level increase 6 months later.



Table 24. Increase in Perceived Skill Level among Community Organization Staff



Already Had Skill

n** M SD n*

Already Had Skill

n**

As a result of this training, how much do you believe you increased your skills in: a) Recognizing signs and

symptoms of oral health issues

2.43 .57 54 5

(8.2%) 2.22 .63 54

4 (6.5%)

b) Providing oral health education and demonstration to parents

2.63 .56 56 1

(1.6%) 2.52 .66 56

3 (4.9%)

c) Deciding if a child needs referral to a dental provider

2.36 .60 50 6 (10.0%) 2.24 .72 50 6

(9.7%)

d) Learning how to brush a young child’s teeth

2.30 .76 46 9 (15.0%) 2.24 .64 46 5

(8.5%)

Note. Item mean scores reflect the following response choices: 1 = very little, 2 = moderate amount, and 3 = a great deal. * The total number of participants providing follow-up surveys that could be matched to the initial survey was 63. However, the sample size for valid (non-missing) responses will vary from question to question. Those who indicated “very little because I already had this skill” (a choice on the original survey) were withheld from the computation of means and standard deviations; only those who responded with “very little,” “some,” and “a great deal” were included in the computations. ** These ns and percentages are based on the total number of valid (non-missing) responses in the initial and follow-up surveys. Because different participants are responding to each question, the sample sizes will be somewhat different..

Figures 11.a. – d. on the next couple of pages illustrate the frequency distributions with bar graphs to show the extent of change among early childhood educators for each of the self-perceived skills.


3.610.3

51.8 53.4

44.6

36.2

0

10

20

30

40

50

60

70

80

90

100

Per

cent

aage

Rep

ort

ing



Figure 11.a. Recognizing Signs and Symptoms of Oral Pathology, Early Childhood Educators and Other Professionals


3.38.6

35.0 32.8

61.7 58.6

0

10

20

30

40

50

60

70

80

90

100

Per

cent

aage

Rep

ort

ing



Figure 11.b. Providing Parent Education/Demonstration, Early Childhood Educators and Other Professionals



7.4

16.1

50.046.4

42.637.5

0

10

20

30

40

50

60

70

80

90

100

Per

cent

aage

Rep

ort

ing



Figure 11.c. Deciding if Child Needs Dental Referral, Early Childhood Educators and Other Professionals


21.6

11.1

35.3

51.9

43.137.0

0

10

20

30

40

50

60

70

80

90

100

Per

cent

aage

Rep

ort

ing



Figure 11.d. Learning How to Brush Child's Teeth, Early Childhood Educators and Other Professionals



WHAT BARRIERS DID CHILDHOOD EDUCATORS AND OTHER PROFESSIONALS ANTICIPATE AND ENCOUNTER IN IMPLEMENTING NEW KNOWLEDGE AND SKILLS? The barrier that community organization staff most frequently anticipated to being able to implement the newly-acquired skills and knowledge was time constraint for delivering parent education and for training colleagues in the curriculum. Concern about possible parental resistance was mentioned next in frequency. Other important barriers included issues related to parent/provider language problems and inadequate administrative support. At the time of follow-up, time constraints in fact did prove to be the most frequently cited actual barrier to implementing colleague and consumer oral health education. Of interest was the fact that such a large proportion (46% initially and 62% at follow up) of the staff left this item blank, possibly indicating they did not foresee or actually experience barriers to implementing the new information and skills they learned from the training.

Table 25. Anticipated and Actual Barriers to Implementing New Knowledge and Self-Perceived Skills

Survey Question n

What barriers do you foresee to implementing the new skills and knowledge you learned from this training? [Initial Survey]

Time constraints to train other staff/implement parent education 66 Parent resistance to attend meetings/non compliance with teachings 48 Parent/provider language barriers/materials need to be translated 35 Inadequate administrative support/low perceived value 32 Inadequate funding to add to current program 26 Parent cultural/traditional beliefs and habits may interfere 22 Difficulty finding dental providers to see these children 19 Miscellaneous 50 No Response 257

What barriers, if any, have actually kept you from implementing the new skills and knowledge you learned from the training? [Follow-Up Survey]

No time to implement parent education/other agencies priorities 23 No time to train other staff on curriculum 7 No supplies for/ability to bill fluoride varnish 4 Inadequate number of community dentists 4 Parental resistance 2 Miscellaneous 5 No Response 73

Note. Survey questions were open-ended ones allowing for the respondent to write an answer in the space provided. Participants in a few cases provided more than one perceived barrier, so no percentages were computed because the “total” would be greater than 100%. Responses were categorized into one of the choices above.


TO WHAT EXTENT WERE DENTAL PROFESSIONALS PROVIDING SERVICES TO YOUNG CHILDREN AND WHAT WERE THE CHANGES? Pediatric Patient Profile We asked about certain characteristics of the pediatric patient mix in the dental offices. The average percentage of respondents’ practices devoted to children aged 0 to 5 and to children receiving some form of public benefits were each approximately 21%. On average only 10% of their practice was made up of children from agricultural or farm worker families, and only about 5% of their practice was made up of children with disabilities or other special needs (Table 26 on the next page). These averages, however, reflect considerable variation and were weighted toward reporting of very low percentages. For example, for item a (age group) in Table 26, approximately 54% of the respondents reported 10% or less of their practice was made up of children 0-5. For item b, 67% of the respondents reported 10% or less of their practice was made up of children receiving benefits. For item c, 80% of the respondents reported 10% or less of their practice was made up of children from agricultural families. And, for item d, 90% of the respondents reported 10% or less of their practice was made up of children with special needs.

OUTCOME: ADOPTION OF DESIRED

BEHAVIORS/PRACTICES

DENTAL PROVIDERS


Table 26. Pediatric Patient Mix in Dental Practices


Regarding all the children ages 0 – 18 in your practice, approximately what percentage is made up of the following children?

a) Children ages 0 to 5 21.1% 24.40 2599

b) Children receiving Medi-Cal, Healthy Families, Healthy Kids or other public program benefits

20.8% 31.88 2557

c) Children from families who are agricultural / farmworkers 10.0% 19.40 2424

d) Children with disabilities or other special health care needs 5.3% 9.89 2550

The data in Table 27 represent those participants who answered the questions about patient mix on both the initial and follow-up surveys. A Bonferroni corrected statistical significance level of .013 was used. Although there were slight decreases 6 months later in the percentage of children seen for all four characteristics, none of the changes was statistically significant Table 27. Dental Pediatric Patient Mix at Training and 6-Months

Initial Follow-up Survey Question M SD n M SD n

M Change

Regarding all the children ages 0 – 18 in your practice, approximately what percentage is made up of the following children?

a) Children ages 0 to 5 24.7% 26.71 252 22.8% 24.54 252 -2.3%


25.8% 35.75 252 25.9% 33.85 252 -0.7%

c) Children from families who are agricultural / farmworkers

11.9% 21.74 236 9.9% 21.21 236 -1.9%

d) Children with disabilities or other special health care needs 5.1% 7.94 251 4.5% 8.72 251 -0.6%

Dental respondents were also asked about their acceptance of age at first visit, frequency of performing certain procedures, the demand for services and the practice capacity for accommodating requests for appointments.


Age at First Visit Although one-third (32.6%) of the general dentists reported at the time of training that they typically started seeing children at age 3, only 14.5% saw them as early as the first birthday as recommended. Almost two-thirds (64.6%) of the pediatric dentists typically started seeing children at age 1(Table 28). Other dental specialties reported varying starting ages but with almost 30% reporting typically starting to see children at the age of 7 and 8. Figure 12 illustrates these data in a bar graph.

Table 28. Age of Child Accepted for First Appointment at Time of Training

General Dentistry (n = 1265)

Pediatric Dentistry (n = 181)

Other Dental Specialty (n = 152) Survey Question

n % n % n %

At what age do you typically start to see young children in your practice?

1 185 14.5 117 64.6 21 13.8 2 275 21.7 35 19.3 9 5.9 3 413 32.6 6 3.3 14 9.2 4 129 10.2 - - 5 3.3 5 85 6.7 4 2.2 5 3.3 6 33 2.6 - - 12 7.9 7 8 0.6 - - 22 14.5 8 18 1.4 1 0.6 20 13.2

No Response / Missing Data 121 9.6 18 9.9 44 28.9

16

24

36.1

11.37.4

2.90.7 1.6

0

10

20

30

40

50

60

70

Per

cent

age

Rep

ort

ing

1 2 3 4 5 6 7 8Age of Child

Figure 12. Age of Child at Acceptance by General Dentists

General Dentists ( n = 1144)


Years in practice—a proxy measure for dentists’ age—was examined to see if there was a relationship to the typical age of a child when first seen (Table 29). General dentist participants in practice longer reported seeing children at older ages at their first visit. While the correlation (relationship) was statistically significant (r = .101, p < .01) it was not very substantial, and was driven by the large sample size. For the other two groups, pediatric dentists and other dental specialists, the relationship between the number of years in practice and the age of children at first visit was not statistically significant (r = .121, p > .01, and r = .137, p > .01, respectively). Table 29. Relationship Between Years in Practice and Age of First Visit by Type of Dentist

General

Dentistry Pediatric Dentistry

Other Dental Specialty

Years in Practice and Age of Child When First Seen in Practice

.101* n = 1097

.121 n = 154

.137 n = 100

* Correlation is significant at the .01 level (2-tailed).

Analysis of variance was used to compare female and male general dentists regarding the typical age that children are first seen. The differences were statistically significant: female dentists typically started seeing children at a younger age than male dentists (Table 30). Table 30. Gender Differences for General Dentists for Age of First Visit (N = 1124)

Female Male Question M SD n M SD n


From 1 year of age to 8 years of age 2.69a 1.26 591 3.11a 1.57 533

aF(1, 1123) = 25.91, p < .05.

The data in Table 31 suggest a possible trend of general dentist participants seeing children at younger ages six months after taking a training course. As a group, 22.8% of matched respondents said at the time of training they typically start to see children at age 1. At the time of follow-up, 28.4% of those completing the initial survey indicated that they saw children at that age, a 5.6% positive change.


Provider Office Capacity As Figures 13 and 14 illustrate, the general trend shows that those in pediatric dentistry, as expected, reported receiving the most calls (4 or more) per week requesting appointments for children under 5 years of age than those in general dentistry or other dental specialties. The majority of respondents in general dentistry and other specialties reported receiving 1 or fewer calls per week requesting appointments for children 0 to 5 years of age. While the majority of dental offices reported having the capacity to accommodate requests for appointments for children aged 0-5 years, about 14% of general dentists’ offices reported not having such capacity.

0

10

20

30

40

50

60

70

80

90

100

Per

cent

age

Rep

ort

ing

We get very few calls (1 per weekor fewer)

We get some calls (2 – 3 per week) We get many calls (4 or more perweek)

Number of Calls

Figure 13. Calls Requesting Appointments for Children 0 - 5 Years of Age

General Dentists ( n = 1165)Pediatric Dentists (n = 166)Other Dental Specialty (n = 120)

Table 31. Age of Child Accepted, at Time of Training and Follow-up


Initial Follow-up Survey

Question

n % n % % Change


1 37 22.8 48 28.4 +24.6 2 35 20.7 33 19.5 -5.8 3 55 32.5 54 32.0 -1.5 4 20 11.8 15 8.9 -24.6 5 10 5.9 9 5.3 -10.2 6 4 2.4 2 1.2 -50.0

No Response/ Missing Data

7 4.1 7 4.1 0.0


0

10

20

30

40

50

60

70

80

90

100

Per

cent

age

Rep

ort

ing

Yes No We don’t see childrenyounger than age 5 in our

office

Figure 14. Capacity to Accommodate All Requests for Appointment for Young Children

General Dentists ( n = 1166)Pediatric Dentists (n = 169)Other Dental Specialty (n = 115)

We matched initial and follow-up surveys for general dentists and computed a chi-square statistic to look for changes in demand and capacity. The differences between the two time periods regarding the number of requests for appointments were not significant (p > .05). Although there was a +2.3 percent change in capacity in the ability to accommodate the requests, the difference was not statistically significant (p > .05, Table 32).

Table 32. General Dentist Provider Capacity at Training and Follow-up


Initial Follow-up Survey Question

n % n % %

Change

Approximately how many calls does your office receive requesting an appointment for a child 0 to 5? We get very few calls (1 per week or fewer) 80 47.3 86 50.9 +7.6 We get some calls (2 – 3 per week) 40 23.7 40 23.7 0.0 We get many calls (4 or more per week) 43 25.4 37 21.9 -13.8 No Response / Missing Data 6 3.6 6 3.6 0.0 Does your office generally have the capacity to accommodate all these requests for appointments for children 0 to 5?

Yes 135 79.9 138 81.7 +2.3 No 18 10.7 17 10.1 -5.6 We don’t see children younger than age 5 in our office

10 5.9 8 4.7 -20.3

No Response / Missing Data 6 3.6 6 3.6 0.0


Frequency of Performing Procedures and Role Delegation There was considerable variation in the frequency with which preventive procedures were performed by the dental providers for children 0-5 and pregnant women/new mothers (Table 33). Those procedures that tended to be performed quite frequently as reported by the total sample were discussion of infant feeding and nutrition counseling; those tending to be performed occasionally included inquiries about oral health, applying fluoride varnish, and coordinating care with child’s medical provider; those tending to be rarely/occasionally performed included performing saliva testing, coordinating care with pregnant patients’ medical provider, and recommending �ylitol gum. Table 33. Frequency of Performing Procedures at Time of Training


Response Choice n Survey Question

Never or Almost Never

Occasionally

Always or

Almost Always

Total n

M

How frequently do you or another member of the dental team ordinarily perform the following in your practice? For children 0 to 5

a) Apply fluoride varnish 1160 41.4%

742 26.5%

899 32.1%

2801 1.91

b) Provide nutrition counseling to parent / caregiver

321 11.4%

1133 40.1%

1373 48.6%

2827 2.37

c) Discuss an infant’s bottle or breastfeeding practices

400 14.2%

1038 36.9%

1378 48.9%

2816 2.35

d) Coordinate care or consult with a child’s medical provider

1090 38.8%

1203 42.8%

518 18.4%

2811 1.80

e) Inquire about the oral health of the child’s mother or caregiver

719 25.6%

1120 39.9%

968 34.5%

2807 2.09

For pregnant women / new mothers

f) Perform saliva testing 2566 91.8%

170 6.1%

59 2.1%

2795 1.10

g) Discuss breastfeeding practices 1567 56.3%

784 28.2%

434 15.6%

2785 1.59

h) Coordinate care or consult with a pregnant patient’s medical provider

1681 60.5%

778 28.0%

320 11.5%

2779 1.51

i) Recommend �ylitol gum 1440 51.7%

823 29.6%

522 18.7%

2785 1.67

Note. Item mean scores reflect the following response choices: 1 = never or almost never, 2 = occasionally, and 3 = always or almost always.


The data in Table 34 below represent those participants who answered these questions on both the initial and follow-up surveys. A Bonferroni corrected statistical significance level of .006 was used. While means and standard deviations were determined and are available, the data are presented by frequencies and percentages as these are sometimes of greater interest. Four of the nine procedures showed a statistically significant difference between the initial and follow-up surveys. For children 0 to 5, participants more frequently applied fluoride varnish and discussed an infant’s bottle or breast feeding practices 6 months after the training. For pregnant patients, dentists discussed breast feeding practices and recommended �ylitol gum more often 6 months after the training.

Table 34. Frequency of Performing Procedures at Time of Training and Follow-up


Survey Question Never or Almost Never

Occasionally

Always or

Almost Always

Never or

Almost Never

Occasionally

Always or Almost Always

How frequently do you or another member of the dental team ordinarily perform the following in your practice? For children 0 to 5

a) Apply fluoride varnish 106

37.9% 87

31.1% 87

31.1% 55

19.4% 106

37.3% 123

43.3%

b) Provide nutrition counseling to parent / caregiver

26 9.3%

112 39.9%

143 50.9%

22 7.6%

91 31.3%

178 61.2%

c) Discuss an infant’s bottle or breastfeeding practices

36 13.0%

96 34.8%

144 52.2%

24 8.3%

80 27.6%

186 64.1%

d) Coordinate care or consult with a child’s medical provider

104 37.4%

121 43.5%

53 19.1%

104 36.1%

144 50.0%

40 13.9%

e) Inquire about the oral health of the child’s mother or caregiver

68 24.2%

115 40.9%

98 34.9%

44 15.3%

126 43.9%

117 40.8%

For pregnant women / new mothers

f) Perform saliva testing 263

94.3% 13

4.7% 3

1.1% 262

92.6% 15

5.3% 6

2.1%

g) Discuss breastfeeding practices 157

56.3% 76

27.2% 46

16.5% 124

43.5% 97

34.0% 64

22.5%

h) Coordinate care or consult with a pregnant patient’s medical provider

162 58.1%

92 33.0%

25 9.0%

162 57.0%

94 33.1%

28 9.9%

i) Recommend �ylitol gum 143

51.8% 78

28.3% 55

19.9% 75

26.3% 126

44.2% 84

29.5%

Note. The total sample size for both the initial and the follow-up surveys was 311. However, the number of valid responses ranged from a sample size of 276 to 291 (and this is what the percentages are based on). P<..006


To examine whether female and male general dentists might serve pregnant patients differently relative to the frequency of coordinating their care or consulting with a pregnant patient’s medical provider, procedure item h in the table above was analyzed by gender for the general dentists. The gender differences were not significant (Table 35). Table 35. Gender Differences in Coordinating Care/Consulting for Pregnant Patients (N=1123)

Female Male Question M SD n M SD n

How frequent do you or another member of the dental team ordinarily coordinate care or consult with a pregnant patient’s medical provider? (General Dentists Only) From 1 = “never or almost never” to 3 = “always or almost always”

1.57 .70 592 1.60 .70 531

Six months after receiving the training, 8.3% of the dental providers whose offices placed sealants and 8.7% of those who applied topical fluoride reported increasing delegation of these procedures as a result of what they learned at the course, thereby allowing dentists to see more patients. Other role changes that occurred were delegation of doing Streptococcus mutans testing and doing coronal polishing (Table 36).

Table 36. Role Change at the Time of Follow-up

Follow-up Survey (N = 346*)

Survey Question

Delegated since

training

n

Was delegated prior to training

n

Not delegated;

DDS does it

n

Total n

As a result of what you learned from the training, which of the following procedures have you delegated to other members of the dental team:

a) Taking x-rays/radiographs 14

4.7% 273

90.7% 14

4.7% 301

b) Placing sealants 25

8.3% 107

35.4% 170

56.3% 302

c) Applying topical fluoride 26

8.7% 234

78.3% 39

13.0% 299

d) Doing mutans testing 10

6.8% 26

17.8% 110

75.3% 146

e) Doing coronal polishing 20

6.6% 233

77.4% 48

15.9% 301

f) Administering anesthesia 3

1.0% 48

16.4% 241

82.5% 292

g) Administering nitrous 4

1.8% 50

22.6% 167

75.6% 221

*All follow-up surveys received were included, regardless of whether they could be matched to an initial survey.


TO WHAT EXTENT DID DENTAL PROVIDERS SAY THEY WERE LIKELY TO AND ACTUALLY SEE MORE CHILDREN 0-5?

One of the key goals for this program was an increase in workforce capacity for seeing more children 0-5, and identifying what it would take to facilitate this. We asked dentist participants initially about their likelihood of seeing more of these patients as a result of taking the training, and then asked them later whether they had increased the number of children 0 to 5. Approximately half of the general as well as the pediatric dentists indicated they were likely or very likely to increase the number of children aged 0-5 in their practice as a result of taking the course (Table 37). Table 37. Dentists’ Anticipation at Training about Seeing More Children 0-5 at Training



Other Dental Specialty (n = 152) Survey Question

n % n % n % As a result of taking this course, how likely are you to increase the number of children 0 to 5 in your practice?

Very Unlikely 55 4.3 12 6.6 41 27.0 Unlikely 89 7.0 8 4.4 14 9.2 Somewhat Unlikely 98 7.7 9 5.0 13 8.6 Somewhat Likely 284 22.5 17 9.4 14 9.2 Likely 304 24.0 18 9.9 12 7.9 Very Likely 309 24.4 76 42.0 14 9.2 No Response / Missing Data 126 10.0 41 22.7 44 28.9

The overall means and standard deviations were: for general dentists M=4.42 (1.42 SD); for pediatric dentists M=4.78 (1.67 SD); for other dental specialties M=2.85 (1.84 SD).

Note. Item mean scores reflect the following response choices: 1 = very unlikely, 2 = unlikely, 3 = somewhat unlikely, 4 = somewhat likely, 5 = likely, and 6 = very likely.

Six months after the training, 15% of general dentists reported they were seeing more children aged 0 to 5 specifically due to taking the course, an important increase but not at the level they anticipated right after attending a training (Table 38). Six (5.9%) of the 102 dentists interviewed by telephone 6-12 months after training reported they had increased the number of children 0-5 in their practice specifically due to taking the course. An additional 63 (62%) dentists reported there had been a slight increase in the number of these children in their practice but felt it was unrelated to the course; they described general pediatric practice-building activities or usual patient attrition as the reasons, not a change in the overall ratio of young children to other patients in the practice. Three (2.9%) of the 102 dentists reported increasing the number of children 0-5 with disabilities or other special needs as a direct result of taking the First Smiles course, describing increased confidence and comfort level.


Table 38. Dentists’ Actual Experience Seeing More Children Six Months Later



Other Dental

Specialty (n = 13)

Survey Question

n % n % n % How has the number of children 0-5 changed in your practice since taking the training?

We see fewer 13 7.7 2 6.7 - -

We see the same number 118 69.8 23 76.7 4 30.8

We see more 25 14.8 5 16.7 1 7.7

No Response / Missing Data 13 7.7 - - 8 61.5

The overall means and standard deviations were: for general dentists M = 2.08 (.49 SD); for pediatric dentists M = 2.10 (.48 SD); for other dental specialties M = 2.20 (.45 SD). Note. Item mean scores reflect the following response choices: 1 = we see fewer, 2 = we see the same number, and 3 = we see more.

Did Gender Make a Difference? Analysis of variance was used to compare female and male general dentists who took a First Smiles course on the likelihood of increasing the number of children in their practice as a result of the training. Females were significantly (F(1, 1120) = 18.89, p < .05) more likely than males to say they would see more children 0 to 5 (Table 39). However, 6 months later there were no significant differences between the genders regarding their actual and intended experience of seeing more 0-5 children in their practice (Table 40). Table 39. Gender Differences for General Dentists’ Willingness to See More Aged 0-5 (N = 1120)

Female Male Survey Question

M SD n M SD n

As a result of taking this course, how likely are you to increase the number of children 0 to 5 in your practice?

From 1 = “very unlikely” to 6 = “very likely” 4.59 1.41 584 4.23 1.41 536

F(1, 1120) = 18.89, p < .05.

Table 40. Gender Differences for General Dentists’ Actually Seeing Children (N = 156)

Female Male Survey Question

M SD n M SD n

How has the number of children 0-5 changed in your practice since taking the course?

From 1 = “we see fewer” to 3 = “we see more” 2.10a .49 86 2.04a .49 70

aF(1, 155) = .614, p >.05.


Did Years in Practice Make a Difference? For both general dentists, there was a significant negative correlation in willingness to see more 0-5 children: those dentists in practice for longer periods of time (and presumably older) said they were less likely to increase the number of these children in their practices (Table 41). Table 41. Relationship between Years in Practice and Likelihood to Increase Children 0-5 (Matched Initial Survey Respondents)

General



Years in practice and likelihood of increasing number of 0-5 children seen in practice

-.228* n = 159

-.335 n = 23

-.026 n = 11

* Correlation is significant at the .01 level (2-tailed). However, when the data were analyzed to look at actual experience since taking the training, years in practice didn’t matter: there were no significant relationships between years in practice for any of the types of dentists (Table 42). Table 42. Relationship between Years in Practice and Children 0-5 Seen in Practice (Matched Follow-up Survey Respondents)

General



Years in practice and actually seeing more 0-5 children in the practice

-.016 n = 154

.025 n = 29

.640 n = 5

What Were the Barriers to Seeing More 0-5 Children? The main barriers to taking more children 0-5 were described by those dentists in the telephone sample of who reported not increasing the number of these children in their practices. The reasons were fairly evenly divided among three factors as shown in Figure 15 below. Personal life issues were described as nearing retirement, cutting back hours, coming back from/about to go on maternity leave and so forth. “Other” comments were of two types: parent resistance to bringing in children so young and the dentist preferring an adult population (“my patients are growing old with me”).


Figure 15. Main Reasons for DDS Not Taking More Children 0-5 (Telephone Interviews, n=102)

Practice too full33%

Personal life issues30%

Don't want to deal with

behavior/crying issues33%

Other4%

The dentists also identified barriers to taking more 0-5 children with disabilities and other special needs. While full practices and personal life circumstances were also reasons given for not seeing these children, lack of confidence in skill level and ability to handle behavioral issues were barriers cited by 45% of the respondents.

What Would it Take for Dentists to See More 0-5 Children? Dental providers indicated at the end of the training course what strategies would be helpful to increase the number of children 0-5 in their practice (Table 31 on the next page). About 55% said more training for staff would make a difference, mostly concerning providing parent education and behavior management of children. Those who commented on training related to clinical skills mentioned the knee-to-knee exam, oral sedation, sealants and fluoride varnish. Examples of “other” training needs included risk assessment, oral health instruction for parents/caregivers, and motivational training for the dentist to want to see young children. The providers who said it would “take more staff” and specified the purpose most commonly cited the demands of managing the behavior of young children. About 41% said having higher reimbursement for procedures (including those not currently covered) was necessary for them to increase the number of children 0-5 in their practice, citing parent education and fluoride varnish most often. Examples of “other” procedures noted were visual exam consults, recall x-rays, and ART (alternative [or atraumatic] restorative treatment). From their responses, it appears some dental providers are not aware that some of these procedures are covered by some insurance plans, including public benefit programs such as Healthy Families.


Table 43. What Dental Providers Said It Would Take to See More Children 0-5 (Initial Survey)

Survey Question

What would it take for you to see more (or any) children 0 to 5 in your practice?

Yes No Strategy

n % n % Response When Specified n

Managing Behavior 126

Clinical Skills 63 Billing 21 Parent Education 129

More Training for the Staff

1298 55.4 1041 44.5 What Kind of Training?

This Type of Course 85

For Parent Education 30

To See More Patients 44

Office Management 19 Managing Young Children 57 Offer Additional Procedures 9

More Staff 577 25.8 1661 74.2 For What Purpose?

Other 20 Fluoride Varnish 55 Saliva Testing 12 Parent Education 80 Exam/Prophy 13 Sedation/Anesthesia 4 Dental Sealants 7

Higher Reimbursement for Procedures

890 40.9 1287 59.1 Which

Procedure?

Other 60

Fluoride Varnish 63 Saliva Testing 8 Parent Education 75 Exam/Prophy 4 Sedation/Anesthesia 6 Dental Sealants 21 Interpreters / Translation 3

Reimbursement for Procedures Not Currently Covered

842 40.1 1258 59.9 What

Procedure?

Other 35

Other:

More Parent Compliance/Education 29

More Cooperative Children 19

Better Office Set-Up/Equipment 16

Different Area Demographics that Increase Demand 10

DDS not willing to see kids 43 Practice too full/adult-oriented 30 We’re already willing/have 38

Nothing More Needed Because:

Various Reasons 28


Respondents volunteered additional comments about what it would take to see more—or any—children 0-5. The most frequently mentioned items related to issues concerning the challenge of having young patients in the office (one dentist stated, “Take 25 years off my age and maybe I’d do it”). Comments in order of mention can be summarized as follows:

Having a dentist/dental staff with more patience/tolerance for young children Having the entire staff find it acceptable to have younger children More advertising that we will see children 0-5 More toys/a quiet play room Having to consider seeing fewer adults to see more children (patient mix issues) Higher reimbursement for amount of time young children take away from other patients

When the dentists interviewed by telephone were asked what it would take for them to see more children 0-5, close to half (48%) said they “needed nothing” and were willing to see the children if parents called and the practice could fit them in (Figure 16). The other half of the dental sample, those who were unable or unwilling to see more young children, reported the following:

Having a dentist/dental staff with more patience/tolerance for young children Need nothing because practice is at capacity/too full (10%) Need nothing because no interest in seeing more children that young (8%) Need nothing because only working part-time (5%) Need someone else to education parents/follow-up with compliance (21%) Need better reimbursement, e.g., Medi-Cal, preventive education (5%) Need DDS or staff training, e.g., for severely disabled; “more complicated” procedures (2%) Need a marketing campaign advocating dentists seeing more children 0-5 (1%)

Figure 16. What it would take for DDS to See More Children 0-5 (Telephone Interviews, n=102)

Need specified29%

Need nothing; will see more

48%

Need nothing; can't/won't see

more23%


Risk Assessment Over a third of the dentists who returned a follow-up survey reported that they always performed a formal risk assessment on new patients aged 0 to 5 (Table 44). When the data were broken down into types of dentists, almost two-thirds of the pediatric dentists reported that they always performed risk assessment, while those in general dentistry were more inconsistent with a little over a quarter of them reporting that they regularly perform risk assessment. Table 44. Dentists’ Frequency of Conducting Formal Risk Assessment After Training, Follow-Up Only

All Dentists* (n = 182)



Other Dental

Specialty (n = 4)

Survey Question

n % n % n % n % How often do you do a formal oral health risk assessment on new patients aged 0 – 5?

Never 35 19.2 31 20.1 2 10.5 1 25.0 Seldom 23 12.6 20 13.0 3 15.8 - - Sometimes 47 25.8 45 29.2 2 10.5 - - Always 62 34.1 44 28.6 12 63.2 2 50.0 No Response / Missing Data 15 8.2 14 9.1 - - 1 25.0

* Data were calculated using only those respondents that marked “dentist” for their profession. The other three groups (general dentistry, pediatric dentistry, and other dental specialty) refer to the respondents’ “nature of or role in the practice.”

Six months after training a little more than a quarter (26%) of the dental providers were using the Risk Assessment form that had been provided as part of the course materials; 40% used some other type of risk assessment form. A third (34%) of the providers did not respond to the question (Figure 17).

Figure 17. Dentists' Use of Risk Assessment Forms After Training

(n = 182)

No Response34%

Uses Another Form40%

Uses Risk Assessment Form

from Training26%


TO WHAT EXTENT WERE PRIMARY CARE PROFESSIONALS PROVIDING PREVENTIVE ORAL HEALTH SERVICES TO YOUNG CHILDREN AND WHAT WERE THE CHANGES? In addition to questions about patient mix, we asked medical providers for an assessment of the extent of dental disease they saw among children in their practice aged 0-5, and how frequently they or their staff performed certain preventive oral health services. Pediatric Patient Profile Children aged 0-5 made up close to half (47.6%) of children 0-18 in the primary care practices, and just under two-thirds (62.8%) of children 0-18 were receiving some form of public benefits. On average, about 14% of 0-18 year-olds in their practice was made up of children from agricultural or farmworker families, and 11% of children with disabilities or other special needs (Table 45). Children in these providers’ practices were more diverse than in the dental providers’ practices. The averages, however, with the exception of item a, represent some variability in how the responses are distributed across the response range. For item b, half of the respondents reported that over 70% of their practice was comprised of children who received public program benefits. For item c, half of the respondents reported that less than 5% of 0-18 year-olds in their practice was comprised of children from agricultural families. And, for item d, about two-thirds of the respondents indicated that children with disabilities comprised less than 5% of 0-18 year-olds in their practice.

Table 45. Child Patient Mix in Primary Care Practices

MEDICAL PROVIDERS

Initial Survey (N = 1646) Survey Question

M SD n

Regarding all the children in your practice ages 0 – 18, approximately what percentage is made up of the following children (Fill in % using your best guess even if you’re not sure)

a) Children ages 0 to 5 47.6% 26.0 1202


62.8% 31.2 1224

c) Children from families who are agricultural / farmworkers 13.8% 22.7 966

d) Children with disabilities or other special health care needs 11.0% 17.3 1078


The data in Table 46 represent those participants who answered these questions on both the initial and follow-up surveys. A Bonferroni corrected statistical significance level of .013 was used. There were no statistically significant changes reported in the patient composition 6 months later.

Table 46. Pediatric Patient Mix in Primary Care Practices at the Time of Training and Follow-up

Initial Follow-up Survey Question M SD n M SD n

M Change

Regarding all the children in your practice ages 0 – 18, approximately what percentage is made up of the following children?

a) Children ages 0 to 5 47.4% 20.9 118 47.0% 23.8 118 -0.4


63.2% 31.9 123 64.9% 31.4 123 +1.6

c) Children from families who are agricultural / farmworkers

15.6% 25.0 94 13.5% 22.2 94 -2.1

d) Children with disabilities or other special health care needs

7.8% 11.5 112 7.4% 11.0 112 -0.4

Children’s Risk Status Primary care providers have a unique opportunity to screen for indications of oral pathology in infants and young children. In the matched sample of initial and follow-up participants, respondents 6 months after training reported seeing a higher percentage of “a few” and “some” children with evidence of disease but a lower percentage of “many” children with such evidence (Table 47). Table 47. Evidence of Dental Disease Reported by Medical Providers at Training and Follow-up

Initial Follow-up Survey Question

n % n %

% Change

In approximately how many 0–5 year-olds in your practice do you see evidence of dental disease (e.g., white/brown/black areas on teeth, gingivitis)?

None or Almost None 3 1.9 4 2.6 +36.8 A Few 21 13.5 25 16.1 +19.3 Some 50 32.3 57 36.8 +13.9 Many 67 43.2 49 31.6 -26.9 No Response / Missing Data 14 9.0 20 12.9 +43.3


Preventive and Referral Practices Prior to attending training, one in five primary care professionals who provided services to pregnant women said they always or almost always referred a pregnant patient to a dentist. Only about one in 8 said they always or almost always coordinated care with a pregnant patient’s dentist, and more than half said they never or almost never did so. Oral health activities aimed at children were practiced a little more frequently. Prior to training, just under half (45.6%) of the respondents who served children always or almost always inquired about the mother or caregiver’s oral health; and one-third (35%) reported always or almost always coordinating or consulting with a child’s dental provider. However, one in four never or almost never did these two things. Two-thirds of the providers (65.3%), on the other hand, reported always or almost always lifting the lip to look for evidence of decay in a child’s mouth (Table 48). Table 48. Frequency of Performing Certain Procedures by Medical Providers


Response Choice n Survey Question

Never or Almost Never

Occasionally

Always or

Almost Always

Total n

M*

1. Prior to this training, how often did you (or another professional in your practice) ordinarily do the following relative to pregnant patients?

a) Routinely refer pregnant patients to a dentist / ask if they have one

317 36.8%

341 39.6%

204 23.7%

862 1.87

b) Coordinate care or consult with a pregnant patient’s dental provider

440 52.3%

289 34.3%

113 13.4%

842 1.61

2. Prior to this training, how often did you (or another professional in your practice) ordinarily do the following relative to children age 0 to 5?

a) Look for evidence of decay by lifting child’s lip when checking the mouth

137 9.5%

361 25.1%

938 65.3%

1436 2.56

b) Inquire about the oral health of the child’s mother or caregiver

356 24.7%

427 29.7%

656 45.6%

1439 2.21

c) Coordinate care or consult with a child’s dental provider

347 24.2%

583 40.7%

501 35.0%

1431 2.11

*Item mean scores reflect the following response choices: 1 = never or almost never; 2 = occasionally; 3 = always or almost always.


The data in Table 49 represent those participants who answered these questions on both the initial and follow-up surveys. A Bonferroni corrected statistical significance level of .008 was used. Although there were no statistically significant differences for any of the practice activities between the two time periods, there was a suggestion of many positive changes.∗ With regard to pregnant women, 51.7% of the primary care providers reported always/almost always referring these patients to a dentist six months later, up from 18.5% who initially reported doing so. The respondents also increased their frequency of always/almost always coordinating care with a pregnant patient’s dental provider. With regard to children aged 0-5, a quarter (24.3%) of the medical providers initially said they never or almost never inquired about the oral health of the child’s caregiver, but six months after training, only 9.9% of the providers reported such a low frequency.

NA = not applicable; not asked in the initial survey.

∗ Note: The large shifts in percentages may appear to be statistically significant—they came close when the means were analyzed—but because the number of cases is very small the change in responses of a couple of respondents can change percentages dramatically.

Table 49. Frequency of Performing Procedures by Healthcare Providers (N = 155)

Initial Survey n

Follow-up Survey n

Survey Question Never or Almost Never

Occasionally


Never or

Almost Never

Occasionally


1. Prior to this training/Since this training, how often did you (or another professional in your practice) ordinarily do the following relative to pregnant patients?

a) Routinely refer pregnant patients to a dentist / ask if they have one

32 49.2%

21 32.3%

12 18.5%

3 10.3%

11 37.9%

15 51.7%

b) Coordinate care or consult with a pregnant patient’s dental provider

41 71.2%

11 16.7%

8 12.1%

10 40.0%

10 40.0%

5 20.0%

c) Recommend �ylitol gum NA NA NA 9

33.3% 12

44.4% 6

22.2% 2. Prior to/Since this training, how often did you (or another professional in your practice) ordinarily do the followingrelative to children age 0 to 5? a) Look for evidence of decay by lifting

child’s lip when checking the mouth 14

9.7% 29

20.0% 102

70.3% 4

3.1% 20

15.3% 107

81.7% b) Inquire about the oral health of the

child’s mother or caregiver 35

24.3% 36

25.0% 73

50.7% 13

9.9% 40

30.5% 78

59.5%

c) Coordinate care or consult with a child’s dental provider

34 23.8%

57 39.9%

52 36.4%

27 20.9%

51 39.5%

52 39.5%


Referral practices of children by primary care providers to dentists varied. On the initial survey for the entire sample, more than a third (38.9%) routinely referred infants and children for dental care, about a quarter (26.4%) sometimes made a referral, and 19% did not (Table 50). In examining those providers who participated in the follow-up survey, the increase from 47.7% to 67.7% of those routinely referring children aged 5 and younger for dental care represents a net increase of approximately 42%.

Table 50. Referrals of Infants and Children to Dentists as Part of Regular Practice

Matched Sample Initial (N = 1646) Initial

(n = 155) Follow-up (n = 155) Survey Question

n % n % n %

As part of your regular practice, do you refer infants and children age 5 and under for dental care?

Yes, routinely 641 38.9 74 47.7 105 67.7

Yes, sometimes 435 26.4 30 19.4 27 17.4

No (Why Not?) 315 19.1 39 25.2 4 2.6

Participant gave reason 35 - 3 - - -

Participant did not give reason 288 - 37 - - -


Despite recommendations from professional associations such as the American Academy of Pediatrics that referrals of children for a first oral health visit should occur by age one, only 14% of the medical providers reported at the time of training typically making a referral at that age (Table 51); 21% referred children by age 2, and another 28% by age 3. In the matched follow-up group, the proportion referring at age 1 increased from 16.1% to 25.8% 6 months after the training, but the percentage change was not statistically significant (chi-square computation, p > .05).


Table 51. Age at Which Medical Providers Typically Refer Young Children to a Dentist


(n = 155) Follow-up (n = 155)

Survey Question

n % n % n %

At what age do you typically refer young children to a dentist?

1 233 14.2 25 16.1 40 25.8

2 343 20.8 41 26.5 35 22.6

3 467 28.4 50 32.3 50 32.3

4 107 6.5 9 5.8 4 2.6

5 56 3.4 3 1.9 1 0.6

6 7 0.4 - - 1 0.6


Risk Assessment Well-child visits provide an opportunity for oral health risk assessment, counseling, early detection and treatment. For those medical providers returning a follow-up survey, 40% reported that they always do a formal oral health risk assessment on new patients aged 0-5; however, 12.4% said they never do this (Table 52). As shown in Figure 18, slightly more respondents doing a formal risk assessment said they used another form than the one provided in the training (33% and 28.9%, respectively). Table 52. Medical Providers’ Frequency of Conducting a Formal Oral Health Risk Assessment After Training

Follow-up Survey (N = 218) Survey Question

n % How often do you do a formal oral health risk assessment on new patients aged 0 – 5?

Never 27 12.4 Seldom 15 6.9 Sometimes 56 25.7

Always 92 42.2

No Response / Missing Data 28 12.8


Figure 18. Medical Providers' Use of Risk Assessment Forms(n = 218)

Uses Risk Assessment Form

from Training28.9%

Uses Another Form33.0%

No Response39.3%

TO WHAT EXTENT DID PRIMARY CARE PROVIDERS ANTICIPATE AND FOLLOW THROUGH WITH PROVIDING PREVENTIVE SERVICES? Because many dentists are not willing to see children aged 0-5, medical providers who routinely see pregnant women and young children offer the best hope for preventing and controlling tooth decay through the application of fluoride varnish. Medical providers reported being very likely to provide both oral health risk assessment and toothbrushing instructions to parents/caregivers as a result of taking the course, but only somewhat likely to provide fluoride varnish (Table 53). Six months after the training, those returning a follow-up survey reported on average occasionally-to-almost always providing risk assessment and toothbrush instruction but almost never providing fluoride varnish (Table 54).

Table 53. Likelihood of Medical Providers Doing Certain Preventive Services

Note. Item mean scores reflect the following response choices: 1 = very unlikely, 2 = unlikely, 3 = somewhat unlikely, 4 = somewhat likely, 5 = likely, and 6 = very likely.

Initial Survey (N = 1646) Survey Question

M SD n

As a result of taking this course, how likely is your practice to provide the following services for children 0 to 5?

a) Oral health risk assessment the way you were taught today 5.35 .90 1441

b) Fluoride varnish 4.47 1.47 1427

c) Tooth-brushing instructions to parents/caregivers 5.31 .92 1442


Table 54. Follow-Through of Medical Providers Doing Certain Preventive Services

Follow-up Survey (N = 218)* Survey Question

M SD n Since the training, how frequently are the following procedures ordinarily performed in your practice with regard to children 0-5?

a) Do an oral health risk assessment as taught in the training 2.48 .69 191

b) Apply fluoride varnish 1.22 .55 190

c) Give tooth-brushing instructions to parents/caregivers 2.39 .72 192

Note. Item mean scores reflect the following response choices: 1 = never or almost never, 2 = occasionally, and 3 = always or almost always. *Because these questions were not asked on the initial survey, all follow-up surveys regardless of whether they could be matched to an initial survey were included in the computations for the means and standard deviations.

We asked the primary care providers what it would take to offer these preventive oral health services to children 0-5 in their practice. Although we requested specific examples if they marked “yes” to one of the strategies shown in Table 55, the majority who responded did not specify anything. About two-thirds (63.6%) said “more training” would be helpful. Of those who gave an explanation of the kind of training needed, the majority related to clinical skills (recognizing signs of oral disease; teaching about brushing techniques); managing behavior; more awareness and understanding of the importance of screening by the entire healthcare team including support staff; and information about available community resources including referral sources for dental services. Table 55. What It Would Take for Medical Providers to Do More Preventive Oral Health Services

Survey Question

What would help you to better provide preventive oral health screening and anticipatory guidance for children 0 to 5 in your practice?

Yes No Strategy

n % n % Response When

Specified n

Managing Behavior 39 Clinical Skills 117 Billing 10

More Training for the Staff

759 63.6 435 36.4 What Kind of

Training? Other 15

Parent Education 25 Open More Appts 62 Handle Paperwork 14 Billing 6

More Staff 306 30.5 696 69.5 For What Purpose?

Other 8

Table continues on next page


Fluoride Varnish 32

Dental Exams 24 Higher Reimbursement for Procedures

441 45.6 527 54.4 Which

Procedure? Other 4

Fluoride Varnish 40

Saliva Testing 7

Reimbursement for Procedures Not Currently Covered

405 44.5 505 55.5 What

Procedure? Other 18

Training to do Parent Education

5

List of willing available DDS

21

Just don’t have enough time

15

Dealing with insurance co 13

Other 128 --* --* --* Specify:

Materials in Spanish

8

*Unable to compute percentage; data for “no” not available in data file.

The 30.5% of providers who said it would “take more staff” generally explained it was to be able to offer more procedures, help manage children during procedures, manage office paperwork, and to provide more education and anticipatory guidance for parents and caregivers. Nearly half (45.6%) of the respondents said having higher reimbursement for procedures (including those not currently covered) was necessary for them to increase the number of children 0-5 in their practice; fluoride varnish was cited most often.∗ Examples of “other” procedures noted were dental screening, cleaning, filling and x-rays, and parent education. Respondents also volunteered additional comments about what it would take to provide more—or any—preventive oral health services to children 0-5. The most frequently mentioned item centered on lack of time and included the following: More time for anticipatory guidance for parents Supplies such as toothbrushes and posters Simple pictorial materials in other languages Better age-appropriate educational materials Better access to community dentists willing to see young children/help with making referrals More general dentists who understand/will see pregnant patients Broader scope of oral health services for Medi-Cal children More education for the general public about the importance of young children’s oral health

∗ See Discussion section in this report for change in reimbursement policy for fluoride varnish.


TO WHAT EXTENT WERE COMMUNITY ORGANIZATION STAFF AND OTHER HEALTH AND SOCIAL SERVICE PROFESSIONALS REFERRING CHILDREN FOR ORAL HEALTH SERVICES? The majority (84%) of early childhood educators and other professional staff referred children aged 0-5 for dental care as part of their regular job (Table 56). Nearly all of those who supplied a reason for not referring explained that it was because someone else in the organization was responsible for making the referral. Six months later, a lower percentage of the staff reported being the one to make a referral.

Table 56. Referrals of Children Aged 0-5 to Dentists as Part of Job or Regular Practice



n % n % n %

As part of your regular job, do you refer children age 5 and younger for dental care?

Yes 466 84.0 54 86.7 47 74.6 No (Why not?) 81 14.6 9 14.3 15 23.8

Participant gave a reason 54 - 8 - - - Participant did not give a reason 27 - 1 - - -

No Response / Missing Data 8 1.4 - - 1 1.6

About a fourth of the staff made referrals of children to a dentist by the recommended age of 1; the proportion essentially did not change 6 months after the training (Table 57).


Table 57. Age at Which Children are Typically Referred to a Dentist



n % n % n %

At what age do you typically refer young children to a dentist?

1 142 25.6 14 22.2 15 23.8 2 60 10.8 8 12.7 9 14.3 3 203 36.6 24 38.1 17 27.0 4 56 10.1 6 9.5 5 7.9 5 2 0.4 1 1.6 1 1.6 No Response / Missing Data 92 16.6 10 15.9 15 23.8


When making a dental referral, early childhood educators and other community agency staff usually supplied the name of a dentist and told the parent that the child needs to see a dentist. They sometimes made the dental appointment for the family but infrequently accompanied them to the dentist. The only significant change (Bonferroni corrected statistical significance level of .013) at the time of follow-up was that educators indicated they were less likely to call a dental office to make an appointment for the child than six months earlier (Table 58). Table 58. Referral Practices of Early Childhood Educators and Other Professionals


Follow-up Survey (N = 63)

Survey Question

1 a 2 3 4 M 1 2 3 4 M

M Change

When you make a dental referral for a child age 5 and younger, how often do you: a) Give the parent/ caregiver the name(s) of a dentist

6 11.3%

6 11.3%

8 15.1%

33 62.3%

3.28 (n=47)

3 5.6%

9 16.7%

16 29.6%

26 48.1%

3.23 (n=47)

-.05

b) Call a dental office to make an appt. for the child

20 37.7%

19 35.8%

9 17.0%

5 9.4%

2.02 (n=46)

25 47.2%

21 39.6%

6 11.3%

1 1.9%

1.72 (n=46) -.30* b

c) Simply tell the parent /caregiver their child needs to see a dentist

4 8.0%

21 42.0%

10 20.0%

15 30.0%

2.73 (n=41)

7 13.7%

18 35.3%

12 23.5%

14 27.5%

2.83 (n=41)

+.10

d) Take or go with parent/ caregiver and child to dentist

34 66.7%

10 19.6%

3 5.9%

4 7.8%

1.53 (n=45)

37 68.5%

14 25.9%

3 5.6%

-

1.38 (n=45)

-.15

Note. The sample size ranged from 50 to 54. a Item mean scores reflect the following response choices: 1 = almost never, 2 = sometimes, and 3 = usually, and 4 = almost always b p < .013. (Note: we can show an asterisk in this table because there was only 1 pair of means in the analysis.


WHAT ACCESS PROBLEMS AND SYSTEM BARRIERS WERE EXPERIENCED? Difficulty in identifying community dental providers who are willing to see children 0-5, particularly children who have disabilities or other special needs or use some form of public assistance program such as Denti-Cal, is often mentioned as the main reason for not making referrals or unsuccessfully trying to make them. We asked both primary care providers and community agencies about their experience in finding dental referral sources for families. Early childhood educators and other staff indicated it was difficult to find dentists to see children who were uninsured; needed anesthesia; and had special needs. They reported less difficulty in finding dentists willing to serve children with Healthy Families or Medi-Cal (Table 59). At the time of follow up (data not shown), these factors still made it a problem to make successful referrals to the extent reported initially but there was one factor where the difference 6 months later was statistically significant: more early childhood educators reported having difficulty finding dentists for uninsured patients/those needing a sliding scale than right after the training (Chi-square analysis, p<.05).

Table 59. Community Agencies’ Experience in Finding a Dentist

Initial Survey n* Survey Question

M SD Have Done

Never Done

What is your experience in finding a local dentist for a child 5 years of age or less who: a) Has a disability or other special needs 2.69 1.03 341 126 b) Receives Medi-Cal benefits 2.19 1.08 427 42 c) Receives Healthy Families benefits 2.00 1.01 413 54 d) Is uninsured and needs a sliding scale 2.64 1.09 383 78 e) Will need anesthesia during treatment 2.76 1.06 364 102

Note. Item mean scores reflect the following response choices: 1 = not at all difficult, 2 = somewhat difficult, 3 = difficult, and 4 = extremely difficult. * Those who indicated “I’ve never done this” (a choice on the original survey) were withheld from the computation of means and standard deviations. P<.05

OUTCOME: IMPROVEMENT IN ACCESS/SYSTEMS CHANGE


A family’s financial resources or insurance coverage almost always was the most important consideration when community agency staff tried to make a referral, although all three factors described in Table 60 were usually considered. Table 60. Factors Community Agencies Consider in Making a Dental Referral


How often do you consider the following factors when referring children age 5 and under to a dentist?

a) Availability of dentists 3.18 1.02 463 b) Family financial resources / insurance 3.29 .97 471 c) Child’s age 3.09 1.03 468

Note. Item mean scores reflect the following response choices: 1 = almost never, 2 = sometimes, 3 = usually, and 4 = almost always.

Medical providers overall reported less difficulty in making referrals for children 0-5 than the community agency staff. They indicated difficulties finding dentists to work with the following children: those who had special needs; needed anesthesia; and were uninsured. They reported it was only somewhat difficult to find dentists willing to see children receiving public program benefits. At the time of follow up, these factors still made it a problem to make successful referrals to about the same extent reported initially and the difference was not statistically significant. Table 61. Primary Care Providers’ Experience in Finding a Referral Dentist


What is your experience in finding a local dentist who will see a child less than 5 years of age who:

a) Has a disability or other special needs 2.80 1.01 129 b) Receives Medi-Cal benefits 2.12 1.03 130 c) Receives Healthy Families benefits 2.01 .98 128 d) Is uninsured and needs a sliding scale 2.69 1.08 127 e) Will need anesthesia during treatment 2.70 1.11 128

Note. Item mean scores reflect the following response choices: 1 = not at all difficult, 2 = somewhat difficult, 3 = difficult, and 4 = extremely difficult.


In addition to system barriers, healthcare professionals’ attitudes can influence access to services. We asked the medical providers why more physicians they knew did not get involved in oral health issues affecting children aged 0-5. (See Table A-13 in the Appendix for statistical information.) The two most commonly cited attitudes that respondents reported hearing were that parents were not sufficiently motivated regarding children’s oral health and didn’t really seem to care enough about baby teeth, and it was difficult to identify dentists for young children (Figure 7). With regard to parent responsibility, some respondents reported they’d heard their colleagues say: “they miss too many appointments;” “they think it’s not important because baby teeth fall out anyway;” “they don’t take responsibility for making sure their child brushes at home;” and, “they don’t go to the dentist themselves so they don’t understand the value.” More than a quarter (28.8%) of medical provider respondents reported hearing that oral health was not really the role of the physician and that “dentists should take care of it;” one in five also mentioned hearing “children that young do not need to see a dentist.” Table 62. Primary Care Providers’ Perceptions about Their Colleagues’ Involvement

* Participants were instructed to “check all that apply” which resulted in some participants giving more than one answer. The total percentage will therefore be greater than 100%.

Survey Question Number of Responses

% of Total Sample*

(N = 1646)

Which attitudes have you most commonly heard among the providers you know about why more doctors don’t get involved in oral health issues affecting children 0 to 5?

Parents aren’t motivated/don’t care enough about baby teeth 618 37.6% Can’t find a dentist anyway for really young children 555 33.7% Shouldn’t be the responsibility of medical providers; dentists take care of it 474 28.8% Children that young don’t need to see a dentist 317 19.3% Other: Takes too much time 29 1.8% Reimbursement/Payment-Related Issues 63 3.8% Other 59 3.6% Did not specify 37 2.2%


618

474

317

555

183

0

100

200

300

400

500

600

700

Fre

quen

cy

Parents aren'tmotivated / don't

care enough aboutbaby teeth

Shouldn't be theresponsibility of

medical providers;dentists take care of

it

Children that youngdon't need to see a

dentist

Can't find a dentistanyway for reallyyoung children

Other

Figure 19. Attitudes Medical Providers Commonly Hear About Why More Doctors Don't Get Involved in

Young Children's Oral Health


HOW DID KEY DENTAL AND MEDICAL PROFESSIONALS AND ORGANIZATIONS PERCEIVE THE IMPACT OF THE ORAL HEALTH INITIATIVE? TO WHAT EXTENT WERE THEY INVOLVED? Key Dental and Medical Leaders Five (31%) key dental and medical leaders from around California returned a completed survey regarding their views about First Smiles (Table 63).13 Four of the five had provided training under the program, and three were members of the project’s Scientific Advisory Committee. All of the respondents perceived the contribution of the First Smiles program on the practice of oral health to have been strong. Three people also believed there had been some level of impact on oral health policies/politics as a result of implementing First Smiles. The impact—described by the respondents as “immense,” “very strong,” “far-reaching,” “significant”—is summarized in the table below. The basis for these individuals’ comments, or evidence cited for their perceptions, ranged from personal knowledge to observation to feedback from dental and medical colleagues. Table 63. Perceptions of Impact of First Smiles

Regarding Oral Health Practices in California:

Raised awareness among DDSs and MDs of the need to have a child seen by DDS as early as possible Raised awareness that oral health problems begin very early, including in utero Raised awareness among dental auxiliary staff of importance of their role in seeing/treating age 0-5 Increased awareness and utilization of pediatric dental services by community-based organizations Increased awareness about caries risk assessment Increased use of fluoride varnish and �ylitol Increased opportunities to educate parents through referral and case management by trained staff

Regarding Oral Health Policies/Politics in California:

Increased awareness by the legislature of problems and potential solutions Increased focused attention on oral health of age 0-5 by state agency officials (e.g., Department of

Health Care Services, Managed Risk Medical Insurance Board) and state and local First 5s Caries Management By Risk Assessment (CAMBRA)* integrated into California dental schools;

working to move the concept from the dental school to private practice CAMBRA protocol embraced by California Dental Association, bringing it credibility and potential for

additional changes over time Fluoride varnish as a medical procedure added to reimbursement for Medi-Cal fee-for-service and

managed care programs Dedicated school nurse time and materials by some school districts for application of fluoride varnish

*See Page 102 for a description of CAMBRA

13 While the overall number of respondents is low, the return rate is acceptable and the information is included here.


Local Dental Societies Twenty (63%) surveys, generally reflective of the state’s dental societies, were returned by local executive directors. Most (75%) dental society respondents stated they had heard of and were familiar with the purpose of First Smiles, though most (70%) reported not being aware of any impact the program had had on the field of dentistry (Table 64). However, the impacts described were consistent with the goals of First 5, i.e., raising awareness, seeing more children 0-5 and applying fluoride varnish, and could have been indirectly influenced by First Smiles program efforts. Additionally, those respondents made particular mention of how well attended the trainings were, how appreciative members were of having an “outside expert” come to their area to put on the training, and the benefit of offering continuing education units. Table 64. Local Dental Societies’ Familiarity and Perceived Impact of First Smiles (N=20)

Item Response1

Level of Familiarity with Program

I’ve never heard of it I’ve heard of it but don’t really know what it’s about I’ve heard of it and am familiar with its objectives

Perceived Impact of Program on Field of Dentistry

I’m not aware of any impact I think the impact has been:1

Made members now more aware of needs More members at least starting to think about the issues More providers seeing more kids 0-5 than before program It helped increase awareness of need for collaboration between dental and medical providers Local CHDP office starting to apply fluoride varnish at well-child visits It helped facilitate the Oral Health Assessment process

1 (5%) 4 (20%) 15 (75%)

14 (70%) 6 (30%)

2 2 1 1 1

1

1More than one response was allowed.

Seventeen (85%) of the dental societies were actively involved in a range of activities from publicizing the trainings through announcements to supplying trainers to putting on trainings the society sponsored (Table 65). Three (15%)–two in southern California and one representing central coast counties—reported not participating in the program.


Table 65. Type of Participation of Local Dental Societies (N=20)

Activity Frequency

Helped to identify trainers from our membership Delivered trainings we sponsored Helped to coordinate an area training/helped with registration Put announcements of trainings in our mailings

Did not participate

3 12 3 5

3

Note: Respondents could cite multiple activities.

First Smiles Trainers Fifteen (38%) of the 40 trainers who delivered medical, dental and early childhood educator trainings returned a completed Trainer Survey. The respondents, 80% of whom had presented the course to more than one of the three target audiences, reported delivering a total of 156 trainings. Over half (60%) had delivered a training to both medical and dental providers (separately or as a mixed group). While it is not known if these respondents are representative of all trainers, the number of courses they delivered appear to suggest they had sufficient experience to provide an informed perspective about the curricula and other program elements. Overall, as shown in Table 66, the respondents found the curricula materials easy to somewhat easy for teaching the core topics (average mean = 2.4). The topic they found easiest to teach was assessing caries risk and protective factors (the caries balance equation); the material related to billing and getting reimbursed for procedures was rated the most difficult (item mean = 3.7). Table 66. Perceived Ease of Using Materials to Teach the Course Topics (N=15)

Frequency (Percent)

Topic

Mean

Very easy

1

Easy

2

Somewhat easy

3

Somewhat difficult

4

Difficult

5

Very Difficult

6

Assessing caries risk and protective factors (the caries balance equation)

1.8 7 (46%) 4 (27%) 4 (27%) 0 0 0

Recognizing signs and symptoms of oral pathology/ dental decay

1.9 6 (40%) 6 (40%) 2 (13%) 1 (7%) 0 0

Providing education and other anticipatory guidance to parents

2.0 5 (33%) 6 (40%) 3 (20%) 1 (7%) 0 0

Managing behavior of very young children 2.3 4 (27%) 4 (27%) 6 (40%) 0 1 (7%) 0

Procedures (fluoride varnish, saliva testing) 2.3 3 (20%) 8 (53%) 1 (7%) 3 (20%) 0 0

Issues related to pregnancy/breastfeeding practices

2.5 2 (13%) 7 (46%) 4 (27%) 1(7%) 1(7%) 0

Managing issues related to serving children with special needs

2.7 2 (13%) 5 (33%) 5 (33%) 2 (13%) 0 1 (7%)

Billing and getting reimbursed for procedures

3.7 2 (13%) 2 (13%) 3 (20%) 2 (13%) 3 (20%) 2 (13%)

Overall Mean 2.4 Note: mean score based on scale of 1-6 with “1” as very easy and “6” as very difficult. Percentages are rounded to the nearest whole number and may not total 100%.


Excluding teaching about the oral health risk assessment form, which only trainers of medical providers were asked to comment on, the course materials were generally viewed as being effective for participant learning (overall mean = 2.1) (Table 67). The topic for which the teaching materials were rated most effective was the one related to assessing caries risk and protective factors (understanding the caries balance equation), similarly highly rated to the question of ease of teaching the topic. Medical provider trainers believed the material for teaching about completing the risk assessment form was only somewhat effective (item mean = 2.9). Table 67. Perceived Effectiveness of Course Materials (N=15)

Frequency (Percent)

Topic

Mean

Very effective

1

Effective

2

Somewhat effective

3

Somewhat ineffective

4

Ineffective

5

Very ineffective

6

Assessing caries risk and protective factors (understanding the caries balance equation)

1.8 6 (40%) 6 (40%) 3 (20%) 0 0 0

Providing education and other anticipatory guidance to parents

2.1 6 (33%) 2 (13%) 7 (47%) 0 0 0

Recognizing signs and symptoms of oral pathology/ dental decay 2.1 5 (33%) 6 (40%) 3 (20%) 0 1 (7%) 0

Knowing how/when/who to refer children to vs. knowing when/ how to manage the problem myself

2.5 2 (13%) 5 (33%) 7 (47%) 0 1 (7%) 0

Overall Mean 2.1 TRAINERS OF MEDICAL PROVIDERS ONLY: (N=9) Oral health risk assessment form

2.8 0 4 (44%) 4 (44%) 0 1 (11)% 0

Note: mean score based on scale of 1-6 with “1” as very effective and “6” as very ineffective. Percentages are rounded to the nearest whole number and may not total 100%.

Trainers reported that CDAF and DHF were conscientious about informing them when there were updates to the curricula (Table 68). The majority (86%) of the trainers also made use of the First Smiles website, the administrative portal where CDAF uploaded all revisions to the curricula, to assist them as trainers. However, two of the respondents reported finding the portal difficult to use, and one explained they had updated the curriculum with their own materials after approval by the Dental Health Foundation and didn’t make use of the website.


Table 68. How Trainers Received Updates

Methods Frequency

Contacted by staff about updates? (N=14) No Yes E-mail U.S. mail Telephone Ever used the First Smiles website? (N=14) No Yes, often Yes, occasionally Was website helpful? (N=12) No Yes, often Yes, occasionally

1 ( 7%) 14 (93%) 12 (86%) 1 (7%) 1 (7%) 2 (14%) 4 (29%) 8 (57%)

1 (8%) 6 (50%) 5 (42%)

Nearly all of the trainers provided written comments about specific elements of the program that affected their ability to train. They gave examples of problems and noted anything particularly positive or effective, as well as made recommendations (Table 69). As evidenced in the findings above, the Instructor’s Guide (curriculum binder) was viewed mostly positively. A number of technical as well as scientific and other concerns were raised about the PowerPoint slides and videos, the program element that received the greatest number of comments. Participant resistance to completing the evaluation questionnaire due to length, not surprisingly, was mentioned by a few trainers, though some reported that administering and collecting the completed forms was not a problem. CDAF and DHF program staff were nearly universally commended for their support and responsiveness to trainers’ needs.

Table 69. Program Element-Specific Trainer Feedback (N=14)

Instructor’s Guide/Curriculum Binder

Trainers’ Guide doesn’t go well with new PowerPoint Easy to follow/well organized (2)* Great curriculum; plenty to cover; able to adapt as needed The color coordination was icing on the cake Binders were thorough but making 3x5 cards for personal use

was helpful Some material was too repetitive Took much time to review new PowerPoint slides and update

personal notes

Slides and Videos

Slides a bit duplicative (2), but this didn’t bother the audience Video portions sometimes had technical glitch (4); better if it was

all on a CD, not “real play” Needed IT support at training site to be able to use; challenging

to use Great as an icebreaker; worth a thousand words Video should have been imbedded in PowerPoint to avoid flipping

back and forth


Graphics not as effective as photographic images Video should show an infant getting an exam and this being a

positive experience; participants comment on this a lot The testimonials were boring Some slides for medical providers were inaccurate; fixed them

myself Video with Rob Reiner not effective (3) Videos make it appear oral assessment takes a long time when in

reality it takes only a few minutes Cultural and linguistic appropriateness of curriculum and take-home materials

Most loved the brochures/well received (2) These are fine/appropriate (2) Did not see anything that was culturally based (2) More information needed tailored to cultural habits (2); (e.g.,

Asian cultures don’t consume a lot of sugar)

Ease of administering the evaluation survey (distributing to participants after delivering the course; mailing to evaluator)

Difficult in a hospital training environment (1) and in medical offices (2) when time was a problem

Very easy; no problem (4) Very challenging to get participants to comply; resistant because

of the length (3) Some didn’t want to list their email address The color [of one survey] made the text difficult to read I didn’t want this responsibility as a trainer Very helpful to have pre-addressed and postage paid mailers

Administration of the program by CDAF or DHF program staff

Great support; very responsive (9), e.g., a problem with CEUs was quickly fixed by staff; very helpful

Very nice people to work with Not coordinated or consistent information or enough or effective

communication prior to courses (2) No schedule for reporting provided ahead of time made planning

difficult; frequent changes to reporting forms and material without new materials provided

Should have hired seasoned trainers to create effective materials and interact with trainers in a more caring, productive way

Other observations or recommendations

Dentists seemed less supportive than physicians of the first-visit-at-age-1 recommendation

Trainings always felt rushed; inadequate time to present everything

Logistics provided by local organizers not always helpful (e.g., no microphone available)

Because caries balance equation is a key issue, use the slide that makes the point in a way that can be remembered (e.g., S …A…. F… E…)

Need more time and specifics on billing for providers to know how to get reimbursed

Felt we were preaching to the choir; those who need to be at these trainings don’t attend

I needed to adapt the basic curriculum (e.g., added oral traumas, adolescent nutrition and oral health)

Wish we had a trainer evaluation form so trainers could get personal feedback on how they did

*When a comment was made by more than one respondent, the number of respondents is noted in parenthesis.


TO WHAT EXTENT WAS LOCAL FIRST 5 INVOLVED IN ORAL HEALTH? HOW DID THEY PERCEIVE FIRST SMILES? The 58 local First 5 commissions are an important source of support for oral health services and programs in their counties, and many have allocated funds toward this purpose. How Aware were Local First 5s of First Smiles? Thirty-two (55%) local First 5 Commissions returned a baseline (FY 2003-04) survey and 34 (59%) returned a follow-up (FY 2007-08) survey regarding this California First 5 Oral Health Initiative. There was a match-up of 24 (71%) respondents with those returning both surveys.∗ The purpose of both surveys was to obtain information about current involvement and funding allocations for oral health, and for the follow-up survey to examine what changes had occurred and to what degree First Smiles might have impacted local efforts. Two-thirds (64%) of the First 5 respondents reported being aware of the First Smiles program, but one-third had not heard of it (Figure 21). Half of those who were aware had had some level of involvement, generally in helping to plan or deliver or send staff to trainings, or to encourage grantee organizations to send appropriate staff to a training.

What Were First 5s’ Perceptions About the Initiative Impact? The respondents who reported awareness of First Smiles commented on what they believed its impact in their county had been. While just under half (45%) said they were not aware of any impact, 55% reported that the Initiative had helped to support the local First 5 efforts related to oral health (Figure 22), for example by providing trainings in the area or training a local provider.

∗ Although the response rate and match-up proportion are acceptable, neither sample should be considered entirely representative of California because Los Angeles County did not respond and so is not included in either group. Among all respondents, however, is a reflective sample of large, medium and small-size counties.

Figure 21. Awareness/Involvement of First 5s(n=31)

Aware/not involved

32%

Not aware 36%

Aware/involved

32%


To What Extent Did First 5s’ Support for Oral Health Change? More than half (53%) of the local First 5 commissions reported currently spending more to support oral health programs and services than when this Initiative began (Figure 23). One-third (35%) are spending about the same, and 12% are spending less. The matched respondents reported they had made a total allocation for oral health of $5,893,690 in FY 2003-04; for these efforts in FY 2007-08, the respondents allocated $10,240,548, nearly double. The funds are primarily supporting direct services (insurance premiums, screening, transportation), although consumer and provider education and fluoridation-related activities were also reported. While the extent of this statewide initiative’s influence on local commission spending for oral health is not known—and factors such as rising costs of child health initiative premiums could have contributed to the increased spending—it is clear from this information and the examples below that support for children’s oral health services grew during the 4-year First Smiles initiative.

Figure 22. Perception of Impact by First 5s (n=22)

Helped support our own efforts

41%

Other impact14%

Not aware of impact45%

Figure 23. First 5s Spending for Oral Health in FY 07/08 Compared to FY 04/05 (n=34)

Spending about same amount

35%

Spending more53%

Spending less12%


Local First 5s supported oral health through child health initiatives (CHI) and grants/contracts for direct services (Figure 24). Examples of direct services supported by local First 5 funds included child health initiative premiums that covered oral health, mobile dental units offering a full range of services or screening, vouchers for treatment services, and school-based sealant programs for children in preschool through 6th grade. Supportive services examples included transportation to care, home oral health assessments and parent education, oral health give-aways (toothbrushes, rinse cups) and no-interest loans to help families with share of cost obligations.

Concerns and Recommendations from First 5s While local commission staff said the First Smiles trainings were very good and well received, some believed the outreach to communities/agencies needed improving through better coordination and communication with county First 5s. One large county commission said it had only heard about the trainings “via word of mouth.” Some of the smaller and rural counties expressed concern that accessing an in-person First Smiles training was difficult because training sessions were generally delivered in more urban areas “to attract the large numbers required by the contract.” Despite this, however, some commissions were able to have one local provider trained as a trainer, and that person delivered the course in the area.

Figure 24. How First 5s Support Oral Health (n=33)

CHI only9%

Both CHI andgrants/contracts

36%

Grants/contracts only55%


WHAT POSITIVE ACCESS AND SYSTEMS CHANGES OCCURRED IN THE FIELD OF DENTISTRY THAT MIGHT HAVE BEEN ATTRIBUTABLE TO OR INFLUENCED BY THIS PROJECT? Medi-Cal Claims Analysis According to Medi-Cal fee-for-service data, between June 2006 (when fluoride varnish first became a medical benefit) through December 2007, 132 medical providers provided 4,867 varnish applications to 4,256 children under age 6. While we cannot say that the fluoride applications are a result of the training—it’s more likely they are a result of adding coverage as a Medi-Cal benefit—we speculate that the training encouraged some medical providers to actually do it, and probably informed some that they could do it, which they might have otherwise been unaware of. Kindergarten Oral Health Requirement In 2006, the California Dental Association sponsored AB 1433 (Emmerson/Laird), landmark legislation that requires that children have a dental check-up by May 31 of their first year in public school, at kindergarten or first grade. The ultimate goal of this new law is to establish a regular source of dental care for every child. The program will also identify children who need further examination and dental treatment, and will identify barriers to receiving care. While not directly attributable to the First Smiles initiative, implementation of the new oral health requirement in California was facilitated by the collaboration between the two efforts, a scope of work objective for this project.


Dental School Curricula and Teaching Concepts One of the indicators for systems change in the field of dentistry attributable or contributable to this project is the number of dental schools increasing the percentage of curriculum focus on children age 0-5, including children with special needs. All five California dental schools responded to the curricula survey in baseline 2004-05 and follow-up 2007-08 academic years. At baseline, two of the schools reported that 30%-39% of the pediatric portion of the general dentistry curricula focused on the 0-5 age group, one school reported 20%-29% pediatric focus, and two schools reported less than 10% (Table 70). Three years later the overall pediatric curricula focus on 0-5 increased with two schools reporting more than 40%; however, three schools—one more than at baseline—reported less than 10% focus on this age group. Also at the time of follow-up, the percentages of didactic pediatric curriculum and clinical experience focused on 0-5 had lessened slightly. With regard to children 0-5 with disabilities and other special needs, four of the schools at follow-up compared to three at baseline reported spending less than 5% of the didactic part of the curriculum on this area; one school, however, greatly increased its emphasis. Clinical experience serving children 0-5 with special needs increased slightly between the two time periods. While the California schools vary in experience, overall it appears the exposure dental students get to this young age group, particularly children with special needs, is still relatively small compared to their exposure to older children and adult patients. California dental schools’ focus on children 0-5 do not appear to be much different than other dental schools in the nation according to our comparative analysis of nearly half of the U.S. dental schools.14 The dental school curricula experience at U.S. schools was more similar than different on all of the items surveyed, but other dental schools tend to offer a little more didactic education and clinical experience with this age group than the California schools, but slightly less focus than California’s for children with disabilities and other special needs.

14 In nearly every case, the same California and other U.S. dental school faculty representative who completed the initial survey also completed the follow-up survey.


Table 70. Undergraduate (Pre-Doctoral) Curriculum Focus on Children Age 0-5, California and Selected U.S. Dental Schools

California U.S.

2004-05 (N=5)

2007-08 (N=5)

2004-05 (N=21)

2007-08 (N=20)

Percentage of curriculum focused on children 0-5 <10% 10% - 19% 20% - 29% 30% - 39% 40%+

2 (40%) 0 ( 0%) 1 (20%) 2 (40%) 0 (0%)

3 (60%) 0 ( 0%) 0 ( 0%) 0 ( 0%) 2 (40%)

4 (19%) 6 (29%) 6 (29%) 1 (5%) 4 (19%)

5 (25%) 3 (15%) 4 (20%) 4 (20%) 4 (20%)

Percentage of didactic part of curriculum focused on 0-5

<10% 10% - 19% 20% - 29% 30% - 39% 40%+

2 (40%) 0 ( 0%) 0 ( 0%) 3 (60%) 0 (0%)

1 (20%) 2 (40%) 0 ( 0%) 1 (20%) 1 (20%)

5 (24%) 4 (19%) 4 (19%) 3 (14%)

5 (24%)

2 (10%) 6 (30%) 3 (15%) 7 (35%) 2 (10%)

Percentage of clinical experience part of curriculum focused on children 0-5

<10% 10% - 19% 20% - 29% 30% - 39% 40%+

1 (20%) 2 (40%) 1 (20%) 1 (20%) 0 (0%)

2 (40%) 2 (40%) 1 (20%) 0 ( 0%) 0 ( 0%)

8 (38%) 8 (38%) 4 (19%) 1 (5%) 0 (0%)

8 (40%) 8 (40%) 0 ( 0%) 2 (10%) 2 (10%)

Percentage of didactic part of curriculum focused on children 0-5 with special needs

0% - 5% 6% - 10% 11% - 25% 26% - 40%

3 (60%) 1 (20%) 1 (20%) 0 (0%)

4 (80%) 0 ( 0%) 0 ( 0%) 1 (20%)

(N=20)

4 (20%) 9 (45%)

1 (5%) 6 (30%)

11 (55%) 6 (30%) 3 (15%) 0 ( 0%)

Percentage of clinical experience part of curriculum focused on children 0-5 with special needs

0% - 5% 6% - 10% 11% - 25% 26% - 40%

3 (60%) 1 (20%) 1 (20%) 0 (0%)

3 (60%) 0 ( 0%) 0 ( 0%) 2 (40%)

(N=19)

11 (58%) 6 (32%) 1 (5%) 1 (5%)

16 (80%) 3 (15%) 1 ( 5%) 0 ( 0%)

Four (80%) of the five California dental schools’ pedagogical models specific to children 0-5 were described as traditional lecture-based for didactic instruction plus simulated lab instruction. In two of these schools, the pre-clinical courses also included a case-based approach to treatment planning; in the fifth school, the instructional design was described as problem-based learning. These did not change appreciably in the follow-up period. The teaching models for the pediatric curricula in the U.S. schools were very similar to California’s. Since the baseline period—where four of the five California dental schools’ pediatric curricula had not changed in the last five years—three schools have experienced “significant curricula changes,” two as recently as last academic year. Several dental schools acknowledged “change


in academia comes slowly.” The bases for making recent (since 2004-05) changes at both California and other U.S. dental schools were primarily attributable to: Adaptation to the AAPD (American Academy of Pediatric Dentistry) guidelines regarding age

1 visit and dental home Recognition of various curriculum deficiencies Increased clinical exposure Recognition of the need for general dentists to become more competent in infant oral health

care Increased awareness of little improvement in early childhood caries (“a call to action”) Change in administration or faculty composition

Table 71. Recency of Undergraduate (Pre-Doctoral) Curriculum Change for Children Age 0-5, California and U.S. Dental School Sample

California U.S.

2004-05 (N=5)

2007-08 (N=5)

2004-05 (N=21)

2007-08 (N=20)

Academic year curriculum last changed 07-08 06/07 05/06 04/05 03/04 02/03 01/02 00/01 Prior to 2000

NA NA NA

0 (0%) 0 (0%) 0 (0%) 0 (0%) 1 (20%) 4 (80%)

0 ( 0%) 2 (40%) 0 ( 0%) 1 (20%) 0 ( 0%) 0 ( 0%)

1 (20%) 0 ( 0%) 1 (20%)

NA NA NA

3 (10%) 1 ( 5%) 6 (29%) 0 (0%) 1 ( 5%)

11 (52%)

1 ( 5%) 1 ( 5%) 6 (30%) 2 (10%) 3 (15%) 3 (15%) 0 ( 0%) 0 ( 0%) 4 (20%)

Teaching Concepts Other changes that occurred in the state dental schools involve a change in the teaching of cariology. The Caries Management By Risk Assessment (CAMBRA) group, a coalition formed in 2002 from representatives of the California, Oregon, Washington, Arizona and Nevada dental schools, has been meeting to implement practical CAMBRA into the schools as well as trying to move the concept from the dental school to private practice. The First Smiles project subsidized these meetings. The California Dental Association House of Delegates passed a resolution in November 2007 supporting the four main principles for CAMBRA implementation: modification of the oral flora to favor health; patient education and informed participation; remineralization of non-cavitated lesions of enamel and dentin/cementum; and minimal operative intervention of cavitated lesions and defective restorations.


The reported efforts of CAMBRA between 2002 and 2007 in the 5 California dental schools include the following: Risk assessment forms were introduced in all the schools.

In one school, students are introduced to the CAMBRA model in the first year; concepts are reinforced in courses in the second year; in the third year students are expected to pass a competency exam in CAMBRA recommendations; in the fourth year clinical course students are expected to include a caries risk assessment in their outcomes of care competency examination.

At another school, formal CAMBRA protocol for age 0-5 was revised in 2006, and caries risk assessment is now required for every new patient exam or recall exam.

Student compliance is said to be high (though faculty are reported to have the low compliance rates).

Additionally, in 2007, Central and Eastern U.S. coalitions were formed with the dental schools in those regions. Because of this major movement, in 2008 there will be three separate CAMBRA workgroup meetings and one “general session” at the World Congress of Minimally Invasive Dentistry conference—where CAMBRA holds its workgroup meetings—with representatives reporting from each region. The Western coalition is responsible for the publication of the October/November CDA Journals, and will publish a 2-part series, “Caries Management by Risk Assessment: A Practitioner’s Guide” in these issues. Dental Schools’ Relationships with Local First 5s We also asked the California dental schools about any relationships they had with local First 5 Commissions. In baseline 2004-05, two of the schools described direct services and collaborative activities supported by First 5, while three either had no relationship or didn’t know of any relationship their school might have had (Table 72). At the time of follow-up in 2007, none of the dental schools had or were aware of any type of relationship with their local First 5. Table 72. California Dental Schools’ Relationships with Their Local First 5 (N=5)

Initial Follow-Up

Type of Relationship

Received a grant to provide direct services/expand capacity Collaborated with community organizations funded by First 5 No relationship Don’t know

1 (20%) 1 (20%) 2 (40%) 1 (20%)

0 ( 0%) 0 ( 0%) 4 ( 80%) 1 (20%)


Medical School Curriculum As part of the First 5 contract, Molina Healthcare worked with UCSF to incorporate oral health into its medical school curriculum and into its family practice residency program. Two UCSF dental faculty, Francisco Ramos-Gomez and Irene Hilton, worked with Rosalia Mendoza in the Department of Family Medicine to develop the program. Medical students now receive a 1-hour lecture as part of the family medicine curriculum. Third- year students will also have a 1.5-day rotation in the oral health screening clinic at San Francisco General Hospital. Family medicine residents receive a 1.5-hour lecture. In the second year of their residency, they spend 2.5 days in the oral health screening clinic at SF General Hospital. Other Changes in the Healthcare System As a result of First Smiles and initial participation in the project by pediatrician Dr. Scott Gee of Northern California Kaiser, Kaiser revised its risk assessment forms to include oral health at each age. However, because the American Academy of Pediatrics recommendation is brushing teeth with fluoride toothpaste beginning at age 2 and the First Smiles curriculum includes the use of fluoride toothpaste as soon as teeth erupt, Kaiser North indicated they did not want to change their clinical guidance unless it was AAP approved. In total, 420 Kaiser pediatricians received training in age-appropriate oral health through First Smiles.


TO WHAT EXTENT DID THE PROJECT CONTRIBUTE TO GREATER LOCAL INTEGRATION AND COORDINATION? Although collaboration among WIC, CHDP (Child Health and Disability Prevention Program), Head Start, and other early childhood stakeholders and local First 5 commissions has been ongoing and preceded the First Smiles program, the collaboration and technical assistance opportunities this program offered contributed to more support for children’s oral health on the local level. Awareness built among First 5s locally, for example, as more commissions are making a commitment to strategies that address oral health. Examples of these efforts include the following: California WIC delivered a special workshop at its statewide conference in 2006 that was

focused on “Building Partnerships and Collaboratives to Improve Oral Health.”

Community oral health advisory committees have been created or expanded in several counties (e.g., Stanislaus, Contra Costa, Shasta) to increase access to oral health services for underserved populations, including children with special needs; educate parents and caregivers about the importance of oral health; recruit more providers, including specialists, to accept Medi-Cal, uninsured and low-income clients; and obtain funding to maintain and expand oral health programs.

California WIC Association, the California WIC Program, Public Health Foundation Enterprises (PHFE) WIC Program, California Children and Families Commission, and Latino Family Media collaborated with Crest/Procter and Gamble to reproduce the second edition of the educational pamphlet Healthy Teeth Begin at Birth. They printed 1 million copies and plan to use these as a standard educational tool throughout the state.

Anderson Center for Dental Care, Rady Children’s Hospital San Diego, conducted a program with the San Diego County Office of Education where children with disabilities were screened and linked to treatment.

Healthy Smiles Orange County’s Seals on Wheels program provided screenings for children and made referrals for care; it also coordinated educational training for School Readiness Nurses to do visual oral screenings and oral health education. Additionally, the County’s Family Support Network incorporated oral screenings into their early childhood developmental assessments.

In collaboration with its local First 5 Commission, Alameda County collaborated with DHF in co-locating and supervising case management staff funded through the Commission. Through advocacy with First 5 this dental outreach activity became a line item in the Commission’s budget rather than a competitive grant content area.


Was There a Change in What Was Reimbursed and by Whom? Effective for dates of service on or after June 1, 2006, fluoride varnish became a new Medi-Cal medical benefit As of that date, Medi-Cal began reimbursing medical providers for this procedure for children younger than six years of age, up to three times in a 12-month period—a major incentive for increasing physician willingness to offer the procedure. Physicians, nurses and medical personnel are now legally permitted to apply fluoride varnish when the attending physician delegates the procedure and establishes a protocol. The reimbursement rate was $18 per application in FY 2006-07, and includes materials and supplies needed for application. Fluoride varnish is also a benefit in Medi-Cal managed care plans, but many plans were unaware that this was the case. The Medi-Cal Managed Care Division issued a letter to the plans on April 18, 2007, informing them of their responsibility to cover the procedure. Although MMCD clarified the requirements (March 6, 2007 All Plan Letter) and informed the plans of their increased capitation rates allowing reimbursement for providers offering topical fluoride varnish to young plan members, some local plans appear to still be working out their reimbursement rates and have not fully implemented the requirement with their participating physician offices. Similarly, confusion about reimbursement for fluoride varnish for federally qualified health centers (FQHCs) and rural health clinics—who can provide it, when/how it can be billed—has resulted in some community-based clinics currently not offering the service. Although fluoride varnish is not covered by the CHDP program, as a result of the project’s notice about fluoride varnish being a Medi-Cal benefit, CHDP and safety net physicians statewide are beginning to develop plans for the physicians to apply fluoride varnish.15 As of this writing, the Healthy Families Advisory Panel is “still considering” recommending coverage of fluoride varnish as a medical procedure to the Managed Risk Medical Insurance Board (MRMIB).16 Some Children’s Health Initiative (“Healthy Kids”) programs are also considering the same and some may be doing it. What Type of Technical Assistance Was Offered? Examples of technical assistance and other project efforts by CDAF and DHF included: Work occurred with the following local First 5s regarding:

Developed customized training for providers based on recommendations from the Quality Assurance Committee for the Children’s Health Initiative (Yolo County)

Facilitated the development of an oral health plan for the county (Tulare County) Discussed potential oral health initiatives (Los Angeles County) Provided technical assistance at a day-long oral health program (Lake County)

15 If the fluoride varnish application is provided in conjunction with a CHDP visit, the provider may not be reimbursed for an additional office visit. 16 Given the proposed rate reduction and dental cap in Healthy Families proposed in the Governor’s FY 08-09 Budget—and the vacancy of the pediatric dentist position on the Panel—currently may not be the most opportune time to pursue the recommendation.


A DHF consultant submitted suggested revisions and additions to the Oral Health section of the First 5 Association’s website.

In 2006, CDAF staff were invited to make a presentation about children’s oral health by the Solano Coalition for Better Health which led to the opportunity of conducting two studies: Solano County Dental Providers’ Willingness to Serve Denti-Cal Children and Knowledge, Attitudes and Preventive Practices Among Low-Income Parents in Solano County.

Project co-principal participated in a panel discussion at the First 5 Statewide Conference in

San Diego along with representatives from MRMIB (Managed Risk Medical Insurance Board).


“I do my own kids’ dental check-ups” – A WIC mother responding to the survey question, “Did you

take your child to a dentist in the last year? If not, why not?”

Training for early childhood educators and other professionals resulted in the direct delivery of oral health education for parents and other caregivers of children 0-5. While the parent education strategies were not directly part of the contract for this program, we implemented parent surveys and focus groups to enrich the dataset and inform the evaluation. Listening to and learning from parents of young children is an important aspect of providing services that can result in increased access and utilization of oral health services, and we used the opportunity of participation by WIC and Head Start to include this additional evaluation sample. CHARACTERISTICS OF THE RECIPIENT PARENTS/CAREGIVERS Written surveys were obtained from 1,318 parents and other caregivers who received education from the community service organizations. Of these, 658 (49.9%) parents completed 6-month follow-up surveys, 593 (90%) of which could be matched to an existing initial survey. Except where otherwise noted, parents were asked to respond to the survey questions with reference to only their children aged 0-5. A little more than 7% of the parents/caregivers described themselves or their family as being agricultural workers, a population of interest to First 5 (Table 73). While the majority of parents did not have a child with special needs, 4.4% reported that they did. The majority (65%) of the parents/caregivers identified themselves as Hispanic; 9.1% were non-Hispanic white, 7% mixed race, 5.6% African American and 5.1% Asian, mostly reflective of the clients served by the participating community service organizations although African Americans were slightly less well represented in the survey data. Spanish was the language reported to be most spoken at home by more than half (57%) of the respondents—and, correspondingly, 54.8% of the returned surveys were the Spanish-version—and English by about one-third (34.9%). The sample available for follow-up was generally similar in characteristics to the total sample, although a larger proportion had missing data.

PARENTS AND OTHER CAREGIVERS


Table 73. Characteristics of Parents/Caregivers Who Received Oral Health Education

VALUES REGARDING ORAL HEALTH Parents/caregivers rated four common health-related services specified in Table 74 that they might seek for their child as all very important. While they gave a slightly higher importance to making sure their child received immunizations, they felt receiving a dental check-up was of nearly equal importance. The differences among the values were not significant (p > .05).

Initial (N = 1318)

Follow-up (N = 658)* Characteristics

n % n %

Agricultural/Farmworker Family Yes 97 7.4 49 7.4 No 1160 88.0 517 78.6 No Response / Missing Data 61 4.6 92 14.0

Children with disability or special health care needs

Yes 58 4.4 18 2.7 No 1200 91.0 545 82.8 No Response / Missing Data 60 4.6 95 14.4

Race / ethnicity? African American / Black 74 5.6 25 3.8 American Indian / Alaska Native 18 1.4 7 1.1 Asian 67 5.1 28 4.3 Hispanic / Latino 857 65.0 413 62.8 Native Hawaiian / Pacific Islander 5 0.4 2 0.3 White, non-Hispanic 120 9.1 41 6.2 Mixed Race 92 7.0 37 5.6 Other 14 1.1 8 1.2 No Response / Missing Data 71 5.4 97 14.7

Language Spoken Most at Home English 460 34.9 168 25.5 Spanish 751 57.0 378 57.4 Other 57 4.3 25 3.8 No Response / Missing Data 50 3.8 87 13.2

Type of Survey Form English Version 590 44.8 244 37.1 Spanish Version 722 54.8 407 61.9 No Response / Missing Data 6 0.5 7 1.1

*Of these 658 surveys, only 593 could be matched to an existing initial survey.


Table 74. Parent/Caregiver Characteristics

Survey Question M SD N

How important do you think the following are on a scale of 1 to 10? Making sure that my children…..

a) get their shots 9.78 1.07 1246 b) have a dental check-up 9.63 1.22 1248 c) get a medical check-up 9.75 1.03 1246 d) have a hearing and eye test 9.66 1.16 1247

Note. Item mean scores reflect the following range of choices: 1 – 3 = not very important, 4 – 7 = important, and 8 – 10 = very important. P > .05 MARKERS FOR DENTAL PROBLEMS Certain events such as taking a child to the emergency room because of tooth pain or having them stay home from school for the same reason may be markers for children’s oral disease. The vast majority of the parents/caregivers in our survey sample had not experienced any of the marker problems described in Table 75; only between 2% and 3.6% had. Table 75. Markers for Dental Disease

YES NO Survey Question

n % n % In the last 6 months did you do any of the following? a) Stay home from work because your child had

tooth pain? 25 2.0 1214 97.9

b) Have your child stay home from child care or preschool because of tooth pain?

44 3.6 1184 96.3

c) Take your child to the emergency room because of tooth pain?

35 2.8 1193 97.1

Note. Reported percentages are calculated from the valid number of responses available for that question (i.e., number of missing responses were not included when calculating the percentage).


TO WHAT EXTENT WERE PARENTS PRACTICING POSITIVE ORAL HEALTH BEHAVIORS FOR THEIR CHILD, AND HOW DID IT CHANGE AFTER RECEIVING EDUCATION? In the majority of families it was the parent or caregiver who most often took responsibility for wiping or cleaning the child’s teeth (Table 76). In about 36% of the families, the young child was reported to be the one responsible for brushing. However, because multiple responses were allowed for this question, it is also the case that others in the family could also share the teeth brushing responsibility with the parent. The roles of teeth brusher did not change appreciably between the two time periods surveyed. More than half brushed their children’s teeth twice a day, about a quarter brushed them once a day and about 12% brushed them after every meal. For those parents completing both the initial and follow-up surveys, the changes in behavior after receiving education were all statistically significant as shown by chi-square analyses. The number of parents brushing their children’s teeth after every meal as well as twice a day increased significantly after 6 months (Table 77).

Table 76. Responsibility for Cleaning Child’s Teeth

Matched Sample (N = 593) Initial

(N = 1318) Initial Follow- Up

Survey Question

n n n Who usually wipes or brushes your children’s teeth?

I do 1109 496 496 Other adult in the family 256 114 105 An older child 52 26 23 The child 479 189 209 No one 26 14 10

Note. Survey question allowed for the respondent to check more than one choice, so no percentages were computed because the “total” would be greater than 100%. Table 77. Frequency of Cleaning Child’s Teeth

Matched Sample (N = 593)

Initial (N = 1318)

Initial Follow- Up Survey Question

n % n % n % How often are the children’s teeth wiped or brushed?

After every feeding/meal/snack 155 11.8 83 14.0 123 20.7 Twice a day 769 58.3 350 59.0 380 64.1 Once a day 296 22.5 114 19.2 69 11.6 Less than every day 69 5.2 32 5.4 17 2.9 No response / Missing data 29 2.2 14 2.4 4 0.7


TO WHAT EXTENT WERE PARENTS UTILIZING ORAL HEALTH SERVICES FOR THEMSELVES AND THEIR CHILD PRIOR TO RECEIVING EDUCATION FROM THE PROGRAM? Parents’ own use of oral health services and the types of services they use may be indicative of access barriers that affect their children’s use of services. Approximately 63% of the parents reported going to the dentist last year for teeth cleaning and/or a dental exam, a higher proportion than the average adult population living below 300% of poverty in California, 55%, according to the 2003 California Health Interview Survey (CHIS).17 More than one-third (34.9%) of the parents reported receiving a treatment-related service, though we don’t know whether those who did not go for treatment may have needed it (Table 78). For those parents completing both the initial and follow-up surveys, little change in the use of dental services was noted at the 6-month period. Table 78. Parent Use of Dental Services

Matched Sample (N = 593) All Initial Surveys

(N = 1318) Initial Follow- Up

Yes No Yes No Yes No

Survey Question

n % n % n % n % n % n %

In the last year, did you go to a dentist for any of the following reasons?

Teeth cleaning 702 63.8 398 30.2 309 63.3 179 36.7 315 60.5 206 39.5

Check-up 642 62.4 387 37.6 274 60.9 176 39.1 280 58.1 202 41.9

Treatment (such as fillings) 331 34.9 617 65.1 134 32.2 282 67.8 146 32.9 298 67.1

Note. Reported percentages are calculated from the valid number of responses available for that question (i.e., number of missing responses were not included when calculating the percentage). About two-thirds (65.8%) of all parents reported taking their child age 0-5 to a dentist in the last year, somewhat similar to the 2005 CHIS statewide average (62%) for parents living under 300% of the federal poverty level. In the matched set of parents, 60.8% had taken a child when initially asked the question and 6 months later 64.1% reported doing so, an important though not statistically significant increase in utilization of dental services. Of these, 26.3% had taken them one time, and 22.6% had taken them two times, with the frequency of visits dropping off markedly after that (Figure 25). However, one-third (34.2%) of the parents said they had not taken any of their age 0-5 children to a dentist in the last year.

17 The comparison with the <300% FPL population rather than the general population more closely matches the demographics of WIC and Head Start families.


The most common reason for taking children to the dentist was for a check-up or cleaning (Table 79). This pattern was also obtained for the follow-up survey. At the dental office the majority of the parents/caregivers perceived they were treated with respect and were allowed to be involved in any dental care decisions for their child. Almost 87% said they were shown what to do at home to promote good oral health and reduce dental disease (Table 80).

Table 79. Purpose of Child’s Dental Visit

Matched Sample (N = 593)

All Initial Surveys

(N = 1318) Initial Follow-

Up Survey Question

n n n If you took any of your children to the dentist in the last year, what did they go for? (Check all that apply)

a) Check-up or cleaning 752 321 312 b) Fluoride 155 54 53 c) Treatment (such as fillings) 218 86 98 d) Other 57 27 16

Note. Survey question allowed for the respondent to check more than one choice, so no percentages were computed because the “total” would be greater than 100%.

39.2% 35.9%

60.8% 64.1%

26.3%

13.5%

22.6%

5.2% 4.6%0.2%

2.2% 0.6%

44.2%

80.4%

0%

10%

20%

30%

40%

50%

60% 70%

80%

90%

100%

No Yes Once 2 times 3 times 4 or moretimes

Did notindicate

Figure 25. In the last year, did you take any of your children to the dentist? If so, how many times?

(N = 593)



Parents’ reasons for not taking their child to a dentist in the last year varied (Table 81) but the most common reasons, when the child was at least one year old, were related to access, such as not having dental insurance and not knowing how or where to find an available dental service. It is noteworthy that by the time of follow-up, only 10% of the parents who had initially reported not knowing how to find a dentist as the reason for not taking their child reported this. Parent attitudes and perceptions, such as believing a child age 1-5 was too young to need a dentist, or “just not getting around to it” also contributed to not taking a child to a dentist. In a few cases, dentists’ attitudes about age-related visits contributed to parents not making an appointment. Some of the write-in comments parents who didn’t take a child to the dentist shared about their views or beliefs included the following: “My child’s behavior has frustrated the dentist previously so I’m reluctant to go;” “I took her once and she was fighting us the whole time so we haven’t gone since;” “We’re waiting until she’s 3 years old;” “Because he doesn’t have any cavities;” “Because her teeth look healthy;” “My son said he didn’t want his teeth cleaned.” These reasons have important implications for parent education, such as helping parents understand not all dental disease can be diagnosed by parent inspection.

Table 80. Parents’ Perception of Experience at the Dental Office

AGREE DISAGREE Survey Question

n % n % If you took your children to the dentist in the last 6 months, do you agree or disagree with the following statements?

a) The dental staff treated us with respect 779 95.3 38 4.7

b) I got to be involved in any dental care decisions for my child

751 93.5 52 6.5

c) The dental staff showed us what we should do at home to prevent problems

694 86.8 106 13.3



Table 81. Reasons Parents Gave for Not Taking Child to the Dentist in the Last Year

Frequency of Response Reason Initial Survey

(n=287)* Follow-Up (n=141)*

Age Related Child < 1 year of age

Attitudes/Perceptions Child 1-5 yrs but parent thinks child is “too young” Parent thinks it’s not important/unnecessary (“no urgent need”) Child 1-5 yrs but DDS said “too young” for a visit Parent unaware of importance until attended class; now agrees Lack of time/forgot/just haven’t gotten to it Fear of dentist/fear of pain

Access Related/Lack of Information Lack of insurance/coverage issue Don’t know how/where/can’t find a dentist Problems making appointment Difficulty finding dentist for child with special needs Transportation Language barriers

Other Have an appointment scheduled, just waiting to go MD hasn’t recommended it Parent does the dental exam themselves

109

36 17 9

14 12 6

40 25 5 3 3 2

6 2 --

38

12 9 4 3

27 4

29 3 2 -- 3 --

6 -- 1

*Note: Survey question allowed for the respondent to check or write in more than one reason, though most parents generally only cited one reason. TO WHAT EXTENT DID PARENTS REPORT DIFFICULTY IN ACCESSING SERVICES? About three-quarters of the respondents reported that they had no problems in trying to find a dentist for their child, a surprising proportion—assuming that most of these parents actually did aim to find a dentist. Of the 24.1% of parents/caregivers who indicated a problem, the most commonly cited difficulties were associated with lack of health insurance or the type of coverage. Nearly half of these parents reported the reason it was difficult to take the child to the dentist was not being able to find a provider who would accept Medi-Cal. Not having any insurance or having Healthy Families also accounted for access barriers. Not trusting dentists and having a child with a disability or other special health care needs accounted for 7% and 3%, respectively, of the difficulties cited (Table 82).


Table 82. Parents’ Experience Finding a Dentist for their Child

Survey Question n %

Have you ever had problems trying to find a dentist to see your child? Yes 298 24.1

No 941 75.9 If “yes,” what reasons made it a problem to take your child to a dentist?

Have Medi-Cal 137 Have Healthy Families 42 Do not trust dentists 21 None of the dental staff can speak my language 18 My child has very bad dental problems 16 My child has a disability or other special health car needs 10 No dental insurance/coverage issue 9 Other reason 64

Can’t find/dentist won’t see children age 0 to 5 16 Appointment difficulties 5 Anesthesia/sedation-related 4 Dentist was not “nice”/ bad visit experience 3 Immigration status concerns 1 Lost dental records 1

Note. Survey question allowed for the respondent to check more than one choice (and so no percentages were computed because the “total” would be greater than 100%). TO WHAT EXTENT DID PARENTS INCREASE AWARENESS AND KNOWLEDGE? As a result of the oral health education, a large majority of the respondents indicated they learned more about causes of tooth decay, how to prevent tooth decay and how to brush children’s teeth. About three-quarters reported they also learned where to find a dentist for their child (Table 83). However, their responses to the posttest questions were not

Table 83. Parents’ Self-Perceived Knowledge Gain

YES NO Survey Question

n % n % After the group discussion on children’s dental health, I learned more than I knew about:

a) What causes tooth decay 1130 94.6 65 5.4 b) How to prevent tooth decay 1151 94.5 67 5.5 c) How to brush child’s teeth 1055 89.6 123 10.4 d) Where to find a dentist for my child 882 78.6 240 21.4



Entirely consistent with their own perceived increase in awareness and knowledge about ways to prevent dental decay and promote oral health. Parents/caregivers did significantly (p<.05) better on questions related to the value of fluoride, type of “good” snacks and transmission of germs from adults (items d, e and f in Table 84), than on the other questions. Questions relating to bottles at bedtime, Medi-Cal and tooth pain did not differ from each other in percentage correct, but were answered significantly differently than questions d, e, and f and particularly g. While 85% of parents understood that fluoride helps to prevent tooth decay, half (49.4%) of them answered incorrectly the question about age at which fluoride toothpaste should be used, as item g was significantly different from all of the other items. For parents who responded to both the initial and follow-up surveys, the only statistically significant change was the drop in percentage correct for question g over the 6- month period.

Table 84. Posttest Results for Parents/Caregivers

Matched Sample (n = 542*)

Survey Question

Total Sample

% Correct (n = 1224*)

Initial %

Correct

6-Month %

Correct

TRUE/FALSE

a) To prevent tooth decay, put only water in the baby’s bottle at bedtime.

71.8 69.7 72.5

b) If you have Medi-Cal or Healthy Families, it doesn’t cover dental services.

74.7 72.3 75.1

c) Tooth pain is one of the main reasons for children missing school.

71.2 72.0 72.5

d) Adults can pass tooth decay germs to their children.

80.2 78.4 82.3

e) Fluoride helps to prevent tooth decay. 85.3 83.2 87.3 f) Snacks like raisins and fruit roll-ups are sticky and

may cause tooth decay. 82.2 82.8 83.2

g) Parents should start brushing their child’s teeth with fluoride toothpaste at age 5.

50.6 50.6 41.9

Total Average Score for True/False Items 73.7 72.7 73.5

Average # of T/F Items Correct (out of 7) 5.2 5.1 5.2

*Sample size is after excluding those cases with 6 or more blank posttest responses on the initial survey (and on the follow-up survey for the matched sample group). These excluded cases were not included in the computation; they were defined as not responding to enough questions to presume that they had challenged all of the test items and could therefore allow us to code a failure to answer a question as an incorrect answer.


As shown in Table 85, parents/caregivers were very satisfied with the consumer education materials about children’s oral health they received during the education session (Scale of 1-4, M = 3.68, SD = .67). Table 85. Parent Satisfaction with Written Materials

Survey Question n %

How satisfied were you with the written materials you received about children’s dental health?

Very Unsatisfied 45 3.4 Unsatisfied 8 0.6 Satisfied 250 19.0 Very Satisfied 942 71.5 No Response / Missing Data 73 5.5

FOCUS GROUP SUBSAMPLE The focus group subsample provides another opportunity to examine parents’ experience and perceptions about children’s oral health. A total of 117 parents and other caregivers attending a WIC or Head Start oral health educational session participated in a focus group (Table 86). Most of the participants were women and the mothers of children 0-5, but several grandparents (primarily women) raising or caring for their grandchildren also participated. The age and race/ethnicity of the focus group participants reflected the client profiles of families receiving WIC and Head Start services and those who completed a written evaluation survey. Except for utilization of dental services and knowledge about oral health, the findings were relatively consistent across all of the focus groups.

Table 86. Focus Group Sites and Parent Sample

County Primary Language Participants

Contra Costa English and Spanish 30 Los Angeles Spanish 39 Sacramento English and Spanish 18 Shasta English 12 Solano Spanish 18 Total 117


Utilization of Services Among the focus group participants, less than half (44%) had visited a dentist within the last year. While 79 (68%) of the parents/caregivers reported ever taking their child to a dentist, only 54 (46%) of them reported taking their child to a dentist at least once in the last year. Parents in the Shasta County focus groups had disproportionately lower usage of dental services both for themselves as well as for their children. Age at First Visit Of the parents who had ever taken their child to a dentist, all said their children had made a first visit by age 5, but only 7% had gone by the recommended age of one year (Figure 26). Another 75% of children saw a dentist for the first time between about ages 2-3, and 18% between about ages 4-5.

Indicators of Dental Disease Tooth pain and missed school and, for parents, missed days of work are important indicators of children’s dental disease. According to the 2003 California Health Interview Survey, parents and other caregivers reported that 4.5% of children age 0-5 missed at least one day of preschool because of a dental problem. This indicator for the WIC and Head Start children in the First Smiles evaluation is slightly more favorable than the statewide average for this age group. Of the 117 focus group parents in our study, 3 (2.5%) reported keeping their child home from preschool or day care due to the child’s tooth pain, and 3 (2.5%) reported staying home from work for this reason in the last year. Also in the last year, 2 (2%) parents had taken their child to an emergency room because of tooth pain. Access to Care While they are often interconnected, factors related to both the health care system and to consumers affect and may act as barriers to dental service use and the adoption of preventive oral health practices.

Figure 26. Age of Child at First Dental Visit

7%

75%

18%

0% 10% 20% 30% 40% 50% 60% 70% 80%

By Age 1 Ages 2-3 Ages 4-5


System Barriers The reasons why children had not seen a dentist within the last year were reported as difficulty finding a provider who would see young children, the most commonly cited, and finding a provider who would accept the family’s form of insurance (primarily Denti-Cal), and limitations related to Denti-Cal scope of services. Between one-half and three-quarters of parents/caregivers reported problems related to these barriers. For example:

being told to wait until child is at least 3 years of age or “can sit still;” being told not to come back because parent failed to give 24-hour cancellation when child

got sick the night before; being told that the office didn’t accept any or any new Denti-Cal patients; being “dropped off” by the Denti-Cal program because the children didn’t use the service

frequently enough. being charged up to $140 extra as an out-of-pocket expense because Denti-Cal did not

pay for nitrous oxide analgesia.

It was not clear if these parents had worked with staff from the organizations hosting the focus groups to try to get assistance to resolve these problems as the impression we got was that many of these were ongoing problems. Another important issue of concern to parents/caregivers centered on the use of sedation. A number of participants had been told that their child would require sedation and a restraining device (which these parents heard as “tying up my child”) and either the provider didn’t offer such a service or the family elected to try to find care elsewhere because they didn’t agree with or understand why these measures would be taken. In fact, three parents reported canceling appointments after being told by the offices that they “would tie my child up to keep them from getting off the chair.” Office policies related to language barriers was only mentioned a few times. Some dental offices were reported to require families to come in when they could bring their own interpreter. Patient Factors as Barriers Transportation and getting time off from work, reported by 15 (13%) and 11 (9.5%) parents, respectively, were the barriers to dental care cited most frequently. Only a couple of parents mentioned having no childcare as the reason for not seeking or missing appointments. Eight (7%) of the parents believed their child was too young to need a dentist (e.g., “he’s only 2 years of age”). Seven (6%) said they had not yet tried to find a dentist, three of whom volunteered, “I have no excuse; I just haven’t done it.” Several parents said they were unsure when to start taking their child to the dentist; two parents noted that they “didn’t know my child was old enough until my doctor told me to go.” Not seeking care due to parent-provider language differences was only cited by three parents. Fear—the child’s or the parent’s from their own past experience—seemed to be an important reason why some children didn’t see a dentist or didn’t return to complete treatment. Some parents said their children would not open their mouths when they visited the dentist; in a few


cases, parents reported their children were “too nervous” to see a dental provider. These comments were usually made in the context of anxiety around sedation and restraints. Some dental providers we surveyed believe patients who have to pay something out of pocket for care versus receiving “free” care (e.g., Denti-Cal) are more likely to take better care of themselves in the first place. Because they feel these parents have a more casual attitude about prevention—“because Denti-Cal will pay for treatment”—and comply less with recommended treatment regimen, we asked parents at four of the focus groups their opinion about these beliefs.18 Between one-quarter and one-third (28%) of parents/caregivers agreed with this perception that having to pay something for dental services might make them more likely to “take better care of my child’s teeth” and follow a dentist’s recommendations—lending some credibility to providers’ perceptions about the influence of payment on patient compliance. Knowledge and Application of Learning Because all of the participants had gone through a First 5 oral health education class or one-on-one educational session at the WIC and Head Start sites, we selected three items from the curriculum to assess parent/caregivers knowledge about oral health. As shown in Table 87, the majority of participants correctly knew they could pass organisms that cause tooth decay to their child through their saliva, and fluoride helped to prevent tooth decay, while most (90%) incorrectly thought children should not use a fluoride toothpaste until they were at least 5 years of age. These results are consistent with the findings described above from the written parent surveys. Parents in the Shasta County focus groups had disproportionately lower usage of dental services both for themselves as well as for their children. Table 87. Percentage of Focus Group Parents with Knowledge of Oral Health Items Oral Health Item

% Who Knew Correct Answer

Adults can pass tooth decay germs to children 61%

Fluoride helps to prevent tooth decay 73%

Parents should wait until child is age 5 to use fluoride toothpaste 10%

Several dietary factors are associated with caries incidence, but the key culprit is increased frequency of sugar intake. While many of the parents/caregivers stated that they understood the value of healthier snacks, and tried to give their children healthy food and beverages, it was difficult to get them to eat and drink them, with children preferring candy, soda, and chips instead. Grocery shopping with children was cited as being an especial ordeal when it came to children demanding sugar-heavy snacks. Some said they tried not to take their kids to the store with them for this reason. Others rationed “bad” snacks to one a day as a means of

18 The question was added after the focus group research began at the request of a dental consultant so could not be posed to the earlier groups.


compromise. A few parents/caregivers “gave up fighting over snacks,” taking the path of least resistance and allowing the child free reign to eat and drink what they wanted. Access to toothbrushes and toothpaste appeared not to be a problem, nor was understanding the value of tooth brushing. However, while all of the participants said they asked their children to brush or helped them to brush, it was not always consistent or overseen by a responsible person. Nighttime brushing presented the biggest challenge. Some parents depended on older children to help; some shared responsibility with another adult in the home (spouse, boyfriend or grandparent) and assumed they were helping; some who shared custody with the child’s other parent or work different shifts from their spouses were not sure whether the other parent was following through. A few parents who worked at night and didn’t get home until their children were already asleep said it was “too late to worry about brushing then.”


As part of the quality control in this program, CDAF and DHF calibrated the 51dental and medical professionals selected as the initial trainer group. The trainers who returned a posttest calibration survey (N=33) scored highly on the posttest, rated the training favorably, agreeing or strongly agreeing that the course references would be useful and the information learned could be applied. They also reported high levels of confidence about using adult learning methods and presenting the curriculum effectively when putting on trainings. All agreed, though not strongly, that they had learned new information and skills. This relatively low agreement regarding new skills reflects trainees’ prior knowledge of children’s oral health issues—one of the reasons they were selected as trainers. The comparatively low agreement relative to presentation of the curriculum was probably a reflection of the modifications necessary to improve the material. During the first year (January – November 2005), CDAF and DHF evaluated the trainers who delivered medical and dental trainings. Posttest scores were used as the criterion, and we supplied quarterly reports of these scores for program staff to analyze. The results were applied as follows: A DHF consultant performed a question-by-question analysis, and for those posttest questions that did not score favorably, our recommendation to make the curriculum clearer in those areas was implemented. Staff recognized that differences among trainers could be due to trainer characteristics, student characteristics, training circumstances and so forth, and used the quarterly reports to determine which trainers were getting the best evaluation results and continued to more frequently use those trainers.

TRAINER EVALUATION


DISCUSSION AND CONCLUSION

“I thought if you couldn’t see a problem there was no reason to go [to the dentist].”

– Preschool parent attending an oral health education class

Increasing access to oral health services for young children, particularly those from families with no dental insurance or with Medi-Cal, requires various approaches designed to complement and reinforce one another. In understanding that caries is the most prevalent chronic infectious disease of early childhood19 and a major cause of school absenteeism, First 5 California created the Oral Health Initiative with several related components. The focus of the workforce component, First Smiles, was training and educating dental and medical providers; a smaller consumer education program addressed the insufficient understanding and education of families and community services providers of the importance of early oral health care. We believe the results of our evaluation of First Smiles are of broad significance and make valuable contributions to oral health practice as well as policy and funding discussions concerning young children. Program Exposure First Smiles reached an impressive proportion of its target numbers with creative, appropriately-tailored strategies such as in-office presentations. The program attracted a more diverse group of providers than dentists and physicians generally practicing in California, participant characteristics that have the potential of influencing future practice behaviors and increasing the impact of the training. Having trained a large group of general dentists with fewer years in practice, for example, may have a payoff of a longer time span for implementing new knowledge and skills. And, having trained a relatively large group of female dentists who indicated seeing younger children and a willingness to see more appears also to be beneficial.

19 US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General, Rockville, MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000.


Provider Knowledge and Abilities Training in oral health of young children continues to be an important need for both medical and dental providers as health professional education to date has with a few exceptions generally ignored the dental component of early childhood.20 First Smiles essentially met its learning objectives with knowledge gain demonstrated in many areas of the curricula such as age of recommended first visit, role of �ylitol gum, and remineralization with fluoride varnish. While dental and medical providers scored highly in recognizing dental care as the leading unmet health care need for children with special health care needs, they did not seem to understand that the behavioral issues for these children are generally the same as for the 0-5 population. Consequently, training related to children with special needs should be a higher priority as dentists need assurance of their ability to integrate these children into their practice. While the type of training session did not seem to matter for the participants relative to the majority of the curriculum, the caries balance equation is complex. Because the medical providers scored higher on that question in the longer training session, more time should probably be spent in the shorter course (i.e., in-office training) for medical providers assuring that participants understand risk factors as they relate to the caries balance equation. Knowledge retention for some of the curricula areas was challenging and there was a general trend for both dental and medical participants to lose some information over the 6-month period, regardless of the length of the course. Community agency staff, on the other hand, tended to retain about as often as they lost information, but none of their losses relative to the posttest items were significant. One reason providers’ knowledge retention was not higher may be because they were absorbed in their own practices when they answered the follow-up posttest or less certain about the information than during the day of the course, or they didn’t use the knowledge often or early on after training. Strategies such as follow-up consultation in provider offices may be a key factor in enhancing retention of information from trainings such as provided by this program. Greater understanding of all of the potential influences that contribute to knowledge retention of these providers is required. Because the course content and length were somewhat different for medical and dental providers, we cannot compare the provider participants’ opinions with each other directly. However, overall feedback from these participants indicated that the groups found the training valuable and applicable and the materials useful, with nearly half the medical providers and close to 60% of the dental providers actually following through in recommending the course to a colleague—figures that are quite favorable. Of concern, however, is early educator staff of community organizations indicating an anticipation of being able to apply what they learned at training and not being able to do so six months later. While the participating agencies (primarily WIC and Head Start) were supportive of training trainers who in turn trained colleague staff, the organizational environment apparently was not able to accommodate the additional time and corresponding cost required to implement new program components. Without administrative buy-in the benefit of the training will be limited if the consumer messages are not delivered by staff to parents of young children.

20 Edelstein BL. Dental care considerations for young children. Spec Care Dentist 2002;22(3):11S-25S.


The topics were found by the majority of program trainers to be easy to teach and the materials effective for participant learning; however there were specific areas that were noted as challenging. Issues needing more attention—from attention to cultural and linguistic appropriateness to communication between project staff and trainers—should be reviewed by DHF and CDAF in future curricula revisions and course offerings. Feedback from course participants showed increased comfort and new self-perceived skills learned and indicated program impact for the goal of skill level change. It is significant that the highest degree of perceived increase reported by all participants was in the area of communicating with parents. Since parents are the gatekeepers of children’s health and educating them about ways to prevent early childhood caries in dental and medical settings is “frequently an exercise in overt persuasion,”21 increased skills in parent counseling and anticipatory guidance is likely to lead to improvements in children’s oral health. The least amount of increase in self-perceived skill reported initially and six months later by dental professionals, learning how to bill and get reimbursed for procedures, implies these providers needed more information about this topic, the topic may not have been covered in some trainings or providers or their staff generally knew about reimbursement procedures. The slightly higher increase in reported skill level by medical providers than dental providers suggests that dental professionals likely started with more of a base of knowledge about the curriculum content related to reimbursement. While medical providers retained the self-perceived skill level as a result of the training between the two time periods the same was not true for dental providers. This is not particularly concerning, however. Participants can be enthusiastic after having just taken a course, maybe overly so; time may add a perspective and provide more realistic appraisals. Caring for Pregnant Patients An important part of primary care providers’ caring for young patients is screening for oral disease. National prevalence rates have been reported of 30% of 2-5 year olds in poverty and 24% in near-poverty showing visual evidence of dental caries,22 and in California tooth decay is found in 50% of all children by the time they reach kindergarten.23 Because primary care providers along with early education specialists may be likelier than dentists to encounter new mothers and infants, they have a unique opportunity to ask about and look for indications of dental disease and other oral health conditions as early as the prenatal period provided they are sufficiently aware and trained to do so. Pregnancy is a “teachable moment” when women are motivated to change behaviors that have been associated with poor pregnancy outcomes. A growing body of research suggests that serious periodontal disease is associated with premature birth and low birth weight. In addition, mothers are the most common transmission source of decay-causing bacteria to their infants.

21 Weinstein P, Harrison R, Benton T. Motivating parents to prevent caries in their young children. J Am Dent Assoc. 2004;135:731-737. 22 Vargas CM, Crall JJ, Schneider DA. Sociodemographic distribution of pediatric dental caries: NHANES III, 1988-1994. J Am Dent Assoc. 1998;129:1229-1238. 23 Mommy it Hurts to Chew. An Oral Health Needs Assessment of California Kindergarten and Third Grade Children. Dental Health Foundation. February 2006.


Yet, studies indicate not only that pregnant women in general underuse dental care but that poor women disproportionately fail to obtain it.24 In California, fewer than one in five pregnant women enrolled in Medi-Cal received any dental services in 2004.25 These factors require enhanced education and training of obstetrical providers concerning oral health in pregnancy. About one-third of the medical providers First Smiles reached identified themselves as obstetrical providers. These providers should now understand their unique opportunity during routine prenatal visits to provide simple, preventive counseling on oral health. The medical-dental collaboration, evidenced by medical providers increasing “always or almost always” referring pregnant women to a dentist and coordinating/consulting with the dental provider, and dentists increasingly conferring with a pregnant patient’s medical provider, is promising. Parents’ Role and Experience Parents usually are the primary decision makers on matters affecting their children’s health and use of health care services and play a key role in achieving the best oral health outcomes. Yet, parents and other caregivers have had limited opportunities to learn that tooth decay is established as a disease process even as the first teeth are coming in. The results of our evaluation underscore the importance of listening to parents of young children to understand their perspectives about the relative importance of oral health, and their experiences seeking oral health care services and adoption of desirable oral health behaviors. The views of low-income and immigrant parents are especially important as these families have more limited access to resources and face greater challenges when seeking care. We know that financial obstacles low-income parents face affect their children’s utilization of dental care services. Our results showed that not having dental insurance was the primary reason that made it a problem for parents to find a dental provider, and the most important factor in community agency staff making successful referrals of children aged 0-5 to a dentist. Despite these obstacles, however, about two-thirds of all parents reported taking their child age 0-5 to a dentist in the last year, perhaps reflecting the benefit for children’s oral health of participation in WIC and Head Start. The fact that these parents’ use of oral health services for themselves was higher than low-income parents statewide (63% compared to 55%) is further indication of the benefit of WIC and Head Start to the oral health of low-income families. Our findings are consistent with other studies documenting parents’ problems in identifying willing providers and overcoming patient-related factors such as fear of the dentist. Dental care and fear or anxiety have long been linked in popular culture,26 and a portion of our survey and focus group parents disclosed this concern about themselves. Because initiating dental care during preschool years has been shown to be significantly related to the mother’s beliefs (and her social network’s beliefs) in the value of preventive dental care,27 addressing these concerns in educational efforts is crucial. While valuing oral health nearly the same as medical check-ups and immunizations, close to 10% of parents continued to believe that their toddler or preschool child was too young to need a dentist; a portion misunderstood when a child could use toothpaste with fluoride (particularly as time went by from the initial oral health education). These

24 Gaffield ML, Gilbert BJ, Malvitz DM, Romaguera R. Oral health during pregnancy: an analysis of information collected by the Pregnancy Risk Assessment Monitoring System. J Am Dent Assoc. 2001;132:1009–1016. 25 A Look at California’s Medicaid Dental Program: Facts and Figures. California Healthcare Foundation. May 2007. 26 Edelstein BL. op cit. p. 19S. 27 Kim, Young O. Rhee. Reducing disparities in dental care for low-income hispanic children. J Health Care for the Poor and Underserved August 2005;16(3):431-443.


misunderstandings and the view of dentist=pain imply areas that could be emphasized more in anticipatory guidance with parents. Access Barriers and Provider Availability Barriers to improving oral health and utilization of dental services for young children are multifaceted and complex. In addition to personal barriers such as attitudes and lack of financial resources, healthcare system barriers challenge optimal use of oral health services. One of the most frequently cited problems or best substantiated barrier in our findings was the inability of medical providers and community organization staff to identify dental providers willing to see young children, particularly low-income, uninsured or children with special needs. As one physician expressed the paradox of learning to do better screening, “It’s frustrating to know how to recognize an oral health problem but not be able to find a resource for dealing with it.” While all respondents reported difficulties in making referrals to a dentist for children 0-5 because of too few available dental providers, early childhood educators and other professionals working in community agencies reported a higher degree of difficulty than medical providers did. This may be because agency staff respondents actually do the referring themselves—and are therefore more aware of the problems—whereas medical providers may depend on their staff to do it and may not follow up, and do not really know how difficult it is to find community dental care. In addition to structural barriers, attitudinal barriers that preclude greater involvement in children’s oral health can be reflected in medical and dental providers’ practice behaviors. Believing that “parents aren’t motivated and don’t value baby teeth” and “it’s a dentist’s responsibility, not a doctor’s” were primary reasons medical providers participating in First Smiles thought their colleagues were not more involved in oral health of young children. However, the broad reach of this program to physicians statewide will likely moderate some of these negative perceptions over time. In addition, Medi-Cal reimbursement for fluoride varnish as a new medical benefit should be a positive motivation for more primary care practices to become involved. Changes in behavior are made slowly and in small steps. It has been pointed out that a generational shift is underway on professional recommendations for dental care so that the idea of a “first dental visit at the first birthday” is still widely unexpected and questioned by many who advise parents and caregivers, including primary medical care providers and even dental professionals.28 The fact that 15% of the general dentists reported seeing more children ages 0-5 six months after training due to taking the course, for example, was a very positive program outcome. It may not be realistic to think that a 2-hour or a 4-hour course would have a greater measurable impact than that on this program goal. Other factors such as low reimbursement rates and client behaviors (appointment keeping and timeliness) are likelier to have a far greater influence on provider willingness to see children 0-5, particularly those with Medi-Cal,29 but were beyond the scope of this program to affect.

28 Edelstein BL. Ibid. 29 US Department of Health and Human Services, Office of the Inspector General. Children’s Dental Services Under Medicaid—Access and Utilization. (OEI-09—93—00240;04/96).


Systems Change One area where long-range improvement in access may come about is as a result of increased dental-medical collaborations. Some of the trainings in this program were delivered to mixed audiences of physicians and dentists. While the results for these sessions were not analyzed separately to know how the findings might have differed, there are emerging data on important oral-systemic linkages that point to an increasing need for dental-medical collaboration and cross-training.30 Consequently, additional opportunities to deliver First Smiles training to combined groups of healthcare professionals, acknowledging the impact more physician training will have on the demand for community dental services, should be considered. Local dental societies became engaged early on as active participants in First Smiles. They proved to be a good resource for supplying trainers and for helping to promote the course, particularly because continuing education units were available. If the CDAF receives continuing support to keep the First Smiles curriculum updated, the course will have a long shelf life and can benefit dental society member and non-member dentists alike, providing continued focus on the 0-5 population. The Oral Health Initiative appears to have had an influence on what California First 5s are paying for or enhanced their services through strategies such as children’s health and other health access initiatives and special needs projects (e.g., demonstration sites). Awareness built over the four years of this initiative as more and more local First 5s made a commitment to oral health. There were also indications that the program influenced greater integration and coordination of services between local stakeholders and community agencies such as CHDP, WIC and Head Start—contributions likely to have long-term effects. Public officials probably gained greater awareness of the problems of early childhood dental disease and its consequences but we did not directly measure this indicator. Physicians who are providing oral health risk assessments to their age 0-5 patients are not going to do a procedure they are not used to doing without reimbursement. Providing fluoride varnish is still not part of established well-child visits, largely because physician offices, including those contracted Medi-Cal managed care providers, are not being reimbursed for it or are unaware of reimbursement. Medical provider participants in this project clearly anticipated providing it when they left the course (mean score 4.5 of 6.0) but six months later infrequently were doing so (1.2 of 6.0). Hence, it is not that reimbursement didn’t make a difference in follow through—it’s the ambiguity about the reimbursement that is accountable. Long-term systems change will also need to come from the institutions that educate dental professionals. Many general dentists are not comfortable treating young children and classroom and chair-side education focusing on age 0-5 at the pre-doctoral level varies. Overall, California dental schools do not currently direct a high percentage of their general didactic or clinical experience curricula on the 0-5 age group. The exposure dental students have to very young patients with disabilities and other special needs is even lower. While the California schools

30 Mouradian WE, Berg JH, Somerman MJ. Addressing disparities through dental-medical collaborations, Part 1. The role of cultural competency in health disparities: training of primary care medical practitioners in children’s oral health. J Dent Educ. 2003;8(67):860-868.


varied in experience and First Smiles might have influenced some of the more recent curricula updates and age focus, overall it appears the exposure dental students get to this young age group, particularly children with special needs, is still relatively small compared to their exposure to older children and adult patients. At the time of follow-up in 2007, none of the dental schools had or were aware of any type of relationship with their local First 5. It would be to commissions’ advantage to network with local area dental schools as a place to obtain expert advisory participation and to facilitate locally-funded strategies for increasing access to and use of oral health services for children 0-5. Finally, while the ability to effectively evaluate the impact of the education and training program would be greatly enhanced by measuring change as evidenced by actual screening results of the children 0-5 seen by providers reached through this program, findings from the 2006 Dental Health Foundation Oral Health Needs Assessment can serve as a baseline when the assessment is repeated in another five years. Given the large proportion of the State’s providers who were reached with First Smiles, caries prevalence rates in 2010 should reflect the effects of this education and training project.


RECOMMENDATIONS

The recommendations below are intended to build on the successes of First Smiles and should be considered, as appropriate, by California First 5 and other funders, as well as CDAF and DHF and other organizations that support early childhood oral health. The resource requirements to carry them out vary of course. There is no particular importance ascribed to the order of the recommendations. 1. The First Smiles curriculum should be strengthened in the areas where the posttest results

for each group indicated the need for more emphasis, and future trainers made aware of these topics. For example, for providers: managing the behavior of children 0-5 with special needs is generally the same as for all children of that age; for parents: adults can pass “tooth decay germs” to their children.

2. Continuing support should be identified for keeping the First Smiles curriculum updated. This

will result in the course having a longer shelf life and maximizing the First 5 investment. 3. Optimally, for in-person training of dental professionals, the 4-hour course should be offered

over the 2-hour course. 4. Based on the effectiveness of the training delivered in medical provider offices, the 1-hour, in-

office training strategy should be supported in additional medical offices, particularly OB-GYN and rural practices. If resources are limited, target large group practices.

5. More opportunities should be supported for training dental professionals about children with

disabilities and other special needs. While there are unique challenges related to this subset of children, it should be emphasized that behavioral issues for these children are generally the same as for the 0-5 population.

6. For greater likelihood of program success when resources are limited, target training and

support strategies to dental providers most likely to see children 0-5: younger dentists and female dentists.


7. Future trainings of this type should include more hands-on experience (actual application of

varnish on infants/toddlers) as part of the training of medical providers. While part of the reason for the relatively poor level of participation of these providers in fluoride varnish application is undoubtedly related to the confusion about reimbursement in the managed care plans, the hands-on experience is an important missing component.

8. There should be more joint training of medical and dental providers, incorporating a hands-on

component for medical providers. This could help establish a collegial relationship between the two, as well as increase the likelihood that medical providers will have a dentist to refer children to.

9. WIC and Head Start agencies should consider ways to make a greater commitment to

integrating the parent oral health curriculum into their client education services so that staff trained to deliver it can more fully apply what was learned during the training. Because WIC and Head Start do not have adequate funding, these organizations need additional support to put the training into practice. More detailed information may be needed from staff as to specific changes that are needed for them to be able to implement new skills and knowledge.

10. More effort should be made to inform primary care providers of the Medi-Cal benefit of

reimbursement for fluoride varnish application. If the reimbursement rate is considerably out of line with the cost for providing it, it should be raised or providers will have little incentive to participate. Advocacy efforts that result in expanded program benefits and increased provider rates (and reduced administrative burdens) should be pursued. These changes are required to create a greater level of access. Additionally, because many of the Medi-Cal managed care physicians were not informed about the benefit by their plans during the course of the project, they may require additional training once the benefit actually kicks in.

11. Healthy Families should cover fluoride varnish as a medical procedure by its health plans, and

that both Healthy Families and Medi-Cal should cover anticipatory guidance, at least for children 3 and under, in both its medical and dental plans.

12. Although academia moves slowly, most of the California dental schools should update and

increase the proportion of didactic and clinical curricula focus on the 0-5 age group (and continue to update it as needed), particularly around behavior management and anticipatory guidance for parents.

13. Funds for training of medical and dental staff in community health centers (Federally Qualified

Health Centers, Rural Health Clinics, Tribal Health Clinics) should be made available. Attempts were made by this program to reach these groups but the approach should be better thought through with the participation of clinic staff and administrators to increase buy-in and participation.

14. Given the frequency that the First Smiles website was accessed and the purposes for which it

was utilized, it would be important to continue support for maintaining it.


15. First 5 California should increase School Readiness (SR) sites’ promotion of oral health and collaboration with dental and primary care providers given the somewhat low percentages of training participants with practices located in the SR zip codes.

16. Although it was beyond the scope of this study to inquire about the oral health content of

California medical and allied health schools’ curricula, it should be assessed. It is likely that, like dental schools, there is a need for incorporating more oral health content in the curricula.

17. The professionals trained through this program constitute an important cadre of individuals

who should be tapped for outreaching to colleagues as well as with schools and community service organizations that serve families of young children. Some with particular qualifications and expertise identified may be valuable assets for the dental schools to utilize in their pre- and post-doctoral didactic and clinical programs focusing on the 0-5 age group.

18. Future strategies that may enhance the efforts of First Smiles are testing the use of case

management as a supplement to training and offering a more intense hands-on clinical curriculum such as POHAP (Pediatric Oral Health Access Program). POHAP provides the potential for a sustainable increase in access to dental care for children by providing general dentists with the increased skills and comfort level necessary to expand their practices for young children, including those with physical and developmental disabilities.


APPENDIX

Table A. Instrumentation & Data Sources for First 5 Oral Health Education & Training Evaluation*

Measures Instrumentation

Knowledge/ Awareness

Knowledge Retention

Skill

Behavior Willing

Behavior Change

Access

Systems

Evaluation Plan Question

Survey A Dental Provider Survey and Posttest x x x x 1,2, 4, 9, 10,

18 Survey B Dental Provider 6-Month

Follow-Up x x x x x 11, 19, 21, 25, 26, 27

Survey C Medical Provider Survey and Posttest x x x x 1,2, 4, 9, 10,

15 Survey D Medical Provider 6-Month

Follow-Up x x x x x 11, 16, 20, 25, 26, 27

Survey E Community Service Provider Survey Posttest x x 5, 24, 8, 12

Survey F Community Provider 6-Month Follow-Up x x x x 15, 22

Survey G Parent Survey and Posttest (English/Spanish) x x x 6, 8, 13, 14

Survey H Parent 6-month Follow-Up (English/Spanish) x x 15, 23

Local First 5 Baseline & Follow-up Expenditures x x 31

Dental Schools Baseline & Follow-up Survey x 28

Dental Society Awareness/ Involvement Survey x 28, 31

Trainers’ Perspectives x x 28,31

Additional Data Sources

Parent Focus Group Questions x x x x x 23, 24 Claims review/analysis formats

x x 20, 25, 26, 27, 28, 30, 32, 33

General Dentist Focused Interviews x x 9, 19, 25 Key Informant Interviews and Surveys x x 21, 27, 28,

29, 31, 32 Key Project Staff Interviews x x x 3, 6, 27, 28,

29 *Copies of instruments available from First 5 California.


GLOSSARY OF TERMS AND ACRONYMS AAPD

American Academy of Pediatric Dentistry Anticipatory Guidance

Provision of age-appropriate information to parents to prepare them for significant developmental milestones. In regard to oral health, information would be provided on such topics as oral hygiene and dietary habits, injury prevention and nonnutritive habits, substance abuse, intraoral/perioral piercing, and speech/language development.

ART

Alternative Restorative Treatment (formerly known as Atraumatic Restorative Treatment). Approved by the American Academy of Pediatric Dentistry, ART is a method of treatment that involves removing decay with hand instruments and placing a restorative material, typically glass ionomer. This is typically only used in patients where traditional restorative treatments are not feasible (very young or uncooperative children or children with special health care needs).

CAMBRA Caries Management By Risk Assessment. A scientific approach to managing the caries disease process by measuring a patient’s risk based on pathological and protective factors, then providing a patient-specific treatment and prevention protocols based on the outcomes.

Caries

Pathological and transmissible disease process that leads to dental decay (cavities).

Caries Balance Developed by Dr. John Featherstone, the balance represents the equilibrium between pathological factors that contribute to caries progression and protective factors that aid in caries prevention. By striking a balance between these two factors, caries can ultimately be prevented.

CDAF California Dental Association Foundation. Joint-venture partner in the Oral Health Education and Training Project.

Dental Home According to the American Academy of Pediatric Dentistry: a source of comprehensive oral health care including acute care and preventive services. Both AAPD and the American Academy of Pediatrics recommend a dental home be established by a child’s first birthday.

Dental providers

Defined for this report as dentists, dental hygienists and dental assistants. The term professionals is also used in place of providers when describing this group.


DHF

Dental Health Foundation. Joint-venture partner in the Oral Health Education and Training Project.

Early Childhood Caries Formerly known as Baby Bottle Tooth Decay, refers to the presence of caries in a child under 71 months of age.

Fluoride Varnish

A resin containing concentrate fluoride that is brushed on teeth to aid in the prevention of caries.

Knee-to-Knee Exam (or Lap-to-Lap) Positioning the small child for an oral evaluation in which the caregiver and clinician sit facing each other with their knees touching and the child sits facing the caregiver on his/her lap then is lowered so the child’s head is resting on the clinician’s lap.

Mean

The most popular way of reporting the middle point of a set of data. The arithmetic “average” is derived by dividing a sum of numbers by their number.

MC Multiple Choice Medical providers

Defined for this report as physicians practicing in pediatrics, obstetrics/gynecology or family practice; pediatric nurse practitioners, and medical residents. The term professionals is also used in place of providers when describing this group.

N

Sample size. For example, the number of respondents in a dataset (N=300). Oral Sedation

As defined by the American Academy of Pediatric Dentistry: Conscious sedation is a management technique that uses medications to assist the child to cope with fear and anxiety and cooperate with dental treatment. Medications and dosages should be selected that are unlikely to cause loss of consciousness in the patient.

Parents/Caregivers Caregivers are other family members, such as grandparents, who may be raising a child. Risk Assessment

Determining the risk of caries during a certain time period through a series of questions and observations on oral hygiene, eating habits and other factors.


Sealants As defined by the American Dental Association: A sealant is a plastic material that is usually applied to the chewing surfaces of the back teeth—premolars and molars. This plastic resin bonds into the depressions and grooves (pits and fissures) of the chewing surfaces of back teeth. The sealant acts as a barrier, protecting enamel from plaque and acids.

Streptococcus Mutans Strain of bacteria that is the main cause of tooth decay.

T/F True/false Xylitol

A naturally occurring sugar that is not metabolized by the streptococcus mutans bacteria, which inhibit the bacteria from attaching to the tooth surface. Studies have shown that the use of Xylitol-containing products lower the bacterial load in the mouth and lessen the likelihood of transmission of the disease from caregiver to child.

Documents

First Smiles Final Evaluation Report