DEVELOPMENT OF A DENTAL ACCESS SURVEY INSTRUMENT FOR CHILDREN WITH AUTISM SPECTRUM DISORDERSBy Roy H. Rogers, B.A., B.S., D.D.S.A thesis submitted in partial fulfillment of the requirements for the degree of Master of Science at Virginia Commonwealth University.Virginia Commonwealth University, June 2003Thesis Director: Frank H. Farrington, D.D.S., M.S.Department of Pediatric DentistryPurpose: The purpose of this study was to develop a survey instrument or questionnaire to evaluate access to dental care for children with autism spectrum disorders.Methods: The research methods of this study were conducted in a 16-step process. Survey questions were evaluated based on analysis of response frequencies and item non-response (missing data), the content of open-ended responses on the questionnaire, the researcher's judgment regarding how well the question worked within the questionnaire design construct, redundancy across questions, and whether or not the question met the project's proposed analytical goal (purpose): to evaluate access to dental care for children with autism spectrum disorders. Judgment-based evaluation of each question was tabulated using Excel spreadsheet format.Results: The overall response rate for the pilot test mailing was 46.8% (22/47). The overall sample size was reduced from n=50 to n=47 due to one undeliverable survey instrument/questionnaire and two survey instrument/questionnaires returned because neither respondent had any children with autism spectrum disorders. The mean age of children sampled was 7.1 years with a standard deviation of 3.6 years. 68.2% (15/22) of the children were male and 31. 8% (7/22) were female. 22.7% (5/22) found it difficult to locate a dentist to treat their child. 54.5% (12/22) of children were treated by a pediatric dentist. 52.9% (9/17) required the use of restraints when being treated by a dentist. 52.4% (11/22) described their child's behavior as uncooperative requiring either nitrous oxide, oral sedatives, or general anesthesia in order to be treated. 81.8% (18/22) of respondents indicated that their child had some form of dental/medical health care coverage including but not limited to private health insurance. Survey questions 9, 10, 14, 15, 20, 25, and 51 were revised, questions 2, 4, 5, 28, and 38 were omitted, and one question was added (question number 4) in the final survey instrument.

Purpose: The purpose of this study is to assess the impact of preventive dental services (screening, oral health education, and fluoride varnish) given by pediatric medical providers with an assessment of caregivers interviewed at baseline and at 6-months follow-up.Methods: Using a prospective cohort study design, an oral health knowledge and socio-demographic questionnaire was delivered to a cross-section of caregivers of preschool-aged children seen at VCU Children's Pavilion. Baseline data was used to conduct a cross-sectional analysis of caregivers prior to their children receiving preventive dental services (screening, oral health education, and fluoride varnish). Subsequently, six months into the program, caregivers of children receiving preventive dental services were retested on their oral health knowledge. The 23-item questionnaire included knowledge, behavior and opinion items on risk factors for dental diseases, care of child's teeth, and socio-demographic characteristics of the family. Data collection occurred in the clinic waiting rooms and the examination rooms. Results: A sample of 120 caregivers completed the baseline questionnaire. Caregivers at baseline reported 89% of the children have never been to a dentist. Sixty-four percent of caregivers have never been told by a doctor or nurse when their child should go to the dentist. After receiving preventive dental care in a primary care setting, there was a significant increase in the use of fluoridated toothpaste and less trouble brushing the child's teeth. Caregivers reported a significant increase in information given to them by medical residents about how to brush the child's teeth.Conclusion: The delivery of preventive dental services in a primary care setting is effective in improving certain aspects of caregiver oral health knowledge, though persistence is needed to further caregiver education in an effort to improve the oral health of children.

The purpose of this study was to assess the baseline oral health quality of life of high-risk children and examine differences in oral health quality of life according to the child's treatment needs at an oral screening exam. We hypothesized that a child's oral health related Quality of Life (QOL) would be correlated with dental treatment needs. This study was a cross-sectional design with subjects who were 8-14 year old patients of Virginia Commonwealth University and/or members of the Boys and Girls Club of Metro Richmond. The oral health quality of life was measured using the Child Perception Questionnaire (CPQ). It is a multidimensional scale that includes items concerning functional aspects including oral pain and discomfort, but also includes psychological and social aspects. The four domains tested are: oral symptoms, functional limitations, emotional well-being and social well-being. The children were asked to report on these domains as they related to their oral health in the past 3 months. The dental treatment needs of the children were categorized as (0) no future needs, or (1) restorative or orthodontic needs. Those with no future needs were scheduled for a 6 months periodic exam and prophylaxis (cleaning). The children in need of restorative treatment were scheduled for such (restorations, stainless steel crowns, extractions), and those in need of orthodontics were referred for consult to an orthodontist. The final sample population consisted of 107 children, predominately African American (84%). The intra-oral screenings revealed 75% of children required future dental treatment, specifically 84% restorative and 12% orthodontic work and 25% in need of preventative recall (cleaning and exam at 6 months). Overall, children reported high levels of oral health quality of life. When asked about the overall health of their teeth, lips, jaws and mouth, 39 % (n=42) reported excellent or very good, 50% (n=53) reported good, and 9% (n=10) reported fair or poor. When asked how "overall life" was affected by oral health, 72% (n=77) reported very little or not at all, 13% (n=14) reported some, and 15% (n=16) reported a lot or very much. There were no significant correlations between the oral health quality of life domains and the children's dental treatment needs.

Purpose: To determine whether Bispectral Index Monitoring is an effective tool for quantifying sedation depth after the administration of oral drug regimens in children.Methods: This retrospective study reviewed the charts of 75 children who received oral conscious sedation for dental treatment. Data collected from the chart included; 1) BIS values at 5 minute intervals and at five critical events: pre-operative, local anesthesia delivery, rubber dam placement (if utilized), during operative treatment, and postoperatively, 2) behavior ratings at the five critical events and an overall behavior assessment, 3) treatment data, and 4) demographic data. Results: The mean BIS value for orally sedation children in this study was 84.53 (SD = 5.76). The mean overall sedation assessment was 2.04 (SD = 1.16). No significant correlation was found between BIS values and behavioral ratings.Conclusion: The BIS monitor provided limited information regarding the depth of sedation in children undergoing oral sedation for dental treatment.

Purpose: The purpose of this study was to determine the knowledge and treatment protocols for physicians in Virginia emergency departments in regards to the emergent treatment of avulsed teeth.Methods: Using a cross sectional survey design, an 8-item questionnaire regarding the treatment of avulsed teeth was emailed to 75 emergency department chairpersons in Virginia. After 30 days, a reminder paper copy of the questionnaire was mailed and an email reminder with the on-line link was sent. After 60 days the study was closed. Comparisons were made using chi-square analysis based on percentages to test for significance. Results: The response rate was 52 % (n = 39). There were no associations between physician knowledge of the treatment of avulsed teeth and whether there was a protocol for treatment, an in-house dental team, or an on-call dentist available. Conclusion: Most of the physicians have some knowledge of the treatment of avulsed teeth; however further training would help ensure appropriate treatment.

Purpose: To determine which maintenance gas (sevoflurane versus desflurane) resulted in a faster emergence from general anesthesia and investigate the patient's emergence agitation. Methods: One group was maintained during general anesthesia with sevoflurane and the other with desflurane. Upon emergence the patient's behavior was evaluated.Results: The average emergence time for desflurane was 9.8; while the average for sevoflurane was 13.98 minutes. Patients who received premedication had an emergence time of 15.43 minutes, while patients who received no premedication emerged after 8.34 minutes.Zofran® was a significant predictor of purposeful actions. Patients were more aware of their surroundings when they received Zofran® compared to patients who did not receive Zofran®.Conclusion: Maintaining with desflurane and not premedicating patients allowed for a faster emergence from general anesthesia. Patients given Zofran® in their IV during the surgery had less emergence agitation then their counterparts.

Purpose: The purpose of this study was to correlate the presence of Streptococcus mutans and Streptococcus sobrinus with the incidence of dental caries in children as detected by the polymerase chain reaction (PCR).Methods: Subjects between the ages 2 to 16 years of age were used in this study. After the subjects received a dental examination, dental plaque samples were collected by rubbing a toothpick on the buccal surface of the most posterior tooth in each quadrant of the mouth. Children were grouped into low, moderate, and high caries risk categories by two different Caries Risk Assessment Tools (CAT 1 and CAT 2). PCR was used to amplify the dextranase (Dex) gene of S. mutans and S. sobrinus. Dextranase is an enzyme that hydrolyses glucans in a plaque matrix and is believed to be involved in the pathogenesis of dental caries. Identification of the amplified Dex gene sequences was made by gel electrophoresis which in turn was used to determine the presence of S. mutans and S. sobrinus.Results: S. mutans was detected in 57% of patients (65/115), S. sobrinus was detected in 10% of patients (12/115) and both organisms were present in 9% of patients (10/115). According to CAT 1, the incidence of S. mutans was 64.6%, 9.2%, and 26.2% in low, moderate, and high caries risk, respectively. The incidence of S. sobrinus was 66.6%, 16.7%, and 16.7% in low, moderate, and high caries risk, respectively. Conclusion: Presence of S. mutans and/or S. sobrinus as evaluated in this study had no direct correlation with caries risk level in children.

The purpose of this study was to examine the use of dental services for young children following a preventive oral health intervention in a pediatric medical clinic. Over a 3 year period (2005-2008), children 0-36 months of age, enrolled in Medicaid, were provided preventive oral health services in a medical setting. Descriptive statistics and multivariate logistic regression were used to determine the effect receiving the preventive oral health services in a medical setting with the outcomes of dental utilization. 15% were determined to have dental caries at the intervention and 42% found to have a dental visit post-intervention. Children determined to have decay at the intervention were significantly more likely to have one or more restorative or adjunctive service post-intervention. After receiving preventive oral health care in a medical clinic, the resulting utilization of dental services was higher than what is commonly reported for dental utilization in infant populations of low-income children.

Purpose: The purpose of this study is to determine the impact that the introduction of articaine has had on local anesthetic selection by general and pediatric dentists for use in three different age groups of children.Methods: Using a cross sectional survey design, a questionnaire regarding the use of local anesthetics in children was mailed to a random sample of 500 general dentists from North Carolina, 500 general dentists from Virginia, and all 230 pediatric dentists from North Carolina and Virginia. The 16-item questionnaire included questions regarding the preferred local anesthetic to use in three different age groups, 2-3 years of age, 4-6 years of age, and 7-10 years of age. Furthermore, the questionnaire also included questions specifically on articaine use in the three different age groups and any related side effects. The association between dental practitioner type and anesthetic use was tested using chi-square or Fisher's exact test.Results: A sample of 337 dentists completed the questionnaire. There was no significant difference in preference of articaine except in older patients aged 7-10 years old where general dentists prefer articaine significantly more than do pediatric dentists (28.1% versus 15.9%). Lidocaine with epinephrine was the local anesthetic that was most preferred in all age groups by all practitioners. Pediatric dentists preferred lidocaine more often than general dentists and general dentists preferred lidocaine without epinephrine more often than pediatric dentists. Twenty-one percent of all dentists surveyed have used articaine in children under 4 years of age and 13% list articaine as the preferred local anesthetic for children under 4 years of age.Conclusion: While lidocaine with epinephrine is still the preferred local anesthetic for use in children, the use of articaine in children is very prevalent among general and pediatric dentists. Articaine use becomes more prevalent as the age of the patient increases and many pediatric and general dentists are using articaine in children under four years of age.

Objective: The purpose of the study was to determine if a co-payment resulted in a differential preference for general anesthesia (GA) or oral sedation (OS) and, if so, to examine whether age, the number of appointments, perceived risks of treatment, child's awareness during treatment, or insurance type appeared to play a role in this preference.Methods: Using a cross-sectional survey design, questionnaires were distributed to caregivers of patients in the waiting room of the Virginia Commonwealth University Pediatric Dental Clinic. Two different questionnaires were distributed randomly. Both surveys described a scenario with the need for dental treatment under general anesthesia (GA) or oral conscious sedation (OS). Seventy five surveys required a $50 co-payment for treatment completed under general anesthesia and the other 75 required the same co-payment for treatment completed under oral conscious sedation. Caregivers were asked to choose treatment modalities as well as to rate factors in their decision making including perceived risks and the number of dental visits. Results: Seventy seven survey respondents selected GA as their preferred treatment option for the described scenario. The other sixty six respondents chose OS sedation. For the insured population, the GA/OS odds ratio for the OS-co-payment group versus the GA-co-payment group was OR=2.21 (95% CI = 1.06, 4.60). In terms of the uninsured, the GA/OS odds ratio for the OS-co-payment group versus the GA-co-payment group was OR=17.5 (95% CI = 1.60, 191). The child's age, awareness during treatment, and type of insurance (public versus private) were not significantly related to treatment choice. The importance of the number of appointments was found to be significant (p-value = 0.0170) and outweighed the effect of the co-payment (p-value = 0.1757). The importance of associated risks was found to be significant (p-value = 0.0171) and this outweighed the effect of the co-payment (p-value = 0.8157).Conclusions: The presence of a co-payment does not as significantly impact the GA versus OS preference while the number of appointments and perceived risks associated with the treatment remain significant.