Global and Community Health Publications

Abstract Objectives At present, there are no published reports assessing pre-doctoral curricular experience or participatory involvement with Environmental Sustainability in Dentistry (ESD) in the United States. This study aims to assess whether students enrolled in US dental schools receive any training with ESD and gauge dental students’ level of interest and attitudes regarding ESD within their dental education. Methods A descriptive cross-sectional study utilizing a 16-questions validated survey was conducted on Qualtrics. Data analysis included descriptive statistics. Results A total of 378 dental students from 17 US dental schools participated (response rate 5%). Students reported that ESD was “quite” or “extremely” important (83%). However, 75% of students reported being “not at all” or “slightly” knowledgeable. Only 5% reported ESD content in their dental education. Students suggested that ESD could be integrated into existing coursework relating to infection control, practice management, and dental public health. Conclusion By understanding students’ level of interest, attitudes toward importance, and current level of curricular content on ESD, dental educators can develop best practices for educating future practitioners on environmental sustainability.

The aim of this study was to evaluate the feasibility and preliminary outcomes of immersive integrated experiential and didactic courses in strengthening competency-based global health learning in dental education. To address global inequities in oral health and student interest in global health, the Harvard School of Dental Medicine introduced two global health courses in 2017-18. The first was a didactic course in the core predoctoral curriculum, and the second, in collaboration with the Inter-American Center for Global Health, was a five-day elective experiential learning course in rural Costa Rica. The experiential course was an extension of the didactic course. All 33 second-year dental students completed the didactic course, and three of those students completed the experiential course. A pre-post survey and a six-month follow-up survey on self-reported knowledge based on course learning objectives were administered. The experiential course students also completed journals and interviews for qualitative analysis. Thirty-two students completed the pre-post didactic course surveys, for a response rate of 94%. There was a 100% response rate on the pre-post didactic surveys by those students who participated in the experiential learning course. While the experiential learning group scored similarly to the class average before the didactic course, they had higher scores than the class averages both immediately after and at the six-month follow-up. All three students reported that the experiential learning course was "extremely effective" in building on what they learned in the didactic course. Qualitative analysis of the journals and interviews suggested enhanced learning from the combination of didactic and experiential methods. These preliminary results support the Global Health Learning Helix Model, a theoretical competency-based teaching model for ethical student global health engagement to better prepare the future generation in tackling oral health disparities both locally and worldwide.

Dental education has seen increases in global health and international educational experiences in many dental schools' curricula. In response, the Consortium of Universities for Global Health's Global Oral Health Interest Group aims to develop readily available, open access resources for competency-based global oral health teaching and learning. The aim of this study was to develop and evaluate a Global Health Starter Kit (GHSK), an interdisciplinary, competency-based, open access curriculum for dental faculty members who wish to teach global oral health in their courses. Phase I (2012-17) evaluated longitudinal outcomes from two Harvard School of Dental Medicine pilot global health courses with 32 advanced and 34 predoctoral dental students. In Phase II (2018), the Phase I outcomes informed development, implementation, and evaluation of the open access GHSK (45 enrollees) written by an interdisciplinary, international team of 13 content experts and consisting of five modules: Global Trends, Global Goals, Back to Basics: Primary Care, Social Determinants and Risks, and Ethics and Sustainability. In Phase III (summer and fall 2018), five additional pilot institutions (two U.S. dental schools, one U.S. dental hygiene program, and two dental schools in low- and middle-income countries) participated in an early adoption of the GHSK curriculum. The increase in perceived knowledge scores of students enrolled in the pilot global health courses was similar to those enrolled in the GHSK, suggesting the kit educated students as well or better in nearly all categories than prior course materials. This study found the GHSK led to improvements in learning in the short term and may also contribute to long-term career planning and decision making by providing competency-based global health education.

Adequate nutrition is essential for maintaining good oral health. Minerals such as magnesium, calcium, and phosphorus found in the diet constitute the main structural components of the tooth. Their inadequacy leads to absorption impairment, increased bleeding tendency, bone resorption, looseness, and premature tooth loss. Inadequacy of those essential minerals is associated with delayed tooth eruption and with enamel or dentin hypoplasia. Taking calcium without magnesium results in soft dental enamel, which cannot resist the acids causing tooth decay. In addition to magnesium, calcium, and phosphorus, adequate vitamin D is needed to maintain optimal oral health. Vitamin D exerts anti-inflammatory effects and helps in calcium absorption and bone remodeling. Moreover, adequate vitamin D status could reduce formation of dental caries by delaying its onset and progression. Here we summarize the oral manifestations of vitamin D and magnesium inadequacy.

Definitions can generate actionable consensus for a given subject matter by resolving important differences in philosophy and best practices and by streamlining activities for a stronger strategic direction. Interest in the global dimensions of oral health, a generally neglected area of global health, is growing; yet, no previously published research has defined the term 'global oral health.' As such, the Global Oral Health Interest Group of the Consortium of Universities for Global Health determined a need for an introductory definition of 'global oral health' to guide program planning, implementation, and evaluation. With the oversight of an expert senior Task Force for the Definition of Global Oral Health, we employed a mixed-methods approach using the more common expert consensus-building Delphi technique combined with the lesser utilized Q methodology. This approach allowed us to identify the interconnectedness of global oral health themes and integrate multiple, seemingly disparate, topics into a single streamlined concept. Our resulting definition is as follows: . The purpose of this short communication is to generate a narrative around our proposed definition of global oral health to support establishing guidelines and developing best practices for academic global oral health programs, policies, and practices that aim to achieve a goal of oral health globally.

Background: Clinical trainees face challenges throughout short-term experiences in global health (STEGH) that are not routinely addressed. Objectives: Describe common professional and ethical dilemmas faced by clinical trainees and identify gaps and solutions for pre, during, and post-STEGH training and mentoring. Methods: We conducted a mixed-methods study among trainees and mentors involved in global health. The study utilized focus groups with trainees (November-December 2015) and online surveys of trainees, in-country and stateside faculty mentors (October 2016-April 2017). Results: 85% (17/20) of students reported feeling prepared for their STEGH; however, 59% (23/39) of faculty felt students were unprepared. A majority of both students (90%) and faculty (77%) stated students would likely experience an ethical dilemma during STEGH. Major themes relating to meaningful global health work were elucidated: personal and inter-professional skills; interpersonal networks and collaboration; and awareness of power dynamics and bias. Conclusions: The most common challenges faced by trainees during STEGH related to leadership, bias, ethics and interprofessional collaboration. Redirecting trainee energies from a focus on 'doing' and deliverables to attitudes (e.g., humility, professionalism) that cultivate personal and professional growth will help create lifelong global health learners and leaders.

To investigate factors associated with infrequent dental use among older adults receiving home- and community-based services. This cross-sectional study analyzed responses from the 2014 National Survey of Older Americans Act participants who received home- and community-based services. Descriptive and multivariable analyses were conducted to examine the association between infrequent dental use and key sociodemographic and health indicators. Infrequent dental use was highest among adults participating in case management and home-delivered meals (63%); the lowest among those participating in congregate meals (41%). Participants who did not complete high school were 2 to 5 times more likely to be infrequent dental users compared to those with educational attainment beyond high school. Among older adults receiving home- and community-based services, improving oral health knowledge and health literacy may reduce infrequent dental use.

Background: New education programs are developing to improve global health awareness. Dental students have demonstrated interest in international settings but are largely unaware of global health topics. The Timothy A. DeRouen Center for Global Oral Health of the University of Washington (UW) and Harvard School of Dental Medicine expanded a competency-based global health curriculum (Global Health Starter Kit) by integrating it within the UW School of Dentistry (UW SOD) existing elective course "Global Oral Health" to undergraduates, pre-, and doctorate students from the UW SOD and Public Health. The study objective was to evaluate the curriculum effectiveness by assessing 1) Knowledge and Attitudes (survey), and 2) Didactic coursework (global trends, global goals, primary care, social determinants and risks, and ethics and sustainability). Methods: Eligibility included enrolled students with both pre- and post-assessments. Descriptive statistics were conducted to present demographic data. Significant changes on survey and didactic evaluations were analyzed with paired t-tests (p < 0.05). Findings: The population (N = 15) represented 88% of the class. All Knowledge categories had a significant increase (p < 0.05), except in the topic of tropical diseases. At baseline, Attitudes categories had high scores and did not significantly increase by the end of the course. Even though all Didactic categories improved, only Social Determinants and Risks showed a significant increase (p < 0.01). Conclusion: Competency-based global health learning can be implemented in the dental curriculum. While the study shows promising results, efforts to identify areas for improvement as well as considerations of the institution's culture need to be assessed and addressed for each teaching cycle.

This study was conducted to determine the level of knowledge, attitude, and practice of oral health care providers toward the use of online medical databases for clinical decision-making processes. The study population included all the licensed oral health care providers living in Rwanda, registered either with the Rwanda Allied Health Professional Council (RAHPC) or Rwanda Medical and Dental Council (RMDC). A self-administered questionnaire was used to collect demographic data as well as data regarding knowledge, attitude, and practice of oral health care providers regarding the use of online medical databases for making clinical decisions. A pilot study with 12 oral health care providers was done before the main study to pretest the questionnaire. The study results show that among the 201 respondents, 80% (N=160) reported using internet-based resources to support their clinical decisions, while 20% (N=41) of oral health care providers do not use online resources when making their clinical decisions. In general, there was a positive attitude towards internet-based resources among the participants, as 92% (N=184) respondents believe that internet-based resources are helpful in clinical decision-making processes. Of clinical importance, 68% respondents (N=136) believe that by using current internet-based information, better clinical care can be offered to their patients. Educating oral health care providers on the useful and appropriate online resources available for supporting clinical decision-making processes might increase the efficiency of patient care.

BACKGROUND: The Rwanda Human Resources for Health Program (HRH Program) is a 7-year (2012-2019) health professional training initiative led by the Government of Rwanda with the goals of training a large, diverse, and competent health workforce and strengthening the capacity of academic institutions in Rwanda. METHODS: The data for this organizational case study was collected through official reports from the Rwanda Ministry of Health (MoH) and 22 participating US academic institutions, databases from the MoH and the College of Medicine and Health Sciences (CMHS) in Rwanda, and surveys completed by the co-authors. RESULTS: In the first 5 years of the HRH Program, a consortium of US academic institutions has deployed an average of 99 visiting faculty per year to support 22 training programs, which are on track to graduate almost 4600 students by 2019. The HRH Program has also built capacity within the CMHS by promoting the recruitment of Rwandan faculty and the establishment of additional partnerships and collaborations with the US academic institutions. CONCLUSION: The milestones achieved by the HRH Program have been substantial although some challenges persist. These challenges include adequately supporting the visiting faculty; pairing them with Rwandan faculty (twinning); ensuring strong communication and coordination among stakeholders; addressing mismatches in priorities between donors and implementers; the execution of a sustainability strategy; and the decision by one of the donors not to renew funding beyond March 2017. Over the next 2 academic years, it is critical for the sustainability of the 22 training programs supported by the HRH Program that the health-related Schools at the CMHS significantly scale up recruitment of new Rwandan faculty. The HRH Program can serve as a model for other training initiatives implemented in countries affected by a severe shortage of health professionals.

BACKGROUND: Oral health affects quality of life and is linked to overall health. Enhanced oral health research is needed in low- and middle-income countries to develop strategies that reduce the burden of oral disease, improve oral health and inform oral health workforce and infrastructure development decisions. OBJECTIVE: To implement the first National Oral Health Survey of Rwanda to assess the oral disease burden and inform oral health promotion strategies. METHODS: In this cross-sectional study, sample size and site selection were based on the World Health Organization (WHO) Oral Health Surveys Pathfinder stratified cluster methodologies. Randomly selected 15 sites included 2 in the capital city, 2 other urban centers and 11 rural locations representing all provinces and rural/urban population distribution. A minimum of 125 individuals from each of 5 age groups were included at each site. A Computer Assisted Personal Instrument (CAPI) was developed to administer the study instrument. RESULTS: Nearly two-thirds (64.9%) of the 2097 participants had caries experience and 54.3% had untreated caries. Among adults 20 years of age and older, 32.4% had substantial oral debris and 60.0% had calculus. A majority (70.6%) had never visited an oral health provider. Quality-of-life challenges due to oral diseases/conditions including pain, difficulty chewing, self-consciousness, and difficulty participating in usual activities was reported at 63.9%, 42.2% 36.2%, 35.4% respectively. CONCLUSION: The first National Oral Health Survey of Rwanda was a collaboration of the Ministry of Health of Rwanda, the University of Rwanda Schools of Dentistry and Public Health, the Rwanda Dental Surgeons and Dental (Therapists) Associations, and Tufts University and Harvard University Schools of Dental Medicine. The international effort contributed to building oral health research capacity and resulted in a national oral health database of oral disease burden. This information is essential for developing oral disease prevention and management strategies as well as oral health workforce and infrastructure.

Studies have shown a relationship between maternal periodontal diseases (PDs) and premature delivery. PDs are commonly encountered oral diseases which cause progressive damage to the periodontal ligament and alveolar bones, leading to loss of teeth and oral disabilities. PDs also adversely affect general health by worsening of cardiovascular and metabolic diseases. Moreover, maternal PDs are thought to be related to increasing the frequency of preterm-birth with low birth weight (PBLBW) in new-borns. Prematurity and immaturity are the leading causes of prenatal and infant mortality and is a major public health problem around the world. Inflamed periodontal tissues generate significantly high levels of proinflammatory cytokines that may have systemic effects on the host mother and the fetus. In addition, the bacteria that cause PDs produce endotoxins which can harm the fetus. Furthermore, studies have shown that microorganisms causing PDs can get access to the bloodstream, invading uterine tissues, to induce PBLBW. Another likely mechanism that connects PDs with adverse pregnancy outcome is maternal vitamin D status. A role of inadequate vitamin D status in the genesis of PDs has been reported. Administration of vitamin D supplementation during pregnancy could reduce the risk of maternal infections and adverse pregnancy outcomes. As maternal PDs are significant risk factors for adverse pregnancy outcome, preventive antenatal care for pregnant women in collaboration with the obstetric and dental professions are required.

Nutrients usually act in a coordinated manner in the body. Intestinal absorption and subsequent metabolism of a particular nutrient, to a certain extent, is dependent on the availability of other nutrients. Magnesium and vitamin D are 2 essential nutrients that are necessary for the physiologic functions of various organs. Magnesium assists in the activation of vitamin D, which helps regulate calcium and phosphate homeostasis to influence the growth and maintenance of bones. All of the enzymes that metabolize vitamin D seem to require magnesium, which acts as a cofactor in the enzymatic reactions in the liver and kidneys. Deficiency in either of these nutrients is reported to be associated with various disorders, such as skeletal deformities, cardiovascular diseases, and metabolic syndrome. It is therefore essential to ensure that the recommended amount of magnesium is consumed to obtain the optimal benefits of vitamin D.

In this article, we briefly summarized evidence that cellular phosphate burden from phosphate toxicity is a pathophysiological determinant of cancer cell growth. Tumor cells express more phosphate cotransporters and store more inorganic phosphate than normal cells, and dysregulated phosphate homeostasis is associated with the genesis of various human tumors. High dietary phosphate consumption causes the growth of lung and skin tumors in experimental animal models. Additional studies show that excessive phosphate burden induces growth-promoting cell signaling, stimulates neovascularization, and is associated with chromosome instability and metastasis. Studies have also shown phosphate is a mitogenic factor that affects various tumor cell growth. Among epidemiological evidence linking phosphate and tumor formation, the Health Professionals Follow-Up Study found that high dietary phosphate levels were independently associated with lethal and high-grade prostate cancer. Further research is needed to determine how excessive dietary phosphate consumption influences initiation and promotion of tumorigenesis, and to elucidate prognostic benefits of reducing phosphate burden to decrease tumor cell growth and delay metastatic progression. The results of such studies could provide the basis for therapeutic modulation of phosphate metabolism for improved patient outcome.

Harvard School of Dental Medicine, University of Maryland School of Dentistry, and the University of Rwanda (UR) are collaborating to create Rwanda's first School of Dentistry as part of the Human Resources for Health (HRH) Rwanda initiative that aims to strengthen the health care system of Rwanda. The HRH oral health team developed three management tools to measure progress in systems-strengthening efforts: 1) the road map is an operations plan for the entire dental school and facilitates delivery of the curriculum and management of human and material resources; 2) each HRH U.S. faculty member develops a work plan with targeted deliverables for his or her rotation, which is facilitated with biweekly flash reports that measure progress and keep the faculty member focused on his or her specific deliverables; and 3) the redesigned HRH twinning model, changed from twinning of an HRH faculty member with a single Rwandan faculty member to twinning with multiple Rwandan faculty members based on shared academic interests and goals, has improved efficiency, heightened engagement of the UR dental faculty, and increased the impact of HRH U.S. faculty members. These new tools enable the team to measure its progress toward the collaborative's goals and understand the successes and challenges in moving toward the planned targets. The tools have been valuable instruments in fostering discussion around priorities and deployment of resources as well as in developing strong relationships, enabling two-way exchange of knowledge, and promoting sustainability.

People who are incarcerated or have a history of incarceration have high rates of dental disease, but access to dental treatment is often a challenge during and after incarceration. Dental students' exposure to this population is unknown: no data exist regarding the number of schools that provide didactic and clinical training in correctional dentistry. The aim of this study was to assess the extent of instruction in correctional dentistry and clinical opportunities at correctional facilities for dental students in the U.S. A survey was distributed to the academic deans at all 66 U.S. dental schools in 2017. Respondents were asked if their institutions had curricular content on correctional health and if they provided clinical opportunities in the correctional setting. Respondents from 30 schools completed the survey, for a response rate of 45%. Nearly two-thirds of the respondents said their institutions offered didactic instruction on the impact of incarceration on health, and eight schools offered a clinical experience at a correctional facility. The most common format was a community-based dental externship involving fourth-year dental students. Oral exams, prophylaxis, and extractions were the most common procedures performed. Respondents from schools that offered a clinical experience agreed more strongly than those that did not that exposure to correctional health care was important and that their students believed incarceration to be a social determinant of health. This study found that a substantial proportion of dental schools offered didactic education on correctional health, but a much smaller number offered student rotations in correctional facilities.

Normal humans of all ages have the innate ability to produce vitamin D following sunlight exposure. Inadequate vitamin D status has shown to be associated with a wide variety of diseases, including oral health disorders. Insufficient sunlight exposure may accelerate some of these diseases, possibly due to impaired vitamin D synthesis. The beneficial effects of vitamin D on oral health are not only limited to the direct effects on the tooth mineralization, but are also exerted through the anti-inflammatory functions and the ability to stimulate the production of anti-microbial peptides. In this article, we will briefly discuss the genesis of various oral diseases due to inadequate vitamin D level in the body and elucidate the potential benefits of safe sunlight exposure for the maintenance of oral and general health.

Phosphate is a common ingredient in many healthy foods but, it is also present in foods containing additives and preservatives. When found in foods, phosphate is absorbed in the intestines and filtered from the blood by the kidneys. Generally, any excess is excreted in the urine. In renal pathologies, however, such as chronic kidney disease, a reduced renal ability to excrete phosphate can result in excess accumulation in the body. This accumulation can be a catalyst for widespread damage to the cellular components, bones, and cardiovascular structures. This in turn can reduce mortality. Because of an incomplete understanding of the mechanism for phosphate homeostasis, and the multiple organ systems that can modulate it, treatment strategies designed to minimize phosphate burden are limited. The Recommended Dietary Allowance (RDA) for phosphorous is around 700 mg/day for adults, but the majority of healthy adult individuals consume far more phosphate (almost double) than the RDA. Studies suggest that low-income populations are particularly at risk for dietary phosphate overload because of the higher amounts of phosphate found in inexpensive, processed foods. Education in nutrition, as well as access to inexpensive healthy food options may reduce risks for excess consumption as well as a wide-range of disorders, ranging from cardiovascular diseases to kidney diseases to tumor formation. Pre-clinical and clinical studies suggest that dietary phosphate overload has toxic and prolonged adverse health effects. Improved regulations for reporting of phosphate concentrations on food labels are necessary so that people can make more informed choices about their diets and phosphate consumption. This is especially the case given the lack of treatments available to mitigate the short and long-term effects of dietary phosphate overload-related toxicity. Phosphate toxicity is quickly becoming a global health concern. Without measures in place to reduce dietary phosphate intake, the conditions associated with phosphate toxicity will likely to cause untold damage to the wellbeing of individuals around the world.

Vulnerable populations are more likely to access medical care than visit a dentist. We introduced a dental team into a student-faculty collaborative clinic that serves a low-income Latino population. Documentation of oral exam findings rose from 11.88% to 50.50% in the year following integration of dental students into the clinic.

BACKGROUND: The authors conducted a systematic review of the literature to assess the impact of dental treatment on overall health care costs for patients with chronic health conditions and patients who were pregnant. TYPES OF STUDIES REVIEWED: The authors searched multiple databases including MEDLINE, Embase, Web of Science, and Dentistry & Oral Sciences Source from the earliest date available through May 2017. Two reviewers conducted the initial screening of all retrieved titles and abstracts, read the full text of the eligible studies, and conducted data extraction and quality assessment of included studies. RESULTS: The authors found only 3 published studies that examined the effect of periodontal treatment on health care costs using medical and dental claims data from different insurance databases. Findings from the qualitative synthesis of those studies were inconclusive as 1 of the 3 studies showed a cost increase, whereas 2 studies showed a decrease. CONCLUSIONS AND PRACTICAL IMPLICATIONS: The small number of studies and their mixed outcomes demonstrate the need for high-quality studies to evaluate the effect of periodontal intervention on overall health care costs.

Globalization, along with the increasing prevalence of non-communicable diseases, their risk factors, and poor oral health, demands global approaches to oral health care. Trained health care workers' providing volunteer services abroad is one model used for improving access to dental services for some communities. Currently, little is known about U.S. dental student involvement in international clinical service volunteerism. The aim of this exploratory study was to capture national survey data from predoctoral dental students about their interest in and experience with global health service trips. The survey sought to assess students' past experiences and current and future interest in programs providing dental and/or medical services in order to lay the foundation for further research. A 12-question web-based survey was distributed in May 2017 to 22,930 students enrolled in U.S. dental schools. A total of 1,555 students responded, for a response rate of 7%. Respondents were evenly distributed across the four academic years. Approximately 22% (n=342) of the respondents had already participated in a service trip experience, 83% reported interest in a service trip while in school, and 92% were interested after graduation. Reported motivations for international trips included the desire to care for the underserved and to obtain a more global view of health and disease. Concerns were expressed regarding costs and time constraints. This study provided preliminary, exploratory data on dental student engagement with international service trips. Both interest and participation in international service trips among responding students were high, reflecting current trends in both dentistry and medicine. Dental education may have an opportunity to guide student engagement in more sustainable and ethical volunteering in the U.S. and abroad.

OBJECTIVES: Research demonstrates the safety and efficacy of community water fluoridation (CWF). Yet, the digitization of communication has triggered the spread of inaccurate information online. The purpose of this study was to analyze patterns of CWF information dissemination by a network of sources on the web. METHODS: We used Media Cloud, a searchable big data platform of over 550 million stories from 50 thousand sources, along with tools to analyze that archive. We generated a network of fluoridation publishers using Media Cloud's keyword identification from August 1, 2015 to July 31, 2016. We defined the media type and sentiment toward CWF for each source and generated a network map of the most influential sources during our study period based on hyperlinking activity. RESULTS: Media Cloud detected a total of 980 stories from 325 different sources related to water fluoridation. We identified nine different media types participating in the dissemination of information: academic, government, scientific group, natural medicine, blogs, mainstream media, advocacy groups, user-generated (e.g., YouTube), and "other." We detected five sub-networks within the overall fluoridation network map, each with its own characteristics. Twenty-one percent of sources were pro-fluoridation, receiving 57 percent of all inlinks, 22 percent of sources were anti-fluoridation, and the rest were neutral (54 percent). CONCLUSIONS: The dominant neutral sentiment of the network may signify that anti- and pro-sides of the debate are viewed as balanced, not just in number but also in quality of information. Despite high inlinks to pro-sources, anti-fluoridation sentiment maintains influence online.

Community-based dental education (CBDE) allows dental students to be immersed in community settings and provide care to populations that are underserved. Exposure to those groups during training may impact provider attitudes, which may be strengthened by supporting students' reflection and exploration of their own attitudes. The aim of this study was to describe the implementation and preliminary results of a pilot longitudinal reflection curriculum integrated into a community-based clinical experience (CBCE) for senior dental students at one U.S. dental school and to report the impact of the reflection curriculum and CBCE on student experiences with populations that are underserved. In academic year 2015-16, all 35 senior dental students at one U.S. dental school were invited to complete an 11-item survey before and after completing a 12-week CBCE with integrated, longitudinal online reflections. Students received feedback from a faculty member after each reflection. All 35 students completed the survey, for a 100% response rate. After the CBCE, the students reported improved clinical efficiency and increased confidence in treatment planning and in treating dental emergencies and dentally anxious patients. They also reported improved understanding of the structure and relevance of community health centers, the role of different health care team members, and the impact of health policy. There was no significant difference in future plans to work with groups that are underserved. These results suggest that the CBCE and reflection curriculum had a positive impact on the students' clinical confidence as well as expanding their understanding of the broader oral health care delivery system. To address persistent oral health disparities, dental schools should continue to adopt CBDE programming that will prepare providers to effectively care for populations that are underserved.

AIMS: This article analyzes the digital childhood vaccination information network for vaccine-hesitant parents. The goal of this study was to explore the structure and influence of vaccine-hesitant content online by generating a database and network analysis of vaccine-relevant content. METHOD: We used Media Cloud, a searchable big-data platform of over 550 million stories from 50,000 media sources, for quantitative and qualitative study of an online media sample based on keyword selection. We generated a hyperlink network map and measured indegree centrality of the sources and vaccine sentiment for a random sample of 450 stories. RESULTS: 28,122 publications from 4,817 sources met inclusion criteria. Clustered communities formed based on shared hyperlinks; communities tended to link within, not among, each other. The plurality of information was provaccine (46.44%, 95% confidence interval [39.86%, 53.20%]). The most influential sources were in the health community (National Institutes of Health, Centers for Disease Control and Prevention) or mainstream media ( New York Times); some user-generated sources also had strong influence and were provaccine (Wikipedia). The vaccine-hesitant community rarely interacted with provaccine content and simultaneously used primary provaccine content within vaccine-hesitant narratives. CONCLUSION: The sentiment of the overall conversation was consistent with scientific evidence. These findings demonstrate an online environment where scientific evidence online drives vaccine information outside of the vaccine-hesitant community but is also prominently used and misused within the robust vaccine-hesitant community. Future communication efforts should take current context into account; more information may not prevent vaccine hesitancy.

PURPOSE: Physician assistants (PA) are health care team members who often work in primary care. Providing oral health education to PAs during training could improve oral health for vulnerable patients who seek treatment in the primary care setting and who are less able to access dental care. The purpose of this study was to assess the effectiveness of a peer-to-peer oral health curriculum taught by dental students to their PA student colleagues. METHODS: Dental students presented an interactive, case-based curriculum, followed by a hands-on oral examination training session. PA student feedback was obtained, and results were analyzed. RESULTS: Students found the content to be highly relevant and well presented. Conveying oral health competencies to future primary care providers may reduce oral health disparities. CONCLUSIONS: PA students reported improved understanding of oral health and indicated they would incorporate what they had learned into their future clinical practice.

We have integrated preventive oral health measures into preventive care visits for children at a federally qualified health center in Boston, Massachusetts. The program, started in 2015, covers 3400 children and has increased universal caries risk screening in primary care to 85%, fluoride varnish application rates to 80%, and referrals to a dental home to 35%. We accomplished this by minimizing pressures on providers' workflow, empowering medical assistants to lead the initiative, and utilizing data-driven improvement strategies, alongside colocated coordinated care.