OBJECTIVES:To identify risk factors for dental fluorosis that cannot be explained by drinking water fluoride concentration alone.METHODS:Two hundred eighty-four Tanzanian children ages 9 to 19 (mean 14.0+/-SD 1.69), who were lifetime residents at differing altitudes (Chanika, 100 m; Rundugai, 840 m; and Kibosho, 1,463 m; Sites 1, 2, and 3 respectively) were examined for dental fluorosis and caries. They were interviewed about their food habits, environmental characteristics and use of a fluoride-containing food tenderizer known locally as magadi. Meal, urine, water and magadi samples supplied by the participants were analyzed for fluoride content. Urine samples were also analyzed for creatinine concentration. Four magadi samples from Sites 1 and 3 were analyzed for complete element composition.RESULTS:Of the 13 water samples from Site 2, 10 contained > or =4 mg/L F, ranging from 1.26 to 12.36 mg/L with a mean+/-SD of 5.72+/-4.71 mg/L. Sites 1 and 3 had negligible water fluoride of 0.05+/-0.05 and 0.18+/-0.32 mg/L respectively. Mean TFI fluorosis scores (range 0-9) for Site 2 were high: 4.44+/-1.68. In Sites 1 and 3, which both had negligible water fluoride, fluorosis scores varied dramatically: Site 1 mean maximum TFI was 0.01+/-0.07 and Site 3 TFI was 4.39+/-1.52. Mean DMFS was 1.39+/-2.45, 0.15+/-0.73 and 0.19+/-0.61 at Sites 1, 2, and 3, respectively. There were no restorations present. Urinary fluoride values were 0.52+/-0.70, 4.34+/-7.62, and 1.43+/-1.80 mg/L F at Sites 1, 2, and 3, respectively. Mean urinary fluoride values at Site 3 were within the normal urinary fluoride reference value range in spite of pervasive severe pitting fluorosis. Meal and magadi analyses revealed widely varied fluoride concentrations. Concentrations ranged from 0.01 to 22.04 mg/L F for meals and from 189 to 83211 mg/L F for magadi. Complete element analysis revealed the presence of aluminum, iron, magnesium, manganese, strontium and titanium in four magadi samples. There were much higher concentrations of these elements in samples from Site 3, which was at the highest altitude and had severe enamel disturbances in spite of negligible water fluoride concentration. An analysis of covariance model supported the research hypothesis that the three communities differed significantly in mean fluorosis scores (P<0.0001). Controlling for urinary fluoride concentration and urinary fluoride:urinary creatinine ratio, location appeared to significantly affect fluorosis severity. Urinary fluoride:urinary creatinine ratio had a stronger correlation than urinary fluoride concentration with mean TFI fluorosis scores (r=0.43 vs r= 0.25).CONCLUSIONS:The severity of enamel disturbances at Site 3 (1463 m) was not consistent with the low fluoride concentration in drinking water, and was more severe than would be expected from the subjects' normal urinary fluoride values. Location, fluoride in magadi, other elements found in magadi, and malnutrition are variables which may be contributing to the severity of dental enamel disturbances occurring in Site 3. Altitude was a variable which differentiated the locations.

Objectives. This evaluation of a state Medicaid dental program describes dental treatment received, relates treatment needed to treatment received, and describes enrollment and use over an 8-year period.Methods. Three databases were linked: (1) clinical records from a 1986/87 statewide epidemiological survey, providing data on treatment need; (2) Medicaid dental claims from 1984 through 1992, providing data on treatment received; and (3) Medicaid enrollment files from 1984 through 1992.Results. Half of Medicaid-enrolled children never used dental services. Among users of dental services, 45% and 25% of children needed restorations in primary and permanent teeth, respectively. In this group, 29% had all needs met, 28% had needs partially met, and 43% had no needs met. Forty-six percent of children sought care for only 1 year.Conclusions. Federal guidelines for dental care are not met in this typical Medicaid population of short-term enrollees who use services sporadically. Programs should aim to increase use and ensure that all needed services, especially preventive procedures such as sealants, can be completed within the short period of time a child attends for care.

OBJECTIVESThis study compared dental caries status and treatment need in four groups of children: those not enrolled in Medicaid, those enrolled in Medicaid who used dental services prior to a dental survey, those enrolled in Medicaid who used services after the survey, and those enrolled in Medicaid who did not use dental services.METHODSThis study used data on 6,620 children 5 to 18 years of age, who were representative of North Carolina schoolchildren and who participated in a statewide oral health survey in 1986-87. Clinical results from the survey were linked with a separate data base of Medicaid claims and enrollment files from 1984 to 1992. With this link, the surveyed children were classified into the four study groups and dental status compared.RESULTSMedicaid-enrolled children who used services prior to the survey had the highest caries prevalence of all groups (DMFS = 1.74 at ages 6 to 11 years), and had fewer treatment needs (D/DMFS = 19%) than children outside of Medicaid (DMFS = 0.95, D/DMFS = 33%). Enrolled children who never used dental services had a caries prevalence (DMFS = 0.83) similar to children outside of Medicaid, yet had greater unmet treatment need (D/DMFS = 62%).CONCLUSIONSCaries prevalence did not differ substantially among groups; however, the level of unmet treatment did very. Some Medicaid-enrolled children had a significant portion of their restorative treatment needs met.

This study investigated the association between caries status and sealant need at a prior survey and subsequent sealant use in a Medicaid program. Clinical data from a 1986-87 statewide epidemiological survey (N = 8026) representative of North Carolina (NC) schoolchildren (grades K-12) were linked with all NC Medicaid dental claims submitted during 1987-92, yielding 570 children in the survey who had at least one dental visit during 1987-1992. From the 570, 390 children were included: 71 who received sealants (S) and 319 who received non-sealant care (NS). Children were excluded based on age, having pre-existing sealants, or having no sealant-eligible molars or premolars. S and NS were compared on baseline dfs, DMFS, and sealant need, controlling for the patient's age, number of visits, and the provider's propensity to seal. At all ages, NS was twice as likely to have had prior dfs or DMFS (OR = 2.04, 95% CI = 1.15, 3.70). The association between sealant receipt and prior sealant need varied by age. At 6 to 11 years, S and NS had equal likelihood of sealant need (OR = 1.41, 95% CI = 0.62, 3.18). At 12 to 15 years, NS had a greater likelihood of sealant need (OR = 6.82, 95% CI = 1.60, 29.08). Caries-free status was associated with subsequent sealant receipt. Prior sealant need caused variability in dentists' decisions, depending on the child's age and past caries experience. Sealants were used infrequently by most providers and for a minority of patients. These findings are important for the Medicaid program and for future non-randomized studies of sealant effectiveness.