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Health care transition from adolescence into adulthood is a complex process that often lacks care coordination, planning, and collaboration among the parties involved. Dental transition is significantly more challenging for adolescents with special health care needs. Shortage of qualified general dentists willing to treat these individuals and low dental reimbursement by public insurance programs are significant barriers to successful transition. Adequate training to increase dental workforce, insurance benefits, protocol development, and research are needed to ensure successful transition for this population. Meanwhile, it is important to target individuals less likely to access adequate oral health care and achieve satisfactory transition.

Dental fluorosis occurs from overingestion of fluoride during tooth formation. However, there is little evidence in the literature on whether or how fluorosis prevalence and severity change over time after tooth eruption. Permanent dentition dental examinations were conducted at ages 9, 13, 17, and 23 as part of the Iowa Fluoride Study, which has followed a cohort from birth. Fluorosis was assessed using the Fluorosis Risk Index (FRI) and Russell’s criteria for differential diagnosis. Measures of fluorosis severity at the person and tooth level were calculated: second highest FRI score at the person level (the maximum FRI score for each tooth was determined and the tooth with the second highest maximum FRI score was used) and highest FRI score at the tooth level. At both the person and tooth levels, a decline in mild to moderate fluorosis severity was observed across adolescence and young adulthood. Across each pair of adjacent examinations at the person level, for participants with a baseline second highest FRI of 0, most participants stayed at 0 (82% to 91%). Many participants with a baseline second highest FRI of 1 had a follow-up score of 0 (47% to 54%), while about a third had a follow-up score of 1 (34% to 38%), and a lower percentage had an increase to a score of 2 (9% to 15%). For participants with baseline second highest FRI score of 2, between 25% and 44% of participants had follow-up FRI scores each of 0, 1, and 2. Similar patterns were observed at the tooth level. These results were consistent with most of the existing, limited literature. Overall, fluorosis severity, which was initially mild to moderate, tended to decline during adolescence and young adulthood. Additional study of how this trend affects esthetic perceptions of fluorosis is warranted.

Aim The functional and structural complexities accompanying syndromic craniosynostosis make dental care for these patients particularly challenging. We report a case of long-term care for a syndromic craniosynostosis patient. The objective of this report is to introduce special care guidance and clinical recommendation, so that oral health care providers, as key members of a multidisciplinary care team, can provide optimal diagnosis, treatment, and management for the patient with syndromic craniosynostosis. Case report The patient of this case report had a medical history of syndromic craniosynostosis involving multiple comorbidities. Over the past 20 years, a multidisciplinary care team has successfully treated the patient. Dental and medical procedures that the patient has received include cranial surgeries, prophylactic dental care, caries control, growth hormone therapy, comprehensive orthodontic treatment in conjunction with orthognathic surgeries, and plastic surgery. Conclusion Oral health care providers can play essential roles in multidisciplinary care for patients with craniosynostosis by understanding the patients' unique oral health conditions and dentofacial deformities. To provide optimal oral health care in a multidisciplinary team, clear communication between the members of the care team is crucial.

Purpose: To investigate the association between premature birth and Early Childhood Caries (ECC) experience, while secondarily evaluating factors that may influence development of caries. Methods: Data collected from patients enrolled at the University of Iowa’s Infant Oral Health Program consisted of prenatal history, child’s demographics, neonatal history, oral hygiene, dietary habits, and clinical findings (visible plaque, enamel defects, and caries). Bivariate and logistic regression analyses were utilized (alpha=0.05). Results: Four hundred and ninety eight randomly matched premature and full-term subjects were included (mean age=21 months [range: 6-71 months]; 51.4% males and 38.9% African Americans). Bivariate analysis revealed no significant differences existed regarding cavitated and non-cavitated caries experience between full-term and premature subjects. Additionally, compared to their counterparts, premature subjects were more likely to eat cariogenic snacks between meals (P=0.028), drink cariogenic beverages >2 times per day (P=0.027), not have their teeth brushed daily (P

Background Hispanics disproportionately experience preventable oral health conditions in the United States. This study aimed to determine the oral health knowledge (OHK) of Hispanic adults in Iowa to identify potential gaps in knowledge. Methods This cross-sectional study included a convenience sample of self-identifying Hispanic adults. Data pertaining to oral health literacy and demographic, cultural, and dental characteristics were collected. OHK was assessed with the Conceptual Measure of Oral Health Knowledge, and it was categorized as low or high. Bivariate analyses and multiple logistic regression models were conducted to identify the variables related to OHK (P Results Three hundred thirty-eight participants completed the questionnaire, 68% of participants completed the questionnaire in Spanish, and 51% of all participants had low OHK. Participants were less likely to correctly answer questions pertaining to children’s oral health, periodontal disease, and oral cancer. Low OHK was associated with having less than 12th grade education, lack of dental insurance, and preference for a Spanish-speaking oral health care provider. Conclusions and Practical Implications OHK appears to be low in this population. Increasing OHK may help decrease oral health disparities and improve oral health outcomes. Furthermore, it is important that oral health care providers have an understanding of barriers that can impede patients’ understanding of the health care system. Specifically, minority populations, such as Hispanics, may have a harder time because of certain cultural differences that exist among this ethnic group.

Objectives To examine the relationships between fluoride intake levels and fluorosis of late-erupting permanent teeth. Methods The current study used information collected from 437 children in the longitudinal Iowa Fluoride Study. Participants' fluoride intake information was collected using questionnaires from birth to age 10 years. Estimated mean daily fluoride intake was categorized into low, moderate, and high intake tertiles for each age interval (2-5, 5-8, and 2-8 years). Bivariate analyses were performed to study the relationships between self-reported fluoride intake levels during three age intervals and dental fluorosis. Results For canines and second molars, the prevalence of mostly mild fluorosis was less than 10% in the lowest fluoride intake tertile and more than 25% in the highest intake tertile. For both first and second premolars, the prevalence in the low and high intake tertiles was approximately 10-15% and 25-40%, respectively. When estimated total daily fluoride intake was 0.04 mg/kg BW during ages 2-8 years, the predicted probability of fluorosis was 16.0%, 20.5%, 21.8%, and 15.4% for canines, 1st and 2nd and premolars and 2nd molars, respectively. We found that an incremental increase in fluoride intake during the age 5- to 8-year interval led to greater odds for development of mostly mild dental fluorosis in late-erupting teeth compared to increases in fluoride intake during other age intervals. Conclusions Our results clearly show that dental fluorosis prevalence is closely related to fluoride intake levels and that teeth have greater susceptibility to fluoride intake during certain age intervals.

Objectives There have been very few longitudinal studies of dental caries in adolescents, and little study of the caries risk factors in this age group. The purpose of this study was to describe different caries trajectories and associated risk factors among members of the Iowa Fluoride Study (IFS) cohort. Methods The IFS recruited a birth cohort from 1992 to 1995, and has gathered dietary, fluoride and behavioural data at least twice yearly since recruitment. Examinations for dental caries were completed when participants were ages 5, 9, 13 and 17 years. For this study, only participants with decayed and filled surface (DFS) caries data at ages 9, 13 and 17 were included (N=396). The individual DFS counts at age 13 and the DFS increment from 13 to 17 were used to identify distinct caries trajectories using Ward's hierarchical clustering algorithm. A number of multinomial logistic regression models were developed to predict trajectory membership, using longitudinal dietary, fluoride and demographic/behavioural data from 9 to 17 years. Model selection was based on the akaike information criterion (AIC). Results Several different trajectory schemes were considered, and a three-trajectory scheme—no DFS at age 17 (n=142), low DFS (n=145) and high DFS (n=109)—was chosen to balance sample sizes and interpretability. The model selection process resulted in use of an arithmetic average for dietary variables across the period from 9 to 17 years. The multinomial logistic regression model with the best fit included the variables maternal education level, 100% juice consumption, brushing frequency and sex. Other favoured models also included water and milk consumption and home water fluoride concentration. The high caries cluster was most consistently associated with lower maternal education level, lower 100% juice consumption, lower brushing frequency and being female. Conclusions The use of a clustering algorithm and use of Akaike's Information Criterion (AIC) to determine the best representation of the data were useful means in presenting longitudinal caries data. Findings suggest that high caries incidence in adolescence is associated with lower maternal educational level, less frequent tooth brushing, lower 100% juice consumption and being female.

It is ten years since the first paper on the Hall Technique was published in the British Dental Journal and almost 20 years since the technique first came to notice. Dr Norna Hall a (now retired) general dental practitioner from the north of Scotland had, for many years, been managing carious primary molar teeth by cementing preformed metal crowns over them, with no local anaesthesia, tooth preparation or carious tissue removal. This first report, a retrospective analysis of Dr Hall's treatments, caused controversy. How could simply sealing a carious lesion, with all the associated bacteria and decayed tissues, possibly be clinically successful? Since then, growing understanding that caries is essentially a biofilm driven disease rather than an infectious disease, explains why the Hall Technique, and other 'sealing in' carious lesion techniques, are successful. The intervening ten years has seen robust evidence from several randomised control trials that are either completed or underway. These have found the Hall Technique superior to comparator treatments, with success rates (no pain or infection) of 99% (UK study) and 100% (Germany) at one year, 98% and 93% over two years (UK and Germany) and 97% over five years (UK). The Hall Technique is now regarded as one of several biological management options for carious lesions in primary molars. This paper covers commonly asked questions about the Hall Technique and speculates on what lies ahead.

Objective: The objective of this study was to assess the impact of an interdisciplinary educational intervention on the knowledge of nursing practitioners regarding perinatal and infant oral health (PIOH) care. Materials and Methods: This was a preexperimental study conducted among nursing practitioners in Lagos, Nigeria. Participants received hands-on training and didactic lectures, which included dental caries etiology and risk factors; oral hygiene and dietary education; teething and its management; dental trauma and its prevention; nonnutritive habits; screening, referrals, and counseling; and fluoride varnish application. Knowledge of the trainees was assessed using pre- and posttest questionnaires. Level of statistical significance was set at P < 0.05. Results: Overall, 110 nurses participated in the study with a mean age of 40.9 ± 10.8 years; 106 (96.4%) were females. Approximately 88% of the participants had not received formal training on PIOH. The baseline mean scores of the participants’ knowledge on oral hygiene, teething, trauma, caries, and oral habits were 4.31 ± 1.9, 9.84 ± 2.6, 2.59 ± 1.7, 4.24 ± 1.8, and 1.45 ± 0.6, respectively; this increased significantly (P < 0.001) following the educational intervention with posttest mean scores as 7.58 ± 0.8, 11.79 ± 1.3, 4.34 ± 1.9, 6.19 ± 1.8, and 1.82 ± 0.4 and six-month evaluation scores as 6.21 ± 1.8,7 10.27 ± 3.1, 4.39 ± 1.5, 5.91 ± 1.8, and 1.79 ± 0.5, respectively. Overall posttest (31.4 ± 4.2) and six-month (28.6 ± 6.2) knowledge scores were significantly higher than the pretest values (22.4 ± 4.8, P < 0.001). At the six-month post-intervention survey, 84% of the nurses reported inclusion of PIOH education in their routine general health education sessions. Conclusion: There was a positive impact of the educational intervention as evidenced by an increase in the knowledge of the nurses on PIOH care and the inclusion of PIOH education in their general health education. A slight decline between posttest and six-month evaluation scores indicates a need for continuous education and evaluation.

In 1986, the American Academy of Pediatric Dentistry adopted a position on infant oral health recommending that the first visit occur within 6 months of the eruption of the first primary tooth. This bold recommendation was based on the recognition that many 3-year-old children had already experienced dental caries and, more troubling, that those who had experienced caries remained susceptible to future decay, even with subsequent preventive intervention. Prior to the adoption of this policy, physicians claimed responsibility for the oral health of the child younger than 36 months of age. The rationale, though somewhat circuitous, assumed that children visited a physician at regular intervals soon after birth but did not see a dentist until later in life. Unfortunately, physicians' knowledge and inclination to practice preventive dentistry have been shown to be lacking. Dental caries in pediatric patients continues to be a serious health problem even though the prevalence has been reduced since 1960. National data on dental caries in children and adolescents in the United States for 2011–2012 showed that nearly 37% of children aged 2–8 years had experienced dental caries in their primary teeth, whereas 21% of children aged 6–11 and 58% of adolescents aged 12–19 had experienced dental caries in their permanent teeth. Therefore it remains to be seen whether the medical community involvement and interventions can effect a change in that pattern. Implementing a major shift in health philosophy, such as instituting infant oral health visits to dentists, is not without problems. Some dentists are reluctant to see these children because of expectations of negative behavior, complex dental needs, a lack of understanding of preventive opportunities, and concern about reimbursement for procedures. Rightfully, physicians question whether a shift in practice that places infants in dental offices will work, given the reluctance of dentists and the scarcity of pediatric dentists who might see these children. The purpose of this chapter is to describe the objectives, procedures, and rationale for infant oral health. The goal would be that dentists would gain a better knowledge of these practices and become more comfortable in treating patients in this age group.

Author(s): Warren, John J; Weber-Gasparoni, Karin; Tinanoff, Norman; Batliner, Terence S; Jue, Bonnie; Santo, William; Garcia, Raul I; Gansky, Stuart A; Early Childhood Caries Collaborating Centers | Abstract: ObjectivesTo summarize diagnostic criteria and examiner training and calibration of the National Institute of Dental and Craniofacial Research-funded Early Childhood Caries Collaborating Centers (EC4) and report examiner calibration results from 2010 to 2014. The EC4 at Boston University, University of Colorado, and University of California San Francisco are performing randomized controlled early childhood caries (ECC) prevention trials with caries as the main outcome measure.MethodsThe EC4 with University of Iowa consultants developed standardized tooth and tooth surface status examination criteria for use in field conditions, examiner training materials, and examiner calibration and re-calibration methodologies. Calibration and re-calibration were performed with 1- to 5-year-old children in the San Francisco Mission District in which assessments from each examiner to be calibrated were compared with those from a single gold standard examiner from 2010 to 2014. Cohen's kappa statistic was used to determine inter-examiner agreement.ResultsA total of seven examiners were successfully (re)calibrated during that period, examining a total of 231 children. Overall unweighted Cohen's kappas for 10 surface conditions exceeded the criterion of 0.70. However, separate agreement for assessment of noncavitated lesions, as in other studies, was lower.ConclusionsAn experienced multidisciplinary and multi-institutional team was able to develop criteria and training materials to anticipate situations and field conditions the main trials would encounter. Examiners were successfully trained and (re)calibrated.

The purpose of this study was to investigate perceived comfort levels, behaviors, and barriers reported by group home caregivers who provide oral hygiene measures to consumers with special health care needs (SHCN) who physically resist the care. A 24-item survey was sent to 884 caregivers employed at six care facilities in Iowa. Bivariate analyses and logistic regression models were used to analyze the data (alpha = 0.05). The overall response rate was 52%. An analysis of the data indicated that caregivers who felt more comfortable providing oral hygiene for consumers who physically resisted the care experienced a higher frequency of consumers not opening their mouths (p = 0.0003), pushing the caregiver away (p = 0.0002), moving their heads uncontrollably (p = 0.0004), spitting at (p = 0.0099), hitting and/or kicking the caregiver (p = 0.0011). Furthermore, these caregivers provided weekly direct care for a greater number of consumers (p = 0.0044), received oral care training from their current facility (p = 0.0424), brushed the teeth of uncooperative consumers at least 75% of the time (p < 0.0001), and felt "somewhat comfortable to very comfortable" flossing their teeth (p < 0.0001). The caregivers' comfort level in providing oral hygiene measures to those consumers with SHCN who physically resist the care appears to be significantly associated with their training and experience working with this population.

To assess the role of sociodemographic, dietary, and clinical factors in early mutans streptococci (MS) colonization in children aged 6 to 24 months who were followed for 18 months.Ninety-four children (mean age: 11.5 ± 4.99 months at baseline) were enrolled in the study from the Women, Infants and Children Supplemental Nutrition Program during 2003-2004. Salivary MS levels of the children were determined at baseline and at 18 months using a semi-quantitative method. Detailed information about the children's beverage consumption pattern, dietary behavior, and clinical information about oral health status was collected at baseline, 9 months, and 18 months. None of the children included in this study had detectable levels of MS at baseline.Of the 94 children at baseline, 36 (38%) had acquired MS by the 18-month follow-up. The presence of5 teeth [OR = 3.55 (1.46-9.04); p = 0.0062] was a significant risk factor for MS acquisition among the baseline variables. At 9 months, sports drinks consumption [OR = 5.56 (1.39-26.26); p = 0.0143] and presence of caries [OR = 9.36 (2.55-40.90); p0.0001] were significantly associated with MS colonization at 18 months. Higher maternal education [OR = 0.3 (0.07-1.36); p = 0.0351] was a protective factor at all the time points.Sugared beverage consumption, tooth-related factors, and lower maternal education can predict MS acquisition in young children.

Currently, research is lacking regarding the use of spill-proof beverage containers (SPBCs). The purpose of this study was to assess the relationship between daytime SPBCs use for sugared beverages, caries, socioeconomic status, and other covariates in high-caries risk 12- to 49-month-old children attending a Women, Infants and Children (WIC) program.Data were analyzed using baseline information from 415 Iowa WIC-enrolled children who participated in a psychoeducational study. Mothers completed a series of detailed questionnaires regarding their SES and their child's beverage consumption. Dental examinations using d1d2.3 (noncavitated and cavitated carious lesions) criteria were completed for the children. Bivariate relationships for consumption of any sugared beverage using SPBCs were assessed and followed by multivariable modeling using logistic regression (alpha=0.05).Only 18 children (four percent) reported using SPBCs for any sugared beverage during the night versus 290 (70 percent) during the day. Daytime consumption of sugared beverages from SPBCs was less likely to be reported in older children (P.001) and in African American children when compared to both Hispanics (P.001) and Caucasians (P=.001).Iowa WIC children primarily consume sugared beverages using spill-proof beverage containers during the day; children who were younger and Hispanic or Caucasian were more likely to use SPBCs to consume sugared beverages.

To examine the relationships between fluoride intake levels and fluorosis of late-erupting permanent teeth.The current study used information collected from 437 children in the longitudinal Iowa Fluoride Study. Participants' fluoride intake information was collected using questionnaires from birth to age 10 years. Estimated mean daily fluoride intake was categorized into low, moderate, and high intake tertiles for each age interval (2-5, 5-8, and 2-8 years). Bivariate analyses were performed to study the relationships between self-reported fluoride intake levels during three age intervals and dental fluorosis.For canines and second molars, the prevalence of mostly mild fluorosis was less than 10% in the lowest fluoride intake tertile and more than 25% in the highest intake tertile. For both first and second premolars, the prevalence in the low and high intake tertiles was approximately 10-15% and 25-40%, respectively. When estimated total daily fluoride intake was 0.04 mg/kg BW during ages 2-8 years, the predicted probability of fluorosis was 16.0%, 20.5%, 21.8%, and 15.4% for canines, 1st and 2nd and premolars and 2nd molars, respectively. We found that an incremental increase in fluoride intake during the age 5- to 8-year interval led to greater odds for development of mostly mild dental fluorosis in late-erupting teeth compared to increases in fluoride intake during other age intervals.Our results clearly show that dental fluorosis prevalence is closely related to fluoride intake levels and that teeth have greater susceptibility to fluoride intake during certain age intervals.

Objectives:Theatraumaticrestorativetreatment(ART)wasdevelopedasanaffordable, patient-friendly dental caries management procedure that does not need extensive operator training or special skills. The aim of this study was to determine factors that influence the decision to use ART using an innovative marketing research technique known as conjoint analysis. Methods: A conjoint survey was completed by 723 members of the American Academyof PediatricDentistry.Threefactors(ageof thechild,levelof cooperation, type of insurance) were varied across three levels to create nine patient scenarios. The weights that practitioners placed on these factors in decisions to use ART in treating carious lesions were determined by conjoint analysis.Factors such as lesion location,depth,and extension werefixed in the nine clinical scenarios. Results: Seven-hundred twenty-three pediatric dentists completed the survey (32 percent).Age of the child was the most important factor in pediatric dentists’ decisions to use ART (46 percent) compared with level of cooperation (41 percent) and typeof insurancecoverage(11percent).Fortheagefactor,theageof 2yearshadthe greatest utility (0.55) compared with age 4 (−0.09) and age 6 (−0.46). For types of insurance coverage, having no insurance (0.124) had the greatest utility compared with having public insurance (−0.119). Conclusions: Although insurance coverage was the least important among the factors, being without insurance, being very young, and being uncooperative was the scenario where pediatric dentists most favored ART when making trade offs between different factors using the conjoint design.

The purpose of this study was to investigate the association between bedsharing and oral health-related feeding behaviors among zero- to three-year-old children.Data were collected from records of children attending the University of Iowa's Infant Oral Health Program (1998 to 2009), including maternal demographics, children's nighttime dietary practices, bedsharing habits, methods to help children sleep, and clinical evidence of plaque and caries. Statistical analyses utilized bivariate and logistic regression analyses.Mother-child dyads (n equals 629) who either bedshared every night (n equals 273) or did not bedshare (n equals 356) were included. Of the 629 children (mean±standard deviation [SD] age equals 21.6±12.1 months), 51 percent were male, 50 percent were nonwhite, and 72 percent lived with both parents. Logistic regression analysis revealed that children who bedshared were more likely to be healthy (OR equals 6.78; P=.008), older (OR equals 1.56; P=.007), nonwhite (OR equals 2.96; P.001), live with a single mother (OR equals 3.41; P.001), breastfed throughout the night (OR equals 4.33; P.001), and bottle-fed and breastfed to help them sleep (OR equals 2.34; P=.03; OR equals 3.27; P=.03, respectively). Moreover, these children were more likely to be in the high caries-risk category (OR equals 2.19; P=.01).Bedsharing was significantly associated with the child's health status, age, race, nighttime feeding habits, and high caries-risk and with whom the child lived. Caries preventive measures should be targeted to mother-child dyads who bedshare.

Objectives. We sought to understand the role of Latino acculturation in dental care utilization in Iowa children. Methods. We used logistic regression to evaluate factors associated with having a previous-year dental check-up with 2005 Iowa Child and Family Household Health Survey data. We constructed models to examine the association with race/ethnicity and used chosen interview language to measure Latino acculturation. Results. After we controlled for several factors, having a regular dental care source, having a dental need, dental insurance status, family income, children's dental health rating, children's age, and brushing habits were associated with having a previous-year dental check-up. Race/ethnicity was indirectly associated with use of dental services through other related factors with significant differences for less-acculturated Latinos. Conclusions. Policymakers and health planners should implement strategies to address individual, community, and system factors affecting racial/ethnic minorities. A regular source of dental care for Latino children that will enhance their access to services should be ensured. Ignoring the needs of the fastest growing segment of children with the poorest oral health and the least access to care will lead to future increase of oral diseases in this population.

The purpose of this study was to investigate the perceived comfort, behaviors, and barriers reported by group home caregivers while providing oral health care to individuals with special healthcare needs (SHCN). A 23-item survey was sent to 428 caregivers in two group homes in Iowa. Bivariate and logistic regression models were used to analyze data (p ≤ 0.05). The overall response rate was 32%. An analysis of the bivariate and multivariate logistic regression indicated that caregivers who felt more comfortable providing care for individuals who verbally and physically resisted oral health care had worked more than 2 years at their current location (p = 0.0323), felt "neutral to very comfortable" brushing (p = 0.0020) and flossing (p < 0.0001) the teeth of individuals with SHCN, and reported "sometimes to always" experiencing these individuals not opening their mouths (p = 0.0127). Comfort in providing oral care to individuals with SHCN appears to be linked to experience and length of time working with this population.

Objectives: The objective of this study is to assess relationships between the presence or absence of mutans streptococci (MS) and other covariates in children aged 12-49 months. Methods: Data were analyzed using baseline information from 411 children enrolled in the Special Supplemental Food Program for Women, Infants and Children (WIC) who participated in a psychoeducational study in Iowa. Children were assessed for MS using a semiquantitative method (RODAC plates). Dental examinations using d1d2.3 criteria and presence of visible plaque on incisors and molars were completed. Mothers completed a series of detailed questionnaires regarding their child's oral health, their socioeconomic status, their child's dietary/oral hygiene habits, and beverage consumption, among other behaviors. Bivariate relationships with the presence of MS were assessed and followed by multivariable modeling using logistic regression (alpha = 0.05). Results: MS was present in 144 children (35 percent). Bivariate relationships with MS presence were identified for multiple covariates that included demographic characteristics, type of beverage consumption, dental caries, and plaque measures. Multivariate logistic regression modeling suggested that MS presence in children was positively associated with nonwhite race of the child, number of teeth present, presence of cavitated lesions, proportion of teeth with plaque, and lower levels of maternal education. Conclusions: The presence of MS was associated with greater caries and plaque scores and with low maternal education and nonwhite racial background.

Objective: To assess and compare examiner reliability of clinical and photographic fluorosis examinations using the Fluorosis Risk Index (FRI) among children in the Iowa Fluoride Study (IFS). Methods: The IFS examined 538 children for fluorosis and dental caries at age 13 and obtained intraoral photographs from nearly all of them. To assess examiner reliability, duplicate clinical examinations were conducted for 40 of the subjects. In addition, 200 of the photographs were scored independently for fluorosis by two examiners in a standardized manner. Fluorosis data were compared between examiners for the clinical exams and separately for the photographic exams, and a comparison was made between clinical and photographic exams. For all three comparisons, examiner reliability was assessed using kappa statistics at the tooth level. Results: Interexaminer reliability for the duplicate clinical exams on the sample of 40 subjects as measured by kappa was 0.59, while the repeat exams of the 200 photographs yielded a kappa of 0.64. For the comparison of photographic and clinical exams, interexaminer reliability, as measured by weighted kappa, was 0.46. FRI scores obtained using the photographs were higher on average than those obtained from the clinical exams. Fluorosis prevalence was higher for photographs (33 percent) than found for clinical exam (18 percent). Conclusion: Results suggest that interexaminer reliability is greater and fluorosis scores are higher when using photographic compared with clinical examinations.

Objective To assess the extent to which chronic condition (CC) status and severity affected how soon children had a dental visit after enrolling in Medicaid.

Objective To assess the impact of chronic condition (CC) status and CC severity, respectively, on the odds of receiving dental treatment under general anesthesia (GA) for Medicaid-enrolled children by age group.

The American Academy of Pediatric Dentistry recommends that children have their first dental visit no later than age one. However, not all dental schools have made hands-on infant oral health programs a reality in their predoctoral programs. To target high-caries risk infants/toddlers and provide dental students more hands-on experience with this age group, the University of Iowa Department of Pediatric Dentistry established an Infant Oral Health Program (IOHP) affiliated with the local Special Supplemental Food Program for Women, Infants, and Children (WIC) clinic. This article reports the IOHP activities and describes how this program is integrated into a dental school curriculum. Most of the children served were around age one, from racial and ethnic minority groups, and had never been to the dentist. More than 600 fourth-year dental students received hands-on experience providing preventive dental care for infants and toddlers. A 2004 survey of dentists who graduated from the University of Iowa suggested that those who rotated at the IOHP while in dental school were more willing to see very young children when compared to dentists who did not rotate at the IOHP. These findings suggest that community-based IOHPs can provide an important community resource for preventive dental care for high-caries risk young children, while complementing the pediatric dental experience in a dental school curriculum.

Objective: This study evaluated relationships between caregiver responses to oral health screening questions and caries in young children. Methods: Two samples of caregivers answered identical eight-item screening questionnaires about their oral health. One sample included children enrolled in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) who were 24 to 42 months of age; the other sample included 3- to 5-year-old children attending a pediatric dental clinic. Using chi-square and relative risk, questionnaire findings were related to children's caries history based on clinical caries exams. Results: Questions significantly (P

Objectives—Early childhood caries is a challenging public health problem in the United States and elsewhere; however, there is limited information concerning risk factors in very young children. The purpose of this study was to assess baseline risk factors for 18-month caries prevalence as part of a longitudinal study of high-risk children. Methods—212 children 6–24 months of age were recruited from a rural community in Iowa. Subjects were enrolled in the WIC program, which provides nutritional support for low-income families with children. Dental examinations using d1d2-3 criteria were conducted at baseline and after 18 months. Caries prevalence was determined at the frank decay level (d2-3 or filled surfaces), as well as at the non-cavitated level (d1), and combined (d1, d2-3 or f surfaces). Risk factor data were collected at baseline and after 9- and 18- months. These data included beverage consumption data, presence of visible plaque, and use of fluoride toothpaste for children as well as mutans streptococci (MS) levels of mothers and children and family socio-demographic factors. Results—128 children (60%) remained in the study after 18 months. Among these children, prevalence of d-1d2-3/f level caries increased from 9% to 77%, while d2-3/f level caries increased from 2% to 20%. Logistic regression models for baseline predictors of d2-3f caries at the 18month follow-up found presence of MS in children (OR=4.4; 95% CI: 1.4, 13.9) and sugarsweetened beverages (OR=3.0; 95% CI: 1.1, 8.6) to be the only significant risk factors. Sociodemographic factors and use of fluoride toothpaste were not significant in these models. Conclusions—Results suggest that early colonization by MS and consumption of sugarsweetened beverages are significant predictors of early childhood caries in high-risk populations.

OBJECTIVES Dental caries in early childhood is an important public health problem. Previous studies have examined risk factors, but they have focused on children during the later stages of the disease process. The purpose of this study was to assess the factors associated with caries in children aged 6 to 24 months as part of a cross-sectional analysis. METHODS Two hundred twelve mothers with children 6 to 24 months of age were recruited from Special Supplemental Nutrition Program for Women, Infants, and Children clinic sites in southeastern Iowa for participation in a longitudinal study of dental caries. Baseline assessments included detailed questions regarding the children's beverage consumption, oral hygiene, and family socioeconomic status. Dental caries examinations using the d(1)d(2-3)f criteria and semiquantitative assessments of salivary mutans streptococci (MS) levels of mother and child were also conducted. Counts of the number of teeth with visible plaque were recorded for maxillary and mandibular molars and incisors. RESULTS Of the 212 child/mother pairs, 187 children had teeth. Among these children, the mean age was 14 months, and 23 of the children exhibited either d(1), d(2-3), or filled lesions. Presence of caries was significantly associated with older age, presence of MS in children, family income

The purpose of this study was to investigate perceived comfort levels, behaviors, and barriers reported by group home caregivers who provide oral hygiene measures to consumers with special health care needs (SHCN) who physically resist the care. A 24-item survey was sent to 884 caregivers employed at six care facilities in Iowa. Bivariate analyses and logistic regression models were used to analyze the data (alpha = 0.05). The overall response rate was 52%. An analysis of the data indicated that caregivers who felt more comfortable providing oral hygiene for consumers who physically resisted the care experienced a higher frequency of consumers not opening their mouths (p = 0.0003), pushing the caregiver away (p = 0.0002), moving their heads uncontrollably (p = 0.0004), spitting at (p = 0.0099), hitting and/or kicking the caregiver (p = 0.0011). Furthermore, these caregivers provided weekly direct care for a greater number of consumers (p = 0.0044), received oral care training from their current facility (p = 0.0424), brushed the teeth of uncooperative consumers at least 75% of the time (p0.0001), and felt "somewhat comfortable to very comfortable" flossing their teeth (p0.0001). The caregivers' comfort level in providing oral hygiene measures to those consumers with SHCN who physically resist the care appears to be significantly associated with their training and experience working with this population.

Objective Very few studies have examined the relationship between timing of fluoride intake and development of dental fluorosis on late-erupting permanent teeth using period-specific fluoride intake information. This study examined this relationship using longitudinal fluoride intake information from the Iowa Fluoride Study. Methods Participants’ fluoride exposure and intake (birth to 10 years of age) from water, beverages, selected food products, dietary fluoride supplements, and fluoride toothpaste was collected using questionnaires sent to parents at 3- and 4- month intervals from birth to 48 months of age and every 6 months thereafter. Three trained and calibrated examiners used the Fluorosis Risk Index (FRI) categories to assess 16 late-erupting teeth among 465 study participants. A tooth was defined as having definitive fluorosis if any of the zones on that tooth had an FRI score of 2 or 3. Participants with questionable fluorosis were excluded from analyses. Descriptive and logistic regression analyses were performed to assess the importance of fluoride intake during different time periods. Results Most dental fluorosis in the study population was mild, with only four subjects (1%) having severe fluorosis (FRI Score 3). The overall prevalence of dental fluorosis was 27.8%. Logistic regression analyses showed that fluoride intake from each of the individual years from age 2 to 8 plays an important role in determining the risk of dental fluorosis for most late-erupting permanent teeth. The strongest association for fluorosis on the late-erupting permanent teeth was with fluoride intake during the sixth year of life. Conclusion Late-erupting teeth may be susceptible to fluorosis for an extended period from about age 2 to 8. Although not as visually prominent as the maxillary central incisors, some of the late-erupting teeth are esthetically important and this should be taken into consideration when making recommendations about dosing of fluoride intake.

The purpose of this study was to investigate the extent of clinical training on atraumatic restorative treatment (ART) among pediatric dentistry residency programs and assess program directors' attitudes toward ART.All U.S. Pediatric Dentistry residency programs' directors were asked to complete a web-based survey. Sixty-one of the 76 directors (80 percent) completed the survey, with no significant response bias.Eighty-nine percent of the responding programs provided clinical instruction on ART. Of these, 30 percent provided ART training often/very often. ART was used mostly in single-surface cavities (43 percent) and as an interim treatment in primary teeth (57 percent). Factors associated with ART clinical training included not placing amalgams in primary teeth (P.03) and having directors with positive attitudes toward ART (P.001). Factors associated with directors' positive attitudes included believing that child's caries risk (P.006), professional guidelines (P.003), and patient insurance status (P.04) were all important in selecting restorative treatment.Atraumatic restorative therapy appears to be underused in pediatric dentistry residency programs in the United States. Residency directors' attitudes were highly predictive of the amount of clinical training provided, suggesting that directors need to be better informed about the use of ART.

The International Dental Federation and World Health Organization have promoted the use of Atraumatic Restorative Treatment (ART) in modern clinical settings worldwide. In the United States, the practice of ART is not believed to be widely used, which may be a result of little attention given to ART training in predoctoral pediatric dentistry curricula in U.S. dental schools. This study investigated the extent of clinical and didactic instruction on ART provided in U.S. dental schools by surveying the predoctoral pediatric dentistry programs in 2010. Of the fifty-seven directors asked to complete the survey, forty-four responded for a response rate of 77 percent. Of these forty-four programs, 66 percent reported providing clinical training on ART, though only 14 percent provide this training often or very often. The types of ART training provided often or very often included interim treatment (18 percent) and single-surface cavities (14 percent) in primary teeth. However, ART was said to be rarely taught as a definitive treatment in permanent teeth (2 percent). Attitude was a major predictor, for clinical training provided and using professional guidelines in treatment decisions were associated with a positive attitude towards ART. These predoctoral pediatric dentistry programs used ART mainly in primary, anterior, and single-surface cavities and as interim treatment. As ART increases access of children to dental care, the incorporation of the ART approach into the curricula of U.S. dental schools should be facilitated by professional organizations.

The atraumatic restorative treatment (ART) was developed as an affordable, patient-friendly dental caries management procedure that does not need extensive operator training or special skills. The aim of this study was to determine factors that influence the decision to use ART using an innovative marketing research technique known as conjoint analysis.A conjoint survey was completed by 723 members of the American Academy of Pediatric Dentistry. Three factors (age of the child, level of cooperation, type of insurance) were varied across three levels to create nine patient scenarios. The weights that practitioners placed on these factors in decisions to use ART in treating carious lesions were determined by conjoint analysis. Factors such as lesion location, depth, and extension were fixed in the nine clinical scenarios.Seven-hundred twenty-three pediatric dentists completed the survey (32 percent). Age of the child was the most important factor in pediatric dentists' decisions to use ART (46 percent) compared with level of cooperation (41 percent) and type of insurance coverage (11 percent). For the age factor, the age of 2 years had the greatest utility (0.55) compared with age 4 (-0.09) and age 6 (-0.46). For types of insurance coverage, having no insurance (0.124) had the greatest utility compared with having public insurance (-0.119).Although insurance coverage was the least important among the factors, being without insurance, being very young, and being uncooperative was the scenario where pediatric dentists most favored ART when making trade offs between different factors using the conjoint design.

The purpose was to compare whether mothers exposed to an autonomy-supportive psychoeducational videotaped message, informed by the self-determination theory (SDT), demonstrated greater changes in oral health knowledge and behavioral intentions as a preventive means for early childhood caries (ECC) than mothers exposed to a neutral message delivered by brochure.Data were collected at baseline, one-, and six-month follow-ups from 415 12- to 49-month-old WIC-enrolled children and their mothers: 283 in the video intervention group and 132 in the brochure control group. Mothers completed questionnaires on maternal knowledge and behavioral intentions for oral health care. Chi-square, Wilcoxon rank-sum, and Mann-Whitney tests were used to analyze data (P.05).Relative to their baseline scores, the intervention group showed a greater increase in knowledge than the control group, both at one-month (P=.002) and six-month follow-ups (P.001). The video group also demonstrated a greater increase in behavioral intentions than controls, both at one-month (P.05) and six-month follow-ups (P.001). Knowledge and behavioral intention levels at six-month follow-up did not differ significantly from those at one-month follow-up, indicating that intervention-based increases in these measures were maintained over time.Data provided evidence of the effectiveness of the autonomy-supportive psychoeducational intervention for ECC prevention relative to a neutral brochure.

The purpose of this study was to investigate the perceived comfort, behaviors, and barriers reported by group home caregivers while providing oral health care to individuals with special healthcare needs (SHCN). A 23-item survey was sent to 428 caregivers in two group homes in Iowa. Bivariate and logistic regression models were used to analyze data (p ≤ 0.05). The overall response rate was 32%. An analysis of the bivariate and multivariate logistic regression indicated that caregivers who felt more comfortable providing care for individuals who verbally and physically resisted oral health care had worked more than 2 years at their current location (p = 0.0323), felt "neutral to very comfortable" brushing (p = 0.0020) and flossing (p0.0001) the teeth of individuals with SHCN, and reported "sometimes to always" experiencing these individuals not opening their mouths (p = 0.0127). Comfort in providing oral care to individuals with SHCN appears to be linked to experience and length of time working with this population.

The purpose of this study was to assess the attitudes and perceptions of the American Academy of Pediatric Dentistry (AAPDM) members regarding conscious sedation.A 22-item survey was e-mailed to 4,358 active AAPD members to identify factors that influence pediatric dentists' practice of conscious sedation in their dental offices. Bivariate and logistic regression models were used to analyze data.A total of 1,219 surveys were returned (28% response rate); 743 (63%) respondents practiced conscious sedation. Help in providing dental care for patients difficult to manage was the primary reason reported for practicing conscious sedation. Conversely, not wanting the liability related to conscious sedation was the main reason reported by those who don't sedate. Bivariate and multivariate logistic regression analyses indicated that dentists were significantly more likely to perform conscious sedation if they practiced more than 3 days a week (P.03), had 11% or more patients with public insurance (P.02), and rated their sedation training as "good or excellent" (P.001).Among respondents, the attitudes of those who practice conscious sedation varied significantly from those who don't with location of the practice and the quality of their sedation training as significant influences on this decision.

The objective of this study is to assess relationships between the presence or absence of mutans streptococci (MS) and other covariates in children aged 12-49 months.Data were analyzed using baseline information from 411 children enrolled in the Special Supplemental Food Program for Women, Infants and Children (WIC) who participated in a psychoeducational study in Iowa. Children were assessed for MS using a semiquantitative method (RODAC plates). Dental examinations using d(1) d(2) .(3) criteria and presence of visible plaque on incisors and molars were completed. Mothers completed a series of detailed questionnaires regarding their child's oral health, their socioeconomic status, their child's dietary/oral hygiene habits, and beverage consumption, among other behaviors. Bivariate relationships with the presence of MS were assessed and followed by multivariable modeling using logistic regression (alpha = 0.05).MS was present in 144 children (35 percent). Bivariate relationships with MS presence were identified for multiple covariates that included demographic characteristics, type of beverage consumption, dental caries, and plaque measures. Multivariate logistic regression modeling suggested that MS presence in children was positively associated with nonwhite race of the child, number of teeth present, presence of cavitated lesions, proportion of teeth with plaque, and lower levels of maternal education.The presence of MS was associated with greater caries and plaque scores and with low maternal education and nonwhite racial background.

To assess and compare examiner reliability of clinical and photographic fluorosis examinations using the Fluorosis Risk Index (FRI) among children in the Iowa Fluoride Study (IFS).The IFS examined 538 children for fluorosis and dental caries at age 13 and obtained intraoral photographs from nearly all of them. To assess examiner reliability, duplicate clinical examinations were conducted for 40 of the subjects. In addition, 200 of the photographs were scored independently for fluorosis by two examiners in a standardized manner. Fluorosis data were compared between examiners for the clinical exams and separately for the photographic exams, and a comparison was made between clinical and photographic exams. For all three comparisons, examiner reliability was assessed using kappa statistics at the tooth level.Interexaminer reliability for the duplicate clinical exams on the sample of 40 subjects as measured by kappa was 0.59, while the repeat exams of the 200 photographs yielded a kappa of 0.64. For the comparison of photographic and clinical exams, interexaminer reliability, as measured by weighted kappa, was 0.46. FRI scores obtained using the photographs were higher on average than those obtained from the clinical exams. Fluorosis prevalence was higher for photographs (33 percent) than found for clinical exam (18 percent).Results suggest that interexaminer reliability is greater and fluorosis scores are higher when using photographic compared with clinical examinations.

La ulceracion traumatica de la superficie ventral de la lengua es una condicion poco comun en bebes y ninos pequenos, la cual se asocia a menudo con los dientes natales y neonatales en los recien nacidos. El objetivo de este reporte es presentar un caso de ulceras bilaterales en la superficie ventral de la lengua causada por la erupcion de los primeros molares mandibulares temporales en un infante de sexo masculino de 14 meses de edad. En nino fue capaz de senalar las lesiones y se nego a consumir ciertas bebidas y alimentos, lo que favorecio un diagnostico precoz. El tratamiento clinico consistio en el suavizado manual de los bordes afilados de los primeros molares inferiores y un regimen casero de solucion de clorhidrato de lidocaina (Xilocaina®, Astra) junto a la solucion esteroidal de acetonido de triamcinolona (Omcilon - A, Brystol-Myers) para el alivio de los sintomas y curacion de la lesion respectivamente. La curacion completa de ambas lesiones y la alimentacion normal se observo en una semana del control de seguimiento. La deteccion temprana de las lesiones y el cumplimiento de los padres con los regimenes caseros recomendados, son factores claves para un resultado exitoso del tratamiento, ya que los casos no tratados de estas lesiones ulcerosas pueden provocar dificultades en la alimentacion y una evolucion inadecuada. Aunque existen varios informes de lesiones ulcerosas en la lengua causada por la erupcion dental, que se asocian generalmente con la erupcion de los incisivos mandibulares temporales (enfermedad de Riga-Fede). Sin embargo, no existen informes de lesiones ulcerosas causadas por otros dientes temporales.

The purpose of this study was to examine the factors associated with early childhood caries (ECC) among children enrolled in 3 centers offering Iowa Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) services in Linn County, Iowa.Data pertaining to dental caries and its determinants were collected for 115 children. Bivariate and multivariable analyses were conducted concerning outcome variables of ECC and having greater than 50 colony-forming units (CFUs) of salivary mutans streptococcus (50 CFUs).The final logistic regression model for factors associated with ECC found that children with presence of visible plaque were 2.78 times more likely to have ECC (odds ratio [OR]=3.78, 95% confidence interval [CI]=1.41-10.16) and children were 0.13 times more likely to have ECC (OR=1.13, 95% CI=1.04-1.26) for each increase of one month in age. A final logistic model concerning greater than 50 CFUs showed that the children with presence of plaque on any maxillary incisor were 2.39 times more likely to have greater than 50 CFUs (OR=3.39, 95% CI=1.28-8.96) and the children were 0.61 times more likely to have greater than 50 CFUs with an increase in cariogenicity of sippy cup contents by 1 level (OR=1.61, 95% CI=1.03-2.50).Presence of visible plaque on maxillary incisors was associated with increased risk for presence of early childhood caries. The presence of visible plaque on any maxillary incisor and more cariogenicity of sippy cup contents were associated with having more than 50 CFUs.

In 2007, the University of Iowa's advanced training program in pediatric dentistry replaced the traditional formocresol vital pulpotomy technique with a 5% sodium hypochlorite (NaOCl) technique. The purpose of this study was to evaluate the clinical/radiographic success over 21 months of 5% NaOCl as the medicament in primary molar pulpotomies compared to published data for formocresol and ferric sulfate pulpotomies.A retrospective chart audit was performed to evaluate results for all primary molar pulpotomies completed during a 12-month period using NaOCl. Dental records were reviewed for clinical and radiographic findings subsequent to pulp therapy. Clinical and radiographic criteria used to determine pulpotomy success were based on scientific literature.One hundred ninety-two NaOCl primary molar pulpotomies were completed in 118 patients; 131 (68%) primary molars from 77 children were available for follow-up examination (mean time since pulpotomy=10.5 months). NaOCl pulpotomies had a 95% clinical and 82% overall radiographic success rate. External root resorption was the most common pathologic finding. Pulpotomy success diminished over time.Clinical and radiographic success rates in this study on NaOCl pulpotomies are comparable to formocresol and ferric sulfate pulpotomies reported in the literature. Further study with longer observation periods is warranted.

Although Medicaid-enrolled children with a chronic condition (CC) may be less likely to use dental care because of factors related to their CC, dental utilization for this population is poorly understood.To assess the relationship between CC status and CC severity, respectively, on dental utilization for Iowa Medicaid-enrolled children.Retrospective cohort study of Iowa Medicaid data (January 1, 2003 to December 31, 2006).Medicaid-enrolled children aged 3 to 14 (N = 71,115) years.The 3M Corporation Clinical Risk Grouping methods were used to assess CC status (no/yes) and CC severity (episodic/life-long/malignancy/complex). The outcome variable was any dental utilization in 2006. Secondary outcomes included use of diagnostic, preventive, routine restorative, or complex restorative dental care.After adjusting for model covariates, Iowa Medicaid-enrolled children with a CC were significantly more likely to use each type of dental care except routine restorative care (P = 0.86) than those without a CC, although the differences in the odds were small (4%-6%). Compared with Medicaid-enrolled children with an episodic CC, children with a life-long CC were less likely to use routine restorative care (P0.0001), children with a malignancy were more likely to use complex restorative care (P0.03), and children with a complex CC were less likely to use each type of dental care except complex restorative care (P = 0.97).There were differences in dental utilization for Iowa Medicaid-enrolled children by CC status and CC severity. Children with complex CCs were the least likely to use dental care. Future research efforts should seek to understand why subgroups of Medicaid-enrolled children with a CC exhibit lower dental utilization.

Objectives: The “optimal” intake of fluoride has been widely accepted for decades as between 0.05 and 0.07 mg fluoride per kilogram of body weight (mg F/kg bw) but is based on limited scientific evidence. The purpose of this paper is to present longitudinal fluoride intake data for children free of dental fluorosis in the early-erupting permanent dentition and free of dental caries in both the primary and early-erupting permanent teeth as an estimate of optimal fluoride intake. Methods: Data on fluoride ingestion were obtained from parents of 602 Iowa Fluoride Study children through periodic questionnaires at the ages of 6 weeks; 3, 6, 9, 12, 16, 20, 24, 28, 32, and 36 months; and then at 6-month intervals thereafter. Estimates of total fluoride intake at each time point were made by summing amounts from water, dentifrice, and supplements, as well as other foods and beverages made with, or containing, water. Caries data were obtained from examinations of children at ages 5 and 9 years, whereas fluorosis data were obtained from examinations of children only at age 9 years. Results: The estimated mean daily fluoride intake for those children with no caries history and no fluorosis at age 9 years was at, or below, 0.05 mg F/kg bw for nearly all time points through the first 48 months of life, and this level declined thereafter. Children with caries had generally slightly less intakes, whereas those with fluorosis generally had slightly higher intakes. Conclusions: Given the overlap among caries/fluorosis groups in mean fluoride intake and extreme variability in individual fluoride intakes, firmly recommending an “optimal” fluoride intake is problematic.

The purpose of this study was to conduct a secondary data analysis of results from a 1985 survey of La Leche League International (LLLI) members to further investigate the relationship between breast-feeding and caries prior to age 3 (CPA3).Subjects were 576 LLLI mothers who responded to a 23-item questionnaire concerning the following factors for their oldest child: (1) breast-feeding habits; (2) fluoride status; (3) use of antibiotics; (4) carbohydrate ingestion; (5) history of caries; and (6) oral hygiene practices.CPA3 was reported in 10% of all children breast-fed for more than 3 years. Later weaning was found to be significantly associated with CPA3 (odds ratio [OR]=2.03; P=.0001). Late initiation of oral hygiene was marginally associated with CPA3 (OR=0.77; P=.08). Among children who developed CPA3, bivariate analyses found a greater frequency of breast-feeding (P=.012) and presence of night-time breast-feeding (P=.049) to be associated with caries detected at an earlier age. Children with caries on their maxillary incisors were more likely to have been breast-fed at night (P=.027) and more frequently during the night (P=.032).This retrospective study, based on a report of La Leche League International members, found later weaning to be significantly associated with an increased likelihood of developing CPA3.