Reducing Alaska Native paediatric oral health disparities: a systematic review of oral health interventions and a case study on multilevel strategies to reduce sugar-sweetened beverage intake

Figures & data

Fig. 1 Flow chart indicating search strategy for qualitative systemic review on oral health interventions for Alaska Native children.

Fig. 2 Flow chart indicating number of references identified and included in final qualitative systemic review on oral health interventions for Alaska Native children.

Table I. Data abstracted from studies included in qualitative systemic review of oral health interventions for Alaska Native children (n =9 studies)

Study category	References	Patient/population	Intervention	Level of intervention	Comparison groups	Outcome	Follow-up period	Challenges	Study limitations
Reducing tooth decay in Head Start children through community and caregiver education	Bruerd & Jones (17)	Alaska Native and American Indian Head Start children (12 study sites)	Oral health education for lay community volunteers, health workers, and site coordinators; educational materials and counselling for caregivers Media campaign on oral health	Provider, Caregiver, Community	Ongoing Baby Bottle Tooth Decay (BBTD) Prevention Program from 1986 to 1994 BBTD Prevention Program discontinued in 1989	Percent reduction in the prevalence of children with BBTD (defined as decay of 2 primary maxillary anterior teeth) Significant decreases in BBTD for communities with ongoing BBTD Prevention Programs but not within communities that discontinued the BBTD Prevention Program	8 years	Programme discontinuation most often because of staff turnover Importance of recruiting study staff members from local population Difficulty of institutionalising pilot programmes into organisation New strategies needed to reach highest risk children who change residences frequently and do not access health care services	Small number of communities that may not be representative of Alaska Native and American Indian communities The absence of tooth-level interventions (e.g. fluoride varnish)
	Bruerd et al. (18)	Alaska Native and American Indian Head Start children (12 study sites)	Oral health education for lay community volunteers, health workers, and site coordinators; Educational materials and counselling for caregivers Media campaign on oral health	Provider, Caregiver, Community	High intensity (community volunteers and site coordinators trained directly by study team) Medium intensity (site coordinators trained by study team at a central location) Low intensity (site coordinators received no training)	Percent reduction in the prevalence of children with BBTD (defined as decay of two primary maxillary anterior teeth) Significant decreases in BBTD within comparison groups and for all 12 study sites	5 years (interim results at year 3 reported)	20% increase in BBTD in the single Alaska Native community (one of the high intensity groups) Waning enthusiasm, personnel loss, lack of follow through on study protocols Limited fidelity monitoring Resources involved in assembling community planning group	No operationalised definition of BBTD (obtained from Bruerd and Jones (17)) Unable to identify intervention components that were most important Small number of communities that may not be representative of Alaska Native and American Indian communities
Dental chemotherapeutics for pregnant women	Jolles et al. (19)	Pregnant Alaska Native women in the Yukon-Kuskokwim Delta	Xylitol chewing gum	Caregiver	Xylitol chewing gum Placebo chewing gum	Percent of children with dental caries	None	Difficulties recruiting and retaining study participants Lack of engaging and attractive advertising within communities about study Lack of face-to-face interaction with community members Lack of local community-based study personnel Lack of input and involvement from participating communities	No outcomes assessed. Trial was discontinued because of problems recruiting and retaining study participants
	Riedy (20)	Pregnant Alaska Native women in the Yukon-Kuskokwim Delta	Xylitol chewing gum	Caregiver	Xylitol chewing gum Placebo chewing gum	Percent of children with dental caries	None	Distrust of researchers Difficulties in accessing geographically isolated communities Problems with travelling to communities because of inclement weather Patient acceptability of dental treatments and chemotherapeutics, especially during pregnancy Low cultural acceptability of gum chewing during lactation Difficulties recruiting participants within study period High cost of conducting research in rural Alaska	No outcomes assessed. Trial was discontinued because of problems recruiting and retaining study participants
Increasing access to dental care by training mid-level providers	Fiset (21)	Alaska DHATs	DHATs	Patient/provider	No comparison group	Record keeping Cavity preparation Cavity restoration Patient management Patient safety	None	DHATs unlikely to solve access to dental care problems in rural Alaska	Single examiner
	Bolin (22)	Alaska DHATs	DHATs	Patient/provider	DHATs Dentists	Clinical technical performance	None	Clinical technical performance one of many measures of quality of care	Single examiner; no intra-rater reliability data provided Control selection protocol unclear
	RTI International (23)	Alaska DHATs	DHATs	Patient/provider	DHATs Dentists	Patient satisfaction, oral health-related quality of life, and perceived access to dental care Oral health status Clinical technical performance Implementation of community-based preventive programmes	None	Difficulties recruiting and retaining qualified DHATs DHATs spend bulk of time treating patient with less emphasis on community-based preventive programmes	Too few DHATs to evaluate effect of DHATs on access to dental care Cross-sectional study design
	Bader et al. (24)	Alaska DHATs	DHATs	Patient/provider	DHATs Dentists	Clinical technical performance	None	Clinical technical performance one of many measures of quality of care	Small number of restorations evaluated
	Kiley et al. (25)	Alaska PDHAs	PDHAs	Patient/provider	Pre-PDHAs PDHAs PDHAs+intensive staff model PDHAs+additional prevention	Simulation model to compare PDHAs versus alternative service delivery models on oral health outcomes (dental utilisation, various measures of tooth decay)	None	PHDAs focus on prevention and outreach, but most communities are in need of providers who can deliver restorative care Inherent tension between improving oral health outcomes for children and adults given limited resources	Selective reporting of oral health outcomes measures The PHDAs+additional prevention model may not be acceptable to pregnant women (no evaluation of patient acceptability of alternative interventions) No evaluation of costs

Fig. 3 Conceptual model of potential multilevel strategies to address risk factors for tooth decay and reduce Alaska Native children's oral health disparities.

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Kiley DP, Haley S, Saylor B, Saylor BL. The value of evidence-based computer simulation of oral health outcomes for management analysis of the Alaska Dental Health Aide Program. University of Alaska Anchorage: Institute of Social and Economic Research. Publication ID: 1286. March 2008. [cited 2012 Oct 5]. Available from: www.iser.uaa.alaska.edu/Publications/workingpapers/WP_08.1_DHA.pdf.

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