1-http://fluoridealert.org/researchers/states/kentucky/
2-
3-School fluoridation studies in Elk Lake, Pennsylvania, and Pike County, Kentucky--results after eight years.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1229128/?page=1
4-American Association for Dental Research Policy Statement on Community Water Fluoridation
http://journals.sagepub.com/doi/abs/10.1177/0022034518797274
5- Ground-Water Quality in Kentucky: Fluoride - University of Kentucky
http://www.uky.edu/KGS/pdf/ic12_01.pdf
6-Kentucky Oral Health Program Brochure - Cabinet for Health.
https://chfs.ky.gov/agencies/dph/dmch/cfhib/Oral%20Health%20Program/beigebrochureoralhealth80107.pdf
7-
8-
9-
PIIS00028177146263
98.pdf
746 JADA, Vol. 131, June 2000
Enamel fluorosis is a hypomineralization of the
enamel caused by the ingestion of an amount of
fluoride that is above optimal levels during
enamel formation.1,2 Clinically, the appearance of
enamel fluorosis can vary. In its mildest form, it
appears as faint white lines or streaks visible
only to trained examiners under controlled exam-
ination conditions. In its pronounced form, fluo-
rosis manifests as white mottling of the teeth in
which noticeable white lines or streaks often
have coalesced into larger opaque areas.2,3 Brown
staining or pitting of the enamel also may be
present.2,3 In its most severe form, actual break-
down of the enamel may occur.2,3
In recent years, there has been an increase in
the prevalence of children seen with enamel fluo-
A B S T R A C T
Background. Few studies have evaluated the
impact of specific fluoride sources on the prevalence of
enamel fluorosis in the population. The author con-
ducted research to determine attributable risk percent
estimates for mild-to-moderate enamel fluorosis in two
populations of middle-school–aged children.
Methods. The author recruited two groups of
children 10 to 14 years of age. One group of 429 had
grown up in nonfluoridated communities; the other
group of 234 had grown up in optimally fluoridated
communities. Trained examiners measured enamel
fluorosis using the Fluorosis Risk Index and meas-
ured early childhood fluoride exposure using a ques-
tionnaire completed by the parent. The author then
calculated attributable risk percent estimates, or the
proportion of cases of mild-to-moderate enamel fluo-
rosis associated with exposure to specific early fluo-
ride sources, based on logistic regression models.
Results. In the nonfluoridated study sample,
sixty-five percent of the enamel fluorosis cases were
attributed to fluoride supplementation under the pre-
1994 protocol. An additional 34 percent were
explained by the children having brushed more than
once per day during the first two years of life. In the
optimally fluoridated study sample, 68 percent of the
enamel fluorosis cases were explained by the children
using more than a pea-sized amount of toothpaste
during the first year of life, 13 percent by having
been inappropriately given a fluoride supple.
East Grand Rapids Dentist: Flouridation Increases Lead Absorption in Childrengj6016
Holistic Grand Rapids Dental Services…Dr. Kevin Flood's Dental and Wellness Center..Cascade, Ada, East Grand Rapids, Kentwood, Caledonia, Wyoming, Bryon Center, Jenison, Rockford, Grandville, Michigan. Visit http://www.eastgrandrapidsdentist.com/.
Child Development & Environmental Toxins - Resources for Healthy Children www.scribd.com/doc/254613619 - For more information, Please see Organic Edible Schoolyards & Gardening with Children www.scribd.com/doc/254613963 - Gardening with Volcanic Rock Dust www.scribd.com/doc/254613846 - Double Food Production from your School Garden with Organic Tech www.scribd.com/doc/254613765 - Free School Gardening Art Posters www.scribd.com/doc/254613694 - Increase Food Production with Companion Planting in your School Garden www.scribd.com/doc/254609890 - Healthy Foods Dramatically Improves Student Academic Success www.scribd.com/doc/254613619 - City Chickens for your Organic School Garden www.scribd.com/doc/254613553 - Huerto Ecológico, Tecnologías Sostenibles, Agricultura Organica www.scribd.com/doc/254613494 - Simple Square Foot Gardening for Schools - Teacher Guide www.scribd.com/doc/254613410 - Free Organic Gardening Publications www.scribd.com/doc/254609890 ~
East Grand Rapids Dentist: Flouridation Increases Lead Absorption in Childrengj6016
Holistic Grand Rapids Dental Services…Dr. Kevin Flood's Dental and Wellness Center..Cascade, Ada, East Grand Rapids, Kentwood, Caledonia, Wyoming, Bryon Center, Jenison, Rockford, Grandville, Michigan. Visit http://www.eastgrandrapidsdentist.com/.
Child Development & Environmental Toxins - Resources for Healthy Children www.scribd.com/doc/254613619 - For more information, Please see Organic Edible Schoolyards & Gardening with Children www.scribd.com/doc/254613963 - Gardening with Volcanic Rock Dust www.scribd.com/doc/254613846 - Double Food Production from your School Garden with Organic Tech www.scribd.com/doc/254613765 - Free School Gardening Art Posters www.scribd.com/doc/254613694 - Increase Food Production with Companion Planting in your School Garden www.scribd.com/doc/254609890 - Healthy Foods Dramatically Improves Student Academic Success www.scribd.com/doc/254613619 - City Chickens for your Organic School Garden www.scribd.com/doc/254613553 - Huerto Ecológico, Tecnologías Sostenibles, Agricultura Organica www.scribd.com/doc/254613494 - Simple Square Foot Gardening for Schools - Teacher Guide www.scribd.com/doc/254613410 - Free Organic Gardening Publications www.scribd.com/doc/254609890 ~
Fluorosis by the Numbers: How Much Is Too Much Fluoride?Molly_Evensen
Fluoride is an essential mineral for oral health. The American Dental Association (ADA) dubbed it as “nature’s cavity fighter.” It helps harden the outer enamel of developing teeth and lessens the risk of dental caries.
Study: Water Fluoridation Helps Reduce Tooth Decay among American Children an...mahoneydds
A study published in the Journal of Dental Research shows that children and adolescents in the US with more access to fluoridated drinking water have fewer chances of having tooth decay.
Participants who have access to community water fluoridation presented a 30 percent decrease in tooth decay experience during the primary dentition during a 12 percent decrease in the permanent dentition. These numbers are higher than those who have less access to community water fluoridation.
130 The Journal of Dental Hygiene Vol. 88 • No. 2 • April 2014.docxmoggdede
130 The Journal of Dental Hygiene Vol. 88 • No. 2 • April 2014
Introduction
Early-severe childhood caries re-
mains a significant public dental
health issue in the U.S. and interna-
tionally.1 The most common chronic
disease in children, dental caries is
5-times more prevalent than asthma
and 7-times more prevalent than
hay fever.2 Approximately 19% of
U.S. children aged 2 to 4 have ex-
perienced visually detectable den-
tal decay. Data from the National
Health Nutrition Examination Survey
(NHANES) reveal that the number of
children aged 2 to 5 with dental car-
ies increased from 24 to 28% from
1999 to 2004.3 Nineteen percent of
U.S. children aged 2 to 4 have visu-
ally detectable dental caries.4 Over-
all, children of poverty experience
more extensive dental disease and
have less access to dental care.5,6 For
example, 25% of children living in
poverty have not seen a dentist be-
fore the age of 5, experience twice
the dental caries as their more afflu-
ent peers and are more likely to have
untreated oral disease.4-6
In 2005, the Virginia Department of Medical As-
sistance Services introduced the Smiles For Children
(SFC) program, providing coverage for diagnostic,
preventive and restorative/surgical procedures, as
well as orthodontic services for Medicaid, Family Ac-
cess to Medical Services Plan (FAMIS) and FAMIS
Plus children.7 The program also provides coverage
for limited medically necessary oral surgery services
for adults age 21 and older. Reasons cited by par-
ents for not involving their children in preventive
dental programs or establishing an ongoing dental
provider or dental home include the inability to take
time off from work, living a transient lifestyle and
being unable to find a dentist who participates in
the SFC program.7-11 Dentists are reluctant to par-
Oral Health Promotion: Knowledge, Confidence,
and Practices in Preventing Early-Severe Childhood
Caries of Virginia WIC Program Personnel
Lorraine Ann Fuller, RDH, MS; Sharon C. Stull, CDA, BSDH, MS; Michele L Darby, BSDH, MS;
Susan Lynn Tolle, BSDH MS
Abstract
Purpose: This study assessed the oral health knowledge, confi-
dence and practices of Virginia personnel in the Special Supple-
mental Food Program for Women, Infants and Children (WIC).
Methods: In 2009, 257 WIC personnel were electronically emailed
via an investigator-designed 22-item Survey Monkey® question-
naire. Descriptive statistics, Chi-square and Fishers Exact tests
compared personnel demographics and oral health knowledge,
confidence and practices at the p≤0.01 and 0.05 significance level.
Results: Response rate was 68%. WIC personnel were knowl-
edgeable about basic oral health concepts. More than half of those
reporting were not confident assessing for visual signs of dental
decay and do not routinely assess for visual signs of decay. Only
4% of personnel apply fluoride therapy.
Conclusion: Findings support the need for health promotion/dis-
ease pre ...
Book lets sensitization pdf_cmoh_bankura_NPPCF_Fluorosis_Medical Officer Boio...drdduttaM
Dear Consultants
Rajsthan
As per your request , I am uploading MO training booklets on NPPCF_Study Materials
I recommend Dr. Susheela Mam book for M.O. training .
1-Racism Consider the two films shown in class Night and Fog,.docxcatheryncouper
1-Racism:
Consider the two films shown in class "Night and Fog", and "Mr. Tanimoto's Journey". What do you think are the salient similarities, if any? What are the crucial differences? Why?
2- Slavery New & Old
Bales notes that New Slavery is very different from Old Slavery. What are some of the differences he describes? What are the links between New Slavery and the Globalized Economy?
Bales also notes that there are things we each can do to end slavery, but that this requires taking a "very dispassionate look at slaves as a commodity" (Bales 250). Why?
Finally, he suggests that activism without a broad-based explanatory framework is worse than none at all. Why does he think so? Do you agree? Why or why not?
3- Human- The Film
How, if at all, does the film "Human" resonate with or reflect themes explored in What Matters? Which of the characters was most compelling to you, and why?
4- Culture and Power Create Scarcity
Recognize that power and culture are inseparable, one does not exist without the other, and currently the dominant form of culture is based upon industrial production requiring essentially infinite energy supplies – which do not in fact exist. So we collectively face a terrible problem. And yet the greatest burden of this problem is being borne by those least able to do anything about it, while at the same time those who benefit most from the economic inequalities imposed by the culture of industrial production and imposed scarcity are unwilling or unable to recognize that things cannot continue as they are. This is our dilemma; one we must solve now or ignore and risk facing unimaginable chaos later.
Concerned about the ultimate implications of his theories about space, time and energy, Einstein pointed out that 20th century problems would never be solved by 19th century thinking. Indeed, by the same token, 21st century problems will not be solved with 20th century thinking either. The same can be said for oversimplified false dichotomies between 'conservatives' and 'liberals' and particularly 'capitalism' and 'communism'. The latter pair of binary opposites are 19th century ideas while the former are legacies of the 20th century.
We are well beyond the political and economic circumstances that informed such artificially limited conceptualizations of the human condition in many, many ways. And yet, these same tired inaccurate philosophical cages are still supposed to encompass the almost infinite variety and subtleties of contemporary global and local political economies? This is essentially the problem Einstein was concerned with when he noted the conceptual poverty of such willed ignorance. Our technological capacity has outstripped our cultural mechanisms of maintaining social control (consider greed: how much is enough?) and exacerbated our ability to impose physically violent solutions to complex and entirely negotiable problems. Our challenge now is to reassert the primacy of compassion and respect for differenc.
Fluorosis by the Numbers: How Much Is Too Much Fluoride?Molly_Evensen
Fluoride is an essential mineral for oral health. The American Dental Association (ADA) dubbed it as “nature’s cavity fighter.” It helps harden the outer enamel of developing teeth and lessens the risk of dental caries.
Study: Water Fluoridation Helps Reduce Tooth Decay among American Children an...mahoneydds
A study published in the Journal of Dental Research shows that children and adolescents in the US with more access to fluoridated drinking water have fewer chances of having tooth decay.
Participants who have access to community water fluoridation presented a 30 percent decrease in tooth decay experience during the primary dentition during a 12 percent decrease in the permanent dentition. These numbers are higher than those who have less access to community water fluoridation.
130 The Journal of Dental Hygiene Vol. 88 • No. 2 • April 2014.docxmoggdede
130 The Journal of Dental Hygiene Vol. 88 • No. 2 • April 2014
Introduction
Early-severe childhood caries re-
mains a significant public dental
health issue in the U.S. and interna-
tionally.1 The most common chronic
disease in children, dental caries is
5-times more prevalent than asthma
and 7-times more prevalent than
hay fever.2 Approximately 19% of
U.S. children aged 2 to 4 have ex-
perienced visually detectable den-
tal decay. Data from the National
Health Nutrition Examination Survey
(NHANES) reveal that the number of
children aged 2 to 5 with dental car-
ies increased from 24 to 28% from
1999 to 2004.3 Nineteen percent of
U.S. children aged 2 to 4 have visu-
ally detectable dental caries.4 Over-
all, children of poverty experience
more extensive dental disease and
have less access to dental care.5,6 For
example, 25% of children living in
poverty have not seen a dentist be-
fore the age of 5, experience twice
the dental caries as their more afflu-
ent peers and are more likely to have
untreated oral disease.4-6
In 2005, the Virginia Department of Medical As-
sistance Services introduced the Smiles For Children
(SFC) program, providing coverage for diagnostic,
preventive and restorative/surgical procedures, as
well as orthodontic services for Medicaid, Family Ac-
cess to Medical Services Plan (FAMIS) and FAMIS
Plus children.7 The program also provides coverage
for limited medically necessary oral surgery services
for adults age 21 and older. Reasons cited by par-
ents for not involving their children in preventive
dental programs or establishing an ongoing dental
provider or dental home include the inability to take
time off from work, living a transient lifestyle and
being unable to find a dentist who participates in
the SFC program.7-11 Dentists are reluctant to par-
Oral Health Promotion: Knowledge, Confidence,
and Practices in Preventing Early-Severe Childhood
Caries of Virginia WIC Program Personnel
Lorraine Ann Fuller, RDH, MS; Sharon C. Stull, CDA, BSDH, MS; Michele L Darby, BSDH, MS;
Susan Lynn Tolle, BSDH MS
Abstract
Purpose: This study assessed the oral health knowledge, confi-
dence and practices of Virginia personnel in the Special Supple-
mental Food Program for Women, Infants and Children (WIC).
Methods: In 2009, 257 WIC personnel were electronically emailed
via an investigator-designed 22-item Survey Monkey® question-
naire. Descriptive statistics, Chi-square and Fishers Exact tests
compared personnel demographics and oral health knowledge,
confidence and practices at the p≤0.01 and 0.05 significance level.
Results: Response rate was 68%. WIC personnel were knowl-
edgeable about basic oral health concepts. More than half of those
reporting were not confident assessing for visual signs of dental
decay and do not routinely assess for visual signs of decay. Only
4% of personnel apply fluoride therapy.
Conclusion: Findings support the need for health promotion/dis-
ease pre ...
Book lets sensitization pdf_cmoh_bankura_NPPCF_Fluorosis_Medical Officer Boio...drdduttaM
Dear Consultants
Rajsthan
As per your request , I am uploading MO training booklets on NPPCF_Study Materials
I recommend Dr. Susheela Mam book for M.O. training .
Similar to 1-httpfluoridealert.orgresearchersstateskentucky2-.docx (20)
1-Racism Consider the two films shown in class Night and Fog,.docxcatheryncouper
1-Racism:
Consider the two films shown in class "Night and Fog", and "Mr. Tanimoto's Journey". What do you think are the salient similarities, if any? What are the crucial differences? Why?
2- Slavery New & Old
Bales notes that New Slavery is very different from Old Slavery. What are some of the differences he describes? What are the links between New Slavery and the Globalized Economy?
Bales also notes that there are things we each can do to end slavery, but that this requires taking a "very dispassionate look at slaves as a commodity" (Bales 250). Why?
Finally, he suggests that activism without a broad-based explanatory framework is worse than none at all. Why does he think so? Do you agree? Why or why not?
3- Human- The Film
How, if at all, does the film "Human" resonate with or reflect themes explored in What Matters? Which of the characters was most compelling to you, and why?
4- Culture and Power Create Scarcity
Recognize that power and culture are inseparable, one does not exist without the other, and currently the dominant form of culture is based upon industrial production requiring essentially infinite energy supplies – which do not in fact exist. So we collectively face a terrible problem. And yet the greatest burden of this problem is being borne by those least able to do anything about it, while at the same time those who benefit most from the economic inequalities imposed by the culture of industrial production and imposed scarcity are unwilling or unable to recognize that things cannot continue as they are. This is our dilemma; one we must solve now or ignore and risk facing unimaginable chaos later.
Concerned about the ultimate implications of his theories about space, time and energy, Einstein pointed out that 20th century problems would never be solved by 19th century thinking. Indeed, by the same token, 21st century problems will not be solved with 20th century thinking either. The same can be said for oversimplified false dichotomies between 'conservatives' and 'liberals' and particularly 'capitalism' and 'communism'. The latter pair of binary opposites are 19th century ideas while the former are legacies of the 20th century.
We are well beyond the political and economic circumstances that informed such artificially limited conceptualizations of the human condition in many, many ways. And yet, these same tired inaccurate philosophical cages are still supposed to encompass the almost infinite variety and subtleties of contemporary global and local political economies? This is essentially the problem Einstein was concerned with when he noted the conceptual poverty of such willed ignorance. Our technological capacity has outstripped our cultural mechanisms of maintaining social control (consider greed: how much is enough?) and exacerbated our ability to impose physically violent solutions to complex and entirely negotiable problems. Our challenge now is to reassert the primacy of compassion and respect for differenc.
1. Consider our political system today, in 2019. Which groups of peo.docxcatheryncouper
1. Consider our political system today, in 2019. Which groups of people are
excluded from participating in the political process?
Please identify at least two groups of people who are excluded and engage with at least one of your colleagues and explain why you either agree or disagree with the group of people that they identified. As always, use your critical thinking skills to answer this.
2.
What speech is protected under the
first amendment
and what speech is
excluded
from first amendment protection? And why?
.
1-Ageism is a concept introduced decades ago and is defined as .docxcatheryncouper
1-Ageism is a concept introduced decades ago and is defined as “the prejudices and stereotypes that are applied to older people sheerly on the basis of their age…” (Butler, Lewis, & Sutherland, 1991).
DQ: What are some common misconceptions you have heard or believed about older adults? What can you do to dispel these myths?
2-Please use textbook as, at least, one reference.
3-Please abide by APA 7th edition format in your writing.
4-Answers should be 2-3 Paragraphs made up of 3-4 sentences each
UNIT 1 CHAPTER 4 LIFE TRANSITIONS AND HISTORY (ATTACHED)
.
1. Create a PowerPoint PowerPoint must include a minimum of.docxcatheryncouper
1.
Create a PowerPoint:
PowerPoint must include a minimum of 12 slides (including Title Slide and Reference slide). Ensure that information is cited in-text throughout the presentation. Use inspirational quotes, graphics, visual aids, and video clips to enhance your presentation. Ensure that information included on your slides is properly paraphrased and cited; the use of direct quotes is prohibited. A minimum of three sources should be included (your textbook counts); ensure sources are credible.
Once you have chosen your format, choose a type of stress (schoolwork, family, job, a relationship, etc) and answer all of the following questions:
1. Give examples that causes the stress.
2. Describe healthy coping mechanisms you can use to help with stress.
3. Discuss of the warning signs of stress is in your life.
4. Describe the short-term effects stress can have on an individual.
5. Describe the long-term effects stress can have on an individual.
.
1. Compare vulnerable populations. Describe an example of one of the.docxcatheryncouper
1. Compare vulnerable populations. Describe an example of one of these groups in the United States or from another country. Explain why the population is designated as "vulnerable." Include the number of individuals belonging to this group and the specific challenges or issues involved. Discuss why these populations are unable to advocate for themselves, the ethical issues that must be considered when working with these groups, and how nursing advocacy would be beneficial.
2.
How does the community health nurse recognize bias, stereotypes, and implicit bias within the community? How should the nurse address these concepts to ensure health promotion activities are culturally competent? Propose strategies that you can employ to reduce cultural dissonance and bias to deliver culturally competent care. Include an evidence-based article that address the cultural issue. Cite and reference the article in APA format.
.
1. Complete the Budget Challenge activity at httpswww.federa.docxcatheryncouper
1. Complete the Budget Challenge activity at: https://www.federalbudgetchallenge.org/challenges/20/pages/overview
a. Keep a record of your selections and why you decided to select them and not the other options. ( keep a record of your selections in piece of paper so you can go back and reflect on your choices in your write-up. For instance, the first choice is about investments. So, on a piece of paper write down whether you selected any of the investment choices and a quick note about why you chose (for example) to spend $30B to establish a National Infrastructure Bank but didn't select to invest in the other options.) your selections as those reflect your own personal, subjective, choices. I will grade the assignment based on whether you have provided a thoughtful written response that answers the questions posted on the instructions.
b. When you’ve finished, save your results summary page.
2. Write a 2.5+ page summary overview of your experience, discussing your budget selections and analyzing your responses. Use the following questions to guide your response, but don't be limited by them:
a. What was challenging?
b. What was easy?
c. What do your selections say about your policy priorities and political ideologies?
** source: (Author Last Name, Year, pg.)
June 2003: WAY IN THE MIDDLE OF THE AIR
“Did you hear about it?”
“About what?”
“The niggers, the niggers!”
“What about ’em?”
“Them leaving, pulling out, going away; did you hear?”
“What you mean, pulling out? How can they do that?”
“They can, they will, they are.”
“Just a couple?”
“Every single one here in the South!”
“No.”
“Yes!”
“I got to see that. I don’t believe it. Where they going — Africa?”
A silence.
“Mars.”
“You mean the planet Mars?”
“That’s right.”
The men stood up in the hot shade of the hardware porch. Someone quit lighting a pipe. Somebody else spat out into the hot dust of noon.
“They can’t leave, they can’t do that.”
“They’re doing it, anyways.”
“Where’d you hear this?”
“It’s everywhere, on the radio a minute ago, just come through.”
Like a series of dusty statues, the men came to life.
Samuel Teece, the hardware proprietor, laughed uneasily. “I wondered what happened to Silly. I sent him on my bike an hour ago. He ain’t come back from Mrs. Bordman’s yet. You think that black fool just pedaled off to Mars?”
The men snorted.
“All I say is, he better bring back my bike. I don’t take stealing from no one, by God.”
“Listen!”
The men collided irritably with each other, turning.
Far up the street the levee seemed to have broken. The black warm waters descended and engulfed the town. Between the blazing white banks of the town stores, among the tree silences, a black tide flowed. Like a kind of summer molasses, it poured turgidly forth upon the cinnamon-dusty road. It surged slow, slow, and it was men and women and horses and barking dogs, and it was little boys and girls. And from the mouths of the people partaking of this tide came the sound of a river. A summer-.
1. Connections between organizations, information systems and busi.docxcatheryncouper
1. Connections between organizations, information systems and business processes.
2. There are a number of benefits associated with cutting edge business analytics.
3. Three conditions that contribute to data redundancy and inconsistency are:
4. Network neutrality
5. Simple Object Access Protocol (SOAP).
6. Outsourcing IT-advantages and disadvantages
7. The security challenges faced by wireless networks
.
1-Experiences with a Hybrid Class Tips And PitfallsCollege .docxcatheryncouper
1-Experiences with a Hybrid Class: Tips And Pitfalls
College Teaching Methods & Styles Journal, 2006, Vol.2(2), p.9-12
Notes
This paper will discuss the author's experiences with converting a traditional classroom-based course to a hybrid class, using a mix of traditional class time and web-support. The course which was converted is a lower-level human relations class, which has been offered in both the traditional classroom-based setting and as an asynchronous online course. After approximately five years of offering the two formats independently, the author decided to experiment with improving the traditional course by adopting more of the web-based support and incorporating more research and written assignments in "out of class" time. The course has evolved into approximately 60% traditional classroom meetings and 40% assignments and other assessments out of class. The instructor's assessment of the hybrid nature of the class is that students are more challenged by the mix of research and writing assignments with traditional assessments, and the assignments are structured in such a way as to make them more "customizable" for each student. Each student can find some topics that they are interested in to pursue in greater depth as research assignments. However, the hybrid nature of the class has resulted in an increased workload for the instructor. The course has been well received by the students, who have indicated that they find the hybrid format appealing.
2-Undergraduate Research Methods: Does Size Matter? A Look at the Attitudes and Outcomes of Students in a Hybrid Class Format versus a Traditional Class Format.
Author
Gordon, Jill A.
Barnes, Christina M.
Martin, Kasey J.
Publisher
Taylor & Francis Ltd
Is Part Of
Journal of Criminal Justice Education, 2009, Vol.20 (3), p.227-249
Notes
The goal of this study is to understand if there are any variations regarding student engagement and course outcomes based on the course format. A new course format was introduced in fall of 2006 that involves a hybrid approach (large lecture with small recitations) with a higher level of student enrollment than traditional research methods courses. During the same time frame, the discipline maintained its traditional research methods courses as well. A survey was administered to all students enrolled in research methods regardless of course format in fall 2006 and spring 2007. Student responses are discussed, including information concerning the preparation, design, cost and benefits of offering a hybrid research methods course format.
3- Distance Education: Linking Traditional Classroom Rehabilitation Counseling Students with their Colleagues Using Hybrid Learning Models.
Author
Main, Doug
Dziekan, Kathryn
Publisher
Springer Publishing Company, Inc.
Is Part Of
Rehabilitation Research, Policy & Education, 2012, Vol.26 (4), p.315-321
Notes
Current distance learning technological advances allow real and virtual classrooms to unite. In this .
RefereanceSpectra.jpg
ReactionInformation.jpg
WittigReactionOfTransCinnamaldehye.docx
Wittig Reaction of trans-Cinnamaldehyde
GOAL: Identify the major isomer of the Wittig reaction
E,E-1,4-diphenyl-1,3-butadiene OR E,Z-1,4-diphenyl-1,3-butadiene
Attached are the:
1. Drawing of the overall reaction
2. Drawing of the structure of the two possible isomers
3. Reference NMR spectra of what is labeled trans, trans-1,4-diphenyl-1,3-butadiene
4. IR spectra
5. UV vis spectra
6. 1H NMR not-detailed
7. 1H NMR detailed
8. BASED ON # 4, 5 and 7 Identify the major isomer of the Wittig reaction, can the integration values of the NMR be used to give approximate percent of each isomer
IR.jpg
UV-visSpectra.jpg
NMR.jpg
NMR-DeterminePredominantIsomer.jpg
...
Reconciling the Complexity of Human DevelopmentWith the Real.docxcatheryncouper
Reconciling the Complexity of Human Development
With the Reality of Legal Policy
Reply to Fischer, Stein, and Heikkinen (2009)
Laurence Steinberg Temple University
Elizabeth Cauffman University of California, Irvine
Jennifer Woolard Georgetown University
Sandra Graham University of California, Los Angeles
Marie Banich University of Colorado
The authors respond to both the general and specific con-
cerns raised in Fischer, Stein, and Heikkinen’s (2009)
commentary on their article (Steinberg, Cauffman, Wool-
ard, Graham, & Banich, 2009), in which they drew on
studies of adolescent development to justify the American
Psychological Association’s positions in two Supreme
Court cases involving the construction of legal age bound-
aries. In response to Fischer et al.’s general concern that
the construction of bright-line age boundaries is inconsis-
tent with the fact that development is multifaceted, variable
across individuals, and contextually conditioned, the au-
thors argue that the only logical alternative suggested by
that perspective is impractical and unhelpful in a legal
context. In response to Fischer et al.’s specific concerns
that their conclusion about the differential timetables of
cognitive and psychosocial maturity is merely an artifact of
the variables, measures, and methods they used, the au-
thors argue that, unlike the alternatives suggested by Fi-
scher et al., their choices are aligned with the specific
capacities under consideration in the two cases. The au-
thors reaffirm their position that there is considerable
empirical evidence that adolescents demonstrate adult lev-
els of cognitive capability several years before they evince
adult levels of psychosocial maturity.
Keywords: policy, science, adolescent development, chro-
nological age
In our article (Steinberg, Cauffman, Woolard, Graham,& Banich, 2009, this issue), we asked whether therewas scientific justification for the different positions
taken by the American Psychological Association (APA) in
two related Supreme Court cases—Hodgson v. Minnesota
(1990; a case concerning minors’ competence to make
independent decisions about abortion, in which APA ar-
gued that adolescents were just as mature as adults) and
Roper v. Simmons (2005; a case about the constitutionality
of the juvenile death penalty, in which APA argued that
adolescents were not as mature as adults). On the basis of
our reading of the extant literature in developmental psy-
chology, as well as findings from a recent study of our own,
we concluded that the capabilities relevant to judging in-
dividuals’ competence to make autonomous decisions
about abortion reach adult levels of maturity earlier than do
capabilities relevant to assessments of criminal culpability,
and that it was therefore reasonable to draw different age
boundaries between adolescents and adults in each in-
stance.
In their commentary on our article, Fischer, Stein, and
Heikkinen (2009, this issue) raised both general and spe-
cif ...
Reexamine the three topics you picked last week and summarized. No.docxcatheryncouper
Reexamine the three topics you picked last week and summarized. Now, break out each case into a list of ethical and legal considerations that might help to analyze each case—summarize the considerations in two paragraphs for each case.
For each case, also ask one legal and one ethical question that might present. Consider the principles of ethics from Week 1 and the laws addressed this week. You should also use outside references to dig deeper into each case for your list.
3 topics identified in paper below from last week
· The Principal of Justice
· Autonomy
· Non-maleficence
Health Care Ethics
Health care ethics is a set of beliefs, moral principles and values that guide health care centers and related institutions to make choices with regard to medical care. Some health ethics include: respect for autonomy, justice and non-maleficence (Percival, 1849).
The principle of justice in health care ensures that there is respect for people’s rights, fair distribution of health resources and respect for laws that are morally acceptable. There are mainly two elements in this principle; equity and equality. Equity ensure that are all cases have equal access to treatment regardless of the patients’ status in ethnic background, age, sexuality, legal capacity, disability, insurance cover or any other discriminating factors.
It is important to study this ethical issue of justice since there have been an increasing report of doctors and medical staff failing to administer certain treatment services to certain kind of patients. Consequently, there have been debates in countries such as the UK over the refusal to give expensive treatment to patients who are likely to benefit from the treatment but cannot afford it. One ethical in the principle of justice is as to whether the health care center is creating an environment for sensible and fair use of health care resources and no particular type of patients are shun away or stigmatized. The legal question is whether the health care center is breaking the law against inequality and discrimination particularly racism, tribalism, gender insensitivity and other discrimination noted and prohibited in the country’s constitution.
The second area of health care ethics is respect for autonomy. Autonomy means self-determination or self-rule. Hence, this principle stipulates that one should be allowed to direct their health life according to their personal rationale. The patients have a right to determine their own destiny freely and independently as well as having their decision respected (Pollard, 1993).
This principle is important for study because not many people would not want to be treated as those with dementia; a disease involving loss of mental power. Many people are afraid of the prospect of not being able to decide their own fate and exercise self-determination. An ethical question in this principle of respect for autonomy is whether the health care center ensures that the patient is provided with ...
Reconstruction
Dates:
The Civil War?_________
Reconstruction? ________
9-9-12
*
*
9/7/2010
Foner Chapter 15
"What Is Freedom?": Reconstruction, 1865–1877
*
After the Civil War, freed slaves and white allies in the North and South attempted to redefine the meaning and boundaries of American freedom. Freedom, once for whites only, now incorporated black Americans. By rewriting laws, African-Americans, for the first time, would be recognized as citizens with equal rights and the right to vote, even in the South. Blacks created their own schools, churches, and other institutions. Though many of Reconstruction’s achievements were short-lived and defeated by violence and opposition, Reconstruction laid the basis for future freedom struggles.
Introduction: Sherman Land
From the Plantation to the Senate
*
After the Civil War, freed slaves and white allies in the North and South attempted to redefine the meaning and boundaries of American freedom. Freedom, once for whites only, now incorporated black Americans. By rewriting laws, African Americans, for the first time, would be recognized as citizens with equal rights and the right to vote, even in the South. Blacks created their own schools, churches, and other institutions. Though many of Reconstruction’s achievements were short-lived and defeated by violence and opposition, Reconstruction laid the basis for future freedom struggles.
Click image to launch video
Q: Chapter 15 includes a new comparative discussion on the aftermath of slavery in various Western Hemisphere societies. You see important commonalities in the struggle over land and labor in post-Emancipation societies. How do you situate the experiences of former slaves in the United States in this borrowed content.
A: Well, just as slavery was a hemispheric institution, so was emancipation. It’s useful for us in thinking about the aftermath of slavery in the United States, the Reconstruction era and after to see what happened to other slaves in places where slavery was abolished. What you see is a similar set of issues and conquests taking place everywhere slaves desire land of their own—this is the No. 1 thing, they want autonomy, they want independence from white control. All of these regions are agricultural, everywhere former slaves demand land. In some places they get land fairly effectively, like in Jamaica, West Indies, where there’s a lot of unoccupied land they can take. In some places they don’t, but that battle to who’s going to have access to land and economic resources is a commonality in the aftermath of slavery. So too is the effort of local plantation owners trying to get the plantation going again and to force slaves to work back on the plantations, or if not, to bring labor from somewhere else—in the West Indies they bring workers from China, from India, from southeast Asia to replace slaves who were moving off on land of their own. They can’t quite do that in the United States—they tried to bring ...
Record, Jeffrey. The Mystery Of Pearl Harbor. Military History 2.docxcatheryncouper
Record, Jeffrey. "The Mystery Of Pearl Harbor." Military History 28.5 (2012): 28-39.Academic Search Complete. Web. 10 Dec. 2013.
According to the article "The Mystery of Pearl Harbor," it briefly examines the reason why Japan starts a war with the United States. On December 7th, 1941, Japan with about 182 aircrafts from the first assault invade U.S. Pacific fleet of Pearl Harbor. Japan's ultimate goal was to overthrow East Asia. The main point of this article is mainly for Japan's goal for economic security and determined to achieve their goal to conquer East Asia. Moreover, they wouldn't let U.S. stop them. Japan was humiliated to be dependent on the United States, including American imported oil. Ultimately, they fought a war that could not won since U.S. was more superior. United States outproduce Japan in every category of ammunition and armaments. If someone were to ask me what this article was about, I would say that this article is an inevitable defeat from Japan.
I believe this source was definitely helpful. This article made me realize how important Pearl Harbor is. If anything, we could have lost to the Japanese and everything would change. Personally, I believe our army played a significant role during the war between Japan and United States. I believe that this source is reliable. This source can be slightly biased because in the article, it says “If the Pacific War was inevitable, was not Japan's crushing defeat as well? If so, then why did Japan start a war that, as British strategist Colin Gray has argued, it "was always going to lose?”
This article can clearly be used for a American history classes. Several of the first paragraphs include a clear understanding and a great topic for students to discuss. This would benefit students who does not know anything about Pearl Harbor. This would be appropriate for students to realize what America has been through during the 1940’s. I admit I now have a better understanding of Pearl Harbor, this article enhanced my perspective and changed the way I view it.
Hanyok, Robert J. "The Pearl Harbor Warning That Never Was." Naval History 23.2 (2009): 50-53. Academic Search Complete. Web. 11 Dec. 2013.
This article particularly argues that Americans believe that the surprising attack from Japan Navy planes could not have happened without some sort of conspiracy or warning. Without a doubt, Americans thought that U.S. political and military leaders kept this serious warning from Pearl Harbor’s commanders. Furthermore, the National Security Agency Documentary, “West Wind Clear seemed to be not found. Robert Hanyok’s attempted to clear up the issue and as a result, the warning for the chief Navy doe- breaker was just a figment of his imagination.
I believe that this article offers reliable sources. Hanyok provides source documents for historical scholars and researchers. This article was extremely helpful due to the controversy with the “West Wind Clear. The goal of this article was basically des ...
Reasons for Not EvaluatingReasons from McCain, D. V. (2005). Eva.docxcatheryncouper
Reasons for Not Evaluating
Reasons from McCain, D. V. (2005). Evaluation basics. Arlington, VA: ASTD Press, pp. 14-16.
Below are reasons to not evaluate, but there are things you can do to overcome these reasons!
· Click Edit (upper right on the tool bar) to get into edit mode.
· Add at least 2 ideas to the page to overcome one or more of these reasons for not evaluating. Please explain in enough detail that someone reading this wiki will be able to understand it!
· Add your name in parenthesis after your idea so we know who contributed which idea!
· Click Save (upper right on tool bar) to save your changes.
1. Evaluation requires a particular skill set.
· Doing evaluation requires no particular skill. It only requires a desire to look into it a course or program and ask the right questions that would answer the whether or not the course was effective. There are many tools that would help in doing an evaluation. (D. Clark)
· Skills can be learned. Learning to evaluate is simply another avenue of training. If the skills to evaluate do not exist in your organization then the training may need to start at the Trainer level before moving on to more organizational specific training, (D Casper)
2. Evaluation is not a priority.
· In order to make progress in any learning environment, it is necessary to initiate check points and measurements producing an evaluation of knowledge (Valle)
· Evaluation is never a priority until things are going bad and the reason is not clear, Evaluation helps us understand where the issues are. (Jim K)
3. Evaluation is not required.
· Currently, as students we are being evaluated to check in our progress ion order to measure our understanding of the tasks given. We get a grade, it is required for this course.(Valle)
· Why are you only providing what is required? Why not go a little further and make the training better? (J. Sprague)
4. Evaluation can result in criticism.
· In order to grow as a person or a company we all need criticism, of course this needs presented in a positive light and in a way that people can learn and grow. (Jim K)
· In today's culture where everybody gets a trophy or everybody gets an "A" no matter how they perform it is not "PC" to criticize someone and hurt their feelings! Criticism is what motivated me to succeed and go beyond just what is normal! We need to stop equating "Criticism" with "Fault Finding" and realize we do more harm than good by not pointing out shortcomings and errors. (D Casper)
5. You can't measure training.
· In my place of work in the industry, we had to measure training. Time was spent in educating employees into new ways to create a product, cost effectiveness, supply management chain and distribution. Measuring effectiveness of the training was in direct correlation with the success of the given product into market.(Valle)
· You can always measure whether or not the training was successful. The key is to look for the right types of measurements. It may be measured ...
Recognize Strengths and Appreciate DifferencesPersonality Dimens.docxcatheryncouper
Recognize Strengths and Appreciate Differences
Personality Dimensions® is the latest evolution in presenting Personality Temperament Theory. It builds on research conducted in Canada over a period or two decades, and the foundations established by the work of Carl Jung, David Keirsey, Linda Berens, as well as a history of Temperament that spans 25 centuries.
The Personality Dimensions® system utilizes a convenient card sort and short questionnaire to reveal personality preferences. In addition to being the first Temperament assessment to incorporate the Introversion/Extraversion dichotomy, Personality Dimensions® also uses four colours along with short descriptors and symbols to represent the Temperament preferences: Inquiring Green, Organized Gold, Authentic Blue, Resourceful Orange. These combined aspects create a common language of understanding with a high level of retention.Know your Personality Dimensions to...
·
· Express yourself appropriately
· Appreciate yourself & others
· Negotiate more effectively
· Narrow gaps and differences
· Identify potential problems early
· Elevate morale and enthusiasm
· Optimize team performance
· Support and encourage others
· Organize efficient teams
· Yield higher productivity
· Influence others positively
Analyzing Personality Demensions:
Introverts:
· Tend to get their energy by spending some time alone.
· Prefer to think things through in their head before sharing their ideas with the larger group. They will often listen to other ideas, conversations and reactions, taking it all in, digesting it and then share their thoughts and ideas with the larger group. By the time they share an idea it has been given a lot of consideration -- they are not just thinking out loud.
· Learn best when they have the time for quiet reflection and are able to work on their own.
· May actually find that the standard brainstorming process shuts down their creative juices as it does not allow them the time they need to internally process information before building on it or reacting to it.
· Often prefer to keep their thoughts and feelings to themselves until they are totally comfortable with the people they will be sharing them with.
· Have a tendency to think through the consequences of a situation before acting.
· Preferred mode of problem solving is to have some quiet time alone to think, reflect on the situation and formulate a solution. They often become energized by this process.
· Project a sense of quiet and calmness. Their body language and tone of voice tends to be softer.
· Tend to have a small circle of people who they call true friends. These are people with whom they are comfortable and are willing to share their thoughts and feelings with.
What causes an Introvert stress at work
Introverts tend to like things to be quieter than Extraverts. A noisy work environment can cause real stress for an Introvert.
They can find it exhausting to work with Extraverts. If an Introvert has to work in situations ...
Real-World DecisionsHRM350 Version 21University of Phoe.docxcatheryncouper
Real-World Decisions
HRM/350 Version 2
1
University of Phoenix Material
Real-World Decisions
Read the following scenarios, which represent real-world decisions, and respond to each in 150 to 200 words.
Scenario One
You are the director of production at a multinational company. Your position is in Tokyo, Japan. Recently, this division experienced production quota problems. You determine that you must identify a team leader who will lead the work team to tackle the problem. You identify several possible team leaders, including Joan, a manager who is an expatriate US citizen and has recently arrived in your company’s Japanese office. You are also aware of Bob, a European national who has worked at the facility for about a year. His experience includes reengineering production processes at one of the company’s production facilities in Europe. The final candidate is Noriko, a Japanese national who has been at the facility for several years.
Questions
The team you assemble is composed of American expatriates and Japanese nationals. Compare the three candidates for the position. Based on cultural norms and traditions, what cultural factors and management styles may benefit or present obstacles for others on the team? Explain.
Response
Scenario Two
You have been assigned to an overseas position with your company. The local government of the host country offers gifts periodically to senior management as a way of thanking them for opening a facility and employing locals. These gifts include cash or merchandise into the thousands of dollars. Typically, to refuse a gift is considered an insult. Your country’s policy is to prohibit employees from accepting anything from clients and customers of more than $50. Your employer values its relationship with the host country and government officials, and it intends to continue operating in the venue.
Questions
How would you address a situation where you are presented with a gift of more than $50? Explain your rationale. How could your actions affect your company? How could your decision affect your working relationship with your company’s and the host country’s officials?
Response
Scenario Three
Christine, the leading expert in information technology (IT) organizational design, works for a large consulting firm and has been asked to work on a temporary assignment in Saudi Arabia. One of her firm’s biggest revenue-generating customers is embarking on an initiative to redesign the IT structure to improve efficiency and effectiveness, and to align the business unit’s output with the organization’s strategic objectives. The customer has read research reports and articles Christine has published, and the chief executive officer has asked Christine to handle this project. She is excited about the professional challenge of the assignment, but she is unsure of adopting customs and practices in a Muslim country.
Questions
Discuss the ethical considerations for Christine and her company. What implications m ...
Real Clear PoliticsThe American Dream Not Dead –YetBy Ca.docxcatheryncouper
Real Clear Politics
“The American Dream: Not Dead –Yet
By Carl M. Cannon and Tom Bevan
March 6, 2019
Solid pluralities of Americans think their country is heading in the wrong direction, have lost faith in its prominent public institutions, and believe both major political parties are an impediment to realizing the American Dream. Nonetheless, that dream persists – threatened, yes, but not nearly dead.
These are the findings in the latest poll from RealClear Opinion Research, focusing on how Americans view their future possibilities and how much economic guidance and oversight should be provided by government. The answers provide a road map for the 2020 election season.
Nearly four times as many respondents say the American Dream is “alive and well” for them personally (27 percent) as those who say it’s “dead” (7 percent). The overwhelming majority express a more nuanced outlook. Two-thirds of those surveyed believe the American Dream is under moderate to severe duress: 37 percent say it is “alive and under threat” while another 28 percent say it is “under serious threat, but there is still hope.”
“In this poll, most people are telling us that the American Dream isn’t working as they believe it should be,” said John Della Volpe, polling director of RealClear Opinion Research. “The overwhelming number of people are not seeing the fruits of working hard, whether it’s through a professional (finances) or a personal (happiness) lens.”
The panel of 2,224 registered voters was probed for its views on other foundational aspects of 21st century American civic life, including their views of capitalism and socialism, and how they see the future unfolding for the younger generation of Americans.
Asked, for example, whether the American Dream is alive for those under 18 years of age, the attitudes were decidedly pessimistic -- especially among Baby Boomers and the so-called Silent Generation (Americans born between the mid-1920 and mid-1940s), those who have been in control of our public and private institutions for decades. While 23 percent of Baby Boomers and Silent Generation voters say the American Dream is alive for them (already the lowest percentage among all age groups) only 15 percent say they believe it will be there for the next generation.
Measuring attitudes about the American Dream means different things to different people. For this survey, RealClear Opinion Research defined it for the poll respondents by using Merriam-Webster’s dictionary, which describes the American Dream as “a happy way of living that can be achieved by anyone in the U.S. especially by working hard and becoming successful.”
As one would expect, perceptions of the health of this idea differ by party, age, education and class. Among the most striking findings in the survey were the variances by ethnicity. Asian-Americans are the most likely to say the American Dream is working for them (41 percent) – twice the percentage as Hispanics. Despite such differences, ...
Recommended Reading for both Papers.· Kolter-Keller, Chapter17 D.docxcatheryncouper
Recommended Reading for both Papers.
· Kolter-Keller, Chapter17 Designing & Managing Integrated Marketing Communications
· Kolter-Keller, Chapter18 Managing Mass Communications: Advertising, Sales Promotions, Events & Experiences and Public Relations
· Kolter-Keller, Chapter19 Managing Personal Communications: Direct and Interactive Marketing, Word of Mouth and Personal Selling
· PDF link to Kolter_keller 14th edition :
· http://socioline.ru/files/5/283/kotler_keller_-_marketing_management_14th_edition.pdf
· Keller,K.L.(2001).Mastering the Marketing Communications Mix: Micro and Macro Perspectives on Integrated Marketing Communication Programs. Journal of Marketing Management, Sep2001, Vol. 17 (7/8), 819-84.
· Luo, Xueming and Donthu, Naveen; Marketing's Credibility: A Longitudinal Investigation of Marketing Communication Productivity and Shareholder Value; The Journal of Marketing. Oct., 2006, Vol. 70, Issue 4, p70-91.
· Wright, E., Khanfar, N.M., Harrington, C., & Kizer,L.E. (2010). The Lasting Effects Of Social Media Trends On Advertising.Journal of Business & Economics Research, Vol. 8 (11), 73-80
Grading Rubric for both papers
· Identifies all or most of the key issues presented by the case.
· Discussion of issues reflects strong critical thinking and analytical skill.
· Discussion/analysis makes all or most of the recommendations called for by the case issues.
· Recommendations are supported by data from all or most of the relevant case facts and exhibits data.
· Data are creatively manipulated and applied. Discussion and recommendations are presented clearly, logically, and succinctly with no or few grammatical or other errors.
· Discussion/analysis reflects strong understanding of principles presented in course readings/materials.
· Where relevant, discussion/analysis employs proper APA style. Length limitations and other form/format requirements (if any) are followed.
1.The Changing Communications Environment 2 pages
Emerging media technologies have vastly empowered customers to decide whether or how they want to receive commercial content. Consumers are no longer passive recipients of marketing communications and the real challenge for a marketer is how to regain the customers’ attention through the clutter.
1 Web-based technologies can be combined with traditional media to build a successful marketing communication campaign. Cite two specific examples of companies/brands using this combination approach and discuss what made these campaigns successful. Did the two use similar techniques?
With the help of relevant examples, can you describe how modern technologies can be used to promote interactivity between the product and the customers? In this context discuss the use of social media to generate excitement around a brand. Can you cite any recently launched new products that have managed to achieve this?
2.Personal Application Paper, one and a half pages
Provide a detailed overview of Procter and Gamb ...
Redd 1PART 11. Target Child Jacob Birthdate April.docxcatheryncouper
Redd | 1
PART 1:
1. Target Child: Jacob
Birthdate: April 14,2012
Classroom: Pre-K
Chronological age range 3years 5mos-3years 6mos
Week#
Date
Time
Total Time
Area Observed
Children/Teachers
1
9/14/15
12:56-1:33
36 minutes
Whole classroom
All children(class list log)
1
9/16/15
12:15-12:22
7 minutes
Classroom and cubbies(for spelling of names)
All children (class list log)
2
9/21/15
11:50-1:00
1hour 10 minutes
Lunch table, carpet area, block area, sink area
Jacob, Kaylee, Jane, Michael, Miss Stephanie, Miss Ashely and Trent
2
9/25/15
11:04-12:07
(11:15-11:50- Outside time)
1hour 3 minutes
Playground, carpet area, lunch table
Jacob, Miss Ashely, student teacher, Mikey, Dominic, Kaylee, Farouq and Quinn
3
9/28/15
10:04-11:10
1hour 6minutes
Block area, dress up/kitchen area, art table, bathroom
Jacob, Miss Ashley, Student teacher, Kaylee, Dominic, and Jane
3
9/30/15
10:01-10:46
45minutes
Kitchen area
Jacob, Kaylee, Jane and Alexander
1-3
Total time for Weeks 1-3 (in hours & minutes) = 4 hours 47 minutes
Inside:4hours 12minutes
Outside: 35 minutes
Week#
Date
Time
Total Time
Area Observed
Children/Teachers
4
10/5/15
9:58-10:54
56minutes
Art table, Kitchen/Dress-up area, Hallway
Jacob, Miss Holly, Kaylee, Dominic, Jane, Mikey, Alexander, Farouq, Victoria and Caliana
4
10/7/15
10:48-12:15
(11:06-11:43-Outside time)
1hour 27 minutes
Playground, carpet area, lunch tables
Jacob, Kaylee, Caliana, Trent, Michael, Student teacher, Alexander, Quinn
5
10/13/15
9:16-10:30
1hour 14minutes
Carpet and kitchen area
Jacob, Miss Holly, Michael, Lucy, Dominic, Kaylee
5
10/15/15
9:15-10:30
1hour 15 minutes
Easel, water station, art table, block area
Jacob, Student teacher, Jane, Caliana, Michael, Trent, Victoria and Dominic
6
10/19/15
10:00-11:55 (11:00-11:55-
Outside time)
1hour 55minutes
Kitchen area, playground carpet area
Jacob, Miss Stephanie, Quinn, Kaylee, Trent and Jane
6
10/21/15
10:00-10:50
50minutes
Kitchen area, playground paint table
Jacob, Kaylee, Victoria, Joshua, Miss Stephanie, Miss Kelly, Harper, Quinn and Alexander
4-6
Total time for Weeks 4-6 (in hours & minutes) = 6hours 37 minutes
Inside: 5hours 9minutes
Outside: 1hour 28minutes
Week#
Date
Time
Total Time
Area Observed
Children/Teachers
7
10/26/15
9:53-10:33
40minutes
Block area and Kitchen area
Jacob, Miss Stephanie, Miss Ashley, Trent,
8
11/2/15
11:17-12:10
(11:17-11:43-
Outside Time)
53minutes
Playground and lunch table
Jacob, Trent, Harper, Miss Holly, Kaylee, Michael and Jane
8
11/4/15
11:02-12:45
(11:06-11:50 Outside Time)
1hour 43 minutes
Playground, lunch table, and carpet area
Jacob, Kaylee, Miss Ashley, Trent, Joshua, Quinn, Farouq, Dominic, and Lucy
8
11/6/15
2:07-3:00 (2:19-2:49 Outside Time)
53 minutes
Carpet area and playground
Jacob, Miss Ashley, Kaylee, Caliana, Harper, Quinn
9
11/9/15
10:53-12:00
(11:01-11:43 Outside Time)
1hour 7minutes
Playground, lunch table
Jacob, Kaylee, Miss Holly, Miss ...
The simplified electron and muon model, Oscillating Spacetime: The Foundation...RitikBhardwaj56
Discover the Simplified Electron and Muon Model: A New Wave-Based Approach to Understanding Particles delves into a groundbreaking theory that presents electrons and muons as rotating soliton waves within oscillating spacetime. Geared towards students, researchers, and science buffs, this book breaks down complex ideas into simple explanations. It covers topics such as electron waves, temporal dynamics, and the implications of this model on particle physics. With clear illustrations and easy-to-follow explanations, readers will gain a new outlook on the universe's fundamental nature.
Thinking of getting a dog? Be aware that breeds like Pit Bulls, Rottweilers, and German Shepherds can be loyal and dangerous. Proper training and socialization are crucial to preventing aggressive behaviors. Ensure safety by understanding their needs and always supervising interactions. Stay safe, and enjoy your furry friends!
This slide is special for master students (MIBS & MIFB) in UUM. Also useful for readers who are interested in the topic of contemporary Islamic banking.
MATATAG CURRICULUM: ASSESSING THE READINESS OF ELEM. PUBLIC SCHOOL TEACHERS I...NelTorrente
In this research, it concludes that while the readiness of teachers in Caloocan City to implement the MATATAG Curriculum is generally positive, targeted efforts in professional development, resource distribution, support networks, and comprehensive preparation can address the existing gaps and ensure successful curriculum implementation.
Exploiting Artificial Intelligence for Empowering Researchers and Faculty, In...Dr. Vinod Kumar Kanvaria
Exploiting Artificial Intelligence for Empowering Researchers and Faculty,
International FDP on Fundamentals of Research in Social Sciences
at Integral University, Lucknow, 06.06.2024
By Dr. Vinod Kumar Kanvaria
This presentation was provided by Steph Pollock of The American Psychological Association’s Journals Program, and Damita Snow, of The American Society of Civil Engineers (ASCE), for the initial session of NISO's 2024 Training Series "DEIA in the Scholarly Landscape." Session One: 'Setting Expectations: a DEIA Primer,' was held June 6, 2024.
This presentation includes basic of PCOS their pathology and treatment and also Ayurveda correlation of PCOS and Ayurvedic line of treatment mentioned in classics.
A review of the growth of the Israel Genealogy Research Association Database Collection for the last 12 months. Our collection is now passed the 3 million mark and still growing. See which archives have contributed the most. See the different types of records we have, and which years have had records added. You can also see what we have for the future.
Introduction to AI for Nonprofits with Tapp NetworkTechSoup
Dive into the world of AI! Experts Jon Hill and Tareq Monaur will guide you through AI's role in enhancing nonprofit websites and basic marketing strategies, making it easy to understand and apply.
How to Build a Module in Odoo 17 Using the Scaffold MethodCeline George
Odoo provides an option for creating a module by using a single line command. By using this command the user can make a whole structure of a module. It is very easy for a beginner to make a module. There is no need to make each file manually. This slide will show how to create a module using the scaffold method.
A workshop hosted by the South African Journal of Science aimed at postgraduate students and early career researchers with little or no experience in writing and publishing journal articles.
1. 1-http://fluoridealert.org/researchers/states/kentucky/
2-
3-School fluoridation studies in Elk Lake, Pennsylvania, and
Pike County, Kentucky--results after eight years.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1229128/?page
=1
4-American Association for Dental Research Policy Statement
on Community Water Fluoridation
http://journals.sagepub.com/doi/abs/10.1177/0022034518797274
5- Ground-Water Quality in Kentucky: Fluoride - University of
Kentucky
http://www.uky.edu/KGS/pdf/ic12_01.pdf
6-Kentucky Oral Health Program Brochure - Cabinet for Health.
https://chfs.ky.gov/agencies/dph/dmch/cfhib/Oral%20Health%2
0Program/beigebrochureoralhealth80107.pdf
7-
8-
9-
PIIS00028177146263
98.pdf
746 JADA, Vol. 131, June 2000
2. Enamel fluorosis is a hypomineralization of the
enamel caused by the ingestion of an amount of
fluoride that is above optimal levels during
enamel formation.1,2 Clinically, the appearance of
enamel fluorosis can vary. In its mildest form, it
appears as faint white lines or streaks visible
only to trained examiners under controlled exam-
ination conditions. In its pronounced form, fluo-
rosis manifests as white mottling of the teeth in
which noticeable white lines or streaks often
have coalesced into larger opaque areas.2,3 Brown
staining or pitting of the enamel also may be
present.2,3 In its most severe form, actual break-
down of the enamel may occur.2,3
In recent years, there has been an increase in
the prevalence of children seen with enamel fluo-
A B S T R A C T
Background. Few studies have evaluated the
impact of specific fluoride sources on the prevalence of
enamel fluorosis in the population. The author con-
ducted research to determine attributable risk percent
estimates for mild-to-moderate enamel fluorosis in two
populations of middle-school–aged children.
Methods. The author recruited two groups of
children 10 to 14 years of age. One group of 429 had
grown up in nonfluoridated communities; the other
group of 234 had grown up in optimally fluoridated
communities. Trained examiners measured enamel
fluorosis using the Fluorosis Risk Index and meas-
ured early childhood fluoride exposure using a ques-
tionnaire completed by the parent. The author then
calculated attributable risk percent estimates, or the
3. proportion of cases of mild-to-moderate enamel fluo-
rosis associated with exposure to specific early fluo-
ride sources, based on logistic regression models.
Results. In the nonfluoridated study sample,
sixty-five percent of the enamel fluorosis cases were
attributed to fluoride supplementation under the pre-
1994 protocol. An additional 34 percent were
explained by the children having brushed more than
once per day during the first two years of life. In the
optimally fluoridated study sample, 68 percent of the
enamel fluorosis cases were explained by the children
using more than a pea-sized amount of toothpaste
during the first year of life, 13 percent by having
been inappropriately given a fluoride supplement,
and 9 percent by the use of infant formula in the
form of a powdered concentrate.
Conclusions. Enamel fluorosis in the non-
fluoridated study sample was attributed to fluoride
supplementation under the pre-1994 protocol and
early toothbrushing behaviors. Enamel fluorosis in
the optimally fluoridated study sample was attrib-
uted to early toothbrushing behaviors, inappropriate
fluoride supplementation and the use of infant for-
mula in the form of a powdered concentrate.
Clinical Implications. By advising
parents about the best early use of fluoride agents,
health professionals play an important role in reduc-
ing the prevalence of clinically noticeable enamel
fluorosis.
RISK OF ENAMEL FLUOROSIS IN NONFLUORIDATED
AND OPTIMALLY FLUORIDATED POPULATIONS:
CONSIDERATIONS FOR THE DENTAL PROFESSIONAL
DAVID G. PENDRYS, D.D.S., PH.D.
5. for enamel fluorosis.17,25 The use
of infant formula in various
forms, before the infant formula
industry’s voluntary reduction
in the fluoride content of its
products, also has been associ-
ated with enamel fluorosis.12,17,33
Findings from two recent stud-
ies suggest that while the risk
of enamel fluorosis associated
with infant formula use may no
longer exist for children living
in nonfluoridated communities,
the use of formula in the pow-
dered concentrate form pre-
pared with optimally fluoridated
water may continue to be an
enamel fluorosis risk factor.21,25
While an increasing number
of studies have reported esti-
mates of the relative risk or the
increased likelihood of enamel
fluorosis associated with specif-
ic early fluoride exposures, rel-
atively few investigations have
evaluated the impact of a spe-
cific fluoride-containing agent
on the prevalence of enamel
fluorosis in the population.12,15,34
This impact is a function of
both the relative risk associated
with a specific fluoride-contain-
ing agent, as well as the preva-
6. lence of exposure to that agent
within the population. It is
thought to be best measured via
estimation of the attributable
risk percent,35 or the percentage
of all fluorosis cases that can be
explained by exposure to a spe-
cific fluoride-containing agent.
The attributable risk, therefore,
becomes an estimate of the
potential reduction in cases
that would occur were the asso-
ciated exposure modified or
eliminated. Because children
may be exposed to several dif-
ferent fluoride-containing
agents during the tooth-devel-
opment period, the most accu-
rate attributable risk percent
estimate for a specific fluoride-
rosis in both optimally fluoridat-
ed and nonfluoridated areas of
the United States.4,5 The great-
est relative increase in fluorosis
prevalence has occurred in non-
fluoridated areas.4 Dentists and
hygienists need to understand
the most likely reasons for this
increase. This will allow them to
advise parents about the most
appropriate use of fluoride to
prevent caries in their children
while minimizing the risk of
their children developing enamel
fluorosis.
7. Dating back to the classic
research of H. Trendley Dean,
it has been well-known that a
concentration of approximately
1 part per million fluoride in
the drinking water imparts sub-
stantial caries protection with
the absence of noticeable enam-
el fluorosis.6-8
Since the advent of optimal
water fluoridation, other pre-
ventive fluoride agents have
been introduced. They include
ingestible fluoride supplements
and fluoride toothpaste, which
may be ingested by young chil-
dren, although it is intended for
topical use.9-11
Studies suggest that behav-
iors associated with the early
use of fluoride toothpaste—such
as the amount of toothpaste
usually used when brushing—
are associated with enamel fluo-
rosis in both optimally fluori-
dated and nonfluoridated popu-
lations in the United States and
elsewhere.12-25 Studies further
suggest that early fluoride sup-
plements use by children living
in nonfluoridated areas have
been an important risk factor
for enamel fluorosis.21,26-32 Not
8. unexpectedly, the inappropriate
use of fluoride supplements by
children living in optimally
fluoridated areas has been
shown to be a strong risk factor
containing agent should be
adjusted for exposure to any
other fluoride-containing
agents.4,35 To date, only two
investigations have reported
adjusted attributable risk per-
cent estimates15,34; and only one
of these investigations has
reported these estimates along
with adjusted confidence inter-
vals, which gives the reader the
best sense of the statistical sig-
nificance of those estimates.34
That study also was the only
one to have reported findings
from the investigation of a U.S.
population.34
A study of Canadian children
who were current residents of
an optimally fluoridated area
reported that 72 percent of the
fluorosis cases could be attrib-
uted to beginning to brush teeth
with fluoride toothpaste during
the first two years of life.12 In
this same study, 22 percent of
the cases were attributed to the
use of infant formula.
10. inappropriately given a fluoride
supplement during the first
eight years of their lives.34
Understanding attributable
risk information reported in
the literature is important;
dentists and hygienists need to
be able to provide the parents
of young children with appro-
priate advice regarding the
early use of fluoride toothpaste
and fluoride supplements. In
this article, I report on results
of research I performed to
determine attributable risk
percent estimates for mild-to-
moderate enamel fluorosis in
two populations of middle-
school–aged children born after
the 1978 fluoride supplement
dosage revision36,37 and after
the decision by U.S. infant for-
mula manufacturers to reduce
and control the fluoride content
of their products38,39 (effective
for those born in 1980 and
after). Because comprehensive,
surface-specific analyses of the
relative risk percent estimates
associated with enamel fluoro-
sis in these two populations
have been previously report-
ed,21,25 key findings from those
reports will be only briefly
11. reviewed in this article.
MATERIALS AND
METHODS
Detailed descriptions of the
methods used in my previous
investigations are published
elsewhere21,25; therefore, only a
brief summary follows. All
study procedures involving
human subjects were approved
by the University of
Connecticut Health Center
Institutional Review Board. The
study subjects consisted of mid-
dle-school–aged children who
had grown up in either six non-
fluoridated Massachusetts and
Connecticut communities or
five optimally fluoridated
Connecticut communities.
Among the subjects who grew
up in nonfluoridated areas of
Massachusetts and Connecticut,
it was found that children who
were reported to have begun
brushing with fluoridated tooth-
paste during the first two years
of life and who reported they
usually brushed more than once
per day had an approximately
three- to fourfold increase in the
risk of enamel fluorosis, depend-
12. ing on the specific enamel sur-
faces affected.21 In this same
population, children who were
reported to have used a fluoride
supplement throughout the sec-
ond through eighth years of life
had an approximately two- to
eightfold increase in the risk of
enamel fluorosis, again depend-
ing on the specific enamel sur-
faces affected.21
The subjects in the second
population grew up in optimally
fluoridated areas in Connecti-
cut.25 These areas had begun
fluoridation many years before
these children were born, and
when the water departments
were contacted, they indicated
that episodes of below-optimum
fluoridation were rare and brief
over the lifetimes of the sub-
jects. In this population, it was
found that children who were
reported to have usually
brushed with more than a pea-
size amount of toothpaste and
who were reported to have usu-
ally brushed more than once
per day had a six- to eightfold
increase in the risk of enamel
fluorosis, depending on the spe-
cific surfaces affected.25
Children in these optimally
13. fluoridated areas who inappro-
priately were given fluoride
supplements had an approxi-
mately six- to 10-fold increase
in the risk of enamel fluorosis,
again depending on the specific
enamel surfaces affected.25 In
this population, the reported
use of infant formula in the
form of a powdered concentrate
produced an approximately
four- to 10-fold increase in the
risk of enamel fluorosis, once
again depending on the specific
surfaces affected.25
Two trained examiners
measured enamel fluorosis
using the Fluorosis Risk
Index.40 For the attributable
risk analyses presented in this
article, I included a subject as a
fluorosis case if he or she had
mild-to-moderate enamel fluo-
rosis as defined by Møller41 that
was characterized by the pres-
ence of paper-white streaking,
coalescence of opacities or both
on more than 50 percent of two
or more enamel surface zones,
anywhere throughout the denti-
tion.41 A fluorosis control was
defined as any subject who was
fluorosis-free throughout the
dentition.
15. was handwritten on the cover of
the questionnaire and into each
of the questions within the ques-
tionnaire. This was done to help
keep parents with several chil-
dren mindful of the specific child
we were asking about.
For each quarter of the first
year of life—birth through 3
months, 4 through 6 months,
and so on—parents were asked
to indicate, by checking the
appropriate box, whether the
subject’s main source of food
was breast milk, ready-to-feed
infant formula, formula in the
form of liquid concentrate, for-
mula in the form of powdered
concentrate, cow’s milk or solid
food. They also were asked to
do this for the second year of
the children’s lives as a whole.
Then they were asked to write
in the usual brand of infant for-
mula used, which allowed me to
determine whether the formula
was milk- or soy-based. For
each of the first eight years,
parents were asked to write in
the city and state (country if
not the United States) where
the subject lived for each year.
Also for each of the first eight
years, parents were asked to
indicate by checking the appro-
16. priate box whether the subject
was given plain vitamins with-
out fluoride, a vitamin drop
with fluoride, a vitamin tablet
with fluoride, a fluoride drop
alone, a fluoride tablet alone or
nothing. Parents were asked to
indicate by circling the best
choice whether the subject usu-
ally did not brush, usually
brushed once a day or usually
brushed more than once a day
during the first eight years, and
by circling the best drawing to
indicate whether the subject
usually placed a pea-sized
amount or more of toothpaste
on his or her toothbrush when
brushing during the first eight
years. Parents were asked to
indicate by circling the appro-
priate age at which the subjects
began to brush and at what
ages they helped the subjects
brush their teeth. For each of
the first eight years, parents
were asked to write in the sub-
jects’ places of residence.
Parents also were asked to indi-
cate whether they used bottled
water or a tap water filter for
more than two of the first eight
years. Finally, they were asked
to indicate their relationship to
the subjects and to indicate by
17. circling the appropriate ages
during which of the subjects’
first eight years they had lived
with them.
I included for analysis only
subjects whose questionnaires
were completed by parents who
had resided with the subjects
for the entire eight-year survey
period. I assessed questionnaire
reliability by having a random-
ly drawn sample of respondents
complete a second question-
naire that was mailed at least
one month after the completion
of the first.
I included in the nonfluori-
dated group analysis only data
from subjects born after 1979
who were residents of a non-
fluoridated community for the
entire eight-year survey period.
For the optimally fluoridated
group analysis, I included only
data from subjects born after
1979 who were residents of an
optimally fluoridated commu-
nity for the entire eight-year
survey period. I determined the
fluoridation status of prior resi-
dences other than in the survey
communities using the
Fluoridation Census.42
18. I derived adjusted attribut-
able risk percent estimates and
adjusted 95 percent confidence
intervals, or CIs, individually
for early fluoride exposures
found to be associated with an
increased risk of mild-to-
moderate enamel fluorosis,
based on logistic regression
analyses.43,44 I derived these
attributable risk percent esti-
mates separately for the nonflu-
oridated study sample and for
the optimally fluoridated study
sample. I included variables
found to have been either
important predictors of enamel
fluorosis or important covari-
ates in the relative risk analy-
ses21,25 in each of the attributa-
ble risk analyses.
RESULTS
A total of 1,091 subjects (94
percent of those enrolled and
15 percent of those eligible to
enroll) were examined for fluo-
rosis in the nonfluoridated
study sample. A total of 867
subjects (95 percent of those
enrolled and 14 percent of
those eligible to enroll) were
examined for fluorosis in the
optimally fluoridated study
20. dated sample. A 12 percent
reliability sample in the nonflu-
oridated sample and a 16
percent reliability sample in
fluoridated revealed an average
agreement between the second
and first questionnaire respons-
es of 87 percent for both study
samples.
A total of 250 subjects with
mild-to-moderate enamel fluo-
rosis and 179 fluorosis-free con-
trols were available in the non-
fluoridated study sample for
analysis, after exclusions based
on year of birth, fluoridation
history or completion of the
questionnaire by someone other
than parents who had lived
with their children throughout
the entire eight-year survey
period. These subjects ranged
in age from 10 to 13 years of
age (mean = 12.5 years), and 57
percent were girls. Eighty-six
percent of these subjects were
lifelong residents of their cur-
rent communities.
A total of 180 subjects with
mild-to-moderate fluorosis and
54 fluorosis-free control sub-
jects were available in the
fluoridated study sample for
21. analysis, again after exclusions
based on year of birth, fluorida-
tion history or completion of the
questionnaire by someone other
than parents who had lived
with their children throughout
the entire eight-year survey
period. These subjects ranged
in age from 10 to 14 years of
age (mean = 12.9 years), and 56
percent were girls.
Tables 1 and 2 show the mul-
tiple logistic-regression–
derived, adjusted attributable
risk percent estimates for these
two study samples. Individual
attributable risk percents do
not add to 100 percent, since
the variables studied in both
samples were not mutually
exclusive exposures.43
For the nonfluoridated study
sample, Table 1 shows that an
estimated 65 percent of the
cases could be attributed to or
explained by exposure to fluo-
ride supplements during the
second through eighth year of
life. Thirty-four percent of the
cases in this sample could be
explained by a history of having
begun to brush with toothpaste
during the first two years and
22. having usually brushed more
than once per day. The logistic-
regression–derived test for
750 JADA, Vol. 131, June 2000
RESEARCH
TABLE 1
29
65
34
8
6
45
* Estimate of cases attributable to each specific fluoride source
based on logistic regression modeling.21 Note that individual
attributable risk
percents do not add up to 100 percent, as fluoride
supplementation and toothbrushing history are not mutually
exclusive exposures.43
† CI: Confidence interval.
‡ Reference group: no supplementation during each of the
identified periods.
§ Reference group: began after year 2; brushed once per day.
FLUORIDATION SOURCE
23. Supplementation History‡
ATTRIBUTABLE RISK PERCENT ESTIMATES*
ATTRIBUTABLE RISK
95 PERCENT CI†
ESTIMATED PERCENTAGE OF ENAMEL FLUOROSIS
CASES ATTRIBUTABLE TO
SPECIFIC FLUORIDE SOURCES IN A NONFLUORIDATED
POPULATION.
Supplemented Year 1
Supplemented Years 2
Through 8
Toothbrushing History§
Began During Years 1
and 2; Brushed More
Than Once per Day
Began During Years 1
and 2; Brushed Once
per Day
Began After Year 2;
Brushed More Than
Once per Day
Used More Than a
Pea-sized Amount of
Toothpaste
−6-52
25. grew up in optimally fluoridat-
ed communities, Table 2 shows
that an estimated 13 percent of
the cases could be explained by
the inappropriate use of fluo-
ride supplements during the
first two years of life. Forty-six
percent of the cases could be
explained by a history of having
usually used more than a pea-
sized amount of toothpaste
when brushing and usually
having brushed more than once
per day. The test for trend
across the three toothbrushing
exposure categories was statis-
tically significant, again sup-
porting the presence of a dose-
response effect. A clear associa-
tion with age when brushing
began was not observed in this
study sample, when adjusted
for usual toothbrushing fre-
quency and amount of tooth-
paste used.
Table 2 also shows that 9
percent of the cases could be
explained by a history of having
used infant formula in the form
of a powdered concentrate as
the main source of food, espe-
cially during the last quarter of
the first year. There was no
26. suggestion of an association
with ready-to-feed infant for-
mula and no significant associa-
tion was observed with liquid
concentrate formula. The
reported use of either bottled
water or a tap water filter was
not statistically significantly
associated with fluorosis in the
analyses from either nonfluori-
dated or optimally fluoridated
populations.
DISCUSSION
Attributable risk percent esti-
mates associated with enamel
fluorosis are useful in assessing
the public health impact of par-
ticular fluoride exposures.
JADA, Vol. 131, June 2000 751
RESEARCH
6-20
25-61
8-35
−6-10
3-15
TABLE 2
27. 13
46
22
2
9
* Estimate of cases attributable to each specific fluoride source
based on logistic regression modeling.24 Note that individual
attributable risk
percents do not add up to 100 percent, as fluoride
supplementation, toothbrushing history and infant formula use
are not mutually exclusive
exposures.43
† CI: Confidence interval.
‡ Reference group: no fluoride supplementation years 1 through
2.
§ Reference group: pea-sized amount of toothpaste, once per
day.
** At 10 to 12 months of age. Referent group: no infant formula
used.
FLUORIDATION SOURCE ATTRIBUTABLE RISK PERCENT
ESTIMATE* ATTRIBUTABLE RISK
95 PERCENT CI†
ESTIMATED PERCENTAGE OF ENAMEL FLUOROSIS
CASES ATTRIBUTABLE TO
SPECIFIC FLUORIDE SOURCES IN AN OPTIMALLY
FLUORIDATED POPULATION.
29. use but are nevertheless
ingested by preschool-aged chil-
dren who typically have not
begun to expectorate any or
enough of the toothpaste with
which they brush.45,46 It is
important when estimating the
attributable risk percent specif-
ic to a particular fluoride expo-
sure that this estimate be
adjusted for the effects of the
other exposures. In this way,
the estimate of the effect of a
particular exposure is not
biased by the other exposures.
It also is important to recognize
that the effect of exposure to a
specific fluoride source within a
population is always in the con-
text of exposure to that source
along with exposure to the
other fluoride sources within
that population. In this way,
the fluorosis impact of one fluo-
ride source among several can
be estimated, and appropriate
professional and public health
action can be taken.
In this study, approximately
two-thirds of mild-to-moderate
enamel fluorosis cases observed
in optimally fluoridated areas
and at least one-third of mild-
to-moderate enamel fluorosis
cases observed in nonfluoridat-
30. ed areas could be attributed to
or explained by habits related
to the early use of fluoride
toothpaste. Three potentially
important behaviors associated
with early toothbrushing are
when toothbrushing began, the
usual daily frequency of tooth-
brushing and the usual amount
of toothpaste used during
brushing. All three of these
behaviors are indicators of the
overall fluoride ingestion associ-
ated with early toothbrushing.
In the nonfluoridated study
population, the age at which
toothbrushing began and the
usual frequency of toothbrush-
ing were most significantly
associated with enamel fluoro-
sis. While not statistically sig-
nificant, these findings suggest
that as much as 45 percent of
the enamel fluorosis cases could
be explained by a history of
having usually used more than
a pea-sized amount of tooth-
paste when brushing.
In the optimally fluoridated
study population, the usual
amount of toothpaste used
when brushing and the usual
daily frequency of toothbrush-
31. ing were most significantly
associated with enamel fluoro-
sis. The statistically significant
trends observed with early
toothpaste use in both study
samples suggests a dose-
response relationship.
A previous investigation of a
Connecticut study population
who grew up in optimally
fluoridated communities esti-
mated that approximately 70
percent of enamel fluorosis
cases could be attributed to
early toothbrushing behav-
iors.34 Findings from Canadian
and Australian studies of chil-
dren who were current resi-
dents of optimally fluoridated
areas suggested that many of
the enamel fluorosis cases seen
in those investigations also
could be attributed to early
toothbrushing habits.12,15 This
study’s findings from the opti-
mally fluoridated study sample
are consistent with those past
reports. Importantly, this
study’s findings from the non-
fluoridated study sample sug-
gest that early toothpaste use
behaviors may affect the
prevalence of enamel fluorosis,
regardless of whether the com-
32. munity is optimally fluoridated.
These findings reinforce the
important opportunity and need
for dentists and hygienists to
guide the parents of preschool-
aged children in proper fluoride
toothpaste use. Specifically,
dental professionals should
advise parents to supervise
their preschool-aged children
during toothbrushing and be
sure that the children use only
a small pea-sized amount of
toothpastes when brushing.
This advice should be given and
followed regardless of whether
the children live in an optimally
fluoridated or nonfluoridated
area. Parents should encourage
their children to expectorate
the toothpaste at the earliest
possible age rather than swal-
low it, avoid toothpastes with
flavors that would encourage
young children to wish to eat
the toothpaste, and keep tooth-
paste and all other fluoride-
containing products out of the
reach of preschool-aged chil-
dren. These findings further
support the call for a lower-
fluoride-concentration tooth-
paste, specifically for use by pre-
school-aged children.34,47-49
34. a child’s drinking water, while
keeping in mind that the child
may have access to more than
one drinking water source dur-
ing the day, both at home and
in a child-care setting, for
example. If the child’s drinking
water is not from a municipal
water supply of known fluoride
concentration, the drinking
water sources must be tested
for their fluoride content. Then,
a proper decision regarding
what fluoride supplementation,
if any, is appropriate can be
made based on the protocol in
Table 3. By doing this, dentists
can avoid inappropriately pre-
scribing fluoride supplements to
children who already are drink-
ing adequately fluoridated
water. It also is important to
determine whether children are
receiving a fluoride supplement
as part of a multiple vitamin
prescribed by a physician.
Dentists should ask parents to
bring to the office any vitamin
preparations their children are
taking so the vitamins can be
evaluated directly. Dentists also
should ask parents to inform
them if the children’s drinking
water sources change.
35. The use of bottled drinking
water complicates the process,
as bottled water’s fluoride con-
tent can vary markedly, and
manufacturers are not required
to list the fluoride content.52 A
one-time test of the fluoride
content of bottled water may
not be sufficient to prescribe a
fluoride supplement, as a
child’s family might change the
brand of bottled water it drinks
or the fluoride concentration
could change.
My current findings indicate
that 13 percent of the cases of
mild-to-moderate enamel fluo-
rosis observed in optimally
fluoridated areas could be
attributed to or explained by
the inappropriate use of fluo-
ride supplements during the
first two years of children’s
lives while they lived in these
optimally fluoridated areas.
This is not surprising. The use
of fluoride supplements by chil-
dren living in optimally fluori-
dated areas has never been
recommended by any profes-
sional organization, given
the likelihood of causing an
above-optimal ingestion of fluo-
ride.50, 51,53-55 Fortunately, the
36. percentage of cases attributa-
ble to inappropriate fluoride
supplementation was relatively
low in this study population
and was approximately one-
half that reported in the only
previously published report of
the attributable risk associated
with enamel fluorosis and
inappropriate fluoride supple-
mentation.34 Nevertheless, this
finding illustrates the need for
dentists and hygienists to
serve as a source of guidance
to parents as to the proper use
of fluoride supplements.
The findings of this investi-
gation suggest that nearly 10
percent of the enamel fluorosis
cases in optimally fluoridated
areas could be explained by
having used infant formula in
the form of a powdered concen-
trate during the first year. I
observed no suggestion of an
association between enamel
fluorosis and infant formula—
in any form—in the nonfluori-
dated population. These find-
ings support the continued con-
JADA, Vol. 131, June 2000 753
RESEARCH
37. None
None
None
None
TABLE 3
None
None
0.25 mg/day
0.50 mg/day
None
0.25 milligrams
per day‡
0.50 mg/day
1.00 mg/day
* Revised schedule accepted by the American Dental
Association,50 the American Academy of Pediatric Dentistry
and the American
Academy of Pediatrics.
† ppm: Parts per million.
‡ 2.2 mg sodium fluoride contain 1 mg fluoride ion.
AGE
39. Therefore, other studies will
need to be conducted to confirm
these findings. In the interim,
however, it may be prudent to
recommend to parents living in
optimally fluoridated areas who
are feeding formula to their
infants, that they either use a
ready-to-feed formula or pre-
pare formula from concentrate
using bottled water with a
known low-fluoride concentra-
tion. Care should be taken,
however, to explain to the par-
ent that drinking optimally
fluoridated water by itself is not
a risk factor for noticeable
enamel fluorosis,6,7 and that
drinking optimally fluoridated
water has proven important
caries preventive benefits.7
The questionnaire used in
these investigations originally
was judged to possess content
validity (that is, adequacy of the
questions to measure what the
questionnaire is suppose to
measure)57,58 by me, my col-
leagues, nondental–trained
pretesters and a National
Institutes of Health scientific
review panel. Throughout its use
in five separate investigations of
several thousand subjects, there
have been few questions raised
40. by respondents relative to the
meaning of questions. Beyond
this, questions in this question-
naire have shown considerable
predictive validity57,58 as used in
the specific investigation report-
ed in this article, as well as in
previous investigations in which
it has been used. For example,
as hypothesized in previous
toothpaste ingestion studies,47
adjusted multivariate analyses
have consistently shown specific
early toothpaste-use variables to
be associated with enamel fluo-
rosis diagnosed by examiners
blind to the children’s fluoride
exposure histories. This supports
the likelihood that the question-
naire has measured what it
intended to measure.
In this type of study (case-
controlled), guessing on the
part of questionnaire respon-
dents always diminishes the
observed association between
fluoride exposure and fluorosis
or hides it entirely.59 In con-
trast, if responses were biased
such that a history of exposure
to one fluoride source really
reflected a true exposure to a
different fluoride source, then
41. the potential for an observed
spurious association would
exist. In this situation, howev-
er, adjustment for the true risk
factor by use of a multivariate
analyses would reveal a true
lack of association between the
spurious factor and fluorosis.
Therefore, the use of fully
adjusted, multivariate analyses
in this investigation lends fur-
ther support to the validity of
observed associations.
CONCLUSIONS
The findings reported in this
article suggest that early tooth-
brushing habits have an impor-
tant impact on the prevalence
of mild-to-moderate enamel fluo-
rosis in both nonfluoridated and
optimally fluoridated areas. At
least one-third of the fluorosis
cases in nonfluoridated areas
and two-thirds of the cases in
optimally fluoridated areas
could be explained by specific
patterns of early fluoride tooth-
paste use.
Approximately two-thirds of
mild-to-moderate enamel fluoro-
sis cases in nonfluoridated areas
could be explained by the use of
42. fluoride supplements under the
pre-1994 supplementation pro-
tocol. Inappropriate use of fluo-
ride supplements explained 13
percent of fluorosis cases in
optimally fluoridated areas. An
additional 9 percent of fluorosis
cases in optimally fluoridated
areas were explained by the use
of infant formula in the form of
a powdered concentrate. This
relationship with infant formula
use was not seen in nonfluori-
dated areas.
These findings reinforce the
important role that health pro-
fessionals can have in reducing
the prevalence of enamel fluoro-
sis in U.S. children today and
suggest that much of the clini-
cally noticeable enamel fluoro-
sis seen today could be prevent-
ed by specific changes in early
childhood behaviors. In particu-
lar, providing the parent of a
young child with appropriate
advice regarding the early use
of fluoride toothpaste and fluo-
ride supplements may have a
significant impact on the preva-
lence of enamel fluorosis in
both nonfluoridated and opti-
mally fluoridated populations. �
Dr. Pendrys is an associate professor,
44. measuring the clinical manifestations of den-
tal fluorosis: overview and critique. Adv Dent
Res 1994;8(1):39-55.
4. Pendrys DG, Stamm JW. Relationship of
total fluoride intake to beneficial effects and
enamel fluorosis. J Dent Res 1990;69:529-38.
5. Clark DC. Trends in prevalence of dental
fluorosis in North America. Community Dent
Oral Epidemiol 1994;22:148-52.
6. Dean HT. The investigation of physiologi-
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Moulton FR, ed. Fluorine and dental health.
Washington: American Association for the
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Publication 19.
7. Dean HT. Fluorine in the control of den-
tal caries. Int Dent J 1954;4:311-77.
8. Newbrun E. Effectiveness of water fluori-
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9. Marthaler T. Clinical cariostatis effects
of various methods and programs. In:
Ekstrand J, Fejerskov O, Silverstone LM,
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10. Murray JJ, Rugg-Gunn AJ, Jenkins
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11. Riordan PJ. Fluoride supplements in
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12. Osuji OO, Leake JL, Chipman ML,
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for dental fluorosis in a fluoridated communi-
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13. Evans DJ. A study of developmental
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class children residing in a non-fluoridated
area. Community Dent Health 1991;8(1):31-8.
14. Milsom K, Mitropoulos CM. Enamel
defects in 8-year-old children in fluoridated
and non-fluoridated parts of Chesire. Caries
Res 1990;24:286-9.
15. Riordan PJ. Dental fluorosis, dental
caries and fluoride exposure among 7-year-
olds. Caries Res 1993;27(1):71-7.
16. Holt RD, Morris CE, Winter GB,
Downer MC. Enamel opacities and dental
caries in children who used a low fluoride
toothpaste between 2 and 5 years of age. Int
Dent J 1994;44:331-41.
17. Pendrys DG, Katz RV, Morse DE. Risk
factors for enamel fluorosis in a fluoridated
population. Am J Epidemiol 1994;140:461-71.
46. 18. Skotowski M, Hunt R, Levy S. Risk fac-
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patients. J Public Health Dent 1995;55:154-9.
19. Ellwood R, O’Mullane D. Dental enamel
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of fluoride in their drinking water. Caries Res
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20. Lalumandier J, Rozier R. The preva-
lence and risk factors of fluorosis among
patients in a pediatric dental practice.
Pediatr Dent 1995;17:19-25.
21. Pendrys DG, Katz RV, Morse DE. Risk
factors for enamel fluorosis in a nonfluoridated
population. Am J Epidemiol 1996;143:808-15.
22. Rock W, Sabieha A. The relationship
between reported toothpaste usage in infancy
and fluorosis of permanent incisors. Br Dent
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23. Wang N, Gropen AM, Ogaard B. Risk
factors associated with fluorosis in a non-
fluoridated population in Norway. Community
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24. Mascarenhas AK, Burt BA. Fluorosis
risk from early exposure to fluoride tooth-
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25. Pendrys DG, Katz RV. Risk factors for
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children born after the U.S. manufacturers’
47. decision to reduce the fluoride concentration
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26. Holm A-K, Andersson R. Enamel miner-
alization disturbances in 12-year-old children
with known early exposure to fluorides.
Community Dent Oral Epidemiol 1982;10:
335-9.
27. Pendrys DG, Katz RV. Risk of enamel
fluorosis associated with fluoride supplemen-
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use. Am J Epidemiol 1989;130:1199-208.
28. Kumar JV, Green EL, Wallace W,
Carnahan T. Trends in dental fluorosis and
dental caries prevalences in Newburgh and
Kingston, N.Y. Am J Public Health 1989;
79(5):565-9.
29. Woolfolk MW, Faja BW, Bagramian RA.
Relation of sources of systemic fluoride to
prevalence of dental fluorosis. J Public
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30. Bohaty BS, Parker WA, Seale NS,
Zimmermann ER. Prevalence of fluorosis-like
lesions associated with topical and systemic
fluoride usage in an area of optimal water
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31. Ismail AI, Brodeur JM, Kavanagh M,
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of dental caries and fluorosis in students, 11-
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32. Riordan PJ, Banks JA. Dental fluorosis
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33. Forsman B. Early supply of fluoride and
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34. Pendrys DG. Risk of fluorosis in a fluo-
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35. Coughlin SS, Benichou J, Weed DL.
Attributable risk estimation in case-control
studies. Epidemiol Rev 1994;16(1):51-64.
36. Driscoll WS, Horowitz HS. A discussion
of optimal dosage for dietary fluoride supple-
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37. American Academy of Pediatrics
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1979;63:150-2.
38. Feigal RJ. Recent modifications in the
use of fluorides by children. Northwest Dent
1983;62(5):19-21.
39. Johnson J Jr, Bawden JW. The fluoride
content of infant formulas available in 1985.
Pediatr Dent 1987;9(1):33-7.
49. 40. Pendrys DG. The Fluorosis Risk Index:
a method for investigating risk factors. J
Public Health Dent 1990;50:291-8.
41. Møller IJ. Clinical standards used for
diagnosing fluorosis. In: McClure FJ, ed.
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Welfare; 1970:72.
42. Fluoridation census 1992. Atlanta, Ga.:
U.S. Department of Health and Human
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LA, Schairer C. Estimating the population
attributable risk for multiple risk factors
using case-control data. Am J Epidemiol
1985;122:904-14.
44. Greenland S. Applications of stratified
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S, eds. Modern epidemiology. 2nd ed.
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45. Barnhart WE, Hiller LK, Leonard GJ,
Michaels SE. Dentifrice usage and ingestion
among four age groups. J Dent Res
1974;53:1317-22.
46. Dowell TB. The use of toothpaste in
infancy. Br Dent J 1981;150:247-9.
47. Beltran ED, Szpunar SM. Fluoride in
toothpastes for children: suggestion for
change. Pediatr Dent 1988;10:185-8.
50. 48. Horowitz HS. The need for toothpaste
with lower than conventional fluoride concen-
trations for preschool-aged children. J Public
Health Dent 1992;52:216-21.
49. Burt BA. Changing patterns of systemic
fluoride intake. J Dent Res 1992;71:1228-37.
50. Burrell KH. Systemic and topical fluo-
rides. In: Ciancio S., ed. ADA guide to dental
therapeutics. Chicago: ADA Publishing Co.
Inc.; 1998:214-25.
51. Committee on Nutrition, American
Academy of Pediatrics. Fluoride supplemen-
tation for children: interim policy recommen-
dations. Pediatrics 1995;95:777.
52. Levy SM, Kiritsy MC, Warren JJ.
Sources of fluoride intake in children. J
Public Health Dent 1995;55(1):39-52.
53. American Dental Association Council on
Dental Therapeutics. Accepted dental re-
medies. 32nd ed. Chicago: American Dental
Association; 1967:395-420.
54. American Academy of Pediatrics
Committee on Nutrition. Fluoride as a nutri-
ent. Pediatrics 1972;49:456-60.
55. American Academy of Pediatrics
Committee on Nutrition. Fluoride supplemen-
tation: revised dosage schedule. Pediatrics
1979;63:150-2.
52. 1. The program is primarily for pre-school children (6 months–6
years), but may be provided up to age 16 (targeting children
who do not attend a school with fluoridated water), who are not
presently receiving fluoridated drinking water, other fluoride
supplements, or vitamins with fluoride.
2. Whether or not a child is receiving fluoride can be
determined by the answers to questions on the questionnaire and
consent form (OH-9). A copy of the form is included in this
section.
3. When bottled water is being used as the primary source of
drinking water, the fluoride content of the water should be
determined. If the child’s legal representative is unaware of the
fluoride content of the bottled water, there are several sources
of information, which can be helpful in learning the fluoride
content of different brands of bottled water. Generally, bottled
water has a toll-free phone number printed on the label, or a
product web site, which can be accessed to learn the fluoride
content of the bottled water. Additional sources for learning the
fluoride content of bottled water can be found at International
Bottled Water Association (IBWA) Information Hotline: 1-800-
WATER-11 or the International Bottled Water Association
Website http://www.bottledwater.org/default.htm. Do not
submit a sample of bottled water for testing, without first
attempting to determine the fluoride content of the bottled
water.
4. If the child is not receiving fluoride in the water supply, an
analysis of the natural fluoride content of the home water
supply must be performed prior to prescribing fluoride
supplementation. Instructions for taking and submitting a water
sample are provided on the reverse side of “Information for
Parents or Guardians”.
53. 5. The maximum amount of fluoride a child under six should
receive is 0.5 mg. fluoride ion per day.
6. Fluoride drops (8 drops–1 mg. fluoride ion) are packaged in
plastic bottles containing one ounce liquid with about 500 drops
(62.5 mg. fluoride ion) per bottle.
7. Fluoride chewable tablets (0.5 mg. fluoride ion) are packaged
in plastic bottles containing 120 tablets (60 mg. fluoride ion)
per bottle.
8. Dosage levels of fluoride drops or tablets depend on the age
of the child and the amount of fluoride in the drinking water
(from fluoride water sample tests). The dosage schedule for
fluoride drops or tablets is included in the fluoride supplement
protocols. For patients with abnormal fluoride test results of
water samples submitted to the State Lab, issuing of fluoride
supplements (drops or tablets) and follow-up should be followed
per protocol.
9.
If the test results from the water sample are:
· Equal to or greater than 2.00 ppm fluoride concentration,
submit another sample of the water source to the State Lab for
confirmation testing.
· If both water samples are equal to or greater than 2.00 ppm up
to 4.00 ppm fluoride concentration, recommend to the parent or
guardian that children equal to or less than 8 years of age
should consume another source of water.
· Equal to or greater than 4.00 ppm fluoride concentration,
recommend that both children and adults should consume
another source of water.
· The Environmental Protection Agency classifies water with
equal to or greater than 2.00 ppm fluoride concentration as the
Secondary Containment Level and water with equal to or greater
than 4.00 ppm fluoride concentration as the Maximum
54. Containment Level for fluoride in water.
· When both water samples are equal to or greater than 4.00
ppm fluoride concentration, the nurse working with the Fluoride
Supplement Program in the local health department should
contact the local health department environmentalists and
request an investigation of the water source.
· If the second water samples, comes back less than 2.00 ppm,
submit a third water sample to the State Lab for testing.
· If fluoride concentration in two of the three samples is less
than 2.00 ppm, follow the Fluoride Supplements Protocols for
water samples with fluoride concentrations less than 2.00 ppm.
If the fluoride concentration in two of the three samples is equal
to or greater than 2.00 ppm, follow Fluoride Supplement
Protocols for water samples with fluoride concentrations equal
to or greater than 2.00 ppm.
· For further clarifications and directions, call the Oral Health
Program at 502-564-3246, extension 4421.
10. Orders for fluoride supplement drops or tablets must be
signed by the health officer, another physician, a dentist, or
another health professional with prescriptive authority.
Protocols may be used—one copy will cover all children in the
program. A sample copy is included in this section. If
prescription blanks are used, a signed prescription for fluoride
must be in each child’s folder.
11. Parents or guardians must be advised concerning the
importance of giving their child no more than the prescribed
amounts of fluoride. It should be called to the attention of the
parent or guardian that excessive amounts (i.e., more than 2 mg.
per day) over an extended period of time (two or three months)
may cause tooth discoloration during their development; with
white spots appearing on the child’s permanent teeth. In
addition, they need to be told of the potentially toxic nature of
fluoride when ingested in large doses at a single time.
55. If, for example, a 22 pound child takes 264 mg. of sodium
fluoride
(120 mg. fluoride ion) at any single time, symptoms of acute
toxicity
can occur (stomach upset, vomiting). The minimum lethal dose
for a
22-pound child is 480 mg. of sodium fluoride.
12. If it is determined that a child will participate in a
preventive dental program, a questionnaire and consent form,
the fluoride analysis of home water supply report, and a record
of the amount of fluoride to be provided, if needed, shall be
made a part of the child’s permanent health record. (Each
participating child in the family must have a signed
questionnaire and consent form and a record of the amount of
fluoride to be taken.)
13. If more than one child in a family is to receive the fluoride
supplement, written instructions for each child must be given to
the parent.
14. A 3-month supply of supplements may be provided for each
child in a family. Empty containers should be returned before
providing a replacement. At this time, a determination should
be made whether circumstances affecting the amount of fluoride
supplement to be provided have changed, such as change in
address, change in water source or the ‘aging out’ of the
impacted children. Questions to Ask Parents
a. Have you moved?
b. Have you changed your water supply? (Hint: even redrilling
a well may impact the fluoride intake of the family.)
c. Has the child been placed on a vitamin supplement with
fluoride?
Fluoride Supplementation Recommendations are based on the
56. current guidelines of the American Dental Association,
http://www.ada.org/2684.aspx#dosschedule
For additional information, please call the Oral Health
Administrator at 502-564-3246, ext 4421.
Water Samples Tested for Fluoride Concentration
Results of Initial Water Sample Test
Fluoride Concentration
Equal to or greater than 2.00 ppm
Submit another sample of the water source to the State Lab for
testing
Less than 2.00 ppm
Follow Fluoride Supplement Protocols
57. Less than 2.00 ppm
Submit another sample of the water source to the State Lab for
testing
Equal to or greater than 4.00 ppm
Recommend children and adults consume another source of
water
RN/RDH responsible for Fluoride Supplement Program at LHD
should contact LHD environmentalist and request an
investigation of the water source
Equal or greater than 2.00 ppm to 4.00 ppm
Recommend children 8 years of age and younger consume
another source of water
2 water samples equal to or greater than 2.00 ppm
Follow chart for readings equal to or greater than 2.00 ppm
2 water samples less than 2.00 ppm
58. Follow Fluoride Supplement Protocols
For further information or directions, contact
the Oral Health Program
502-564-3246 x 4421
FLUORIDE SUPPLEMENT PROTOCOL
Infants and preschool children who are not drinking fluoridated
water or who are not taking vitamins with fluoride should be
given this essential nutrient. A laboratory test done on a sample
of the drinking water supply will tell how much fluoride is in
the water and the amount of the supplement that may be needed.
Call the Oral Health Program at 502-564-3246 to order forms,
fluoride supplements, water sample, and collection kits or if
further information is needed.
HEALTH RISK OR CONDITION
TREATMENT/ INTERVENTION
EDUCATION/ COUNSELING
FOLLOW-UP
Unfluoridated drinking water source may be:
· Well
· Cistern
· Bottled
· Spring
Distribute one (1) bottle of fluoride drops and/or one (1) bottle
of fluoride tablets to each child with individualized doses as
follows:
NaFrinse Drops – 1 bottle has about 500 drops fluoride.
NaFrinse Tablets – 1 bottle contains 120 tablets.
Children under 3 are not issued tablets. Dosage depends on age
of child and amount of fluoride in drinking water.
At each preventive visit ask:
1. Have you moved?
59. 2. Has the source of your child’s drinking water changed?
3. Is child taking vitamin with fluoride supplement?
Yes response to #1 and 2—assess new water supply, if indicated
Yes response to #3—discontinue fluoride supplementDOSAGE
Age of child
Fluoride in water
0 to 0.3 ppm
Fluoride in water
0.3 to 0.6 ppm
Fluoride in water
0.6 ppm and above
Age birth – 6 months
None
None
None
Age 6 months – 3 yrs
2 drops – .25 mg 1 time per day
(8 month supply)
None
None
Age 3 – 6 yrs
4 drops – .50 mg 1 time per day
(4 month supply)
or
1 tablet – .50 mg 1 time per day
(About a 4 month supply)
2 drops – .25 mg 1 time per day
(8 month supply)
Must give drops. There are no .25 mg tablets.
None
Age 6 – 16 yrs *
*Children who do not attend school with a fluoridated water
supply may continue in the program.
8 drops – 1.0 mg 1 time per day
60. (2 month supply)
or
2 tablets – .50 mg 1 time per day (2 month supply)
4 drops – .50 mg 1 time per day
(4 month supply)
or
1 tablet – .50 mg 1 time per day
(4 month supply)
None
Dispose of unused drops or tablets by:
· Returning any unused liquid or tablets to LHD
· Flushing unused liquid or tablet down toilet
· Placing unused liquid or tablets in disposable trash container
Source: American Dental Association’s Council on Scientific
Affairs: Fluoride Supplement Dosage Schedule: 2010
_____________________________________________________
_____
Physician, Dentist, Other
Date
PIIS00028177146282
69.pdf
C O M M E N T A R Y G U E S T E D I T O R I A L
628 JADA, Vol. 140 http://jada.ada.org June 2009
Editorials represent the opinions of the authors
and not those of the American Dental Association.
61. Fluoridated toothpaste
and the prevention of early
childhood caries
A failure to meet the needs
of our young
I
n the United States, dental caries is on the rise in children, es-
pecially among the very young and the poor.1 The cause is not
fully understood but likely is related to the consumption of in-
creasingly available, inexpensive foods containing excess sug-
ars, as well as to the now-ubiquitous habit of snacking and
drinking sweetened drinks throughout the day.2,3
Dental services for low-income children in the United States,
cov-
ered through the Early Periodic Screening, Diagnosis and
Treatment
(EPSDT) Program—Medicaid’s child health insurance
program—
have achieved limited success in reducing dental caries. Access
to
dentists accepting Medicaid payment remains a major obstacle
for
these children.4 As a consequence, in some states, public health
offi-
cials have encouraged medical care providers to screen children
from
birth to 24 months of age for dental care needs and to apply
sodium
fluoride varnish during primary care visits.5 Researchers are
investi-
gating other strategies, such as combining povidone-iodine and
fluo-
62. ride varnish or xylitol syrups and confections.6,7
A more accessible and less costly strategy to prevent caries
among
young children is the regular use of fluoridated toothpaste. Con-
cerned about the rising rates of early childhood caries (ECC), an
ex-
pert panel convened in 2007 by the U.S. government
recommended
that children younger than 2 years who are at high risk of
experienc-
ing caries brush twice per day with a “smear” of regular U.S.
fluo-
ride toothpaste (typically containing about 1,100 parts per
million
fluoride) and that children aged 2 to 6 years brush twice daily
with
no more than a pea-sized amount of U.S. fluoridated
toothpaste.8
Regular toothpaste typically contains about 1,100 parts per
million
fluoride.
However, there is resistance among dentists, physicians and
par-
ents in the United States to using regular fluoridated toothpaste
with very young children; the U.S. Food and Drug
Administration
(FDA) Drug Facts label discourages its use in this population.
Fluoridated toothpaste is packaged with the mandatory warning:
“Keep out of reach of children under 6 years of age. If more
than
used for brushing is accidentally swallowed, get medical help or
con-
64. ommendation will have little
impact, particularly while the
FDA limits the directions for
use to “adults and children
2 years of age and older.”9
The concentration of fluoride
in toothpaste varies from coun-
try to country in accord with
government regulations, which
makes it difficult to compare
study results. The FDA allows
dentifrices containing 850 to
1,150 ppm total fluoride for use
by children 2 years and older
and 1,500 ppm fluoride for use
by those 6 years and older.
However, consumers and health
care providers often do not un-
derstand the distinction. The la-
beling is confusing because of
the different forms of fluoride
used and the use of percent
weight/volume measures; un-
derstanding these technical
terms requires health literacy
beyond that of many Americans.
It is time for the dental pro-
fession, the dental industry and
the government to reconsider
instructions to parents regard-
ing the use of fluoridated tooth-
paste for children younger than
2 years. Unfortunately, the lit-
erature concerning toothpaste
65. use in the very young is scant.
Fluoridated toothpaste is highly
effective in preventing caries in
children’s permanent denti-
tion,10 but only one study has
demonstrated its efficacy in
doing so in the primary denti-
tion of very young children.
Described by its authors as an
effectiveness study of a program
for parents with low incomes,
not a trial of toothpaste’s effica-
cy, it nonetheless provided a
comparison of the use of fluori-
dated toothpaste—either
440 ppm (monosodium fluoride
0.304 percent weight/volume) or
1,450 ppm (sodium fluoride 0.32
percent weight/volume)—with
no use of fluoridated tooth-
paste.11 The investigators as-
signed families to receive tooth-
paste and educational materials
regularly by mail while their
children were aged 1 to 51/2
years. Clinical examinations
conducted when the children
were 5 to 6 years old found an
advantage for children in the
1,450-ppm fluoride group rela-
tive to those in the 440-ppm
group and to those in the un-
treated control group. Overall,
they found that the 440-ppm
66. fluoride intervention had no ad-
vantage relative to the control.
In a study of 1,100-ppm fluoride
toothpaste used by preschool
children in China, You and col-
leagues12 reported equivocal
findings. This latter study does
not meet FDA scientific stand-
ards for a randomized clinical
trial of a regulated drug, but its
results suggest that further in-
vestigation of fluoridated tooth-
paste in very young children is
warranted.
The benefit identified by
Davies and colleagues11 of use of
the 1,450-ppm toothpaste was
not without associated risk. A
follow-up study found that those
who received the 1,450-ppm flu-
oride toothpaste had significant-
ly more fluorosis—some with
fluorosis scores in the range con-
sidered esthetically objection-
able according to standardized
measures used in public
health—than did those who re-
ceived the 440-ppm fluoride
toothpaste.13 Scores observed in
the objectionable range were
among children who lived in rel-
atively less deprived communi-
ties, suggesting an association
between better adherence to
67. home hygiene goals (that is,
brushing begun at an early age)
and greater risk of developing
fluorosis. Data from Bentley and
colleagues14 suggested the same.
Instructing parents to use a
smear or a pea-sized amount of
fluoride toothpaste with their
young children is not universal-
ly effective in reducing the
amount applied to the tooth-
brush. Also, it may be possible
to apply too little toothpaste.
Itthagarun and colleagues15 con-
cluded, “Reduction of the
amount of fluoride toothpaste to
less than a pea-size in order to
minimize the risk of fluorosis
should be undertaken with cau-
tion because it may compromise
the cariostatic effects of the
toothpaste, as shown by in vitro
studies.” Other researchers had
reached a similar conclusion in
an earlier study involving sali-
vary fluoride analyses.16 Thus,
the amounts of U.S. 1,100-ppm
fluoride toothpaste being recom-
mended for use by our youngest
children may be ineffective.
In the United States, in con-
trast to some other countries
(such as England and
Australia), no fluoridated tooth-
69. in the United States who are at
high risk of developing caries—
and changing instructions for
use on toothpaste labels, if ap-
propriate—can benefit many
children at little cost relative to
current investments in dental
research and profits from oral
care products. Parents and pro-
fessionals in poor and minority
communities in the United
States have told us in the
course of our research that they
would support a randomized
placebo-controlled study of a
special fluoridated toothpaste
for infants and toddlers. Thus,
we conclude on the basis of ex-
isting science and the rising lev-
els of dental caries that clinical
trials of fluoridated toothpaste
for very young children in the
United States are overdue. ■
Dr. Milgrom is a professor, Department of
Dental Public Health Sciences, and director,
Northwest Center to Reduce Oral Health
Disparities, University of Washington, Box
357475, Seattle, Wash. 98195-7475, e-mail
“[email protected]”. Address reprint re-
quests to Dr. Milgrom.
Dr. Huebner is an associate professor,
Department of Health Services, University of
Washington, Seattle, and the director, gradu-
70. ate program in Maternal and Child Health
Public Health Leadership, University of
Washington, Seattle.
Dr. Ly is an acting assistant professor,
Department of Dental Public Health Sciences,
University of Washington, Seattle.
Disclosure. None of the authors reported
any disclosures.
The development of this article was sup-
ported in part by grant U54DE019346 from
the National Institute of Dental and
Craniofacial Research, National Institutes of
Health, Bethesda, Md.
1. U.S. Department of Health and Human
Services. Figure 21-1: Progress quotient chart
for focus area 21—oral health. In: Healthy
People 2010 Midcourse Review. Modified
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midcourse/html/tables/pq/PQ-21.htm”.
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Determinants of early childhood caries in low-
income African American young children.
Pediatr Dent 2008;30(4):289-296.
3. Thitasomakul S, Piwat S, Thearmontree
A, Chankanka O, Pithpornchaiyakul W,
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71. 4. Milgrom P, Weinstein P, Huebner C,
Graves J, Tut O. Empowering Head Start to
improve access to good oral health for chil-
dren from low income families (published on-
line ahead of print Feb. 2, 2008). Matern
Child Health J.
5. dela Cruz GG, Rozier RG, Slade G.
Dental screening and referral of young chil-
dren by pediatric primary care providers.
Pediatrics 2004;114(5):e642-e652.
6. Berkowitz RJ, Koo H, McDermott MP, et
al. Adjunctive chemotherapeutic suppression
of mutans streptococci in the setting of severe
early childhood caries: an exploratory study. J
Public Health Dent (in press).
7. Milgrom P, Ly KA, Tut OK, et al. Xylitol
pediatric topical oral syrup to prevent dental
caries: a double blind, randomized clinical
trial of efficacy. Arch Pediatr Adolesc Med (in
press).
8. Health Resources and Services
Administration, Maternal and Child Health
Bureau. Appendix A: Decision support ma-
trix—topical fluoride recommendations. In:
Topical Fluoride Recommendations for High-
Risk Children: Development of Decision
Support Matrix, Recommendations from
Maternal and Child Health Bureau Expert
Panel. Washington: Altarum Institute; 2009.
“mohealthysmiles.typepad.com/
Topical%20fl%20recommendations%20for%20
hi%20risk%20children.pdf”. Accessed April
72. 16, 2009.
9. Anticaries drug products for over-the-
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10. Marinho VC, Higgins JP, Sheiham A,
Logan S. Fluoride toothpastes for preventing
dental caries in children and adolescents.
Cochrane Database Syst Rev 2003;(1):
CD002278.
11. Davies GM, Worthington HV, Ellwood
RP, et al. A randomised controlled trial of the
effectiveness of providing free fluoride tooth-
paste from the age of 12 months on reducing
caries in 5-6 year old children. Community
Dent Health 2002;19(3):131-136.
12. You BJ, Jian WW, Sheng RW, et al.
Caries prevention in Chinese children with
sodium fluoride dentifrice delivered through a
kindergarten-based oral health program in
China. J Clin Dent 2002;13(4):179-184.
13. Tavener JA, Davies GM, Davies RM,
Ellwood RP. The prevalence and severity of
fluorosis in children who received toothpaste
containing either 440 or 1,450 ppm F from the
age of 12 months in deprived and less de-
prived communities. Caries Res 2006;
40(1):66-72.
14. Bentley EM, Ellwood R, Davies RM.
Fluoride ingestion from toothpaste by young
children. Br Dent J 1999;186(9):460-462.
73. 15. Itthagarun A, King NM, Rana R. Effects
of child formula dentifrices on artificial caries
like lesions using in vitro pH-cycling: prelimi-
nary results. Int Dent J 2007;57(5):307-313.
16. DenBesten P, Ko HS. Fluoride levels in
whole saliva of preschool children after brush-
ing with 0.25 g (pea-sized) as compared to 1.0
g (full-brush) of a fluoride dentifrice. Pediatr
Dent 1996;18(4):277-280.
17. Twetman S, Axelsson S, Dahlgren H, et
al. Caries-preventive effect of fluoride tooth-
paste: a systematic review. Acta Odontol
Scand 2003;61(6):347-355.
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RESEARCH ARTICLE
Oral Health–Promoting School Environments and Dental Caries
76. in Québec Children
Anu Edasseri, MSc,1 Tracie A. Barnett, PhD,2 Khady Kâ,
PhD,3 Mélanie Henderson, PhD,4 Belinda Nicolau, PhD1
Introduction: Dental caries are highly prevalent among children
and have negative health consequences. Their occurrence may
depend in part on school-based environmental or policy- related
factors, but few researchers have explored this subject. This
study aimed to identify oral health promoting school
environment types and estimate their relation with 2-year dental
caries incidence among Québec children aged 8–10 years.
Methods: This study used data from two visits (completed in
2008 and 2011) of the QUALITY (Québec Adipose Lifestyle
Investigation in Youth) cohort, which recruited white children
at risk of obesity and their families from Greater Montreal
schools. Measures included school and neighborhood
characteristics, and Decayed, Missing, Filled-Surfaces index
scores. Principal component and cluster analyses, and
generalized estimating equations were conducted.
Results: Data were available for 330 children attending 200
schools. Based on a series of statistical analyses conducted in
2016, the authors identified three distinct school environment
types. Type 1 and 2 schools had strong healthy eating programs,
whereas Type 3 had weak programs. Type 1 schools had
favorable neighborhood food environments, whereas Type 2 and
3 had unfavorable ones. Adjusting for potential confounders,
children attending Type 1 and 2 schools had 21% (incidence
rate ratio1⁄40.79, 95% CI1⁄40.68, 0.90) and 6% (incidence rate
ratio1⁄40.94, 95% CI1⁄40.83, 1.07) lower 2-year incidence of
dental caries, respectively, compared with Type 3 schools.
Conclusions: School-based oral health promotion programs
combined with a favorable neighbor- hood can lower dental
caries incidence in school children.
Am J Prev Med 2017;53(5):697–704. & 2017 American Journal
of Preventive Medicine. Published by Elsevier Inc. All rights
reserved.
77. INTRODUCTION
Despite improved detection and treatment
modalities, dental caries remain the most com-
mon chronic oral disease among children and a
major public health concern affecting 60%−90% of
school-aged children worldwide.1 Oral conditions
(untreated caries, severe periodontitis, and tooth loss)
affect nearly 3.9 billion people worldwide; untreated
decay in permanent teeth is the most prevalent condition,
affecting 35% of the population and ranking 80th among
the top 100 causes of disability-adjusted life years.2 North
American children have the second highest lifetime
caries experience measured by the Decayed, Missing,
and Filled-Teeth index (Decayed Missing Filled-
3
youth have experienced dental caries, with a higher prevalence
and severity found among youth from a low socioeconomic
background.4 Moreover, oral health is a determinant of general
health and plays an important role in quality of life.5 Finally,
oral disease is the fourth
From the 1Division of Oral Health and Society, Faculty of
Dentistry, McGill University, Montreal, Québec, Canada;
2Epidemiology and Biostatistics Unit, Institut National de la
Recherche Scientifique−Institut Armand Frappier, Laval,
Québec, Canada; 3University of Montreal Hospital Research
Centre, Montreal, Québec, Canada; and 4Department of Pedia-
trics, Université de Montréal, Centre Hospitalier Universitaire
Sainte- Justine, Montreal, Québec, Canada
Address correspondence to: Belinda Nicolau, PhD, Faculty of
Dentistry, McGill University, 2001 McGill College Avenue,
Suite 527, Montreal, QC Canada, H3A 1G1. E-mail:
[email protected]
0749-3797/$36.00
https://doi.org/10.1016/j.amepre.2017.07.005
Teeth1⁄42.08) worldwide. More than half of Canadian
78. & 2017 American Journal of Preventive Medicine. Published by
Elsevier Inc. All rights Am J Prev Med 2017;53(5):697–704 697
reserved.
698 Edasseri et al / Am J Prev Med 2017;53(5):697–704
most expensive condition to treat and is therefore a major
economic burden to both society and individuals.1 Fortunately,
dental caries are mostly preventable, and even reversible, if
detected in early stages and if effective intervention is
available. However, the effectiveness of oral health education
and clinical preventive programs in improving oral health
outcomes is questionable.6,7 Dental health education may
increase knowledge, but whether it translates into better oral
health behaviors is still a matter of debate.6–8 In fact,
information giving alone may be ineffective and may even
increase health inequity because people with the highest need
are frequently less educated, with fewer economic resources to
make healthier choices.9,10 Also, focusing on clinical
prevention, such as sealants and topical fluorides, alone is
palliative7 and not
cost effective.11
Health promotion strategies that go beyond the
individual level to integrate elements of policy develop- ment
and social and physical environmental factors may be more
effective for disease prevention than isolated behavior-specific
interventions.7,12 The WHO’s concept of health promoting
schools highlights the importance of the environment, and
advocates for a comprehensive approach in transforming
schools as healthy settings.13 Considering oral health
promotion as an integral com- ponent of health promoting
schools, WHO has proposed guidelines for oral health
promoting schools.14 Schools worldwide have attempted to
adapt and implement school-based oral health promotion
programs according to these guidelines.
These initiatives generally had a favorable impact on reduction
of dental caries in children,15–17 however, instances of failure
were also reported.18,19 Although the Québec government
79. responsible for schools in the current study published guidelines
for school health promotion in 2005,20 the authors did not find
any studies evaluating its effect on oral health outcomes.
Other school-related variables may play important roles in
determining children’s health and health behav- iors, notably
neighborhood disadvantage. For example, favorable school
socioeconomic environment is inversely related to dental caries
in Québec school children.21 In addition, school SES, based on
average percentage of low- income families in the school
neighborhood, appears to modify the association between oral
health promotion and dental caries reduction, the effect being
stronger among low SES schools,15 where the need is the
greatest.
Disadvantaged neighborhoods may also have more nutritionally
poor food sources; hence, children attend- ing schools located
in disadvantaged neighborhoods may be more likely to adopt
poor dietary habits. Some evidence suggests an adverse effect
of an unhealthy food environment around schools on pediatric
obesity.22
A previous study published by the QUALITY (Québec Adipose
Lifestyle Investigation in Youth) cohort group found that a
higher number of “unhealthful” compared with “healthful” food
stores in the proximity of schools had undesirable effects on
children’s dietary habits.23 However, studies on the
surrounding food environment and children’s dietary habits
provide inconsistent find- ings and are mostly cross-
sectional22; there is a need for additional longitudinal
studies.22
Despite major criticism of traditional preventive and behavioral
approaches, many interventions targeting isolated behaviors
persist. Few studies have looked at comprehensive programs in
schools that incorporated policy elements and participatory
approaches15,16,18; a literature search identified only one such
study from Canada15 and none from Québec. In addition, fewer
studies have considered school neighborhood disadvant-
age,15,16 and the authors identified none that included the
80. surrounding food environment in their assessment of the oral
health promoting school environment. Therefore, the aims are to
identify distinct school environments based on oral health
promoting and neighborhood environmental factors, and to
estimate the relation between school environment types and 2-
year dental caries incidence among Québec children aged 8–10
years.
METHODS
Study Sample
Data were from an ongoing prospective study, the QUALITY
cohort, which investigates the natural history of metabolic risk
in youth. A full description of this study can be found
elsewhere.24 Briefly, the QUALITY cohort recruited 630 white
children aged 8–10 years at baseline from schools located
within 75 km of three major urban centers in the province of
Québec. Both biological parents had to be available and at least
one of them had to be obese (BMI ≥30 or waist circumference
4102 cm in men and 488 cm in women) for inclusion in the
study. An ancillary study included a formal evaluation of the
schools attended by QUALITY partic- ipants and the
neighborhood for children attending schools in the Montreal
Census Metropolitan Area (home to 480% of QUAL- ITY
participants). Among the 296 schools (attended by 506 children
of the QUALITY study) in the Montreal Census Metropolitan
Area, 247 schools (attended by 430 children) agreed to
participate in the study. The current study uses data collected in
Visit 1 (baseline, aged 8–10 years) and Visit 2 (children aged
10–12 years), which were completed in 2008 and 2011,
respectively.
The QUALITY cohort study obtained ethics approval from
several IRBs, including the Centre Hospitalier Universitaire
Sainte- Justine and McGill University. Parents and school
principals signed consent forms and children provided assent.
Measures
Trained dentists performed the clinical oral health examination
in a dental office during the hospital visit. This study used the
81. Child Dental Health Survey of England, Wales, and Northern
Ireland
www.ajpmonline.org
diagnostic criteria to record dental caries.25 Two-year dental
caries incidence was measured as the difference in the Decayed,
Missing, Filled-Surfaces (DMF-S) index between Visits 1 and 2.
Surfaces that were not examined in either visit were excluded
from the DMF-S index calculation. Five observations had
negative DMF-S incremental values. In each of these cases,
some of the initial caries lesions in Visit 1 were replaced by
sealants in Visit 2 and thus were not counted in Visit 2, leading
to negative differences. As this is equivalent to a difference of
0, the 2-year dental caries incidence in all these cases was also
recorded as 0.
Data on age, sex, and parental SES were collected using
structured questionnaires administered to parents at Visit 1.
Parental SES was measured using two variables: parental
education and parental income. Parental education, collected as
a seven- category variable, was later combined for both parents
and categorized into (1) one or two parents with high school or
less; (2) one or two parents with collège d'enseignement général
et professionnel/vocational or trade school; and (3) one or two
parents with university degree. The annual household income
before taxes was collected as 12 categories ranging from
o$10,000 to ≥$140,000 Canadian dollars. This variable was
later adjusted for the number of people living in the house26
and further grouped into quartiles.
Trained research assistants collected school environment data
by interviewing school principals with the aid of structured
questionnaires. Questions related to healthy eating promotion
policies in schools were derived from recognized guidelines for
Québec schools, including the Institute of Medicine Recommen-
dations for Schools to Address Childhood Obesity,27 the School
Health Index,28 the School Health Policy and Programs
Survey,29 and the Coalition for School Nutrition.30
School neighborhood disadvantage information was obtained
82. from the 2006 Canadian Census. The authors constructed a
material deprivation index of the area within 1,000 m of street
network around each school. The index comprises “the
proportion of individuals without a high school diploma, the
employment population ratio and the average personal income”
for people aged ≥15 years in census dissemination areas, with a
higher value representing lower deprivation.31 This variable
was classified into tertiles ranging from high (0) to low (2)
deprivation. The numbers of convenience and fast-food stores
within 500 m around each school were calculated using the GIS
from the Montreal Epide- miological and Geographic Analysis
of Population Health Out- comes and Neighbourhood Effect
database that contains information until May 2005.32 These
variables were then dicho- tomized into at least one store within
500 m (unfavorable) versus none within 500 m (favorable).
Statistical Analysis
The analyses for this paper were conducted in 2016. Principal
component analysis (PCA) with a polychoric correlation matrix
was used to group variables measuring schools’ healthy eating
promotion policies. Oblimin oblique rotation was applied to
differentiate the components and those with eigen values 41
were retained.
Subsequently, the authors performed a hierarchical agglomer-
ative average linkage cluster analysis using the components
identified by PCA, along with variables that measured presence
of dental health/hygiene programs and formal healthy eating
promotion initiatives, school’s surrounding food environment
and SES, to identify distinct types of school environments.
Cluster stop rules (Calinski−Harabasz pseudo-F index, and
Duda−Hart and Je [2]/Je [1] indices) were used to select the
optimal number of clusters.33
After preliminary descriptive and exploratory analyses, the
authors used generalized estimating equations with a binomial
link function, exchangeable correlation matrix, and school as
the grouping variable, to model the association between school
environment types and 2-year dental caries incidence in
83. children, adjusting for potential confounders. All analyses were
preformed using Stata/SE, version 12.
RESULTS
Out of the 430 children (attending 247 schools) for whom
school data were available, 357 had data on dental caries for
both visits. The authors further excluded 27 children because of
missing data for other covariates. The mean age for the final
sample of 330 children was 9.2 years (SD1⁄40.9 years) at
baseline. The mean DMF-S for Visits 1 and 2 were 0.6
(SD1⁄41.4) and 2.0 (SD1⁄42.9), respectively (Table 3).
PCA and cluster analyses were performed in 226 schools (21
schools were excluded because of missing values). PCA
included ten variables, which loaded on three components
(Table 1 and Appendix Table 1, available online). Three distinct
types of school environ- ments were identified based on cluster
analysis and the school types were defined by examining the
mean or proportion of each variable within each cluster (Table
2). Type 1 included schools located in neighborhoods with high
SES, favorable surrounding food environments, strong healthy
eating promotion, and weak dental care programs (50.9% of all
schools). Type 2 included schools located in neighborhoods
with low SES, unfavorable surrounding food environments,
strong healthy eating promotion and strong dental care programs
(36.1%). Type 3 comprised schools located in neighborhoods
with average SES, unfavorable surrounding food environ-
ments, weak healthy eating promotion, and average dental care
programs (13.0%).
Finally, the authors used generalized estimating equa- tion to
model the association between the three variables representing
school environment types and 2-year dental caries incidence.
Using Type 3 school as a reference, children attending Type 1
and 2 schools had 21% (incidence rate ratio1⁄40.79, 95%
CI1⁄40.68, 0.90) and 6% (incidence rate ratio1⁄40.94, 95%
CI1⁄40.83, 1.07) lower 2- year incidence of dental caries,
respectively, after adjust- ing for age, sex, parental SES, and
baseline DMF-S index (Table 4).
84. November 2017
Edasseri et al / Am J Prev Med 2017;53(5):697–704 699
700 Edasseri et al / Am J Prev Med 2017;53(5):697–704 Table
1. Variable Loading Pattern in Principal Component Analysis
Component
Variable 1 2 3 variance
Unexplained
Willingness to participate in healthy eating promotion of:
School management 0.4876 — — 0.1524
Teachers 0.4423 — — 0.2016
Daycare managers 0.4740 — — 0.1964
Community 0.4478 — — 0.2851
Agreement with community to promote healthy eating within
school 0.3448 — — 0.5884
School makes room for families to engage in volunteer
activities — 0.5879 — 0.5096
Frequently informs parents about health promotion activities in
schools — 0.5509 — 0.4839
Educates teachers on the importance of promoting healthy living
— 0.5655 — 0.4078
Strict rule for approval of catering service menu by a
nutritionist — — 0.6770 0.3284
School sells drinks and snacks in accordance with principles of
healthy eating — — 0.6909 0.3417 during fundraising programs
DISCUSSION
This study aimed to identify school environment profiles based
on oral health promoting and neighborhood environmental
factors and estimate their impact on
2-year dental caries incidence. The study identified three
distinct school environment types and the results suggest that a
favorable school environment can lower the incidence of dental
caries in children. These findings are in agreement with
previous cross-sectional studies
Table 2. Description of the School Environment Types Based on
the Variables Used in the Cluster Analysis
85. Cluster
Variables used in cluster analysis 1 (n1⁄499)a 2 (n1⁄475)a 3
(n1⁄426)a
School Material Deprivation Index
M (SD) 1.22 (0.80) 0.67 (0.72) 0.92 (0.84)
Range 0 to 2 0 to 2 0 to 2
Presence of a convenience store or a fast-food store within 500
m around the school (yes1⁄41/no1⁄40)
Yes, n (%) 0 (0) 75 (100) 26 (100)
Formal school initiatives to promote healthy eating
(yes1⁄41/no1⁄40)b
Yes, n (%) 83 (84) 75 (100) 0 (0)
Component 1: Willingness of school to promote healthy eating
within school and involvement of community partnersb
M (SD) 5.34 (0.73) 5.38 (0.85) 5.05 (1.12)
Range 2.99 to 6.33 1.71 to 6.45 1.07 to 6.31
Component 2: Encouraging teachers and parents to promote
healthy lifestyles in childrenb
M (SD) 3.36 (0.55) 3.26 (0.55) 2.97 (0.63)
Range 1.34 to 3.89 1.88 to 3.88 1.98 to 3.82
Component 3: Great attention to providing healthy food within
schoolb
M (SD) 0.83 (0.54) 0.68 (0.56) 0.42 (0.49)
Range −0.24 to 1.59 −0.31 to 1.56 −0.24 to 1.52
Visit by any dental health professional at school
(yes1⁄41/no1⁄40)c
Yes, n (%) 88 (89) 71 (95) 24 (92)
Programs providing dental hygiene education (yes1⁄41/no1⁄40) c
Yes, n (%) 79 (80) 65 (87) 22 (85)
Programs other than the provision of dental hygiene education
(yes1⁄41/no1⁄40)c
Yes, n (%) 46 (47) 28 (37) 14 (54)
aTotal 200 schools included in the complete case analysis.
bThe types of schools were graded as strong/average/weak in
healthy eating promotion, based the on the distribution of these
86. variables in three
clusters.
cThe types of schools were graded as strong/average/weak in
dental care programs, based the on the distribution of these
variables in three clusters.
www.ajpmonline.org
Edasseri et al / Am J Prev Med 2017;53(5):697–704 701 Table
3. Distribution of Sociodemographic Characteristics and Mean
DMF-S in Children Within Each School Environment
Cluster
Type
Total (n1⁄4330 1 (n1⁄4168 2 (n1⁄4119 3 (n1⁄443 Variable
[100%]) [50.9%]) [36.1%]) [13.0%])
Age, years, M (SD) 9.2 (0.9) 9.2 (0.9) 9.3 (0.9) 9.0 (0.9)
Sex, n (%)
Boys 191 (57.9) 93 (55.4) 73 (61.3) 25 (58.1)
Girls 139 (42.1) 75 (44.6) 46 (38.7) 18 (41.9)
Household income, n (%)
o$29,070 78 (23.6) 38 (22.6) 33 (27.7) 7 (16.3)
$29,070–$42,579 79 (23.9) 40 (23.8) 30 (25.2) 9 (20.9)
$42,580–$56,271 85 (25.8) 33 (19.6) 38 (31.9) 14 (32.6)
4$56,271 88 (26.7) 57 (33.9) 18 (15.1) 13 (30.2)
Parental education, n (%)
One or both parents hold a high school degree or 25 (7.6) 15
(8.9) 10 (8.4) 0 less
One or both parents completed CEGEP/vocational 121 (36.7) 67
(39.9) 39 (32.8) 15 (34.9) or trade school
One or both parents hold a university degree 184 (55.8) 86
(51.2) 70 (58.8) 28 (65.1)
DMF-S Index, M (SD)
Baseline DMF-S 0.6 (1.4) 0.5 (1.2) 0.7 (1.6) 0.8 (1.5)
DMF-S Visit 2 2.0 (2.9) 1.6 (2.3) 2.3 (3.3) 3.0 (3.5)
CEGEP, collège d'enseignement général et professionnel; DMF-
S, Decayed, Missing, Filled-Surfaces.
investigating the impact of comprehensive oral health
87. promotion approaches.15,16 In contrast, a school-based study
using a participatory approach to reduce sugar intake of
children failed to bring about any change in diet
behaviors or reduction of dental caries. This failure may have
been attributable to the narrow scope of the policy, which
restricted children’s food intake to fruits and milk during school
breaks rather than focusing on overall diet
Table 4. Association Between School Environment Types and 2-
year Dental Caries Incidence (GEE, n1⁄4330)
Variables in the model Change in DMF-S over 2 years, M (SD)
IRRa (95% CI)
School environment
Type 1 1.1 (1.7) 0.79 (0.68–0.90)
Type 2 1.7 (2.6) 0.94 (0.83–1.07)
Type 3 2.3 (2.7) 1
Age — 1.06 (1.00–1.12)
Sex
Male 1.4 (2.2) 1
Female 1.5 (2.2) 1.06 (0.96–1.18)
Household income
o$29,070 2.1 (2.7) 1
$29,070–$42,579 1.5 (1.8) 0.97 (0.85–1.10)
$42,580–$56,271 1.3 (2. 4) 0.98 (0.84–1.15)
4$56,271 1.0 (1.8) 0.95 (0.78–1.15)
Parental education
One or both parents hold a high school degree or less 3.0 (3.2) 1
One or both parents completed CEGEP/vocational or trade
school 1.6 (2.1) 0.77 (0.67–0.87)
One or both parents hold a university degree 1.2 (2.1) 0.71
(0.62–0.82)
Baseline DMF-Sa — 1.08 (1.05–1.10)
aBaseline DMF-S was separately included in the model to better
capture the variations in the baseline caries risk of children,
which may not be captured by the difference in DMF-S indices
over 2 years.
CEGEP, collège d'enseignement général et professionnel; DMF-
88. S, Decayed, Missing, Filled-Surfaces; IRR, incidence rate ratio.
November 2017
702 Edasseri et al / Am J Prev Med 2017;53(5):697–704
behaviors. Moreover, the program did not include measures to
raise the awareness of teachers, children, or parents regarding a
healthy diet18 and did not consider the broader built and social
environments around the schools, which could potentially
influence children’s food habits.
In this study, Type 1 schools, which showed the strongest
protective association with dental caries, had strong healthy
eating environments inside the schools as well as favorable food
environments around the schools. This finding suggests that an
environment promoting healthy eating, that also incorporates
the socioenviron- mental and policy aspects of health
promotion, may be particularly effective in reducing dental
caries. This observation aligns with the common risk factor
approach to oral health promotion, which advocates for an
integrated strategy, targeting risk factors (e.g., high sugar diet)
that are common to multiple chronic diseases, and their
underlying determinants.9
Moreover, this study’s results highlight the impor- tance of
school neighborhood disadvantage factors on dental caries
incidence in schoolchildren. Type 1 schools were located in the
highest SES neighborhood and had favorable surrounding food
environments, whereas Type 2 and 3 schools, located in
neighbor- hoods with relatively low SES, had unfavorable
surrounding food environments. The additional pro- tective
influence of Type 1 schools may be attributable to the reduced
access to nutritionally poor food sources in the school
neighborhoods. A previous study in QUALITY cohort children
reported that unhealth- ful stores around schools may have a
negative influence on the dietary choices of children attending
that school,23 which provides insight on the potential mediating
pathway.
It is also notable that despite scoring the lowest in dental
health-specific programs, Type 1 schools were associated with