A Cross-Sectional Analysis of Community Water Fluoridation and Prevalence of Pediatric Dental Surgery Among Medicaid Enrollees | Pediatrics | JAMA Network Open | JAMA Network
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Figure.  Decreasing Dental Surgery Prevalence With Increasing Proportion of Population With Access to Community Water Fluoridation
Decreasing Dental Surgery Prevalence With Increasing Proportion of Population With Access to Community Water Fluoridation

Graph depicts the association of dental surgery prevalence with proportion of population with access to community water fluoridation. Proportion of county population with access to community water fluoridation ranges from 0% to 100% (0-1).

Table 1.  County-Level Sociodemographic, Dental Workforce, and Oral Health Characteristics for Medicaid-Enrolled Children in 5 States, 2011-2012
County-Level Sociodemographic, Dental Workforce, and Oral Health Characteristics for Medicaid-Enrolled Children in 5 States, 2011-2012
Table 2.  Association Between Proportion of County Population With Access to Community Water Fluoridation and Pediatric Oral Health Outcomes
Association Between Proportion of County Population With Access to Community Water Fluoridation and Pediatric Oral Health Outcomes
Table 3.  Association Between Counties With Proportion of County With Access to Community Water Fluoridation and Pediatric Ambulatory Care Quality Indicators
Association Between Counties With Proportion of County With Access to Community Water Fluoridation and Pediatric Ambulatory Care Quality Indicators
1.
Allukian  M  Jr, Carter-Pokras  OD, Gooch  BF,  et al.  Science, politics, and communication: the case of community water fluoridation in the US.   Ann Epidemiol. 2018;28(6):401-410. doi:10.1016/j.annepidem.2017.05.014PubMedGoogle ScholarCrossref
2.
Murthy  VH.  Surgeon General’s perspectives: community water fluoridation—one of CDC’s “10 Great Public Health Achievements of the 20th Century”.   Public Health Rep. 2015;130(4):296-298. doi:10.1177/003335491513000402PubMedGoogle ScholarCrossref
3.
Slade  GD, Grider  WB, Maas  WR, Sanders  AE.  Water fluoridation and dental caries in U.S. children and adolescents.   J Dent Res. 2018;97(10):1122-1128. doi:10.1177/0022034518774331PubMedGoogle ScholarCrossref
4.
Kumar  JV, Adekugbe  O, Melnik  TA.  Geographic variation in Medicaid claims for dental procedures in New York State: role of fluoridation under contemporary conditions.   Public Health Rep. 2010;125(5):647-654. doi:10.1177/003335491012500506PubMedGoogle ScholarCrossref
5.
Elmer  TB, Langford  JW, Morris  AJ.  An alternative marker for the effectiveness of water fluoridation: hospital extraction rates for dental decay, a two-region study.   Br Dent J. 2014;216(5):E10. doi:10.1038/sj.bdj.2014.180PubMedGoogle Scholar
6.
Spencer  AJ, Do  LG, Ha  DH.  Contemporary evidence on the effectiveness of water fluoridation in the prevention of childhood caries.   Community Dent Oral Epidemiol. 2018;46(4):407-415. doi:10.1111/cdoe.12384PubMedGoogle ScholarCrossref
7.
Malin  AJ, Till  C.  Exposure to fluoridated water and attention deficit hyperactivity disorder prevalence among children and adolescents in the United States: an ecological association.   Environ Health. 2015;14:17. doi:10.1186/s12940-015-0003-1PubMedGoogle ScholarCrossref
8.
Green  R, Lanphear  B, Hornung  R,  et al.  Association between maternal fluoride exposure during pregnancy and IQ scores in offspring in Canada.   JAMA Pediatr. 2019;173(10):940-948. doi:10.1001/jamapediatrics.2019.1729PubMedGoogle ScholarCrossref
9.
Barberio  AM, Quiñonez  C, Hosein  FS, McLaren  L.  Fluoride exposure and reported learning disability diagnosis among Canadian children: implications for community water fluoridation.   Can J Public Health. 2017;108(3):e229-e239. doi:10.17269/CJPH.108.5951PubMedGoogle ScholarCrossref
10.
Broadbent  JM, Thomson  WM, Ramrakha  S,  et al.  Community water fluoridation and intelligence: prospective study in New Zealand.   Am J Public Health. 2015;105(1):72-76. doi:10.2105/AJPH.2013.301857PubMedGoogle ScholarCrossref
11.
Canadian Agency for Drugs and Technologies in Health. Community water fluoridation: a review of neurological and cognitive effects. Published October 23, 2019. Accessed July 14, 2020. https://cadth.ca/community-water-fluoridation-exposure-review-neurological-and-cognitive-effects-0
12.
Latifi-Xhemajli  B, Begzati  A, Veronneau  J, Kutllovci  T, Rexhepi  A.  Effectiveness of fluoride varnish four times a year in preventing caries in the primary dentition: a 2 year randomized controlled trial.   Community Dent Health. 2019;36(2):190-194.PubMedGoogle Scholar
13.
Singh  A, Purohit  BM.  Caries preventive effects of high-fluoride vs standard-fluoride toothpastes: a systematic review and meta-analysis.   Oral Health Prev Dent. 2018;16(4):307-314.PubMedGoogle Scholar
14.
Meyer  J, Margaritis  V, Mendelsohn  A.  Consequences of community water fluoridation cessation for Medicaid-eligible children and adolescents in Juneau, Alaska.   BMC Oral Health. 2018;18(1):215. doi:10.1186/s12903-018-0684-2PubMedGoogle ScholarCrossref
15.
Fisher-Owens  SA, Gansky  SA, Platt  LJ,  et al.  Influences on children’s oral health: a conceptual model.   Pediatrics. 2007;120(3):e510-e520. doi:10.1542/peds.2006-3084PubMedGoogle ScholarCrossref
16.
[No authors listed.]  Guideline on behavior guidance for the pediatric dental patient.   Pediatr Dent. 2016;38(6):185-198.PubMedGoogle Scholar
17.
[No authors listed.]  Policy on hospitalization and operating room access for oral care of infants, children, adolescents, and individuals with special health care needs.   Pediatr Dent. 2017;39(6):104-105.PubMedGoogle Scholar
18.
Bruen  BK, Steinmetz  E, Bysshe  T, Glassman  P, Ku  L.  Potentially preventable dental care in operating rooms for children enrolled in Medicaid.   J Am Dent Assoc. 2016;147(9):702-708. doi:10.1016/j.adaj.2016.03.019PubMedGoogle ScholarCrossref
19.
Lee  HH, Faundez  L, Yarbrough  C, Lewis  CW, LoSasso  AT.  Patterns in pediatric dental surgery under general anesthesia across 7 state Medicaid programs.   JDR Clin Trans Res. Published online February 10, 2020. doi:10.1177/2380084420906114PubMedGoogle Scholar
20.
US Food and Drug Administration. FDA drugs safety communication: FDA approves label changes for use of general anesthetic and sedation drugs in young children. Published April 27, 2017. Accessed July 14, 2020. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-approves-label-changes-use-general-anesthetic-and-sedation-drugs
21.
McCann  ME, de Graaff  JC, Dorris  L,  et al; GAS Consortium.  Neurodevelopmental outcome at 5 years of age after general anaesthesia or awake-regional anaesthesia in infancy (GAS): an international, multicentre, randomised, controlled equivalence trial.   Lancet. 2019;393(10172):664-677. doi:10.1016/S0140-6736(18)32485-1PubMedGoogle ScholarCrossref
22.
Davidson  AJ, Disma  N, de Graaff  JC,  et al; GAS Consortium.  Neurodevelopmental outcome at 2 years of age after general anaesthesia and awake-regional anaesthesia in infancy (GAS): an international multicentre, randomised controlled trial.   Lancet. 2016;387(10015):239-250. doi:10.1016/S0140-6736(15)00608-XPubMedGoogle ScholarCrossref
23.
Flick  RP, Katusic  SK, Colligan  RC,  et al.  Cognitive and behavioral outcomes after early exposure to anesthesia and surgery.   Pediatrics. 2011;128(5):e1053-e1061. doi:10.1542/peds.2011-0351PubMedGoogle ScholarCrossref
24.
Ing  CH, DiMaggio  CJ, Malacova  E,  et al.  Comparative analysis of outcome measures used in examining neurodevelopmental effects of early childhood anesthesia exposure.   Anesthesiology. 2014;120(6):1319-1332. doi:10.1097/ALN.0000000000000248PubMedGoogle ScholarCrossref
25.
Sun  LS, Li  G, Miller  TL,  et al.  Association between a single general anesthesia exposure before age 36 months and neurocognitive outcomes in later childhood.   JAMA. 2016;315(21):2312-2320. doi:10.1001/jama.2016.6967PubMedGoogle ScholarCrossref
26.
McCann  ME, Soriano  SG.  Does general anesthesia affect neurodevelopment in infants and children?   BMJ. 2019;367:l6459. doi:10.1136/bmj.l6459PubMedGoogle ScholarCrossref
27.
Lee  JJ, Sun  LS, Levy  RJ.  Report on the Sixth Pediatric Anesthesia Neurodevelopmental Assessment (PANDA) Symposium, “Anesthesia and Neurodevelopment in Children”.   J Neurosurg Anesthesiol. 2019;31(1):103-107. doi:10.1097/ANA.0000000000000538PubMedGoogle ScholarCrossref
28.
von Elm  E, Altman  DG, Egger  M, Pocock  SJ, Gøtzsche  PC, Vandenbroucke  JP; STROBE Initiative.  The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.   Ann Intern Med. 2007;147(8):573-577. doi:10.7326/0003-4819-147-8-200710160-00010PubMedGoogle ScholarCrossref
29.
Drury  TF, Horowitz  AM, Ismail  AI, Maertens  MP, Rozier  RG, Selwitz  RH.  Diagnosing and reporting early childhood caries for research purposes: a report of a workshop sponsored by the National Institute of Dental and Craniofacial Research, the Health Resources and Services Administration, and the Health Care Financing Administration.   J Public Health Dent. 1999;59(3):192-197. doi:10.1111/j.1752-7325.1999.tb03268.xPubMedGoogle ScholarCrossref
30.
Meyer  BD, Lee  JY, Casey  MW.  Dental treatment and expenditures under general anesthesia among Medicaid-enrolled children in North Carolina.   Pediatr Dent. 2017;39(7):439-444.PubMedGoogle Scholar
31.
American Academy of Pediatric Dentistry. General anesthesia coverage. Committee on Dental Benefits Programs website. Accessed March 16, 2020. https://www.aapd.org/advocacy/legislative-and-regulatory-issues/general-anesthesia-coverage/
32.
US Centers for Disease Control and Prevention. Public water systems. Published April 7, 2014. Accessed March 10, 2020. https://www.cdc.gov/healthywater/drinking/public/index.html
33.
US Centers for Disease Control Prevention. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Published 2013. Accessed July 14, 2020. https://www.cdc.gov/nchs/icd/icd9cm.htm
34.
Nasseh  K, Vujicic  M.  The impact of Medicaid reform on children’s dental care utilization in Connecticut, Maryland, and Texas.   Health Serv Res. 2015;50(4):1236-1249. doi:10.1111/1475-6773.12265PubMedGoogle ScholarCrossref
35.
Agency for Healthcare Research and Quality. Prevention quality indicators overview. Accessed July 17, 2020. https://www.qualityindicators.ahrq.gov/modules/pqi_overview.aspx
36.
Health Resources & Services Administration. Area health resources files. Accessed January 3, 2013. https://data.hrsa.gov/topics/health-workforce/ahrf
37.
DeNavas-Walt  C, Proctor  BD. Income and poverty in the United States: 2014. US Census Bureau. Published September 2015. Accessed July 14, 2020. https://www.census.gov/content/dam/Census/library/publications/2015/demo/p60-252.pdf
38.
Guarnizo-Herreño  CC, Wehby  GL.  Dentist supply and children’s oral health in the United States.   Am J Public Health. 2014;104(10):e51-e57. doi:10.2105/AJPH.2014.302139PubMedGoogle ScholarCrossref
39.
Ismail  AI, Lim  S, Sohn  W, Willem  JM.  Determinants of early childhood caries in low-income African American young children.   Pediatr Dent. 2008;30(4):289-296.PubMedGoogle Scholar
40.
Wigen  TI, Baumgartner  CS, Wang  NJ.  Identification of caries risk in 2-year-olds.   Community Dent Oral Epidemiol. 2018;46(3):297-302. doi:10.1111/cdoe.12366PubMedGoogle ScholarCrossref
41.
Sen  B, Blackburn  J, Kilgore  ML,  et al.  Preventive dental care and long-term dental outcomes among ALL Kids enrollees.   Health Serv Res. 2016;51(6):2242-2257. doi:10.1111/1475-6773.12469PubMedGoogle ScholarCrossref
42.
Savage  MF, Lee  JY, Kotch  JB, Vann  WF  Jr.  Early preventive dental visits: effects on subsequent utilization and costs.   Pediatrics. 2004;114(4):e418-e423. doi:10.1542/peds.2003-0469-FPubMedGoogle ScholarCrossref
43.
Brambrink  AM, Evers  AS, Avidan  MS,  et al.  Isoflurane-induced neuroapoptosis in the neonatal rhesus macaque brain.   Anesthesiology. 2010;112(4):834-841. doi:10.1097/ALN.0b013e3181d049cdPubMedGoogle ScholarCrossref
44.
Zou  X, Patterson  TA, Divine  RL,  et al.  Prolonged exposure to ketamine increases neurodegeneration in the developing monkey brain.   Int J Dev Neurosci. 2009;27(7):727-731. doi:10.1016/j.ijdevneu.2009.06.010PubMedGoogle ScholarCrossref
45.
Jevtovic-Todorovic  V, Hartman  RE, Izumi  Y,  et al.  Early exposure to common anesthetic agents causes widespread neurodegeneration in the developing rat brain and persistent learning deficits.   J Neurosci. 2003;23(3):876-882. doi:10.1523/JNEUROSCI.23-03-00876.2003PubMedGoogle ScholarCrossref
46.
Ikonomidou  C, Bosch  F, Miksa  M,  et al.  Blockade of NMDA receptors and apoptotic neurodegeneration in the developing brain.   Science. 1999;283(5398):70-74. doi:10.1126/science.283.5398.70PubMedGoogle ScholarCrossref
47.
Warner  DO, Zaccariello  MJ, Katusic  SK,  et al.  Neuropsychological and behavioral outcomes after exposure of young children to procedures requiring general anesthesia: the Mayo Anesthesia Safety in Kids (MASK) Study.   Anesthesiology. 2018;129(1):89-105. doi:10.1097/ALN.0000000000002232PubMedGoogle ScholarCrossref
48.
Kanellis  MJ, Damiano  PC, Momany  ET.  Medicaid costs associated with the hospitalization of young children for restorative dental treatment under general anesthesia.   J Public Health Dent. 2000;60(1):28-32. doi:10.1111/j.1752-7325.2000.tb03288.xPubMedGoogle ScholarCrossref
49.
Amin  MS, Bedard  D, Gamble  J.  Early childhood caries: recurrence after comprehensive dental treatment under general anaesthesia.   Eur Arch Paediatr Dent. 2010;11(6):269-273. doi:10.1007/BF03262761PubMedGoogle ScholarCrossref
50.
Almeida  AG, Roseman  MM, Sheff  M, Huntington  N, Hughes  CV.  Future caries susceptibility in children with early childhood caries following treatment under general anesthesia.   Pediatr Dent. 2000;22(4):302-306.PubMedGoogle Scholar
51.
Lee  HH, Lehew  CW, Avenetti  D, Buscemi  J, Koerber  A.  Understanding oral health behaviors among children treated for caries under general anesthesia.   J Dent Child (Chic). 2019;86(2):101-108.PubMedGoogle Scholar
52.
US Centers for Disease Control and Prevention. 2012 Fluoridation statistics: state fluoridation percentage calculations and states ranked by fluoridation percentage. Published 2012. Accessed October 18, 2019. https://www.cdc.gov/fluoridation/statistics/2012stats.htm
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    1 Comment for this article
    EXPAND ALL
    Lack of trust in community water supplies
    Donald DeNucci, DDS, MS | Atrium Health, Charlotte, NC
    Because of the lack of trust in community water supplies reinforced by the Flint, Michigan disaster, I posit that the real culprit is parental substitution of bottled water for community water in this population. If the purveyors of bottled water could be convinced to provide a readily available fluoridated water product in major grocery stores, the problem of rampant childhood caries in this population could be significantly reduced. To the best of my knowledge, no such product is readily available in major grocery chains. Behavioral change is often most successful when adapted to the current practices of the target population. Convincing parents that their children should consume community water supplies will likely not meet with success.
    CONFLICT OF INTEREST: None Reported
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    Original Investigation
    Public Health
    August 12, 2020

    A Cross-Sectional Analysis of Community Water Fluoridation and Prevalence of Pediatric Dental Surgery Among Medicaid Enrollees

    Author Affiliations
    • 1Department of Anesthesiology, University of Illinois at Chicago, Chicago
    • 2Department of Economics, University of Illinois at Chicago, Chicago
    • 3Department of Economics, DePaul University, Chicago, Illinois
    JAMA Netw Open. 2020;3(8):e205882. doi:10.1001/jamanetworkopen.2020.5882
    Key Points español 中文 (chinese)

    Question  Is access to community water fluoridation associated with lower rates of pediatric dental surgical procedures in high-risk populations?

    Findings  In this cross-sectional study of Medicaid-enrolled children from 5 states, increasing the proportion of the population exposed to community water fluoridation water was associated with a lower prevalence of caries-related visits in both adjusted and unadjusted analyses and with a lower prevalence of dental surgical procedures in unadjusted analysis only.

    Meaning  These findings suggest that for children at high risk of caries, community water fluoridation should be considered as an intervention to prevent childhood caries and to decrease the prevalence of dental surgical procedures.

    Abstract

    Importance  Dental surgery under general anesthesia (DGA) is an ineffective, costly treatment for caries. Interventions to reduce the need for DGA are challenging because children’s parents may not seek care until surgery is required. Community water fluoridation (CWF) effectively prevents early childhood caries, but its effectiveness in reducing severe early childhood caries is unknown.

    Objective  To determine whether access to CWF is associated with the prevalence of DGA.

    Design, Setting, and Participants  This is a cross-sectional analysis of Medicaid claims data from 2011 to 2012. Deidentified data were derived from Medicaid claims and enrollee files for Massachusetts, Texas, Connecticut, Illinois, and Florida for children aged 9 years and younger enrolled in either a fee-for-service or managed care plan through their state’s Medicaid program. Linear regression models tested for associations between CWF and covariates. Multivariable linear regression models tested for associations between CWF and outcomes. Regression models included clustered SEs at the county level. Data analysis was performed from December 2018 to March 2020.

    Exposures  Access to CWF was determined by estimating the proportion of a county’s total population that had access to a fluoridated public water system.

    Main Outcomes and Measures  The main outcome was county-level DGA prevalence. Other outcomes were caries-related visit prevalence and patient quality indicators (asthma and diabetes). Covariates included county-level demographic, socioeconomic, and dental practitioner variables.

    Results  A total of 436 counties within 5 states per year (872 county-year observations), were included in the analysis. Adjusted analysis revealed that a 10% increase in the proportion of county’s population access to CWF was associated with lower caries-related visit prevalence (−0.45 percentage points; 95% CI, −0.59 to −0.31 percentage points; P < .001). Increasing CWF access in 10% increments was associated with decreased DGA prevalence in unadjusted analysis (−0.39 percentage points; 95% CI, −0.67 to −0.12 percentage points; P = .006) but not in adjusted analysis (−0.23 percentage points; 95% CI, −0.49 to 0.02 percentage points; P = .07). Increasing the proportion of county’s access to CWF by 10% was not associated with the prevalence of asthma-related exacerbations (−0.02 percentage points; 95% CI, −0.10 to 0.05 percentage points; P = .53) or diabetes-related exacerbations (−0.0003 percentage points; 95% CI, −0.0014 to 0.0009 percentage points; P = .66).

    Conclusions and Relevance  This study extends our understanding of CWF’s benefits for children’s oral health. Specifically, these findings suggest that increasing a population’s access to CWF’s is associated with decreased caries-related visits and may also be associated with use of dental surgical services within high-risk populations.

    Introduction

    Community water fluoridation (CWF) is the most effective and cost- efficient dental public health intervention.1 Fluoridation of drinking water is among the top 10 US public health achievements of the 20th century.2 The use of CWF for population oral health has been associated with lower rates of caries, particularly in primary teeth.3 Regional studies4,5 have shown an association of CWF with reducing disease severity, which, in turn, is associated with utilization of caries-related procedures among residents aged 0 to 21 years. The timing of exposure to CWF is critical. Exposure in early childhood substantially reduces caries disease burden, not only during childhood but throughout the life span, with an exposure-response effect.6

    However, the potential adverse outcomes of early childhood exposure to fluoridated water are controversial. Childhood exposure to fluoridated water has been associated with attention-deficit/hyperactivity disorder in the US.7 The recently described association of in utero exposure to fluoridated water with childhood neurodevelopmental issues8 is balanced by criticisms of study limitations and prior studies9-11 that refute the associations between fluoride and neurodevelopmental outcomes. Although the causal link between CWF and neurodevelopment and behavior disorders remains to be determined, fluoride’s benefits in preventing caries are better established.12-14 What is unknown is the extent to which CWF, an effective population-level preventive intervention, can reduce severe early childhood caries (S-ECC) and its associated treatments. The development of S-ECC is associated with a child’s social determinants of oral health, which reflect factors related to the child’s environment and the family’s oral health beliefs, behaviors, and parent-child personal dynamics.15 Provision of general anesthesia has been recognized as a necessary service to facilitate dental treatments in patients who require extensive treatment, have special health care needs, and/or experience acute situational anxiety,16,17 which is often the case in children with S-ECC. In the US, dental operations performed under general anesthesia (DGAs) represent a significant financial burden to public insurance programs such as Medicaid, which provides health care coverage for low-income children and adults, with state-level variations in eligibility.18,19 Under the Early and Periodic Screening, Diagnosis, and Treatment Program, Medicaid covers DGA events for select children. Therefore, DGA events do not pose great financial stress to families. However, on the health care system level, Medicaid expenditures on pediatric hospital and ambulatory surgery center–based DGA have been estimated to be approximately $450 million.18 Total Medicaid expenditures are likely much higher, because office-based DGAs account for 40% to 75% of all DGA events in some states.19 Furthermore, provision of general anesthesia to young children has been scrutinized because of a 2015 US Food and Drug Administration warning on the use of commonly used anesthetic agents,20 which may not be supported in the translation from basic science to clinical trials.21-27 The objective of this study is to determine whether access to CWF is associated with the prevalence of DGA events among young Medicaid-enrolled children across 5 states.

    Methods
    Study Design and Setting

    In this cross-sectional analysis of Medicaid claims data from 2011 to 2012, the unit of analysis is on the county level, which was defined using the county of residence variable in the Medicaid enrollment file. This study was approved by the institutional review board of the University of Illinois at Chicago. Because the study used claims for health services used by Medicaid-enrolled children across several states, obtaining informed consent was not feasible; therefore, a waiver of informed consent was granted. This study follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cross-sectional studies.28

    Study Population and Setting

    The definition of S-ECC refers to clinical disease in primary dentition among children younger than 6 years.29 State Medicaid programs vary in their coverage of general anesthesia for dental surgery, with an upper limit defined up to age 8 years.30,31 We included children aged 9 years or younger enrolled in either a fee-for-service or managed care plan through their state Medicaid program in 2011 to 2012. The unit of analysis was on the county level, and prevalences of outcomes were based on claims for services.

    Data

    A convenience sample of deidentified data was derived from Medicaid claims and enrollee files for Massachusetts, Texas, Connecticut, Illinois, and Florida in 2011 to 2012. Specifically, Medicaid Analytic eXtract Personal Summary and Other Therapy files were obtained from the Centers for Medicare & Medicaid Services.

    Explanatory Variable

    We defined county-level access to CWF by creating a continuous variable to estimate the proportion of a county’s population with access to fluoridated water (proportion CWF) with values 0 to 1 representing 0% to 100% of a county’s population. Centers for Disease Control and Prevention data on fluoridation of public water systems (PWSs) is found on the My Water’s Fluoride website.32 The Centers for Disease Control and Prevention treats a PWS as fluoridated if the fluoride concentration is 0.6 mg/L (parts per million) or greater. The proportion of a county’s access to CWF was estimated as follows:

    Image description not available.,

    where i denotes the number of PWSs.

    Outcomes: Surgical Events, Caries-Related Visits, and Patient Quality Indicators

    The primary outcome of interest was receipt of caries-related surgical treatment with general anesthesia, or DGA. Individuals diagnosed with dental caries were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification, codes 521.00 through 521.09.33 The provision of general anesthesia was identified with the following American Dental Association’s Code on Dental Procedures and Nomenclature and/or the American Medical Association’s Current Procedural Terminology codes: D9220, 00170, 00172, 00174, and 00176. Caries-related dental procedures were identified with the following Code on Dental Procedures and Nomenclature codes: D0120, D0150, D0210, D0272, D0330, D1120, D1203, D1351, D2150, D2331, D2930, D3220, D3310, and D7140.34 The prevalence of DGA was calculated as the proportion of children who had a DGA event among children who had a caries-related visit.

    Caries-related visit prevalence was a secondary outcome. As a more general measure of population disease burden, the prevalence of caries-related visits was estimated by the proportion of children with a caries-related claims (defined earlier in this article) among all children enrolled in Medicaid in the study period.

    We defined patient quality indicators as secondary outcomes. The Agency for Healthcare Research and Quality (AHRQ) has created Prevention Quality Indicators (PQIs) to be used as tools to identify hospital admissions for conditions that should be treated and managed on an outpatient basis. PQIs are used to identify ambulatory care–sensitive conditions, which provide “insight into the quality of the health care system outside the hospital setting.”35 The PQI for asthma and diabetes admission rates is defined by AHRQ as discharges with a principal International Classification of Diseases, Ninth Revision, Clinical Modification code for asthma (49300-49302, 49310-49312, 49320-49322, 49381, and 49390-49392) or diabetes (25010-25013, 25020-25023, and 25030-25033). PQIs for asthma exclude cases with diagnosis codes for cystic fibrosis and anomalies of the respiratory system. We limited PQIs to children aged 0 to 9 years to remain consistent with age limitations of caries-related visits and DGA visits.

    Covariates

    The primary threat to the validity of our findings is that of omitted variable bias—in other words, any association between CWF and DGA might be due to confounding factors that affect both DGA and CWF levels. For example, if low-income counties tend to have low access to fluoridation, failure to control for income levels could lead to biased results. All covariates were estimated at the county level to compare with county-level estimates of outcomes. Variables included county-level demographic characteristics, such as age (proportion of population <10 years old), race/ethnicity (White, Black, or Hispanic), and measures of socioeconomic status. To measure county-level socioeconomic status, the enrollee county data from Medicaid Analytic eXtract Enrollment files were linked to the Health Resources and Services Administration’s Area Resource File.36 County-level socioeconomic status variables included percentage of persons born outside the US, per capita personal income, median household income, percentage of persons in deep poverty (income <50% of the federal poverty level),37 percentage of persons in poverty (income <100% of federal poverty level), percentage of persons aged 25 years and older with education less than a high school diploma, percentage of persons aged 25 years and older with 4 or more years of college, unemployment rate, and median home value. Because a greater supply of dentists is associated with improved oral health outcomes among children,38 we included the ratio of dentists per 100 000 people on a county level. We display our regression results with and without covariates to test the sensitivity of our findings to potential omitted variable bias.

    Statistical Analysis

    We measured associations between CWF and covariates using linear regression models. Multivariable linear regression models tested for associations with caries-related visit prevalence, DGA prevalence, and PQIs (asthma and diabetes). Regression models included clustered SEs at the county level. We used 2-sided t tests to determine statistical significance, which was determined a priori to be P < .05. Counties with missing data for covariates (8 counties over the course of 2 years) were not included in analysis (eTable 1 in the Supplement). Imputation of the missing data using state-level means was performed and included in a sensitivity analysis (eTable 2 in the Supplement). Data management and analysis was performed using STATA statistical software version 14.2 (StataCorp). Data analysis was performed from December 2018 to March 2020.

    Results

    A total of 436 counties per year across 5 states were included in the analysis, yielding 872 county-year observations. The unit of analysis is on the county level. The mean proportion of a county’s population with CWF access was 0.69 (95% CI, 0.67-0.71) (Table 1). The mean prevalence of caries-related visits was 0.150 (95% CI, 0.145-0.155) and that of DGA visits (surgical visits among caries-related visits) was 0.10 (95% CI, 0.09-0.11).

    Increasing the proportion of a county’s access to CWF was associated with decreased caries-related visits. Every 10% increase in the proportion of the population’s access to CWF was associated with a decrease in the prevalence of caries-related visits in both unadjusted analysis (−0.31 percentage points; 95% CI, −0.47 to −0.15 percentage points; P < .001) and adjusted analyses (−0.45 percentage points; 95% CI, −0.59 to −0.31 percentage points; P < .001) (Table 2).

    The prevalence of dental surgery ranged from 6% to 14% and generally decreased as the proportion of the county’s population access to CWF increased from 0% to 100% (Figure). Increasing CWF access in 10% increments was associated with decreased DGA prevalence in unadjusted analysis (−0.39 percentage points; 95% CI, −0.67 to −0.12 percentage points; P = .006) but not in adjusted analysis (−0.23 percentage points; 95% CI, −0.49 to 0.02 percentage points; P = .07) (Table 2).

    To test whether the association of CWF access with surgical prevalence could be explained by other factors regarding utilization of health services (eg, poor access to timely preventive services or characteristics of the population that might be related to preventive and tertiary health service utilization), we tested for the association between differences in access to CWF and exacerbations of asthma and diabetes (Table 3). In adjusted analysis, a 10% increase in the proportion of a county’s access to CWF was not associated with asthma exacerbations (mean dependent variable, 0.0749; −0.02 percentage points; 95% CI, −0.10 to 0.05 percentage points; P = .53). Similarly, adjusted analysis revealed no association between increasing the proportion of county’s access to CWF by 10% and diabetes exacerbations (mean dependent variable, 0.00015; −0.0003 percentage points; 95% CI, −0.0014 to 0.0009 percentage points; P = .66).

    Sensitivity analysis to test the effect of missing data on the association between CWF access and primary outcomes yielded no change in coefficient magnitude or significance of association compared with analysis that excluded counties with missing data. In adjusted analysis, increasing the proportion of a county’s access to CWF by 10% was associated with a decrease in caries-related visits by 0.427 percentage points (95% CI, −0.566 to −0.289 percentage points; P < .001) but was not associated with a decrease in DGA visits (−0.236 percentage points; 95% CI, −0.496 to 0.025 percentage points; P = .08) (eTable 2 in the Supplement).

    Discussion

    This study supports prior work on the benefits of CWF beyond primary prevention.14 The financial burden of pediatric DGA in hospital and ambulatory settings on the Medicaid system has been estimated to total $450 million.18 However, we have observed that a large proportion of DGA events occur in dental office settings in select states, suggesting that the true total financial burden to the Medicaid system exceeds $450 million.19 We found that, in unadjusted analysis, increasing a population’s access to CWF was associated with lower DGA prevalence among children who had caries-related visits, which may serve as a proxy for S-ECC. In addition, our findings provide a greater perspective on our understanding of risks and benefits associated with children’s exposure to fluoride. Although recent work suggested that there is an association of in utero exposure to fluoride with early childhood neurodevelopment,8 it should be noted that criticism has been aimed at multiple study limitations (eg, nonhomogeneous distribution of data, potential errors and biases in the estimation of material fluoride exposure and in outcome measurement, and potential omitted variable bias).11 Furthermore, prior work has not supported an association between fluoride exposure and pediatric neurodevelopment.9,10 Our findings, as they relate to tertiary oral health services, are unexpected, because the development of S-ECC in the US is largely thought to be driven by oral health behaviors, such as preventive dental care, regular toothbrushing, or reducing intake of sugary foods and beverages,39-42 which have all been targeted by interventions to improve children’s oral health.

    Because of concerns regarding potential omitted variable bias, we estimated regression models with outcomes that are unlikely to be directly associated with fluoridation levels but would instead reflect unmeasured county-level socioeconomic characteristics. Specifically, we wanted to determine whether CWF is associated with higher admission rates for another preventable health condition, such as exacerbations associated with asthma or diabetes. Again, PQIs would be associated with CWF only if other (unobserved) local area factors related to the health care system and socioeconomic determinants of health were associated with CWF levels. Finding an association between CWF and PQIs would tend to invalidate any observed association between CWF and DGA because it would instead suggest the presence of confounding variables (ie, omitted variable bias). The lack of an association between CWF and PQIs suggests that an association between CWF and DGA is unlikely to be related to unobserved local area factors.

    In addition to reducing severe caries, the use of CWF may help avoid a preventable surgery with general anesthesia, which has multiple benefits. A preponderance of basic science and animal model studies43-46 have demonstrated the neurotoxic and neurological effects of commonly used medications for moderate sedation and general anesthesia. Ongoing clinical trials21,25 have not supported an association between single anesthetic exposure and general intelligence or learning, but there is evidence suggesting that multiple exposures may decrease neuropsychological domains affecting executive functioning.25,47 The US Food and Drug Administration approved a label change regarding possible neurotoxic effects of general anesthetic and sedation medications in children younger than 3 years, warning that “exposure to these medicines for lengthy periods of time or over multiple surgeries or procedures may negatively affect brain development in children younger than 3 years.”20 Beyond potential adverse clinical outcomes, reducing dental surgical procedures has immediate financial implications for health care systems. Reducing the demand for dental operations addresses a substantial source of dental expenditures within the Medicaid system, because in a single-state study,48 25% of dental expenditures were associated with 8% of children younger than 6 years. Furthermore, a child who presents for dental surgery is likely to require further treatment for caries in the future. Most patients who undergo DGA experience recurrence of dental disease within 12 to 24 months after surgery,49,50 likely because surgical interventions do not address the etiological factors rooted in behaviors and health beliefs. Primary prevention efforts are often aimed at changing oral health behaviors. However, among many families affected by S-ECC, oral health behaviors are associated with social determinants of health (eg, caregiver psychosocial factors, household financial insecurity, or prior negative experiences with the dental delivery system).51

    Strengths and Limitations

    This study addresses possible confounding factors that might also explain the association between low CWF levels and higher DGA prevalence by adjusting for county-level demographics, socioeconomic indicators, and dental practitioner density. We also explored the possibility that counties with low CWF levels might also share characteristics with health care systems that experience high levels of pediatric asthma and diabetes exacerbations, which have been termed by the AHRQ as ambulatory care–sensitive indicators. Higher levels of these ambulatory care–sensitive indicators would signal that health care systems were not adequately addressing conditions that can be managed through access to timely preventive outpatient care.

    Our study has a number of limitations to consider in the application of results to a more generalized population. First, data were sourced from 5 states. We did not include data from the noncontiguous states of Alaska and Hawaii, which are the 41st and 50th lowest states in terms of access to CWF.52 Geographical bias may have influenced our findings, because the data largely represent coastal areas of the US (Texas, Florida, Massachusetts, and Connecticut). Although our data included a wide range of DGA prevalence (<1% to >10%), inclusion of a greater number of states would minimize clustering effects by unmeasured sources. Data sources limited our ability to measure access to CWF among Medicaid-enrolled children. Our measure of county-level access to CWF represents the general county population and did not specify by insurance status. Data sources also limited our ability to determine the population’s use of PWSs. Although populations may have access to CWF, we were unable to verify the degree to which communities were consuming CWF or bottled water. Second, our interpretation of findings is limited by the cross-sectional study design, which allows us to comment on association, not causal inference, between CWF and DGA prevalence. Because of budget limitations, we were unable to obtain additional years of data, which would have allowed for longitudinal analysis. Third, our study design does not allow us to address an exposure-dose response. We did not assess the duration of time that counties had access to CWF, nor did we estimate the duration of time the individuals in our study population resided in counties with CWF.

    Conclusions

    The adverse effects of fluoridated water have not been established beyond the level of association. Public health policy should be based on a stronger degree of certainty regarding cause and effect. The public health importance of our findings relates to the contribution toward the evidence of CWF’s benefits for children’s oral health, which is a well-established public health intervention for the primary prevention of caries. These findings suggest that among children who had caries-related visits, CWF may be associated with reduced development of S-ECC, as reflected by decreased use of surgical services in the unadjusted model. In addition, although access to CWF may be associated with lower pediatric dental surgery prevalence in the Medicaid population, it is important to note that dental surgical procedures persist in this population. Although broad policies may serve as an effective intervention to improve population oral health, this does not obviate the need for continued work to develop and test interventions that address oral health risk factors at the family level. Our findings should be incorporated into ongoing cost-benefit analyses of this public health intervention.

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    Article Information

    Accepted for Publication: March 21, 2020.

    Published: August 12, 2020. doi:10.1001/jamanetworkopen.2020.5882

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Lee HH et al. JAMA Network Open.

    Corresponding Author: Helen H. Lee, MD, MPH, Department of Anesthesiology, University of Illinois at Chicago, 1740 W Taylor St, MC 515, Ste 3200W, Chicago, IL 60612 (leehelen@uic.edu).

    Author Contributions: Drs Lee and Faundez had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: All authors.

    Acquisition, analysis, or interpretation of data: Lee, Faundez.

    Drafting of the manuscript: Lee, LoSasso.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: All authors.

    Obtained funding: Lee.

    Supervision: Lee.

    Conflict of Interest Disclosures: None reported.

    Funding/Support: The Foundation for Anesthesia Education and Research and the Anesthesia Quality Institute provided funding for data acquisition.

    Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Meeting Presentation: This article was presented as an abstract at the Annual Meeting of the International Association for Dental Research; June 20, 2019; Vancouver, BC, Canada.

    References
    1.
    Allukian  M  Jr, Carter-Pokras  OD, Gooch  BF,  et al.  Science, politics, and communication: the case of community water fluoridation in the US.   Ann Epidemiol. 2018;28(6):401-410. doi:10.1016/j.annepidem.2017.05.014PubMedGoogle ScholarCrossref
    2.
    Murthy  VH.  Surgeon General’s perspectives: community water fluoridation—one of CDC’s “10 Great Public Health Achievements of the 20th Century”.   Public Health Rep. 2015;130(4):296-298. doi:10.1177/003335491513000402PubMedGoogle ScholarCrossref
    3.
    Slade  GD, Grider  WB, Maas  WR, Sanders  AE.  Water fluoridation and dental caries in U.S. children and adolescents.   J Dent Res. 2018;97(10):1122-1128. doi:10.1177/0022034518774331PubMedGoogle ScholarCrossref
    4.
    Kumar  JV, Adekugbe  O, Melnik  TA.  Geographic variation in Medicaid claims for dental procedures in New York State: role of fluoridation under contemporary conditions.   Public Health Rep. 2010;125(5):647-654. doi:10.1177/003335491012500506PubMedGoogle ScholarCrossref
    5.
    Elmer  TB, Langford  JW, Morris  AJ.  An alternative marker for the effectiveness of water fluoridation: hospital extraction rates for dental decay, a two-region study.   Br Dent J. 2014;216(5):E10. doi:10.1038/sj.bdj.2014.180PubMedGoogle Scholar
    6.
    Spencer  AJ, Do  LG, Ha  DH.  Contemporary evidence on the effectiveness of water fluoridation in the prevention of childhood caries.   Community Dent Oral Epidemiol. 2018;46(4):407-415. doi:10.1111/cdoe.12384PubMedGoogle ScholarCrossref
    7.
    Malin  AJ, Till  C.  Exposure to fluoridated water and attention deficit hyperactivity disorder prevalence among children and adolescents in the United States: an ecological association.   Environ Health. 2015;14:17. doi:10.1186/s12940-015-0003-1PubMedGoogle ScholarCrossref
    8.
    Green  R, Lanphear  B, Hornung  R,  et al.  Association between maternal fluoride exposure during pregnancy and IQ scores in offspring in Canada.   JAMA Pediatr. 2019;173(10):940-948. doi:10.1001/jamapediatrics.2019.1729PubMedGoogle ScholarCrossref
    9.
    Barberio  AM, Quiñonez  C, Hosein  FS, McLaren  L.  Fluoride exposure and reported learning disability diagnosis among Canadian children: implications for community water fluoridation.   Can J Public Health. 2017;108(3):e229-e239. doi:10.17269/CJPH.108.5951PubMedGoogle ScholarCrossref
    10.
    Broadbent  JM, Thomson  WM, Ramrakha  S,  et al.  Community water fluoridation and intelligence: prospective study in New Zealand.   Am J Public Health. 2015;105(1):72-76. doi:10.2105/AJPH.2013.301857PubMedGoogle ScholarCrossref
    11.
    Canadian Agency for Drugs and Technologies in Health. Community water fluoridation: a review of neurological and cognitive effects. Published October 23, 2019. Accessed July 14, 2020. https://cadth.ca/community-water-fluoridation-exposure-review-neurological-and-cognitive-effects-0
    12.
    Latifi-Xhemajli  B, Begzati  A, Veronneau  J, Kutllovci  T, Rexhepi  A.  Effectiveness of fluoride varnish four times a year in preventing caries in the primary dentition: a 2 year randomized controlled trial.   Community Dent Health. 2019;36(2):190-194.PubMedGoogle Scholar
    13.
    Singh  A, Purohit  BM.  Caries preventive effects of high-fluoride vs standard-fluoride toothpastes: a systematic review and meta-analysis.   Oral Health Prev Dent. 2018;16(4):307-314.PubMedGoogle Scholar
    14.
    Meyer  J, Margaritis  V, Mendelsohn  A.  Consequences of community water fluoridation cessation for Medicaid-eligible children and adolescents in Juneau, Alaska.   BMC Oral Health. 2018;18(1):215. doi:10.1186/s12903-018-0684-2PubMedGoogle ScholarCrossref
    15.
    Fisher-Owens  SA, Gansky  SA, Platt  LJ,  et al.  Influences on children’s oral health: a conceptual model.   Pediatrics. 2007;120(3):e510-e520. doi:10.1542/peds.2006-3084PubMedGoogle ScholarCrossref
    16.
    [No authors listed.]  Guideline on behavior guidance for the pediatric dental patient.   Pediatr Dent. 2016;38(6):185-198.PubMedGoogle Scholar
    17.
    [No authors listed.]  Policy on hospitalization and operating room access for oral care of infants, children, adolescents, and individuals with special health care needs.   Pediatr Dent. 2017;39(6):104-105.PubMedGoogle Scholar
    18.
    Bruen  BK, Steinmetz  E, Bysshe  T, Glassman  P, Ku  L.  Potentially preventable dental care in operating rooms for children enrolled in Medicaid.   J Am Dent Assoc. 2016;147(9):702-708. doi:10.1016/j.adaj.2016.03.019PubMedGoogle ScholarCrossref
    19.
    Lee  HH, Faundez  L, Yarbrough  C, Lewis  CW, LoSasso  AT.  Patterns in pediatric dental surgery under general anesthesia across 7 state Medicaid programs.   JDR Clin Trans Res. Published online February 10, 2020. doi:10.1177/2380084420906114PubMedGoogle Scholar
    20.
    US Food and Drug Administration. FDA drugs safety communication: FDA approves label changes for use of general anesthetic and sedation drugs in young children. Published April 27, 2017. Accessed July 14, 2020. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-approves-label-changes-use-general-anesthetic-and-sedation-drugs
    21.
    McCann  ME, de Graaff  JC, Dorris  L,  et al; GAS Consortium.  Neurodevelopmental outcome at 5 years of age after general anaesthesia or awake-regional anaesthesia in infancy (GAS): an international, multicentre, randomised, controlled equivalence trial.   Lancet. 2019;393(10172):664-677. doi:10.1016/S0140-6736(18)32485-1PubMedGoogle ScholarCrossref
    22.
    Davidson  AJ, Disma  N, de Graaff  JC,  et al; GAS Consortium.  Neurodevelopmental outcome at 2 years of age after general anaesthesia and awake-regional anaesthesia in infancy (GAS): an international multicentre, randomised controlled trial.   Lancet. 2016;387(10015):239-250. doi:10.1016/S0140-6736(15)00608-XPubMedGoogle ScholarCrossref
    23.
    Flick  RP, Katusic  SK, Colligan  RC,  et al.  Cognitive and behavioral outcomes after early exposure to anesthesia and surgery.   Pediatrics. 2011;128(5):e1053-e1061. doi:10.1542/peds.2011-0351PubMedGoogle ScholarCrossref
    24.
    Ing  CH, DiMaggio  CJ, Malacova  E,  et al.  Comparative analysis of outcome measures used in examining neurodevelopmental effects of early childhood anesthesia exposure.   Anesthesiology. 2014;120(6):1319-1332. doi:10.1097/ALN.0000000000000248PubMedGoogle ScholarCrossref
    25.
    Sun  LS, Li  G, Miller  TL,  et al.  Association between a single general anesthesia exposure before age 36 months and neurocognitive outcomes in later childhood.   JAMA. 2016;315(21):2312-2320. doi:10.1001/jama.2016.6967PubMedGoogle ScholarCrossref
    26.
    McCann  ME, Soriano  SG.  Does general anesthesia affect neurodevelopment in infants and children?   BMJ. 2019;367:l6459. doi:10.1136/bmj.l6459PubMedGoogle ScholarCrossref
    27.
    Lee  JJ, Sun  LS, Levy  RJ.  Report on the Sixth Pediatric Anesthesia Neurodevelopmental Assessment (PANDA) Symposium, “Anesthesia and Neurodevelopment in Children”.   J Neurosurg Anesthesiol. 2019;31(1):103-107. doi:10.1097/ANA.0000000000000538PubMedGoogle ScholarCrossref
    28.
    von Elm  E, Altman  DG, Egger  M, Pocock  SJ, Gøtzsche  PC, Vandenbroucke  JP; STROBE Initiative.  The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.   Ann Intern Med. 2007;147(8):573-577. doi:10.7326/0003-4819-147-8-200710160-00010PubMedGoogle ScholarCrossref
    29.
    Drury  TF, Horowitz  AM, Ismail  AI, Maertens  MP, Rozier  RG, Selwitz  RH.  Diagnosing and reporting early childhood caries for research purposes: a report of a workshop sponsored by the National Institute of Dental and Craniofacial Research, the Health Resources and Services Administration, and the Health Care Financing Administration.   J Public Health Dent. 1999;59(3):192-197. doi:10.1111/j.1752-7325.1999.tb03268.xPubMedGoogle ScholarCrossref
    30.
    Meyer  BD, Lee  JY, Casey  MW.  Dental treatment and expenditures under general anesthesia among Medicaid-enrolled children in North Carolina.   Pediatr Dent. 2017;39(7):439-444.PubMedGoogle Scholar
    31.
    American Academy of Pediatric Dentistry. General anesthesia coverage. Committee on Dental Benefits Programs website. Accessed March 16, 2020. https://www.aapd.org/advocacy/legislative-and-regulatory-issues/general-anesthesia-coverage/
    32.
    US Centers for Disease Control and Prevention. Public water systems. Published April 7, 2014. Accessed March 10, 2020. https://www.cdc.gov/healthywater/drinking/public/index.html
    33.
    US Centers for Disease Control Prevention. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Published 2013. Accessed July 14, 2020. https://www.cdc.gov/nchs/icd/icd9cm.htm
    34.
    Nasseh  K, Vujicic  M.  The impact of Medicaid reform on children’s dental care utilization in Connecticut, Maryland, and Texas.   Health Serv Res. 2015;50(4):1236-1249. doi:10.1111/1475-6773.12265PubMedGoogle ScholarCrossref
    35.
    Agency for Healthcare Research and Quality. Prevention quality indicators overview. Accessed July 17, 2020. https://www.qualityindicators.ahrq.gov/modules/pqi_overview.aspx
    36.
    Health Resources & Services Administration. Area health resources files. Accessed January 3, 2013. https://data.hrsa.gov/topics/health-workforce/ahrf
    37.
    DeNavas-Walt  C, Proctor  BD. Income and poverty in the United States: 2014. US Census Bureau. Published September 2015. Accessed July 14, 2020. https://www.census.gov/content/dam/Census/library/publications/2015/demo/p60-252.pdf
    38.
    Guarnizo-Herreño  CC, Wehby  GL.  Dentist supply and children’s oral health in the United States.   Am J Public Health. 2014;104(10):e51-e57. doi:10.2105/AJPH.2014.302139PubMedGoogle ScholarCrossref
    39.
    Ismail  AI, Lim  S, Sohn  W, Willem  JM.  Determinants of early childhood caries in low-income African American young children.   Pediatr Dent. 2008;30(4):289-296.PubMedGoogle Scholar
    40.
    Wigen  TI, Baumgartner  CS, Wang  NJ.  Identification of caries risk in 2-year-olds.   Community Dent Oral Epidemiol. 2018;46(3):297-302. doi:10.1111/cdoe.12366PubMedGoogle ScholarCrossref
    41.
    Sen  B, Blackburn  J, Kilgore  ML,  et al.  Preventive dental care and long-term dental outcomes among ALL Kids enrollees.   Health Serv Res. 2016;51(6):2242-2257. doi:10.1111/1475-6773.12469PubMedGoogle ScholarCrossref
    42.
    Savage  MF, Lee  JY, Kotch  JB, Vann  WF  Jr.  Early preventive dental visits: effects on subsequent utilization and costs.   Pediatrics. 2004;114(4):e418-e423. doi:10.1542/peds.2003-0469-FPubMedGoogle ScholarCrossref
    43.
    Brambrink  AM, Evers  AS, Avidan  MS,  et al.  Isoflurane-induced neuroapoptosis in the neonatal rhesus macaque brain.   Anesthesiology. 2010;112(4):834-841. doi:10.1097/ALN.0b013e3181d049cdPubMedGoogle ScholarCrossref
    44.
    Zou  X, Patterson  TA, Divine  RL,  et al.  Prolonged exposure to ketamine increases neurodegeneration in the developing monkey brain.   Int J Dev Neurosci. 2009;27(7):727-731. doi:10.1016/j.ijdevneu.2009.06.010PubMedGoogle ScholarCrossref
    45.
    Jevtovic-Todorovic  V, Hartman  RE, Izumi  Y,  et al.  Early exposure to common anesthetic agents causes widespread neurodegeneration in the developing rat brain and persistent learning deficits.   J Neurosci. 2003;23(3):876-882. doi:10.1523/JNEUROSCI.23-03-00876.2003PubMedGoogle ScholarCrossref
    46.
    Ikonomidou  C, Bosch  F, Miksa  M,  et al.  Blockade of NMDA receptors and apoptotic neurodegeneration in the developing brain.   Science. 1999;283(5398):70-74. doi:10.1126/science.283.5398.70PubMedGoogle ScholarCrossref
    47.
    Warner  DO, Zaccariello  MJ, Katusic  SK,  et al.  Neuropsychological and behavioral outcomes after exposure of young children to procedures requiring general anesthesia: the Mayo Anesthesia Safety in Kids (MASK) Study.   Anesthesiology. 2018;129(1):89-105. doi:10.1097/ALN.0000000000002232PubMedGoogle ScholarCrossref
    48.
    Kanellis  MJ, Damiano  PC, Momany  ET.  Medicaid costs associated with the hospitalization of young children for restorative dental treatment under general anesthesia.   J Public Health Dent. 2000;60(1):28-32. doi:10.1111/j.1752-7325.2000.tb03288.xPubMedGoogle ScholarCrossref
    49.
    Amin  MS, Bedard  D, Gamble  J.  Early childhood caries: recurrence after comprehensive dental treatment under general anaesthesia.   Eur Arch Paediatr Dent. 2010;11(6):269-273. doi:10.1007/BF03262761PubMedGoogle ScholarCrossref
    50.
    Almeida  AG, Roseman  MM, Sheff  M, Huntington  N, Hughes  CV.  Future caries susceptibility in children with early childhood caries following treatment under general anesthesia.   Pediatr Dent. 2000;22(4):302-306.PubMedGoogle Scholar
    51.
    Lee  HH, Lehew  CW, Avenetti  D, Buscemi  J, Koerber  A.  Understanding oral health behaviors among children treated for caries under general anesthesia.   J Dent Child (Chic). 2019;86(2):101-108.PubMedGoogle Scholar
    52.
    US Centers for Disease Control and Prevention. 2012 Fluoridation statistics: state fluoridation percentage calculations and states ranked by fluoridation percentage. Published 2012. Accessed October 18, 2019. https://www.cdc.gov/fluoridation/statistics/2012stats.htm
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