摘要：Objectives. The aim of this study was to examine caregivers’ refusal of preventive medical and dental care for children. Methods. Prevalence rates of topical fluoride refusal based on dental records and caregiver self-reports were estimated for children treated in 3 dental clinics in Washington State. A 60-item survey was administered to 1024 caregivers to evaluate the association between immunization and topical fluoride refusal. Modified Poisson regression models were used to estimate prevalence rate ratios (PRRs). Results. The prevalence of topical fluoride refusal was 4.9% according to dental records and 12.7% according to caregiver self-reports. The rate of immunization refusal was 27.4%. In the regression models, immunization refusal was significantly associated with topical fluoride refusal (dental record PRR = 1.61; 95% confidence interval [CI] = 1.32, 1.96; P < .001; caregiver self-report PRR = 6.20; 95% CI = 3.21, 11.98; P < .001). Caregivers younger than 35 years were significantly more likely than older caregivers to refuse both immunizations and topical fluoride ( P < .05). Conclusions. Caregiver refusal of immunizations is associated with topical fluoride refusal. Future research should identify the behavioral and social factors related to caregiver refusal of preventive care with the goal of developing multidisciplinary strategies to help caregivers make optimal preventive care decisions for children. The 2013 Institute of Medicine report Childhood Immunization Schedule and Safety: Stakeholder Concerns, Scientific Evidence, and Future Studies provides an up-to-date review of immunization safety for children. 1 This report, along with numerous other publications, indicates that childhood immunizations are safe, have decreased morbidity and mortality by reducing the incidence of serious diseases, and play an important role in population-based disease prevention. 2–4 Similarly, topical fluoride is safe, effective, and prevents dental caries, 5 the most common disease worldwide. 6 However, as is the case with all drugs and preventive therapies, immunizations and topical fluoride are not completely risk-free, which can lead to concerns among caregivers regarding preventive care for children. Most children in the United States receive immunizations as recommended, but immunization hesitancy and refusal among caregivers are growing problems. According to a recent study, 20% of children 6 to 23 months of age did not receive recommended immunizations. 7 Another study reported an increase in the percentage of immunization-hesitant caregivers from 2.5% to 9.5% between 2006 and 2009. 8 Overall immunization refusal rates range from 1.6% to 2.4%, and they are known to cluster geographically within school districts, communities, and counties. 9,10 More than 90% of pediatricians and 60% of family medicine physicians report having treated at least 1 child whose caregiver had previously refused immunizations. 11 Reasons for immunization hesitancy or refusal include concerns about safety and side effects, religious objections, and philosophical or personal beliefs. 12–20 The public health consequences of immunization refusal include outbreaks of life-threatening diseases (e.g., measles, pertussis, rubella), hospitalizations, and threats to herd immunity. 21–27 The dental caries process begins with intake of dietary fermentable carbohydrates, which are metabolized by intraoral bacteria. Over time, these bacteria produce acids that demineralize tooth structure. Topical fluorides are defined as any fluoride source (e.g., fluoridated drinking water, toothpaste, mouth rinses) that promotes remineralization and inhibits demineralization on the tooth surface. Regular exposure to topical fluorides helps to prevent tooth decay. 28 Inadequate or irregular exposure to topical fluorides leads to increased risk of dental caries (cavities), which requires dental treatments such as fillings, crowns, or extractions. When left untreated, dental caries can lead to pain, infection, hospitalization, and, in rare cases, death. The social and economic consequences span the life course and include missed school days, poor grades, and teasing or bullying at school among children and underemployment and lower earnings among adults. 29–32 Low levels of fluoride are found in drinking water, toothpastes, and mouth rinses. Individuals at increased risk for dental caries who lack access to fluoridated water can be prescribed fluoride tablets or drops that are taken daily at home. 33 High-risk individuals may periodically have higher levels of fluoride applied to their teeth in the form of fluoride gels, foams, and varnishes during dental or medical visits. Relatively few studies have addressed fluoride hesitancy and refusal among caregivers. One study examined predictors of fluoride varnish refusal but focused on child behaviors and provider factors as correlates of refusal by children. 34 A number of investigations have identified caregiver concerns regarding fluoride safety, particularly among caregivers of children with autism spectrum disorders. 35–37 Most studies focus on opposition to community water fluoridation. 38–40 Concerns about topical fluoride may stem from the handful of cases of accidental hyperfluoridation of community water, 41–49 which is extremely rare and most commonly results in temporary nausea and vomiting. Since the 1980s, there have been fewer than 20 incidents of hyperfluoridation across community water systems, which serve 72.4% of the US population. 50 However, 1 documented death related to water fluoridation was reported in Hooper Bay, Alaska, in 1992. This incident was caused by insufficient system monitoring and an equipment malfunction, 47 highlighting the importance of proper training and oversight of water hygienists responsible for fluoridating water. Dental fluorosis, in which the teeth exhibit diffuse, whitish mottling, is a more prevalent side effect associated with fluoride overexposure. 51–53 Fluorosis occurs with chronic intake of low levels of fluoride during early childhood, particularly when young children brush their teeth unsupervised and ingest fluoridated toothpaste in excess of the amount needed to prevent dental caries. 54 Topical fluorides provided during dental visits are not known to cause dental fluorosis. 54 Immunizations and topical fluorides are front-line preventive strategies in pediatric medicine and dentistry. As such, the growing number of caregivers who refuse preventive care for children is a significant public health concern. The links between medical care and dental care use among children 55–57 suggest that caregivers’ refusal of immunizations and refusal of fluoride are related behaviors; however, to my knowledge, no investigations to date have examined this relationship. In this study, the goals were to estimate the prevalence of caregiver refusal of topical fluoride through chart review and survey data and to evaluate the association between immunization and topical fluoride refusal. Such work has important public health implications for developing clinical strategies that can be deployed by medical, dental, and public health professionals to help caregivers make optimal preventive care decisions for children.
