Public Health and Healthcare

Abstract: ntroduction: Despite multi-decade reforms aimed at Universal Health Coverage (UHC), out-of-pocket (OOP) expenditure remains a primary barrier to healthcare access in Sub-Saharan Africa (SSA). While macro-level financing policies are well-documented, the agency of the "street-level" health workforce in navigating these policies at the point of care is under-researched. This scoping review aims to map the perceptions, experiences, and discretionary practices of primary care workers that mitigate or exacerbate OOP payments in Sub-Saharan Africa. Methods: Following the Arksey and O'Malley (2005) framework, a comprehensive search of PubMed, Scopus, and Google Scholar will be conducted for studies published between 2012 and 2025. Data extraction will focus on the frontline practices of primary care staff. Analysis will be guided by Street-Level Bureaucrat Theory, examining how worker discretion, resource scarcity, and client interactions shape the implementation of financial risk protection. Discussion: The findings will provide a critical lens on the "implementation gap" in health financing, shifting the focus from top-down policy design to the frontline actors who ultimately determine the financial burden faced by patients.

Abstract: Background/Objectives: Adolescence is a critical period for establishing lifelong oral health behaviours; however, persistent oral health problems and limitations in conventional school-based oral health education (OHE) highlight the need for more engaging and scalable approaches. Emerging digital modalities, such as artificial intelligence (AI)-based virtual human (VH) education, offer a promising alternative but remain insufficiently evaluated in adolescent populations. This study aimed to evaluate the effectiveness of AI-based virtual human–based oral health education (VOHE) program compared with conventional face-to-face oral health education (FOHE) among adolescents. Methods: A cluster randomised pretest–post-test intervention design was employed. Participants received either VOHE or FOHE, followed by assessment using a structured questionnaire based on the Knowledge–Attitude–Practice (KAP) model. A total of 268 middle school students were assessed for changes in oral health literacy (OHL) and oral health-related KAP. A linear mixed-effects model was applied to evaluate the effects of time, group (VOHE vs. FOHE), and their interaction, with participants treated as random effects to account for within-individual correlations. Results: Both groups demonstrated significant improvements in OHL and oral health related KAP following the intervention (all p < 0.05). However, no significant group × time interaction effects were observed for any outcome variables (all p > 0.05), suggesting that VOHE achieved educational outcomes comparable to those of FOHE. These findings indicate that AI-based VH education may provide an effective and scalable approach for adolescent OHE. Conclusions: VOHE demonstrated effectiveness comparable to FOHE and may serve as a feasible alternative or complementary approach for adolescent OHE. AI-based VH education also has potential applicability as an accessible digital health intervention for school- and community-based oral health promotion, particularly in digitally mediated or resource-limited educational settings.

Abstract: Background/Objectives: Artificial intelligence reshapes clinical practice and its effect on physician-patient relationship requires reconsideration of frameworks that have shaped modern medical ethics. When physician delegate expertise to algorithms they cannot verify, it becomes unclear who bears clinical responsibility. Methods: This article applies theoretically grounded normative approach to explore ethical conditions under which artificial intelligence can be integrated into clinical practice without compromising the moral foundations of medicine. The analysis is primarily based on Pellegrino and Thomasma’s concept of internal morality of medicine and the physician’s act of profession. It further draws on Kantian ethics of human dignity, Levinasian relational ethics, virtue ethics, and Vallor’s concept of technomoral wisdom. Results: AI systems do not satisfy the conditions under which moral responsibility can be ascribed to them. Clinical moral agency lies in the capacity to bear three distinct responsibilities – epistemic, relational, and phronetic – none of which can be fulfilled by AI. The implementation of AI in healthcare, therefore, must occur strictly under the condition of Meaningful Human Control, rather technical function of human oversight over algorithmic outputs. To ensure that MHC can function as an effective and ethically grounded safeguard, we propose five normative requirements: primacy of clinical judgement, prohibition of forced automation, traceability and explainability, transparency towards patients, and clinical authority over diagnostic tools. A dialog between the physician and the patients should remain the foundation of clinical decision-making. Proposed normative requirements aim to preserve internal morality of medicine in a form that harmoniously combines both technological progress and established medical ethics.

Abstract: Securing electronic health records (EHRs) is critical in the modern healthcare landscape, where digital transformation enhances connectivity and data-driven decision-making. This paper introduces a secure framework that integrates voice-based authentication, blockchain technology, and machine learning to protect EHRs, particularly in IoT-enabled, high-frequency wireless communication environments. The new distributed system utilizes blockchain technology to improve the security and integrity of medical records. Voice authentication, which incorporates a biometric element, facilitates user verification. A working model was designed to show the system’s feasibility along with a case study on heart health monitoring. Simulated results demonstrated better block creation time, transaction latency, and validation accuracy.

Abstract: This study examines the retail food environment surrounding public schools in Michigan using a multiscale, multidimensional framework. A cross-sectional spatial analysis integrates relative healthfulness (modified Retail Food Environment Index, mRFEI), availability (outlet density), and accessibility (network-based walking time) across school districts, census tracts, block groups, and school-centered buffers. The analysis includes 3,530 public schools, 7,680 fast food restaurants, and 2,065 convenience stores. Results show pronounced spatial heterogeneity and clustering of unhealthful outlets (Nearest Neighbor Index = 0.284, p < 0.001), with many located near schools. Approximately 34% of schools are within a 10-minute walk of a fast food restaurant, increasing to 65% within 20 minutes. Urban schools face significantly higher exposure—2.27–2.80 times more fast food outlets and shorter walking times than rural schools (p ≤ 0.002)—with consistent gradients across city, suburban, town, and rural contexts. Overall, school neighborhood food environments are highly structured, obesogenic, and inequitable. By integrating multiple spatial scales and dimensions, this study advances food environment research and provides policy-relevant evidence for targeted, place-based interventions to improve access to healthier food around schools.

Abstract: COVID-19, caused by a novel virus, SARS-CoV-2, has now become international endemic. It posed a challenge to the global biomanufacturing industry for rapid diagnostics, effective therapeutics, and scalable vaccine manufacturing. The biomanufacturing industry played a central role in meeting this challenge by accelerating the development, production, and distribution of SARS‑CoV‑2 diagnostic assays and vaccines. This review provides an overview of SARS‑CoV‑2 biology, major variants, followed by a detailed examination of diagnostic technologies. We further highlight the development process of mRNA vaccine technologies, emphasizing advances in lipid nanoparticle formulation, and large‑scale manufacturing. The review also discusses the biomanufacturing sector’s rapid mobilization to overcome supply‑chain constraints, workforce shortages, and acceleration in regulatory affairs. Collectively, this work underscores how scientific innovation, industrial agility, and cross‑sector collaboration enabled the rapid deployment of diagnostics and vaccines that were essential to controlling the COVID‑19 pandemic.

Abstract: Purpose: To provide an evidence calibrated, time bound clinical framework for the use of 38% silver diamine fluoride (SDF) as interim stabilization for severe early childhood caries (SECC) in young children, addressing gaps in existing guidelines regarding treatment duration, exit criteria, equity, and system accountability. Methods: This framework was developed from the American Academy of Pediatric Dentistry (AAPD) guidance (2017–2025), the 2024 Cochrane review, real world utilization studies, and a narrative review proposing a preservation to precision heuristic. Recommendations are expressed using GRADE terminology. Results: The framework includes ten recommendations, a systems drift principle, explicit time thresholds (< 6 months, 6–12 months, >12 months), a 12 month reassessment mandate, equity guardrails, a bridge vs destination consent model, and a future research agenda. A clinical vignette contrasts appropriate short term bridging with prolonged temporization due to access barriers. Conclusion: SDF is conditionally recommended for caries arrest in primary teeth. In children with SECC, SDF should be used within a documented, time bound preservation to precision pathway. SDF should not become an open ended substitute for definitive restorative care. Equity explicit implementation prevents the framework from penalizing underserved children.

Abstract: Background/Objectives: Indigenous children in La Guajira, Colombia, live in a context of structural vulnerability that may compromise growth and nutritional status. This study aimed to characterize anthropometric patterns and longitudinal nutritional changes in Wayúu children under five years of age. Methods: We conducted a prospective cohort study in 398 children from 27 Wayúu communities in Manaure, La Guajira, over an 8-month period. Anthropometric measurements were obtained by pediatricians and classified using standard indicators based on WHO growth references. A descriptive and bivariate analysis was performed for the full sample, and longitudinal changes were evaluated in a follow-up subgroup. Results: At baseline, 92.46% of children presented at least one nutritional alteration, and 89.95% had malnutrition or developmental delay. Stunting was the most frequent condition (89.95%), whereas acute malnutrition was less common. In the longitudinal subgroup, 41.67% of children worsened in at least one indicator, with a significant increase in nutritional risk over time. Older children showed worse weight-for-age and height-for-age indicators than younger children, while no significant differences were observed by sex. Conclusions: Wayúu children under five years in Manaure show a pattern dominated by chronic, symmetrical growth impairment with worsening anthropometric trajectories over time. These findings highlight the need for sustained, culturally adapted, and multisectoral strategies to prevent and manage childhood malnutrition in Indigenous populations.

Abstract: Singapore’s rapidly ageing population presents significant challenges for healthcare planning and long-term care provision. This study applies ARIMA time-series modeling to forecast the number of older adults requiring assistance in daily living between 2025 and 2035. Using historical population data, nursing home residency figures, and simulated indicators of disability and living arrangements, the model projects assisted living demand rising from 19,741 individuals in 2025 to 29,443 in 2035—a 49.2% increase. While forecasts are conservative due to reliance on informal care from family members and foreign domestic helpers, structural shifts such as smaller family sizes and reduced caregiver availability may drive demand higher. The methodology highlights the importance of accounting for disability prevalence and informal care. Findings underscore the need for strategic planning to expand assisted living infrastructure, workforce capacity, and policy frameworks. Singapore’s case contributes to global literature by illustrating ageing trajectories relevant to other developed societies.

Abstract: Background: Non-communicable diseases (NCDs) account for the majority of global mortality, yet healthcare systems remain largely oriented toward the treatment of acute conditions. This study examines the structural mismatch between contemporary disease patterns and healthcare system organization. Methods: A narrative analytical review was conducted using secondary data from the Global Burden of Disease (GBD) study and World Health Organization (WHO) reports, supplemented by literature from PubMed, Scopus, and Google Scholar (2000–2026). Findings were interpreted using epidemiological transition theory, health systems analysis, and political economy frameworks. Results: The analysis identifies multiple structural drivers of treatment-oriented healthcare systems, including economic incentives favoring curative services, short-term political decision-making cycles, and the historical dominance of the biomedical model. These factors contribute to systematic underinvestment in prevention, rising healthcare expenditures, and persistent global inequalities in access to medical technologies, as demonstrated during the COVID-19 pandemic. The current model is associated with increasing economic burden and projected losses in global productivity by 2030–2050. Conclusions: The findings indicate that the current healthcare model is structurally misaligned with population health needs. Improving health outcomes and system sustainability requires a reorientation toward prevention, long-term health metrics, and the evidence-based integration of complementary approaches within healthcare systems.

Abstract: Background: Immunization programmes rely on cold-chain systems to protect vaccine quality, but these systems also generate waste streams that are not consistently addressed within conventional health-care waste frameworks. These include electronic temperature monitoring devices, data loggers, batteries, packaging materials, cooling accessories, damaged vaccine carriers, sensors, voltage stabilizers, obsolete parts, and decommissioned refrigerators and freezers. Methods: This review was conducted as a secondary evidence review with structured policy and guidance mapping. Peer-reviewed literature and guidance documents from global, technical, and national sources were reviewed to map cold-chain waste streams, assess policy and operational coverage, and identify relevant management pathways. Findings: Cold-chain waste is generated across vaccine shipment, storage, transport, outreach, maintenance, repair, replacement, and decommissioning. Existing guidance addresses some components, particularly obsolete refrigerators and freezers, but smaller items such as Q-tags, data loggers, batteries, sensors, packaging materials, ice packs, and broken accessories are covered indirectly, partially, or not as a unified programme-management issue. Relevant guidance is distributed across health-care waste management, e-waste regulation, procurement, asset management, vaccine logistics, and cold-chain equipment decommissioning documents. Interpretation: Cold-chain waste should not be treated as uniformly hazardous, but it should be recognized as a distinct operational category within immunization systems. A practical response requires risk-based classification, segregation, inventory, reuse or repair where appropriate, linkage with approved e-waste and disposal systems, stronger procurement clauses, and integration into EVM assessments, continuous improvement plans, vaccine-store SOPs, and national logistics working group processes. A concise global reference framework could help countries manage cold-chain waste through existing health, environmental, procurement, and asset-management systems.

Abstract: University students face dietary transitions shaped by time constraints, campus food environments, and intensive exposure to food-related content on social media, yet the mechanisms linking digital exposure to observable food choices and overall diet quali-ty remain insufficiently modeled in Latin American contexts. This study examined whether social-media-driven food norms (NI) and in-restaurant food choices (CD) se-quentially mediate the effect of Instagram (IG) and TikTok (TK) exposure on overall diet quality (Y), while incorporating physical activity (PA) as an independent predic-tor. A cross-sectional survey was administered to 615 university students consuming in campus restaurants in La Libertad, Northern Peru. Data were analyzed through PLS-SEM (SmartPLS 4) with 5,000 bootstrap resamples and BCa 95% confidence in-tervals; Y was operationalized through a culturally adapted KIDMED index. All five structural hypotheses were supported: TK → NI (β = 0.479) exceeded IG → NI (β = 0.349); NI → CD (β = 0.473) and PA → CD (β = 0.216) operated as independent path-ways; and CD → Y (β = 0.255) confirmed the distal link. NI fully mediated both digital pathways toward food choices. Diet quality in university restaurants is reconfigured primarily through normative, not informational, digital mechanisms, suggesting norm-based interventions over nutrition-information campaigns.

Abstract: This introduction to Overreach: The Deadly Price of Regulatory Surveillance explores the complex interplay between pharmaceutical knowledge, government regulation, and individual autonomy in the United States. The text argues that Americans’ unprecedented consumption of pharmaceuticals is the product of a century-long alliance between medical professionals seeking to eliminate competition and a federal government expanding its regulatory domain. This alliance forged the concepts of “pharmaceutical fact,” the regulatory structures defining drug legitimacy, and “pharmaceuticalization,” the process by which increasing aspects of human life are framed as pharmaceutical problems. These frameworks, the author contends, are not neutral but constitute a sociopolitical system that determines who has authority over medical decisions and the limits of personal autonomy. Drawing on the work of Thomas Szasz, the critique highlights the evolution of the “Therapeutic State,” where state power and medical authority become inseparably linked, resulting in surveillance, behavioral control, and exclusion from necessary medicines for those outside the system. The book traces how professional organizations, in partnership with federal agencies, used regulation to enforce their definitions of scientific fact, transforming both the nature of medicines and the roles of those who dispense them. Through the lens of Nico Stehr’s “knowledge capitalism,” the text demonstrates that pharmaceutical knowledge has been turned into monopoly property, enforced through legal and regulatory mechanisms like the FDA and international agreements such as TRIPS. This transformation, the author asserts, underlies the economic and social power of the pharmaceutical industry, shaping access to medicines and the governance of individual bodies. The introduction frames the book’s central inquiry: whether the current system serves patients or entrenches a regime of knowledge monopolism and state authority.

Abstract: Background/Objectives: COVID-19 vaccine resistance was detrimental to herd immunity and worsened COVID-19 morbidity and mortality during outbreaks. Despite more evidence showing reactionary behavior among residents exposed to vaccine mandates, little research has been conducted on the effects of state proof-of-vaccine (POV) mandate bans in the United States (US). We sought to investigate the causal effects of POV mandate bans, overall and stratified by policy passage via executive order or state legislature, on 1st-dose COVID-19 vaccinations. Methods: In the contiguous US, 21 states enacted POV mandate bans from 2/8/2021–10/25/2021. Using a geographic regression discontinuity design, we selected treatment and control counties within 150 miles of the POV mandate ban state border. The resulting sample was 4,612 county-observations and 2,466 unique counties. We conducted two-way fixed effects estimation to compare changes in bimonthly, 1st-dose COVID-19 vaccinations among individuals under 65 years old before and after POV mandate ban enactment between treatment and control counties. Results: Among executive order POV mandate ban counties, we saw a reduction in the decreasing 1st-dose COVID-19 trend following POV mandate ban enactment. This corresponded to an additional 32.6% increase in 1st-dose COVID-19 vaccinations in Weeks 1–2, 34.5% in Weeks 3–4, 35.0% in Weeks 5–6, and 36.9% in Weeks 7–8 post-POV mandate ban enactment when compared to control counties. Conclusions: These findings suggest that executive order POV mandate bans reversed reactance to vaccine mandates. Future public health efforts should consider potential reactance to mandatory policies and tailor efforts to community values.

Abstract: In the past year, the medical regulation of psilocybin-assisted therapy has expanded across additional international jurisdictions, requiring an update to the original medico-legal synthesis. Newly established or clarified regulatory pathways in New Zealand, Germany, Switzerland, the Czech Republic, and at the United States federal level reflect continued evolution in therapeutic governance. Within the United States, Utah and New Mexico have now joined Oregon and Colorado in establishing lawful medical access pathways. These developments build upon earlier reforms in Alberta, Canada and Australia, where structured psychiatric prescribing frameworks were implemented.This update consolidates recent statutory amendments and regulatory decisions to provide a current comparative overview of jurisdictions permitting lawful medical use of psilocybin. By distinguishing comprehensive medical regulation from restricted or exceptional access schemes, this revised analysis maintains clarity within an increasingly dynamic global regulatory landscape.

Abstract: Background/Objectives: Breast cancer represents a major public health and economic challenge, generating substantial costs for healthcare systems, patients, and the broader economy. In Poland, comprehensive assessments capturing the full societal burden remain limited. This study aimed to estimate the cost of illness of breast cancer in Poland in 2024 from a societal perspective, including direct and indirect costs, and to assess their distribution across cost bearers. Methods: A cost-of-illness analysis was conducted using a societal perspective. Data were derived from administrative sources, including the National Health Fund (NFZ), Social Insurance Institution (ZUS), Central Statistical Office (GUS), and National Cancer Registry (NCR), supplemented with a patient survey (n = 289). Direct medical, direct non-medical, and indirect costs were estimated. Productivity losses were valued using a human capital approach with a GDP-based productivity metric adjusted by a correction factor. Results: Total costs of breast cancer in Poland in 2024 were dominated by indirect costs, which accounted for approximately 73% of the total burden. Direct costs represented 27% and included €837.7 million in public healthcare expenditures and €322.4 million in patient-borne costs. Among indirect costs, absenteeism, presenteeism, unpaid work, and informal caregiving contributed substantially, with productivity losses exceeding several hundred million euros in each category. The largest single indirect component was absenteeism, followed by presenteeism and unpaid work. Conclusions: Breast cancer imposes a substantial societal burden in Poland, driven predominantly by indirect costs. These findings highlight the importance of adopting a societal perspective in economic evaluations and support the inclusion of productivity losses in health policy decision-making.

Abstract: While South Africa’s Constitution guarantees the right to healthcare for all who live in the country, health inequities exist based on migrant status. This paper examined how discrimination intersects with structural and institutional practices to produce unequal access to healthcare services for black foreign migrants in South Africa. Desk reviews of policy frameworks and relevant academic literature were used to analyze the existing disconnect in South Africa’s rights-based legal commitments and the lived realities of foreigners. Adopting a theoretical framework that integrates structural violence, intersectionality, and bureaucratic discretion, the findings are discussed by conceptualizing discrimination as a structural and interpersonal determinant of health. The study found that foreign nationals’ experiences regarding access to healthcare services are not incidental but embedded within complex socio-political dynamics of scarce resources, institutional practices, and institutional ambiguity. The consequences of these inequities involve delayed care-seeking and increased vulnerability to preventable diseases among black immigrants, with a broader public health risk. Drawing from the study, policy clarity is recommended, and the strengthening of mechanisms to ensure equitable access to healthcare in the country.

Abstract: Background/Objectives. The 13-valent pneumococcal conjugate vaccine (PCV13), followed by the 23-valent pneumococcal polysaccharide vaccine (PPV23; PCV13→PPV23), was recommended for adults with high-risk conditions and all adults aged ≥65 years. With the availability of the 20-valent PCV (PCV20), which provides broader protection against pneumococcal disease, Taiwan CDC recently recommended to replace PCV13→PPV23 with PCV20. However, there is no economic evidence to support the recommendation. Therefore, the objective of the study is to assess the short- and long-term clinical and economic value of PCV20 to support the recommendation. Methods. A lifetime cost-effectiveness analysis (CEA) based on a single cohort and five-year budget impact analysis (BIA) based on rolling cohorts were conducted from a healthcare system perspective to evaluate replacing PCV13→PPV23 with PCV20 among high-risk adults aged 18–64 years and all adults aged 65–99 years. Results. In CEA, PCV20 was estimated to reduce pneumococcal disease cases by 4,684 and deaths by 160 among the model population (N = 5.5M) over a lifetime horizon. Total costs decreased by NT $2.3 billion while quality-adjusted life-years (QALYs) increased by 944, making PCV20 the dominant strategy versus PCV13→PPV23. BIA showed budget savings of NT $5.4 billion over five years including NT$2.4 billion in the first year. Conclusions. Switching to PCV20 for adults with high-risk conditions and all adults aged ≥ 65 years would substantially reduce the burden of pneumococcal disease and related deaths, leading to cost and budget savings for Taiwan's healthcare system.

Abstract:

Background and Objectives: Multiple sclerosis (MS) is a chronic autoimmune neuroinflammatory condition associated with significant disability. Given the increasing number of patients with MS, the growing number of available disease-modifying therapies (DMTs), and the substantial economic burden associated with MS, it is critically important to determine which treatment options are the most cost-effective. The economic burden of MS is considerable, and high-cost DMTs, whose prices continue to rise, represent the primary driver of health expenditures related to MS. The primary aim of this narrative review is to provide a brief review of the economic issues related to MS DMTs, including pricing trends, economic burden, and their impact on patient care, and to propose potential policy solutions. Materials and Methods: The aim of the study was to compare the cost effectiveness of The annual costs of DMTs from 1993 to 2023 in USA. An examination of DMT pricing trends suggests that pricing has been influenced in part by within-class competition and the availability of generic DMT options. Results: Over the past decade, the prices of DMTs have increased by more than 50%. Currently, the annual cost of many DMTs used in the treatment of MS has exceeded $100,000, and their economic value is widely debated. The high cost of DMTs and difficulties in timely access to medications can lead to psychological stress among many patients. Studies on cost-effectiveness indicate that the clinical benefits provided by DMTs do not fully justify their high costs, which further exacerbates issues related to economic accessibility. Conclusions: Collaborative neuropsychiatric care models, in which neurologists and mental health professionals work in coordination, may improve symptom recognition, optimize adherence to DMTs, and enhance overall functioning. Given that treatment non-adherence and reduced quality of life negatively affect cost-effectiveness outcomes, early psychiatric intervention may indirectly improve the economic value profile of high-cost DMTs.

Abstract: Background: Dental caries remain a major public health issue among Italian children, with prevalence exceeding 60% in specific subgroups and marked socioeconomic gra-dients. Objectives: This multicenter study aimed to describe caries experience, malocclusions, and oral hygiene status in pediatric populations residing in three Italian regions and to develop and preliminarily evaluate the feasibility of an integrated care pathway for the prevention and management of caries and malocclusions. Materials and Methods: Within the Italian Centre for Diseases Control and Prevention (CCM) 2024 program (ID 10), 795 children aged 6–11 years were examined in school settings and via mobile dental units. Caries experience was assessed using the dmft/DMFT indices and International Caries Detection and Assessment System (ICDAS) criteria. Malocclusions were evaluated using the Index of Orthodontic Treatment Need (IOTN). Oral hygiene was assessed through standardized clinical indices. The proposed care pathway comprises three tiers: (1) universal, school based oral health education; (2) targeted clinical preventive and interceptive interventions; and (3) telemedici-ne/AI supported follow up for high risk children. Descriptive and multivariable statistical analyses were performed. Results: Overall caries burden was low. No statistically significant differences in dmft/DMFT were observed between males and females. A non significant trend toward higher caries indices was found among children with a positive breastfeeding history. By contrast, oral hygiene level was strongly associated with caries indices: children with insufficient hygiene had the highest dmft/DMFT, those with mediocre hygiene showed intermediate values, and those with optimal hygiene presented the lowest caries expe-rience. In multivariable models, oral hygiene emerged as the main independent pre-dictor of dmft/DMFT. Conclusions: In this low caries cohort, oral hygiene was confirmed as the principal mo-difiable determinant of caries risk. A tiered, school and community based care pathway focused on hygiene promotion, early screening, and minimally invasive clinical inter-ventions appears feasible and potentially scalable, with the aim of reducing the burden of caries and malocclusions and improving equity in pediatric oral health.