Addressing children's oral health inequalities in Northern Ireland: a research-practice-community partnership initiative

Caries Preventive Interventions and Oral Health Inequalities: A Scoping Review

INTRODUCTION

Dental caries remains one of the most prevalent but preventable diseases among children worldwide and especially affects children with a lower socioeconomic status or ethnic minority background. It is important that all groups of children are reached by preventive interventions to reduce oral health inequalities. So far, it is unknown whether children from different social and ethnic groups benefit equally from potentially effective oral health interventions.

OBJECTIVES

This scoping review aimed to identify European public health interventions that report their effect on dental caries across different social groups.

METHODS

Four databases were searched for studies evaluating the effect of oral health interventions on dental caries among children from 0 to 12 y, and studies were included when results were presented by children of different social groups separately.

RESULTS

A total of 14 studies were included, representing 4 different countries: 3 randomized and 11 nonrandomized studies. Most studies were performed at schools. Six studies showed results indicative of a reduction in oral health inequalities, 4 studies showed results that potentially widen oral health inequalities, and 5 studies showed results that were indicative of no impact on oral health inequalities. Interventions that contain early approaches, with a high frequency, approaching multiple levels of influence, and including at least the broader organizational or public policy level, may have the potential to reduce oral health inequalities among children from birth to young adolescence.

CONCLUSION

We recommend researchers to perform high-quality intervention studies and to evaluate the effectiveness of oral health intervention always in different socioeconomic or ethnic groups separately, to better understand their contribution toward oral health (in)equalities.

KNOWLEDGE TRANSFER STATEMENT

This review offers insight in the differential effects that oral health interventions might have across different social groups. Its results can be used to develop interventions that might reduce oral health inequalities among children. Also, we recommend future researchers to always evaluate the effects of any preventive oral health measure in different social groups separately.

Dental caries prevention strategies among children and adolescents with immigrant - or low socioeconomic backgrounds- do they work? A systematic review

BACKGROUND

This systematic review was designed to uncover the most reliable evidence about the effects of caries preventive strategies in children and adolescents of immigrant or low socioeconomic backgrounds.

METHODS

According to pre-determined inclusion and exclusion criteria, relevant articles focusing on underprivileged groups were electronically selected between January1995 and October 2015. The literature search was conducted in five databases; PubMed, Embase, CINAHL, SweMed+ and Cochrane Library. Accepted languages for included articles were English, German and Scandinavian languages. Abstracts and selected articles in full text were read and assessed independently by two review authors. Systematic reviews and meta-analyses were not included. Also articles with topics of water fluoridation and fluoride toothpaste were excluded, this due to all existing evidence of anti-caries effect for disadvantaged groups. The key data about the main characteristics of the study were compiled in tables and a quality grading was performed.

RESULTS

Thirty-seven articles were selected for further evaluation. Supervised toothbrushing for 5-year-old school children was found to be an effective prevention technique for use in underprivileged groups. Also a child/mother approach, targeting nutrition and broad oral health education of mothers showed effectiveness. For older children, a slow-release fluoride device and application of acidulated phosphate fluoride (APF) gel showed to be effective.

CONCLUSION

On the basis of this review, we maintain that in addition to studies of water fluoridation and fluoride toothpaste, there are other preventive intervention studies providing scientific evidence for caries reduction among children and adolescents with immigrant or low socioeconomic backgrounds.

WITHDRAWN: Community-based population-level interventions for promoting child oral health

BACKGROUND

Dental caries and gingival and periodontal disease are commonly occurring, preventable chronic conditions. Even though much is known about how to treat oral disease, currently we do not know which community-based population-level interventions are most effective and equitable in preventing poor oral health.

OBJECTIVES

Primary • To determine the effectiveness of community-based population-level oral health promotion interventions in preventing dental caries and gingival and periodontal disease among children from birth to 18 years of age. Secondary • To determine the most effective types of interventions (environmental, social, community and multi-component) and guiding theoretical frameworks.• To identify interventions that reduce inequality in oral health outcomes.• To examine the influence of context in the design, delivery and outcomes of interventions.

SEARCH METHODS

We searched the following databases from January 1996 to April 2014: MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Education Resource Information Center (ERIC), BIOSIS Previews, Web of Science, the Database of Abstracts of Reviews of Effects (DARE), ScienceDirect, Sociological Abstracts, Social Science Citation Index, PsycINFO, SCOPUS, ProQuest Dissertations & Theses and Conference Proceedings Citation Index - Science.

SELECTION CRITERIA

Included studies were individual- and cluster-randomised controlled trials (RCTs), controlled before-and-after studies and quasi-experimental and interrupted time series. To be included, interventions had to target the primary outcomes: dental caries (measured as decayed, missing and filled deciduous teeth/surfaces, dmft/s; Decayed, Missing and Filled permanent teeth/surfaces, DMFT/S) and gingival or periodontal disease among children from birth to 18 years of age. Studies had to report on one or more of the primary outcomes at baseline and post intervention, or had to provide change scores for both intervention and control groups. Interventions were excluded if they were solely of a chemical nature (e.g. chlorhexidine, fluoride varnish), were delivered primarily in a dental clinical setting or comprised solely fluoridation.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed screening, data extraction and assessment of risk of bias of included studies (a team of six review authors - four review authors and two research assistants - assessed all studies). We calculated mean differences with 95% confidence intervals for continuous data. When data permitted, we undertook meta-analysis of primary outcome measures using a fixed-effect model to summarise results across studies. We used the I2 statistic as a measure of statistical heterogeneity.

MAIN RESULTS

This review includes findings from 38 studies (total n = 119,789 children, including one national study of 99,071 children, which contributed 80% of total participants) on community-based oral health promotion interventions delivered in a variety of settings and incorporating a range of health promotion strategies (e.g. policy, educational activities, professional oral health care, supervised toothbrushing programmes, motivational interviewing). We categorised interventions as dietary interventions (n = 3), oral health education (OHE) alone (n = 17), OHE in combination with supervised toothbrushing with fluoridated toothpaste (n = 8) and OHE in combination with a variety of other interventions (including professional preventive oral health care, n = 10). Interventions generally were implemented for less than one year (n = 26), and only 11 studies were RCTs. We graded the evidence as having moderate to very low quality.We conducted meta-analyses examining impact on dental caries of each intervention type, although not all studies provided sufficient data to allow pooling of effects across similar interventions. Meta-analyses of the effects of OHE alone on caries may show little or no effect on DMFT (two studies, mean difference (MD) 0.12, 95% confidence interval (CI) -0.11 to 0.36, low-quality evidence), dmft (three studies, MD -0.3, 95% CI -1.11 to 0.52, low-quality evidence) and DMFS (one study, MD -0.01, 95% CI -0.24 to 0.22, very low-quality evidence). Analysis of studies testing OHE in combination with supervised toothbrushing with fluoridated toothpaste may show a beneficial effect on dmfs (three studies, MD -1.59, 95% CI -2.67 to -0.52, low-quality evidence) and dmft (two studies, MD -0.97, 95% CI -1.06 to -0.89, low-quality evidence) but may show little effect on DMFS (two studies, MD -0.02, 95% CI -0.13 to 0.10, low-quality evidence) and DMFT (three studies, MD -0.02, 95% CI -0.11 to 0.07, moderate-quality evidence). Meta-analyses of two studies of OHE in an educational setting combined with professional preventive oral care in a dental clinic setting probably show a very small effect on DMFT (-0.09 weighted mean difference (WMD), 95% CI -0.1 to -0.08, moderate-quality evidence). Data were inadequate for meta-analyses on gingival health, although positive impact was reported.

AUTHORS' CONCLUSIONS

This review provides evidence of low certainty suggesting that community-based oral health promotion interventions that combine oral health education with supervised toothbrushing or professional preventive oral care can reduce dental caries in children. Other interventions, such as those that aim to promote access to fluoride, improve children's diets or provide oral health education alone, show only limited impact. We found no clear indication of when is the most effective time to intervene during childhood. Cost-effectiveness, long-term sustainability and equity of impacts and adverse outcomes were not widely reported by study authors, limiting our ability to make inferences on these aspects. More rigorous measurement and reporting of study results would improve the quality of the evidence.

Community-based population-level interventions for promoting child oral health

BACKGROUND

Dental caries and gingival and periodontal disease are commonly occurring, preventable chronic conditions. Even though much is known about how to treat oral disease, currently we do not know which community-based population-level interventions are most effective and equitable in preventing poor oral health.

OBJECTIVES

Primary • To determine the effectiveness of community-based population-level oral health promotion interventions in preventing dental caries and gingival and periodontal disease among children from birth to 18 years of age. Secondary • To determine the most effective types of interventions (environmental, social, community and multi-component) and guiding theoretical frameworks.• To identify interventions that reduce inequality in oral health outcomes.• To examine the influence of context in the design, delivery and outcomes of interventions.

SEARCH METHODS

We searched the following databases from January 1996 to April 2014: MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Education Resource Information Center (ERIC), BIOSIS Previews, Web of Science, the Database of Abstracts of Reviews of Effects (DARE), ScienceDirect, Sociological Abstracts, Social Science Citation Index, PsycINFO, SCOPUS, ProQuest Dissertations & Theses and Conference Proceedings Citation Index - Science.

SELECTION CRITERIA

Included studies were individual- and cluster-randomised controlled trials (RCTs), controlled before-and-after studies and quasi-experimental and interrupted time series. To be included, interventions had to target the primary outcomes: dental caries (measured as decayed, missing and filled deciduous teeth/surfaces, dmft/s; Decayed, Missing and Filled permanent teeth/surfaces, DMFT/S) and gingival or periodontal disease among children from birth to 18 years of age. Studies had to report on one or more of the primary outcomes at baseline and post intervention, or had to provide change scores for both intervention and control groups. Interventions were excluded if they were solely of a chemical nature (e.g. chlorhexidine, fluoride varnish), were delivered primarily in a dental clinical setting or comprised solely fluoridation.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed screening, data extraction and assessment of risk of bias of included studies (a team of six review authors - four review authors and two research assistants - assessed all studies). We calculated mean differences with 95% confidence intervals for continuous data. When data permitted, we undertook meta-analysis of primary outcome measures using a fixed-effect model to summarise results across studies. We used the I2 statistic as a measure of statistical heterogeneity.

MAIN RESULTS

This review includes findings from 38 studies (total n = 119,789 children, including one national study of 99,071 children, which contributed 80% of total participants) on community-based oral health promotion interventions delivered in a variety of settings and incorporating a range of health promotion strategies (e.g. policy, educational activities, professional oral health care, supervised toothbrushing programmes, motivational interviewing). We categorised interventions as dietary interventions (n = 3), oral health education (OHE) alone (n = 17), OHE in combination with supervised toothbrushing with fluoridated toothpaste (n = 8) and OHE in combination with a variety of other interventions (including professional preventive oral health care, n = 10). Interventions generally were implemented for less than one year (n = 26), and only 11 studies were RCTs. We graded the evidence as having moderate to very low quality.We conducted meta-analyses examining impact on dental caries of each intervention type, although not all studies provided sufficient data to allow pooling of effects across similar interventions. Meta-analyses of the effects of OHE alone on caries may show little or no effect on DMFT (two studies, mean difference (MD) 0.12, 95% confidence interval (CI) -0.11 to 0.36, low-quality evidence), dmft (three studies, MD -0.3, 95% CI -1.11 to 0.52, low-quality evidence) and DMFS (one study, MD -0.01, 95% CI -0.24 to 0.22, very low-quality evidence). Analysis of studies testing OHE in combination with supervised toothbrushing with fluoridated toothpaste may show a beneficial effect on dmfs (three studies, MD -1.59, 95% CI -2.67 to -0.52, low-quality evidence) and dmft (two studies, MD -0.97, 95% CI -1.06 to -0.89, low-quality evidence) but may show little effect on DMFS (two studies, MD -0.02, 95% CI -0.13 to 0.10, low-quality evidence) and DMFT (three studies, MD -0.02, 95% CI -0.11 to 0.07, moderate-quality evidence). Meta-analyses of two studies of OHE in an educational setting combined with professional preventive oral care in a dental clinic setting probably show a very small effect on DMFT (-0.09 weighted mean difference (WMD), 95% CI -0.1 to -0.08, moderate-quality evidence). Data were inadequate for meta-analyses on gingival health, although positive impact was reported.

AUTHORS' CONCLUSIONS

This review provides evidence of low certainty suggesting that community-based oral health promotion interventions that combine oral health education with supervised toothbrushing or professional preventive oral care can reduce dental caries in children. Other interventions, such as those that aim to promote access to fluoride, improve children's diets or provide oral health education alone, show only limited impact. We found no clear indication of when is the most effective time to intervene during childhood. Cost-effectiveness, long-term sustainability and equity of impacts and adverse outcomes were not widely reported by study authors, limiting our ability to make inferences on these aspects. More rigorous measurement and reporting of study results would improve the quality of the evidence.

Intersectoral action for health equity: a rapid systematic review

BACKGROUND

Action on the social determinants of health is considered a necessary approach to improving health equity. Most of the social determinants of health lie outside the sphere of the health sector and thus collaboration with governmental and non-governmental sectors outside of health are required to develop policies and programs to improve health equity. Case studies of intersectoral action are available, however there is limited information about the impact of intersectoral action on the social determinants of health and health equity.

METHODS

Search and retrieval of literature published between 2001 and 2011 was conducted in 6 databases. A staged screening of titles and abstracts, and later full-text, was conducted by two independent reviewers. Reviewers independently assessed the quality of the articles deemed relevant for inclusion. Data were extracted and synthesized in narrative format for all included studies, conducted by one reviewer and checked by another.

RESULTS

17 articles of varied methodological quality met the inclusion criteria. One systematic review investigating partnership interventions found mixed and limited impacts on health outcomes. Primary studies evaluating the impact of upstream and midstream interventions showed mixed effects. Downstream interventions were generally moderately effective in increasing the availability and use of services by marginalized communities.

CONCLUSIONS

The literature evaluating the impact of intersectoral action on health equity is limited. The included studies identified reveal a moderate to no effect on the social determinants of health. The evidence on the impact of intersectoral action on health equity is even more limited. The lack of evidence should not be interpreted as a lack of effect. Rigorous evaluations of intersectoral action are needed to strengthen the evidence base of this public health practice.