Relative contribution of dental services to the changes in caries levels of 12-year-old children in 18 industrialized countries in the 1970s and early 1980s

Brazilian primary dental care in a universal health system: Challenges for training and practice

OBJECTIVES

To report the challenges for training and practice for the Brazilian primary dental care in a universal health system.

METHODS

Health, education and protection rights against poverty are guaranteed by the 1988 Brazilian Constitution and public health in Brazil is provided by the Unified Health System (SUS), one of the largest public health systems in the world. According to SUS, every Brazilian citizen has the right to free primary oral health care as secondary and tertiary care, offering a unique opportunity to integrate oral care within general health care.

RESULTS

The Brazilian undergraduate Dental curriculum was updated in 2021 aiming to graduate general practitioners with a major in comprehensive health care in primary health care, integrated with public and general health. This curriculum update requires at least 20% of the academic hours to be exercised outside the university walls (extramural or community work), preferably within the SUS.

CONCLUSIONS

Considering the World Health Organization (WHO) agenda, Brazil needs to advance the innovative oral health workforce, the integration of oral health into primary care, the population access to essential dental medicines and optimal fluorides for caries control.

CLINICAL SIGNIFICANCE

It is necessary political action and the engagement of multiple stakeholders, mainly from the health and education sectors, to improve primary health care.

Utilization of machine learning models in predicting caries risk groups and oral health-related risk factors in adults

BACKGROUND

The aim of this study was to analyse the risk factors that affect oral health in adults and to evaluate the success of different machine learning algorithms in predicting these risk factors.

METHODS

This study included 2000 patients aged 18 years and older who were admitted to the Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Gaziantep University, between September and December 2023. In this study, patients completed a 30-item questionnaire designed to assess the factors that affect the decayed, missing, and filled teeth (DMFT). Clinical and radiological examinations were performed, and DMFT scores were calculated after completion of the questionnaire. The obtained data were randomly divided into a 75% training group and a 25% test group. The preprocessed dataset was analysed using various machine learning algorithms, including naive Bayes, logistic regression, support vector machine, decision tree, random forest and Multilayer Perceptron algorithms. Pearson's correlation test was also conducted to assess the correlation between participants' DMFT scores and oral health risk factors. The performance of each algorithm was evaluated to determine the most appropriate algorithm, and model performance was assessed using accuracy, precision, recall and F1 score on the test dataset.

RESULTS

A statistically significant difference was found between various factors and DMFT-based risk groups (p < 0.05), including age, sex, body mass index, tooth brushing frequency, socioeconomic status, employment status, education level, marital status, hypertension, diabetes status, renal disease status, consumption of sugary snacks, dry mouth status and screen time. When considering machine learning algorithms for risk group assessments, the Multilayer Perceptron model demonstrated the highest level of success, achieving an accuracy of 95.8%, an F1-score of 96%, and precision and recall rates of 96%.

CONCLUSIONS

Caries risk assessment using a simple questionnaire can identify individuals at risk of dental caries, determine the key risk factors, provide information to help reduce the risk of dental caries over time and ensure follow-up. In addition, it is extremely important to apply effective preventive treatments and to prevent the general health problems that are caused by the deterioration of oral health. The results of this study show the potential of machine learning algorithms for predicting caries risk groups, and these algorithms are promising for future studies.

Life course social mobility, race and tooth loss in adulthood: The role of dental health services

OBJECTIVES

To evaluate the extent to which dental care factors in adulthood modify and, at the same time, mediate the association between race/ethnicity and social mobility from childhood to adulthood with two oral health outcomes in adults.

METHODS

In 2012, 1222 individuals 20-59 years old participated in the second wave of the Epi-Floripa Study in Florianopolis, Brazil. Exposures included social mobility based on adulthood and childhood events, dental care in previous years, type of dental care coverage, reason for dental visits and race. The number of missing and decayed teeth were dichotomised as MT >0 and DT >0.

RESULTS

The prevalence of missing and decayed teeth was 61.9% and 23.0%, respectively. Age-sex adjusted inequalities in decayed and missing teeth among Black and White individuals were 41.2 percentage points (pp) (95% CI: 3.9-78.7) and 53.1 pp (19.5:86.7), respectively. Inequalities between those persistently higher and lower in socioeconomic position were 42.6 pp (14.6-70.7) and 90.0 pp (62.1-100). The Relative Excess of Risk due to Interaction (RERI) was not statistically significant (p < 0.05). Oaxaca-Blinder decomposition analyses showed that dental care variables accounted for a small proportion of inequalities.

CONCLUSIONS

This result implies that dental care is unlikely to significantly reduce or increase oral health inequalities in this particular population.

Racial inequality in complete dental prosthesis delivered: can public services reduce inequities?

OBJECTIVES

To investigate the association between access and delivery of complete dental prosthesis according to the proportion of the black population in Brazilian municipalities and to oral health policies.

MATERIALS AND METHODS

Ecological data from 2017 to 2021 relating to the delivery of complete dentures stratified by race was collected in all Brazilian cities. We calculated a racial inequality indicator by subtracting the percentage of the black population from the percentage of complete dental prostheses that were delivered to blacks in each municipality. Logistic and linear regression models were carried out.

RESULTS

We found that 49.2% (2737) of municipalities delivered complete prostheses. The service was more frequently available in municipalities where black individuals made up 20-80% (odds ratio [OR] = 1.45, 95% confidence interval [CI] 1.15; 1.81), those with dental specialty centers (DSC) (OR = 3.04, 95%CI 2.50; 3.68), and those with more oral health teams (OHTs) (OR = 3.43, 95%CI 2.81; 4.18). Where dental prostheses were available, racial inequities favored the white population by 7.7 percentage points (p < 0.01). Increased inequality was observed in municipalities with more OHTs and/or a higher proportion of black individuals (>80%).

CONCLUSIONS

Although municipalities with a DSC, and with more OHTs offer better access to complete dental prosthesis for blacks, racial inequality still impacts the delivery of the service. Primary and secondary healthcare services may even exacerbate this.

CLINICAL RELEVANCE

Policymakers should monitor racial inequities in healthcare services. The currently unmet needs of black people are critical, especially in cities with more OHTs and/or increased proportions of black people.

Effects of universal oral healthcare coverage in an adult population: A long-term nationwide natural experiment

OBJECTIVES

A large and long-term natural experiment occurred in Finland from the late 1980s-2000, when adults' entitlement to subsidized oral healthcare was strongly dependent on the arbitrary classification based on their year of birth: people born in 1956 or later were entitled to subsidized care, while people born before 1956 were not. The aim of this study was to investigate the effect of this expanded universal oral healthcare coverage on service use and oral health outcomes.

METHODS

Data from annual nationally representative cross-sectional postal surveys among 15-64-year-olds between 1990 and 2014 were used. For this study, the following outcome variables were formed: experiencing toothache during the past month (yes/no), the number of missing teeth with three different thresholds (over 10, over 5 or at least 1 missing tooth), brushing more than once a day and the number of visits to the dentist. Regression discontinuity plots and bias-corrected local polynomial regression discontinuity estimators measuring the effect of the extended universal coverage on the outcomes at the year-of-birth cut-off of 1956 were generated separately from the data from 1990 to 2000 and from 2002 to 2014.

RESULTS

Between 1990 and 2000, the number of visits to the dentist (0.2 visits, 95% CI, confidence intervals: -0.03; 0.43) and the proportion of those who visited the dentist during the past 12 months (4.2%, 95% CI: 0.1%; 8.3%) increased at the year-of-birth cut-off of 1956. There were minor drops (1.5%-1.9%) in the number of missing teeth across all thresholds (over 10, over 5, or at least 1 missing teeth) at the cut-off. Analyses with the data from the surveys from 2002 to 2014 showed that there were no discontinuities in these outcomes at the cut-off of 1956. Regression discontinuity estimates related to toothache experience and toothbrushing frequency were inconclusive due to high variability in the underlying data and the likely small effect of the more universal coverage on these outcomes.

CONCLUSIONS

The current study provided evidence of the beneficial effects of universal oral healthcare coverage on the oral healthcare service use and teeth preservation from a large and long-term natural experiment occurred in Finland from the late 1980s to 2000.

Assessment of the contextual effects on the prevalence of periodontitis: a systematic review

This study reviews the influence of contextual factors on periodontitis based on a systematic search of studies recorded in the PubMed, Scopus, Web of Science, and EMBASE databases. Periodontitis was assessed by clinical attachment loss and probing depth for studies with data on the socioeconomic status (SES) of a specific area (area-level SES) or dental care service (service-level) in a catchment area among individuals aged 18 and over. Two independent reviewers performed study selection, data extraction, and assessment of methodological quality. Of the 646 articles identified, 13 were included in the systematic review, representing 101,362 individuals from five countries (USA, UK, Brazil, China, and Uruguay). A higher prevalence of periodontitis was described in lower SES neighborhoods, more deprived postcodes, and poorer provinces. Gini Index results were mixed and inconclusive. Three studies showed that higher coverage of primary dental care at the municipal level was associated with a lower prevalence of periodontitis. Contextual factors at the area-level SES and dental care service might influence periodontitis, but the existing evidence is unclear. The contextual effect is important for periodontal health and may contribute to the prevalence of periodontitis, independent of well-known risk factors and individual levels.

Association between socioeconomic contextual factor, dental care service availability, and prevalence of periodontitis in Brazil: a multilevel analysis

This study aimed to examine the effect of dental care services on periodontitis cases in Brazilian municipalities. The sample comprised 3,426 individuals aged 35-44 years. Moderate to severe periodontitis with clinical attachment loss and probing depth was the dependent variable, both > 3mm. Its exploratory variables were grouped into four categories: (1) individual characteristics; (2) contextual development indicators; (3) health service and structural factors; and (4) dental care use. Data were collected using the SBBrasil 2010 Project, the Brazilian Institute of Geography and Statistics, the Brazilian Information System of Primary and Secondary Care, and the Program to Improve Access and Quality of Dental Specialization Centers (PMAQ-CEO). Multilevel logistic regression was used to assess associations of periodontitis with individual and context variables. Municipalities with > 1 CEO or > 1 of any centers were associated with periodontitis, with OR = 0.97 (95%CI: 0.55-1.71) and OR = 0.41 (95%CI: 0.17-0.97), respectively. Prevalence of periodontitis was more likely in older people, lower education levels, and individuals that sought dental visits for pain/extraction and periodontal treatment. Other dental care services availability were not associated with the prevalence of periodontitis.

Individual, Family, and Socioeconomic Contributors to Dental Caries in Children from Low- and Middle-Income Countries

Introduction: Collective evidence on risk factors for dental caries remains elusive in low- and middle-income countries (LMICs). The objective was to conduct a systematic review and meta-analysis on risk factors for dental caries in deciduous or permanent teeth in LMICs. Methods: Studies were identified electronically through databases, including Cochrane Oral Health Group Trials Register, Cochrane Central Register of Controlled Trials, PubMed/MEDLINE, and CINAHL, using “prevalence, dental caries, child, family, socioeconomic, and LMIC” as the keywords. A total of 11 studies fit the inclusion criteria. Quality assessment of the included studies was performed using the Newcastle-Ottawa Scale (NOS). The MedCalc software and Review Manager 5.4.1 were used. Results: From 11,115 participants, 38.7% (95% CI: 28.4−49.5%) had caries and 49.68% were female. Among those with caries, 69.74% consumed sugary drinks/sweets (95% CI: 47.84−87.73%) and 56.87% (95% CI: 35.39−77.08%) had good brushing habits. Sugary drinks had a two times higher likelihood of leading to caries (OR: 2.04, p < 0.001). Good oral hygiene reduced the risk of caries by 35% (OR: 0.65, p < 0.001). Concerning maternal education, only secondary education reduced the likelihood of caries (OR: 0.96), but primary education incurred 25% higher risks (OR: 1.25, p = 0.03). A 65% reduction was computed when caregivers helped children with tooth brushing (OR: 0.35, p = 0.04). Most families had a low socioeconomic status (SES) (35.9%, 95% CI: 16.73−57.79), which increased the odds of caries by 52% (OR: 1.52, p < 0.001); a high SES had a 3% higher chance of caries. In the entire sample, 44.44% (95% CI: 27.73−61.82%) of individuals had access to dental services or had visited a dental service provider. Conclusion: Our findings demonstrate that high sugar consumption, low maternal education, and low and high socioeconomic status (SES) increased the risk of dental caries in LMICs. Good brushing habits, higher maternal education, help with tooth brushing, and middle SES provided protection against caries across LMIC children. Limiting sugars, improving oral health education, incorporating national fluoride exposure programs, and accounting for sociodemographic limitations are essential for reducing the prevalence of dental caries in these settings.

[Changes in the prevalence of decayed permanent teeth in Brazil and upper-middle income countries in the years 1990 and 2017]

The distribution of caries is uneven and strongly associated with the different socioeconomic profiles of countries. The scope of this study was to describe the changes in the prevalence of decayed permanent teeth in Brazil and in upper-middle income countries for the years 1990 and 2017. It is a descriptive study based on secondary data extracted from the Global Burden of Disease. The 53 countries included in the upper-middle income group were included. Caries prevalence estimates were collected for the years 1990 and 2017. The percentage change in prevalence was calculated between the two years. The values of the Human Development Index (HDI) for each country were also collected. The results show the trend of a reduction in the prevalence of decayed permanent teeth in Brazil and in most upper-middle income countries. The prevalence of untreated caries in Brazil was 38.17% in 1990 and 37.46% in 2017. Brazil occupies the 41st position in the ranking of the reduction in the prevalence of caries among the 53 countries evaluated. The countries that achieved the greatest reductions in the prevalence of caries were those with an improvement in their HDI. In this respect, the need to review public oral health policies is revealed, as well as a reflection on addressing the inequities present in the countries surveyed.

[Implementation of the Brazilian National Oral Health Policy and its influence on oral health conditions in Brazilian state capitals in the first decade of the 21st century]

The study aimed to analyze strategies for the implementation of the Brazilian National Oral Health Policy (PNSB) and its influence on oral health conditions in state capitals in the first decade of the 21st century. This is a policy assessment study. Data on oral health conditions were obtained from the databases of the Brazilian National Oral Health Surveys in 2003 and 2010 (SBBrasil 2003 and SBBrasil 2010), calculating the annual percent change in variables pertaining to oral health conditions as dependent variables for Brazilian state capitals. The PNSB was analyzed according to its conceptual foundations: oral healthcare model, organization of the supply of oral health services, implementation of oral health promotion strategies, and existence of fluoridation of the public water supply. Data were obtained from the national health databases and face-to-face interviews with oral health coordinators in 13 state capitals. The analyses were controlled and adjusted by the target population's socioeconomic conditions. An association was observed between the characteristics of oral health promotion, services supply, and model of care, indicating that the public services' dynamic is dependent on the management priorities and the policy's conduction. In conclusion, the PNSB is implemented differently in Brazil's state capitals according to the ways its guidelines are conducted in each capital and whether it favors best practices and strategies in oral healthcare. However, the influence of the PNSB is still not clear on the modification of oral health indicators from 2003 to 2010.

Vitamin D, pregnancy and caries in children in the INMA-Asturias birth cohort

BACKGROUND

Vitamin D is traditionally associated with the metabolism of calcium and phosphorus, a process essential for the mineralization of hard tissue such as bone or tooth. Deficiency of this vitamin is a problem worldwide, however. Given the possibly significant role of Vitamin D in odontogenesis in children, the objective of our study was to determine the influence of vitamin D levels in the blood on dental anomalies in children between 6 and 10 years of age, by means of 25-hydroxy vitamin D tests performed during pregnancy and the first years of life.

METHODS

The data analyzed were sourced from data belonging to the INMA-Asturias birth cohort, a prospective cohort study initiated in 2004 as part of the INMA Project. The 25-hydroxy vitamin D (25(OH)D) test was performed with samples from 188 children in the INMA-Asturias birth cohort with a dental examination performed between 6 and 10 years of age. The samples were taken at three stages: in the mother at 12 weeks of gestation, and subsequently in the child at 4 and 8 years of age. Diet, nutritional and oro-dental hygiene habits were also analyzed by means of questionnaires.

RESULTS

The results indicate a significant association between caries and correct or incorrect brushing technique. With incorrect brushing technique, the prevalence of caries was 48.89%, but this dropped to 22.38% with correct brushing technique. An association was also found between tooth decay and frequency of sugar intake. The prevalence of caries was 24.54% with occasional sugar intake, but this rose to 56% with regular sugar intake. On the other hand, levels < 20 ng/ml in both mother and child at 8 years of age would also be risk factors (ORgest = 2.51(1.01-6.36) and OR8years = 3.45(1.14-11.01)) for the presence of caries in children. The risk of caries practically tripled where 25(OH) D values were < 20 ng/ml.

CONCLUSIONS

Although incorrect brushing technique and regular sugar consumption was found to be the main cause of caries in the children, the low concentrations of vitamin D in the blood of the pregnant mothers may have magnified this correlation, indicating that the monitoring of vitamin D levels during pregnancy should be included in antenatal programmes. It is particularly striking that 50% of the children were deficient in vitamin D at the age of 4, and that dental floss was practically absent from regular cleaning routines.

Risk factors for dental caries in Latin American and Caribbean countries

Identifying the risk factors for dental caries is vital in epidemiology and clinical practices for developing effective preventive strategies, both, at the individual and collective levels. Different causality/determination models have been proposed to understand the development process of dental caries. In the present review, we designed a model inspired by the world-known social determinants models proposed in the 90s and more recently in the 10s, wherein the contextual factors are placed more externally and encompass the individual factors. The contextual factors included those related to the cultural and societal values, as well as the social and health government policies. The individual factors were classified into the following categories: socioeconomic (social class, occupation, income, and education level), demographic characteristics (age, sex, and ethnicity), behavioral factors (non-use of fluoride dentifrice, sugar consumption, poor oral hygiene, and lack of preventive dental care), and biological factors (recent caries experience/active caries lesions, biofilm retentive factors, developmental defects of the enamel, disabilities, saliva amount and quality, cariogenic biofilm). Each of these variables was addressed, while focusing on the current evidence from studies conducted in Latin American and Caribbean countries (LACC). Based on the proposed model, educational aspects were addressed, and individual caries risk assessment and management decisions were proposed; further, implications for public health policies and clinical practice were described. The identification of modifiable risk factors for dental caries should be the basis for multi-strategy actions that consider the diversity of Latin American communities.

Relationship between Obesity and Oral Health Behavior in Primary and Junior High School Students: A Cross-sectional Study

It has been reported that people who brush their teeth frequently might be more health-conscious and maintain healthier lifestyle habits. The relationship between obesity and oral health behavior in childhood is unknown, however. The aim of the present study was to fill this gap by investigating obesity and factors associated with oral health behavior in Japanese primary and junior high school students. A total of 475 primary school students (fifth-grade, age 10-11 years) and 408 junior high school students (first-grade, age 12-13 years) were included. All the participants underwent a regular health check-up and completed a self-reported questionnaire. The data thus obtained were subjected to multiple logistic regression analyses to identify the relationship between obesity and factors associated with oral health behavior. In primary school students, a dislike of physical activity was the only factor showing a significant association with obesity (p<0.05). In addition, however, tooth brushing <2 times per day and a lack of regular clinical dental care showed a significant association with obesity in junior high school students (p<0.05). The present results suggest a significant association between regular clinical dental care and tooth brushing and obesity in junior school students.

Detection of Approximal Caries Lesions in Adults: A Cross-sectional Study

Detection and management of posterior approximal caries lesions are still problematic. Inspection of approximal surfaces is challenging, and bitewing radiographs are used when direct vision is not possible. Unfortunately, there is no definite radiographic appearance to identify lesion cavitation with absolute certainty. Many lesions detected radiographically within the outer half of dentin are not cavitated, often resulting in unnecessary restorative treatment. Our study compared radiographic depth of approximal caries lesions with presence of cavitation in adults using visual inspection following temporary tooth separation (TTS). We conducted this observational descriptive cross-sectional study at two dental schools in two cities in Chile. Clinicians were unaware of radiographic depths of lesions and examined 147 participants (57.3% female and 42.7% male) following TTS. Using the common classification system that consists of E0 (no lesion), E1 (lesion within the outer half of enamel), E2 (lesion within the inner half of enamel), D1 (lesion within the outer third of dentin), D2 (lesion within the middle third of dentin), and D3 (lesion within the inner third of dentin), a trained dentist evaluated all the processed films. Cavitation was detected in only three sites (0.22%) within the E0 category, seven sites (3.41%) in E1, five sites (14.8%) in E2, four sites (14.8%) in D1, six sites (50%) in D2, and eight sites (61.5%) in D3. Considering that restorative treatment should be indicated strictly for cavitated lesions, our findings support indication for restorative treatment for D3 lesions and the rationale for TTS for D1-D2 caries lesions to allow direct visual inspection to determine whether there is surface cavitation.

Caries severity declined besides persistent untreated primary teeth over a 22-year period: Trends among children in Goiânia, Brazil

BACKGROUND

Evidence of time trends in early childhood caries in low- and middle-income countries in the second decade of the year 2000 is scarce.

AIM

To assess the trends in early childhood caries prevalence and severity in 2- to 5-year-old children over a 22-year period (1993-2015) in Goiânia, Midwest Brazil. Additionally, we aimed to investigate the changes regarding affected dental arches and teeth.

DESIGN

A time-lag analysis of trends in caries was carried out using data from three cross-sectional studies based on the World Health Organization diagnostic criteria, in 1993 (N = 1362), 2001 (N = 1620), and 2015 (N = 548).

RESULTS

Caries prevalence declined from 45.1% in 1993 to 29.0% in 2015. Prevalence of severe caries (dmft ≥ 6) in 2015 was nearly one-third of that found in 1993, and the SiC index (mean dmft of the highest tertile) decreased from 4.55 to 3.32. Decline was higher in the 1993-2001 than in the 2001-2015 time-lag. Posterior teeth and second molars had the greatest reductions. High proportions of untreated caries were found in all ages and survey years.

CONCLUSION

There were significant changes in caries prevalence and severity, marked by a striking decline from 1993 to 2001, followed by a less prominent decrease up to 2015, and high levels of untreated caries.

Commentary: Necessity of Blending Dental Education Into the Mainstream of Medical Education as a Specialty Area: Advocating for a Reform Idea Aiming to Promote the Health System Performance in Iran

With the knowledge we have today about the concept of health and its complexities and determinants, the separation between medical and dental education (DE) does not seem reasonable anymore. Dentistry has mainly developed based on a mechanical approach to treat the related problems. This makes the efforts for reorientation of dental care (DC) toward a preventive approach, relying upon dentists as the chief oral health (OH)-related workforce, inefficient. This is while effective strategies have been identified for prevention, as the key to simultaneously control the burden and costs of the ubiquitous oral diseases, at both individual and population levels without dentists. We think that approaching OH as an integral part of the general well-being requires fundamental changes in the structure of OH system including a substantial revision in the current situation of dentistry as an autonomous health profession with a separate education from the main body of the medicine. In this short article, we briefly discuss the necessity of blending DE into the mainstream of medical education and actual consideration of dentistry as a medical specialty area. After discussing the subject at two levels (health-care system and national levels), the next sections draw attention to some complementary issues.

Socioeconomic Inequalities in the Oral Health of People Aged 15-40 Years in Kurdistan, Iran in 2015: A Cross-sectional Study

Objectives

The aim of this study was to evaluate socioeconomic inequalities in the prevalence of dental caries among an urban population.

Methods

This study was conducted among 2000 people 15-40 years of age living in Kurdistan, Iran in 2015. Using a questionnaire, data were collected by 4 trained dental students. The dependent variable was the decayed, missing, and filled teeth (DMF) index. Using principal component analysis, the socioeconomic status (SES) of families was determined based on their household assets. Inequality was measured using the concentration index; in addition, the Oaxaca analytical method was used to determine the contribution of various determinants to the observed inequality.

Results

The concentration index for poor scores on the DMF index was -0.32 (95% confidence interval [CI], -0.40 to -0.36); thus, poor DMF indices had a greater concentration in groups with a low SES (p<0.001). Decomposition analysis showed that the mean prevalence of a poor DMF index was 43.7% (95% CI, 40.4 to 46.9%) in the least privileged group and 14.4% (95% CI, 9.5 to 9.2%) in the most privileged group. It was found that 85.8% of the gap observed between these groups was due to differences in sex, parents' education, and the district of residence. A poor DMF index was less prevalent among people with higher SES than among those with lower SES (odds ratio, 0.31; 95% CI, 0.19 to 0.52).

Conclusions

An alarming degree of SES inequality in oral health status was found in the studied community. Hence, it is suggested that inequalities in oral health status be reduced via adopting appropriate policies such as the delivery of oral health services to poorer groups and covering such services in insurance programs.

A systematic review of the effects of supervised toothbrushing on caries incidence in children and adolescents

BACKGROUND

The anticaries effect of supervised toothbrushing, irrespective of the effect of fluoride toothpaste, has not been clearly determined yet.

AIM

To assess the effects of supervised toothbrushing on caries incidence in children and adolescents.

DESIGN

A systematic review of controlled trials was performed (CRD42014013879). Electronic and hand searches retrieved 2046 records, 112 of which were read in full and independently assessed by two reviewers, who collected data regarding characteristics of participants, interventions, outcomes, length of follow-up and risk of bias.

RESULTS

Four trials were included and none of them had low risk of bias. They were all carried out in schools, but there was great variation regarding children's age, fluoride content of the toothpaste, baseline caries levels and the way caries incidence was reported. Among the four trials, two found statistically significant differences favouring supervised toothbrushing, but information about the magnitude and/or the precision of the effect estimate was lacking and in one trial clustering effect was not taken into consideration. No meta-analysis was performed due to the clinical heterogeneity among the included studies and differences in the reporting of data.

CONCLUSIONS

There is no conclusive evidence regarding the effectiveness of supervised toothbrushing on caries incidence.

Impact of untreated dental caries on the daily activities of children

OBJECTIVES

Untreated dental caries can compromise oral health-related quality of life (OHRQoL). However, it is not clear which specific daily activities related to OHRQoL are compromised by the presence of this problem. Therefore, the purpose of this study was to identify which specific daily activities are affected by the presence of untreated dental caries using a representative sample of Brazilian children.

METHODS

A cross-sectional study using a representative sample of Brazilian children (12 years of age) was conducted. The presence of untreated dental caries was assessed using the "decayed - D" component of the DMFT (decayed, missing, and filled teeth) index. Clinical exams were conducted by trained and calibrated dentists. The daily activities were evaluated using the survey Oral Impacts on Daily Performance (OIDP), considering items and domains. Descriptive, bivariate, and multiple analyses were conducted (α = 0.05).

RESULTS

A total of 7,247 children were included, and 39.9 percent had at least one tooth with untreated dental caries, with 33.5 percent experiencing an impact on at least one of the OIDP activities. This study identified a greater chance of the presence of untreated dental caries in children having an impact on the psychological domain (P = 0.006), as well as on the "difficulty eating" (P = 0.007), and "difficulty sleeping" (P = 0.023) items.

CONCLUSION

The presence of untreated dental caries among Brazilian children was associated with an impact on specific daily activities (difficulty eating and sleeping) and the psychological domain of OHRQoL.

A health-promoting community dental service in Melbourne, Victoria, Australia: protocol for the North Richmond model of oral health care

Despite the best efforts and commitment of oral health programs, there is no evidence that the current surgical output-based model of oral health care is delivering better oral health outcomes to the community. In fact, Australian evidence indicates the oral health of the community could be getting worse. It is now well-understood that this traditional surgical model of oral health care will never successfully manage the disease itself. It is proposed that a health-promoting, minimally invasive oral disease management model of care may lead to a sustainable benefit to the oral health status of the individual and community groups. The aim of this paper is to describe such a model of oral health care (MoC) currently being implemented by the North Richmond Community Health Oral Health (NRCH-OH) program in Melbourne, Victoria, Australia; this model may serve as a template for other services to re-orient their healthcare delivery towards health promotion and prevention. The paper describes the guiding principles and theories for the model and also its operational components, which are: pre-engagement while on the waitlist; client engagement at the reception area; the assessment phase; oral health education (high-risk clients only); disease management; and reviews and recall.

Does the Decline in Caries Prevalence of Latin American and Caribbean Children Continue in the New Century? Evidence from Systematic Review with Meta-Analysis

Objective

To carry out a systematic review with meta-analysis of prevalence of caries in Latin America and Caribbean children considering studies performed in this new century.

Methods

Two reviewers searched PubMed, Embase, LILACS and governmental databases through May 2016 to identify papers published in English, Portuguese or Spanish. Studies in those countries performed with 5–6 or 11–13 year-old children and that presented separate prevalence figures from primary and permanent teeth were selected. We performed a descriptive analysis of studies and meta-analysis to calculate the overall prevalence and 95% confidence intervals (95% CI) in both primary and permanent teeth. We also analyzed the trends of prevalence of caries through the years and influence of other variables on caries prevalence using multilevel analysis.

Results

Seventy-five studies were included from the 1,306 articles initially retrieved. The meta-analysis of caries prevalence grouped for Latin American and the Caribbean countries were highly different from Brazil and other investigated countries for primary teeth (5–6 years-old—Brazil: 0.52, other countries:0.70) and permanent teeth (11–12 years-old—Brazil: 0.56, other countries: 0.63). For studies conducted only in Brazil the prevalence was significant lower for primary but not for permanent teeth. In Brazil, a downward trend of caries prevalence was observed in 11-13-year-old children.

Conclusion

Despite the decline of caries prevalence in permanent teeth, mainly in Brazil, the disease still affects more than half of the children population in Latin American and Caribbean countries in the 21^st Century.

Social Factors Associated with the Decline in Caries in Brazilian Children between 1996 and 2010

Dental caries levels have declined in children since the 1970s in many countries. Most of the postulated main reasons for the decline are speculative and have not been rigorously evaluated. The objective of this study was to assess the relationship between some social factors and the decline in dental caries in Brazilian 12-year-old children from 1996 to 2010. Secondary analysis of national data was performed in 27 Brazilian state capitals. A panel data regression model with fixed effects and multiple linear regression were used to verify the relationship between the explanatory and the dependent variables and also the time-trend effect. The results showed that the DMFT (decayed, missing, and filled teeth) decreased by about 3% per year, and the percentage of caries-free children increased by 4.5% per year. For DMFT and percentage caries free, the results for the panel data regression showed a significant association for the Human Development Index (HDI) in the adjusted model (p = 0.010). When the overall changes over time were compared, the Gini index had a significant association with the overall change in DMFT in the final model of the multiple regression analysis (p = 0.033). Our results indicate that the maintenance of good levels of human development, which includes better education, income, and longevity, are important factors relating to improving levels of oral health in 12-year-old Brazilian children. However, to accelerate this process in cities with the worst caries situation, income inequality should be tackled.

Fluoride mouthrinses for preventing dental caries in children and adolescents

BACKGROUND

Fluoride mouthrinses have been used extensively as a caries-preventive intervention in school-based programmes and by individuals at home. This is an update of the Cochrane review of fluoride mouthrinses for preventing dental caries in children and adolescents that was first published in 2003.

OBJECTIVES

The primary objective is to determine the effectiveness and safety of fluoride mouthrinses in preventing dental caries in the child and adolescent population.The secondary objective is to examine whether the effect of fluoride rinses is influenced by:• initial level of caries severity;• background exposure to fluoride in water (or salt), toothpastes or reported fluoride sources other than the study option(s); or• fluoride concentration (ppm F) or frequency of use (times per year).

SEARCH METHODS

We searched the following electronic databases: Cochrane Oral Health's Trials Register (whole database, to 22 April 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2016, Issue 3), MEDLINE Ovid (1946 to 22 April 2016), Embase Ovid (1980 to 22 April 2016), CINAHL EBSCO (the Cumulative Index to Nursing and Allied Health Literature, 1937 to 22 April 2016), LILACS BIREME (Latin American and Caribbean Health Science Information Database, 1982 to 22 April 2016), BBO BIREME (Bibliografia Brasileira de Odontologia; from 1986 to 22 April 2016), Proquest Dissertations and Theses (1861 to 22 April 2016) and Web of Science Conference Proceedings (1990 to 22 April 2016). We undertook a search for ongoing trials on the US National Institutes of Health Trials Register (http://clinicaltrials.gov) and the World Health Organization International Clinical Trials Registry Platform. We placed no restrictions on language or date of publication when searching electronic databases. We also searched reference lists of articles and contacted selected authors and manufacturers.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials where blind outcome assessment was stated or indicated, comparing fluoride mouthrinse with placebo or no treatment in children up to 16 years of age. Study duration had to be at least one year. The main outcome was caries increment measured by the change in decayed, missing and filled tooth surfaces in permanent teeth (D(M)FS).

DATA COLLECTION AND ANALYSIS

At least two review authors independently performed study selection, data extraction and risk of bias assessment. We contacted study authors for additional information when required. The primary measure of effect was the prevented fraction (PF), that is, the difference in mean caries increments between treatment and control groups expressed as a percentage of the mean increment in the control group. We conducted random-effects meta-analyses where data could be pooled. We examined potential sources of heterogeneity in random-effects metaregression analyses. We collected adverse effects information from the included trials.

MAIN RESULTS

In this review, we included 37 trials involving 15,813 children and adolescents. All trials tested supervised use of fluoride mouthrinse in schools, with two studies also including home use. Almost all children received a fluoride rinse formulated with sodium fluoride (NaF), mostly on either a daily or weekly/fortnightly basis and at two main strengths, 230 or 900 ppm F, respectively. Most studies (28) were at high risk of bias, and nine were at unclear risk of bias.From the 35 trials (15,305 participants) that contributed data on permanent tooth surface for meta-analysis, the D(M)FS pooled PF was 27% (95% confidence interval (CI), 23% to 30%; I(2) = 42%) (moderate quality evidence). We found no significant association between estimates of D(M)FS prevented fractions and baseline caries severity, background exposure to fluorides, rinsing frequency or fluoride concentration in metaregression analyses. A funnel plot of the 35 studies in the D(M)FS PF meta-analysis indicated no relationship between prevented fraction and study precision (no evidence of reporting bias). The pooled estimate of D(M)FT PF was 23% (95% CI, 18% to 29%; I² = 54%), from the 13 trials that contributed data for the permanent teeth meta-analysis (moderate quality evidence).We found limited information concerning possible adverse effects or acceptability of the treatment regimen in the included trials. Three trials incompletely reported data on tooth staining, and one trial incompletely reported information on mucosal irritation/allergic reaction. None of the trials reported on acute adverse symptoms during treatment.

AUTHORS' CONCLUSIONS

This review found that supervised regular use of fluoride mouthrinse by children and adolescents is associated with a large reduction in caries increment in permanent teeth. We are moderately certain of the size of the effect. Most of the evidence evaluated use of fluoride mouthrinse supervised in a school setting, but the findings may be applicable to children in other settings with supervised or unsupervised rinsing, although the size of the caries-preventive effect is less clear. Any future research on fluoride mouthrinses should focus on head-to-head comparisons between different fluoride rinse features or fluoride rinses against other preventive strategies, and should evaluate adverse effects and acceptability.

Calcium Prerinse before Fluoride Rinse Reduces Enamel Demineralization: An in situ Caries Study

A calcium (Ca) prerinse before a fluoride (F) rinse has been shown to increase oral F levels. We tested the anticaries effect of this combination in a dose-response in situ caries model. In a double-blind, crossover experiment, 10 volunteers carried enamel slabs in palatal appliances for 14 days, during which they rinsed twice/day with one of four rinse combinations: (1) a placebo prerinse (150 mM sodium lactate) followed by a distilled water rinse (negative control); (2) a placebo prerinse followed by a 250 ppm F rinse; (3) a placebo prerinse followed by a 1,000 ppm F rinse, or (4) a Ca prerinse (150 mM Ca, as calcium lactate) followed by a 250 ppm F rinse. Sucrose solution was dripped onto the slabs 8×/day to simulate a high cariogenic challenge. The percent surface hardness loss (%SHL) was significantly lower in the Ca prerinse used with the 250 ppm F rinse group (%SHL = 38.0 ± 21.0) when compared with the F rinse alone (%SHL = 59.5 ± 24.1) and similar to the 1,000 ppm F rinse group (%SHL = 42.0 ± 18.3). Compared with the 250 ppm F rinse, the Ca prerinse increased biofilm fluid F only twice (nonsignificant). However, it greatly increased F in biofilm solids (∼22×). The Ca prerinse had little effect on loosely or firmly bound enamel F. The results showed an increased level of protection against demineralization by the use of a Ca prerinse, which seems to be caused by the enhancement of F concentration in the biofilm.

Theoretical basis and explanation for the relationship between area-level social inequalities and population oral health outcomes - A scoping review

This study was conducted to review the evidence on the association between area-level social inequalities and population oral health according to type and extent of social theories. A scoping review was conducted of studies, which assessed the association between area-level social inequality measures, and population oral health outcomes including self-rated oral health, number of teeth, dental caries, periodontal disease, tooth loss, oral health-related quality of life (OHRQoL) and dental pain. A search strategy was applied to identify evidence on PubMed, MEDLINE (Ovid), EMBASE, Web of Science, ERIC, Sociological Abstracts, Social Services Abstracts, references of selected studies, and further grey literature. A qualitative content analysis of the selected studies was conducted to identify theories and categorize studies according to their theoretical basis. A total of 2892 studies were identified with 16 included in the review. Seven types of social theories were used on 48 occasions within the selected studies including: psychosocial (n=13), behavioural (n=10), neo-material (n=10), social capital (n=6), social cohesion (n=4), material (n=3) and social support (n=2). Of the selected studies, four explicitly tested social theories as pathways from inequalities to population oral health outcomes, three used a theoretical construct, seven used theories for post-hoc explanation and two did not have any use of theory. In conclusion, psychosocial theories were used most frequently. Although theories were often mentioned, majority of these studies did not test a social theory.

Debating Water Fluoridation Before Dr. Strangelove

In the 1930s, scientists learned that small amounts of fluoride naturally occurring in water could protect teeth from decay, and the idea of artificially adding fluoride to public water supplies to achieve the same effect arose. In the 1940s and early 1950s, a number of studies were completed to determine whether fluoride could have harmful effects. The research suggested that the possibility of harm was small. In the early 1950s, Canadian and US medical, dental, and public health bodies all endorsed water fluoridation. I argue in this article that some early concerns about the toxicity of fluoride were put aside as evidence regarding the effectiveness and safety of water fluoridation mounted and as the opposition was taken over by people with little standing in the scientific, medical, and dental communities. The sense of optimism that infused postwar science and the desire of dentists to have a magic bullet that could wipe out tooth decay also affected the scientific debate.

Effect of a school-based oral health education programme on use of recommended oral self-care for reducing the risk of caries by children in Nigeria

OBJECTIVE

Caries is a major oral health problem children with efforts focused on promoting use of caries prevention methods. The aim of the study is to assess the effect of a school-based oral health education programme on use of oral self-care measures for reducing caries.

METHODS

A structured school-based oral health education programme was implemented in six schools in Ile-Ife, Nigeria for 4 years. At the end of the project, information was sought from school children in their last year and final 2 years of studies on the use of fluoridated toothpaste, consumption of sugar-containing snacks more than once a day, frequency of tooth brushing and flossing, and time of the last dental check-up. Predictors of the use of preventive oral health practices for caries were determined.

RESULTS

School children who received the intervention were more likely to report frequent use of fluoride-containing toothpastes (P < 0.001), more likely to brush twice a day (P = 0.03), less likely to consuming sugar-containing snacks less than once a day (P = 0.03) and less likely to use dental floss once a day (P < 0.001) when compared to the control group.

CONCLUSION

This long term school based educational programme was able to increase school children's use of fluoride-containing toothpaste and twice daily tooth brushing, which are critical tools for reducing the risk of caries.

Fluoride gels for preventing dental caries in children and adolescents

BACKGROUND

Topically applied fluoride gels have been widely used as a caries-preventive intervention in dental surgeries and school-based programmes for over three decades. This updates the Cochrane review of fluoride gels for preventing dental caries in children and adolescents that was first published in 2002.

OBJECTIVES

The primary objective is to determine the effectiveness and safety of fluoride gels in preventing dental caries in the child and adolescent population.The secondary objectives are to examine whether the effect of fluoride gels is influenced by the following: initial level of caries severity; background exposure to fluoride in water (or salt), toothpastes, or reported fluoride sources other than the study option(s); mode of use (self applied under supervision or operator-applied), and whether there is a differential effect between the tray and toothbrush methods of application; frequency of use (times per year) or fluoride concentration (ppm F).

SEARCH METHODS

We searched the Cochrane Oral Health Group Trials Register (to 5 November 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library 2014, Issue 11), MEDLINE via OVID (1946 to 5 November 2014), EMBASE via OVID (1980 to 5 November 2014), CINAHL via EBSCO (1980 to 5 November 2014), LILACS and BBO via the BIREME Virtual Health Library (1980 to 5 November 2014), ProQuest Dissertations and Theses (1861 to 5 November 2014) and Web of Science Conference Proceedings (1945 to 5 November 2014). We undertook a search for ongoing trials on ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform on 5 November 2014. We placed no restrictions on language or date of publication in the search of the electronic databases. We also searched reference lists of articles and contacted selected authors and manufacturers.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials where blind outcome assessment was stated or indicated, comparing topically applied fluoride gel with placebo or no treatment in children up to 16 years. The frequency of application had to be at least once a year, and study duration at least one year. The main outcome was caries increment measured by the change in decayed, missing and filled tooth surfaces in both permanent and primary teeth (D(M)FS and d(e/m)fs).

DATA COLLECTION AND ANALYSIS

At least two review authors independently performed study selection, data extraction and 'Risk of bias' assessment. We contacted study authors for additional information where required. The primary measure of effect was the prevented fraction (PF), that is, the difference in mean caries increments between the treatment and control groups expressed as a percentage of the mean increment in the control group. We performed random-effects meta-analyses where we could pool data. We examined potential sources of heterogeneity in random-effects metaregression analyses. We collected adverse effects information from the included trials.

MAIN RESULTS

We included 28 trials (3 of which are new trials since the original review), involving 9140 children and adolescents. Most of these trials recruited participants from schools. Most of the studies (20) were at high risk of bias, with 8 at unclear risk of bias.Twenty-five trials (8479 participants) contributed data for meta-analysis on permanent tooth surfaces: the D(M)FS pooled prevented fraction (PF) estimate was 28% (95% confidence intervals (CI) 19% to 36%; P < 0.0001; with substantial heterogeneity (P < 0.0001; I(2) = 82%); moderate quality evidence). Subgroup and metaregression analyses suggested no significant association between estimates of D(M)FS prevented fractions and the prespecified trial characteristics. However, the effect of fluoride gel varied according to the type of control group used, with D(M)FS PF on average being 17% (95% CI 3% to 31%; P = 0.018) higher in non-placebo-controlled trials (the reduction in caries was 38% (95% CI 24% to 52%; P < 0.0001, 2808 participants) for the 10 trials with no treatment as control group, and 21% (95% CI 15% to 28%; P < 0.0001, 5671 participants) for the 15 placebo-controlled trials. A funnel plot of the 25 trials in the D(M)FS PF meta-analysis indicated a relationship between prevented fraction and study precision, with an apparent lack of small studies with statistically significant large effects.The d(e/m)fs pooled prevented fraction estimate for the three trials (1254 participants) that contributed data for the meta-analysis on primary teeth surfaces was 20% (95% CI 1% to 38%; P = 0.04; with no heterogeneity (P = 0.54; I(2) = 0%); low quality evidence).There was limited reporting of adverse events. Only two trials reported information on acute toxicity signs and symptoms during the application of the gel (risk difference 0.01, 95% CI -0.01 to 0.02; P = 0.36; with no heterogeneity (P = 36; I(2) = 0%); 490 participants; very low quality evidence). None of the trials reported information on tooth staining, mucosal irritation or allergic reaction.

AUTHORS' CONCLUSIONS

The conclusions of this updated review remain the same as those when it was first published. There is moderate quality evidence of a large caries-inhibiting effect of fluoride gel in the permanent dentition. Information concerning the caries-preventive effect of fluoride gel on the primary dentition, which also shows a large effect, is based on low quality evidence from only three placebo-controlled trials. There is little information on adverse effects or on acceptability of treatment. Future trials should include assessment of potential adverse effects.

Factors that drive dentists towards or away from dental caries preventive measures: systematic review and metasummary

BACKGROUND

Dental caries is a serious public health concern. The high cost of dental treatment can be avoided by effective preventive measures, which are dependent on dentists' adherence. This study aimed to evaluate the factors that drive dentists towards or away from dental caries preventive measures.

METHODS AND FINDINGS

This systematic review was registered in PROSPERO (CRD42012002235). Several databases as well as the reference lists and citations of the included publications were searched according to PRISMA guidelines, yielding 18,276 titles and abstracts, which were assessed to determine study eligibility. Seven qualitative studies and 41 surveys (36,501 participants) remained after data extraction and interpretation. A total of 43 findings were abstracted from the reports and were grouped together into 6 categories that were judged to be topically similar: education and training, personal beliefs, work conditions, remuneration, gender, place of residence and patients. The main findings for adherence based on their calculated frequency effect sizes (ES) were teamwork (21%) and post-graduation (12%), while for non-adherence were biologicism (27%), and remuneration for preventive procedures (25%). Intensity ES were also calculated and demonstrated low prevalence of the findings. Quality assessment of the studies demonstrated that the methodological quality, particularly of surveys, varied widely among studies.

CONCLUSIONS

Despite the questionable quality of the included reports, the evidence that emerged seems to indicate that further education and training coupled with a fairer pay scheme would be a reasonable approach to change the balance in favor of the provision of dental caries preventive measures by dentists. The results of this review could be of value in the planning and decision making processes aimed at encouraging changes in professional dental practice that could result in the improvement of the oral health care provided to the population in general.

Appraisal of the national response to the caries epidemic in children in Nigeria

BACKGROUND

This article reviews the caries profile for children in Nigeria and proposes an appropriate framework for addressing the silent caries epidemic.

DISCUSSION

We reviewed the caries prevalence among children in Nigeria, assessed the existing responses to the caries epidemic including the national oral healthcare delivery situation in the country and discussed the current caries management in children. We then proposed a response framework for Nigeria. We argue that successful interventions will require the adoption of a socio-ecological model. This would ensure that the micro-, meso-, exo- and macrosystems required to support the behavioural, structural and biological interventions for promoting caries prevention are addressed. National oral health surveys are required to help understand the epidemiology, social determinants of and factors that undermine the ability of children to access oral health care. A global caries prevention agenda for children would help get the government's support for a national response agenda. Currently, there is no global call for action on the caries epidemic in children. This lack of an agenda needs to be urgently addressed.

SUMMARY

A combination of approaches for the prevention of caries in children in Nigeria is needed. A national survey is needed to generate the needed evidence for the planning of community relevant responses to the national caries epidemic in children. The design of a global health agenda for children is an important first step that can facilitate the development of a national oral health programme for children in Nigeria.

Fluoride varnishes for preventing dental caries in children and adolescents

BACKGROUND

Topically-applied fluoride varnishes have been used extensively as an operator-applied caries-preventive intervention for over three decades. This review updates the first Cochrane review of fluoride varnishes for preventing dental caries in children and adolescents, which was first published in 2002.

OBJECTIVES

To determine the effectiveness and safety of fluoride varnishes in preventing dental caries in children and adolescents, and to examine factors potentially modifying their effect.

SEARCH METHODS

We searched the Cochrane Oral Health Group's Trials Register (to 13 May 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 4), MEDLINE via OVID (1946 to 13 May 2013), EMBASE via OVID (1980 to 13 May 2013), CINAHL via EBSCO (1980 to 13 May 2013), LILACS and BBO via the BIREME Virtual Health Library (1980 to 13 May 2013), ProQuest Dissertations and Theses (1861 to 13 May 2013), and Web of Science Conference Proceedings (1945 to 13 May 2013). A search for ongoing trials was undertaken on ClinicalTrials.gov on 13 May 2013. There were no restrictions on language or date of publication in the search of the electronic databases.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials with blind outcome assessment used or indicated, comparing topically-applied fluoride varnish with placebo or no treatment in children up to 16 years during at least one year. The main outcome was caries increment measured by the change in decayed, missing and filled tooth surfaces in both permanent (D(M)FS) and primary (d(e/m)fs) teeth.

DATA COLLECTION AND ANALYSIS

At least two review authors assessed all search results, extracted data and undertook risk of bias independently. Study authors were contacted for additional information. The primary measure of effect was the prevented fraction, that is the difference in mean caries increments between the treatment and control groups expressed as a percentage of the mean increment in the control group. The caries increments nearest to three years were used from each included study. Random-effects meta-analyses were performed where data could be pooled. Potential sources of heterogeneity were examined in random-effects meta-regression analyses. Adverse effects information was collected from the included trials.

MAIN RESULTS

Twenty-two trials with 12,455 participants randomised (9595 used in analyses) were included. For the 13 that contributed data for the permanent tooth surfaces meta-analysis, the pooled D(M)FS prevented fraction estimate comparing fluoride varnish with placebo or no treatment was 43% (95% confidence interval (CI) 30% to 57%; P < 0.0001). There was substantial heterogeneity, confirmed statistically (P < 0.0001; I(2) = 75%), however this body of evidence was assessed as of moderate quality. The pooled d(e/m)fs prevented fraction estimate was 37% (95% CI 24% to 51%; P < 0.0001) for the 10 trials that contributed data for the primary tooth surfaces meta-analysis, also with some heterogeneity (P = 0.009; I(2) = 59%). Once again this body of evidence was assessed as of moderate quality. No significant association between estimates of D(M)FS or d(e/m)fs prevented fractions and the pre-specified factors of baseline caries severity, background exposure to fluorides, application features such as prior prophylaxis, concentration of fluoride, frequency of application were found. There was also no significant association between estimates of D(M)FS or d(e/m)fs prevented fractions and the post hoc factors: whether a placebo or no treatment control was used, length of follow-up, or whether individual or cluster randomisation was used, in the meta-regression models. A funnel plot of the trials in the main meta-analyses indicated no clear relationship between prevented fraction and study precision. In both methods, power is limited when few trials are included. There was little information concerning possible adverse effects or acceptability of treatment.

AUTHORS' CONCLUSIONS

The conclusions of this updated review remain the same as those when it was first published. The review suggests a substantial caries-inhibiting effect of fluoride varnish in both permanent and primary teeth, however the quality of the evidence was assessed as moderate, as it included mainly high risk of bias studies, with considerable heterogeneity.

Addressing oral health disparities, inequity in access and workforce issues in a developing country

The health sector challenges in India like those in other low and middle income countries are formidable. India has almost one-third of the world's dental schools. However, provisions of oral health-care services are few in rural parts of India where the majority of the Indian population resides. Disparities exist between the oral health status in urban and rural areas. The present unequal system of mainly private practice directed towards a minority of the population and based on reparative services needs to be modified. National oral health policy needs to be implemented as a priority, with an emphasis on strengthening dental care services under public health facilities. A fast-changing demographic profile and its implications needs to be considered while planning for the future oral health-care workforce. Current oral health status in developing countries, including India, is a result of government public health policies, not lack of dentists. The aim of the article is to discuss pertinent issues relating to oral health disparities, equity in health-care access, dental workforce planning and quality concerns pertaining to the present-day dental education and practices in India, which have implications for other developing countries.

Change in FS-T index in adults in the German national oral health surveys between 1989 and 2005

OBJECTIVES

To assess changes in the number of functioning teeth (filled and sound teeth, FS-T index) from 1989/1992 to 2005 in West and East Germany and to evaluate survey- and region-specific associations between sociodemographic and behavioral risk factors and the FS-T index.

METHODS

Within the German Oral Health Studies, random samples from 35-44-year-olds were drawn in 1989, 1992, 1997 and 2005. The FS-T index and a questionnaire with socioeconomic and behavioral items were assessed. Negative binomial regression models were evaluated, including all sociodemographic and behavioral factors simultaneously as independent variables.

RESULTS

For West Germany, median FS-T index increased by 3 teeth between 1989 and 2005 (Ptrend < 0.001). In East Germans, FS-T index was similar in 1992 and 1997 (median, 24), but increased by one tooth until 2005 (Ptrend < 0.001). For West and East Germany, middle and high school education were significantly associated with higher FS-T indices in all surveys, although effects were most pronounced in 2005. Being married, reporting regular dental visits and good oral hygiene were significantly related to a higher number of functioning teeth in at least one survey year.

CONCLUSIONS

Dental health assessed as the number of functioning teeth improved between 1989/92 and 2005 in both German parts and across all educational levels. However, considering the educational level, dental health was less equally distributed in 2005 compared with previous surveys.

Factors associated with dental and medical care attendance in UK resident Yemeni khat chewers: a cross sectional study

Background

The chewing of khat leaf with tobacco smoking amongst Yemenis, Somalis and Ethiopians is reported to impact oral and general health. The health status and particularly dental and medical care attendance of UK-khat chewers has not received attention. This study aimed to explore health status and dental and medical attendance and its associated factors in UK permanently resident Yemeni khat chewers.

Methods

A cross- sectional study with a purposively selected sample of 204 khat chewers was conducted. Data were collected through face to face interviews. Data analysis included descriptive, Chi-square tests and binary logistic regressions.

Results

The mean age for this study sample was 44.84 (SD = ±19.70) years and 35% were employed. Forty five percent reported symptomatic medical attendance for self reported health conditions in the last two weeks whilst 44% had symptomatic dental attendance. Higher khat chewing dependency levels associated positively with both symptomatic dental and medical attendance (p = 0.004, OR = 1.14, 95%CI = 1.04-1.25; p = 0.003; OR = 1.16, 95%CI = 1.05-1.29, respectively). Higher social participation levels associated negatively with symptomatic dental attendance (p = 0.034, OR = 0.98, 95%CI = 0.96-0.99) whilst increase in age and self-reported health conditions associated positively with symptomatic medical attendance (p = 0.030, OR = 1.03, 95%CI = 1.01-1.06; p = 0.001, OR = 4.51, 95%CI = 2.02-10.08, respectively).

Conclusions

In this study of khat chewers, a significant proportion reported symptomatic dental and medical attendance. Demographic, psychosocial and self reported general health conditions were associated significantly with dental and medical attendance. Strategies to improve the dental and medical care attendance amongst this group should focus on these and other unexplored underlying factors.

Influence of family structure on dental caries experience of preschool children in Sri Lanka

BACKGROUND

The prevalence of dental caries in preschool children has not been declining in the recent past. A growing body of research suggests that social and behavioural factors may play a considerable role in the aetiology of dental caries.

AIMS

The objective of this study was to determine the relationship between the family structure and dental caries experience in preschool children.

METHODS

A descriptive cross-sectional study was carried out in children aged 3-5 years in Wattala Divisional Secretariat area in Colombo district of Sri Lanka. An interviewer-administered questionnaire was used to obtain information from the parents on family structure including the size, birth rank, age spacing between the next oldest and youngest sibling and age of parent at birth of the subject. The dental caries status of the children was assessed using WHO standard criteria for primary teeth.

RESULTS

Family size, birth rank, age difference between the subject and next oldest sibling and parent's age at birth of the subject were significantly associated with the dental caries experience of the preschool children at bivariate level. In a stepwise multiple linear regression analysis family size, birth rank and the parent's age at birth of the child remained statistically significant.

CONCLUSION

The present findings suggest that family structure might significantly affect the caries experience of preschool children.

[Time series analysis of dental care procedures in Brazilian public services, 1994-2007]

The objectives of this study were to describe the time series of monthly rates of five dental care procedures in the Brazilian public health system and to assess changes in trends of dental procedures from 1994 to 2007. Data were collated from the Outpatient Information System of the Unified Health System (SIA-SUS). Monthly rates of total dental care procedures, preventive procedures, collective procedures, restorations and extractions for the whole country and total procedures for each macro-region were calculated. Time series were analyzed using moving average and SARIMA models. There was a decrease in trends of restorative care and tooth extraction rates. The major alterations occurred between January 1998 and January 2000. In October 1999 the total rate of dental procedures per thousand inhabitants increased by 30.5 procedures, i.e. 55%, and after the introduction of the Oral Health Teams (ESB) in the Family Health Program (PSF) in December 2000, the increase was 5.9 procedures, i.e. 6.9%. There were also strong seasonal variations. The conclusion was that the main changes in the series occurred due to the municipalization process, though after the introduction of the ESB-PSF program, there was an increase in the total rate of dental procedures.

Saúde bucal e uso dos serviços odontológicos em função do Índice de Necessidades em Saúde: São Paulo, 2008

A Secretaria Municipal de Saúde de São Paulo desenvolveu o Índice de Necessidades em Saúde (INS) para identificar áreas prioritárias para a oferta de serviços. Em 2008 realizou um Levantamento das Condições de Saúde Bucal. Pretende-se, neste estudo ecológico, analisar o perfil de saúde bucal em relação ao INS. As variáveis, estratificadas para as idades de 5, 12 e 15 anos, foram: porcentagem de indivíduos com dificuldade no acesso ao serviço odontológico; média do ceod e CPOD; prevalência da necessidade de extração e de livres de cárie. As informações foram analisadas para as 25 Supervisões Técnicas de Saúde (STS). Empregou-se o teste estatístico de covariância, o coeficiente de correlação de Pearson e o modelo de regressão linear. Observou-se uma correlação positiva entre maiores INS e a dificuldade de acesso aos serviços. Nas STS com maiores INS houve maior experiência de cárie, maior necessidade de exodontias e menor prevalência de livres de cárie. Reforça-se a necessidade de priorizar as áreas de privação social para melhorar a condição de saúde da população.

Longitudinal study of dental caries increment in Malaysian school children: a 5-year cohort study

The aim of this 5-year longitudinal cohort study was to assess the prevalence, severity, and trends in caries increment and impact of the School Dental Incremental Care Programme (SDICP). Data were gathered from school dental records as part of the SDICP. A sample of 1830 children were included and checked for caries experience annually using World Health Organization criteria. In total, 95.4% of the children were caries free in 2004, and caries experience declined to 70.5% in 2009 with an average of 4.9% annually. At baseline, the mean DMFT (confidence interval [CI]) was 0.06 (0.05-0.08) and increased to 0.58 (0.53-0.63) in 2009. Children with active caries were 4.4% in 2004, and figures rose to 9.6% in 2009. The FT component increased most rapidly during these 5 years from 0.2% to 25.1%. Overall caries prevalence and increment was low in this study. Proportions of FT component were higher as compared with DT component with low rate of extractions during the latter years of the study.

Dentistry and population approaches for preventing dental diseases

Dental professionals are expected to engage in oral disease prevention, but their tools limit the approach to chair side activities based on the common notion that the major dental diseases, dental caries, gingivitis and periodontitis, are behavioural diseases shaped by individual lifestyles. However, lifestyles also have causes and individual behaviours reflect cultural norms, expectations and opportunities that are socio-economically determined and structurally maintained. Importantly, the effects of the societal and socio-economic determinants reach way above their influences as individual attributes, and effective approaches to the prevention and control of oral diseases are aligned with this causal chain. Unfortunately, the ethos and philosophy of dentistry is focused to a downstream, patient-centred, curative and rehabilitative approach to oral diseases. Whilst such services are needed to care for those who have already suffered the consequences of oral diseases, they do not influence population oral health. A more balanced distribution of efforts and resources along the whole range of intervention points from the downstream curative to the upstream structural healthy policy approaches is required if appropriate, evidence-based, effective, cost-effective, sustainable, equitable, universal, comprehensive and ethical delivery of health care, including oral health care, is the goal. The implementation of healthy policies and sound approaches to population oral health will require substantial commitment and political will on the part of the public and their elected officials.

Dental caries and the nutritional status of preschool children: a spatial analysis

OBJECTIVE: This cross-sectional study sought to conduct a spatially analysis of the distribution of dental caries and the nutritional status (NS) of 5-year-old preschool children of public schools in the city of Araraquara, São Paulo, Brazil. METHODS: The sample was selected in a stratified probabilistic manner. A dental examination was conducted to investigate the dmft index. The anthropometric indicators of the weight/height (W/H), height/age (H/A), weight/age (W/A) and body mass index (BMI) were calculated to estimate the NS. A descriptive statistical analysis was conducted and a thematic map was created. At the end of the study 491 children had full address codification. A GPS device was used to ascertain the geographic reference points. A pluri-directional semi-variogram was elaborated. RESULTS: It was revealed that both variables presented a pure nugget effect showing the absence of a spatial correlation, in other words the dmft and nutritional status are not regionalized variables, and their values do not reveal direct spatial dependence. CONCLUSIONS: Dental caries and nutritional status are health conditions that do not reveal spatial dependence. Ultimately, the combination of these indicators with others can produce spatial dependence effects.

Global oral health inequalities: task group--implementation and delivery of oral health strategies

This paper reviews the shortcomings of present approaches to reduce oral diseases and inequalities, details the importance of social determinants, and links that to research needs and policies on implementation of strategies to reduce oral health inequalities. Inequalities in health are not narrowing. Attention is therefore being directed at determinants of major health conditions and the extent to which those common determinants vary within, between, and among groups, because if inequalities in health vary across groups, then so must underlying causes. Tackling inequalities in health requires strategies tailored to determinants and needs of each group along the social gradient. Approaches focusing mainly on downstream lifestyle and behavioral factors have limited success in reducing health inequalities. They fail to address social determinants, for changing people's behaviors requires changing their environment. There is a dearth of oral health research on social determinants that cause health-compromising behaviors and on risk factors common to some chronic diseases. The gap between what is known and implemented by other health disciplines and the dental fraternity needs addressing. To re-orient oral health research, practice, and policy toward a 'social determinants' model, a closer collaboration between and integration of dental and general health research is needed. Here, we suggest a research agenda that should lead to reductions in global inequalities in oral health.