National supervised toothbrushing program and dental decay in Scotland

Modeling the cost-effectiveness of school-based supervised toothbrushing program in reducing the dental caries burden in India

BACKGROUND

Supervised toothbrushing (STB) significantly reduces the incidence and progression of dental caries. School years present a favorable age for introducing such healthy habits for a lifetime.

AIM

To estimate the cost-effectiveness of implementing a STB program in India in preventing dental caries incidence.

DESIGN

An operational framework of a national STB program was devised. A mathematical model was then developed to evaluate this program's clinical effectiveness and economic impact in the Indian scenario. This study considered a hypothetical cohort of the Indian population aged from 6 to 75 years. Two groups were compared: no intervention and STB in government schools. The health outcomes assessed were a number of tooth caries incidences averted and quality-adjusted life years gained.

RESULTS

The STB program in the government schools of India would prevent at least one tooth from developing caries in an individual's lifetime. Considering the current treatment-seeking behavior, the STB program saves INR 153 (US$ 1.95) per carious tooth incidence averted and INR 22 202 (US$ 283) per QALY gained.

CONCLUSION

In India, the school-based STB program is expected to be a cost-effective strategy for reducing the dental caries burden and its associated treatment costs.

A review of water fluoridation studies and the effect on dental caries and treatment costs, undertaken in Scotland

Objectives This review aimed to investigate the effect of water fluoridation on the dental health of Scottish people by comparing results of starting and discontinuing fluoridation in Scotland.Data sources Data sources were retrieved from electronic databases. The grey literature was also searched. Articles were selected if the population of interest was Scottish. The objective was to evaluate the influence of water fluoridation on dental caries using the dmft/s, DMFT/S (decayed, missing and filled teeth/surfaces) or deft/s indices (decayed, extraction needed, filled teeth/surfaces).Data extraction Name of the authors, publication years, location of the study, sample size, type of study design, age of participants, method of assessing the outcome, data related to the exposure and the outcome, and the overall result of each study were extracted. The data were collected based on the effect of water fluoridation and its cessation on dental caries and the type of dentition.Results Nine studies were included in the review. The findings revealed that the introduction of water fluoridation led to reductions in caries. Moreover, after the cessation of fluoridation, caries levels continued to remain lower in the fluoridated groups. Additionally, fluoridation had the effect of reducing the cost of dental treatment.Conclusion Water fluoridation was effective in improving dental caries among the Scottish child population. New studies are required to provide contemporary evidence for water fluoridation in Scotland.

Environmental impact of the supervised toothbrushing programme amongst children in Scotland

OBJECTIVES

To understand the environmental impact of providing a nationwide supervised toothbrushing programme (Childsmile) for 5-year-old children in Scotland.

METHODS

A life cycle assessment was conducted to assess the annual environmental effects of the supervised toothbrushing programme in early years childcare, as well as each dental procedure (dental restoration under local anaesthesia (LA), single tooth extraction under LA, and multiple teeth extraction under general anaesthesia) spanning from 2001/02 to 2009/10. The expected savings in annual carbon dioxide equivalent (CO2e) emissions for all combined dental treatments in subsequent years were calculated compared to those in 2001/02.

RESULTS

An overall decrease in CO2e emissions was evident in the Childsmile programme and across all dental procedures. The estimated reduction in emissions across all procedures varied from 102.5 tonnes in 2002/03 to 461.1 tonnes in 2009/10 when compared to 2001/02. Within three years, the expected emissions savings from all combined dental procedures surpassed the emissions generated by implementing the Childsmile programme.

CONCLUSIONS

Over time, there was a significant reduction in annual CO2e emissions for all combined dental treatments in children. In the eighth year of the Childsmile, emissions savings were more than 4.5 times greater than the emissions generated during its implementation.

CLINICAL SIGNIFICANCE

The study highlights the importance of educating public by individual dentists about the environmental impact of caries prevention programmes and paediatric dental treatments as this may influence patient choice. It also encourages commissioners of community dental programmes to support the implementation of supervised toothbrushing programmes in early years childcare.

Probabilistic graphical modelling of early childhood caries development

In order to develop a statistical model for complex interactions among factors affecting early childhood caries development (ECC), 234 children from the "XXXX oral growth longitudinal study" were analysed at ages 3, 4 and 5. A questionnaire for children's parents (clinical history, nutritional and oral hygiene habits) and clinical oral examinations were recorded each year. The probabilistic dependence structure on the most significant factors was modelled with an Undirected Graphical Model (UGM or Markov random fields) which provides a probabilistic reasoning approach for the establishment of multi-way associations. The best fitting UGM was estimated through the maximum likelihood principle and two-way factor associations were verified through Fisher's exact statistical hypothesis tests for count data. The effect of sugar intake on caries incidence is mediated by oral hygiene; for caries incidence, oral hygiene quality is more relevant than toothbrushing time; the effect of pacifier on caries incidence is statistically significant only when considered in combination with breastfeeding time. Among behavioural ECC risk factors, the quality of oral hygiene, and not the toothbrushing frequency, is a primary factor that modulates the sugar intake in his primary role of the ECC developer. School-based oral health programs for ECC prevention should be improved with supervised toothbrushing program. UGM analysis could improve the school-based oral health programs with more effective and efficient prevention strategies based on the hierarchical interactions among the ECC risk factors. Oral hygiene plays a pivotal role in early childhood caries and can modulate positively or negatively their development. Supervised toothbrushing is a crucial intervention to be included in the daily educational and clinical practice and in the school-based oral health promotion programs. Trial registration: Clinical trial registration number: NCT02798809.

The role of income and frequency of dental visits in the relationship between dental sealant use and resin fillings after extended coverage: a retrospective cohort study

BACKGROUND

Prevention and treatment services use is closely associated with socioeconomic factors, such as income. This study aimed to investigate the relationship between implementing the sealant program and resin fillings restoration and to explore the role of income and frequency of dental visits in this relationship.

METHODS

This retrospective cohort study used the cohort database from the National Health Information Database of the National Health Insurance Service. The study population comprised 494,731 children born in 2007. A logistic regression model for the experience of resin fillings and a linear regression model for weighted utilization of them were used to identify the independent effects of dental sealants, income, and frequency of dental visits. All analyses were conducted using the SAS Enterprise Guide version 7.1 (SAS Institute Inc., Cary, NC, USA).

RESULTS

The ratio based on income level was almost proportional in all groups except the medical aid group, which had a rate as high as that of the wealthier group. Children without sealants were 1.05 times more likely to have resin fillings than others after adjusting for income level and frequency of visiting dental clinics in the final model. However, an opposite relationship between sealant experiences and resin fillings was observed in the previous model without dental visits. The gap in the weighted resin filling scores according to socioeconomic variables showed a similar tendency.

CONCLUSIONS

Income and frequency of dental visits might be confounding factors for the relationship between dental sealant and resin fillings. It is necessary to consider the complex relationship between socioeconomic indicators and service use while studying oral health inequality.

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.

Association between neighborhood disadvantage and children's oral health outcomes in urban families in the Chicago area

Purpose

The prevalence of childhood caries in urban Chicago, compared with national and state data, indicates that neighborhood context influences oral health. Our objective was to delineate the influence of a child's neighborhood on oral health outcomes that are predictive of caries (toothbrushing frequency and plaque levels).

Methods

Our study population represents urban, Medicaid-enrolled families in the metropolitan Chicago area. Data were obtained from a cohort of participants (child-parent dyads) who participated in the Coordinated Oral Health Promotion (CO-OP) trial at 12 months of study participation (N = 362). Oral health outcomes included toothbrushing frequency and plaque levels. Participants' neighborhood resource levels were measured by the Area Deprivation Index (ADI). Linear and logistic regression models were used to measure the influence of ADI on plaque scores and toothbrushing frequency, respectively.

Results

Data from 362 child-parent dyads were analyzed. The mean child age was 33.6 months (SD 6.8). The majority of children were reported to brush at least twice daily (n = 228, 63%), but the mean plaque score was 1.9 (SD 0.7), classified as "poor." In covariate-adjusted analyses, ADI was not associated with brushing frequency (0.94, 95% CI 0.84-1.06). ADI was associated with plaque scores (0.05, 95% CI 0.01-0.09, p value = 0.007).

Conclusions

Findings support the hypothesis that neighborhood-level factors influence children's plaque levels. Because excessive plaque places a child at high risk for cavities, we recommend the inclusion of neighborhood context in interventions and policies to reduce children's oral health disparities. Existing programs and clinics that serve disadvantaged communities are well-positioned to support caregivers of young children in maintaining recommended oral health behaviors.

Effectiveness of school-based strategies to prevent tooth decay in Filipino children: A cluster-randomized trial

OBJECTIVES

Evidence for affordable and pragmatic programmes to address the burden of untreated tooth decay in children in low- and middle-income settings is limited. This study aimed to (1) assess the effect of a government-run, school-based daily group toothbrushing programme compared to standard school-based oral health education on the incidence of dental caries and odontogenic infections in Filipino children over a period of 3 years; and (2) assess the additional preventive effect of on-demand oral urgent treatment (OUT) and weekly fluoride gel application.

METHODS

A cluster-randomized trial was conducted in Camiguin, Philippines. Schools in three regions were randomly assigned to one of three intervention groups: The Essential Health Care Programme (EHCP), which includes daily toothbrushing with fluoride toothpaste; EHCP plus twice-yearly access to on-demand urgent oral treatment (EHCP + OUT) and EHCP plus weekly application of high-concentrated fluoride gel (EHCP + Fluoride). Schools in a nearby province with a similar child population were selected as external concurrent control group. Clinical oral examinations were performed by calibrated dentists from a random sample of 682 seven-year-old students who were examined at baseline and over the following 3 years. Outcome variables were the number of decayed primary teeth, the number of decayed, missing and filled permanent teeth (DMFT) and surfaces (DMFS), and the number of permanent teeth with pulpal involvement, ulcerations, fistula or abscess (PUFA). Data were analysed using multilevel mixed-effects negative binomial regression.

RESULTS

Three years after implementation, increments in dental caries and odontogenic infections in permanent teeth did not significantly differ between the EHCP and control group, yet the incidence of DMFT was lower by 22% in children receiving EHCP. Compared to controls, children receiving EHCP + Fluoride had a significantly lower increment of DMFT, DMFS and PUFA by 40%, 40% and 47%, respectively. Children receiving EHCP + OUT had lower incidence rates of DMFT and DMFS than control children by 23% and 28%, respectively. A lower incidence rate was also found for PUFA, but the effect was not statistically significant.

CONCLUSIONS

Findings suggest that the weekly application of fluoride gel and urgent oral treatment, in addition to daily school-based toothbrushing with fluoride toothpaste, are realistic and effective strategies to lower the burden of dental caries in Filipino children. Implementation challenges may explain why no substantial caries-preventive benefits were demonstrated for school-based toothbrushing only. Intervention compliance should be considered in future programme implementation and evaluation research.

Patterns in Oral Hygiene and Dietary Habits in School Children during the COVID-19 Pandemic

Aim

To assess oral hygiene and dietary patterns in school children participating in a school-based preventive oral health program during the COVID-19 pandemic.

Materials and methods

In this cross-sectional study, an anonymous questionnaire exploring oral hygiene and dietary patterns during the COVID-19 pandemic was completed by parents of school children. Data were compared among different schools, school years, and between genders using nonparametric tests. Associations among further nominal and categorical variables related to oral hygiene and dietary habits were also assessed using the chi-square test.

Results

Only 26% (n = 32) of parents reported that their children brushed their teeth the recommended amount of twice or more per day during the pandemic. In addition, 17.2% of the parents reported less brushing than before the pandemic. A total of 40 parents (32.8%) reported that their child consumed unhealthy beverages once a day or more. Comparison between genders revealed that male participants were drinking significantly unhealthier than female (p = 0.038). Sugary foods were consumed once a day or more by 63.1% of children. No significant differences were found between public and church schools. Significant direct associations were found between changes in dietary habits and brushing frequency (p = 0.017), between parental concern regarding the interruption of the school program and decreased brushing frequency (p = 0.005), and negative changes in dietary habits (p = 0.013).

Clinical significance

Within the limitations of this study, the present significant findings observed during the pandemic support the importance of school programs in promoting oral hygiene and healthy dietary habits of children.

How to cite this article

Agius A-M, Gatt G, Cortes ARG, et al. Patterns in Oral Hygiene and Dietary Habits in School Children during the COVID-19 Pandemic. Int J Clin Pediatr Dent 2023;16(2):205-210.

Impact of virtual supervised tooth brushing on caries experience and quality of life among primary school children: study protocol for a randomized controlled trial

BACKGROUND

Dental caries is one of the most common diseases affecting children world widely as well as in the Kingdom of Saudi Arabia. Supervised tooth brushing programs are implemented throughout the world to provide young children's developing teeth with additional fluoride as a form of dental caries prevention. While school-based supervised tooth brushing programs have been proven to improve young children's oral health, virtual supervised teeth brushing programs have not been assessed. The purpose of this protocol is to assess the impact of virtual supervised tooth brushing on caries experience and quality of life among primary school students in Riyadh, Saudi Arabia.

METHODS

This is a cluster randomized controlled trial comparing a virtual supervised tooth brushing program against no intervention applied. A total of 1192 (596 in each group) 8-9-year-old children in Riyadh primary schools, Saudi Arabia, will be recruited for the trial. Schools (cluster) will be randomly selected and allocated to either group. Clinical assessment for caries experience will be conducted in six points (baseline, + 3 months, + 6 months, + 12 months, + 24 months, + 36 months) by dental hygienists using the World Health Organization criteria. Data on sociodemographic behavioral factors and children's quality of life will be collected with every clinical assessment through a structured questionnaire. The primary outcome is the change in caries experience (the number of teeth with untreated dental caries, filled and missing teeth) in both primary and permanent teeth over 36 months.

DISCUSSION

Virtual education as well as some health consultation through the pandemic period had enabled an effective IT infrastructure in Saudi Arabia. Virtual supervised tooth brushing is a proposed initiative. It is also an opportunity for targeting a large portion of the population with a high level of disease as a quarter of the Saudi population is younger than 15 years. This project should provide high level evidence on the effectiveness of virtual supervised tooth brushing. The findings should potentially inform policies related to the continuation/implementation of school-based programs in Saudi Arabia.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT05217316. Registered on 19 January 2022.

A qualitative study of barriers and facilitators to the implementation of a pilot school-based, toothbrushing programme

Background

While supervised toothbrushing programmes have been established in many countries of the world, little is known about different perspectives on their implementation. The aim of the study was to explore stakeholders' barriers and facilitators to implementation of a school-based toothbrushing programme in Taiwan.

Methods

Focus groups and interviews were used to explore the views of elementary school students, teachers, staff, and nurses in a piloted school-based toothbrushing programme. The topic guides were developed according to the Theoretical Domains Framework (TDF) to cover the behavioural factors systematically and comprehensively. Data were analysed with content analysis.

Results

Overall, 36 students, 29 teachers/staff, and five school nurses (N = 65) were included. The overarching theme was the importance of habit formation for both staff and children to ensure that toothbrushing as part of the programme was embedded into the school schedule and routine. While children did not necessarily appear to retain the dental knowledge which was taught in the programme, the provision of fluoride toothpaste and toothbrush for their use in schools allowing teachers and staff to choose the timing of the brushing and engaging classmates to supervise each other were found to be key factors.

Conclusions

Implementing a school-based toothbrushing programme with the support of staff and active engagement of children can help children to develop a toothbrushing habit. Classmate-supervised toothbrushing may reduce the burden on teachers and staff to implement the programme.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-022-02494-7.

Parent-reported toothbrushing behaviour in the Portuguese preschool population

PURPOSE

Study toothbrushing behaviours and associated factors in a Portuguese preschool population.

METHODS

The study population was the parents of children attending Portuguese kindergartens. The data on sociodemographic and toothbrushing behaviours, at home and at school, were collected by an online questionnaire. The data analysis was performed using Chi-square, Fisher, Mann-Whitney and Kruskal-Wallis tests (α = 0.05).

RESULTS

The sample included 711 parents. Most of the children brushed their teeth at home at least twice-a-day (65.3%), with the help of an adult (62.9%). The majority of the children did not brush their teeth at school (71.2%); however, only 9.9% of the parents reported that they don't/wouldn't authorise it. Considering both toothbrushing, at home and at school, 75% of the children brushed their teeth twice-a-day. However, only 7.8% of the children performed all the correct toothbrushing related procedures. Toothbrushing at school was more frequent in private kindergartens (p < 0.001). A higher level of education was associated with non-authorisation of toothbrushing at school (p = 0.019) and with performing the correct toothbrushing related procedures (p = 0.007). Attending an oral health professional appointment was also associated with performing the correct toothbrushing related procedures (p = 0.005).

CONCLUSION

Toothbrushing twice-a-day was frequent in the studied population, however, the percentage of children who brushed at school was low, as well as the percentage of children who performed all the correct toothbrushing related procedures. Toothbrushing at school was more likely in private kindergartens. Performing correct toothbrushing related procedures was more frequent in children who had a previous oral health appointment and whose parents had a higher education level.

The environmental impact of community caries prevention - part 2: toothbrushing programmes

Introduction Community-level caries prevention programmes includes supervised toothbrushing in schools and the provision of toothbrushes and toothpaste. The environmental impact of these interventions is an important factor to consider when commissioning these services.Materials and methods A comparative life cycle assessment (LCA) was conducted to quantify the environmental impact of a five-year-old child receiving one of two toothbrushing programmes over a one-year period; supervised toothbrushing in school, or the provision of toothbrushes and toothpaste.Results Supervised toothbrushing had a lower environmental impact than provision of toothbrushes and toothpaste in all 16 impact categories measured. The water use needed for children to brush their teeth was the greatest contributing factor to the provision of toothbrushes and toothpaste, accounting for an average of 48.65% of the impact results.Discussion All community-level caries prevention programmes have an associated environmental cost. LCA is one way to quantify the environmental impact of healthcare services and can be used along with cost and clinical effectives data to inform public healthcare policy. Organisations responsible for these programmes could use the results of this study to consider ways to reduce the environmental impact of their services.

Oral health status and practices of 6- to 7-year-old children in Amman, Jordan: a cross-sectional study

Background

Dental caries affects the majority of children in Jordan, with some evidence of its prevalence steadily increasing. Previous studies have shown that families struggle to establish good oral health practices. The aim of this study was to evaluate the current oral health status and practices of 6- to7-year-old children in Amman, Jordan.r

Methods

A cross-sectional cohort study. The sample consisted of 6- to 7-year-old children attending six randomly selected schools in Amman, Jordan. Measures collected were: I) Caries experience (d3mft/D3MFT), II) Oral hygiene, measured using the Simplified Oral Hygiene Index, III) Dietary, toothbrushing, and dental attendance practices, measured using diaries and parental questionnaires, IV) Participants’ basic characteristics: age, education and employment. Data were analysed using SPSS20.

Results

In total, 942 children were recruited. Four hundred and fifty-seven were boys, 485 were girls. Their average age was 6.5 years. Eighty-nine percent had decay in their primary teeth. Mean d3mft was 5.1(1 (range = 0–12, SD = 2.9). Only 8% of carious teeth were restored. Mean DMFT score was 0.3 (range = 0–4, SD = 0.8). Mean debris score was 1.07 (range = 0–3, SD = 0.37). Children indicated that they brush their teeth 1.6 times a day (range = 0–3, SD = 0.6). The majority (81%) were unsupervised. Sixty-seven percent of parents did not know the appropriate fluoride toothpaste concentration. Children were having 1.5 sugary snacks in-between their meals (Range = 1–6, SD = 1.1). They scored a mean of 2.5 (Range = 0–5.87, SD = 1.7) in sweetened drinks intake (recommended ≤ 1) and 2.8 (Range = 0–18.57, SD = 1.5) in non-core food intake (recommended ≤ 2) on a dietary questionnaire. Most parents (84%) indicated that their child attends the dentist only when in pain, and 18% indicated that their child is extremely afraid of dentists. Only 32% and 18% were familiar with fluoride varnish and fissure sealants, respectively. Regression analysis revealed that debris score and dental attendance were reliable predictors of caries experience.

Conclusions

Six- to seven-year-old children in Amman, Jordan have a high caries experience. Most show signs of poor oral hygiene, excessive intake of cariogenic foods, and symptomatic dental attendance. Their parents lack knowledge on fluoride varnish and fissure sealants. There is a need for oral health promotion tailored to this cohort's need.

A Video-Game-Based Oral Health Intervention in Primary Schools—A Randomised Controlled Trial

Background: Poor oral health practices and high levels of dental caries have been reported among children in the developing world. Video games have been successful in promoting oral health in children. The aim of this study was to assess the impact of an oral-health-education video game on children’s dietary knowledge and dietary and toothbrushing practices; Methods: Two Schools in Amman, Jordan were randomly selected and assigned to either intervention or control. Six- to eight-year old children took part. The intervention group played the oral-health-education video game; the control group received no intervention. The groups were compared in terms of changes in: child dietary knowledge, dietary and toothbrushing practices, plaque scores, and parental familiarity with preventive treatments. Data were submitted to statistical analysis with the significance level set at p ≤ 0.05. Results: Two hundred and seventy-eight children took part. Most (92%) had carious teeth. At baseline, children reported having more than one sugary snack a day and only 33% were brushing twice a day. Most parents were unaware of fluoride varnish (66%) or fissure sealants (81%). At follow-up, children in the intervention group had significantly better dietary knowledge, and parents in both groups became more familiar with fluoride varnish. There were no significant changes in children’s plaque scores, toothbrushing and dietary practices, or parental familiarity with fissure sealants in either group. Conclusions: Using an oral-health-education video game improved children’s dietary knowledge. However, future efforts should target children together with parents, and need to be supplemented by wider oral-health-promotion.

Economic Evaluation of the Protecting Teeth @ 3 Randomized Controlled Trial

INTRODUCTION

An economic evaluation (EE) was conducted alongside a randomized controlled trial (the Protecting Teeth @ 3 Study [PT@3]), exploring the additional preventive value of fluoride varnish (FV) application at 6-monthly intervals in nursery schools compared to treatment as usual (TAU) in the same nurseries. TAU represented a multicomponent national child oral health improvement intervention, the Childsmile program, apart from nursery FV.

METHODS

The EE was a within-trial cost-utility analysis (CUA) comparing the FV and TAU groups. The CUA was conducted from a National Health Service perspective and followed relevant methods guidance. Within-trial costs included intervention costs and health care resource use costs. Health outcomes were expressed in quality-adjusted life years (QALYs) accrued over the 2-y follow-up period. The Child Health Utility 9 Dimensions questionnaire was used to obtain utility scores. National reference costs were used, a discount rate of 1.5% for public health interventions was adopted, multiple imputation methods for missing data were employed, sensitivity analyses were conducted, and incremental cost-utility ratios were calculated.

RESULTS

Data from 534 participants from the 2014-2015 PT@3 intake were used in the EE analyses, n = 265 (50%) in the FV arm and n = 269 (50%) in the TAU arm. Mean incremental cost per child in the FV arm was £68.37 (P = 0.382; 95% confidence interval [CI], -£18.04 to £143.82). Mean incremental QALY was -0.004 (P = 0.636; 95% CI, -0.016 to 0.007). The probability that the FV intervention was cost-effective at the UK £20,000 threshold was 11.3%.

CONCLUSION

The results indicate that applying FV in nurseries in addition to TAU (all other components of Childsmile, apart from nursery FV) would not be deemed cost-effective given current UK thresholds. In view of previously proven clinical effectiveness and economic worthiness of the universal nursery toothbrushing component of Childsmile, continuation of the additional, targeted nursery FV component in its pre-COVID-19 form should be reviewed given its low probability of cost-effectiveness.

KNOWLEDGE TRANSFER STATEMENT

The results of this study can be used by child oral health policy makers and dental public health professionals. They can form part of the evidence to inform the Scottish, UK, and international guidance on community-based child oral health promotion programs.

The impact of the COVID-19 pandemic on oral health inequalities and access to oral healthcare in England

While the impact of the coronavirus disease (COVID-19) pandemic on health inequalities is documented, oral health has been absent from this discussion. This commentary highlights the potential impacts of the COVID-19 pandemic on oral health inequalities in England in February 2021. It includes a literature review, Public Health England and Kantar Worldpanel sales data on health behaviours and analysis of NHS dental services data. Purchasing data indicate, except for smoking, increases in health-compromising behaviours. Since the resumption of dental services, NHS general dental service use modestly recovered among adults but not children by October 2020. There are clear inequalities among children and older adults, with more deprived groups having lower uptake of dental service use than more affluent groups. Oral cancer referrals and hospital admissions for tooth extractions in children dramatically declined, with the latter primarily affecting children in more deprived areas. Many oral health programmes in schools and care homes were disrupted or suspended throughout this period. All these indicate that oral health inequalities have widened due to the COVID-19 pandemic. An oral health plan of action requires prioritising long-term investment in public health programmes and transforming commissioning pathways to support those with the greatest needs to access oral healthcare services.

People living in more deprived areas have fared worse than people living in less deprived areas, in terms of uptake of NHS primary dental care following the resumption of services in June 2020.

The cessation of oral health improvement programmes in the community and the dramatic decline of hospital dental services due to the COVID-19 pandemic have also primarily impacted the more socially disadvantaged groups, further widening inequalities.

Addressing the widened oral health inequalities requires long-term investment in oral health, prioritising public health programmes and supporting access to services.

Dental health of preschool children after two-years of a supervised tooth brushing program in Southern Israel

Background

Supervised tooth brushing is an important part of leading national oral health improvement programs in different countries.

With the cessation of water fluoridation in 2014, a new program was immediately required to provide community-based caries prevention, especially amongst young children.

The aim of this study was to determine whether a supervised tooth brushing program (STBP) in kindergartens could reduce dental caries amongst preschool children, when compared with children from the same community who did not participate in the program. The study was performed 2 years after the start of the program.

Methods

Two Jewish and two Arab local authorities (one participating and one control) were randomly chosen. In each local authority, 4 kindergartens (children aged 5) were randomly chosen, giving a total of 16 kindergartens. Children in the intervention group brushed once daily at kindergartens, with fluoridated toothpaste, for two school- years. All the children were examined using the WHO Oral Health Survey Methods Ed.4.

Results

Two hundred eighty-three five-year-old children were examined, 157 of them Jewish (86 participants in STBP, 71 non-participants) and 126 Arab (59 vs 67 respectively). Among Jewish children, the fraction of untreated decayed teeth was 61% in the participant group and 65% for non-participants, and amongst the Arab children 69% vs. 90% respectively. The fraction of treated decayed teeth for the participant group was 37% compared to 29% for the non-participants among Jewish children, whilst for the Bedouin group it was 23% vs. 8% respectively.

Conclusions

After 2 years, supervised tooth brushing with fluoride toothpaste shows a favorable effect. This study suggests that dental health of children participating in STBP was better than the control group. Fewer carious teeth and more treated carious lesions were recorded in this group. This program can be applied to low SES communities nationwide.

Guidelines for fluoride concentration in toothpaste for children should be re-considered based on high caries levels.

Association of oral hygiene practices with the outcome of untreated dental caries and its clinical consequences in pre- and primary school children: A cross-sectional study in a northern province of Saudi Arabia

Objectives

To assess the association amongst oral hygiene practices, untreated dental caries (UDC) and clinical consequences of UDC in pre‐ and primary school children aged 3–5 and 6–7 years.

Materials and methods

A total of 250 subjects were recruited. The demographic and oral hygiene data were collected using a closed‐ended questionnaire. The UDC was measured using the ‘d/D' component of the decayed, missing, filled teeth (dmft/DMFT) index, and its clinical consequences were recorded using the ‘p/P' component of the pulpal involvement, ulceration, fistula and abscess (pufa/PUFA) index. The data were analyzed by multiple logistic regression.

Results

Overall, 94.2% and 56.5% of the participants had one or more UDC and pulp involvement (p ≥ 1), respectively in 3–5‐year‐old age group. In the 6‐7‐year‐ age group the prevalence of UDC was 26.7% and the pulp involvement was 11.6%. Children who brushed with their fingers were 4.7 times more likely to have UDC (crude odds ratio [COR] = 4.71; 95% CI: 1.21–18.40). Twice‐daily brushing resulted in a 39% (p = 0.732) lower likelihood of having UDC compared with once‐daily brushing (COR = 0.61; 95% CI: 0.04, 10.09). Children with irregular brushing frequency were 3.2 times more likely to have pulpal involvement (COR = 3.21; 95% CI: 1.74–5.93).

Conclusion

Finger brushing, irregular frequency of brushing and lack of parental supervision whilst brushing were associated with UDC and its consequences.

Prevalence of dental caries and associated factors among school-aged children in Tripoli, Libya: a cross-sectional study

Background

In many developing countries, the prevalence of dental caries has increased due to lifestyle changes, lack of preventive services, and inadequate access to dental care. In Arab countries, the increased prevalence of caries has correlated with economic growth over the past decades, resulting in greater access to unhealthy foods and higher consumption of sugar, particularly among children. However, few studies have assessed caries prevalence among pediatric populations in Arab countries. The objective of this study was to assess the prevalence of dental caries and factors associated with caries among children in Tripoli, Libya.

Methods

This cross-sectional study included a convenience sample of 1934 children in first grade (age 6–7 years, n = 1000) and seventh grade (age 11–12 years, n = 934). Four health centers in Tripoli were selected for screening based on location and participation in school-entry health examinations. Data were collected through self-administered parent surveys and visual dental screenings by trained examiners from September 24 to October 15, 2019. The survey comprised questions about socioeconomic characteristics and oral health behaviors, including toothbrushing, sugar consumption, and dental care history. During screenings, untreated decay, missing teeth, and filled teeth (DMFT or dmft) were recorded. Prevalence of tooth decay was calculated as the proportion of children with high DMFT/dmft scores. Binary logistic and negative binomial regression analyses (with significance at p ≤ 0.05) were used to assess factors associated with caries.

Results

Among 1000 first-grade children, 78.0% had decay in their primary teeth, with a mean dmft of 3.7. Among 934 seventh-grade children, 48.2% had caries in their permanent teeth, with a mean DMFT of 1.7. The most significant factors associated with caries prevalence were socioeconomic, such as screening site (first grade, p = 0.02; seventh grade, p < 0.001) and maternal employment (seventh grade, p = 0.02), and behavioral, such as toothbrushing duration (seventh grade, p = 0.01), past dental treatment (both grades, p < 0.001), and past emergency visit (both grades, p < 0.001).

Conclusions

Caries prevalence was associated with several behavioral and socioeconomic factors, including screening site, maternal employment, toothbrushing duration, past dental treatment, and past emergency visit. Efforts should be made to address these factors to minimize barriers and improve oral health behavior and care utilization. These findings can be used to evaluate current public health initiatives and inform future planning.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-01545-9.

Evaluation of a national complex oral health improvement programme: a population data linkage cohort study in Scotland

OBJECTIVES

Child dental caries is a global public health challenge with high prevalence and wide inequalities. A complex public health programme (Childsmile) was established. We aimed to evaluate the reach of the programme and its impact on child oral health.

SETTING

Education, health and community settings, Scotland-wide.

INTERVENTIONS

Childsmile (national oral health improvement programme) interventions: nursery-based fluoride varnish applications (FVAs) and supervised daily toothbrushing, community-based Dental Health Support Worker (DHSW) contacts and primary care dental practice visits-delivered to the population via a proportionate universal approach.

PARTICIPANTS

50 379 children (mean age=5.5 years, SD=0.3) attending local authority schools (2014/2015).

DESIGN

Population-based individual child-level data on four Childsmile interventions linked to dental inspection survey data to form a longitudinal cohort. Logistic regression assessed intervention reach and the independent impact of each intervention on caries experience, adjusting for age, sex and area-based Scottish Index of Multiple Deprivation (SIMD).

OUTCOME MEASURES

Reach of the programme is defined as the percentage of children receiving each intervention at least once by SIMD fifth. Obvious dental caries experience (presence/absence) is defined as the presence of decay (into dentine), missing (extracted) due to decay or filled deciduous teeth.

RESULTS

15 032 (29.8%) children had caries experience. The universal interventions had high population reach: nursery toothbrushing (89.1%), dental practice visits (70.5%). The targeted interventions strongly favoured children from the most deprived areas: DHSW contacts (SIMD 1: 29.5% vs SIMD 5: 7.7%), nursery FVAs (SIMD 1: 75.2% vs SIMD 5: 23.2%). Odds of caries experience were markedly lower among children participating in nursery toothbrushing (>3 years, adjusted OR (aOR)=0.60; 95% CI 0.55 to 0.66) and attending dental practice (≥6 visits, aOR=0.55; 95% CI 0.50 to 0.61). The findings were less clear for DHSW contacts. Nursery FVAs were not independently associated with caries experience.

CONCLUSIONS

The universal interventions, nursery toothbrushing and regular dental practice visits were independently and most strongly associated with reduced odds of caries experience in the cohort, with nursery toothbrushing having the greatest impact among children in areas of high deprivation.

Fluoride Varnish in Nursery Schools: A Randomised Controlled Trial – Protecting Teeth @3

Studies suggest that fluoride varnish (FV) application can reduce dental caries in child populations. The multiple-component national child oral health improvement programme in Scotland (Childsmile) includes nursery-based universal supervised toothbrushing and deprivation-targeted FV applications, together with community and dental practice prevention interventions. This trial, a double-blind, two-arm randomised control trial, aimed to assess the effectiveness and cost-effectiveness of the nursery-based FV applications plus treatment-as-usual (TAU) Childsmile programme interventions, compared to TAU Childsmile interventions alone, in children not targeted to receive nursery FV as part of the programme. Participating children in the first year of nursery (aged three), with or without existing caries, were randomised to either FV or TAU and followed up for 24 months until the first year of primary school. Treatments were administered at six-monthly intervals. The primary endpoint was “worsening of d3mft” from baseline to 24 months. Secondary endpoints were worsening of d3mfs, d3t, mt, and ft. Individual record-linkage captured wider programme activities and tertiary endpoints. A total of 1,284 children were randomised, leading to 1,150 evaluable children (n = 577 FV, n = 573 TAU, 10% dropouts). Mean age was 3.5 years, 50% were female (n = 576), 17% had caries at baseline (n = 195), all balanced between the groups. Most children received three/four treatments. Overall, 26.9% (n = 155) had worsened d3mft in the FV group, and 31.6% (n = 181) in the TAU group, with an odds ratio (OR) of 0.80 (0.62–1.03), p = 0.078. The results for worsening of the secondary endpoints were: d3mfs 0.79 (0.61–1.01) p = 0.063, d3t 0.75 (0.57–0.99) p = 0.043, mt 1.34 (0.75–2.39) p = 0.319, and ft 0.77 (0.53–1.14) p = 0.191. We calculated a number needed to treat of 21 and a cost of GBP 686 to prevent a single worsening of d3mft. There was a modest non-significant reduction in the worsening of d3mft in the nursery FV group compared to TAU, suggesting that this intervention is unlikely to represent an effective or cost-effective addition to the population oral health improvement programme.

The impact of a school-based tooth-brushing program on dental caries: a cross-sectional study

Background

Promotion of oral health in children is recognized as one of the components of health-promoting schools (HPSs). However, few studies have addressed supportive school environments for children’s oral health. This study aimed to evaluate the status of dental caries in school children at HPSs, with the objective of examining the impact of a supportive school environment for oral health, considering the lifestyles of individual children and the socioeconomic characteristics of their communities.

Methods

Data of 2043 5th-grade students in 21 elementary schools in Ichikawa city between 2008 and 2013 were analyzed. Children’s oral health status was evaluated using the decayed, missing, and filled permanent teeth (DMFT) index. A self-reported lifestyle questionnaire, a survey of the school environment promoting tooth-brushing, and community socioeconomic characteristics derived from the National Census data were included in the analyses. Bivariate analyses were conducted to evaluate the children’s DMFT status, and zero-inflated negative binominal (ZINB) regression was used to assess the relationships between DMFT and other variables.

Results

Prevalence of dental caries in the permanent teeth of 5th-grade children (aged 10–11 years) was 33.3%, with a mean DMFT score (± SD) of 0.83 ± 1.50. According to multilevel ZINB regression analysis, children from schools with after-lunch tooth-brushing time showed a higher odds ratio (OR) for excess zero DMFT (OR = 1.47, 95% CI = 1.00–2.15, P = 0.049) as compared to those from schools without it. Neither bivariate analysis nor ZINB model analysis revealed any significant influence of children’s gender or use of a toothpaste with fluoride.

Conclusions

The school-based environment supportive of oral health was significantly associated with a zero DMFT status in children. School-based efforts considering the socioeconomic characteristics of the area warrant attention even with declining prevalence of dental caries.

Structural equation modelling for associated factors with dental caries among 3-5-year-old children: a cross-sectional study

Background

The aim of the current study was to explore the factors influencing dental caries among 3–5-year-old children in Sichuan Province and the interrelationship between these factors using structural equation modelling (SEM).

Methods

A cross-sectional study was conducted among 2746 3–5-year-old children in Sichuan Province. Examination of caries was conducted on all children and a questionnaire was answered by the children’s caregiver. SEM alternative models were constructed to interpret the intricate relationships between socio-economic status (SES), caregiver’s oral health knowledge, attitudes, children’s oral health behaviours and children’s dental caries.

Result

The results showed that dental caries were significantly associated with dietary behaviours (β = 0.11, SE = 0.03, P = 0.001, BC 95% CI =0.05/0.18) and SES (β = − 0.17, SE = 0.03, P<0.001, BC 95% CI = -0.23/− 0.10) directly, While the indirect effect of SES on dmft is in an opposite direction (β = 0.08, SE = 0.02, BC 95% CI = 0.04/0.12).

Conclusion

We found that unhealthy dietary behaviours increased the prevalence of dental caries. However, oral health knowledge and attitude failed to affect dietary behaviour in this model. This result warns that oral health education should strengthen feeding-related knowledge. Meanwhile, it also reminds that it is easier known than done. Future oral health education should focus on exploring a more effective way for the public to turn knowledge into action.

Economic evaluation of an expanded caries-preventive program targeting toddlers in high-risk areas in Sweden

OBJECTIVE

To economically evaluate a caries-preventive program "Stop Caries Stockholm" (SCS) where a standard program is supplemented with biannual applications of fluoride varnish in toddlers and compared it with the standard preventive program.

MATERIAL AND METHODS

Data from the cluster randomized controlled field trial SCS including 3403 children, conducted in multicultural areas with low socioeconomic status was used. The difference in mean caries increment between the examinations; when the toddlers were 1 and 3 years old, was outcome measure of the intervention. The program was evaluated from a societal as well as a dental health care perspective. The incremental cost-effectiveness ratio (ICER) was calculated as the incremental cost for each defs prevented.

RESULTS

Average dental health care costs per child at age 3 years were EUR 95.77 for the supplemental intervention and EUR 70.52 for the standard intervention. The ICER was EUR 280.56 from a dental health care perspective and EUR 468.67 and considered high.

CONCLUSIONS

The supplemental caries intervention program was not found to be cost-effective. The program raised costs without significantly reducing caries development. A better alternative use of the resources is recommended.

TRIAL REGISTRATION

www.controlled-trials.com (ISRCTN35086887).

Toothbrushing behavior in children - an observational study of toothbrushing performance in 12 year olds

Background

Many countries offer systematic group prevention programs in kindergarten and school in order to promote children’s oral health. Little is known, however, about the actual toothbrushing abilities of children when group prevention programs end.

Methods

In Germany, all children take advantage from a nationwide group prevention program (called “Gruppenprophylaxe”) lasting from kindergarten up to sixth grade (12 years of age). Standardized recommendations are given concerning brushing systematics and brushing movements. N = 174 children at the age of 12 were thus randomly selected from two German towns and were asked to perform toothbrushing to the best of their abilities in front of a mirror which also served as a camera. Brushing behavior was analyzed by video analysis.

Results

Children brushed their teeth for an average of 200 s ± 80.48 s (mean ± SD). Still, more than 55% missed at least one sextant when brushing inner surfaces, 16% missed them all. Only 7.5% of the children brushed both inner and outer surfaces by the intended movements (vertical movements on the inner surfaces and circular movements on the outer surfaces) for at least 90% of the respective brushing time. Instead, horizontal brushing was very common on the lateral surfaces.

Conclusions

The present analysis indicates that children have low efficiency to adopt the tooth-brushing recommendations given in prevention programs. This is surprising as great endeavors are made to help children internalize the recommendations. Future research is needed to better understand which factors impede adoption of toothbrushing recommendations in children and which efforts are necessary to improve their toothbrushing abilities.

Electronic supplementary material

The online version of this article (10.1186/s12903-019-0755-z) contains supplementary material, which is available to authorized users.

Family-centred oral health promotion through Victorian child-health services: a pilot

Maternal and Child Health Services (MCHS) provide ideal settings for oral disease prevention. In Victoria (Australia), child mouth-checks (Lift-the-Lip) and oral health promotion (OHP) occur during MCHS child visits. This study trialled Tooth-Packs (OHP resources, toothbrushes, toothpastes) distribution within MCHS to (i) assess the impacts of Tooth-Packs distribution on child and family oral health (OH) behaviours and knowledge, including Maternal and Child Health Nurses (MCHN) child referral practices to dental services, and (ii) determine the feasibility and acceptability of incorporating Tooth-Packs distribution into MCHN OHP practices. A mixed-methods evaluation design was employed. MCHN from four high-needs Victorian Local Government Areas distributed Tooth-Packs to families of children attending 18-month and/or 24-month MCHS visits (baseline). Families completed a questionnaire on OH and dietary practices at baseline and 30-month follow-up. Tooth-Packs distribution, Lift-the-lip mouth-checks and child OH referrals were conducted. Guided discussions with MCHN examined intervention feasibility. Overall, 1585 families received Tooth-Packs. Lift-the-lip was conducted on 1493 children (94.1%). Early childhood caries were identified in 142 children (9.5%) and these children were referred to dental services. Baseline to follow-up behavioural improvements (n = 230) included: increased odds of children having ever seen an OH professional (OR 28.0; 95% CI 7.40–236.88; p &lt; 0.001), parent assisted toothbrushing twice/day (OR 1.76; 95% CI 1.05–3.00; p = 0.030) and toothpaste use &gt;once/day (OR 2.82; 95% CI 1.59–5.24; p &lt; 0.001). MCHN recommendations included distribution of Tooth-Packs to at-risk children &lt;12-months of age. MCHS provide an ideal setting to enable timely family-centred OHP intervention and adoption of good OH behaviours at an early age.

Early childhood caries among 3- to 5-year-old children in Hong Kong

OBJECTIVE

The aim of this study was to describe the prevalence of dental caries among 3- to 5-year-old children in Hong Kong and to investigate the factors associated with their dental caries status.

METHODS

Seven kindergartens in Hong Kong were selected using stratified random sampling. The 3- to 5-year-old kindergarten children were invited to join the study. The participants' parents were asked to complete a questionnaire regarding their children's demographic and socio-economic backgrounds, their dental habits and their own dental knowledge. Dental caries experience was measured using the decayed, missing and filled primary teeth (dmft) index. The visible plaque index was adopted for recording oral hygiene. The relationships between caries experience and children's demographic backgrounds, dental habits, oral hygiene and parental dental knowledge were studied using a zero-inflated negative binomial (ZINB) regression analysis.

RESULTS

Among the 1,204 participating preschool children, the overall prevalence of dental caries (dmft > 0) was 46%. The mean dmft score was 2.1 ± 3.4. The prevalences of dental caries among the 3-, 4- and 5-year-old children were 38%, 43% and 55%, respectively. ZINB regression analysis revealed that the study children who were boys, came from families with lower incomes, had dental visit experiences, had higher plaque scores and had parents with lower levels of dental knowledge, had higher dmft scores (P < 0.05).

CONCLUSIONS

Dental caries is prevalent among preschool children in Hong Kong. The caries experiences of the study children are associated with gender, family income, parental dental knowledge, dental visit experience and oral hygiene.

The effect of introducing a financial incentive to promote application of fluoride varnish in dental practice in Scotland: a natural experiment

BACKGROUND

Financial incentives are often used to influence professional practice, yet the factors which influence their effectiveness and their behavioural mechanisms are not fully understood. In keeping with clinical guidelines, Childsmile (Scotland's oral health improvement programme) advocates twice yearly fluoride varnish application (FVA) for children in dental practice. To support implementation Childsmile offered dental practitioners a fee-per-item payment for varnishing 2-5-year-olds' teeth through a pilot. In October 2011 payment was extended to all dental practitioners. This paper compares FVA pre- and post-roll-out and explores the financial incentive's behavioural mechanisms.

METHODS

A natural experimental approach using a longitudinal cohort of dental practitioners (n = 1090) compared FVA pre- (time 1) and post- (time 2) financial incentive. Responses from practitioners who did not work in a Childsmile pilot practice when considering their 2-5-year-old patients (novel incentive group) were compared with all other responses (continuous incentive group). The Theoretical Domains Framework (TDF) was used to measure change in behavioural mechanisms associated with the incentive. Analysis of covariance was used to investigate FVA rates and associated behavioural mechanisms in the two groups.

RESULTS

At time 2, 709 74%, of eligible responders, were followed up. In general, FVA rates increased over time for both groups; however, the novel incentive group experienced a greater increase (β [95% CI] = 0.82 [0.72 to 0.92]) than the continuous incentive group. Despite this, only 33% of practitioners reported 'always' varnishing increased risk 2-5-year-olds' teeth following introduction of the financial incentive, 19% for standard risk children. Domain scores at time 2 (adjusting for time 1) increased more for the novel incentive group (compared to the continuous incentive group) for five domains: knowledge, social/professional role and identity, beliefs about consequences, social influences and emotion.

CONCLUSIONS

In this large, prospective, population-wide study, a financial incentive moderately increased FVA in dental practice. Novel longitudinal use of a validated theoretical framework to understand behavioural mechanisms suggested that financial incentives operate through complex inter-linked belief systems. While financial incentives are useful in narrowing the gap between clinical guidelines and FVA, multiple intervention approaches are required.

A systems approach using the functional resonance analysis method to support fluoride varnish application for children attending general dental practice

BACKGROUND

All children attending General Dental Practice in Scotland are recommended to receive twice-yearly applications of sodium fluoride varnish to prevent childhood caries, yet application is variable. Development of complex interventions requires theorizing and modelling to understand context. This study applies the Functional Resonance Analysis Method (FRAM) to produce a sociotechnical systems model and identify opportunities for intervention to support application.

METHODS

The FRAM was used to synthesise data which were: routine monitoring of fluoride varnish application in 2015/16; a longitudinal survey with practitioners (n = 1090); in-depth practitioner and key informant interviews (n = 43); and a 'world café' workshop (n = 56).

RESULTS

We describe a detailed model of functions linked to application, and use this to make recommendations for system-wide intervention.

CONCLUSIONS

Rigorous research is required to produce accessible models of complex systems in healthcare. This novel paper shows how careful articulation of the functions associated with fluoride varnish application can support future improvement efforts.

Effectiveness of an oral health intervention program for children with congenital heart defects

Background

Children with congenital heart defects (CHD) are reported to have poorer oral health compared with healthy children. The aim of the present study was to evaluate the effectiveness of an intensive oral health care program among children with CHD followed from infancy to the age of 5 years, by comparing their oral health status at 5 years with a control group of children with CHD who had not received the program.

Methods

In this longitudinal study, children in western Norway with a need for lifelong follow-up due to congenital heart defects were invited to participate (n = 119). Children born in 2008–2011 were offered an oral health intervention program from infancy to the age of 5 years. The outcome measures for evaluating the intervention were dental caries prevalence, dental erosion, plaque index and gingival bleeding index. The data of the intervention group were compared with cross sectional oral health data of 5 year old controls with CHD born 2005–2007 (already published).

Results

Early oral health intervention did not affect the prevalence of caries (25.3% versus 25.4%) or dental erosion (22.2% versus 19.7%) of children with CHD assessed at 5 years. Children in the intervention group were less likely than those in the control group to present with both dental plaque and gingival bleeding at age 5 years. In spite of no difference in caries prevalence between the groups, caries affected children (d_1-5mft) in the intervention group had fewer teeth affected by caries than children in the control group (p = 0.06). The care index was reported to be higher in the intervention group compared with the control group, implying that fewer children in the intervention group suffered from untreated dentine caries. Parents in the intervention group were more likely to brush their children’s teeth twice a day than parents of children in the control group.

Conclusion

The oral health promotive program did not influence the prevalence of caries nor dental erosion. However, the findings indicated better oral hygiene, reduced gingival bleeding and less untreated dentine caries in the intervention compared with the control group.

Trial registration

ClinicalTrials.gov NCT03311438. Registration date: October 17th 2017, retrospectively registered.

Electronic supplementary material

The online version of this article (10.1186/s12903-018-0495-5) contains supplementary material, which is available to authorized users.

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.

Caries experience of children in primary schools with long-term tooth brushing programs: A pilot Australian study

OBJECTIVE

The aim of this study was to evaluate a primary school-based tooth brushing (TB) program conducted in a low socio-economic area of Queensland, Australia, to determine its effectiveness in reducing caries.

METHODS

Records kept at the central dental clinic of the district were used to analyse the caries experience (decayed, missing, filled teeth [dmft/DMFT]) and caries prevalence in children from two schools with long-term TB programs (TB) (N=1191) and three Non-TB schools (N=553). The schools were matched by socio-economic indices.

RESULTS

Historical records showed that the baseline caries experience in all TB and Non-TB primary schools were similar at each primary school year. After a mean period of 5-9 years of the TB program, the caries experience (mean decayed, missing, filled teeth, dmft/DMFT) and prevalence were lower for TB group than Non-TB group. In the primary dentition, the overall mean dmft (±standard deviation) of TB group (2.53±3.00) was significantly lower than the Non-TB group (3.06±3.30) (P<.001). Similarly, in the permanent dentition, the overall mean DMFT of TB group (0.47±1.05) was reduced significantly compared to the Non-TB group (1.15±1.72) (P<.001). The overall caries prevalence in the TB group was 68% compared to 78% in Non-TB (P<.001). Overall, the mean annual DMFT increments of children in the TB schools were also significantly less compared with children in the Non-TB schools (P<.001).

CONCLUSION

A long-term primary school TB program significantly reduced caries experience and caries prevalence in an optimally fluoridated (1-ppm), very low socio-economic district.

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.

Using intervention mapping to develop a home-based parental-supervised toothbrushing intervention for young children

BACKGROUND

Dental caries in young children is a major public health problem impacting on the child and their family in terms of pain, infection and substantial financial burden on healthcare funders. In the UK, national guidance on the prevention of dental caries advises parents to supervise their child's brushing with fluoride toothpaste until age 7. However, there is a dearth of evidence-based interventions to encourage this practice in parents. The current study used intervention mapping (IM) to develop a home-based parental-supervised toothbrushing intervention to reduce dental caries in young children.

METHODS

The intervention was developed using the six key stages of the IM protocol: (1) needs assessment, including a systematic review, qualitative interviews, and meetings with a multi-disciplinary intervention development group; (2) identification of outcomes and change objectives following identification of the barriers to parental-supervised toothbrushing (PSB), mapped alongside psychological determinants outlined in the Theoretical Domains Framework (TDF); (3) selection of methods and practical strategies; (4) production of a programme plan; (5) adoption and implementation and (6) Evaluation.

RESULTS

The comprehensive needs assessment highlighted key barriers to PSB, such as knowledge, skills, self-efficacy, routine setting and behaviour regulation and underlined the importance of individual, social and structural influences. Parenting skills (routine setting and the ability to manage the behaviour of a reluctant child) were emphasised as critical to the success of PSB. The multi-disciplinary intervention development group highlighted the need for both universal and targeted programmes, which could be implemented within current provision. Two intervention pathways were developed: a lower cost universal pathway utilising an existing national programme and an intensive targeted programme delivered via existing parenting programmes. A training manual was created to accompany each intervention to ensure knowledge and standardise implementation procedures.

CONCLUSIONS

PSB is a complex behaviour and requires intervention across individual, social and structural levels. IM, although a time-consuming process, allowed us to capture this complexity and allowed us to develop two community-based intervention pathways covering both universal and targeted approaches, which can be integrated into current provision. Further research is needed to evaluate the acceptability and sustainability of these interventions.

EFFECTIVE CARIES PREVENTION IN A HEBRIDEAN ISLAND POPULATION

BACKGROUND

The Isle of Islay has a remote-rural population. Two dentists have been responsible for the care of the majority of the school-age children for 15 years. The island affords a unique situation to measure caries prevalence in a relatively static population.

AIM

This study measures the changes in the dental caries experience of five and 12-year olds exposed to a preventive-based approach to improving dental health, which included a school-based tooth-brushing programme (four to 12-year-olds).

DESIGN

Data from practice-based records were collected for children aged five and 12 in the years 1999-2003 and 2012-2014. Indices including percentage of children with no obvious caries, decayed, missing or filled teeth (dmft/DMFT) and care indexes were calculated, translated into graphs and compared to Scotland's National Dental Inspection Programme (NDIP) data.

RESULTS

478 children were included in the study. The mean number in each year group for five-year-olds was 28 (SD ± 5.65) and for 12-year-olds was 31.75 (SD ± 8.30). The percentage of children caries-free increased from 39% to 85% (five-year-olds) and 31% to 97% (12-year-olds). DMFT decreased from 3.04 to 0.30 (five-year-olds) and 3.74 to 0.03 (12-year-olds). Figures for care index and percentage of first permanent molars fissure sealed were higher than national data averages.

CONCLUSION

Caries prevalence decreased in children in Islay aged five and 12 years over the period 1999-2014. There was no control group but the differences described above can be associated with the introduction of a preventive approach, however they cannot be assumed to be causative.

Fluoride stability in dentifrices stored in schools in a town of northern Brazil

The aim of this study was to analyze fluoride stability in dentifrices stored during nine months in schools from Careiro da Várzea, State of Amazonas, Brazil. Analysis of total fluoride concentration, total soluble fluoride, and ionic fluoride in the dentifrice samples was performed in four different time periods: at the time of purchase (baseline); after three months, after six months, and after nine months of storage. Fluoride concentration was determined using a specific electrode (Orion 96-09) connected to an ion analyzer (Orion A-720) and calibrated with fluoride standard solutions containing 2.0 to 32.0 ppm F. The results obtained during the measurements were analyzed by analysis of variance (one-way ANOVA), followed by Tukey's test for comparison of the means. After nine months of storage, total soluble fluoride, the active form of fluoride, decreased by 21.9%. As total soluble fluoride was below the minimum required for anticaries efficacy (1,000 ppm F) in the fourth analysis, it may be concluded that anticaries potential decreased with storage time.

The effect of motivational interviewing on oral healthcare knowledge, attitudes and behaviour of parents and caregivers of preschool children: an exploratory cluster randomised controlled study

Background

Motivational Interviewing (MI) has been used across primary healthcare and been shown to be effective in reducing the prevalence of early childhood caries (ECC) in preschool children. This study aimed to compare the effect of MI, in contrast to traditional dental health education (DHE), on oral health knowledge, attitudes, beliefs and behaviours among parents and caregivers of preschool children in Trinidad.

Method

The design of this exploratory study included a cluster randomised controlled trial and semi-structured focus groups. Six preschools (79 parents and caregivers) in Eastern Trinidad were randomly assigned to a test or control group (3 preschools in each group). Parents and caregivers in the test-group (n = 25) received a talk on dental health using an MI approach and the control-group (n = 54) received a talk using traditional DHE. Both groups received additional, written dental health information. The MI group also received two telephone call follow-ups as part of the MI protocol. Both groups were given questionnaires before the talks and four months later. Question items included oral health knowledge, beliefs, attitudes, brushing behaviour, oral health self-efficacy, oral health fatalism and a specific instrument to asses ‘readiness for change’, the Readiness Assessment of Parents Concerning Infant Dental Decay (RAPIDD). Participants in the test-group were also invited to take part in a focus group to share their views on the dental health talk.

Results

At four month follow-up, knowledge items on fluoride use, tooth brushing, dietary practice and dental attendance increased in both the test (DHE + MI) and control (DHE) groups ((p < 0.05, Chi Square test). In the test-group there were increases in mean child tooth brushing frequency and reduction in oral health fatalism (p < 0.05 t-test). Findings from a thematic analysis of the focus group suggested that the MI talk and telephone follow-up were well accepted and helpful in supporting parent and caregiver efforts to improve oral health practices for their preschool children.

Conclusion

In this exploratory controlled study there was some evidence that using an MI approach when delivering oral health information had a positive effect on parent/ caregiver oral health knowledge, attitudes and behaviours compared to traditional DHE. There is need for further research involving the use of brief-counselling techniques in this Caribbean population.

Improving Child Oral Health: Cost Analysis of a National Nursery Toothbrushing Programme

Dental caries is one of the most common diseases of childhood. The aim of this study was to compare the cost of providing the Scotland-wide nursery toothbrushing programme with associated National Health Service (NHS) cost savings from improvements in the dental health of five-year-old children: through avoided dental extractions, fillings and potential treatments for decay.

Elimination of 'the Glasgow effect' in levels of dental caries in Scotland's five-year-old children: 10 cross-sectional surveys (1994-2012)

BACKGROUND

Socioeconomic inequalities in health within Glasgow, Scotland, are among the widest in the world. This is largely attributed to socio-economic conditions. The 'Glasgow Effect' labels the finding that the high prevalence of some diseases cannot be fully explained by a conventional area-based socio-economic metric. This study aimed to investigate whether differences in dental caries between Glasgow's resident children and those in the Rest of Scotland could be explained by this metric and whether differences were of fixed magnitude, over time.

METHODS

Scotland's National Dental Inspection Programme (NDIP) cross-sectional data for five-year-old children in years: 1994, 1996, 1998, 2000, 2003, 2004, 2006, 2008, 2010, and 2012 (n = 92,564) were utilised. Endpoints were calculated from the mean decayed, missing and filled teeth score (d3mft) and percentage with obvious decay experience. Socioeconomic status was measured by DepCat, a Scottish area-based index. The Glasgow Effect was estimated by the odds-ratio (OR) of decay for Glasgow versus the Rest of Scotland adjusted by age, gender and DepCat. Inequalities were also assessed by the Significant Caries Index (SIC), SIC 10, and Scottish Caries Inequality Metric (SCIM 10).

RESULTS

Decay levels for deprived Glasgow children have reduced to be similar to those in the Rest of Scotland. In 1993, OR for d3mft > 0 for those living in the Glasgow area was 1.34(1.10, 1.64), p = 0.005. This reduced below unity in 2012, OR = 0.85(0.77, 0.93), p < 0.001. There were downward trends (p < 0.001) in absolute inequality measured by SIC and SIC 10 in each of the geographic areas. The SCIM 10 demonstrated further reductions in inequality across the population. The downward trends for all the inequality measures were larger for Glasgow than the Rest of Scotland.

CONCLUSIONS

Over the interval, Glasgow has eliminated the earlier extra health inequalities. When comparing 'like for like' by socioeconomic status there is now no higher level of dental caries in the Greater Glasgow area.