Internet-Based Cognitive Behavioral Therapy for Children and Adolescents With Dental or Injection Phobia: Randomized Controlled Trial

BACKGROUND

Dental phobia (DP) and injection phobia (IP) are common in children and adolescents and are considered some of the biggest obstacles to successful treatment in pediatric dentistry. Cognitive behavioral therapy (CBT) is an evidence-based treatment for anxiety and phobias. As the availability of CBT in dentistry is low, internet-based CBT (ICBT) was developed. Open trials have shown that ICBT is a promising intervention, but randomized trials are lacking.

OBJECTIVE

This randomized controlled trial tests whether therapist-guided ICBT supported by a parent could reduce fear, allowing children and adolescents with DP or IP to receive dental treatment.

METHODS

We enrolled 33 participants (mean age 11.2, SD 1.9 y) whom a clinical psychologist had diagnosed with DP, IP, or both. After inclusion, participants were randomized to either ICBT (17/33, 52%) or a control group of children on a waitlist (16/33, 48%). ICBT was based on exposure therapy and comprised a 12-week at-home program combined with visits to their regular dental clinic. Participants corresponded weekly with their therapist after completing each module, and 1 parent was designated as a coach to support the child in the assignments during treatment. All participants completed measurements of the outcome variables before treatment start and after 12 weeks (at treatment completion). The measurements included a structured diagnostic interview with a clinical psychologist. Our primary outcome measure was the Picture-Guided Behavioral Avoidance Test (PG-BAT), which assesses the ability to approach 17 dental clinical procedures, and a positive clinical diagnosis. Secondary outcome measures included self-report questionnaires that measured self-efficacy and levels of dental and injection anxiety. The children and their parents completed the questionnaires.

RESULTS

All participants underwent the 12-week follow-up. After treatment, 41% (7/17) of the participants in the ICBT group no longer met the diagnostic criteria for DP or IP, whereas all participants in the control group did (P=.004). Repeated-measure ANOVAs showed that ICBT led to greater improvements on the PG-BAT compared with the control group; between-group effect sizes for the Cohen d were 1.6 (P<.001) for the child-rated PG-BAT and 1.0 (P=.009) for the parent-rated PG-BAT. Reductions in our secondary outcomes-dental fear and anxiety (P<.001), negative cognitions (P=.001), and injection fear (P=.011)-as well as improvements in self-efficacy (P<.001), were all significantly greater among children in the ICBT group than in the controls. No participants reported adverse events.

CONCLUSIONS

ICBT seems to be an effective treatment for DP and IP in children and adolescents. It reduced fear and anxiety and enabled participants to willingly receive dental treatment. ICBT should be seriously considered in clinical practice to increase accessibility; this therapy may reduce the need for sedation and restraint and lead to better dental health in children and adolescents.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02588079; https://clinicaltrials.gov/study/NCT02588079.

Late Complications in Long-Term Childhood Cancer Survivors: What the Oral Health Professional Needs to Know

With diagnostic and therapeutic advances, over 80% of children diagnosed with cancer become long-term survivors. As the number of childhood cancer survivors (CCS) continues to increase, dental practitioners become more likely to have CCS among their patients. CCS may develop late complications from damage caused by their cancer treatment to endocrine, cardiovascular, musculoskeletal, and other organ systems. These complications may surface decades after the completion of treatment. Adverse outcomes of childhood cancer treatment frequently involve oral and craniofacial structures including the dentition. Tooth development, salivary gland function, craniofacial growth, and temporomandibular joint function may be disturbed, increasing oral health risks in these individuals. Moreover, CCS are at risk of developing subsequent malignancies, which may manifest in or near the oral cavity. It is important that dental practitioners are aware of the childhood cancer history of their patients and have knowledge of potential late complications. Therefore, this narrative review aims to inform dental practitioners of late oral complications of cancer treatment modalities commonly used in pediatric oncology. Furthermore, selected common non-oral late sequelae of cancer therapy that could have an impact on oral health and on delivering dental care will be discussed.

Prevalence and stability of blood-injection-injury phobia in childhood-A prospective community study in Norway

AIM

An individual with a blood-injection-injury (BII) phobia often avoids exposure to triggers, such as blood tests and clinic appointments, leading to potentially serious health complications. This population-based study examined the prevalence, stability and course of BII phobia in children and adolescents.

METHODS

The data came from the Trondheim Early Secure Study, conducted from 2007 to 2018. All children born in Trondheim, Norway, in 2003 and 2004 were invited to attend. Clinical interviews were conducted by trained personnel to assess BII phobia in 1042 children (51% female) every 2 years from 4 to 14 years of age. Latent growth curves and logistic regression analyses were used in the data analysis.

RESULTS

Just under 20% of the cohort experienced a BII phobia at least once, with no significant sex differences. The prevalence of BII phobias increased from 3% at 4 years of age and peaked at about 8% at 10 years of age, before levelling off. The two-year stability increased as 12-14 years of age approached.

CONCLUSION

The prevalence of BII was affected by age, but not sex. Early BII phobias often recede with time, but children may need treatment if they persist from 8 years of age.

Dental professionals' views on motivational interviewing for the prevention of dental caries with adolescents in central Norway

BACKGROUND

Establishing positive oral health behaviours during adolescence should be a key priority to improve lifelong oral health. However, changing adolescent behaviours is known to be a challenge. Motivational interviewing (MI) is a method of working with patients to activate their motivation for change and has shown promising results within the dental setting. Yet, little is known about the actual experiences and perspectives of Norwegian dental health professionals in delivering motivational interviewing as part of routine care to their young patients. The overall aim of the present study was to explore the implementation of motivational interviewing by dentists and dental hygienists, employed by the Norwegian Public Dental Service, for their adolescent patients.

METHODS

As part of the larger #Care4YoungTeeth <3 project, a Norwegian Research Council funded four-year Collaborative Project to Meet Societal and Industry-related Challenges, an online survey was developed and administered to dental personnel (n = 168) in one region of Central Norway. Data were analysed by descriptive statistics and two-sample tests of proportions at the 95% confidence level.

RESULTS

A total of 98 dental personnel responded to the survey (response rate 58.3%), of which 37 were dental hygienists (response rate 72.5%) and 61 were dentists (response rate 52.1%). A greater proportion of hygienists reported implementing this intervention compared to dentists (78.4% versus 50.8%; p = 0.007). Similarly, a greater proportion of hygienists (83.8%) stated that they had received training in MI compared to dentists (65.6%; p = 0.051). About 80% of dentists and 90% of dental hygienists felt that they understood the principles of MI. However, only about 45% and 60%, respectively, felt confident in its use. Dental hygienists found MI more usable in their work (p = 0.052), to a greater extent want to use MI (p = 0.002) and found that using MI works well (p < 0.001), as compared to dentists.

CONCLUSIONS

A high proportion of dental professionals working within a Norwegian public dental service have received training in MI. However, barriers to implementation for adolescent patients and differences in practice between dentists and hygienists warrant further enquiry.

Incidence, severity, and temporal development of oral complications in pediatric allogeneic hematopoietic stem cell transplant patients - a multicenter study

PURPOSE

Oral mucositis is a common complication for patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT) and causes pain and difficulties in functions like eating and swallowing, resulting in lower quality of life and greater need of treatment with opioids and parenteral nutrition. This prospective multicenter study focused on pediatric recipients of HSCT in the neutropenic phase concerning oral complications, timing, severity, and patient experience.

METHODS

The cohort comprised 68 patients, median age 11.1 years (IQR 6.3) receiving allogeneic HSCT at three clinical sites. Medical records were retrieved for therapy regimens, concomitant medications, oral and dental history, and subjective oral complaints. Calibrated dentists conducted an oral and dental investigation before HSCT. After HSCT graft infusion, study personnel made bedside assessments and patients filled out a questionnaire once or twice a week until neutrophil engraftment.

RESULTS

We followed 63 patients through the neutropenic phase until engraftment. 50% developed oral mucositis of grades 2-4. Peak severity occurred at 8-11 days after stem cell infusion. Altogether, 87% had subjective oral complaints. The temporal distribution of adverse events is similar to the development of oral mucositis. The most bothersome symptoms were blisters and oral ulcerations, including mucositis; 40% reported severe pain and major impact on activities of daily living despite continuous use of opioids.

CONCLUSION

This study highlights the burden of oral complications and their negative effect on the health and quality of life of HSCT recipients.

Associations of adverse childhood experiences with caries and toothbrushing in adolescents. The Young-HUNT4 Survey

BACKGROUND

Adverse childhood experiences (ACEs) are associated with poor oral health. Using a life course theoretical framework, this study explored the associations of specific and cumulative ACEs with caries and toothbrushing frequency in a Norwegian adolescent population.

METHODS

Participants were adolescents (n = 6351) age 13-17 years from The Young-HUNT4 Survey. Clinical data were retrieved from dental health records. Oral health outcomes were toothbrushing frequency, dentine caries experience (Decayed, Missing, and Filled Teeth - DMFT), and enamel caries. ACE exposure variables were physical abuse, sexual abuse, witness to violence, parental separation/divorce, parental alcohol problems, and bully victimization. Negative binominal regression models (incident rate ratios, IRRs; 95% confidence intervals, CIs) were used to determine the associations of the various ACEs with caries; logistic regression analyses (odds ratios, ORs; 95% CIs) were used to estimate associations with toothbrushing frequency. Potential effect modification by age was assessed using likelihood ratio test.

RESULTS

Adolescents exposed to physical abuse by others, sexual abuse by peers, parental separation/divorce, bullying, or who had witnessed violence, were more likely to report non-daily toothbrushing compared with those with no exposure to the given ACEs. Each cumulative increase in ACE exposure was associated with a 30% higher likelihood of non-daily toothbrushing (OR 1.30, 95% CI 1.19-1.42). Similarly, increasing number of adversities were associated with both higher dentine caries experience (IRR 1.06, 95% CI 1.02-1.09) and higher enamel caries (IRR 1.07, 95% CI 1.03-1.11). This effect was modified by age (13-15 vs. 16-17 years) for dentine caries experience. Furthermore, there was evidence of effect modification by age with bully victimization for both toothbrushing frequency (Pinteraction = 0.014) and dentine caries experience (Pinteraction < 0.001). Specifically, bully victimization was associated with a higher likelihood of non-daily toothbrushing (OR 2.59, 95% CI 1.80-3.72) and higher dentine caries experience (IRR 1.30, 95% CI 1.14-1.50) among 16-17-year-olds.

CONCLUSIONS

Several specific ACEs were associated with non-daily toothbrushing and a higher caries experience among Norwegian adolescents in the Young-HUNT4 Survey.

Dental caries at enamel and dentine level among European adolescents - a systematic review and meta-analysis

BACKGROUND

In contrast with the last century, caries epidemiology has begun integrating enamel caries into determinations of caries prevalence and experience. The objective of the present systematic review and meta-analysis was to assess the caries status including estimations of enamel caries, of European adolescents.

METHOD

Four databases (Medline Ovid, Embase, CINAHL, and SweMed+) were systematically searched from 1 January 2000 through 20 September 2021 for peer-reviewed publications on caries prevalence and caries experience in 12-19-year-olds; that also included evaluations of enamel lesions. Summary estimates were calculated using random effect model.

RESULTS

Overall, 30 publications were selected for the systematic review covering 25 observational studies. Not all studies could be used in the meta-analyses. Caries prevalence was 77% (n = 22 studies). Highest prevalence was reported in the age groups 16-19 years, and in studies where caries examinations were done before 2010. The overall mean DMFT score was 5.93 (n = 14 studies) and it was significantly lower among Scandinavian adolescents than among other European adolescents (4.43 vs. 8.89). The proportion of enamel caries (n = 7 studies) was 50%, and highest in the lowest age group (12-15 years). Results from the present systematic review reflected the caries distribution to be skewed at individual-, tooth- and surface levels; at tooth and surface level, also changed according to age.

CONCLUSIONS

Although studies in which the caries examinations had been done in 2010 or later documented a reduction in caries prevalence, caries during adolescence still constitutes a burden. Thus, the potential for preventing development of more severe caries lesions, as seen in the substantial volume of enamel caries during early adolescence, should be fully exploited. For this to happen, enamel caries should be a part of epidemiological reporting in national registers.

Association between self-reported dental fear and exposure to violence among adolescents-A population-based study

BACKGROUND

The etiology of dental fear (DF) is multifactorial and involves other contributing factors than dental traumatic experiences.

AIM

To study, among adolescents, associations between DF and exposure to child physical abuse (CPA), intimate partner violence (IPV), and bullying.

DESIGN

We extracted data from a population-based survey of 4977 adolescents who were 15-17 years old in 2017. The questionnaire queried socioeconomic background factors, DF, self-perceived oral health, general health, and exposure to child abuse. To estimate associations between DF and exposure to child abuse, we used multivariate logistic regression analysis.

RESULTS

Overall, 8.2% reported DF, girls (10.5%) reported DF significantly more often than boys (5%), and adolescents not identifying themselves as girl or boy reported the highest prevalence of DF (25.5%; p < .001). 15.3% had been exposed to child physical abuse; 11.1%, to IPV; and 11.2%, to bullying. Experiences of IPV and bullying, but not physical abuse, were statistically significantly associated with DF. The odds of developing DF for adolescents exposed to any type of violence was 1.9 times the odds for adolescents with no exposure to child abuse.

CONCLUSION

Exposure to violence is associated with dental fear in adolescents.

Acculturation and 4-year caries increment among children of foreign-born mothers in Sweden: a register-based cohort study

Background

To study the association of maternal age upon arrival and length of residence in Sweden with the 4-year caries increment in their children between ages 3 and 7 years in relation to the human development index (HDI) of the maternal country of origin.

Method

This registry-based cohort study included all children born in 2000–2003 who resided in Stockholm County, Sweden, at age 3 years and who were followed up at age 7 (n = 63,931). Negative binomial regressions were used to analyze different models adjusted for sociodemographic factors.

Results

Children of foreign-born mothers, regardless of the HDI of the maternal country of origin, had a higher risk of caries increment between ages 3 and 7 years than children of Swedish-born mothers. Furthermore, children of mothers who had arrived from a low or medium HDI country had a lower caries increment if their mothers arrived before age 7 compared with after age 7. Nearly half (44%) of the children whose mothers arrived in Sweden at age ≥ 20 years from a low HDI country had a caries increment compared to 22% of the children whose mothers had arrived in Sweden before 7 years of age. Furthermore, children whose mothers were born in a low HDI country and had resided in Sweden ≤ 19 years had approximately 1.5 times higher risk of caries increment compared to children of mothers who had resided in Sweden for more than 20 years.

Conclusions

Caries increment in the children of foreign-born mothers was associated with the age of their mother when she arrived in Sweden and was lower when the mother had arrived before age 7 years. This indicates an intergenerational effect that carries over to the children and is greater the longer the mother has participated in Swedish dental healthcare.

Cost analysis of prosthetic rehabilitation in young patients with Amelogenesis imperfecta

OBJECTIVES

Children and adolescents with amelogenesis imperfecta (AI) have extensive treatment needs, but costs have not been explored previously. We calculated the costs of prosthetic rehabilitation and analyzed whether costs of treatment begun in early adolescence are lower compared with in early adulthood.

METHODS

Data from the dental records of 25 patients with AI and 25 age- and sex-matched controls were analyzed. Patients were followed for a mean period of 12.3 ± 1.5 years. Number of dental visits, dental treatment costs, and indirect costs were calculated during three time periods, before, during and after prosthetic therapy. Swedish national reference prices for general and specialist dental care were used.

RESULTS

The mean number of visits was significantly higher in the AI group: 43.3 ± 19.7 (controls: 17.5 ± 19.8; p < .001). Mean total costs were 8.5 times higher for patients with AI: €16,257 ± 5,595 (controls: €1,904 ± 993). Mean number of crowns made in patients with AI was 12 ± 7 (range 1 - 31). Indirect costs were significantly higher in the AI group and constituted 22% of the total costs. After crown therapy, costs between groups ceased to differ significantly. Calculations of total costs in the hypothetical scenario (discount rate at 3% annually) were €18,475 for prosthetic rehabilitation began at age 12 years compared with €20,227 if treatment began at 20 years of age.

CONCLUSIONS

Prosthetic rehabilitation costs for children and adolescents with AI can be high. Early crown therapy is associated with lower costs and a lower number of dental visits.

CLINICAL IMPLICATIONS

Early crown therapy in children and adolescents with severe AI is a cost-reducing treatment associated with few complications and reduced need of dental care during adolescence compared with treatment begun at age 20.

Development level of the country of parental origin on dental caries in children of immigrant parents in Sweden

AIM

To study the association of parental country of origin-expressed as low-, medium- and high-Human Development Index (HDI) countries-with caries experience in children of immigrant families in Stockholm.

METHODS

This registry-based cohort study included all children born in 2000-2003 who resided in Stockholm County, Sweden, at age 3 years (n = 83,147) with follow-up at 7 years of age. A logistic regression was performed for the multivariate analysis with adjustments for socio-demographic factors.

RESULTS

After adjustments, logistic regression analyses revealed that, compared with Swedish children of the same age, the risk of caries was highest when the immigrant parents originated in a medium (OR 4.22 (95% CI 3.99:4.47)) or low (OR 2.80 (95% CI 2.56:3.06)) income country background at age 7 years, but was increased also for high-income country background, OR 1.77 (95% CI 1.52-2.05). Furthermore, the risk of presenting with caries experience at age 7 years increased for all children in the 1^st (lowest) household income quintile in the host country Sweden.

CONCLUSION

This study shows that the developmental level of the parental country of birth as well as the family socioeconomic position in Sweden influence the risk for caries development in their children.

Abnormalities in Tooth Formation after Early Bisphosphonate Treatment in Children with Osteogenesis Imperfecta

Treatment with intravenous bisphosphonate (BP) in children and adolescents with osteogenesis imperfecta (OI) started in Sweden in 1991. No human studies on the role of BP therapy in development of disturbances in tooth mineralization or tooth morphology have been published. The study cohort comprised 219 individuals who were divided into four groups: group 1, BP treatment onset before 2 years of age (n = 22); group 2, BP treatment onset between 2 and 6 years of age (n = 20); group 3, BP treatment onset between 6 and 10 years of age (n = 13); and a control group of patients with OI who had not received BP therapy (n = 164). The chi-square test was used in between-group comparisons of the prevalence of tooth agenesis. The prevalence of tooth agenesis was significantly higher in children who began BP treatment before the age of 2 years (group 1; 59%,) compared to the controls (10%; p < 0.001) and to children who had begun BP therapy between ages 2 and 6 years (group 2; 10%; p = 0.009) or between ages 6 and 10 years (group 3; 8%; p = 0.003). Different types of disturbances in the enamel formation were seen in 52 premolars, where 51 were seen in those who began BP treatment before the age of 2 years. To conclude, starting BP treatment before the age of 2 years increases the risk of abnormalities in tooth formation manifesting as morphological aberrations, tooth agenesis, and enamel defects.

Development of dental caries and risk factors between 1 and 7 years of age in areas of high risk for dental caries in Stockholm, Sweden

Purpose

To explore caries predictors at age 1 year and caries development at ages 5 and 7 years in two groups of children following different fluoride-based preventive programs.

Methods

We conducted a prospective cluster-randomized controlled intervention trial with two parallel arms comparing two prevention programs: one program included fluoride varnish applications every 6 months, the other did not; otherwise, the programs were the same. Participants were 1- and 3-year-old children enrolled at 23 dental clinics in high-risk areas in Stockholm, Sweden. The baseline examination included structured interviews. Caries data were extracted from dental records. The primary outcome measures were ICDAS 1–6 > 0 at baseline (age 1 year) and defs > 0 at ages 2, 3, 5, and 7 years. The secondary outcome measure at age 7 was DFS > 0.

Results

Continuous caries development occurred: defs > 0 in 23% at 5 years and in 42% at 7 years. We found no difference in caries development between children who had or had not received fluoride varnish as toddlers. At age 1-year, significant predictors for dental caries in later preschool years were immigrant background, family income, and sweets consumption. Fluoride toothpaste > once a day at 1 year had an OR < 1 for defs > 0 at 5- and 7 years.

Conclusions

For toddlers, fluoride varnish does not seem to be an adequate prevention tool. Brushing with fluoride toothpaste from 1 year of age could not arrest caries development. Immigrant background was the strongest predictor. A new toolbox as well as collaborative upstream actions for reducing free-sugar intake are needed.

Self-reported symptoms of temporomandibular pain and jaw dysfunction in adolescents are associated with exposure to violence

BACKGROUND

Temporomandibular disorders (TMDs) are multifactorial, and high levels of stress seem to increase symptoms. The association with exposure to violence has not been explored in adolescent populations.

OBJECTIVE

To examine the association of self-reported symptoms of temporomandibular pain and jaw dysfunction with child physical abuse, intimate partner violence, forced sexual intercourse, and bullying victimisation.

METHODS

An epidemiological, cross-sectional, school-based study was conducted in Olinda, northeast Brazil. The sample comprised 2,431 adolescents aged 14-19 years. TMD-related symptoms and exposure to violence were assessed with questions from the 3Q/TMD screener and queries on exposure to different forms of violence. Multilevel logistic regressions were conducted to evaluate how 3Q screen-positive responses are associated with self-reported exposure to violence.

RESULTS

Self-reported TMD-related symptoms had a prevalence of 40.5%. Significantly more females than males screened positive to all 3Q/TMD questions (p < .001). Adolescents experiencing intimate partner violence (p = .012) and bullying (p < .001) had significantly higher odds of 3Q positive responses than those who reported no exposure to violence. Significant associations of TMD-related symptoms with forced sexual intercourse (p = .014) and with bullying (p = .007) were observed.

CONCLUSION

Adolescents with self-reported symptoms of temporomandibular pain and jaw dysfunction were significantly more often exposed to some type of violence. The number of adolescents reporting TMD-related symptoms increased in a dose-response manner with the number of violence forms the individual had experienced.

Determinants of self-perceived oral health in adolescents: A cross-sectional study

BACKGROUND

Self-perceived oral health (SPOH) is a summary of multiple determinants related to oral health and has been suggested for use in clinical practice as a health assessment tool.

AIM

To analyse determinants of SPOH among adolescents.

DESIGN

In 2018, we selected 1742 participants from eight high schools in Olinda/PE, Brazil, using a multistage stratified cluster sample. The main survey item of SPOH was 'How would you rate your oral health'. Determinants of were queried with a questionnaire and a clinical examination: socio-demographic variables, exposure to family violence, somatic symptoms, and orofacial and general health factors. Pearson's chi-square test and logistic regressions evaluated associations between determinants and SPOH.

RESULTS

Very poor SPOH had a prevalence of 8.7%. Nearly half (43.5%) rated their oral health as 'fair'. Very poor SPOH was associated with poor self-perceived general health (OR = 2.60), anterior open bite (OR = 2.24), not cohabiting with one or both parents (OR = 2.40), caries experience (OR = 1.93), dental pain (OR = 1.91), and temporomandibular disorders (OR = 1.77).

CONCLUSION

Very poor self-perceived oral health indicates life stress and associates with poor oral conditions. Assessments should be used to explore individual treatment needs and abilities to comply with recommendations.

Impact of an extended postnatal home visiting programme on oral health among children in a disadvantaged area of Stockholm, Sweden

AIM

To evaluate oral health outcomes and early oral health promotion of children in a Swedish, parental support programme conducted in a collaboration between Child Health Services and Social Services.

METHODS

The intervention offered first-time parents six home visits from a paediatric nurse and a parental advisor with Social Services. On the fourth visit (infant age 6-8 months), parents received a toothbrush and fluoride toothpaste from non-dental staff. Twice, at child ages 18 and 36 months, a dentist used the International Caries Detection and Assessment System to record caries and conducted a structured interview with the parents on oral health habits. The intervention group (n = 72) was compared to a reference group (n = 100) from the standard child healthcare programme, which included one home visit.

RESULTS

Significantly, caries prevalence was lower and tooth brushing habits more consistent in the intervention group compared to the reference group in the standard child health programme. The difference was most pronounced at 18 months and had decreased at the 36-month follow-up.

CONCLUSION

The extended postnatal home visiting programme had a positive impact on oral health. Early oral health promotion delivered by non-dental professionals could be a beneficial approach to early caries prevention.

U-shaped association between maternal age at delivery and dental caries in offspring

OBJECTIVE

To determine the association between maternal age at delivery and caries in offspring.

MATERIALS AND METHODS

This registry-based cohort study included all children born between 2000 and 2003 and who were residing in Stockholm County, Sweden, at 7 years of age. Between 2007 and 2010, the cohort (n = 65,259) was examined to determine caries experience (deft scores) at 7 years of age. Age of mother at childbirth was retrieved from the patient histories. Data were analysed using linear regressions.

RESULTS

The lowest mean deft occurred in children born to mothers aged 25-34 years. The final model - adjusted for sex, income, educational level, migration background, family situation, smoking, obesity, small for gestational age, and number of siblings - found that young mothers and older mothers were significant risk indicators for caries experience at 7 years of age.

CONCLUSIONS

The present study found a U-shaped relationship between maternal age at childbirth and caries experience in the offspring at age 7 years. The offspring of mothers under 25 or over 34 years of age are at greater risk of having more teeth with caries experience.

Oral mucositis after tacrolimus/sirolimus or cyclosporine/methotrexate as graft-versus-host disease prophylaxis

OBJECTIVES

To determine whether treatment with tacrolimus plus sirolimus (Tac/Sir) as a prophylaxis for graft-versus-host disease worsens severe oral mucositis and delays healing compared to cyclosporine plus methotrexate (CsA/Mtx) following haematopoietic stem cell transplantation.

SUBJECTS AND METHODS

The study comprised 141 patients: 73 randomized to receive Tac/Sir and 68 to receive CsA/Mtx. The oral mucositis assessment scale and toxicity grading according to WHO were used to assess the severity, peak and duration of oral mucositis from the day -3 to day 24 post-transplant.

RESULTS

Eighty-seven patients developed oral mucositis in the first 24 days post-transplant. No significant difference in oral mucositis severity between the Tac/Sir and CsA/Mtx groups was observed. The peak oral mucositis score occurred on day 10 in both groups. Although oral mucositis scores had returned to baseline in the CsA/Mtx group on day 24 post-transplant, no significant difference compared with the Tac/Sir group was found.

CONCLUSIONS

The introduction of tacrolimus/sirolimus as a graft-versus-host disease prophylaxis in haematopoietic stem cell transplantation increased neither the incidence nor severity of oral mucositis compared with cyclosporine/methotrexate. Furthermore, oral mucositis healing was not prolonged and followed the same time pattern as cyclosporine/methotrexate.

Bisphosphonate Therapy and Tooth Development in Children and Adolescents with Osteogenesis Imperfecta

Osteogenesis imperfecta (OI) is a heterogeneous connective tissue disorder characterized by repeated fractures and skeletal disorders. At present, bisphosphonate (BP) therapy is the gold standard for OI treatment. The present retrospective study evaluated the effect of BP therapy on tooth development and eruption of permanent teeth in a cohort of children receiving pamidronate. Three groups were studied: patients with OI who were treated with BPs (n = 45), patients with OI who were not treated with BPs (n = 117), and age- and gender-matched healthy controls (n = 121). Dental age, dental maturity, and tooth eruption were assessed on panoramic radiographs using the methods of Demirjian et al. (Hum Biol 45(2):211-227, 1973) and Haavikko (Suom Hammaslaak Toim 66(3):103-170, 1970) and were evaluated using the t-test, Chi-square test, and the Mann-Whitney U test. Dental age in the study group was significantly (p < 0.05) lower than chronological age compared with both control groups. Dental maturity and the eruption of permanent teeth were also significantly (p < 0.05) delayed in the study group in relation to the two control groups. The dental age was significantly lower (p < 0.001) in patients with OI type III treated with BPs compared with healthy controls and the dental maturation was significantly delayed in patients with OI type IV treated with BPs compared with those not treated. In conclusion, BP therapy in OI patients seems to lower the dental age, delay the dental maturity, and tooth eruption. BP administration before 2 years of age might be a contributing factor.

Child physical abuse, declining trend in prevalence over 10 years in Sweden

AIM

To study trends in prevalence and risk factors of child physical abuse over 10 years in Sweden.

METHODS

This study analysed responses from school surveys in 2008, 2011, 2014 and 2017 in Södermanland County, Sweden with average 5125 respondents per year, 15 and 17 years old. There were identical questions on exposure to violence and risk factors including parental employment, separated parents, disability or disease, foreign background and lack of adult support. Intimate partner violence was included at three occasions. Data were analysed with bi- and multivariate models, and mean of accumulated risks were compared.

RESULTS

Child physical abuse decreased significantly between 2008 and 2017. Repeated abuse decreased to a less degree than abuse once. In bivariate analyses, the share of risk factors declined for those exposed to physical abuse. In multiple analyses, it was found significant associations with exposure. There was and a dose-relationship between numbers of accumulated risk categories and self-reported abuse.

CONCLUSION

Exposure to child physical abuse decreased substantially between 2008 and 2017. However, prevalence of abuse is still unacceptable, and the finding that prevalence of the more severe forms of CPA decreased less during the same time, draws attention to the need of ongoing efforts.

Adverse birth outcomes and the risk of dental caries at age 3 years

BACKGROUND

Since birth outcome is associated with maternal and newborn health, it can be a predictor of the future health of the child.

AIM

To investigate the association between adverse birth outcomes and dental caries.

DESIGN

The present registry-based cohort study included all children born in 2000-2003, residing in Stockholm County, Sweden and who received a dental examination at the age of 3 years (n = 74 748). National registries supplied data on socioeconomic conditions, maternal health, maternal health behavior, and birth outcomes. Forward stepwise binary logistic regression was performed to determine predictors of caries experience in the 3-year-olds.

RESULTS

Of the subjects, 6.0% had caries experience (decayed, extracted, and filled teeth [deft] ≥ 1), 5.6% were born preterm (<37 weeks); 2.2% were born small (SGA) and 3.7% large (LGA) for gestational age. Of the studied adverse birth outcomes, only SGA was significantly associated with caries experience at 3 years of age, and only for mothers who had refrained from smoking during pregnancy.

CONCLUSIONS

SGA is associated with caries experience in 3-year-old children; however, this relationship occurs only in mothers who did not smoke during pregnancy.

Reciprocal longitudinal relationship between dental fear and oral health in schoolchildren

BACKGROUND

No longitudinal study has evaluated the mutual relationship between dental fear and oral health in the same investigation.

AIM

To evaluate the reciprocal longitudinal relationship between dental fear and oral health in schoolchildren.

DESIGN

This longitudinal study monitored 416 Brazilian children aged 5-7 years of age at baseline for 2 years. The decayed, filled and missing teeth were clinically assessed for each child. Dental fear was evaluated by Dental Anxiety Question. Multilevel mixed-effects linear and logistic regressions analysed the reciprocal relationship between dental fear and oral health.

RESULTS

Children with caries experience had 1.8 times higher odds of dental fear compared to children who were caries free. The presence of a carious tooth increased the odds of dental fear by 1.2 times. Children with dental fear had 0.46 additional carious tooth; an additional 0.22 tooth indicated for extraction; and a 0.67 higher caries experience score compared to children without dental fear.

CONCLUSIONS

We observed a reciprocal relationship between dental fear and poor oral health. Both parents and dentists should provide realistic information for the children, discouraging biased negative expectations regarding dental treatment. Ultimately, the child would acquire positive perceptions of the dental environment, reducing their phobia and consequently improving oral health.

Mutations in COL1A1/A2 and CREB3L1 are associated with oligodontia in osteogenesis imperfecta

Background

Osteogenesis imperfecta (OI) is a heterogeneous connective tissue disorder characterized by an increased tendency for fractures throughout life. Autosomal dominant (AD) mutations in COL1A1 and COL1A2 are causative in approximately 85% of cases. In recent years, recessive variants in genes involved in collagen processing have been found. Hypodontia (< 6 missing permanent teeth) and oligodontia (≥ 6 missing permanent teeth) have previously been reported in individuals with OI. The aim of the present cross-sectional study was to investigate whether children and adolescents with OI and oligodontia and hypodontia also present with variants in other genes with potential effects on tooth development. The cohort comprised 10 individuals (7.7–19.9 years of age) with known COL1A1/A2 variants who we clinically and radiographically examined and further genetically evaluated by whole-genome sequencing. All study participants were treated at the Astrid Lindgren Children’s Hospital at Karolinska University Hospital, Stockholm (Sweden’s national multidisciplinary pediatric OI team). We evaluated a panel of genes that were associated with nonsyndromic and syndromic hypodontia or oligodontia as well as that had been found to be involved in tooth development in animal models.

Results

We detected a homozygous nonsense variant in CREB3L1, p.Tyr428*, c.1284C > A in one boy previously diagnosed with OI type III. COL1A1 and COL1A2 were the only two genes among 9 individuals which carried a pathogenic mutation. We found rare variants with unknown significance in several other genes related to tooth development.

Conclusions

Our findings suggest that mutations in COL1A1, COL1A2, and CREB3L1 may cause hypodontia and oligodontia in OI. The findings cannot exclude additive effects from other modifying or interacting genes that may contribute to the severity of the expressed phenotype. Larger cohorts and further functional studies are needed.

Birth order is associated with caries development in young children: a register-based cohort study

BACKGROUND

Birth order has been shown to affect the health of the child; less is known, however, about how birth order affects caries development in children. Thus, the present study investigated the association between birth order and dental caries development in young children.

METHODS

This retrospective registry-based cohort study included all children born in 2000-2003 who were residing in Stockholm County, Sweden, at age 3 years (n = 83,147). The study followed the cohort until subjects reached 7 years of age. Children with registry data on dental examinations and sociodemographic characteristics at ages 3- and 7 years constituted the final study cohort (n = 65,259). The outcome variable was "caries increment from age 3- to 7 years" (Δdeft > 0) and the key exposure, "birth order", was divided into five groups. A forward stepwise logistic binary regression was done for the multivariate analysis with adjustments for sociodemographic factors.

RESULTS

At age 3 years, 94% had no fillings or manifest caries lesions. During the study period, 22.5% (n = 14,711) developed dental caries. The final logistic regression analysis found a statistically significant positive association between birth order and caries increment. Further, excess risk increased with higher birth order; with the mother's first-born child as reference, risk for the second-born child was OR 1.17, 95% CI = 1.12-1.23; for the third-born child, OR 1.47, 95% CI = 1.38-1.56; for the fourth-born child, OR 1.69, 95% CI = 1.52-1.88; and for the fifth-born or higher birth-order child, OR 1.84, 95% CI = 1.58-2.14.

CONCLUSIONS

These findings show that birth order influences caries development in siblings, suggesting that birth order can be regarded as a predictor for caries development in young children. This factor may be helpful in assessing caries risk in preschool children and should be considered in caries prevention work in young children with older siblings.

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).

Experiences of Being a Parent to a Child with Amelogenesis Imperfecta

Amelogenesis imperfecta (AI) is a hereditary developmental disorder affecting the enamel of teeth. Affected patients present with tooth hypersensitivity, rapid tooth wear, or fractures of enamel as well as alterations in color and shape, all of which compromise esthetic appearance and masticatory function. Chronic conditions in childhood severely impact the whole family, affecting normal family routines and/or increasing the family’s financial burden. The aim of this study was to explore experiences and the impact on daily life of being a parent to a child with severe forms of amelogenesis imperfecta. Parents of children and adolescents with AI participated in an interview with a psychologist. The transcribed interviews were analyzed using thematic analysis. The parents talked about several concerns about having a child with AI. Four main themes emerged from the interviews: Feelings associated with passing on a hereditary disorder, knowledge decreases stress, unfamiliarity with the diagnosis, and psychosocial stress. In these main categories we identified several subthemes. Feelings associated with passing on a hereditary disorder included the subtheme of guilt/shame; knowledge decreases stress included knowledge about diagnosis in the family and support from dental health care professionals; Unfamiliarity with diagnosis included missed diagnosis, fear of not getting correct treatment, and insufficient pain control; finally, the subtheme Psychosocial stress included fear of child being bullied and emergency dental visits. The findings show that parents of children with severe amelogenesis imperfecta report similar experiences as do parents of children with other chronic and rare diseases.

Dentinogenesis imperfecta type II in Swedish children and adolescents

Background

Dentinogenesis imperfecta (DGI) is a heritable disorder of dentin. Genetic analyses have found two subgroups in this disorder: DGI type I, a syndromic form associated with osteogenesis imperfecta (OI), and DGI type II, a non-syndromic form. The differential diagnosis between types I and II is often challenging. Thus, the present cross-sectional study had two aims: to (i) investigate the prevalence and incidence of DGI type II among Swedish children and adolescents and (ii) search out undiagnosed cases of DGI type I by documenting the prevalence of clinical symptoms of OI in these individuals. We invited all public and private specialist pediatric dental clinics (n = 47) in 21 counties of Sweden to participate in the study. We then continuously followed up all reported cases during 2014−2017 in order to identify all children and adolescents presenting with DGI type II. Using a structured questionnaire and an examination protocol, pediatric dentists interviewed and examined patients regarding medical aspects such as bruising, prolonged bleeding, spraining, fractures, hearing impairment, and family history of osteoporosis and OI. Joint hypermobility and sclerae were assessed. The clinical oral examination, which included a radiographic examination when indicated, emphasized dental variables associated with OI.

Results

The prevalence of DGI type II was estimated to be 0.0022% (95% CI, 0.0016–0.0029%) or 1 in 45,455 individuals. Dental agenesis occurred in 9% of our group. Other findings included tooth retention (17%), pulpal obliteration (100%), and generalized joint hypermobility (30%). Clinical and radiographic findings raised a suspicion of undiagnosed OI in one individual, a 2-year-old boy; he was later diagnosed with OI type IV.

Conclusions

These results show a significantly lower prevalence of DGI type II than previously reported and point to the importance of excluding OI in children with DGI.

Electronic supplementary material

The online version of this article (10.1186/s13023-018-0887-2) contains supplementary material, which is available to authorized users.

Socioeconomic Determinants, Maternal Health, and Caries in Young Children

Introduction

Maternal health during pregnancy plays a part in child health, and several conditions have been associated with adverse child outcomes.

Objectives

To determine the socioeconomic determinants and maternal health factors associated with dental caries in young children.

Methods

This cross-sectional study is part of a register-based cohort study including all children who were born from 2000 to 2003 and were residing in Stockholm County, Sweden, at age 3 y (n = 73,658). The study followed the cohort until individuals were 7 y old. The final study cohort comprised all children examined at 3 and 7 y (n = 65,259). Data on socioeconomic conditions, maternal health, and maternal health behavior were extracted from Swedish national registries. The multivariate analyses used 2 outcomes: caries experience at age 3 and 7 y (deft > 0 [decayed, extracted, and filled teeth]).

Results

The results of this study show that socioeconomic and maternal health behaviors during pregnancy are important determinants of oral health in their preschool offspring. When all significant risk factors were present, the cumulative probability of being diagnosed with dental caries at age 7 y was 75%.

Conclusion

This study also showed that maternal obesity and smoking during pregnancy were predictors of dental caries in preschool children. Strategies must be developed for increasing maternal motivation and self-efficacy and providing mothers with knowledge and caries-preventive tools.

Knowledge Transfer Statement

The results of this study inform clinicians about the importance of including a more detailed history regarding maternal health and maternal health behaviors during pregnancy to assess caries risk in preschool children. Education, income, and other socioeconomic factors are difficult to modify in the short term. Therefore, strategies must be developed to increase parental motivation and self-efficacy to give parents the determination, knowledge, and tools for prevention.

Oral health in children investigated by Social services on suspicion of child abuse and neglect

Child abuse and neglect (CAN) are likely to have negative consequences on health; however, for oral health, studies on associated outcomes are sparse. The purpose of this study was to assess oral health and oral health behaviors in relation to suspected CAN among children being investigated by the Swedish Social Services. The material comprised data from the Social Services and dental records; the sample, 86 children and 172 matched controls. The children in the study group had a higher prevalence of dental caries than the control group; in addition, levels of non-attendance and dental avoidance were high, as was parental failure to promote good oral health. We found four factors that, taken together, indicated a high probability of being investigated because of suspected CAN: prevalence of dental caries in primary teeth, fillings in permanent teeth, dental health service avoidance, and referral to specialist pediatric dentistry clinics. If all four factors were present, the cumulative probability of being investigated was 0.918. In conclusion, there is a high prevalence of dental caries, irregular attendance, and a need for referral a pediatric dental clinic among Swedish children under investigation due to suspected CAN. Social context is an important factor in assessing the risk of developing dental caries, the inclination to follow treatment plans, and the prerequisites for cooperation during treatment. Routinely requesting dental records during an investigation would provide important information for social workers on parental skills and abilities to fulfill the basic needs of children.

Internet-Based Cognitive Behavioral Therapy for Children and Adolescents With Dental Anxiety: Open Trial

Background

Cognitive behavioral therapy (CBT) is an evidence-based method for treating specific phobias, but access to treatment is difficult, especially for children and adolescents with dental anxiety. Psychologist-guided Internet-based CBT (ICBT) may be an effective way of increasing accessibility while maintaining treatment effects.

Objective

The aim of this study was to test the hypothesis that psychologist-guided ICBT improves school-aged children’s and adolescents’ ability to manage dental anxiety by (1) decreasing avoidance and affecting the phobia diagnosis and (2) decreasing the dental fear and increasing the target groups’ self-efficacy. The study also aimed to examine the feasibility and acceptability of this novel treatment.

Methods

This was an open, uncontrolled trial with assessments at baseline, posttreatment, and the 1-year follow-up. The study enrolled and treated 18 participants. The primary outcome was level of avoidance behaviors, as measured by the picture-guided behavioral avoidance test (PG-BAT). The secondary outcome was a diagnostic evaluation with the parents conducted by a psychologist. The specific phobia section of the structured interview Kiddie-Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime (K-SADS-PL) was used. Other outcome measures included level of dental anxiety and self-efficacy. The ICBT, which employed exposure therapy, comprised 12 modules of texts, animations, dentistry-related video clips, and an exercise package (including dental instruments). Participants accessed the treatment through an Internet-based treatment platform and received Web-based guidance from a psychologist. Treatment also included training at dental clinics. Feasibility and acceptability were assessed by measures of engagement, adherence, compliance, completed measures, patient and parent satisfaction scale, and staff acceptability.

Results

The level of avoidance (according to the primary outcome measure PG-BAT) and dental anxiety decreased and self-efficacy increased significantly (P<.001), within-group effect sizes for both the primary outcome (Cohen d=1.5), and other outcomes were large in the range of 0.9 and 1.5. According to K-SADS-PL, 53% (8/15) of the participants were free from diagnosable dental anxiety at the 1-year follow-up. At the 1-year follow-up, improvements were maintained and clinically significant, with 60% (9/15) of participants who had been unable to manage intraoral injection of local anesthetics before ICBT reporting having accomplished this task at a dental clinic. The target group showed improvement in all the outcome measures. High levels of feasibility and acceptability were observed for the treatment.

Conclusions

ICBT is a promising and feasible treatment for dental anxiety in children and adolescents. Integrating it into routine pediatric dental care would increase access to an effective psychological treatment. The results of this open trial must be replicated in controlled studies.

Impact of biannual treatment with fluoride varnish on tooth-surface-level caries progression in children aged 1-3 years

OBJECTIVE

This study describes caries progression at tooth-surface level in children from 1 to 3 years of age and the impact of biannual treatment with fluoride varnish.

METHODS

Children who participated in a cluster-randomized controlled trial and had shown signs of dental caries were included in this study (n=801). International Caries Detection and Assessment System (ICDAS) was used to classify dental caries. The present study compared children receiving a standard yearly intervention to children receiving the same standard preventive intervention supplemented with an application of fluoride varnish every half year.

RESULTS

The maxillary incisors were the first teeth to develop cavitation (ICDAS 3-6) and also mostly affected. Further analyses focusing on maxillary incisors buccal surfaces showed that sound surfaces had least progression and that progression to extensive decay was more common in teeth that had exhibited moderate decay. A summarizing progression index (PI) was calculated for the buccal surfaces of the maxillary incisors. Between 1 and 2 years of age PI was 26% and between 2 and 3 years of age PI was 21%. The progression on buccal incisors and on occlusal first primary molars did not differ between intervention groups (p≤0,05).

CONCLUSION

No impact on caries progression for biannual treatment with fluoride varnish was found.

CLINICAL SIGNIFICANCE

Using fluoride varnish as a complement to standard intervention in toddlers did not add in the prevention of dental caries or its progression. The education of parents in the use fluoride toothpaste as they start brushing the teeth of their children is essential.

Safety and Side Effects of Using Placenta-Derived Decidual Stromal Cells for Graft-versus-Host Disease and Hemorrhagic Cystitis

Mesenchymal stromal cells (MSCs) are increasingly used in regenerate medicine. Placenta-derived decidual stromal cells (DSCs) are a novel therapy for acute graft-versus-host-disease (GVHD) and hemorrhagic cystitis (HC) after allogeneic hematopoietic stem cell transplantation (HSCT). DSCs are more immunosuppressive than MSCs. We assessed adverse events and safety using DSCs among 44 treated patients and 40 controls. The median dose of infused cells was 1.5 (range 0.9–2.9) × 10⁶ DSCs/kg. The patients were given 2 (1–5) doses, with a total of 82 infusions. Monitoring ended 3 months after the last DSC infusion. Three patients had transient reactions during DSC infusion. Laboratory values, hemorrhages, and transfusions were similar in the two groups. The frequency of leukemic relapse (2/2, DSC/controls) and invasive fungal infections (6/6) were the same in the two groups. Causes of death were those seen in HSCT patients: infections (5/3), respiratory failure (1/1), circulatory failure (3/1), thromboembolism (1/0), multiorgan failure (0/1), and GVHD and others (2/7). One-year survival for the DSC patients with GVHD was 67%, which was significantly better than achieved previously at our center. One-year survival was 90% in the DSC-treated HC group. DSC infusions appear safe. Randomized studies are required to prove efficacy.

Caesarean Section Does Not Increase the Risk of Caries in Swedish Children

Caesarean section has been shown to affect the health of the child. Only a few studies have investigated whether the mode of delivery is associated with dental caries, and they present conflicting results. Our study investigated whether dental caries was associated with delivery method in Swedish preschool children. This retrospective register-based cohort study included all children born from 2000 to 2003 who were residing in Stockholm County, Sweden, at 3 y of age (n = 83,147). The study followed the cohort until individuals were 7 y of age. Children examined at 3 and 7 y constituted the final study cohort (n = 65,259). We dichotomized the key exposure “delivery starts by caesarean section” and analyzed it in univariate analyses as well as in multivariate analyses. The multivariate analyses used 3 outcomes: caries experience at age 3 (deft >0 [decayed, extracted, and filled teeth]), caries increment between 3 and 7 y of age (Δdeft > 0), and caries experience at age 7 (deft > 0). Of the final cohort, 15% (n = 9,587) were delivered by caesarean section. At 3 y of age, the results showed no statistically significant association between caesarean section and caries experience (odds ratio = 0.92, 95% confidence interval [CI] = 0.82 to 1.04). Between 3 and 7 y of age, the association of caesarean section on caries increment was 0.88 (95% CI = 0.83 to 0.94) and at 7 y of age, 0.88 (caries experience; 95% CI = 0.82 to 0.94). Higher mean values for caries experience and caries increment were observed in vaginally delivered children. We found that preschool children who were delivered by caesarean section do not represent a group with an excess risk of developing dental caries. Furthermore, the statistically significant associations with caries increment and caries experience at age 7 were negative.

Knowledge Transfer Statement: Children born by caesarean section are at greater risk of developing asthma and obesity. The proportion of elective caesarean sections without a medical indication has increased over the years; therefore, it is important to know how this mode of delivery affects oral health of the child. The results show that children who are delivered by caesarean section are not at greater risk of developing dental caries, and clinicians can use these findings in their risk assessment.

Mutations in COL1A1 and COL1A2 and dental aberrations in children and adolescents with osteogenesis imperfecta - A retrospective cohort study

Osteogenesis imperfecta (OI) is a heterogeneous group of disorders of connective tissue, caused mainly by mutations in the collagen I genes (COL1A1 and COL1A2). Dentinogenesis imperfecta (DGI) and other dental aberrations are common features of OI. We investigated the association between collagen I mutations and DGI, taurodontism, and retention of permanent second molars in a retrospective cohort of 152 unrelated children and adolescents with OI. The clinical examination included radiographic evaluations. Teeth from 81 individuals were available for histopathological evaluation. COL1A1/2 mutations were found in 104 individuals by nucleotide sequencing. DGI was diagnosed clinically and radiographically in 29% of the individuals (44/152) and through isolated histological findings in another 19% (29/152). In the individuals with a COL1A1 mutation, 70% (7/10) of those with a glycine substitution located C-terminal of p.Gly305 exhibited DGI in both dentitions while no individual (0/7) with a mutation N-terminal of this point exhibited DGI in either dentition (p = 0.01). In the individuals with a COL1A2 mutation, 80% (8/10) of those with a glycine substitution located C terminal of p.Gly211 exhibited DGI in both dentitions while no individual (0/5) with a mutation N-terminal of this point (p = 0.007) exhibited DGI in either dentition. DGI was restricted to the deciduous dentition in 20 individuals. Seventeen had missense mutations where glycine to serine was the most prevalent substitution (53%). Taurodontism occurred in 18% and retention of permanent second molars in 31% of the adolescents. Dental aberrations are strongly associated with qualitatively changed collagen I. The varying expressivity of DGI is related to the location of the collagen I mutation. Genotype information may be helpful in identifying individuals with OI who have an increased risk of dental aberrations.

Child maltreatment - prevalence and characteristics of mandatory reports from dental professionals to the social services

BACKGROUND

Dental professionals are required to report suspicions of child maltreatment to the social services. As yet, no studies assess the prevalence of these mandated reports from dental care services or their content.

AIM

This study investigates the prevalence and characteristics of mandated reports from dental professionals to the social services. Furthermore, it analyses associations between dental professionals reporting suspicions of maltreatment with such reports from other sources.

DESIGN

The study collected dental mandatory reports from within one municipality of Sweden during 2008-2014. The material consisted of a total of 147 reports by dental professionals regarding 111 children.

RESULTS

The total prevalence of reports from dental care services to the social services was 1.5 per 1000 children with a significant increase between 2008 and 2011 (P < 0.001). The primary cause for a report concerned parental deficiencies in care (n = 93) and secondly, a concern for dental neglect (n = 52) (P < 0.001). Among all reports, 86% involved children with prior contacts with the social services.

CONCLUSION

Reports to the social services from dental care services on suspicions of child maltreatment concern parental deficiencies (failure to attend appointments) and neglect (dental neglect). Mandated reports from dental care services often co-occur with other mandated reports.

Oral microflora in preschool children attending a fluoride varnish program: a cross-sectional study

Background

To compare the oral microflora in preschool children attending a fluoride varnish program with a reference group receiving a standard oral health program without fluoride varnish applications. A second aim was to relate the microbial composition to the caries prevalence.

Methods

Five hundred seven 3-year-old children were enrolled from a cohort of 3403 preschool children taking part in a community based oral health project. Two hundred sixty-three of them had attended caries-preventive program with semi-annual applications of a fluoride varnish since the age of 1 year (test group) while 237 had received standard preventive care (reference group). Oral samples were collected with a sterile swab and analysed with checkerboard DNA-DNA hybridization using 12 pre-determined bacterial probes. Caries and background data were collected from clinical examinations and questionnaires.

Results

Gram-positive streptococci (S. intermedius, S. salivarius, S. oralis) were most frequently detected and displayed the highest counts in both groups. There were no significant differences between the groups concerning prevalence of any of the selected bacterial strains except for S. oralis that occurred less frequently in the reference group. In children with caries, V. parvula were significantly more common (p < 0.05) while strains of Lactobacillus, Bifidobacterium and Neisseria were more prevalent among the caries-free children (p < 0.05).

Conclusions

A 2-year community program with semi-annual fluoride varnish applications did not seem to significantly influence the oral microflora in preschool children.

Trial registration

www.controlled-trials.com (ISRCTN35086887) 20131216 ‘retrospectively registered’.

Cognitive Behavioral Therapy for Children with Dental Anxiety: A Randomized Controlled Trial

Dental anxiety affects approximately 9% of children and is associated with poor oral health, pain, and psychosocial problems. The objective of this study was to investigate the efficacy of cognitive behavioral therapy (CBT) for children with dental anxiety in specialist pediatric dentistry. The study used a parallel-group superiority randomized controlled trial design. The primary outcome measure was the behavioral avoidance test; assessors were blind to treatment allocation. Participants were 8 boys and 22 girls 7 to 18 y old (mean ± SD, 10 ± 3.1). Children fulfilling the diagnostic criteria for dental anxiety were randomized to CBT (n = 13) or treatment as usual (n = 17), such as various sedation methods. Psychologists provided 10 h of CBT based on a treatment manual. Treatments were conducted in a naturalistic real-world clinical setting. Assessments were conducted before the treatment, 3 mo after the start of treatment, and at 1-y follow-up. The analyses of the primary outcome measure by repeated-measures analysis of variance and independent t test showed that children receiving CBT made superior, statistically significant improvements at follow-up (16.8 ± 2.4) compared with treatment as usual (11.4 ± 3.1, P < 0.01). A large between-group effect size (Cohen’s d = 1.9) was found. Following treatment, 73% of those in the CBT group managed all stages of the dental procedures included in the behavioral avoidance test compared with 13% in the treatment-as-usual group. Furthermore, 91% in the CBT group compared with 25% in the treatment-as-usual group no longer met the diagnostic criteria for dental anxiety at the 1-y follow-up according to the secondary outcome measure. Measures of dental anxiety and self-efficacy showed larger improvements in the CBT group compared with controls. We conclude that CBT is an efficacious treatment for children and adolescents with dental anxiety and should be made accessible in pediatric dentistry (ClinicalTrials.gov: NCT01798355).

Knowledge transfer statement: The results of this study can be used by decision makers and clinicians when planning to implement evidence-based treatment in pediatric dentistry and give children and adolescents access to methods for treating dental anxiety. The results can also be used by parents of children with dental anxiety when asking dentists to cooperate with psychologists using cognitive behavioral therapy.

Amelogenesis Imperfecta and Early Restorative Crown Therapy: An Interview Study with Adolescents and Young Adults on Their Experiences

Patients with Amelogenesis imperfecta (AI) can present with rapid tooth loss or fractures of enamel as well as alterations in enamel thickness, color, and shape; factors that may compromise aesthetic appearance and masticatory function. The aim was to explore the experiences and perceptions of adolescents and young adults living with AI and receiving early prosthetic therapy. Seven patients with severe AI aged 16 to 23 years who underwent porcelain crown therapy participated in one-to-one individual interviews. The interviews followed a topic guide consisting of open-ended questions related to experiences of having AI. Transcripts from the interviews were analyzed using thematic analysis. The analysis process identified three main themes: Disturbances in daily life, Managing disturbances, and Normalization of daily life. These themes explain the experiences of patients living with enamel disturbances caused by AI and receiving early crown therapy. Experiences include severe pain and sensitivity problems, feelings of embarrassment, and dealing with dental staff that lack knowledge and understanding of their condition. The patients described ways to manage their disturbances and to reduce pain when eating or drinking, and strategies for meeting other people. After definitive treatment with porcelain crown therapy, they described feeling like a normal patient. In conclusion the results showed that adolescents and young adults describe a profound effect of AI on several aspects of their daily life.

Effectiveness of Early Preventive Intervention with Semiannual Fluoride Varnish Application in Toddlers Living in High-Risk Areas: A Stratified Cluster-Randomized Controlled Trial

This study evaluated whether toddlers in an extended preventive program of semiannual fluoride varnish applications from 1 year of age had a lower incidence of caries than those undergoing a standard program. A cohort of 1-year-old children (n = 3,403) living in multicultural areas of low socioeconomic standing in Stockholm participated in a cluster-randomized controlled field trial with two parallel arms. The children attended 23 dental clinics. Using the ICDAS II criteria, the examiners recorded caries at baseline and after 1 and 2 years. The children in the reference group received a standardized oral health program once yearly between 1 and 3 years of age. The children in the test group received the same standard program supplemented with topical applications of fluoride varnish every 6 months. We compared the test group and the reference group for the prevalence and increment of caries. At baseline, 5% of the children had already developed caries (ICDAS II 1-6). We reexamined the children after 1 year (n = 2,675) and after 2 years (n = 2,536). Neither prevalence nor caries increment differed between the groups. At 3 years of age, 12% of the children had developed moderate and severe carious lesions (ICDAS II 3-6), with a mean increment of 0.5 (SD 2.4) in the test group and 0.6 (SD 2.2) in the reference group. In conclusion, semiannual professional applications of fluoride varnish, as a supplement to a standard oral health program, failed to reduce caries development in toddlers from high-risk communities.

Oral health-related quality of life before and after crown therapy in young patients with amelogenesis imperfecta

BACKGROUND

Amelogenesis imperfecta (AI) is a rare, genetically determined defect in enamel mineralization associated with poor esthetics and dental sensitivity. Because the condition is associated with negative social outcomes, this study evaluated oral health-related quality of life (OHRQoL), dental fear, and dental beliefs before and after early prosthetic crown therapy for AI during adolescence.

METHODS

The study included 69 patients with AI, aged 6-25 yr: 33 males and 36 females (mean age 14.5 ± 4.3); healthy controls (n = 80), patients with cleft lip and palate (CLP; n = 30), and patients with molar incisor hypomineralization (MIH; n = 39). All matched in age and gender, and all but the CLP group insocioeconomic area. Patients completed three questionnaires measuring OHRQoL (OHIP-14), dental fear (CFSS-DS), and dental beliefs (DBS-R). Twenty-six patients with severe AI between ages 9 and 22 yr received crown therapy and completed the questionnaires twice: before and after therapy.

RESULTS

OHIP-14 scores were significantly higher among patients with AI (7.0 ± 6.7), MIH (6.8 ± 7.6) and CLP (13.6 ± 12.1) than healthy controls (1.4 ± 2.4) (p < 0.001). After crown therapy, quality of life problems in the 26 patients with severe AI decreased significantly, from 7.8 ± 6.1 to 3.0 ± 4.8 (p < 0.001). Early prosthetic therapy did not increase dental fear or negative attitudes toward dental treatment.

CONCLUSIONS

OHRQoL increased after early crown therapy in patients with severe AI. Therapy did not increase dental fear or negative attitudes toward dental treatment.

Children and parents' experiences of cognitive behavioral therapy for dental anxiety--a qualitative study

BACKGROUND

There is a high prevalence of dental anxiety in children and adolescents. Cognitive behavioral therapy is emerging as a treatment option.

AIM

The purpose of this study is to explore how children with dental anxiety and their parents experience cognitive behavioral therapy (CBT) in dentistry.

DESIGN

We interviewed 12 children and one of their parents and conducted a thematic analysis of the transcribed interviews.

RESULTS

Perspective shift emerged as overarching theme in our thematic analysis. This theme consisted of three main themes, which were mastery, safety, and reduced fear. Six subthemes were also identified according to our analyses. Mastery includes two subthemes, gradual exposure and autonomy and control. Subthemes and sources for safety feeling were therapeutic alliance and changed appraisal. The theme reduced fear also consisted of two subthemes; reduced anticipatory anxiety and coping.

CONCLUSIONS

The results show that parents and children had positive experiences of CBT and its outcome and were able to benefit from this psychological treatment when dealing with dental anxiety.

A cross-sectional study on oral health and dental care in intellectually able adults with autism spectrum disorder

Background

Autism spectrum disorder (ASD) is characterized by impairments in social interaction and communication, restricted patterns of behaviour, and unusual sensory sensitivities. The hypotheses to be tested were that adult patients with ASD have a higher caries prevalence, have more risk factors for caries development, and utilize dental health care to a lesser extent than people recruited from the normal population.

Methods

Forty-seven adults with ASD, (25 men, 22 women, mean age 33 years) and of normal intelligence and 69 age- and sex-matched typical controls completed a dental examination and questionnaires on oral health, dental hygiene, dietary habits and previous contacts with dental care.

Results

Except for increased number of buccal gingival recessions, the oral health was comparable in adults with ASD and the control group. The group with ASD had less snacking, but also less frequent brushing of teeth in the mornings. The stimulated saliva secretion was lower in the ASD group, regardless of medication. Frequencies of dental care contacts were equal in both groups. The most common reason for missing a dental appointment was forgetfulness in the ASD group.

Conclusions

Adults with ASD exhibited more gingival recessions and considerably lower saliva flow compared to healthy controls. Despite equal caries prevalence, the risk for reduced oral health due to decreased salivary flow should be taken into consideration when planning dental care for patients with ASD. Written reminders of dental appointments and written and verbal report on oral health status and oral hygiene instructions are recommended.

A Randomized Controlled Trial of Crown Therapy in Young Individuals with Amelogenesis Imperfecta

Amelogenesis imperfecta (AI) is a rare, genetically determined defect in enamel mineralization. Existing treatment recommendations suggest resin-composite restorations until adulthood, although such restorations have a limited longevity. New crown materials allow for minimal preparation techniques. The aim of this study was to compare the quality and longevity of 2 crown types—Procera and IPS e.max Press—in adolescents and young adults with AI. A secondary aim was to document adverse events. We included 27 patients (11 to 22 y of age) with AI in need of crown therapy in a randomized controlled trial using a split-mouth technique. After placing 119 Procera crowns and 108 IPS e.max Press crowns following randomization, we recorded longevity, quality, adverse events, and tooth sensitivity. After 2 y, 97% of the crowns in both crown groups had excellent or acceptable quality. We found no significant differences in quality between Procera and IPS e.max Press crowns. Tooth sensitivity was significantly reduced after crown therapy ( P < 0.001). Endodontic complications occurred in 3% of crowns. The results show that it is possible to perform crown therapy with excellent results and without severe complications in young patients with AI. The study is registered at http://www.controlled-trials.com (ISRCTN70438627).

Basic oral care for hematology-oncology patients and hematopoietic stem cell transplantation recipients: a position paper from the joint task force of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) and the European Society for Blood and Marrow Transplantation (EBMT)

PURPOSE

Hematology-oncology patients undergoing chemotherapy and hematopoietic stem cell transplantation (HSCT) recipients are at risk for oral complications which may cause significant morbidity and a potential risk of mortality. This emphasizes the importance of basic oral care prior to, during and following chemotherapy/HSCT. While scientific evidence is available to support some of the clinical practices used to manage the oral complications, expert opinion is needed to shape the current optimal protocols.

METHODS

This position paper was developed by members of the Oral Care Study Group, Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) and the European Society for Blood and Marrow Transplantation (EBMT) in attempt to provide guidance to the health care providers managing these patient populations.

RESULTS

The protocol on basic oral care outlined in this position paper is presented based on the following principles: prevention of infections, pain control, maintaining oral function, the interplay with managing oral complications of cancer treatment and improving quality of life.

CONCLUSION

Using these fundamental elements, we developed a protocol to assist the health care provider and present a practical approach for basic oral care. Research is warranted to provide robust scientific evidence and to enhance this clinical protocol.

Is treatment under general anaesthesia associated with dental neglect and dental disability among caries active preschool children?

AIM

To study if treatment under general anaesthesia (GA) is associated with dental neglect or dental disability.

STUDY DESIGN

This was a retrospective study.

METHODS

Dental records of all children in the age 0-6 years who underwent GA at a specialist paediatric dentistry clinic during 2006-2011 were studied with regard to decayed-missed-filled teeth, traumatic injuries, emergency visits, behaviour management problems and the history of attendance. The final sample consisted of 134 children. Matched controls were selected among recall patients who had not received treatment under GA.

STATISTICS

Fishers exact test or Pearson Chi-square test analysed response distribution and comparisons between groups, and for multivariate analyses, logistic regression was used.

RESULTS

The results show that children treated under GA had significantly higher caries prevalence, apical periodontitis and infections due to pulpal necrosis. Dental neglect as well as dental disability was significantly more prevalent in the GA group compared to the control group. In a multivariate analysis with dental neglect as independent factor, dental disability was the only significant factor (p = 0.006).

CONCLUSIONS

Children treated under general anaesthesia were significantly more often diagnosed with both dental neglect and dental disability. Dental disability was the only factor significantly related to dental neglect. There is a need for improved documentation in the dental records to better identify dental neglect and dental disability, and also a continued training of dentists regarding child protection.