Is food insecurity associated with dental caries?

DATA SOURCES

Eight electronic databases including APA PsycINFO, CINAHL, Embase, LILACS, PubMed, Ovid, Scopus and Web of Science were searched from date of inception to November 2021. An updated search was conducted in August 2022. Google Scholar was accessed including Open Grey and ProQuest. Reference lists of the included studies were analysed for potentially eligible studies.

STUDY SELECTION

Observational studies (cross-sectional, case-control and cohort) that evaluated the association between dental caries and food insecurity were eligible for analysis. Qualitative studies, reviews and meeting abstracts were excluded. There were no restrictions on language or publication date.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently screened titles and abstracts. A third experienced researcher was consulted if there was disagreement. Food insecurity status was the exposure with dental caries the outcome. The authors retrieved effect measures, 95% CI's and P values where available. Heterogeneity was assessed via I2 and R2. A total of 514 records were initially identified. Once duplicates were removed, 19 references were assessed in full. The association between food insecurity and dental caries were presented as odds-ratios, relative risks and prevalence ratios with 95% CIs. A random-effects model was fitted to all meta-analyses.

RESULTS

Evaluation identified 14 studies for the qualitative synthesis and 7 studies for the quantitative synthesis. The total sample size for the 14 studies was 150,546 individuals. Quantitative data merged from two studies found food-insecure individuals more prone to dental caries than food-secure individuals (OR = 1.62; 95% CI, 1.01-2.60; P = 0.045). In two studies that used binary data to compare food security or insecurity, food insecure individuals were more likely to exhibit dental caries (OR = 1.66; 95% CI, 1.36-2.02; P < 0.0001).

CONCLUSIONS

People experiencing food insecurity are more likely to exhibit dental caries than those who have food security.

Barriers to Accessing Primary Dental Care in Adults with Alcohol Dependence: A Qualitative Study

BACKGROUND

People with alcohol dependence (AD) frequently experience oral health problems, but their dental attendance is poor, with limited evidence to the reasons why from their perspective.

OBJECTIVE

To explore perceived barriers, motivators, and facilitators to accessing primary dental care in people with AD.

METHODS

Qualitative study consisting of remote one-to-one and group semistructured interviews with a convenience sample of adults with lived experience of AD in northern England. Data were audio-recorded, transcribed, and coded. A reflexive thematic analysis method was used; use of COM-B model informed data interpretation.

RESULTS

Twenty adults with lived experience of AD participated in 18 one-to-one interviews and 1 group interview (of 3 participants). Barriers to access were fear and physical, social, and environmental factors (physical effects of AD, financial barriers, nonprioritization of oral health). Motivators to access were pain and prioritization of oral health. Facilitators to access were patterns of alcohol use (i.e., sobriety) and dental service provision within recovery services.

CONCLUSIONS

Fear of "the dentist" is a major barrier to accessing dental care, and pain is the primary motivator, among people with AD, although neither are unique to this population. Fear and physical, social, and environmental barriers to access contribute to problem-oriented attendance, which negatively affect oral health outcomes. Opportunity to facilitate attendance increases when a person is in remission from AD through their physical capabilities improving. Increasing capability and opportunity can influence attendance beyond the automatic motivation of pain. Provision of dental care within recovery services could facilitate access to care. Understanding the "web of causation" is key to developing any intervention to improve dental access in people with AD. Further research is needed from the perspective of other adult populations with lived experience of AD, as well as of dental professionals, to gain deeper insight into barriers, facilitators, and possible solutions.

KNOWLEDGE TRANSFER STATEMENT

The results of this study can help dental professionals understand factors affecting access to primary care in people with alcohol dependence to provide knowledge that may reduce stigma surrounding the disease. Results also demonstrate areas for intervention development for public policy.

Evaluation of student-perceived competence of interprofessional working in Gerodontology

OBJECTIVE

To evaluate pharmacy, dental and dental therapy undergraduate students' perceived competence of interprofessional working before and after attending an interprofessional education (IPE) Gerodontology workshop.

BACKGROUND

Whilst there is international recognition of the importance of collaboration between the dental profession and systemic healthcare providers to enhance patient care, there remains a paucity of research into IPE in Gerodontology.

MATERIALS AND METHODS

Pharmacy, dental and dental therapy undergraduate students attended a 2-hour Gerodontology case-based workshop. Students completed anonymised Interprofessional Collaborative Competencies Attainment Surveys (ICCAS) before and after attendance.

RESULTS

108 questionnaires were received, 7 were withdrawn (1 incomplete with only pre-workshop side completed, 6 did not identify degree programme). From 101 included questionnaires, 37 were from pharmacy, 56 dental and 8 dental therapy students resulting in response rates of 84%, 82% and 67%, respectively. Each student group recorded an increase in positive reflective competence median (IQR) after taking part in the workshop. Overall median (IQR) reflective competence before the workshop was 6 (1), 5 (2) and 6 (2) for pharmacy, dental and dental therapy students, respectively, which increased to 7 (1) for all groups. There was variability in reflective competence before attending the workshop between dental and pharmacy students for two questions, and dental and dental therapy students for two different questions.

CONCLUSION

All students reported increased reflective competence of interprofessional working following the workshop. These findings suggest that introduction of IPE events into Gerodontology curricula may improve student understanding and appreciation of interprofessional working when providing care for older people.

Health visitors' views on promoting oral health and supporting clients with dental health problems: a qualitative study

BACKGROUND

Inequalities in dental decay in young children persist, resulting in high admission rates for general anaesthetics for tooth extractions. Health visitors have the potential to improve dental attendance and oral health in families least likely to engage with dental services. There is little evidence on health visitor views on this.

METHODS

Semi-structured interviews were conducted with a purposive sample of 17 health visitors working in both affluent and deprived areas in a single UK city. Interviews were audio recorded, transcribed, anonymized and analysed following a constructivist grounded theory approach.

RESULTS

Knowledge of oral health was high and health visitors requested oral health education specific to the communities they worked in. Health visitors reported effective, formal referral processes to other health services but not to primary NHS dental services even when dealing with infants in pain. Health visitors interviewed were largely unaware of specific NHS dental services which reduce barriers to dental care including interpreting services and dental services for children with additional needs.

CONCLUSIONS

Health visitors interviewed were knowledgeable and enthusiastic about oral health but not about dental services. Inadequate links with NHS dental services may limit their effectiveness in oral health improvement and this needs to be addressed.

Development and retention of the dental workforce: findings from a regional workforce survey and symposium in England

Background

To help promote a flexible and sustainable workforce in dentistry, it is necessary to access accurate and timely data about the structure and nature of the evolving dental team. This paper considers the results and learning from a region-wide dental workforce survey conducted in one area of Health Education England and how the team has changed since the last survey a decade earlier.

Methods

A mixed-methods approach comprised two phases. In Phase 1 a customised workforce questionnaire was sent to all dental practices registered with the Care Quality Commission in the North East of England and North Cumbria in March 2016. Findings then informed Phase 2, a regional symposium held in October 2016, where interactive workshops generated qualitative data that elaborated on factors influencing workforce development.

Results

Of 431 primary dental care practices identified, 228 questionnaires were returned - a 53% response rate. The largest professional groups were dental nurses (n = 1269, 53% by headcount; 50% of fte) and dentists (34% by headcount; 42% by fte), though there had been increases in numbers of all staff groups over the decade, which was most marked for dental therapists (from 1 per 39 dentists to 1 per 8 dentists). The dental team predominantly fell into ‘younger’ age groups (< 46 years age), with evidence of a significant increase in the number of dentists reporting part-time working in a practice since the last survey. Around one third of dental practices reported employing dental nurses with additional skills (n = 74, 32.5%) or dental therapists (n = 73, 32%), and nearly half employed a dental hygienist (n = 104, 46%). However, there was considerable variability in whether these staff actually carried out the range of skills within their scope of practice. Factors shaping workforce development were identified as, the national context, loss of expertise, patients’ health needs and expectations, surgery premises and financial constraints.

Conclusions

The composition and work patterns of the primary care dental workforce have changed markedly over the last decade, though utilisation of skill-mix continues to be constrained. Consideration of factors determining career progression of dentists and dental care professionals is needed to optimise a sustainable future workforce.

Children and parents' perspectives on the acceptability of three management strategies for dental caries in primary teeth within the 'Filling Children's Teeth: Indicated or Not' (FiCTION) randomised controlled trial - a qualitative study

Background

The Filling Children’s Teeth: Indicated Or Not? (FiCTION) randomised controlled trial (RCT) aimed to explore the clinical- and cost-effectiveness of managing dental caries in children’s primary teeth. The trial compared three management strategies: conventional caries management with best practice prevention (C + P), biological management with best practice prevention (B + P) and best practice prevention alone (PA)-based approaches. Recently, the concept of treatment acceptability has gained attention and attempts have been made to provide a conceptual definition, however this has mainly focused on adults. Recognising the importance of evaluating the acceptability of interventions in addition to their effectiveness, particularly for multi-component complex interventions, the trial design included a qualitative component. The aim of this component was to explore the acceptability of the three strategies from the perspectives of the child participants and their parents.

Methods

Qualitative exploration, based on the concept of acceptability. Participants were children already taking part in the FiCTION trial and their parents. Children were identified through purposive maximum variation sampling. The sample included children from the three management strategy arms who had been treated and followed up; median (IQR) follow-up was at 33.8 (23.8, 36.7) months. Semi-structured interviews with thirteen child-parent dyads. Interviews were transcribed verbatim and analysed using a framework approach.

Results

Data saturation was reached after thirteen interviews. Each child-parent dyad took part in one interview together. The participants were eight girls and five boys aged 5–11 years and their parents. The children’s distribution across the trial arms was: C + P n = 4; B + P n = 5; PA n = 4. Three key factors influenced the acceptability of caries management in primary teeth to children and parents: i) experiences of specific procedures within management strategies; ii) experiences of anticipatory dental anxiety and; iii) perceptions of effectiveness (particularly whether pain was reduced). These factors were underpinned by a fourth key factor: the notion of trust in the dental professionals – this was pervasive across all arms.

Conclusions

Overall children and parents found each of the three strategies for the management of dental caries in primary teeth acceptable, with trust in the dental professional playing an important role.

Dental professionals' experiences of managing children with carious lesions in their primary teeth - a qualitative study within the FiCTION randomised controlled trial

Background

The lack of evidence for the effective management of carious lesions in children’s primary teeth has caused uncertainty for the dental profession and patients. Possible approaches include conventional and biological management alongside best practice prevention, and best practice prevention alone. The FiCTION trial assessed the effectiveness of these options, and included a qualitative study exploring dental professionals’ (DPs) experiences of delivering the different treatment arms. This paper reports on how DPs managed children with carious lesions within FiCTION and how this related to their everyday experiences of doing dentistry.

Methods

Overall, 31 DPs from FiCTION-trained dental surgeries in four regions of the UK participated in semi-structured interviews about their experiences of the three treatment arms (conventional management of carious lesions and prevention (C + P), biological management of carious lesions and prevention (B + P) or prevention alone (PA)). A theoretical framework, drawing on social practice theory (SPT), was developed for analysis.

Results

Participants discussed perceived effectiveness of, and familiarity with, the three techniques. The C + P arm was familiar, but some participants questioned the effectiveness of conventional restorations. Attitudes towards the B + P arm varied in terms of familiarity, but once DPs were introduced to the techniques, this was seen as effective. While prevention was familiar, PA was described as ineffective. DPs manage children with carious lesions day-to-day, drawing on previous experience and knowledge of the child to provide what they view as the most appropriate treatment in the best interests of each child. Randomisation undermined these normal choices. Several DPs reported deviating from the trial arms in order to treat a patient in a particular way. Participants valued evidence-based dentistry, and expect to use the results of FiCTION to inform future practice. They anticipate continuing to use the full range of treatment options, and to personally select appropriate strategies for individual children.

Conclusions

RCTs take place in the context of day-to-day practices of doing dentistry. DPs employ experiential and interpersonal knowledge to act in the best interests of their patients. Randomisation within a clinical trial can present a source of tension for DPs, which has implications for assuring individual equipoise in future trials.

Best-practice prevention alone or with conventional or biological caries management for 3- to 7-year-olds: the FiCTION three-arm RCT

BACKGROUND

Historically, lack of evidence for effective management of decay in primary teeth has caused uncertainty, but there is emerging evidence to support alternative strategies to conventional fillings, which are minimally invasive and prevention orientated.

OBJECTIVES

The objectives were (1) to assess the clinical effectiveness and cost-effectiveness of three strategies for managing caries in primary teeth and (2) to assess quality of life, dental anxiety, the acceptability and experiences of children, parents and dental professionals, and caries development and/or progression.

DESIGN

This was a multicentre, three-arm parallel-group, participant-randomised controlled trial. Allocation concealment was achieved by use of a centralised web-based randomisation facility hosted by Newcastle Clinical Trials Unit.

SETTING

This trial was set in primary dental care in Scotland, England and Wales.

PARTICIPANTS

Participants were NHS patients aged 3-7 years who were at a high risk of tooth decay and had at least one primary molar tooth with decay into dentine, but no pain/sepsis.

INTERVENTIONS

Three interventions were employed: (1) conventional with best-practice prevention (local anaesthetic, carious tissue removal, filling placement), (2) biological with best-practice prevention (sealing-in decay, selective carious tissue removal and fissure sealants) and (3) best-practice prevention alone (dietary and toothbrushing advice, topical fluoride and fissure sealing of permanent teeth).

MAIN OUTCOME MEASURES

The clinical effectiveness outcomes were the proportion of children with at least one episode (incidence) and the number of episodes, for each child, of dental pain or dental sepsis or both over the follow-up period. The cost-effectiveness outcomes were the cost per incidence of, and cost per episode of, dental pain and/or dental sepsis avoided over the follow-up period.

RESULTS

A total of 72 dental practices were recruited and 1144 participants were randomised (conventional arm, n = 386; biological arm, n = 381; prevention alone arm, n = 377). Of these, 1058 were included in an intention-to-treat analysis (conventional arm, n = 352; biological arm, n = 352; prevention alone arm, n = 354). The median follow-up time was 33.8 months (interquartile range 23.8-36.7 months). The proportion of children with at least one episode of pain or sepsis or both was 42% (conventional arm), 40% (biological arm) and 45% (prevention alone arm). There was no evidence of a difference in incidence or episodes of pain/sepsis between arms. When comparing the biological arm with the conventional arm, the risk difference was -0.02 (97.5% confidence interval -0.10 to 0.06), which indicates, on average, a 2% reduced risk of dental pain and/or dental sepsis in the biological arm compared with the conventional arm. Comparing the prevention alone arm with the conventional arm, the risk difference was 0.04 (97.5% confidence interval -0.04 to 0.12), which indicates, on average, a 4% increased risk of dental pain and/or dental sepsis in the prevention alone arm compared with the conventional arm. Compared with the conventional arm, there was no evidence of a difference in episodes of pain/sepsis among children in the biological arm (incident rate ratio 0.95, 97.5% confidence interval 0.75 to 1.21, which indicates that there were slightly fewer episodes, on average, in the biological arm than the conventional arm) or in the prevention alone arm (incident rate ratio 1.18, 97.5% confidence interval 0.94 to 1.48, which indicates that there were slightly more episodes in the prevention alone arm than the conventional arm). Over the willingness-to-pay values considered, the probability of the biological treatment approach being considered cost-effective was approximately no higher than 60% to avoid an incidence of dental pain and/or dental sepsis and no higher than 70% to avoid an episode of pain/sepsis.

CONCLUSIONS

There was no evidence of an overall difference between the three treatment approaches for experience of, or number of episodes of, dental pain or dental sepsis or both over the follow-up period.

FUTURE WORK

Recommendations for future work include exploring barriers to the use of conventional techniques for carious lesion detection and diagnosis (e.g. radiographs) and developing and evaluating suitable techniques and strategies for use in young children in primary care.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN77044005.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 1. See the NIHR Journals Library website for further project information.

Meeting the needs of patients with disabilities: how can we better prepare the new dental graduate?

Background Over the last two decades, the introduction of equality legislation has resulted in disabled people having improved opportunities and better access to services. Within the field of oral health care, the specialty of special care dentistry exists to act as an advocate for those with disabilities and it is recognised that there is a need to reduce health inequalities. To ensure the future dental workforce is able to respond to the needs of those with disabilities, education is key. This raises the question: 'are we adequately preparing future dental professionals to fulfil their obligations?'.Aim To explore final year dental students' insight into issues of disability in order to inform the undergraduate special care dentistry programme.Method Qualitative methods using focus groups were employed to address the research issue. The data were analysed using thematic analysis.Results Four main themes were identified: 'perceptions of disability', 'experience of disability', 'patient management' and 'teaching and learning'. The level of preparedness varied among students and could be attributed to: knowledge of disability issues; previous experience of people with disabilities; how education in the field of special care dentistry was delivered. Students identified the need for more structure to their teaching and increased exposure to the disabled community.Conclusion The issues identified reflect current literature and highlight the importance of addressing disability within the wider undergraduate curriculum. Responding to the 'student voice' has the potential to tailor elements of the special care dentistry programme, in order to address their educational needs.

Use of programme budgeting and marginal analysis to set priorities for local NHS dental services: learning from the north east of England

Background

Priority setting is necessary where competing demands exceed the finite resources available. The aim of the study was to develop and test a prioritization framework based upon programme budgeting and marginal analysis (PBMA) as a tool to assist National Health Service (NHS) commissioners in their management of resources for local NHS dental services.

Methods

Twenty-seven stakeholders (5 dentists, 8 commissioners and 14 patients) participated in a case-study based in a former NHS commissioning organization in the north of England. Stakeholders modified local decision-making criteria and applied them to a number of different scenarios.

Results

The majority of financial resources for NHS dental services in the commissioning organization studied were allocated to primary care dental practitioners' contracts in perpetuity, potentially constraining commissioners' abilities to shift resources. Compiling the programme budget was successful, but organizational flux and difficulties engaging local NHS commissioners significantly impacted upon the marginal analysis phase.

Conclusions

NHS dental practitioners' contracts resemble budget-silos which do not facilitate local resource reallocation. 'Context-specific' factors significantly challenged the successful implementation and impact of PBMA. A local PBMA champion embedded within commissioning organizations should be considered. Participants found visual depiction of the cost-value ratio helpful during their initial priority setting deliberations.

A Pilot Study to Assess Feasibility of Lay Representation in Dental School Admissions Interviews

Regulatory bodies in the dental profession often include members of the public as a way to ensure that patient interests are represented. With student selection for admission to dental school being a multifaceted, highly competitive process, this study was motivated by curiosity about the value of involving members of the public in the admissions process. At Newcastle University School of Dental Sciences, UK, semi-structured selection interviews conducted by two members of the faculty staff are part of the process. In the 2016-17 and 2017-18 admissions cycles, four lay representatives joined a number of the interview sessions. The aim of this study was to determine the feasibility of having a lay person present during the selection interview and whether this could become an integral part of the admissions process. A secondary purpose was to internally validate the processes in place for the interviews by considering the alignment of judgments of the panel and lay representatives. This study followed a two-stage, mixed-methods design. Quantitative analysis compared numerical interview scores awarded by the panel and lay representative when present. Scores for each question domain and overall interview score were compared. Qualitative analysis was carried out by conducting a focus group with lay representatives to seek insight into their experience and reflections on the interview processes. Thematic analysis was used, and overarching themes identified. The results showed no statistically significant difference between the interview panel and lay persons' scores for each domain or overall score awarded for the interview. The thematic analysis identified three overarching themes: reason for volunteering, process and training, and thoughts on style of interview used. These results suggest that involvement of lay people from the local community was feasible, and there was interest in continuing this involvement from the volunteers themselves.

Systematic Review of Evidence Pertaining to Factors That Modify Risk of Early Childhood Caries

INTRODUCTION

A systematic review of evidence on the impact of modifiable risk factors on early childhood caries (ECC) was conducted to inform recommendations in a World Health Organization manual on ECC prevention.

OBJECTIVES

To systematically review published evidence pertaining to the effect of modifiable risk factors on ECC.

METHODS

Twelve questions relating to infant feeding, diet, oral hygiene, and fluoride were addressed, as prioritized by a World Health Organization expert panel. Questions pertaining to the use of fluoride toothpaste were excluded due to its proven efficacy. The target population was children aged <72 mo. Data sources included Medline, Embase, CINAHL, and PubMed, and all human epidemiologic studies were included. The highest level of evidence was used for evidence synthesis and, where possible, meta-analysis. The review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) statement, with evidence assessed via the GRADE method.

RESULTS

Of the 13,831 papers identified, 627 were screened in duplicate; of these, 139 were included. The highest-level evidence indicated that breastfeeding ≤24 mo does not increase ECC risk but suggested that longer-duration breastfeeding increases risk (low-quality evidence). Low-quality evidence indicated increased risk associated with consumption of sugars in bottles. Only 1 study had data on the impact of sugars in complementary foods, which increased risk. Moderate-quality evidence showed a benefit of oral health education for caregivers (odds ratio, 0.39; 95% CI, 0.19 to 0.80, P = 0.009). Meta-analysis of data on the impact on ECC from living in a fluoridated area showed a significant effect (mean difference, -1.25; 95% CI, -1.24 to -0.36; P = 0.006). Limited moderate- and low-quality data indicated a benefit of fluoride exposure from salt and milk, respectively.

CONCLUSION

The best available evidence indicates that breastfeeding up to 2 y of age does not increase ECC risk. Providing access to fluoridated water and educating caregivers are justified approaches to ECC prevention. Limiting sugars in bottles and complementary foods should be part of this education.

KNOWLEDGE TRANSFER STATEMENT

This research is being used by the World Health Organization in developing a toolkit on the prevention and management of early childhood caries. The information will guide 1) governments in developing national oral health plans and 2) clinicians when providing preventive advice, including that regarding infant feeding practices. It will help ensure that advice is in line with current World Health Organization guidelines and the best available evidence.

Resource allocation in NHS dentistry: recognition of societal preferences (RAINDROP): study protocol

Background

Resources in any healthcare systems are scarce relative to need and therefore choices need to be made which often involve difficult decisions about the best allocation of these resources. One pragmatic and robust tool to aid resource allocation is Programme Budgeting and Marginal Analysis (PBMA), but there is mixed evidence on its uptake and effectiveness. Furthermore, there is also no evidence on the incorporation of the preferences of a large and representative sample of the general public into such a process. The study therefore aims to undertake, evaluate and refine a PBMA process within the exemplar of NHS dentistry in England whilst also using an established methodology (Willingness to Pay (WTP)) to systematically gather views from a representative sample of the public.

Methods

Stakeholders including service buyers (commissioners), dentists, dental public health representatives and patient representatives will be recruited to participate in a PBMA process involving defining current spend, agreeing criteria to judge services/interventions, defining areas for investment and disinvestment, rating these areas against the criteria and making final recommendations. The process will be refined based on participatory action research principles and evaluated through semi-structured interviews, focus groups and observation of the process by the research team. In parallel a representative sample of English adults will be recruited to complete a series of four surveys including WTP valuations of programmes being considered by the PBMA panel. In addition a methodological experiment comparing two ways of eliciting WTP will be undertaken.

Discussion

The project will allow the PBMA process and particularly the use of WTP within it to be investigated and developed. There will be challenges around engagement with the task by the panel undertaking it and with the outputs by stakeholders but careful relationship building will help to mitigate this. The large volume of data will be managed through careful segmenting of the analysis and the use of the well-established Framework approach to qualitative data analysis. WTP has various potential biases but the elicitation will be carefully designed to minimise these and some methodological investigation will take place.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3302-8) contains supplementary material, which is available to authorized users.

Tooth brushing frequency and risk of new carious lesions

Data sourcesMedline, Embase, CINHAL and the Cochrane databases.Study selectionTwo reviewers selected studies, and case-control, prospective cohort, retrospective cohort and experimental trials evaluating the effect of toothbrushing frequency on the incidence or increment of new carious lesions were considered.Data extraction and synthesisTwo reviewers undertook data abstraction independently using pre-piloted forms. Study quality was assessed using a quality assessment tool for quantitative studies developed by the Effective Public Health Practice Project (EPHPP). Meta-analysis of caries outcomes was carried out using RefMan and meta-regressions undertaken to assess the influence of sample size, follow-up period, caries diagnosis level and study methodological quality.ResultsThirty-three studies were included of which 13 were considered to be methodologically strong, 14 moderate and six weak. Twenty-five studies contributed to the quantitative analysis. Compared with frequent brushers, self-reported infrequent brushers demonstrated a higher incidence of carious lesions, OR=1.50 (95%CI: 1.34 -1.69). The odds of having carious lesions differed little when subgroup analysis was conducted to compare the incidence between ≥2 times/d vs <2 times/d; OR=1.45; (95%CI; 1.21 - 1.74) and ≥1 time/d vs <1 time/d brushers OR=1.56; (95%CI; 1.37 - 1.78). Brushing <2 times/day significantly caused an increment of carious lesions compared with ≥2/day brushing, standardised mean difference [SMD] =0.34; (95%CI; 0.18 - 0.49). Overall, infrequent brushing was associated with an increment of carious lesions, SMD= 0.28; (95%CI; 0.13 - 0.44). Meta-analysis conducted with the type of dentition as subgroups found the effect of infrequent brushing on incidence and increment of carious lesions was higher in deciduous, OR=1.75; (95%CI; 1.49 - 2.06) than permanent dentition OR=1.39; (95% CI: 1.29 -1.49). Meta-regression indicated that none of the included variables influenced the effect estimate.ConclusionsIndividuals who state that they brush their teeth infrequently are at greater risk for the incidence or increment of new carious lesions than those brushing more frequently. The effect is more pronounced in the deciduous than in the permanent dentition. A few studies indicate that this effect is independent of the presence of fluoride in toothpaste.

Forty years of national surveys: An overview of children's dental health from 1973-2013

INTRODUCTION

The first national survey of children's dental health in England and Wales was carried out in 1973. Subsequent surveys, in 1983, 1993 and 2003, included all United Kingdom health departments. The 2013 survey involved England, Wales and Northern Ireland.

AIM

To consider all five surveys, from 1973 to 2013, so as to summarise trends in the dental health of children in the UK over the last 40 years.

MATERIALS AND METHOD

The 2013 survey was commissioned by the Health &Social Care Information Centre and all surveys used data collected during dental examinations conducted in schools on a random sample of children by NHS dentists, together with a questionnaire to parents of those children. In 2013, a pupil questionnaire for 12- and 15-year-olds was introduced, to complement information received from parents and carers.

RESULTS

A total of 69,318 children, aged 5-15 years, were involved, from 1973-2013. Caries prevalence has reduced from 72% to 41% in 5-year-olds, and from 97% to 46% in 15-year-olds in 40 years. Changes in periodontal disease, orthodontic treatment, accidental damage to anterior teeth, tooth surface loss and enamel defects, are also summarised. Behavioural and attitudinal characteristics observed in the 2013 report are listed.

CONCLUSIONS

Caries is now concentrated in a minority of children. The prevalence of gingivitis has not changed a great deal in 40 years. About half of those children assessed 'in orthodontic need' receive treatment.

Mechanisms of the placebo effect in pain and psychiatric disorders

Placebo effect research over the past 15 years has improved our understanding of how placebo treatments reduce patient symptoms. The expectation of symptom improvement is the primary factor underlying the placebo effect. Such expectations are shaped by past experiences, contextual cues and biological traits, which ultimately modulate one's degree of response to a placebo. The body of evidence that describes the physiology of the placebo effect has been derived from mechanistic studies primarily restricted to the setting of pain. Imaging findings support the role of endogenous opioid and dopaminergic networks in placebo analgesia in both healthy patients as well as patients with painful medical conditions. In patients with psychiatric illnesses such as anxiety disorders or depression, a vast overlap in neurological changes is observed in drug responders and placebo responders supporting the role of serotonergic networks in placebo response. Molecular techniques have been relatively underutilized in understanding the placebo effect until recently. We present an overview of the placebo responder phenotypes and genetic markers that have been associated with the placebo effect in pain, schizophrenia, anxiety disorders and depression.

Learning from contract change in primary care dentistry: A qualitative study of stakeholders in the north of England

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Commissioners’ ability to reallocate resources between contracts is constrained.

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Patients are unclear about the costs of dental treatment and the NHS charge bands.

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Dentists dislike the target-based approach involving units of dental activity.

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Disease prevention is not adequately rewarded under the current dental contract.

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The quality of dental care provided by dentists should be measured and rewarded.

The aim of this research was to explore and synthesise learning from stakeholders (NHS dentists, commissioners and patients) approximately five years on from the introduction of a new NHS dental contract in England. The case study involved a purposive sample of stakeholders associated with a former NHS Primary Care Trust (PCT) in the north of England. Semi-structured interviews were conducted with 8 commissioners of NHS dental services and 5 NHS general dental practitioners. Three focus group meetings were held with 14 NHS dental patients. All focus groups and interviews were audio recorded and transcribed verbatim. The data were analysed using a framework approach. Four themes were identified: ‘commissioners’ views of managing local NHS dental services’; ‘the risks of commissioning for patient access’; ‘costs, contract currency and commissioning constraints’; and ‘local decision-making and future priorities’. Commissioners reported that much of their time was spent managing existing contracts rather than commissioning services. Patients were unclear about the NHS dental charge bands and dentists strongly criticised the contract's target-driven approach which was centred upon them generating ‘units of dental activity’. NHS commissioners remained relatively constrained in their abilities to reallocate dental resources amongst contracts. The national focus upon practitioners achieving their units of dental activity appeared to outweigh interest in the quality of dental care provided.

Solution-based circuits enable rapid and multiplexed pathogen detection

Electronic readout of markers of disease provides compelling simplicity, sensitivity and specificity in the detection of small panels of biomarkers in clinical samples; however, the most important emerging tests for disease, such as infectious disease speciation and antibiotic-resistance profiling, will need to interrogate samples for many dozens of biomarkers. Electronic readout of large panels of markers has been hampered by the difficulty of addressing large arrays of electrode-based sensors on inexpensive platforms. Here we report a new concept--solution-based circuits formed on chip--that makes highly multiplexed electrochemical sensing feasible on passive chips. The solution-based circuits switch the information-carrying signal readout channels and eliminate all measurable crosstalk from adjacent, biomolecule-specific microsensors. We build chips that feature this advance and prove that they analyse unpurified samples successfully, and accurately classify pathogens at clinically relevant concentrations. We also show that signature molecules can be accurately read 2  minutes after sample introduction.

Optimized templates for bottom-up growth of high-performance integrated biomolecular detectors

Electrochemical deposition of metals represents an important approach in the bottom-up fabrication of nanostructures and microstructures. We have used this approach to generate high-performance chip-based biosensors using silicon as a platform for the generation of sensor arrays. Here, we explore the applicability of different materials to support the electrodeposition and identify the parameters that are essential for robust sensor growth. We show that inexpensive materials can be used as templates for electrodeposition, and demonstrate that these low-cost sensors exhibit clinically-relevant levels of sensitivity and specificity. In particular, we prove herein that the glass-based sensors successfully detect E. coli in urine, when present at the 100 cfu μL(-1) levels found typically in samples of patients with urinary tract infections.

A soil ingestion pilot study of a population following a traditional lifestyle typical of rural or wilderness areas

The relatively few soil ingestion studies underpinning the recommended soil ingestion rates for contaminated site human health risk assessments (HHRAs) that have been conducted to date assessed soil ingestion in children living in urban or suburban areas of the United States, and to a lesser extent, Europe. However, the lifestyle of populations living in North American urban and suburban environments is expected to involve limited direct contact with soil. Conversely, many populations, such as indigenous and Aboriginal peoples residing in rural and wilderness areas of North America and worldwide, participate in activities that increase the frequency of direct contact with soil. Qualitative exposure of Aboriginal populations inhabiting wilderness areas suggest that high levels of soil ingestion may occur that are many times greater than those recommended by regulatory agencies for use in HHRAs. Accordingly, a study of subjects selected from a wilderness community in Canada was conducted using mass balance tracer methods to estimate soil ingestion and the results compared with previous soil ingestion studies and regulatory guidelines for the soil ingestion rates used in HHRA of contaminated sites. A pilot study of 7 subjects living in the Nemiah Valley of British Columbia was conducted over a 3-week period. The mean soil ingestion rate estimated in this study using the 4 elemental tracers with the lowest food-to-soil ratios (i.e., Al, Ce, La, Si), was observed to be approximately 75 mg d(-1) (standard deviation 120 mg d(-1)), the median soil ingestion rate was 50 mg d(-1), and the 90th percentile was 211 mg d(-1). These soil ingestion rate estimates are higher than the soil ingestion estimates currently recommended for HHRAs of adults, and higher than those obtained in most previous studies of adults. However, the estimates are lower than the earlier qualitative assessments of subsistence lifestyles.

Managing resources in NHS dentistry: using health economics to inform commissioning decisions

BACKGROUND

The aim of this study is to develop, apply and evaluate an economics-based framework to assist commissioners in their management of finite resources for local dental services. In April 2006, Primary Care Trusts in England were charged with managing finite dental budgets for the first time, yet several independent reports have since criticised the variability in commissioning skills within these organisations. The study will explore the views of stakeholders (dentists, patients and commissioners) regarding priority setting and the criteria used for decision-making and resource allocation. Two inter-related case studies will explore the dental commissioning and resource allocation processes through the application of a pragmatic economics-based framework known as Programme Budgeting and Marginal Analysis.

METHODS/DESIGN

The study will adopt an action research approach. Qualitative methods including semi-structured interviews, focus groups, field notes and document analysis will record the views of participants and their involvement in the research process. The first case study will be based within a Primary Care Trust where mixed methods will record the views of dentists, patients and dental commissioners on issues, priorities and processes associated with managing local dental services. A Programme Budgeting and Marginal Analysis framework will be applied to determine the potential value of economic principles to the decision-making process. A further case study will be conducted in a secondary care dental teaching hospital using the same approach. Qualitative data will be analysed using thematic analysis and managed using a framework approach.

DISCUSSION

The recent announcement by government regarding the proposed abolition of Primary Care Trusts may pose challenges for the research team regarding their engagement with the research study. However, whichever commissioning organisations are responsible for resource allocation for dental services in the future; resource scarcity is highly likely to remain an issue. Wider understanding of the complexities of priority setting and resource allocation at local levels are important considerations in the development of dental commissioning processes, national oral health policy and the future new dental contract which is expected to be implemented in April 2014.

Developing an assessment in dental public health for clinical undergraduates attending a primary dental care outreach programme

BACKGROUND

This paper describes the development and implementation of a Dental Public Health (DPH) assessment within the Primary Dental Care Outreach (PDCO) course at Newcastle University. The assessment was piloted alongside the delivery of the Bachelor of Dental Surgery (BDS) curriculum in accordance with established learning outcomes.

AIM

To design and implement a pilot summative assessment, incorporating patients' social histories obtained by undergraduate students attending primary dental care outreach clinics.

METHOD

Undergraduates were tasked with obtaining a detailed social history from a patient seen during their two-year outreach attachment. Each student submitted a written account of their patient's social history and placed this in context by researching a number of demographic and social variables centred upon their patient's home residence. The final component involved writing a concise case feature for a nominated newspaper based upon the case history, where students were encouraged to identify one or more public health messages using language appropriate to a lay readership.

RESULTS

Seventy one clinical undergraduates (98.6% of the year-group) subsequently submitted all components of the assessment. Eighty six per cent of the year-group was deemed to have passed the assessment with 9.9% achieving a 'Merit' grade and 76% a 'Satisfactory' grade. Following the assessment, students and clinical teachers were asked for their feedback through a focus group for staff, and a brief feedback form for students.

CONCLUSION

Undergraduates subsequently reported greater awareness of the significance and importance of obtaining a detailed social history and its relevance when devising appropriate and realistic treatment plans.

Managing resources in NHS dentistry: the views of decision-makers in primary care organisations

OBJECTIVE

To investigate priority setting and decision-making in primary care organisations and to determine how resources are managed in order to meet the oral health needs of local populations.

METHOD

This is a qualitative study. The purposive sample comprised twelve dental public health consultants and six senior finance representatives from contrasting care systems across the United Kingdom. Participants completed a written information sheet followed by a recorded semi-structured telephone interview. Conversations were professionally transcribed verbatim and analysed independently by two investigators using the constant comparative method.

RESULTS

The emergent themes focused upon: the role of participants in decision-making; professional relationships; managing change; information needs; and identifying and managing priorities. There was wide interpretation with respect to participants' roles and perceived information needs for decision-making and commissioning. A unifying factor was the importance placed by participants upon trust and the influence of individuals on the success of relationships forged between primary care organisations and general dental practitioners.

CONCLUSION

To facilitate decision-making in primary care organisations, commissioners and managers could engage further with practitioners and incorporate them into commissioning and resource allocation processes. Greater clarity is required regarding the role of dental public health consultants within primary care organisations and commissioning decisions.

A study to assess the validity of clinical judgement in determining paediatric dental anxiety and related outcomes of management

OBJECTIVE

The aim of the present study was to determine the validity of subjective anxiety assessment and the outcomes of management of children receiving operative dental treatment.

SETTING

The study was conducted at the Departments of Sedation and Child Dental Health, Newcastle Dental Hospital, Newcastle upon Tyne, UK.

SUBJECTS AND METHODS

One hundred children and adolescents aged between 8 and 15 years participated in the study. Clinicians subjectively allocated 50 children for treatment with local analgesia alone (low anxiety), and identified 50 children who had the potential to benefit from nitrous oxide and oxygen sedation (high anxiety). Participants then completed the State-Trait Anxiety Inventory for Children (STAIC), the Venham Picture Test (VPT) and the Child Fear Survey Schedule-Dental Subscale (CFSS-DS). A global rating scale classified behaviour during dental treatment.

RESULTS

State anxiety and dental fear prior to treatment were significantly higher in children allocated to receive inhalation sedation (P = 0.004 and P = 0.005, respectively). There was no significant difference in trait anxiety or post-treatment state anxiety between the two groups (P = 0.69 and P = 0.06, respectively). Only 11% displayed 'negative' behaviour during treatment: 82% of this group represented those allocated to receive sedation.

CONCLUSION

Children receiving inhalation sedation were significantly more anxious prior to treatment than children receiving treatment with local analgesia alone. The findings support the subjective assessment of anxiety in children; however, objective anxiety measures may assist clinicians in identifying specific fears, which may ultimately aid patient management.

Epstein-Barr virus and post-transplant lymphoproliferative disease

There is convincing evidence that Epstein-Barr virus (EBV) is associated with post-transplant lymphoproliferative disease (PTLD). Primary EBV infection following transplantation occurs in as many as 90% of cases of PTLD in children and pretransplant EBV seronegativity is a recognized risk factor for developing PTLD. Other risk factors include young age at the time of transplant, the type of transplant that the recipient receives and the type and intensity of immunosuppression. The clinical presentation is often nonspecific and tissue biopsy is necessary to establish the diagnosis. There appears to be a correlation between PTLD and EBV viral load measured by polymerase chain reaction (PCR) of the peripheral blood and quantitative PCR may be a useful guide in the management of PTLD. Antiviral drugs and cytomegalovirus-immunoglobulin G may have a role in preventing PTLD. Because PTLD results from functional over-immunosuppression, the initial treatment is reduction of immunosuppression. Antiviral agents, interferon, immuno-based monoclonal therapy, cell-based therapy and chemotherapy also have a potential role in treating this disorder. At the present time there is no standardized approach to the evaluation and treatment of PTLD.

Reversal of protein-losing enteropathy with heparin therapy in three patients with univentricular hearts and Fontan palliation

We studied three pediatric patients with protein-losing enteropathy in conjunction with univentricular hearts and right atrial to pulmonary artery anastomosis (Fontan operation) before and during heparin therapy. Each patient showed dramatic improvements in symptoms, marked elevations in serum albumin levels, and quantitative reversal of enteric protein loss within a few weeks of beginning therapy. These findings suggest that heparin may be an important treatment for this poorly understood condition.

Scanning optical microellipsometer for pure surface profiling

We describe a scanning optical interferometer that can simultaneously perform ellipsometry measurements and thus provides a true surface profile. This is accomplished by projecting the back focal plane of the objective lens onto a CCD array. The measured phase differences between the p- and s-polarization components are converted, by using a specially developed algorithm, to optical phase changes caused by material variations. The compensation process is then applied to extract the true profile of the object surface. Experimental results obtained with the system are shown.

LSD flashback syndrome exacerbated by selective serotonin reuptake inhibitor antidepressants in adolescents

Two adolescents with a long history of abuse of lysergic acid diethylamide (LSD) and symptoms consistent with major depressive disorder, on initiation of antidepressant therapy with selective serotonin reuptake inhibitor agents, had the new onset or worsening of LSD flashback syndrome. The similarity in neuroreceptor physiology for both LSD and serotonin suggests that the LSD flashback syndrome may be induced by these drugs in patients with a history of LSD abuse.

Extended-focus phase imaging with an interferometric confocal microscope

We describe results obtained when a modified differential interferometer is used in a new imaging modality that we call extended-focus phase imaging. This modality is the phase analog of extended-focus imaging used in the confocal microscope. Our technique is applied to the measurement of the differential phase response of minute topographical variations on tilted samples. Results are presented that demonstrate the ability of the technique to produce high lateral resolution phase scans on samples with long-range warp and tilt over a range much greater than the depth of field of the objective lens, thus effectively allowing the depth of field of the phase microscope to be increased indefinitely.

Lactate oxidation for the detection of mitochondrial dysfunction in human skin fibroblasts

To screen fibroblasts for defects in lactate/pyruvate oxidation, cells were grown to confluence in 25-cm2 flasks, rinsed, and incubated in glucose-free media containing 25 microM L-lactate and 0.1 microCi [D,L-1-14C]lactate. Lactate oxidation was measured as the amount of lactate oxidized in nmol of 14CO2 generated/mg protein/min. Fibroblasts from patients with mitochondrial or peroxisomal disorders had decreased lactate oxidation compared to the control (CON): CON, 1.9 +/- 0.13 nmol/mg/min; neonatal adrenoleukodystrophy (NALD), 0.45 +/- 0.01 (P < 0.001); rhizomelic chondrodysplasia punctata (RCDP), 0.13 +/- 0.002 (P < 0.001); mitochondrial defect of unknown etiology (MIT), 0.77 +/- 0.003 (P < 0.001); pyruvate dehydrogenase (PDH) deficiency, 0.98 +/- 0.02 (P < 0.001). This method is useful for screening fibroblasts for defects in lactate oxidation in patients with mitochondrial or peroxisomal disorders. Confirmation of the site of the defect may then be investigated with specific assays, e.g., PDH, in cellular homogenates: CON, 0.93 +/- 0.02 nmol/mg/min; NALD, 0.55 +/- 0.02; RCDP, 0.44 +/- 0.02; MIT, 0.53 +/- 0.03; PDH deficiency, 0.19 +/- 0.02.

Lactic acidosis and mitochondrial dysfunction in two children with peroxisomal disorders

Mitochondrial myopathies and defects in oxidative phosphorylation have been described in some patients with peroxisomal disorders. Although peroxisomes and mitochondria play a role in the beta-oxidation of fatty acids, the metabolic interactions between the two are not well defined. Defects in peroxisomal beta-oxidation are associated with extracellular accumulation of very long-chain fatty acids and may be accompanied by alterations in the intracellular pool of fatty acyl-CoAs, which are known to alter mitochondrial function. This study was initiated to examine alterations in the intracellular pool of acyl-CoAs and mitochondrial function in two children with generalized disorders of peroxisomal function and clinical lactic/pyruvic acidaemia. Fibroblasts were cultured from skin biopsies obtained from one child with neonatal adrenoleukodystrophy (NALD) and another with rhizomelic chondrodysplasia punctata (RCDP). Fibroblast lactate oxidation was significantly inhibited in NALD by 76% and RCDP by 92% compared to control values of 1.9 +/- 0.1 nmol/min per mg protein. Pyruvate dehydrogenase (PDH) (mean +/- SEM; activity nmol/min per mg protein) was: NALD 0.55 +/- 0.02 (p < 0.01), RCDP 0.44 +/- 0.02 (P < 0.01), and controls 0.83 +/- 0.02. The acid-insoluble (long-chain and very long-chain) acyl-CoA levels (mean +/- SEM; pmol/mg protein) were: NALD 129 +/- 69 (p < 0.01), RCDP 65 +/- 15 (p < 0.05), and control 45 +/- 7. These two patients with generalized peroxisomal disorders exhibited an increase in intracellular acyl-CoA species accompanied by decreased PDH activity and clinical lactic/pyruvic acidaemia.

Dietary ether lipid incorporation into tissue plasmalogens of humans and rodents

Chronic feeding of 1-O-octadecyl-sn-glycerol (batyl alcohol) to patients suffering from congenital deficiency in tissue ether glycerolipids showed an increase in the plasmalogens content of their erythrocytes. However, nothing is known about the ether lipid content of other tissues in these patients. Feeding 1-O-heptadecyl-sn-glycerol to young rats showed that this uncommon ether lipid was incorporated to a high extent into the plasmalogens of all tissues except brain. Comparative studies with other precursors, such as 3-O-heptadecyl-sn-glycerol, heptadecanol and heptadecanoic acid, indicated a stereospecific incorporation of the dietary 1-O-alkyl-sn-glycerols into tissue plasmalogens without cleavage of the ether bond. Dietary ether lipids were also shown to be transferred from mothers to suckling rats, but not from pregnant rats to fetuses. The implication of these results to possible dietary ether lipid therapy for patients suffering from peroxisomal disorders is discussed.

Immunology of inflammatory bowel disease: summary of the proceedings of the Subcommittee on Immunosuppressive Use in IBD

As outlined, scanty data exist with regard to immunologic therapy in children with IBD despite the fact that the pediatric population affords a unique opportunity for clinical evaluation. Children are less affected by modifying conditions such as smoking, alcohol ingestion, and the long-term use of medications, and because of their specific needs for ponderal and linear growth, children might benefit most from immunological therapy that has been proven to be steroid sparing. Therefore, clinical trials to evaluate the efficacy of 6-MP and/or azathioprine in growing children with Crohn's disease would appear to provide a fruitful avenue for collaborative research. Efforts to organize a multicenter evaluation of these agents have been initiated. The studies are crucial in evaluating the efficacy and safety of immunosuppressive therapy in the pediatric population with IBD.

Peroxisomal disorders: clinical commentary and future prospects

Recent progress in the classification, biochemistry, and molecular biology of peroxisomal disorders is reviewed from a clinical perspective. Diseases such as Zellweger syndrome, neonatal adrenoleukodystrophy, infantile Refsum disease, hyperpipecolic acidemia, chondrodysplasia punctata, and Leber amaurosis share a common phenotype and involve deficiency of multiple peroxisomal enzymes. These disorders are associated with diverse metabolic abnormalities which are useful in pre- or postnatal diagnosis and distinguish these disorders from others such as X-linked adrenoleukodystrophy, adult Refsum disease, hyperoxaluria type I, and acatalasemia. Peroxisome structure is difficult to quantify histologically, since recent studies emphasize its developmental variability and tissue heterogeneity. The ability to manipulate this structure by dietary or pharmaceutical means provides a novel approach to therapy. At the molecular level, deficiency of peroxisomal enzymes responsible for fatty acid beta-oxidation or ether lipid synthesis reflects enhanced protein degradation due to abnormal peroxisomes; messenger RNA for the beta-oxidation enzymes is transcribed normally in peroxisomal disorders and can be increased by peroxisome proliferators. At least one integral structural protein of the peroxisome is synthesized normally in Zellweger syndrome. Hypotheses for the basic defect include defective regulation, uptake, or coenzyme stimulation of imported proteins, as well as defective biosynthesis. One clue to this defect may be a similar evolutionary history of peroxisomes and mitochondria which would explain their common alteration in Zellweger syndrome.

Widened sutures in childhood meningitis: unrecognized sign of an acute illness

Disagreement exists over the time for sutural widening to occur with increased intracranial pressure in children. Twenty-four children ranging in age from 2 months to 4 years with acute meningitis had skull films upon admission to C. S. Mott Children's Hospital. Nine of the children had widened sutures on initial skull films. Sutural widening was documented as early as 2 days after onset of meningitis. Occasionally, skull films may help in the diagnosis of meningitis.