A systematic review of the association between food insecurity and behaviours related to caries development in adults and children in high-income countries.

OBJECTIVES: To synthesize and appraise the evidence regarding the relationship between food insecurity and behaviours associated with dental caries development in adults and children in high-income countries. METHODS: A systematic review including observational studies assessing the association between food insecurity and selected dietary (free sugar consumption) and non-dietary factors (tooth brushing frequency; use of fluoridated toothpaste; dental visiting; oral hygiene aids; type of toothbrush used; interdental cleaning frequency and mouthwash use) related to dental caries development in adults and children in high-income countries. Studies specifically looking at food insecurity during the COVID-19 pandemic were excluded. Searches were performed in MEDLINE, Embase, Global Health and Scopus from inception to 25 May 2023. Two authors screened the search results, extracted data and appraised the studies independently and in duplicate. Study quality was assessed using the Newcastle-Ottawa Scale (with modifications for cross-sectional studies). Vote counting and harvest plots provided the basis for evidence synthesis. RESULTS: Searches identified 880 references, which led to the inclusion of 71 studies with a total of 526 860 participants. The majority were cross-sectional studies, conducted in the USA and reported free sugar consumption. Evidence for the association between food insecurity and free sugar intake from 4 cohort studies and 61 cross-sectional studies including 336 585 participants was equivocal, particularly in the sugar-sweetened beverage (SSB) consumption post-hoc subgroup, where 20 out of 46 studies reported higher SSB consumption in food insecure individuals. There was consistent, but limited, evidence for reduced dental visiting in adults experiencing food insecurity compared to food secure adults from 3 cross-sectional studies including 52 173 participants. The relationship between food insecurity and dental visiting in children was less clear (3 cross-sectional studies, 138 102 participants). A single cross-sectional study of 3275 children reported an association between food insecurity and reported failure to toothbrush the previous day. CONCLUSIONS: This review did not identify clear associations between food insecurity and behaviours commonly implicated in the development of dental caries that would explain why individuals experiencing food insecurity are more likely to have dental caries than those who have food security. There was some evidence of decreased dental visiting in adults experiencing food insecurity. Common methodological weaknesses across the evidence base related to the selection of participants or control of potentially confounding variables. Consequently, the quality of evidence for all outcomes was downgraded to very low. More research is needed to explore access to oral hygiene products and household environments conducive to habitual oral self-care in food insecure populations.

Is dental caries associated with lower respiratory tract infections?

Design This study comprised an analysis of data from a cohort, born in the Finnish city of Espoo between January 1 1984 and March 31 1990.Objectives The objective of the study was to investigate the effect of dental caries on the risk of lower respiratory tract infections (LRTI) in participants aged 20-27, using data collected during the 20-year follow-up conducted in 2010-2011.Data Dental caries experience was determined by asking study participants 'Estimate, how many teeth with a filling you have?' LRTI was defined as at least one occurrence in the 12 months prior to the administration of the 20-year questionnaire. LTRI data were obtained by asking participants if they had suffered from influenza or pneumonia, bronchitis, bronchiolitis or unspecified lower respiratory tract infection. In addition, data were obtained from the National Hospital Discharge Register. Risk ratios were determined using Poisson regression models.Results Having a high number of filled teeth was associated with an increased number of LRTIs (adjusted relative risk 1.24) and was not modified by the family's socioeconomic status or by smoking.Conclusions The authors suggest that dental caries increases the risk of LRTIs, but concede that common risk factors might explain at least partly the observed relation between filled teeth and LRTIs.

The prevalence of enamel and dentine caries lesions and their determinant factors among children living in fluoridated and non-fluoridated areas.

OBJECTIVE: To determine the prevalence and severity of dental caries (at dentine and enamel levels of diagnosis) amongst Malaysian children and to investigate determinant factors associated with caries detection at these different thresholds. METHODS: This study involved life-long residents aged 12 years-old in fluoridated and non-fluoridated areas in Malaysia (n=595). The survey was carried out in 16 public schools by a calibrated examiner, using ICDAS-II criteria. A questionnaire on socio-demographic and oral hygiene practices was self-administered by parents/guardians. Data were analysed using Mann-Whitney U tests and logistic regression. RESULTS: The overall response rate was 74.4%. Caries prevalence at the dentine level or at the dentine and enamel level was significantly (p⟨0.001) higher among children in the non-fluoridated area (D1₋6MFT⟩0 = 82.4%, D4₋6MFT⟩0 = 53.5%) than in the fluoridated area (D1₋6MFT⟩0 = 68.7%, D4₋6MFT⟩0 = 25.5%). Considering only the decayed component of the index, no significant differences were observed between the two areas when the detection threshold was set at enamel caries (D1₋3) (p=0.506). However, when the detection criteria were elevated to the level of caries into dentine (D4₋6) there were clear differences between the fluoridated and non-fluoridated areas (p=0.006). Exposure to fluoridated water proved a significant predictor for lower caries prevalence in the statistical model. Children whose father and mother had a low monthly income had a significantly higher dentine caries prevalence. CONCLUSION: Results confirmed existing evidence of the benefit of water fluoridation in caries prevention. Detection criteria set at caries into dentine shows clear differences between fluoridated and non-fluoridated areas. Exposure to fluoridated water and socio-economic status were associated with caries prevalence.

Exploring the feasibility of using routinely collected data to produce antibiotic prescribing profiles for general dental practitioners in Wales.

This article describes a project that assessed whether routinely collected antibiotic prescribing and NHS dental treatment data could be linked to produce personalised prescribing profiles for general dental practitioners working in Wales, UK. Dental public health competencies required for this work included: Multi-agency working to develop a sustainable system of monitoring antibiotic prescribing in primary dental care in Wales, Dental public health intelligence, Development of dental service quality indicators.

Editorial-How soon is soon enough? The challenge of implementing behaviours conducive to good oral health in at-risk infants and toddlers.

This commentary is about one of the last great challenges facing dental public health. It is a problem I will discuss in a United Kingdom context, but the issues will, I am sure, be of relevance to all readers of this Journal wherever they practice. It is a problem that I spent many hours trying to address when I was in the early stages of my career. Now, when I am nearer the end than the beginning, it is still a problem. The issue? Preventing dental decay in those aged under 3 years old, who in the main, reside in areas of social and economic disadvantage.

The acceptability of fluoride varnish and fissure sealant treatments in children aged 6-9 delivered in a school setting.

OBJECTIVE: To assess the acceptability of fluoride varnish and fissure sealant treatments for children. To investigate the acceptability of delivering this treatment in a school setting for children, parents, clinicians and school staff. BASIC RESEARCH DESIGN: Semi-structured interviews (with children, parents, clinicians and school staff) and a questionnaire (for school staff) as part of a two-arm, randomised clinical trial. PARTICIPANTS: Children aged 6-9, their parents, clinical staff and school staff. INTERVENTIONS: Fluoride varnish or fissure sealant was delivered to children from the ages of 6 to 9 years for 36 months, by a community dental service in a school setting. Fluoride varnish was re-applied every 6 months; fissure sealant was applied once to first permanent molars and re-applied as required. RESULTS: Interviews with children a few days after treatment indicated little difference in preference; acceptability at this point was driven by factors such as finding it fun to visit 'the van' (i.e. mobile dental unit) and receiving a "sticker" rather than specific treatment received. Interviews with parents, clinicians and school staff indicated high acceptability of delivering this type of intervention in a school setting; this may have been partly due to the service being delivered by a well-established, child-oriented community dental service which delivered the clinical trial. CONCLUSIONS: Preventive fluoride varnish and fissure sealant treatments in a school setting has high overall acceptability.

The changing epidemiology of oral cancer: definitions, trends, and risk factors.

Objective: This review has three objectives, namely: (i) to discuss how oral cancer is and ought to be defined and recorded; (ii) to present up-to-date data on the incidence burden of the disease in the four countries of the UK, and review recent analyses of trends in the disease; and (iii) to summarise recent evidence on risk factors of the disease. Methods: Cancer definitions were clarified by the International Classification of Diseases accounting for anatomical and aetiological differences; descriptive epidemiology included international / UK literature review and information requests for incidence data from the UK cancer registries (2000-2016); analytical epidemiology focused on reviewing the findings of the International Head and Neck Cancer Epidemiology (INHANCE) consortium, which has pooled data from multiple case-control studies providing the best estimates of risk factors. Results: Emerging evidence of the role played by risk factors in different anatomical sites means that oral cavity cancer and oropharynx cancer should be considered distinct disease entities ­ and a standardised attribution of anatomical subsites will be helpful in ensuring consistency in how data are presented. In 2016, over 3,700 people were diagnosed with oral cavity cancer and over 3,500 people were diagnosed with oropharyngeal cancer in the UK. Incidence of oropharyngeal cancer is rapidly rising across the UK. Rates of oral cavity cancer are higher in Northern Ireland and higher still (and relatively stable) in Scotland, but rising in England and Wales. INHANCE data show that while the consumption of alcohol and tobacco are the prime risk factors for oral cavity and oropharyngeal cancers, they provide greater certainty in the preventive benefits of reducing these risk factors. The role played by other factors such as low socioeconomic status, genetics, oral health, and human papillomavirus (only for oropharyngeal cancer) have become clearer. Conclusions: This epidemiology provides a strong foundation for designing and managing both population and individual oral cavity and oropharyngeal cancer control strategies.

Why might patients in the UK consult a general medical practitioner when experiencing dental problems? A literature review of patients' perspectives.

OBJECTIVE: to systematically appraise and synthesise the existing evidence regarding the reasons why patients in the UK may consult a general medical practitioner (GMP) when experiencing a dental problem. BASIC RESEARCH DESIGN: a systematic review of the scientific and grey literature published between 1996 and 2017. PARTICIPANTS: dental service users (adults or children) from the UK and/or their carers who were seeking, or had sought, care for a dental problem from a GMP. MAIN OUTCOMES: patients' perspectives on reasons for consulting a GMP were qualitatively synthesised according to Levesque et al.'s conceptual framework of access to health care. RESULTS: Out of 1,232 references screened, 2 studies met the inclusion criteria for the review. They identified the following factors that can influence care-seeking for dental problems: patients' interpretation of their symptoms; their understanding of practitioners' scope of practice; the availability of timely dental care; and the affordability of care. Both studies had weaknesses with regard to either their conduct and/or reporting. CONCLUSIONS: Choice of practitioner for dental problems is likely to be influenced by both the beliefs and attitudes of the individual patient and the organisation and attributes of the providers of dental and medical care. However, in light of the quality of the existing evidence base, there is a need for high-quality studies exploring the reasons why patients in the UK may seek care from a GMP when experiencing dental problems.

Reasons for placement and replacement of crowns in general dental practice.

Objectives: The aim of this study was to investigate the reasons for placement and replacement of crowns in general dental practice. Methods: Forty general dental practitioners recorded the principal reason for the provision of new (initial) and replacement crowns for a maximum of up to 20 patients over a 20-week period. Results: A total of 664 patients received 783 crowns during the period of this study. Of these, 69% (n = 542) were new (initial) placements and 31% (n = 241) were replacements. Overall, tooth fracture (45%, n = 241) was the most frequently reported reason for new/ initial crown placements. Aesthetics (21%, n = 53) and secondary/recurrent caries (20%; n = 47) were the most frequent reasons for crown replacement. Maxillary premolars (27%, n = 145) and mandibular molars (25%, n = 137) were the teeth that received most initial crown placements. In contrast, maxillary incisors (50%, n = 115) were the most common teeth to receive a replacement crown. Dentists were more likely to replace a crown if they had not placed the original crown: 74% of replacement crowns (n = 178) were placed by a different dentist. Most patients had only one crown placed or replaced per course of treatment (n = 611; 90%). Conclusions: The results of this study reveal the prescribing habits of dentists in relation to provision of initial and replacement crowns. The vast majority of patients had only one crown provided per course of treatment, which is probably a reflection of funding schemes and changing patterns of oral health. This sample reported fewer replacement crowns than previous studies. In keeping with existing literature, crowns were more frequently replaced when the treating dentist had not placed the initial crown. However, against this, more replacements were provided for more long-standing patients (5+ years attendance) compared to those with shorter attendance history (<5 years). In an area where high quality evidence is lacking, further consensus on the need for placement and replacement crowns is needed. Such information would assist dentists to provide high-quality care and commissioners in developing an evidence-based service.

Fissure Seal or Fluoride Varnish? A Randomized Trial of Relative Effectiveness.

Fissure sealant (FS) and fluoride varnish (FV) are effective in preventing dental caries when compared with a no-treatment control. However, the relative clinical effectiveness of these interventions is uncertain. The objective of the study was to compare the clinical effectiveness of FS and FV in preventing dental caries in first permanent molars (FPMs) in 6- to 7-y-olds. The study design was a randomized clinical trial, with 2 parallel arms. The setting was a targeted-population program that used mobile dental clinics in schools located within areas of high social and economic deprivation in South Wales. A total of 1,016 children were randomized 1:1 to receive either FS or FV. Resin-based FS was applied to caries-free FPMs and maintained at 6-mo intervals. FV was applied at baseline and at 6-mo intervals for 3 y. The main outcome measures were the proportion of children developing caries into dentine (D4-6MFT) on any 1 of up to 4 treated FPMs after 36 mo. At 36 mo, 835 (82%) children remained: 417 in the FS arm and 418 in the FV arm. A smaller proportion of children who received FV ( n = 73, 17.5%) versus FS ( n = 82, 19.6%) developed caries into dentine on at least 1 FPM (odds ratio [OR] = 0.84; 95% CI, 0.59 to 1.21; P = 0.35), a nonstatistically significant difference between FS and FV treatments. The results were similar when the number of newly decayed teeth (OR = 0.86; 95% CI, 0.60 to 1.22) and tooth surfaces (OR = 0.85; 95% CI, 0.59 to 1.21) were examined. In a community oral health program, semiannual application of FV resulted in caries prevention that was not significantly different from that obtained by applying and maintaining FS after 36 mo (EudraCT: 2010-023476-23; ISRCTN: ISRCTN17029222).

Prevalence of Recommendations Made Within Dental Research Articles Using Uncontrolled Intervention or Observational Study Designs.

BACKGROUND: Evidence to inform clinical practice is reliant on research carried out using appropriate study design. The objectives of this work were to (i) identify the prevalence of articles reporting on human studies using uncontrolled intervention or observational research designs published in peer-reviewed dental journals and (ii) determine the nature of recommendations made by these articles. METHODS: Six peer-reviewed dental journals were selected. Issues published in January to June 2013 were examined and the types of articles published categorized. Following pre-defined inclusion/exclusion criteria, human studies classified as using uncontrolled intervention or observational research designs were subject to detailed review by two independent investigators, to examine if they presented clinical, policy or research recommendations and if these recommendations were supported by the data presented. RESULTS: 52.9% (n = 156) of studies published during the time period met the inclusion criteria. Studies with uncontrolled intervention or observational research designs comprised a larger proportion of the primary research studies published in the journals with lower impact factors (73.3%; n = 107) compared to the high impact journals (38.9%; n = 49). Analysis showed that 60.9% (n = 95) of the included studies made recommendations for clinical practice/dental policy. In 28.2% (n = 44) of studies, the clinical/policy recommendations made were judged to not be fully supported by the data presented. CONCLUSIONS: Many studies published in the current dental literature, which are not considered to produce strong evidence, make recommendations for clinical practice or policy. There were some cases when the recommendations were not fully supported by the data presented.

The teaching of Dental Public Health - 50 years on.

In 1966, James published an article in the British Dental Journal (and reprinted here) which made recommendations on the teaching of dental public health. The following commentary reviews the ideas put forward by James and how these relate to concepts of dental public health in the undergraduate dental curricula of 2016 .

The association between parents' perceived social norms for toothbrushing and the frequency with which they report brushing their child's teeth.

OBJECTIVES: To determine whether parents' judgements on how often other parents brush their children's teeth are associated with the frequency with which they brush their own children's teeth, and their satisfaction with their child's brushing routine. METHODS: A cross-sectional questionnaire survey completed by 297 parents of children aged 3-6. Parents were asked how often they brushed their own child's teeth per week, how often they thought other parents did so, and how satisfied they were with their child's toothbrushing routine. Demographic data were also collected. RESULTS: The mean frequency that parents brushed their children's teeth was 12.5 times per week. Multiple regression analysis tested the relationship between parents' perceptions of other parents brushing frequency (mean 10.5 times per week) and how often they brushed their own child's teeth, controlling for socio-demographic factors, and yielded a positive association (p < 0.001). There was a positive association between parents' satisfaction with their child's brushing routine and the extent to which they thought it was better than that of the average child (p < 0.001). CONCLUSIONS: Parents' judgements on how frequently other parents brush their children's teeth are associated with their own behaviour and satisfaction. Re-framing oral health messages to include some form of social normative information ("most parents do this") may prove more persuasive than simple prescriptive advice ("you should do this").

General dental practitioners' perceptions of antimicrobial use and resistance: a qualitative interview study.

BACKGROUND: Dentists are responsible for 9-10% of all antibiotics dispensed in primary care in the UK, many of which may be provided contrary to clinical guidelines. Since antibiotic consumption has been identified as a major cause of antibiotic resistance, dental prescribing may be a significant contributor to this important public health problem.Objective This study aims to explore general dental practitioners' (GDPs) perceptions and attitudes towards antibiotic use and resistance. METHOD: Qualitative interview study with 19 purposively sampled GDPs working in Wales. A set of open-ended questions were developed and amended during semi-structured telephone interviews. Interviews were recorded, transcribed verbatim and codes were developed using thematic analysis. RESULTS: Perceptions of antibiotic use and resistance varied widely between practitioners, particularly with respect to the prevalence and impact of resistant strains on the management of dentoalveolar infection, and the impact of dental prescribing on the emergence of resistance. GDPs reported that their antibiotic prescribing decisions were driven by both clinical pressures and wider public health considerations. CONCLUSIONS: Interventions to enhance the quality of antibiotic prescribing in primary care dentistry should address issues associated with inappropriate prescribing as well as providing education about the causes, prevalence and impact of antibiotic resistance.

Addressing oral health inequalities in the United Kingdom--the impact of devolution on population-based fluoride policy.

The front covers of the current volume of the British Dental Journal (Volume 215) feature drawings by children participating in the Welsh national oral health improvement programme - Designed to Smile. This programme involves 78,350 children in the Principality, who are deemed at greatest risk of tooth decay, participating in daily toothbrushing in 1,211 nurseries and schools. It mirrors the Childsmile programme in Scotland. Since devolution in 1999, approaches to oral health improvement across the United Kingdom have diverged. This article considers the way in which population-based policies with regards to fluoride use have varied between countries.

Attitudes towards establishing a daily supervised school-based toothbrushing programme--determined by Q-sort methodology.

OBJECTIVES: This study used Q-sort methodology to determine the views of staff involved in a national school-based daily toothbrushing programme. METHODS: Q-methodology is a mixed-method approach in which participants are asked to sort a collection of statements according to degree of agreement with them. Factor analysis identified subgroups of like-minded participants and revealed areas of consensus and disagreement. 24 Community Dental Service staff managing or delivering the toothbrushing programme were asked to rank 49 statements derived from previous qualitative interviews. RESULTS: Varimax rotation produced a three-factor solution with five/six participants loading significantly into each group. Groups divided largely according to staff role: Factor 1, mainly support workers (assistants with no oral-health background); Factor 2, managers; and factor 3, oral health educators (dental nurses with teaching qualifications). As staff new to the area of oral-health, the views of support workers were of particular interest. Unlike others, this group saw Designed to Smile as a unique health promotion scheme and wanted to involve as many children as possible, regardless of oral-disease risk. Managers' perceptions of issues affecting the establishment of the programme differed from those staff in day-to-day contact with the 515 schools in which the toothbrushing took place. CONCLUSIONS: This study used a long established but little used technique to ascertain the commonality of views of staff These data may be of value not only in managing the current programme, but for anyone who may be considering developing such a toothbrushing scheme.

Undergraduate students' experiences of outreach placements in dental secondary care settings.

INTRODUCTION: Outreach teaching is delivered as part of the undergraduate curricula of many dental schools. Evaluations of outreach in primary care settings have found learning opportunities beyond those available in the dental school setting, but less is known about secondary care placements. The aim of this evaluation was to assess dental students' experiences of an undergraduate outreach placement in secondary care. MATERIALS AND METHODS: Questionnaire survey based on a single cohort of final-year undergraduate dental students at Cardiff University who had completed a 1-week outreach secondment to a District General Hospital. RESULTS: Fifty-five of the 57 eligible students completed the questionnaire. Outreach placements in secondary care were experienced to provide positive additional educational benefit and were considered to be worthwhile by many (but not all) students. Clinical opportunities and staff teaching varied by site. DISCUSSION: In the current programme, the variability of student experience during secondments to secondary care means that some students report more benefit than others. However, even apparently negative experiences, such as cancelled operating lists, can contribute to the overall outcome in that they accurately reflect the reality of hospital practice. CONCLUSION: Careful management of secondary care undergraduate secondments is needed to ensure worthwhile learning experiences.