Associations between caries levels and BMI measures among five-year-old children. Analysis and cross-sectional multi-variable analysis at individual child level.

OBJECTIVES: To establish the existence and directions of any associations between measures of body mass index (BMI) with caries levels using individual measures of each as derived from national surveys in England. METHODS: The BMIs of five-year-old children calculated from the 2017 National Child Measurement Programme and caries measures from the 2016-17 Public Health England (PHE) National dental epidemiology survey were securely linked at a child level. Comparison at individual level of caries levels and BMI z scores was done using multivariable regression. RESULTS: Records for 67,033 children were linked and allocated a deprivation quintile. An association between BMI Z score categories and caries levels was established. Caries prevalence was higher among overweight (24.4%) and very overweight (27.6%) children compared with those of average BMI (22.5%). Odds ratios were statistically significant at 1.08 and 1.14 for prevalence among overweight and very overweight children. Children of low BMI were found to have higher caries severity (1.2 d3mft) and extent (4.4 d3mft among those with any caries) compared to children of healthy BMI (0.7 d3mft, 3.3 d3mft) with statistically significant Incidence Rate Ratio of 1.24. Underweight children were more likely to have caries experience and more severe attack compared with children of healthy weight. Deprivation and ethnicity were confounding factors. CONCLUSIONS: There is some association between child BMI status and caries levels whereby caries prevalence among children of higher BMI is increased. The associations are over and above those of deprivation, ethnicity and water fluoridation individually, but these factors impact on the strength of the link between BMI and caries.

A multi-variable analysis of four factors affecting caries levels among five-year-old children; deprivation, ethnicity, exposure to fluoridated water and geographic region.

OBJECTIVE: To assess the role of factors posited to affect population caries levels across England. BASIC RESEARCH DESIGN: Multivariable regression analysis assessing four potential determinants of caries severity and prevalence: deprivation, exposure to fluoridated water, ethnicity and geographic region Participants: Random sample of 121,875 five-year-old children in England in the 2014/15 academic year. MAIN OUTCOME MEASURES: Decayed, missing and filled teeth, with decay measured at the dentinal level, (d3mft), presented as prevalence (dmft⟩0) and extent of decay among children who have any (d3mft if d3mft>0). INDEPENDENT VARIABLES: Parental reported ethnicity from school records, index of multiple deprivation (IMD) scores, region and exposure to water fluoridation calculated utilising home postcodes. RESULTS: The data support wider literature displaying associations between caries and deprivation across a social gradient. The important, new findings are deprivation, some ethnic groups and lack of exposure to water fluoridation are all associated with increased prevalence and severity of caries when considered together and independently. New evidence supports the impact of water fluoridation on health inequalities in that the greatest impact of exposure to fluoridated water was seen in the most deprived children and those from an Asian / Asian British ethnic group. CONCLUSIONS: Five-year-old children who were from the most deprived areas, not exposed to fluoridated water, of an Eastern European ethnic group and living in the North West demonstrated the highest prevalence and severity of caries in the survey under scrutiny. This is of public health importance, providing evidence for population groups to target with health improvement activities.

Why are caries levels reducing in five-year-olds in England?

Objective To explore possible reasons for the reduction in population caries levels among 5-year-old children in England since 2008.Design An ecological study to explore possible reasons for the apparent reduction in dental caries, which included changes in survey methods, deprivation levels and ethnic mix of the population, impact of community level oral health improvement interventions, reductions in sugar intake, and increases in the availability of fluoride.Setting Data were drawn from three consecutive epidemiological surveys undertaken in 2007/8 and 2011/12 (NHS Dental Epidemiology programme for England), and 2014/15 (Public Health England Dental Public Health Epidemiology Programme). Evidence about the possible reasons for the observed reduction in caries levels was drawn from a range of national sources.Main outcomes measures Severity and prevalence of caries at dentinal level as measured by visual means alone among children aged five years.Results Reasons relating to changes in methods used in the survey, deprivation and ethnicity were rejected, along with community level interventions, as reasons for whole population level change. The factor relating to reduced sugar intake was neither rejected nor sustained. Reasons relating to increased fluoride availability, in particular that for increased concentration in children's toothpastes, was sustained.Conclusions The reduction in caries levels among 5-year-olds has most likely been brought about by the wider availability of children's toothpaste containing at least 1,000 ppm fluoride, along with other factors.

The caries experience of 5 year-old children in Scotland in 2013-2014, and in England and Wales in 2014-2015. Reports of cross-sectional dental surveys using BASCD criteria.

OBJECTIVE: We report the findings from and comment on the surveys of the oral health of 5-year-old children undertaken in Scotland (2013-14), Wales (2014-15) and England (2014-15). This was the fourteenth survey in Scotland since 1988. In England and Wales it is the third survey since 2007 when changes were required in consent arrangements. METHOD: Representative samples were drawn within Health Boards across Scotland and local authorities across England and Wales. Consent was sought via opt-out parental consent in Scotland and opt-in parental consent in England and Wales. Children examined were those aged five in England and those in Primary 1 (school year aged 5 to 6) in Scotland and Wales. Examinations were conducted in schools by trained and calibrated examiners. Caries was visually diagnosed at the dentinal threshold. RESULTS: There is a continuing decline in d3mft in all three countries. d3mft was 1.27 (opt-out consent) for Scotland, 0.84 for England (opt-in consent) and 1.29 for Wales (opt-in consent). Tooth decay levels remain higher in more deprived areas across Great Britain, with clear inequalities gradients demonstrated across all geographies. Attempts to measure changes in dental health inequalities across the three countries show no conclusive trends. CONCLUSION: Inter-country comparisons provide further oral health intelligence despite differences in approach and timing. The third surveys in England and Wales using the new consent arrangements have enabled trend analysis. Dental health inequalities gradients were shown across all geographies and all of the indicators of inequality.

Feasibility, utility and impact of a national dental epidemiological survey of three-year-old children in England 2013.

UNLABELLED: Dental epidemiological surveys of children often focus on caries levels of five-year-olds as they are accessible and amenable to examination. Standardised surveys of this age group have been successfully carried out in the UK for many years. If improvements to caries level at age five are to be made then it is important to know when caries develops in the preceding years and what the likely causes are. This paper reports on the feasibility, utility and impact of a standardised survey of three-year-old children which took place in England. METHOD: Standardised examinations were carried out on consented three-year-olds attending child care sites which had been randomly sampled using a method described in a national protocol. Feasibility was assessed by compliance results, utility from examples of use of the data and impact by a count of media responses at the time of publication. RESULTS: Data from 53,814 examinations provided caries level estimates for 88% of lower tier local authorities, this number representing 8% of the population of this age cohort. Of the children for whom parental consent was provided, 8% refused to be examined at school and 9% were absent. The arising information was used in a variety of ways by local authorities and health planners. The media response was strong with coverage by TV, radio, printed press and online reporting. CONCLUSION: This national survey of the oral health of three year olds was feasible but more labour intensive than surveys of school age children and the information derived has good utility and impact.

A summary of knowledge about the oral health of older people in England and Wales.

OBJECTIVE: To summarise what is currently known about the oral health of older adults in England and Wales. BASIC RESEARCH DESIGN: Summary of the main findings from a recent review of oral health surveys and demographic and health data relating to older people in the UK (West Midlands, North West, Bolton and Kirklees, East London and the City of London and Wales). Their findings were compared, where possible to estimates from the 2009 Adult Dental Health Survey. FINDINGS: A higher proportion of older adults in England and Wales have untreated caries and signs of severe caries than the general adult population. The majority of dentate residents in the care homes surveyed had untreated caries. Despite the poorer oral health of residents in care homes, managers of such services report difficulty in accessing routine and emergency dental care. CONCLUSIONS: Existing epidemiological data in England and Wales show that older people in residential and nursing care homes have poorer oral health than the general adult population and inequitable access to dental services. Greater comparability and utility would be gained from regional oral health surveys if standards were agreed for this age group with regard to sampling, consent, questionnaires and clinical measures.

Determining need for treatment in residual pituitary adenomas.

AIM: The optimal management of residual pituitary adenoma after resection is not clearly defined, with some authors proposing early radiosurgery or radiotherapy for patients with evidence of residual tumor on postoperative imaging and others recommending observation alone. This retrospective study seeks to determine the most appropriate treatment for patients with evidence of residual tumor on postoperative MRI. METHODS: Forty-one consecutive patients who underwent transsphenoidal resection of pituitary adenomas between 2002 and 2005 and were followed radiographically and clinically for a mean of 4.4 years were analyzed. RESULTS: Despite an official interpretation by a board-certified neuroradiologist suggesting the presence of residual tumor postoperatively in twenty-four out of forty-one patients, only four patients (16.7%) required additional intervention during the follow-up period. None of the patients received perioperative radiotherapy. CONCLUSION: This suggests that aggressive management of radiographically suspected residual tumor may not be indicated and that observation with serial imaging may be sufficient in the management of patients with residual tumor.

The caries experience of 5-year-old children in Scotland, Wales and England in 2011-2012: reports of cross-sectional surveys using BASCD criteria.

OBJECTIVE: This paper collates differences in methods and trends in caries prevalence in surveys of the oral health of young children undertaken in Scotland, Wales and England in 2011-12. For Wales and England this was the second survey carried out since changes were required in consent arrangements. METHOD: In compliance with BASCD criteria representative samples were drawn within the geographies of primary care organisations across the UK, and within Local Authorities across England and Wales. Consent was sought in two ways; via opt-in parental consent in England and Wales and opt-out parental consent in Scotland. Children aged five were examined in England and those aged 5 to 6 were examined in Wales and Scotland. Examinations were conducted in schools by trained and calibrated examiners and caries was diagnosed at the dentinal threshold using visual criteria. RESULTS: In Scotland there is a continuing decline in caries prevalence in young school children. Comparison with the previous survey using positive consent in England and Wales shows a decline in caries in both England and Wales although decay levels remain higher in more deprived areas. CONCLUSION: International comparisons assist in interpreting data and trends even if there are some differences in approach. A trend line is more useful than a single data point for monitoring of oral health. This second survey using positive parental consent in England and Wales has enabled trend analysis for the first time since the consent arrangements changed.

Investigation of bias related to non-return of consent for a dental epidemiological survey of caries among five-year-olds.

UNLABELLED: Estimates of caries levels derived from an epidemiological survey of five-year-olds in England were lower than expected. This survey used, for the first time, a consent method which involved parents providing positive, written consent for their child to be included in the survey. This contrasted to the previous method when negative consent was used. AIM: To interrogate the dataset to try and establish the reasons for the lower than expected estimates and explore the effect of non-return of parental consent, including the role of deprivation. BASIC RESEARCH DESIGN: Statistical analysis of an existing dataset and a sub-set of this dataset. MAIN OUTCOME MEASURES: Estimates of caries prevalence and severity in groups and sub-groups of a population-based, random sample of five-year-olds. RESULTS: Hypotheses relating to possible changes in the process of data collection and analysis were rejected as reasons for the apparent reduction in disease estimates, as was the impact of oral and general health improvement programmes. Analysis of higher non-return levels on differences between past and current estimates and analysis of the associations between caries estimates, non-consent and summed deprivation measures based on home postcodes showed some relationships between these variables but could not identify a simple relationship. CONCLUSION: There is a more complex relationship between non-return of consent and disease levels than can be explained by deprivation alone.

Trajectories of change in sagebrush steppe vegetation communities in relation to multiple wildfires.

Repeated perturbations, both biotic and abiotic, can lead to fundamental changes in the nature of ecosystems, including changes in state. Sagebrush steppe communities provide important habitat for wildlife and grazing for livestock. Fire is an integral part of these systems, but there is concern that increased ignition frequencies and invasive species are fundamentally altering them. Despite these issues, the majority of studies of fire effects in systems dominated by Artemisia tridentata wyomingensis have focused on the effects of single burns. The Arid Lands Ecology Reserve (ALE), in south-central Washington (U.S.A.), was one of the largest contiguous areas of sagebrush steppe habitat in the state until large wildfires burned the majority of it in 2000 and 2007. We analyzed data from permanent vegetation transects established in 1996 and resampled in 2002 and 2009. Our objective was to describe how the fires, and subsequent postfire restoration efforts, affected communities' successional pathways. Plant communities differed in response to repeated fire and restoration; these differences could largely be ascribed to the functional traits of the dominant species. Low-elevation communities, previously dominated by obligate seeders, moved furthest from their initial composition and were dominated by weedy, early-successional species in 2009. Higher-elevation sites with resprouting shrubs, native bunchgrasses, and few invasive species were generally more resilient to the effects of repeated disturbances. Shrub cover has been almost entirely removed from ALE, although there was some recovery where communities were dominated by resprouters. Bromus tectorum dominance was reduced by herbicide application in areas where it was previously abundant, but it increased significantly in untreated areas. Several resprouting species, notably Phlox longifolia and Poa secunda, expanded remarkably following competitive release from shrub canopies and/or abundant B. tectorum. Our results suggest that community dynamics can be understood through a state and transition model with two axes (shrub/grass and native/invasive abundance), although such models also need to account for differences in plant functional traits and disturbance regimes. We use our results to develop a conceptual model that will be validated with further research.

The caries experience of 11 to 12 year-old children in Scotland and Wales and 12 year-olds in England in 2008-2009: reports of co-ordinated surveys using BASCD methodology.

OBJECTIVE: This paper brings together summarised findings on surveys of 106,828 mainstream school pupils aged 11-12 years old undertaken in Scotland, Wales and England in 2008/09. These surveys are the latest in a series using common criteria for measurement and a range of consent arrangements which, for this age group, allow comparison between the three "countries" and over time. METHOD: Representative samples were drawn within the geographies of primary care organisations in the three countries and within English Local Authorities according to BASCD criteria for sampling. Consent was sought from pupils in Wales and England and passive consent was used in Scotland. Children aged twelve were examined in England and children in school year 7 (rising 12) were examined in Wales and Scotland. Examinations were conducted in schools by trained and calibrated examiners using BASCD standard criteria and caries was diagnosed at the dentinal threshold using visual criteria. RESULTS: The trend for reducing caries prevalence and severity continues in this age group in all three countries. Unlike data for 5 year old children, the impact of seeking positive consent from pupils does not appear to have introduced bias into the results. Variation in caries levels between and within geographical areas continues. CONCLUSION: Caries prevalence surveys of children aged 11-12 years have been conducted across Great Britain. Those carried out with positive consent appear to produce unbiased results, comparable with previous surveys. Health inequalities in this age group persist, as does the burden of disease for those with end-stage caries.

Economic evaluation of ezetimibe combined with simvastatin for the treatment of primary hypercholesterolaemia.

OBJECTIVE: This study aims to assess the cost-effectiveness of ezetimibe plus simvastatin (E/S) versus atorvastatin or simvastatin monotherapy as second-line treatment of primary hypercholesterolaemia from the Dutch healthcare perspective. METHODS: The evaluation used a Markov model and patient data from the Dutch EASEGO study in which patients failing to reach goal low-density lipoprotein cholesterol levels on atorvastatin 10 mg or simvastatin 20 mg had their dose doubled or switched to ezetimibe 10 mg plus generic simvastatin 20 mg (E10/S20). The second scenario, based on Dutch guidelines, switched patients from simvastatin 40 mg to atorvastatin 40 mg, or ezetimibe 10 mg was added to simvastatin 40 mg (E10/S40). The key effectiveness input measure was change in total cholesterol/high-density lipoprotein ratio obtained from the EASEGO study. In conformity with published studies linking reduced lipid levels to reduced risk of cardiovascular events, the present model assumed that a lipid decrease with ezetimibe may be a signal for reduced risk of cardiovascular events. Model parameters were derived from published literature. Sensitivity analyses were performed for the key parameters. RESULTS: In the EASEGO scenario, incremental cost-effectiveness ratio for E10/S20 was 3497/quality-adjusted life-years (QALY) vs atorvastatin 20 mg and 26,417/QALY vs simvastatin 40 mg. In the Dutch guidelines scenario, E10/S40 was dominant (more effective and cost-saving) vs atorvastatin 40 mg. Varying model inputs had limited impact on the cost-effectiveness of E/S. CONCLUSIONS: The analysis showed the cost-effectiveness of E/S versus atorvastatin 20 mg or simvastatin 40 mg (EASEGO scenario) at a threshold of 30,000/QALY and vs atorvastatin 40 mg was dominant (Dutch guidelines). Thus, E/S seems a valuable cost-effective second-line treatment option for patients not attaining lipid treatment goals.

The caries experience of 5 year-old children in Scotland, Wales and England in 2007-2008 and the impact of consent arrangements. Reports of co-ordinated surveys using BASCD criteria.

OBJECTIVE: This paper brings together summarised findings and comment on surveys of young children undertaken in Scotland, Wales and England in 2007-08. These surveys are the latest in a series using common criteria for measurement but changes in the consent arrangements for Wales and England mean that these datasets are no longer directly comparable with Scottish data. METHOD: Representative samples were drawn within the geographies of primary care organisations in the three countries, and in England within Local Authorities also, according to BASCD criteria. Consent was sought in three different ways. Children aged five were examined in England and those in Primary 1 (rising 6) were examined in Wales and Scotland. Examinations were conducted in schools by trained and calibrated examiners and caries was diagnosed at the dentinal threshold using visual criteria. RESULTS: The impact of seeking positive consent appeared to depress the caries severity and prevalence in Wales and England whilst the reduced caries levels in Scotland may be attributed to the pro-active health improvement measures affecting this cohort. The results for positive consent suggest bias against participation of children with higher levels of tooth decay. CONCLUSION: Caries prevalence surveys of children at the start of formal education have been conducted in Great Britain. Those carried out with the need for positive parental consent have produced new baseline data. Data presented after 2007-08 should be annotated to show the participation rate and the inappropriateness of comparing data collected using different types of consent.

Summary of: the dental health of three-year-old children in Greater Glasgow, Scotland.

OBJECTIVE: To report on the dental health of three-year-old children in Greater Glasgow, and to examine the amount of dental caries associated with deprivation in this young age group. DESIGN: Dental inspections in nursery schools. SUBJECTS AND METHODS: The national inspection programme using BASCD criteria was extended to include an additional group of nursery attending three-year-olds in Greater Glasgow in 2006/7 and 2007/8. Caries experience was analysed by logistic regression models and ROC plots. RESULTS: Fourteen percent of this population was sampled in 2006/7 and 19% in 2007/8 (usable data n = 1,711 in 2006/7, 2,428 in 2007/8). Mean d(3)mft was 1.1 in 2006/7 and 1.0 in 2007/8. The prevalence of caries experience was 26% in 2006/7 and 25% in 2008/9 (33% and 32%, respectively, for children in deprived areas). The adjusted odds-ratio for caries experience for children living in the most deprived areas was 2.90 (2.31, 3.64), p <0.001. There was a high rate of caries in the upper anterior teeth. CONCLUSION: It was feasible to conduct large scale caries surveys of three-year-olds in a nursery setting. Poor dental health and inequality commence early in life. Caries prevention should be targeted toward deprived families from birth.

A cluster randomised controlled trial to evaluate the effectiveness of fluoride varnish as a public health measure to reduce caries in children.

This cluster randomised controlled study assessed the effectiveness of twice-yearly applications of fluoride varnish as a public health measure to reduce dental caries in children living in relatively deprived communities. The test (n = 334) and control (n = 330) children in 2 school years (unit of randomisation) attended 24 state primary schools and were 6-8 years of age at the start. Good baseline balance was found. Duraphat varnish was applied at school on 5 occasions over 26 months, by dental therapists. A combined visual and fibre-optic transillumination examination included all surfaces of primary and first permanent molars at baseline and after 26 months for small and large enamel and dentine lesions. At the final examination the only statistically significant difference was in the caries increment for small enamel lesions in the primary dentition, with the test children having fewer lesions. This study failed to demonstrate that the twice-yearly application of fluoride varnish provided at school reduced dental caries in children living in this community. The low level of response and a lower than expected caries increment had a major impact on the effectiveness of the intervention, since the children who participated were least likely to have benefited from the programme, whereas those who might have benefited did not consent.

Meta-analysis of the cholesterol-lowering effect of ezetimibe added to ongoing statin therapy.

OBJECTIVE: To review and analyse the evidence for the cholesterol-lowering effect of ezetimibe in adult patients with hypercholesterolaemia who are not at low-density lipoprotein cholesterol (LDL-C) goal on statin monotherapy. RESEARCH DESIGN: Systematic review and meta-analysis. METHODS: MEDLINE and EMBASE were searched to identify ezetimibe randomised controlled trials (RCTs) published between January 1993 and December 2005. The meta-analysis combined data from RCTs, with a minimum treatment duration of 6 weeks, that compared treatment with ezetimibe 10 mg/day or placebo added to current statin therapy. The difference between treatments was analysed for four co-primary outcomes: mean percentage change from baseline in total cholesterol (TC), LDL-C, and high-density lipoprotein cholesterol (HDL-C), and number of patients achieving LDL-C treatment goal. Meta-analysis results are presented for a modified version of the inverse variance random effects model. RESULTS: Five RCTs involving a total of 5039 patients were included in the meta-analysis. The weighted mean difference (WMD) between treatments significantly favoured the ezetimibe/statin combination over placebo/statin for TC (-16.1% (-17.3, -14.8); p < 0.0001), LDL-C (-23.6% (-25.6, -21.7); p < 0.0001) and HDL-C (1.7% (0.9, 2.5); p < 0.0001). The relative risk of reaching the LDL-C treatment goal was significantly higher for patients on ezetimibe/statin relative to those on placebo/statin (3.4 (2.0, 5.6); p < 0.0001). In pre-defined sub-group analyses of studies in patients with coronary heart disease, the WMD between treatments remained significantly in favour of ezetimibe/statin (p < 0.0001) for TC and LDL-C but was no longer significant for HDL-C. Elevations in creatine kinase, alanine aminotransferase or aspartate aminotransferase that were considered as an adverse effect did not differ significantly between treatments. CONCLUSIONS: The meta-analysis we performed included only five studies and was restricted to analysis of the changes in cholesterol levels relative to baseline. However, the results suggest that ezetimibe co-administered with ongoing statin therapy provides significant additional lipid-lowering in patients not at LDL-C goal on statin therapy alone, allowing more patients to reach their LDL-C goal.

Challenges associated with the evaluation of a dental health promotion programme in a deprived urban area.

OBJECTIVE: This paper reports the results of a community trial to measure the clinical impact of a linked series of interventions on Early Childhood Caries (ECC) and general caries levels among five-year-old children. It exemplifies the problems of undertaking population based interventions in deprived communities. RESEARCH DESIGN: Two health districts (Primary Care Groups) were matched for dental disease levels and socio-demographic factors. One was randomly allocated to be the active intervention PCG, the other the comparison PCG. Children in the active PCG received a series of interventions to support positive dental health behaviour from the age of 8 to 32 months. Clinical examinations were undertaken on a cohort of 5-year-old children in both active and comparison PCGs. SETTING: In the active PCG, children who attended designated clinics for their 8-month developmental checks and/or MMR inoculations at 12 to 15 months, were given gift bags, the first contained a trainer cup, the second fluoride toothpaste (1450 ppm F) and toothbrush. Parents were also given written, pictorial and verbal advice on oral care. Further supplies of toothpaste and brushes were posted to the children's homes at 20, 26 and 32 months. When five years of age children in the two PCGs were examined in school. OUTCOME MEASURES: Severity and prevalence of ECC and general caries. Levels of participation. RESULTS: Among participants in the active PCG the prevalence of ECC, general caries and extraction experience and mean dmft (20%: 54%: 3%: 2.2) were lower than in 'participants' in the comparison area (32%: 64%: 12%: 3.7). All differences were statistically significant. When all children (participants and non-participants) in the two PCGs were compared, the differences were much reduced (30%: 63%: 6%: 3.1 vs. 32%: 64%: 12%: 3.6). A higher proportion of children in the active PCG area (47%) were found not to have participated in the interventions, when compared to 21% in the comparison area. Disease levels in the non-participants in the active PCG were particularly high. The impact of participation bias, changes in baseline balance, population mobility and alternative study design on outcomes are explored. CONCLUSION: The impact of non-participation in a deprived, urban conurbation with high levels of population mobility are sufficient to dilute the impact of a health intervention such that few benefits are discernible at a population level.

The prevalence and severity of fluorosis in children who received toothpaste containing either 440 or 1,450 ppm F from the age of 12 months in deprived and less deprived communities.

This study compared fluorosis in the upper central incisors of children from socially diverse backgrounds who had received either 440- or 1,450-ppm F toothpaste from 12 months of age. The children were resident in non-fluoridated districts in the north-west of England. They received either 440- or 1,450-ppm F toothpaste and advice regarding its use until the age of 5-6 years. Dental fluorosis (TF index) was assessed on digital images of dried teeth when the children (n = 1,268) were 8-10 years old. In the less deprived districts the prevalences of fluorosis (TF >or=0) for the 1,450- and 440-ppm F groups were 34.5 and 23.7% (p = 0.006). In the deprived districts the prevalences of fluorosis were 25.2 and 19.5% (p = 0.2). Overall the prevalences of TF >or=2 were 7 and 2.1% for the 1,450- and 440-ppm F groups and 2.2 and 0.2% for TF >or=3. These differences were statistically significant (p < 0.003). There was a strong association between the deprivation status of wards and fluorosis. Only 1 subject with a TF score of 3 was identified in the two most deprived quintiles of the Townsend score. It is concluded that careful targeting of programmes of this type to children living in high caries risk deprived communities carries only a small risk of aesthetically objectionable fluorosis (TF >2) whether low or high fluoride toothpastes are used. High fluoride (1,450 ppm F) toothpastes should not be provided on a community basis to very young children in less deprived communities.

Milk fluoridation: a comparison of dental health in two school communities in England.

OBJECTIVE: To compare levels of caries experience in children attending schools in Wirral that have a fluoridated milk programme with children in a similar community which does not have a fluoridated milk programme. STUDY DESIGN: A cross sectional study measuring caries experience in first permanent molars. Children were examined on an 'intention to treat' basis and the effect of clustering of children within schools was taken into account. PARTICIPANTS: 690 children in Wirral (test group) and 1,835 children in Sefton (comparison group) were examined for caries experience (DMFT/DT/DFS) in 2003. The mean ages of the children examined in the test and comparison groups were 10.79 and 10.83 years respectively. RESULTS: Mean DMFT/DT/DFS values were 1.01/0.59/1.20 respectively in the test group and 1.46/1.02/1.89 respectively in the comparison group. Multiple linear regression analysis taking clustering of children within schools into account and with the Index of Multiple Deprivation 2000 as an explanatory variable gave the coefficients and p-values for DMFT/DT/DFS of 0.49 (p < 0.001)/0.43 (p < 0.001)/0.74 (p < 0.001) respectively. CONCLUSION: A difference in children with caries experience of 13% and a difference in children with active decay of 16% was found when a district with a community fluoridated milk programme was compared with a district without a fluoridated milk programme.

A staged intervention dental health promotion programme to reduce early childhood caries.

OBJECTIVE: This paper reports the results of a community trial to assess the effects of a multi-stage dental health promotion programme in reducing Early Childhood Caries (ECC). RESEARCH DESIGN: Two health districts (Primary Care Groups) were matched for dental disease levels and socio-demographic factors. One was randomly allocated to be the test Primary Care Group (PCG), the other the control PCG. Children in the test PCG received a series of interventions to support positive dental health behaviour from the age of 8 to 32 months. Interviews were conducted with parents of children aged 21 months and clinical examinations were undertaken on a larger cohort of children aged 3-4 years in test and control PCGs. SETTING: The interventions were gift bags containing a trainer cup, toothpaste containing 1,450 ppm F and toothbrush, and advice given to the children's parents on attendance at designated clinics and medical practices and further paste and brushes posted to the children's homes. Parents were interviewed on the telephone. Examinations took place at Children's Centres and nursery departments attached to primary schools. OUTCOME MEASURES: Severity and prevalence of ECC and general caries and proportion of parents reporting adopting dentally healthy behaviours. RESULTS: In the test PCG the prevalence of ECC in children who had received the interventions was 16.6% compared with 23.5% of children in the control area, a reduction of 29% (p=0.003). The mean dmft (1.17) and prevalence of general caries experience (28.7%) in the test children were also significantly lower than for children in the control PCG (1.72: 39.2%) (p=0.001). Analysis from a community perspective, which included data from all children examined in both areas, showed the prevalence of ECC in the test and control PCGs was 21.3% and 22.8% respectively and the mean dmft 1.47 and 1.72. The proportion with general caries experience remained statistically significant in favour of the test area 33.8% vs 39.9% (p=0.01). Parents in the test PCG were more likely to report cessation of bottle use (33% vs 18%), use of sugar-free drinks (49% vs 24%), commencement of brushing before first birthday (45% vs 27%) and twice daily brushing (52% vs 34%). CONCLUSION: The parents who received this multi-stage intervention were more likely to report adoption of three positive oral health behaviours; using a trainer cup from one year of age, using safe drinks and brushing twice daily with a fluoride toothpaste. The programme failed to reduce the prevalence of ECC in the community but the prevalence of ECC and general caries experience among the children who participated was less than among children in the control PCG.