Inequalities in access to NHS primary care dental services in Scotland during the COVID-19 pandemic.

Introduction This study aimed to quantify the impact of the COVID-19 pandemic on access and inequalities in primary care dental services among children and adults in Scotland.Methods Access was measured as any NHS Scotland primary care dental contacts derived from administrative data from January 2019 to May 2022, linked to the area-based Scottish Index of Multiple Deprivation for children and adults, and related to population denominator estimates from National Record Scotland. Inequalities for pre-pandemic (January 2019-January 2020) and recent (December 2021-February 2022, and March 2022-May 2022) periods for both children and adults were calculated and compared using the slope index of inequality and relative index of inequality.Results Following the first lockdown (March 2020) there was a dramatic fall to near zero dental contacts, followed by a slow recovery to 64.8% of pre-pandemic levels by May 2022. There was initial widening of relative inequalities in dental contacts in early 2022, which, more recently, had begun to return to pre-pandemic levels.Conclusion COVID-19 had a major impact on access to NHS primary dental care, and while inequalities in access are apparent as services recover from lockdown, these inequalities are not a new phenomenon.

Improving participation and engagement with a COVID-19 surveillance programme in an outpatient setting.

BACKGROUND: On 3 August 2020, Public Health Scotland commenced a prospective surveillance study to monitor the prevalence of COVID-19 among asymptomatic outpatients attending dental clinics across 14 health boards in Scotland. OBJECTIVES: The primary aim of this quality improvement project was to increase the number of COVID-19 tests carried out in one of the participating sites, Glasgow Dental Hospital and School. The secondary aim was to identify barriers to patient participation and staff engagement when implementing a public health initiative in an outpatient setting. METHOD: A quality improvement working group met weekly to discuss hospital findings, identify drivers and change ideas. Details on reasons for patient non-participation were recorded and questionnaires on project barriers were distributed to staff. In response to findings, rapid interventions were implemented to fast-track increases in the numbers of tests being carried out. RESULTS: Over 16 weeks, 972 tests were carried out by Glasgow Dental Hospital and School Secondary Care Services. The number of tests per week increased from 19 (week 1) to 129 (week 16). This compares to a similar 'control' site, where the number of tests carried out remained unchanged; 38 (week 1) to 36 (week 16). The most frequent reason given for non-participation was fear that the swab would hurt. For staff, lack of time and forgetting to ask patients were identified as the most significant barriers. CONCLUSION: Public health surveillance programmes can be integrated rapidly into outpatient settings. This project has shown that a quality improvement approach can be successful in integrating such programmes. The key interventions used were staff engagement initiatives and front-line data collection. Implementation barriers were also identified using staff questionnaires.

Barriers to providing dental care for older people.

DATA SOURCES: The Medline, Embase and CINAHL databases were searched together with the reference lists of selected publications. STUDY SELECTION: Studies published since January 1990 and published in English that looked at barriers, experienced by dentists, to delivering oral health care to people over the age of 65 were included. Study quality was assessed independently using criteria developed by the Dutch Cochrane Centre. DATA EXTRACTION AND SYNTHESIS: Study assessment and data extraction were carried out independently by two reviewers and a qualitative summary presented. RESULTS: Seven cross-sectional studies were included. The focus was primarily on dentists delivering oral health care to older people in care homes with only one focused on barriers experienced by dentists working in their own practice and delivering oral health care to community-dwelling older people. The most common barriers to delivering oral health care to older people were identified respectively as: the lack of adequate equipment in a care home and no area for treatment available (n = 4) and the lack of adequate reimbursement for working in a care home (n = 5). In addition, the inadequate training and experience in delivering oral health care to older care home residents (n = 2) were mentioned. Four publications indicated the loss of time from private practice as a barrier to delivering oral health care in a care home. CONCLUSIONS: Most articles retrieved described barriers experienced by dentists delivering oral health in care homes: much less is known about oral health care for community-dwelling older people. Therefore, we suggest that additional research should be initiated to investigate in more detail the barriers dentists experience in delivering oral health care to older people in their own dental practices.

Evidence that fluoride in the infant formula causes enamel fluorosis weak.

DATA SOURCES: Information was sourced from PubMed, the Cochrane Library, the Web of Science, Controlled Trials, Clinical Trials (a service of the US National Institutes of Health), ProQuest UMI (a dissertation and thesis database), National Institute for Health and Clinical Excellence, Virtual Health Library, Bireme-PAHO-WHO, and the Latin America and Caribbean Centre on Health Sciences Information, along with the reference lists of relevant reports and review articles. Authors were contacted for missing information. STUDY SELECTION: Studies conducted in humans were selected if they evaluated fluorosis and infant formula. Studies focussed exclusively on primary teeth were excluded. There were no restrictions on study designs. DATA EXTRACTION AND SYNTHESIS: Two authors independently extracted data and assessed study quality. Disagreements were resolved by discussion. Summary odds ratios and confidence intervals were calculated using a random-effects model. Heterogeneity was quantified using the I(2) statistic and publications bias using a funnel plot and Egger test. RESULTS: Twenty-seven out of 41 studies evaluating the effect of infant formula on enamel fluorosis risk were included. These 27 papers reported the results of 19 observational studies (comprising one prospective cohort study, five retrospective cohort studies, six case-control studies, four cross-sectional studies and three historical-control studies). Seventeen of these 19 studies reported odds ratios (OR) and, among these, infant formula consumption was associated with a higher prevalence of enamel fluorosis in the permanent dentition [summary OR, 1.8; 95% confidence interval (CI), 1.4-2.3]. The studies showed significant heterogeneity (66%) and evidence of publication bias (P 0.002). Metaregression suggests that the OR associating infant formula with enamel fluorosis increased by 5% for each 0.1-ppm increase in the reported levels of fluoride in the water supply (OR, 1.05; 95% CI, 1.02-1.09). CONCLUSIONS: Infant formula consumption may be associated with an increased risk of developing at least some detectable level of enamel fluorosis, but this depends on the level of fluoride in the water supply. The evidence that the fluoride in the infant formula caused enamel fluorosis was weak, as other mechanisms could explain the observed association.

Regular rinsing with chlorhexidine does not reduce caries in older adults.

DESIGN: This was a placebo-controlled randomised clinical trial (RCT). INTERVENTION: An active daily rinse of 0.12% chlorhexidine (CHX) was compared with a similar placebo rinse. Subjects alternated between daily rinsing for 1 month, followed by weekly rinsing for 5 months for 5 years. OUTCOME MEASURE: The primary outcome was the probability of transition from a sound to a nonsound tooth (an 'event') in each group, specifically, a transition from a sound surface to a surface that became extracted, filled or decayed. Two secondary analyses were performed: an analysis where surfaces that were extracted without an intervening state of decayed or filled were censored, and an analysis where surfaces that were extracted or filled without ever being called decayed at any time were censored. The primary test statistics for evaluating treatment effects was based on the proportional hazards model. RESULTS: Over the 5-year course of the study, 273 elders (24.8%) did not complete all five followup visits; 57 (5.2%) died, and 15 (1.4%) became edentate. This was lower than the 10% attrition rate every year that had been projected at baseline. The study failed to identify an effect of regular CHX rinsing on the preservation of sound tooth structure on either the roots or the crowns of teeth in low-income older adults. Caries attack rates and hazard ratios are shown in Tables 1 and 2. No adverse events, including anaphylactic reactions, rashes or gastrointestinal disturbances, were reported by the subjects. CONCLUSIONS: These findings suggest that regular rinsing with CHX does not have a substantial effect on the preservation of sound tooth structure in older adults.

Staff training improved oral hygiene in patients following stroke.

DATA SOURCES: Reports were identified using the Cochrane Stroke Group and Oral Health Group trials registers, the Cochrane CENTRAL trial register, Cochrane Library, Medline, Cinahl, Research Findings Electronic Register, National Research Register, ISI Science and Technology Proceedings, Dissertation Abstracts and Conference Papers Index, and the reference lists from relevant papers. Authors and researchers in the field were also contacted. STUDY SELECTION: Randomised controlled trials (RCT) that evaluated one or more interventions designed to improve oral hygiene were selected. Trials based on a mixed population were included, provided it was possible to extract data specific to individuals post-stroke. DATA EXTRACTION AND SYNTHESIS: Two review authors independently classified identified trials according to the inclusion and exclusion criteria, assessed the trial quality and extracted data. Clarification was sought from study authors when required. RESULTS: Eight eligible RCT trials were identified but only one provided stroke-specific information. In it, an oral healthcare education training programme delivered to nursing homecare assistants was compared with a delayed training intervention in the control group. Comparisons were made at 1 and 6 months after the intervention, using primary outcome measures of dental plaque and denture plaque, and three secondary outcomes. The data available for the 67 individuals who had suffered a stroke (obtained from the larger cluster-RCT) showed that denture plaque scores were significantly reduced up to 6 months (P<0.00001) after the intervention. Staff knowledge (P 0.0008) and attitudes (P 0.0001) towards oral care also improved significantly despite high staff turnover rates. CONCLUSIONS: Based on one study with a small number of stroke survivors, providing specialist oral care training for carers in a nursing-home setting improves their knowledge of and attitudes towards the provision of oral care. In turn, residents\[primes] dentures were cleaner, although other oral hygiene measures did not change. Further evidence relating to oral care interventions is severely lacking, in particular with reference to care in hospital for those following stroke.

An assessment of teenagers' perceptions of dental fluorosis using digital simulation and web-based testing.

OBJECTIVES: To develop a new model to establish teenagers' perceptions of the aesthetic impact of fluorosis, in the context of overall facial appearance. This web-based model was used to compare different degrees of fluorosis at any one distance, while also comparing the same level of fluorosis at different 'distances'. METHODS: A 14-year-old subject was used as the model face. Different degrees of fluorosis were 'built-up' on this subject's teeth using digital simulation. A web-based questionnaire showed 30 photographs, displaying four levels of fluorosis, in addition to fluorosis-free, at five different 'distances'. The closest images were shown with and without retractors, while the more distant pictures showed more of the subject's face. Teenage pupils (n = 217) were then asked to grade the acceptability of the appearances and indicate if they would wish treatment for each such appearance. RESULTS: At any one distance, acceptability fell as fluorosis level increased. When the same degree of fluorosis was compared at different distances, acceptability improved as the teeth were viewed from further away. Pictures taken without retractors had higher acceptability than those taken with retractors in place. CONCLUSIONS: Teenagers can discriminate between various degrees of fluorosis. However, more distant viewing of fluorosed teeth, within the overall context of the face, improves acceptability of the appearance.