The CATFISH study: An evaluation of a water fluoridation program in Cumbria, UK.

OBJECTIVES: The objective was to assess the effectiveness of a Water Fluoridation program on a contemporary population of children. METHODS: The study used a longitudinal prospective cohort design. In Cumbria, England, two groups of children were recruited and observed over a period of 5-6 years. The Birth Cohort consisted of families recruited from two hospitals in Cumbria where children were conceived after water fluoridation was reintroduced. The systemic and topical effects of community water fluoridation were evaluated in the Birth Cohort. The Older Cohort were approximately 5 years old and recruited from primary schools in Cumbria, shortly after water fluoridation was reintroduced. The predominantly topical effects of fluoridated water were evaluated in the Older Cohort. The primary outcome was the proportion of children with clinical evidence of caries experience in their primary (Birth Cohort) or permanent teeth (Older Cohort). Unadjusted and adjusted regression models were used for analysis. RESULTS: The final clinical examinations for the Birth Cohort involved 1444 participants (mean age 4.8 years), where 17.4% of children in the intervention group were found to have caries experience, compared to 21.4% in the control group. A beneficial effect of water fluoridation was observed adjusting for deprivation (a socioeconomic measure), sex, and age, (adjusted odds ratio 0.74 95% CI 0.55 to 0.98). The final Older Cohort clinical examinations involved 1192 participants (mean age 10.8 years) where 19.1% of children in the intervention group were found to have caries experience compared to 21.9% in the control group (adjusted odds ratio 0.80, 95% CI 0.58 to 1.09). For both the Birth Cohort and Older Cohort there was evidence of a beneficial effect on dmft/DMFT count (IRR 0.61, 95% CI 0.44, 0.86) and (IRR 0.69, 95% CI 0.52, 0.93) respectively. No conclusive proof was found to indicate that the effectiveness of water fluoridation differed across area deprivation quintiles. CONCLUSIONS: In the contemporary context of lower caries levels and widespread use of fluoride toothpaste, the impact of water fluoridation on the prevalence of caries was smaller than previous studies have reported. It is important to consider the clinical importance of the absolute reduction in caries prevalence against the use of other dental caries preventive measures.

A Cluster Randomised Controlled Trial of a Targeted Distributed Toothpaste and Toothbrushing Programme.

INTRODUCTION: The aim was to assess the effectiveness of a distributed, targeted toothbrush and toothpaste programme on referrals for tooth extraction under Dental General Anaesthetic (DGA), in children of high-risk families compared to usual care. METHODS: A recruiter and assessor-blinded, clustered parallel randomised control trial (RCT). Families with one or more children aged between 3 and 10 years having undergone a DGA operation for extraction of carious teeth, were approached within hospitals in the North West of England. Families were randomised at the cluster level in a 1:1 ratio. All eligible children within the family consented to the study. The primary outcome was participant referral for a DGA 6-24-month post-randomisation. RESULTS: A total of 961 families (1,671 children) were randomised, 482 families (832 children) to the intervention, and 479 families (839 children) to the control group. Families (1,662 children, 955 families) were included in the final analysis (825 intervention, 837 control). Marginal regression models (generalised estimating equation approach) taking into account cluster membership were used to model the effectiveness of the intervention at 24 and 48 month follow-up, including the variables, age, sex, and IMD quintile. Seventy-six children (9.2%) in the intervention group had a DGA referral within 2 years compared to 57 children (6.8%) in the control group. The study found no effect of a clinically meaningful difference between the intervention group and usual care (risk ratio 1.36, 95% CI: 0.98-1.89) in reducing referral for DGA for a targeted postal toothpaste/toothbrush program in a contemporary, population with previous family experience of DGA residing in an area of high deprivation. CONCLUSION: The target of the intervention (families of children with a DGA) was the correct focus given the referrals observed over 2 and 4 years. The study can aid policymakers, local authorities and commissioners to understand repeat DGA within families and further need for intervention.

Economic evaluation of a water fluoridation scheme in Cumbria, UK.

OBJECTIVES: The addition of fluoride to community drinking water supplies has been a long-standing public health intervention to improve dental health. However, the evidence of cost-effectiveness in the UK currently lacks a contemporary focus, being limited to a period with higher incidence of caries. A water fluoridation scheme in West Cumbria, United Kingdom, provided a unique opportunity to study the contemporary impact of water fluoridation. This study evaluates the cost-effectiveness of water fluoridation over a 5-6 years follow-up period in two distinct cohorts: children exposed to water fluoridation in utero and those exposed from the age of 5. METHODS: Cost-effectiveness was summarized employing incremental cost-effectiveness ratios (ICER, cost per quality adjusted life year (QALY) gained). Costs included those from the National Health Service (NHS) and local authority perspective, encompassing capital and running costs of water fluoridation, as well as NHS dental activity. The measure of health benefit was the QALY, with utility determined using the Child Health Utility 9-Dimension questionnaire. To account for uncertainty, estimates of net cost and outcomes were bootstrapped (10 000 bootstraps) to generate cost-effectiveness acceptability curves and sensitivity analysis performed with alternative specifications. RESULTS: There were 306 participants in the birth cohort (189 and 117 in the non-fluoridated and fluoridated groups, respectively) and 271 in the older school cohort (159 and 112, respectively). In both cohorts, there was evidence of small gains in QALYs for the fluoridated group compared to the non-fluoridated group and reductions in NHS dental service cost that exceeded the cost of fluoridation. For both cohorts and across all sensitivity analyses, there were high probabilities (>62%) of water fluoridation being cost-effective with a willingness to pay threshold of £20 000 per QALY. CONCLUSIONS: This analysis provides current economic evidence that water fluoridation is likely to be cost-effective. The findings contribute valuable contemporary evidence in support of the economic viability of water fluoridation scheme.

The use of radiographs to assess the impact of the distance between the contact area and the crest of the bone to predict the presence or absence of interdental papilla: an in vivo study.

Introduction Black triangles (interdental papilla) pose an aesthetic problem for both the patient and the clinician. They also can have an impact on phonetics and periodontal health. It is useful to predict the presence of a black triangle to inform the patient of potential aesthetic compromises. The aim of this study to assess whether the risk of black triangle formation can be predicted using radiographs.Material and methods In total, 404 interproximal sites from 80 random patients attending for a periodontal assessment were measured after radiographs were digitised. The percentage of black triangles within the range of measurements of the crestal bone to the contact area from <5 mm up to 8 mm and over was then calculated.Results At a distance of 5 mm or less, the papilla was present 87.5% of the time. At 6 mm, a black triangle was present 51.4% of the time, and at 7 mm or greater, a black triangle was present 72.7% of the time. When these results were compared to other studies that had different criteria and methods, they were all very similar.Conclusion Using radiographs appears to be useful in assessing the presence or absence of a black triangle in patients who are assessed for periodontal disease, prosthetic replacement, implants in the aesthetic zone, or cosmetic treatment.

Portrayal of oral hygiene and risk behaviours in animated movies.

Background: Behaviours depicted in movies and TV shows can significantly affect one's behaviour. Children are particularly susceptible to these effects as their habits are still forming. Oral hygiene behaviours play a crucial role in preventing or slowing down the progression of dental diseases, which are among the most common yet preventable diseases in the world. Therefore, it is important to understand if popular movies include oral hygiene behaviours or risk-related behaviours, which can in effect influence children's behaviour. Aim: The aim of this study is to review the top grossing animated movies of all time to record and collect on screen portrayals of oral hygiene practices and risk behaviours related to oral health. Methodology: Top 30 highest grossing animated feature films (over 40 min duration) were coded using a structured coding instrument to capture oral hygiene and risk-related behaviours related to oral health. Two coders performed coding using the standardised instrument. Results: Overall, 93% of behaviours were coded as a risk behaviour, with 7% coded as positive oral hygiene behaviour. Within the risk behaviour category, the majority (74%) were based around the consumption of sugar with risk behaviour occurring in 23 out of 30 movies (76%), while oral hygiene practices occurred in 6 out of 30 movies (20%); one movie depicted neither oral hygiene nor oral health risk behaviours. About 53% of behaviours were purely visual, 10% verbal, and 37% a combination of verbal and visual. Anthropomorphic characters and movie settings resulted in more behaviours related to oral health, either hygiene or mainly risk behaviours, depicted. Conclusion: Despite their importance in shaping habits and attitudes, animated movies portrayed a significant number of risk behaviours related to oral health with depiction of beneficial behaviours remaining limited. Consideration should be given on how to best portray behaviours that promote and enhance optimal oral hygiene behaviours to achieve and sustain better oral health for children.

Inequities and oral health: A behavioural sciences perspective.

OBJECTIVES: The importance of tackling ongoing dental health inequities, observed both within and across countries, cannot be overstated. Alarmingly, health inequities in some areas are widening, resulting in an urgent need to act. The objective of this commentary is to explore oral health inequities through the lens of behavioral science and discuss adapting evidence based interventions for populations experiencing health inequities. METHOD/RESULTS: The first section of this paper aims to describe the role of health disparities and inequities within oral health, with a specific focus on behaviours. The determinants, from upstream to downstream, and the interplay between these levels of intervention are discussed. This is followed by an overview of oral health promotion interventions, again with a focus on behaviours, which could potentially improve oral health while also taking into account oral health inequities. It is essential to translate evidence-based interventions (EBIs) to populations that have the greatest burden of disease. The second section of this paper discusses the rationale for cultural adaption of EBIs, criteria to justify EBIs and considers different cultural adaptation strategies necessary for the development and testing of effective, engaging, equitable and culturally relevant interventions. CONCLUSIONS: We conclude with future directions for the development of theory-based multi-level interventions, guided by extent evidence-based interventions, and transdisciplinary approaches to science and key stakeholders such as patients, providers and payers.

Bedtime Routine Characteristics and Activities in Families with Young Children in the North of England.

Bedtime routines have been shown to have significant associations with health, wellbeing and development outcomes for children and parents. Despite the importance of bedtime routines, most research has been carried out in the United States, with little information on bedtime routine characteristics and activities for families in other countries such as the United Kingdom and England in particular. Additionally, little is known about the possible effects of weekends vs. weekdays on the quality of bedtime routines. Finally, traditional, retrospective approaches have been most used in capturing data on bedtime routines, limiting our understanding of a dynamic and complex behaviour. The aim of this study was to explore bedtime routine characteristics and activities in families in the North of England with a real-time, dynamic data collection approach and to examine possible effects of weekend nights on the quality of bedtime routines. In total, 185 parents with children ages 3 to 7 years old provided data around their bedtime routine activities using an automated text-survey assessment over a 7-night period. Information on socio-economic and demographic characteristics were also gathered during recruitment. A small majority of parents managed to achieve all crucial elements of an optimal bedtime routine every night, with 53% reporting brushing their children's teeth every night, 25% reading to their children every night and 30% consistently putting their children to bed at the same time each night. Results showed significant differences between weekend (especially Saturday) and weekday routines (F(1, 100) = 97.584, p < 0.001), with an additional effect for parental employment (F(1, 175) = 7.151, p < 0.05). Results highlight variability in bedtime routine activities and characteristics between families. Many families undertook, in a consistent manner, activities that are closely aligned with good practices and recommendations on what constitutes an optimal bedtime routine, while others struggled. Routines remained relatively stable during weekdays but showed signs of change over the weekend. Additional studies on mechanisms and elements affecting the formation, development and maintenance of bedtime routines are needed alongside studies on supporting and assisting families to achieve optimal routines.

Bedtime Oral Hygiene Behaviours, Dietary Habits and Children's Dental Health.

Background: Oral hygiene behaviours as well as dietary habits before bed can affect children's dental health resulting in higher prevalence of dental disease. Dental disease can affect children's health, development and even school performance. If left untreated, dental disease can progress and it can lead to extractions under general anaesthetic causing further distress for children and families. Consistent and appropriate oral hygiene behaviours and dietary habits can prevent dental diseases from occurring in the first place. Objective: This cross-sectional study examines the relationship between oral hygiene behaviours, dietary habits around bedtime and children's dental health. Methods: A total of 185 parents with children between the ages of 3 and 7 years from deprived areas participated in the study. Data on bedtime routine activities were collected using an automated text-survey system. Children's dental health status was established through examination of dental charts and dmft (decayed, missed, filled teeth) scores. Results: In total, 52.4% of parents reported that their children's teeth were brushed every night. The majority of children (58.9%) had dmft scores over zero. In total, 51 (46.7% of children with dmft score over 0 and 27.5% of all children) children had active decay. The mean dmft score for those experiencing decay was 2.96 (SD = 2.22) with an overall mean dmft score of 1.75 (SD = 2.24). There were significant correlations between frequency of tooth brushing, frequency of snacks/drinks before bed and dmft scores (r = -0.584, p < 0.001 and r = 0.547, p = 0.001 respectively). Finally, higher brushing frequency was associated with a lower likelihood of a dmft score greater than 0 (Exp(B) = 0.9). Conclusions: Despite families implementing oral hygiene behaviours as part of their bedtime routines those behaviours varied in their consistency. Results of this study highlight the need for additional studies that consider bedtime routine-related activities and especially the combined effects of oral hygiene practices and dietary habits due to their potentially important relationship with children's dental health.

Defining and measuring bedtime routines in families with young children-A DELPHI process for reaching wider consensus.

INTRODUCTION: Bedtime routines are one of the most common family activities. They affect children' wellbeing, development and health. Despite their importance, there is limited evidence and agreement on what constitutes an optimal bedtime routine. This study aims to reach expert consensus on a definition of optimal bedtime routines and to propose a measurement for bedtime routines. METHOD: Four-step DELPHI process completed between February and March 2020 with 59 experts from different scientific, health and social care backgrounds. The DELPHI process started with an expert discussion group and then continued with 3 formal DELPHI rounds during which different elements of the definition and measurement of bedtime routines were iteratively refined. The proposed measurement of bedtime routines was then validated against existing data following the end of the DELPHI process. RESULTS: At the end of the four round DELPHI process and with a consistent 70% agreement level, a holistic definition of bedtime routines for families with young children between the ages of 2 and 8 years was achieved. Additionally, two approaches for measuring bedtime routines, one static (one-off) and one dynamic (over a 7-night period) are proposed following the end of the DELPHI process. A Bland-Altman difference plot was also calculated and visually examined showing agreement between the measurements that could allow them to be used interchangeably. DISCUSSION: Both the definition and the proposed measurements of bedtime routines are an important, initial step towards capturing a behavioural determinant of important health and developmental outcomes in children.

Perceived Barriers and Facilitators for Bedtime Routines in Families with Young Children.

OBJECTIVES: Bedtime routines are a highly recurrent family activity with important health, social and behavioural implications. This study examined perceived barriers to, and facilitators of, formulating, establishing, and maintaining optimal bedtime routines in families with young children. DESIGN: Participants completed a semi-structured interview based on the Theoretical Domains Framework (TDF). Analysis followed a deductive approach. PARTICIPANTS: A total of 32 parents participated in the study. Most participants (N = 30) were females, were white (N = 25) and stay at home parents (N = 12). RESULTS: Key barriers included lack of appropriate knowledge and sources of information, problematic skills development, social influences, cognitive overload, and lack of motivation for change. Facilitators included social role, access to resources, positive intentions, beliefs about consequences and reinforcement. In particular, optimal bedtime routines were less likely to be enacted when parents were tired/fatigued and there was a strong effect of habit, with suboptimal routines maintained over time due to past experiences and a lack of awareness about the importance of a good bedtime routine. CONCLUSIONS: Several theory-based, and potentially modifiable, determinants of optimal bedtime routines were identified in this study, providing important information for future interventions. Several of the key determinants identified were transient (tiredness) and/or non-conscious (habit), suggesting that future interventions may need to be deployed in real time, and should extend beyond conventional techniques.

An Interactive Text Message Survey as a Novel Assessment for Bedtime Routines in Public Health Research: Observational Study.

BACKGROUND: Traditional research approaches, especially questionnaires and paper-based assessments, limit in-depth understanding of the fluid dynamic processes associated with child well-being and development. This includes bedtime routine activities such as toothbrushing and reading a book before bed. The increase in innovative digital technologies alongside greater use and familiarity among the public creates unique opportunities to use these technical developments in research. OBJECTIVE: This study aimed to (1) examine the best way of assessing bedtime routines in families and develop an automated, interactive, text message survey assessment delivered directly to participants' mobile phones and (2) test the assessment within a predominately deprived sociodemographic sample to explore retention, uptake, feedback, and effectiveness. METHODS: A public and patient involvement project showed clear preference for interactive text surveys regarding bedtime routines. The developed interactive text survey included questions on bedtime routine activities and was delivered for seven consecutive nights to participating parents' mobile phones. A total of 200 parents participated. Apart from the completion of the text survey, feedback was provided by participants, and data on response, completion, and retention rates were captured. RESULTS: There was a high retention rate (185/200, 92.5%), and the response rate was high (160/185, 86.5%). In total, 114 participants provided anonymized feedback. Only a small percentage (5/114, 4.4%) of participants reported problems associated with completing the assessment. The majority (99/114, 86.8%) of participants enjoyed their participation in the study, with an average satisfaction score of 4.6 out of 5. CONCLUSIONS: This study demonstrated the potential of deploying SMS text message-based surveys to capture and quantify real-time information on recurrent dynamic processes in public health research. Changes and adaptations based on recommendations are crucial next steps in further exploring the diagnostic and potential intervention properties of text survey and text messaging approaches.

Increasing questionnaire response: evidence from a nested RCT within a longitudinal birth cohort study.

BACKGROUND: High response rates are essential when questionnaires are used within research, as representativeness can affect the validity of studies and the ability to generalise the findings to a wider population. The study aimed to measure the response rate to questionnaires from a large longitudinal epidemiological study and sought to determine if any changes made throughout data collection had a positive impact on the response to questionnaires and addressed any imbalance in response rates by participants' levels of deprivation. METHODS: Data were taken from a prospective, comparative study, designed to examine the effects of the reintroduction of water fluoridation on children's oral health over a five-year period. Response rates were analysed for the first year of data collection. During this year changes were made to the questionnaire layout and cover letter to attempt to increase response rates. Additionally a nested randomised control trial compared the effect on response rates of three different reminders to complete questionnaires. RESULTS: Data were available for 1824 individuals. Sending the complete questionnaire again to non-responders resulted in the highest level of response (25%). A telephone call to participants was the only method that appeared to address the imbalance in deprivation, with a mean difference in deprivation score of 2.65 (95% CI -15.50 to 10.20) between the responders and non-responders. CONCLUSIONS: Initially, low response rates were recorded within this large, longitudinal study giving rise to concerns about non-response bias. Resending the entire questionnaire again was the most effective way of reminding participants to complete the questionnaire. As this is a less labour intensive method than for example, calling participants, more time can then be spent targeting groups who are underrepresented. In order to address these biases, data can be weighted in order to draw conclusions about the population.

Long-term variability in artificially and naturally fluoridated water supplies in England.

OBJECTIVES: To understand the potential impact of exposure misclassification on water fluoridation studies in England, this paper aims to describe the long-term variation in water fluoride concentrations in both artificially and naturally fluoridated water supplies. METHODS: Water fluoridation dose monitoring data were requested from all five English public water suppliers who artificially fluoridate their water, as well as from one water company that supplies naturally fluoridated water. Descriptive statistics were calculated, including annual means, standard deviations, minimum-maximum and absolute and relative frequencies. RESULTS: Data were made available by two of the five English water companies who supply artificially fluoridated water and one water company that supplies naturally fluoridated water (40 398 individual samples). The data for fluoridated water spanned 18-35 years, whilst the data on naturally fluoridated water spanned 14 years. The artificially fluoridated samples showed wide variation in fluoride dose control, both between different water treatment works and over time. Mean fluoride concentrations in the artificially fluoridated supplies ranged from 0.53 (SD 0.47) to 0.93 (SD 0.22) mg F/L and were within the optimal range of 0.7-1.0 mg F/L in 27.7%-77.8% of samples. The naturally fluoridated supplies had a higher mean fluoride concentration of 1.06 (SD 0.18) and 1.15 (SD 0.16) mg F/L than the artificially fluoridated supplies, with lower variation over time. The naturally fluoridated supplies were above the optimal range in 75.5% and 53% of samples. CONCLUSIONS: Assumptions that populations living in areas with a water fluoridation scheme have received optimally fluoridated water (0.7-1.0 mg F/L) are invalid. To support future research endeavours, as well as to provide 'external control' and facilitation of optimal dosing, it is recommended that a quarterly record of water fluoride concentrations (mean, standard deviation and minimum and maximum) are made available for every water supply in England, in a format that can be mapped against residential postcodes.

Development and pilot study of an oral health literacy tool for older adults.

AIM: Oral health literacy is emerging as an important element in oral health promotion, but few studies have been conducted in older adults. This work aimed to develop and validate the Test of Functional Health Literacy in Dentistry for Older Adults (OA-TOFHLiD). METHODS: The tool was developed by a researcher and then evaluated by experts for face validity. A convenience sample was conducted to recruit 105 older adults, aged more than 60 years in Chiang Mai, Thailand, in 2016. 2 existing health literacy tools and the newly developed test were administered and oral health statuses were examined by a dentist. RESULTS: The mean age of the participants was 67.4 years (SD = 5.86). The OA-TOFHLiD scores were positively correlated with education, income, self-reported general literacy, health literacy scores and dental caries. However, it was negatively correlated with the number of decayed and missing teeth (P < .05). Cronbach's alpha was 0.88 and the intraclass correlation coefficient was 0.86. CONCLUSION: This study demonstrated that OA-TOFHLiD has acceptable validity and reliability; however, it is suggested that the predictive validity of this tool should be improved.

Further opportunities for digital imaging in dental epidemiology.

Dental epidemiological research permits accurate tracking of the prevalence and distribution of oral disease across population groups, enabling planning and evaluation of public health interventions and healthcare service provision. This first section of this paper aimed to review traditional assessment methods in dental epidemiology and to consider the methodological and logistical benefits provided by digital imaging, both generally and specifically in relation to an established dual-camera system. The remainder of this paper describes the results of a semi-structured examination of an image archive from previous research utilising a dual-camera system, exploring whether the diagnostic yield of the images might be increased. Common oral conditions are presented alongside suggestions of the diagnostically useful data displayed in example images. Possible scoring mechanisms are discussed with consideration of the limitations that might be encountered for each condition. The retrospective examination suggests further data is obtainable from images acquired using the dual-camera system, however, consideration should be given to how best to validate this clinically. Additionally, other imaging modalities are discussed whilst taking into account the potential limitations of the dual-camera system.

Automatic detection and classification of dental fluorosis in vivo using white light and fluorescence imaging.

OBJECTIVES: To assess a novel method of automatic fluorosis detection and classification from white light and fluorescent images. METHODS: Dental images from 1,729 children living in two fluoridated and two non-fluoridated UK cities were utilised. A novel detection and classification algorithm was applied to each image and TF scores were obtained using thresholding criteria. These were compared to clinical reference standard images. Comparisons between reference and automated assessments were undertaken to record correct and incorrect classifications and the ability of the system to separate the fluoridated and non-fluoridated populations. RESULTS: The automated system performed well and was able to differentiate the two populations (P < 0.0001) to the same degree as the reference standard. When using the highest score from the clinical assessment the agreement between automated and clinical assessments was 0.56 (Kappa SE = 0.0160, p < 0.0001). CONCLUSIONS: Assessment of dental fluorosis is typically undertaken by clinical examiners in epidemiological studies. The training and calibration of such examiners is complex and time consuming and the assessments are subject to bias - frequently because of the examiner's awareness of the water fluoridation status of subjects. The use of remote scoring using photographs has been advocated but still requires trained examiners. This study has shown that image-processing methodologies applied to white light and fluorescent images could automatically score fluorosis and statistically separate fluoridated and non-fluoridated areas. The system requires further refinement to manage confounding factors such as the presence of non-fluoride opacities and tooth stain.

Digital epidemiology - Calibrating readers to score dental images remotely.

BACKGROUND: There is growing interest to use digital photographs in dental epidemiology. However, the reporting of procedures and metric-based performance outcomes from training to promote data quality prior to actual scoring of digital images has not been optimal. METHODS: A training study was undertaken to assess training methodology and to select a group of scorers to assess images for dental fluorosis captured during the 2013-2014 National Health and Nutrition Examination Survey (NHANES). Ten examiners and 2 reference examiners assessed dental fluorosis using the Deans Index (DI) and the Thylstrup-Fejerskov (TF) Index. Trainees were evaluated using 128 digital images of upper anterior central incisors at three different periods and with approximately 40 participants during two other periods. Scoring of all digital images was done using a secured, web-based system. RESULTS: When assessing for nominal fluorosis (apparent vs. non-apparent), the unweighted Kappa for DI ranged from 0.68 to 0.77 and when using an ordinal scale, the linear-weighted kappa for DI ranged from 0.43 to 0.69 during the final evaluation. When assessing for nominal fluorosis using TF, the unweighted Kappa ranged from 0.67 to 0.89 and when using an ordinal scale, the linear-weighted kappa for TF ranged from 0.61 to 0.77 during the final evaluation. No examiner improvement was observed when a clinical assessment feature was added during training to assess dental fluorosis using TF, results using DI was less clear. CONCLUSION: Providing examiners theoretical material and scoring criteria prior to training may be minimally sufficient to calibrate examiners to score digital photographs. There may be some benefit in providing an in-person training to discuss criteria and review previously scored images. Previous experience as a clinical examiner seems to provide a slight advantage at scoring photographs for DI, but minimizing the number of scorers does improve inter-examiner concordance for both DI and TF.

Bedtime routines child wellbeing & development.

BACKGROUND: Bedtime routines has shown important associations with areas associated with child wellbeing and development. Research into bedtime routines is limited with studies mainly focusing on quality of sleep. The objectives of the present study were to examine the relationship between bedtime routines and a variety of factors associated with child wellbeing and to examine possible determinants of bedtime routines. METHODS: A total of 50 families with children between 3 and 5 years old took part in the study. Data on bedtime routines, parenting styles, school readiness, children's dental health, and executive function were collected. RESULTS: Children in families with optimal bedtime routines showed better performance in terms of executive function, specifically working memory (t (44)= - 8.51, p ≤ .001), inhibition and attention (t (48)= - 9.70, p ≤ .001) and cognitive flexibility (t (48)= - 13.1, p ≤ .001). Also, children in households with optimal bedtime routines scored higher in their readiness for school (t (48)= 6.92, p ≤ .001) and had better dental health (U = 85.5, p = .011). Parents in households with suboptimal bedtime routines showed worse performance on all measures of executive function including working memory (t (48)= - 10.47, p ≤ .001), inhibition-attention (t (48)= - 10.50, p ≤ .001) and cognitive flexibility (t (48)= - 13.6, p ≤ .001). Finally, parents with optimal bedtime routines for their children deployed a more positive parenting style in general (i.e. authoritative parenting) compared to those with suboptimal bedtime routines (t (48)= - 6.45, p ≤ .001). CONCLUSION: The results of the present study highlight the potentially important role of bedtime routines in a variety of areas associated with child wellbeing and the need for further research.