Specialists' management of permanent dentition traumatic dental injuries in 7-16-year-olds: A qualitative study.

BACKGROUND/AIM: Specialist paediatric dentists are integral to dental trauma care pathways. General dentists rely on specialist input, more so in complex cases. Little is known about specialists' role in these pathways or the perceived barriers they face. The aim is to explore specialists' role in managing traumatic dental injuries in the permanent dentition in children. MATERIAL/METHODS: Face-to-face (remote video) online semi-structured interviews were undertaken. All UK specialists were invited by email. Purposeful sampling aimed to investigate representation from the devolved nations, presence/absence of working within a managed-clinical network and level of care provision. Interviews were audio-recorded and transcribed verbatim. Transcripts were thematically analysed. RESULTS: Data saturation was reached after nine interviews. Three main themes established were: inconsistent access to care; the need to formalise traumatic dental injuries care pathways; educationally upskilling general dentists. Geographical variation in provision of specialist and out-of-hours/emergency department care meant patients risked not receiving care by the most appropriate individual. Formalizing care pathways by clearly defining the role of each stakeholder (specialist, dentist, medical professionals and parents) and developing a method to assess complexity was perceived to be essential to improving treatment outcomes. Upskilling general dentists in trauma management appeared essential. A potential lack of engagement was raised, with a suggestion that trauma management education should become core continuing-professional development. CONCLUSIONS: Specialist input should be available in the management of traumatic dental injuries. Current access to specialist care is inequitable across the UK. Formalizing care pathways and upskilling general dentists could ease inconsistencies.

Is food insecurity associated with dental caries?

DATA SOURCES: Eight electronic databases including APA PsycINFO, CINAHL, Embase, LILACS, PubMed, Ovid, Scopus and Web of Science were searched from date of inception to November 2021. An updated search was conducted in August 2022. Google Scholar was accessed including Open Grey and ProQuest. Reference lists of the included studies were analysed for potentially eligible studies. STUDY SELECTION: Observational studies (cross-sectional, case-control and cohort) that evaluated the association between dental caries and food insecurity were eligible for analysis. Qualitative studies, reviews and meeting abstracts were excluded. There were no restrictions on language or publication date. DATA EXTRACTION AND SYNTHESIS: Two reviewers independently screened titles and abstracts. A third experienced researcher was consulted if there was disagreement. Food insecurity status was the exposure with dental caries the outcome. The authors retrieved effect measures, 95% CI's and P values where available. Heterogeneity was assessed via I2 and R2. A total of 514 records were initially identified. Once duplicates were removed, 19 references were assessed in full. The association between food insecurity and dental caries were presented as odds-ratios, relative risks and prevalence ratios with 95% CIs. A random-effects model was fitted to all meta-analyses. RESULTS: Evaluation identified 14 studies for the qualitative synthesis and 7 studies for the quantitative synthesis. The total sample size for the 14 studies was 150,546 individuals. Quantitative data merged from two studies found food-insecure individuals more prone to dental caries than food-secure individuals (OR = 1.62; 95% CI, 1.01-2.60; P = 0.045). In two studies that used binary data to compare food security or insecurity, food insecure individuals were more likely to exhibit dental caries (OR = 1.66; 95% CI, 1.36-2.02; P < 0.0001). CONCLUSIONS: People experiencing food insecurity are more likely to exhibit dental caries than those who have food security.

The Atypical Red Eye: A Case of Scleritis with Peripheral Ulcerative Keratitis Secondary to Granulomatosis with Polyangiitis.

This report presents a rare case of scleritis with peripheral ulcerative keratitis secondary to granulomatosis with polyangiitis (GPA). A 65-year-old Caucasian male presented to a regional ophthalmology service with an atypical red eye. His immune work-up demonstrated positive anti-neutrophil cytoplasmic IgG autoantibodies (ANCA) with anti-proteinase 3 antibody (PR3) elevation. Multi-system vasculitis was discovered including lung, liver, bladder, prostate, nasal and paranasal sinuses involvement. His ocular sequelae included significant peripheral corneal thinning requiring cyanoacrylate gluing, juxtalimbal conjunctival resection, and bandage lens placement. He was treated with systemic methylprednisolone and rituximab achieving remission with ongoing prednisone and methotrexate maintenance therapy. This case demonstrates the importance of recognizing ocular manifestations of GPA as a first presentation of systemic vasculitis.

Climate-mediated population dynamics of a migratory songbird differ between the trailing edge and range core.

Understanding the demographic drivers of range contractions is important for predicting species' responses to climate change; however, few studies have examined the effects of climate change on survival and recruitment across species' ranges. We show that climate change can drive trailing edge range contractions through the effects on apparent survival, and potentially recruitment, in a migratory songbird. We assessed the demographic drivers of trailing edge range contractions using a long-term demography dataset for the black-throated blue warbler (Setophaga caerulescens) collected across elevational climate gradients at the trailing edge and core of the breeding range. We used a Bayesian hierarchical model to estimate the effect of climate change on apparent survival and recruitment and to forecast population viability at study plots through 2040. The trailing edge population at the low-elevation plot became locally extinct by 2017. The local population at the mid-elevation plot at the trailing edge gradually declined and is predicted to become extirpated by 2040. Population declines were associated with warming temperatures at the mid-elevation plot, although results were more equivocal at the low-elevation plot where we had fewer years of data. Population density was stable or increasing at the range core, although warming temperatures are predicted to cause population declines by 2040 at the low-elevation plot. This result suggests that even populations within the geographic core of the range are vulnerable to climate change. The demographic drivers of local population declines varied between study plots, but warming temperatures were frequently associated with declining rates of population growth and apparent survival. Declining apparent survival in our study system is likely to be associated with increased adult emigration away from poor-quality habitats. Our results suggest that demographic responses to warming temperatures are complex and dependent on local conditions and geographic range position, but spatial variation in population declines is consistent with the climate-mediated range shift hypothesis. Local populations of black-throated blue warblers near the warm-edge range boundary at low latitudes and low elevations are likely to be the most vulnerable to climate change, potentially leading to local extirpation and range contractions.

Evaluation of student-perceived competence of interprofessional working in Gerodontology.

OBJECTIVE: To evaluate pharmacy, dental and dental therapy undergraduate students' perceived competence of interprofessional working before and after attending an interprofessional education (IPE) Gerodontology workshop. BACKGROUND: Whilst there is international recognition of the importance of collaboration between the dental profession and systemic healthcare providers to enhance patient care, there remains a paucity of research into IPE in Gerodontology. MATERIALS AND METHODS: Pharmacy, dental and dental therapy undergraduate students attended a 2-hour Gerodontology case-based workshop. Students completed anonymised Interprofessional Collaborative Competencies Attainment Surveys (ICCAS) before and after attendance. RESULTS: 108 questionnaires were received, 7 were withdrawn (1 incomplete with only pre-workshop side completed, 6 did not identify degree programme). From 101 included questionnaires, 37 were from pharmacy, 56 dental and 8 dental therapy students resulting in response rates of 84%, 82% and 67%, respectively. Each student group recorded an increase in positive reflective competence median (IQR) after taking part in the workshop. Overall median (IQR) reflective competence before the workshop was 6 (1), 5 (2) and 6 (2) for pharmacy, dental and dental therapy students, respectively, which increased to 7 (1) for all groups. There was variability in reflective competence before attending the workshop between dental and pharmacy students for two questions, and dental and dental therapy students for two different questions. CONCLUSION: All students reported increased reflective competence of interprofessional working following the workshop. These findings suggest that introduction of IPE events into Gerodontology curricula may improve student understanding and appreciation of interprofessional working when providing care for older people.

Visual recovery following surgical intervention for pituitary apoplexy correlated with preoperative optical coherence tomography.

Pituitary apoplexy is a rare but potentially fatal endocrinological emergency which can be difficult to diagnose as presenting symptoms vary significantly. Optimal management requires early diagnosis and collaboration between ophthalmology, endocrinology and neurosurgical services. We present a case of pituitary apoplexy in a 52-year-old Caucasian female who was referred by her optometrist to Palmerston North Hospital Eye Clinic with a three-week history of sudden onset moderate bifrontal headaches, two weeks of non-specific peripheral visual changes and dense bitemporal inferior quadrantanopia on formal visual field testing. Ocular motility and slit lamp examination were unremarkable and retinal nerve fibre layer (RNFL) was relatively preserved on optical coherence tomography (OCT). MRI demonstrated a haemorrhagic pituitary macroadenoma elevating and compressing the optic chiasm without cavernous extension. Blood tests revealed mild hypothyroidism, hypocortisolism, hypogonadotropism and hyperprolactinaemia. The patient was commenced on hydrocortisone and levothyroxine replacement and proceeded for urgent transsphenoidal tumour resection at Wellington Regional Hospital. Histology revealed a non-functioning macroadenoma. The patient was asymptomatic and visual field tests had normalised three weeks post-operatively. Six weeks post-operatively, thyroid function and cortisol levels were normal and replacement therapies were ceased.

Analytical approaches for evaluating passive acoustic monitoring data: A case study of avian vocalizations.

The interface between field biology and technology is energizing the collection of vast quantities of environmental data. Passive acoustic monitoring, the use of unattended recording devices to capture environmental sound, is an example where technological advances have facilitated an influx of data that routinely exceeds the capacity for analysis. Computational advances, particularly the integration of machine learning approaches, will support data extraction efforts. However, the analysis and interpretation of these data will require parallel growth in conceptual and technical approaches for data analysis. Here, we use a large hand-annotated dataset to showcase analysis approaches that will become increasingly useful as datasets grow and data extraction can be partially automated.We propose and demonstrate seven technical approaches for analyzing bioacoustic data. These include the following: (1) generating species lists and descriptions of vocal variation, (2) assessing how abiotic factors (e.g., rain and wind) impact vocalization rates, (3) testing for differences in community vocalization activity across sites and habitat types, (4) quantifying the phenology of vocal activity, (5) testing for spatiotemporal correlations in vocalizations within species, (6) among species, and (7) using rarefaction analysis to quantify diversity and optimize bioacoustic sampling.To demonstrate these approaches, we sampled in 2016 and 2018 and used hand annotations of 129,866 bird vocalizations from two forests in New Hampshire, USA, including sites in the Hubbard Brook Experiment Forest where bioacoustic data could be integrated with more than 50 years of observer-based avian studies. Acoustic monitoring revealed differences in community patterns in vocalization activity between forests of different ages, as well as between nearby similar watersheds. Of numerous environmental variables that were evaluated, background noise was most clearly related to vocalization rates. The songbird community included one cluster of species where vocalization rates declined as ambient noise increased and another cluster where vocalization rates declined over the nesting season. In some common species, the number of vocalizations produced per day was correlated at scales of up to 15 km. Rarefaction analyses showed that adding sampling sites increased species detections more than adding sampling days.Although our analyses used hand-annotated data, the methods will extend readily to large-scale automated detection of vocalization events. Such data are likely to become increasingly available as autonomous recording units become more advanced, affordable, and power efficient. Passive acoustic monitoring with human or automated identification at the species level offers growing potential to complement observer-based studies of avian ecology.

Ripple effects mapping: capturing the wider impacts of systems change efforts in public health.

BACKGROUND: Systems approaches are currently being advocated and implemented to address complex challenges in Public Health. These approaches work by bringing multi-sectoral stakeholders together to develop a collective understanding of the system, and then to identify places where they can leverage change across the system. Systems approaches are unpredictable, where cause-and-effect cannot always be disentangled, and unintended consequences - positive and negative - frequently arise. Evaluating such approaches is difficult and new methods are warranted. METHODS: Ripple Effects Mapping (REM) is a qualitative method which can capture the wider impacts, and adaptive nature, of a systems approach. Using a case study example from the evaluation of a physical activity-orientated systems approach in Gloucestershire, we: a) introduce the adapted REM method; b) describe how REM was applied in the example; c) explain how REM outputs were analysed; d) provide examples of how REM outputs were used; and e) describe the strengths, limitations, and future uses of REM based on our reflections. RESULTS: Ripple Effects Mapping is a participatory method that requires the active input of programme stakeholders in data gathering workshops. It produces visual outputs (i.e., maps) of the programme activities and impacts, which are mapped along a timeline to understand the temporal dimension of systems change efforts. The REM outputs from our example were created over several iterations, with data collected every 3-4 months, to build a picture of activities and impacts that have continued or ceased. Workshops took place both in person and online. An inductive content analysis was undertaken to describe and quantify the patterns within the REM outputs. Detailed guidance related to the preparation, delivery, and analysis of REM are included in this paper. CONCLUSION: REM may help to advance our understanding and evaluation of complex systems approaches, especially within the field of Public Health. We therefore invite other researchers, practitioners and policymakers to use REM and continuously evolve the method to enhance its application and practical utility.

Primary Care Dentists' management of permanent dentition traumatic dental injuries in 7- to 16-year-olds: A sequential mixed-methods study.

BACKGROUND/AIMS: Primary care dentists play a pivotal role in the management of traumatic dental injuries in children, despite little evidence on the barriers they face in providing care. The aim of this study was to explore and contextualize the knowledge and attitudes of general dental practitioners regarding their management of permanent dentition traumatic dental injuries in children aged 7-16 years old. MATERIAL AND METHODS: A two-phase sequential mixed-methods study included a questionnaire that was disseminated to all 619 primary care dentists, identified via a triangulated sampling strategy, based across the north-east of England (Phase I). Statistical analyses were performed using Mann-Whitney U- and Kruskal-Wallis tests, Spearman's correlation and chi-square test. Multivariate factor analysis, with principal components extraction, was used to test between multiple ordinal variables. Respondents were invited to a face-to-face or telephone semi-structured interview (Phase II). Interviews were transcribed verbatim and analysed using inductive thematic analysis. RESULTS: Primary care dentists were less confident in managing complex dental trauma. Inadequate financial remuneration was the main reason for not providing care, often prompting a referral to the local dental hospital. This was more apparent for those who qualified before 2000. More recently qualified dentists felt the long-term costs, related to traumatic dental injuries, were insufficiently remunerated. Most still provided emergency management, irrespective of remuneration, as long as they had the requisite knowledge and skills. Four major themes arose: impact of traumatic dental injuries on patients, parents and primary care dentists; barriers to providing treatment; educational opportunities for primary care dentists; and interactions between primary and secondary care services. CONCLUSIONS: There is high confidence in managing simple traumatic dental injuries but less for complex injuries. A lack of sufficient financial remuneration associated with the long-term management of dental trauma was the main barrier for dentists to manage these cases.

Transatlantic engagement: a novel dental educational exchange.

Introduction Newcastle University School of Dental Sciences (NUSDS) and Indiana University School of Dentistry in the United States of America (IUSD) are like-minded institutions committed to civic engagement. Over the last 15 years, both universities have built civic engagement into the dental curricula, however each institution operates within significantly different healthcare systems.Aim Co-development of unique collaborative dental education; the first UK/US educational exchange programme engaged with the dental student community.Design A dental educational exchange was developed enabling NUSDS and IUSD students to learn alongside each other within dental and community settings in both countries. Students participate in a unique face-to-face collaborative and interdisciplinary education programme within respective dental schools and by a series of video conferences scheduled before on-site visits. They gain mutual awareness of delivery, access to care and possible barriers facing patients relating to the oral healthcare systems in England, the state of Indiana and the USA. Logistical considerations were significant, aided by scoping visits to the respective partner school and video conferencing. Planning encompassed timetable restrictions, scheduling student video conferences, students' clinical access/observerships, occupational health clearances, overall educational content, student/staff evaluation and potential areas for education research.Conclusions Currently in its fourth year, this is a unique example of a collaborative educational exchange between the UK and USA.

Impact of a health marketing campaign on sugars intake by children aged 5-11 years and parental views on reducing children's consumption.

BACKGROUND: The association between Free Sugars intake and non-communicable diseases such as obesity and dental caries is well documented and several countries are taking measures to reduce sugars intakes. Public Health England (PHE) instigated a range of approaches to reduce sugars, including a national health marketing campaign (Sugar Smart). The campaign aimed to raise awareness of the amount of sugars in foods and drinks and to encourage parents to reduce their children's intake. The aim of this study was to determine whether the campaign was effective in altering dietary behaviour, by assessing any impact of the campaign on sugars intake among children aged 5-11 years. Parental perceptions of the campaign and barriers to reducing sugars intake were also explored. METHODS: Parents of 873 children aged 5-11 years, identified from an existing PHE database, were invited to take part. Dietary information was collected online using Intake24 before, during, and at 1, 10 and 12 months following the campaign. Change in sugars intake was assessed using mixed effects linear regression models. One-to-one telephone interviews were conducted with a purposive sample of parents to explore perceptions of the campaign and identify barriers and facilitators to reducing children's sugars intake. RESULTS: Completion rates for dietary assessment ranged from 61 to 72% across the follow up time points. Qualitative telephone interviews were conducted with 20 parents. Total sugars intake decreased on average by ~ 6.2 g/day (SD 43.8) at peak campaign and the percentage of energy from total sugars significantly decreased immediately and 1 year post campaign. The percentage of energy from Free Sugars significantly decreased across all time points with the exception of the long term follow up at 12-months post campaign. The percentage of energy intake from total fat increased. Parents expressed a willingness to reduce sugars intakes, however, identified barriers including time constraints, the normalisation of sugary treats, and confusing information. CONCLUSIONS: A health marketing campaign had a positive impact in reducing sugars intake but reductions in sugars were not sustained. Parents want to reduce their child's sugars intake but societal barriers and confusion over which sources of sugars to avoid hamper efforts to change.

Risk Factors for Poststroke Shoulder Pain: A Systematic Review and Meta-Analysis.

OBJECTIVE: To identify the risk factors identified within 1-month poststroke that predict the onset of poststroke shoulder pain (PSSP) within the first year after stroke. METHODS: Five databases (AMED, CINAHL, EMBASE, Medline, and PubMed) were searched from inception to April 2019. Prospective cohort studies that measured a potential risk factor for PSSP within the first month after stroke were included. Two authors independently reviewed and selected articles for inclusion. Risk of bias was assessed using the Quality in Prognosis Studies tool. Data extracted included raw data for odds ratio (OR) calculations, definition and measurement of pain, study limitations, and baseline characteristics of participants. The review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: Nine articles were retrieved that met the inclusion criteria, and 6 presented data to use in meta-analysis. Fifty-four different factors were identified as potential risk factors. Meta-analysis was possible for 4 factors; sex (OR .93, confidence interval [CI] .75-1.15), laterality (OR .78, CI .59-1.05), diabetes (OR 2.09, CI 1.16-3.78), and history of shoulder pain (OR 2.78, CI 1.29-5.97). Reduced motor function in the upper limb was also identified as a significant risk factor through qualitative synthesis. CONCLUSIONS: Reduced motor function in the upper limb, diabetes, and a history of shoulder pain were identified as significant risk factors for the development of PSSP within the first year after stroke. Recommendations to standardize future studies in this area have been made, and it is suggested that defining subtypes of PSSP may aid future interventional studies.

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

BACKGROUND: The lack of evidence for the effective management of carious lesions in children's primary teeth has caused uncertainty for the dental profession and patients. Possible approaches include conventional and biological management alongside best practice prevention, and best practice prevention alone. The FiCTION trial assessed the effectiveness of these options, and included a qualitative study exploring dental professionals' (DPs) experiences of delivering the different treatment arms. This paper reports on how DPs managed children with carious lesions within FiCTION and how this related to their everyday experiences of doing dentistry. METHODS: Overall, 31 DPs from FiCTION-trained dental surgeries in four regions of the UK participated in semi-structured interviews about their experiences of the three treatment arms (conventional management of carious lesions and prevention (C + P), biological management of carious lesions and prevention (B + P) or prevention alone (PA)). A theoretical framework, drawing on social practice theory (SPT), was developed for analysis. RESULTS: Participants discussed perceived effectiveness of, and familiarity with, the three techniques. The C + P arm was familiar, but some participants questioned the effectiveness of conventional restorations. Attitudes towards the B + P arm varied in terms of familiarity, but once DPs were introduced to the techniques, this was seen as effective. While prevention was familiar, PA was described as ineffective. DPs manage children with carious lesions day-to-day, drawing on previous experience and knowledge of the child to provide what they view as the most appropriate treatment in the best interests of each child. Randomisation undermined these normal choices. Several DPs reported deviating from the trial arms in order to treat a patient in a particular way. Participants valued evidence-based dentistry, and expect to use the results of FiCTION to inform future practice. They anticipate continuing to use the full range of treatment options, and to personally select appropriate strategies for individual children. CONCLUSIONS: RCTs take place in the context of day-to-day practices of doing dentistry. DPs employ experiential and interpersonal knowledge to act in the best interests of their patients. Randomisation within a clinical trial can present a source of tension for DPs, which has implications for assuring individual equipoise in future trials.

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

BACKGROUND: To help promote a flexible and sustainable workforce in dentistry, it is necessary to access accurate and timely data about the structure and nature of the evolving dental team. This paper considers the results and learning from a region-wide dental workforce survey conducted in one area of Health Education England and how the team has changed since the last survey a decade earlier. METHODS: A mixed-methods approach comprised two phases. In Phase 1 a customised workforce questionnaire was sent to all dental practices registered with the Care Quality Commission in the North East of England and North Cumbria in March 2016. Findings then informed Phase 2, a regional symposium held in October 2016, where interactive workshops generated qualitative data that elaborated on factors influencing workforce development. RESULTS: Of 431 primary dental care practices identified, 228 questionnaires were returned - a 53% response rate. The largest professional groups were dental nurses (n = 1269, 53% by headcount; 50% of fte) and dentists (34% by headcount; 42% by fte), though there had been increases in numbers of all staff groups over the decade, which was most marked for dental therapists (from 1 per 39 dentists to 1 per 8 dentists). The dental team predominantly fell into 'younger' age groups (< 46 years age), with evidence of a significant increase in the number of dentists reporting part-time working in a practice since the last survey. Around one third of dental practices reported employing dental nurses with additional skills (n = 74, 32.5%) or dental therapists (n = 73, 32%), and nearly half employed a dental hygienist (n = 104, 46%). However, there was considerable variability in whether these staff actually carried out the range of skills within their scope of practice. Factors shaping workforce development were identified as, the national context, loss of expertise, patients' health needs and expectations, surgery premises and financial constraints. CONCLUSIONS: The composition and work patterns of the primary care dental workforce have changed markedly over the last decade, though utilisation of skill-mix continues to be constrained. Consideration of factors determining career progression of dentists and dental care professionals is needed to optimise a sustainable future workforce.

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

BACKGROUND: The Filling Children's Teeth: Indicated Or Not? (FiCTION) randomised controlled trial (RCT) aimed to explore the clinical- and cost-effectiveness of managing dental caries in children's primary teeth. The trial compared three management strategies: conventional caries management with best practice prevention (C + P), biological management with best practice prevention (B + P) and best practice prevention alone (PA)-based approaches. Recently, the concept of treatment acceptability has gained attention and attempts have been made to provide a conceptual definition, however this has mainly focused on adults. Recognising the importance of evaluating the acceptability of interventions in addition to their effectiveness, particularly for multi-component complex interventions, the trial design included a qualitative component. The aim of this component was to explore the acceptability of the three strategies from the perspectives of the child participants and their parents. METHODS: Qualitative exploration, based on the concept of acceptability. Participants were children already taking part in the FiCTION trial and their parents. Children were identified through purposive maximum variation sampling. The sample included children from the three management strategy arms who had been treated and followed up; median (IQR) follow-up was at 33.8 (23.8, 36.7) months. Semi-structured interviews with thirteen child-parent dyads. Interviews were transcribed verbatim and analysed using a framework approach. RESULTS: Data saturation was reached after thirteen interviews. Each child-parent dyad took part in one interview together. The participants were eight girls and five boys aged 5-11 years and their parents. The children's distribution across the trial arms was: C + P n = 4; B + P n = 5; PA n = 4. Three key factors influenced the acceptability of caries management in primary teeth to children and parents: i) experiences of specific procedures within management strategies; ii) experiences of anticipatory dental anxiety and; iii) perceptions of effectiveness (particularly whether pain was reduced). These factors were underpinned by a fourth key factor: the notion of trust in the dental professionals - this was pervasive across all arms. CONCLUSIONS: Overall children and parents found each of the three strategies for the management of dental caries in primary teeth acceptable, with trust in the dental professional playing an important role.

Brain Myelin Water Fraction and Diffusion Tensor Imaging Atlases for 9-10 Year-Old Children.

BACKGROUND AND PURPOSE: Myelin water imaging (MWI) and diffusion tensor imaging (DTI) provide information about myelin and axon-related brain microstructure, which can be useful for investigating normal brain development and many childhood brain disorders. While pediatric DTI atlases exist, there are no pediatric MWI atlases available for the 9-10 years old age group. As myelination and structural development occurs throughout childhood and adolescence, studies of pediatric brain pathologies must use age-specific MWI and DTI healthy control data. We created atlases of myelin water fraction (MWF) and DTI metrics for healthy children aged 9-10 years for use as normative data in pediatric neuroimaging studies. METHODS: 3D-T1 , DTI, and MWI scans were acquired from 20 healthy children (mean age: 9.6 years, range: 9.2-10.3 years, 4 females). ANTs and FSL registration were used to create quantitative MWF and DTI atlases. Region of interest (ROI) analysis in nine white matter regions was used to compare pediatric MWF with adult MWF values from a recent study and to investigate the correlation between pediatric MWF and DTI metrics. RESULTS: Adults had significantly higher MWF than the pediatric cohort in seven of the nine white matter ROIs, but not in the genu of the corpus callosum or the cingulum. In the pediatric data, MWF correlated significantly with mean diffusivity, but not with axial diffusivity, radial diffusivity, or fractional anisotropy. CONCLUSIONS: Normative MWF and DTI metrics from a group of 9-10 year old healthy children provide a resource for comparison to pathologies. The age-specific atlases are ready for use in pediatric neuroimaging research and can be accessed: https://sourceforge.net/projects/pediatric-mri-myelin-diffusion/.

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

BACKGROUND: Historically, lack of evidence for effective management of decay in primary teeth has caused uncertainty, but there is emerging evidence to support alternative strategies to conventional fillings, which are minimally invasive and prevention orientated. OBJECTIVES: The objectives were (1) to assess the clinical effectiveness and cost-effectiveness of three strategies for managing caries in primary teeth and (2) to assess quality of life, dental anxiety, the acceptability and experiences of children, parents and dental professionals, and caries development and/or progression. DESIGN: This was a multicentre, three-arm parallel-group, participant-randomised controlled trial. Allocation concealment was achieved by use of a centralised web-based randomisation facility hosted by Newcastle Clinical Trials Unit. SETTING: This trial was set in primary dental care in Scotland, England and Wales. PARTICIPANTS: Participants were NHS patients aged 3-7 years who were at a high risk of tooth decay and had at least one primary molar tooth with decay into dentine, but no pain/sepsis. INTERVENTIONS: Three interventions were employed: (1) conventional with best-practice prevention (local anaesthetic, carious tissue removal, filling placement), (2) biological with best-practice prevention (sealing-in decay, selective carious tissue removal and fissure sealants) and (3) best-practice prevention alone (dietary and toothbrushing advice, topical fluoride and fissure sealing of permanent teeth). MAIN OUTCOME MEASURES: The clinical effectiveness outcomes were the proportion of children with at least one episode (incidence) and the number of episodes, for each child, of dental pain or dental sepsis or both over the follow-up period. The cost-effectiveness outcomes were the cost per incidence of, and cost per episode of, dental pain and/or dental sepsis avoided over the follow-up period. RESULTS: A total of 72 dental practices were recruited and 1144 participants were randomised (conventional arm, n = 386; biological arm, n = 381; prevention alone arm, n = 377). Of these, 1058 were included in an intention-to-treat analysis (conventional arm, n = 352; biological arm, n = 352; prevention alone arm, n = 354). The median follow-up time was 33.8 months (interquartile range 23.8-36.7 months). The proportion of children with at least one episode of pain or sepsis or both was 42% (conventional arm), 40% (biological arm) and 45% (prevention alone arm). There was no evidence of a difference in incidence or episodes of pain/sepsis between arms. When comparing the biological arm with the conventional arm, the risk difference was -0.02 (97.5% confidence interval -0.10 to 0.06), which indicates, on average, a 2% reduced risk of dental pain and/or dental sepsis in the biological arm compared with the conventional arm. Comparing the prevention alone arm with the conventional arm, the risk difference was 0.04 (97.5% confidence interval -0.04 to 0.12), which indicates, on average, a 4% increased risk of dental pain and/or dental sepsis in the prevention alone arm compared with the conventional arm. Compared with the conventional arm, there was no evidence of a difference in episodes of pain/sepsis among children in the biological arm (incident rate ratio 0.95, 97.5% confidence interval 0.75 to 1.21, which indicates that there were slightly fewer episodes, on average, in the biological arm than the conventional arm) or in the prevention alone arm (incident rate ratio 1.18, 97.5% confidence interval 0.94 to 1.48, which indicates that there were slightly more episodes in the prevention alone arm than the conventional arm). Over the willingness-to-pay values considered, the probability of the biological treatment approach being considered cost-effective was approximately no higher than 60% to avoid an incidence of dental pain and/or dental sepsis and no higher than 70% to avoid an episode of pain/sepsis. CONCLUSIONS: There was no evidence of an overall difference between the three treatment approaches for experience of, or number of episodes of, dental pain or dental sepsis or both over the follow-up period. FUTURE WORK: Recommendations for future work include exploring barriers to the use of conventional techniques for carious lesion detection and diagnosis (e.g. radiographs) and developing and evaluating suitable techniques and strategies for use in young children in primary care. TRIAL REGISTRATION: Current Controlled Trials ISRCTN77044005. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 1. See the NIHR Journals Library website for further project information.

WHAT WAS THE QUESTION?: Tooth decay is common; it can lead to pain, days off school for children and days off work for parents and is a financial burden to the NHS. There is uncertainty about the best way of managing decay in young children. This trial aimed to find out whether or not there was a difference in the amount of pain and/or infection suffered by children having their decay treated with one of the following: fillings, having decay sealed in or using preventative treatment alone. Which method represented the best value was also explored. WHAT DID WE DO?: For young children with decay, the Filling Children's Teeth: Indicated Or Not? (FiCTION) trial compared the difference between fillings, sealing in the decay and using preventative treatment alone over 3 years in NHS dental practices in Scotland, England and Wales. We recruited 1144 children aged 3­7 years with one or more holes in their baby back teeth (molars), but without pain/infection, and placed them at random into one of three groups: (1) tooth numbing, removing decay and filling(s) with preventative treatment; (2) sealing in decay with fillings or caps and preventative treatment but no numbing; or (3) preventative treatment alone. WHAT DID WE FIND?: Recruitment was challenging but was achieved. There was no evidence of a difference in children's experience of pain or infection, quality of life or dental anxiety between groups. All three ways of treating decay were acceptable to children, parents and dental professionals. Sealing in with preventative treatment was most likely to be considered the best way of managing children's decay if we are willing to pay a minimum of £130 to avoid an episode of pain or infection. WHAT DOES THIS MEAN?: As there was no evidence of a difference between the three treatment groups in pain/infection experienced, treatment choice should continue to be based on shared decision-making between the child, parent and clinician to agree the best option for the individual child.

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

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

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

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

How does priority setting for resource allocation happen in commissioning dental services in a nationally led, regionally delivered system: a qualitative study using semistructured interviews with NHS England dental commissioners.

OBJECTIVES: To understand approaches to priority setting for healthcare service resource allocation at an operational level in a nationally commissioned but regionally delivered service. DESIGN: Qualitative study using semistructured interviews and a Framework analysis. SETTING: National Health Service dentistry commissioning teams within subregional offices in England. PARTICIPANTS: All 31 individuals holding the relevant role (dental lead commissioner in subregional offices) were approached directly and from this 14 participants were recruited, with 12 interviews completed. Both male and female genders and all regions were represented in the final sample. RESULTS: Three major themes arose. First, 'Methods of priority setting and barriers to explicit approaches' was a common theme, specifically identifying the main methods as: perpetuating historical allocations, pressure from politicians and clinicians and use of needs assessments while barriers were time and skill deficits, a lack of national guidance and an inflexible contracting arrangements stopping resource allocation. Second, 'Relationships with key stakeholders and advisors' were discussed, showing the important nature of relationships with clinical advisors but variation in the quality of these relationships was noted. Finally, 'Tensions between national and local responsibilities' were illustrated, where there was confusion about where power and autonomy lay. CONCLUSIONS: Commissioners recognised a need for resource allocation but relied on clinical advice and needs assessment in order to set priorities. More explicit priority setting was prevented by structure of the commissioning system and standard national contracts with providers. Further research is required to embed and simplify adoption of tools to aid priority setting.