Longitudinal Study of Caries Development from Childhood to Adolescence.

The World Health Organization (WHO) stated that globally, dental caries is the most important oral condition. To develop effective prevention strategies requires an understanding of how this condition develops and progresses over time, but there are few longitudinal studies of caries onset and progression in children. The aim of the study was to establish the pattern of caries development from childhood into adolescence and to explore the role of potential risk factors (age, sex, ethnicity, and social deprivation). Of particular interest was the disease trajectory of dentinal caries in the permanent teeth in groups defined by the presence or absence of dentinal caries in the primary teeth. Intraoral examinations to assess oral health were performed at 4 time points by trained and calibrated dentist examiners using a standardized, national diagnostic protocol. Clinical data were available from 6,651 children. Mean caries prevalence (% D3MFT > 0) was 16.7% at the first clinical examination (ages 7-9 y), increasing to 31.0%, 42.2%, and 45.7% at subsequent examinations. A population-averaged model (generalized estimating equations) was used to model the longitudinal data. Estimated mean values indicated a rising D3MFT count as pupils aged (consistent with new teeth emerging), which was significantly higher (4.49 times; 95% confidence interval, 3.90-5.16) in those pupils with caries in their primary dentition than in those without. This study is one of the few large longitudinal studies to report the development of dental caries from childhood into adolescence. Children who developed caries in their primary dentition had a very different caries trajectory in their permanent dentition compared to their caries-free contemporaries. In light of these results, caries-free and caries-active children should be considered as 2 separate populations, suggesting different prevention strategies are required to address their different risk profiles.

A review of a child population dental preventive programme in Halton and St Helens.

INTRODUCTION: An evaluation was undertaken to measure the dental health of five cohorts of 5-year-old children living in Halton and St Helens, each cohort having had a different length of time they were exposed to a population dental prevention programme before their fifth birthday. METHOD: The dental health of each of five consecutive cohorts of 5-year-old children was measured epidemiologically using standardised methods. RESULTS: The mean level of active decay (dt) in the cohort that had the greatest exposure to the preventive intervention (cohort 5, 2011/12) was 0.83, whereas the mean level of active decay in the cohort with no exposure to the preventive programme (cohort 1, 2007/8) was 1.07. This represents a reduction of 22% in the mean level of active decay in 5-year-olds. There was also a 5.9% absolute increase in the number of 5-year-old children free from decay experience between cohorts 5 and 1. Children living in Halton and St Helens with postcodes in the more socially deprived index of multiple deprivation (IMD) tertiles gained the most from the programme. Comparing cohort 5 and cohort 1, the increase in the proportion of children free from decay was greatest in IMD tertiles 1 and 2 and least in IMD tertile 3 (least socially disadvantaged). CONCLUSION: Following a four-year population dental preventive programme the dental health of 5-year-old children living in Halton and St Helens has improved and dental health inequalities have reduced. As there was no control group, the effects seen are associative and cannot be assumed to be causative.

A cluster-randomized controlled trial: fluoride varnish in school children.

We conducted a school-based parallel cluster randomized controlled trial with 36-month follow-up of children aged 7 to 8 years. Primary schools were randomly assigned to 2 groups: 3 applications of fluoride varnish (22,600 ppm) each year or no intervention. The primary outcome was DFS increment in the first permanent molars, with the hypothesis that 9 applications of varnish over 3 years would result in a lower increment in the test group. Follow-up measurements were recorded by examiners blind to the allocation. Ninety-five schools were randomized to the test and 95 to the reference groups; 1473 (test) and 1494 (reference) children participated in the trial. An intention-to-treat analysis was carried out with random effects models. The DFS increment was 0.65 (SD 2.15) in the test and 0.67 (SD 2.10) in the reference groups, respectively. There was no statistically significant difference between the groups. We were unable to demonstrate an effect for fluoride varnish when it was used as a public health intervention to prevent caries in the first permanent molar teeth (Inter-national Standard Randomized Controlled Trial Registration: ISRCTN: #72589426).

Preventing decay in children: dare we risk the 'risk assessment' model in practice?

Encouraging dental prevention seems like a logical approach given that dental decay is a preventable disease and while the 2006 dental contract provides preventive opportunities, there is confusion about the best approach to the prevention of decay in those children that attend their dentist. Should we provide prevention for all children attending their dentist (the population approach) or should we target those children who are at greatest risk (risk assessment approach)?

Dental general anaesthesia--will the service disappear? A pilot study.

OBJECTIVES: To identify likely future trends in recruitment of consultant anaesthetists to the ambulatory dental general anaesthetic (DGA) services. PARTICIPANTS: The sample consisted of all anaesthetic specialist registrars (SpRs) in their final year of training, within Mersey and South-Western Deaneries in the U.K. RESEARCH DESIGN: A questionnaire divided into a quantitative section to establish level of training in ambulatory DGA, and a qualitative section designed to elicit opinions and attitudes towards ambulatory DGA services. RESULTS: The response rate was 75% (27/36). Within both regions 81% (22/27) had received practical training in ambulatory DGA procedures. SpRs in the South-Western Deanery held the greatest misgivings about the ambulatory DGA technique. Once appointed to Consultant position only 11% (3/27) of respondents expressed a definite interest in providing ambulatory DGA services. CONCLUSIONS: Within the Northwest and Southwest of England, most specialist registrars in anaesthetics receive training in ambulatory DGA, although their future commitment to the delivery of these services is questionable.

A comparative needs assessment of the dental health of adults attending dental access centres and general dental practices in Halton & St Helens and Warrington PCTs 2007.

INTRODUCTION: Dental access centres (DACs) were introduced in England at the turn of the twenty-first century in response to a growing problem of access to NHS dental services. DACs were expected to offer NHS dental care primarily to those patients that were unwilling or unable to attend 'high street' dental practice. At the same time, the new NHS primary care dental contract in England, introduced in April 2006, has been associated in some areas with access difficulties, with routine dental patients having difficulty accessing NHS dental care. In light of these changes, have DACs become an alternative provider of NHS dental services to patients seeking routine dental care? METHOD: In summer 2007, a cross sectional dental epidemiological study was undertaken in Halton & St Helens PCT and Warrington PCT to compare the dental health and attitudes to dental visiting of adult patients attending DACs and neighbouring 'high street' dental practices. RESULTS: The results of the study showed that DAC patients: were younger and from a more disadvantaged background than patients attending 'high street' practices; had worse oral health than 'high street' dental patients; experienced more frequent episodes of dental pain than 'high street' dental patients and were more likely to be dentally anxious; had different attitudes to dental health than their 'high street' counterparts. CONCLUSIONS: The study suggests that the DACs in Halton, St Helens and Warrington are offering treatment to a different population of patients to that seen in neighbouring 'high street' practices and therefore the DACs are fulfilling the function expected of them locally.

The performance of a screening test for urgent dental treatment need in a prison population.

OBJECTIVE: To compare the performance of a questionnaire-based assessment of dental pain delivered by non-dental prison nursing staff against a clinical examination performed by an experienced prison dentist (gold standard). SETTING: The research fieldwork took place in the healthcare department at HMP Brixton located in South London. METHODS: The cohort were those who had complained of dental/facial pain to the prison authorities and were therefore placed on the waiting list for emergency dental care. Subjects were asked to complete the screening test and were then clinically examined by trained and calibrated dentists. The screening test was in the form of a 12-item questionnaire designed to categorise a population reporting dental pain into one of three groups. The screening test results were compared with the diagnosis of a clinical examination. RESULTS: Ninety-six subjects were recruited during the 16-week study period. Of the 96 prisoners recruited, 27 of those failed to complete the screening test and/or the diagnostic examination even though they had reported pain previously. When sensitivity and specificity values were calculated for the 96 prisoners recruited, the sensitivity was fairly high (81%) and the specificity was poor (33%). However, when these values were calculated for the sub-population, those that completed both the screening test and diagnostic examination (n = 69), the sensitivity did not improve particularly (83%) but the specificity value fell substantially to 13%. CONCLUSIONS: This study highlighted the problems of conducting research in the prison environment, for example increased security preventing researchers from gaining access into the prison and general pressures on prison staff. Additionally, the study demonstrated that screening is not effective in local prisons with a high turnover of prisoners.

The incidence of dental caries in the primary molar teeth of young children receiving National Health Service funded dental care in practices in the North West of England.

INTRODUCTION: A prospective cohort study was undertaken to describe the incidence of dental caries, as recorded by GDPs, in the primary molar teeth of children aged approximately 3-6 years attending general dental practices in the North West of England. METHOD: Detailed dental records of children aged 3-6 years attending 50 general dental practices were assembled over a period of three years. Data from these records were analysed to estimate caries incidence rates at the subject and tooth level. RESULTS: The study population consisted of 739 children aged between 2.8 and 6.2 years; 620 children (84%) were caries free at recruitment. The incidence of developing a first carious (into dentine) lesion in caries free children increased with age. At age four the incidence of the first carious lesion was 9.5 per 100 person years and at age seven it was 19.6 per 100 person years. The tooth specific incidence of caries was found to be approximately 5-6 times greater in children with caries at recruitment than in caries free children. A sub-analysis on 566 children that were followed for more than two years revealed that of 486 children caries free at recruitment 132 (27%) developed caries in their primary molar teeth. By contrast, of the 80 children that had caries in their molar teeth at recruitment, one had eight carious molar teeth and 57 (72%) of the remaining 79 developed new cavities during the follow up period. CONCLUSIONS: Caries incidence increases with age. There is a 5-6 times difference in the incidence of new cavities between caries free children and children with caries, irrespective of when a child developed the disease. As a consequence children with the disease and without the disease should be considered as two different populations; this has implications for care strategies applied to each population.

The occurrence of dental pain and extractions over a 3-year period in a cohort of children aged 3-6 years.

OBJECTIVES: To describe the occurrence of dental pain and extractions in young children in relation to the caries and restoration history of their primary molar teeth. METHODS: A prospective cohort study of 739 children aged 2.8 to 6.2 years attending 50 dental practices in the North West of England followed for 3 years. Incidence rates for pain and extraction in primary molar teeth were calculated for children with and without dental caries. Tooth years at risk of extraction or pain were calculated for each primary molar according to whether they were caries-free, carious and unrestored, or restored. RESULTS: A total of 119 (16.1 percent) children had caries at recruitment and 157 developed caries during follow-up. Each year approximately one in five children with caries, but only one in 100, who was caries-free, presented with dental pain. In the whole population, each year, approximately one in 40 children had a primary molar tooth extracted but in children with caries it was one in 10. In the total cohort, incidence.of pain was higher in unrestored carious teeth than restored, but incidence of extraction was higher in restored than in unrestored teeth. CONCLUSION: The majority of children attending general dental practice remained caries-free and did not experience pain or extraction over 3 years. Children with caries had a substantial risk of developing pain or having an extraction. The study was unable to demonstrate that restoring carious primary molar teeth prevents pain and extraction.

An investigation of the nature of research into dental health in prisons: a systematic review.

OBJECTIVES: To establish the nature of research into dental health undertaken in prisons. DATA SOURCES: Databases were searched electronically. This process was supplemented by hand searching of references. DATA SELECTION: Two independent reviewers made initial selections and subsequently carried out full text screening. Discrepancies were discussed with a third reviewer and disagreements were resolved by consensus. DATA EXTRACTION: Fifty potentially relevant studies were identified and further screened for inclusion. Of this number, 29 studies were excluded; the remaining 21 were deemed appropriate to include in the review. The primary focus of the papers identified was the oral health status of inmates, assessed by clinical examinations of decayed, missing and filled teeth (DMFT) and periodontal status, and self-report measures of oral health behaviours and service utilisation. Attempts were made to reduce sources of bias by selecting random samples of inmates and standardising measurement techniques, and addressing potential confounding effects. Few studies considered the potential impact of socio-economic status on disease levels. In some studies the oral health of inmate populations was compared to that of non-institutionalised individuals. Studies report high prevalence of oral disease, though precise levels differ according to the composition of the samples. CONCLUSIONS: The heterogeneity of populations studied and methods of assessment precludes simple generalisation, but the consistent trend appears to be that the oral health status of inmates is poor and also poor in comparison with non-institutionalised individuals where appropriate comparisons have been made.

The failure rate of NHS funded molar endodontic treatment delivered in general dental practice.

OBJECTIVE: To describe the quality and record the outcomes of root canal therapy on mandibular, first permanent molar teeth provided by GDPs working according to NHS contracts. DESIGN: Descriptive, retrospective cohort study. SETTING: Twelve general dental practices in Salford, North West England. SUBJECTS AND METHOD: All patients aged 20-60 years attending the practices who had received a NHS-funded root filling in a mandibular first permanent molar between January 1998 and December 2003. The radiographic quality of root fillings in the teeth was assessed by an endodontic specialist and categorised into optimal, suboptimal and teeth which had no radiograph, or an unreadable radiograph. Teeth were also dichotomised into those restored with a crown and those restored with an intracoronal restoration. Failure as an outcome was defined as if a tooth was extracted, the root filling was replaced or periradicular surgery was performed on the tooth. Crude failure rates per 100 years were calculated for optimally, sub-optimally root filled teeth and for those with no or an unreadable radiograph, and according to how the tooth was coronally restored. Survival was assessed using Kaplan-Meier curves and Cox proportional hazards were used to determine factors linked with increased failures. RESULTS: One hundred and seventy-four teeth were included in the study, of which 16 failed. The crude failure rates per 100 years with a root filled tooth were very low and differed little (p = 0.9699) for optimally (2.6), sub-optimally (2.5) root filled teeth and for those with no or an unreadable radiograph (2.9), with approximately one in 37 root filled mandibular first molar teeth failing each year. The majority of root fillings fail within the first two years (N = 10, 62.5%). Some 67 teeth (38.5%) were restored with a crown, none of which failed during the follow up period compared to those with a plastic restoration (p = 0.0004). CONCLUSIONS: The very low failure rates have significant implications for the design of research studies investigating outcomes of endodontic therapy. The similar failure rates for teeth that had optimal and suboptimal root fillings suggest that endodontic treatment is not as technique sensitive as previously thought. The results also support the notion that the coronal restoration is more important than radiographic appearance of the root filling.

The introduction of the new dental contract in England - a baseline qualitative assessment.

OBJECTIVE: To record immediately prior to its inception the views of key stakeholders about the new dental contract introduced in April 2006. METHOD: Nineteen participants (11 dental practice principals and eight primary care trust dental leads) were interviewed using a semi structured approach to find out their views and opinions about dental practice, the reasons for introducing the new dental contract, its implementation and content of the new dental contract. An analysis based upon the constant comparative method was used to identify the common themes about these topics. RESULTS: Practice principals expressed satisfaction with working under pilot Personal Dental Services schemes but there was a concern among dental leads about a fall in dental activity among some dentists. All participants believed the new contract was introduced for political, financial and management reasons. All participants believed that it was introduced to limit and control the dental budget. Participants felt that implementation of the contract was rushed and there was insufficient negotiation. There were also concerns that the contract had not been tested. Dental practitioners were concerned about the calculation and future administration of the unit of dental activity system, the fixing of the budget and the fairness of the new dental charge scheme. Dental leads were concerned about patient access and retention and recruitment of dentists under the new contract. CONCLUSIONS: The study found a number of reasons for unease about the new dental contract; it was not perceived as being necessary, it was implemented at speed with insufficient negotiation and it was seen as being untested. Numerous and varied problems were foreseen, the most important being the retention of dentists within the NHS. Participants felt the contract was introduced for financial, political and managerial reasons rather than improving patient care. The initial high uptake of the new dental contract should not be viewed as indicating a high level of approval of its content.

The prescription and outcomes of fissure sealants applied to a group of high caries risk children by general dental practitioners working in the North West of England.

OBJECTIVE: To describe the use and outcomes of fissure sealants applied to the first permanent molars (FPMs) of children with high caries risk. DESIGN: Retrospective cohort study. SETTING: General dental practices in North West England. PARTICIPANTS: 677 children between the ages of 5 and 14 years who had dmfs > or =2, and regularly attended 50 general dental practitioners. OUTCOMES: Analyses were performed at patient level. Logistic regression models, taking into account the clustering of subjects within dental practices, were fitted to identify whether the decision to fissure seal FPMs was significantly associated with gender, socio-economic status, number of carious primary teeth and percentage of carious primary teeth filled. Similar logistic regression models were fitted for caries experience in FPMs. RESULTS: Poorer children were significantly (p < 0.05, OR = 0.84, 95% CI = 0.71, 0.99) less likely to receive fissure sealants than affluent children, whilst girls (p < 0.01, OR = 1.54, 95% CI = 1.12, 2.12) were more likely to have sealants than boys. The total number of carious primary teeth was also a significant (p < 0.01, OR = 1.15, 95% CI = 1.06, 1.25) independent predictor of dentists' decisions to fissure seal FPMs. For each carious primary tooth, the odds of having caries in FPMs increased by 1.16 (95% CI = 1.06, 1.26). Analysis showed that pit and fissure caries in FPMs was not affected by the presence or absence of fissure sealants. CONCLUSIONS: The decision to fissure seal FPMs is affected by caries experience in the primary dentition. Girls and affluent children were more likely to receive fissure sealants. It appears that the placement of fissure sealants by general dental practitioners was not effective in preventing pit and fissure caries in these high-risk children.

General dental practitioner's views on dental general anaesthesia services.

OBJECTIVE: Policy has recently changed on provision of dental general anaesthetic services in England. The aim of this study was to investigate general dental practitioners' views about dental general anaesthetics, the reduction in its availability and the impact on care of children with toothache. RESEARCH DESIGN: Qualitative study using semi-structured interviews and clinical case scenarios. PARTICIPANTS: General dental practitioners providing NHS services in the North West of England. RESULTS: 93 general dental practitioners were interviewed and 91 answered a clinical case scenario about the care they would provide for a 7-year-old child with multiple decayed teeth presenting with toothache. Scenario responses showed variation; 8% would immediately refer for general anaesthesia, 25% would initially prescribe antibiotics, but the majority would attempt to either restore or extract the tooth causing pain. Interview responses also demonstrated variation in care, however most dentists agree general anaesthesia has a role for nervous children but only refer as a last resort. The responses indicated an increase in inequalities, and that access to services did not match population needs, leaving some children waiting in pain. CONCLUSIONS: Most general dental practitioners support moving dental general anaesthesia into hospitals but some believe that it has widened health inequalities and there is also a problem associated with variation in treatment provision. Additional general anaesthetic services in some areas with high levels of tooth decay are needed and evidence based guidelines about caring for children with toothache are required.

Approaches taken to the treatment of young children with carious primary teeth: a national cross-sectional survey of general dental practitioners and paediatric specialists in England.

AIM: To measure the distribution of choices for the treatment of a child with differing severities of caries in a primary molar tooth among specialists in paediatric dentistry and general dental practitioners (GDPs) in England. METHOD: Two surveys were undertaken using the same tool. The populations invited to take part in the study were confined to dentists practising in England in 2004. They were 500 GDPs selected at random from the list of all GDPs with a National Health Service (NHS) contract identified by the Dental Practice Board (DPB) and all 148 specialists in paediatric dentistry appearing on the General Dental Council specialist register. The selected dentists were sent a questionnaire containing four hypothetical clinical case scenarios in which the severity of dental caries in a single primary molar differed. Each clinical case scenario had a list of possible treatment options and participants were asked to select their single most preferred treatment option. To maximise the response rate there were three mailing rounds. RESULTS: Of the 500 GDPs and 148 paediatric specialists sent a questionnaire, 322 (64%) GDPs and 115 (78%) specialists responded. The answers to each of the case scenarios indicate differences of opinion both between and among GDPs and specialists in the care they would recommend for a child with caries in a primary molar tooth. This variation in opinion about care was more pronounced for a single deep carious lesion than for a less severe lesion. The spread of treatment options chosen in each scenario indicates disagreement among GDPs and specialists about restorative techniques and philosophy of care. CONCLUSION: In England there is wide variation among GDPs and specialists in paediatric dentistry about the best way to treat a young child with caries in a primary molar tooth. Well designed studies are urgently needed to provide strong evidence for the most effective way to manage the dental care of children.

Exploring factors that influence general dental practitioners when providing advice to help prevent caries in children.

OBJECTIVE: To increase understanding about how and to whom general dental practitioners provide preventive advice to reduce caries in young children. DESIGN: Qualitative study using semi-structured interviews. SETTING: The North West of England. Interviews took place between March and September 2003. SUBJECTS AND METHODS: Ninety-three general dental practitioners practising within the general dental service were interviewed about the care they provide to young children. The interviews were recorded, transcribed and analysed using a constant comparative method. RESULTS: Children with caries were more likely to be questioned about diet and oral hygiene and if dentists believed parents to be motivated they were more inclined to spend time providing advice. Most dentists seemed to believe that education was the key to preventing caries and gave preventive advice in the form of a short educative talk. There was little use of visual aids or material for parents to take home. CONCLUSION: Preventive advice is given in an ad hoc way with no formal targeting. Most dentists deliver preventive advice as a short educative talk with no props or additional materials. Use of visual aids, providing materials for parents to take home and greater emphasis on partnership might help improve the impact of advice.

Exploring the content of the advice provided by general dental practitioners to help prevent caries in young children.

OBJECTIVES: To increase understanding about the content of preventive advice and care offered by general dental practitioners to young children. DESIGN: Qualitative study using semi-structured interviews. Setting The North West of England. Interviews took place between March and September 2003. SUBJECTS AND METHODS: Ninety-three general dental practitioners practising within the general dental service were interviewed about the care they provide to young children. The interviews were recorded, transcribed and analysed using a constant comparative method. RESULTS: Preventive advice given to parents of young children is usually about sugar consumption and tooth brushing behaviour but the emphasis and specific messages provided varies among general dental practitioners. Use of fluorides varied considerably, suggesting that some dentists either have reservations or are unclear about the appropriate use of fluorides. The study indicates important variation in the content of preventive care. CONCLUSION: There is important variation in the approach of general dental practitioners to the core activity of preventing caries in young children and some views expressed are not supported by the evidence base.