COVID-19 case management in primary dental care settings in Yorkshire and the Humber.

Introduction Emerging guidance during the COVID-19 pandemic aimed to minimise transmission risk within dental settings. This service evaluation provides an overview of reported cases of COVID-19 among primary dental care staff within Yorkshire and the Humber.Methods Data for COVID-19 cases reported within dental practices between November 2020 and August 2021 were extracted from the Public Health England, Health Protection Zone database and summarised using descriptive statistics.Results In total, 421 cases across 223 dental practices were reported, with 221 close contacts and 77 outbreaks identified. Cases/contacts were highest among dental nurses (51/49%). Household and community (42/22%) were the most frequently reported sources of transmission, with the majority of staff-to-staff contacts (60%) occurring in communal/non-clinical areas.Discussion There was a low number of reported COVID-19 cases/contacts among dental professionals, with most cases suspected to have acquired the infection from outside of the dental setting. The majority of personal protective equipment breaches occurred within communal/non-clinical areas. When infection prevention and control guidance was followed, there were no incidences of staff or patients becoming contacts or cases.Conclusion With adherence to strict protocols, the risk of COVID-19 transmission in the dental setting was low within the context of this review. The evaluation highlighted the importance of collaborative working during the pandemic.

'What is my risk really?': a qualitative exploration of preventive interventions among individuals at risk of rheumatoid arthritis.

Objectives: Intervention in the pre-arthritis phase of RA could prevent or delay the onset of disease. The primary aim of this study was to explore perspectives of being at risk and potential preventive interventions among individuals at risk of developing RA and to identify factors influencing their engagement with prevention. A secondary aim, established during the analytical process, was to understand and compare different approaches to health-related behaviours related to prevention of RA. Methods: Anti-CCP-positive (CCP+) at-risk individuals with musculoskeletal symptoms but no synovitis participated in semi-structured interviews. Data were analysed using reflexive thematic analysis, followed by a secondary ideal-type analysis. Results: Nineteen CCP+ at-risk individuals (10 women; age range 35-70 years) participated. Three overarching themes were identified: being CCP+ at risk; aiming to prevent RA; and influencers of engagement. Participants described distress related to symptoms and uncertainty about disease progression. Many participants had concerns about medication side effects. In contrast, most participants expressed willingness to make lifestyle changes with the aim of preventing RA. Engagement with preventive measures was influenced by symptom severity, personal risk level, co-morbidities, experiences of taking other medications/supplements, knowledge of RA, risk factors and medications, and perceived effort. Three types of participants were identified from the data: proactive preventers, change considerers and fearful avoiders. Overall orientation to health behaviours also impacted the attitude towards preventing RA. Conclusion: Findings could inform recruitment and retention in RA prevention research and promote uptake of preventive interventions in clinical practice.

What factors influence refugees' attendance to dental care services?

DATA SOURCES: Four electronic databases: MEDLINE (via Ovid), Embase (via Ovid), Web of Science, and American Psychology Association PsycINFO. STUDY SELECTION: Quantitative observational or interventional studies, published until the end of February 2022 with no restrictions to date, language, or region of publication. DATA EXTRACTION AND SYNTHESIS: Screening performed by one author and a second author independently reviewed a random sample of 10% of the articles. Disagreements were resolved in consultation with a third author. RESULTS: The results were presented as a narrative review due to large heterogeneity of data. Nine studies met the eligibility criteria and most of them were rated as fair quality. The main factors influencing refugees access to dental care services were demographic and socioeconomic characteristics and English language proficiency. CONCLUSIONS: The review suggests that individual-level factors may have a predisposing effect on refugees' access, but had limited evidence on other enabling and contextual factors.

Best practice models for dental care delivery for people experiencing homelessness.

People experiencing homelessness have been encountering significant barriers in accessing healthcare services, including dental care services. There are several definitions for homelessness: it includes people sleeping rough but also people living in temporary accommodation. These categories are dynamic and individuals often find themselves on a continuum oscillating between sleeping rough and living in temporary accommodation. Their health-seeking behaviours are shaped by their living arrangements; therefore, one single model of dental care service delivery might not capture the needs of all those experiencing homelessness within an area. The service models presented in this paper are based on primary care delivery, mobile dental units and community clinics. Each of these models presents advantages and disadvantages and consideration should be given to delivering these on a complementary basis to maximise access to dental care, regardless of where patients are on the continuum between sleeping rough and living in temporary accommodation.

'It surprised me a lot that there is a link': a qualitative study of the acceptability of periodontal treatment for individuals at risk of rheumatoid arthritis.

OBJECTIVES: Current evidence suggests that periodontal disease could be a causal risk factor for rheumatoid arthritis (RA) onset and progression. Earlier periodontal intervention in individuals at risk of RA could provide a unique opportunity to prevent or delay the onset of RA. This study aimed to explore the acceptability of periodontal treatment as a measure to potentially prevent RA among at-risk individuals and healthcare professionals. METHODS: Semistructured interviews were conducted with anti-CCP positive at-risk individuals (CCP+ at risk) and a range of healthcare professionals. At-risk participant data were analysed using reflexive thematic analysis; subsequent coding of healthcare professional data was deductive, based on a preidentified set of constructs. RESULTS: Nineteen CCP+ at-risk and 11 healthcare professionals participated. Three themes (six subthemes) were identified: (1) understanding risk (knowledge of shared at-risk factors; information and communication); (2) oral health perceptions and experiences (personal challenges and opportunities for dental intervention and oral health maintenance; external barriers) and (3) oral health treatment and maintenance (making oral health changes with the aim of preventing RA; acceptability of participation in periodontal research). CONCLUSIONS: Periodontal disease is common in individuals at risk of RA, but the impact of poor oral health may not be well understood. Oral health information should be tailored to the individual. CCP+ at-risk participants and healthcare professionals identified seeking dental treatment can be hindered by dental phobia, treatment costs or inability to access dentists. While CCP+ at-risk individuals may be reluctant to take preventive medications, a clinical trial involving preventive periodontal treatment is potentially acceptable.

Outcomes of periodontal therapy in rheumatoid arthritis: The OPERA feasibility randomized trial.

AIM: Periodontitis is independently associated with rheumatoid arthritis (RA); however, there is limited data on whether periodontal treatment improves overall RA disease activity. We conducted a pilot feasibility randomized controlled clinical trial to test whether intensive periodontal therapy reduces RA disease activity in patients with active RA and periodontitis. MATERIALS AND METHODS: The following inclusion criteria were applied: patients with RA and periodontitis, aged 18+, stable on treatment with disease-modifying anti-rheumatic drugs for ≥3 months, disease activity score (DAS28) ≥3.2, and DAS28 >5.1 only if patient unwilling to take biologics. Participants meeting the inclusion criteria were randomized to immediate intensive periodontal therapy or to delayed therapy (control group) administered by a dental hygienist in a secondary care setting. Data were collected at baseline and at 3 and 6 months of follow-up. Participants randomized to the control group (delayed therapy) received the standard of care for the duration of the trial, including oral hygiene instructions delivered by a dental hygienist, and the same periodontal therapy as the intervention group after study completion (i.e., 6 months after randomization). The periodontal inflammation surface area was calculated using clinical attachment loss (CAL), periodontal probing pocket depth, and bleeding on probing. Cumulative probing depth was also measured. We examined the effect of periodontal therapy on periodontal outcomes and on clinical markers of disease activity in RA, as measured by the DAS28-C-reactive protein score as well as musculo-skeletal ultrasound grey scale and power Doppler scores. RESULTS: A total of 649 patients with RA were invited to participate in the study. Of these, 296 (46%) consented to participate in the screening visit. A sample of 201 patients was assessed for eligibility, of whom 41 (20%) did not meet the RA inclusion criteria and 100 (50%) did not meet the periodontal disease criteria. Among the 60 (30%) eligible participants, 30 were randomized to immediate periodontal therapy and 30 were allocated to the control group. The loss to follow-up was 18% at the end of the trial. There were no major differences with regard to baseline characteristics between the groups. Periodontal therapy was associated with reduced periodontal inflamed surface area, cumulative probing depths, RA disease activity scores, and ultrasound scores over the course of the trial. There was no change in CAL. CONCLUSIONS: Overall, the trial was feasible and acceptable to the study participants. Recruitment to and satisfactory retention in a randomized controlled trial on the effect of periodontal treatment on RA patients is possible, albeit challenging. In this feasibility study of patients with RA and periodontitis, periodontal treatment resulted in significant improvements in periodontal disease outcomes and overall RA disease activity, although complete resolution of periodontal inflammation was difficult to achieve in some cases.

Do missing teeth cause early-onset cognitive impairment? Re-examining the evidence using a quasi-natural experiment.

PURPOSE: Multiple studies have reported a positive association between missing teeth and cognitive impairment. While some authors have postulated causal mechanisms, existing designs preclude assessing this. METHODS: We sought evidence of a causal effect of missing teeth on early-onset cognitive impairment in a natural experiment, using differential exposure to fluoridated water during critical childhood years (ages 5-20 years) in England as the instrument. We coded missing teeth from 0 (≤ 12 missing) to 3 (all missing) and measured the association with cognitive impairment in the English Longitudinal Study of Ageing data (2014-5), covering 4958 persons aged 50-70 years. RESULTS: We first replicated previous evidence of the strongly positive association of missing teeth with cognitive impairment (ß = 0.25 [0.11, 0.39]), after adjusting for socio-demographic covariates, such as age, gender, education, and wealth. Using an instrumental variable design, we found that childhood exposure to water fluoridation was strongly associated with fewer missing teeth, with being exposed to fluoridated water during childhood (16 years) associated with a 0.96 reduction in the missing teeth scale (ß = - 0.06 [- 0.10, - 0.02]). However, when using the instrumented measure of missing teeth, predicted by probability of fluoride exposure, we found that missing teeth no longer had an association with cognitive impairment (ß = 1.48 [- 1.22, 4.17]), suggesting that previous oral health-cognitive impairment associations had unobserved confounding. CONCLUSIONS: Our findings are consistent with the possibility that unobserved confounding leads to the oft-observed association between missing teeth and early-onset cognitive impairment, suggesting that the relationship is spurious rather than causal.

Improving the fit of filtering facepiece respirators.

Aims To assess the effectiveness and acceptability of smartphone customised frame technology to improve the fit of disposable filtering facepiece class 3 (FFP3) respirators for dental staff who previously failed fit testing.Method In total, 20 volunteers who previously failed FFP3 fit testing were recruited to use smartphone technology (Bellus3D FaceApp) to have a 3D-printed bespoke face frame produced for them. They underwent qualitative fit testing with and without the frame with two freely available disposable FFP3 respirator designs (mask A: GVS F31000 Segre folded model; mask B: Valmy Spireor). The order of testing was random. Ease of use of the smartphone technology and the comfort of the frame were determined by questionnaire.Results Fit test passes increased from 5% without the frame to 70% and 95%, respectively, for masks A and B with the frame (p <0.01). Very few participants reported using the technology as difficult (n = 1/20) or the frame uncomfortable (n = 3/20) or difficult to wear (n = 0/20).Conclusion Customised frames produced using smartphone technology improved qualitative fit test pass rates for two commonly available FFP3 respirators. Using smartphone technology for frame design, wearing a frame and frame comfort levels were all acceptable to the majority of participants.

Foundation dentists supporting vaccination programmes in England.

Background In 2020/21, as part of the COVID-19 pandemic response and for the first time in England, newly qualified foundation dentists (FDs) were trained to participate in flu and COVID-19 vaccination programmes to offer additional workforce capacity. The largest of these efforts was in Yorkshire and the Humber where 106 FDs were trained and ready to mobilise. The aim of this service evaluation was to appraise the use of FDs in delivering vaccinations.Methods Mixed methods using an online questionnaire to FDs and in-depth remote interviews conducted with host organisations, Public Health England, Health Education England and others.Results The questionnaire response rate was 89% (n = 94), with 54 FDs having participated in vaccinations at a rate of 50-100 vaccines per day. All were confident with flu vaccine administration and most (n = 44/54) with COVID-19 vaccination. Eleven stakeholder interviews were conducted. Main barriers included the siloed delivery of dental care from other health services, resulting in collaborative barriers and a lack of understanding about the profession's skillsets. Facilitators included host organisations' capacity to hold multiple honorary contracts and provide competency sign-off.Conclusion Utilising the dental workforce to deliver vaccinations was feasible at a time of crisis and when trainees' access to dental patients was limited.

Should We Be Screening for and Treating Periodontal Disease in Individuals Who Are at Risk of Rheumatoid Arthritis?

There is increasing evidence supporting an association between periodontal disease (PD) and rheumatoid arthritis (RA), both mechanistically and clinically. Trials have shown that treating PD in people with RA may improve RA disease activity. Patients with musculoskeletal symptoms without arthritis, who test positive for cyclic-citrullinated protein antibodies, are at risk of RA (CCP+ at-risk), with seropositivity preceding arthritis onset by months or years. Importantly, there is evidence to suggest that periodontal inflammation may precede joint inflammation in CCP+ at-risk and, therefore, this could be a trigger for RA. There has been increased research interest in RA prevention and the phenotyping of the pre-RA disease phase. This review will examine the merits of identifying individuals who are CCP+ at-risk and performing screening for PD. In addition, we discuss how PD should be treated once identified. Finally, the review will consider future research needed to advance our understanding of this disease association.

Corrigendum: The Dental Team: An Additional Resource for Delivering Vaccinations.

[This corrects the article DOI: 10.3389/fmed.2020.606242.].

A Local Dental Network Approach to the COVID-19 Pandemic: Innovation Through Collaboration.

STRUCTURE: We present the principles for selecting and initiating hubs, the integration with secondary care services and the supply of personal protective equipment. PROCESS: The main elements are communication, the development of referral processes to manage complex cases and data collection. OUTCOME: Through work with local dental stakeholders, 23 clusters and 36 hubs were set up covering a large geographical area.The integrated network of hubs and clusters has strengthened collaboration between providers and policy makers. Various leadership approaches facilitated the readiness for the transition to recovery. The new local collaborative structures could be used to support local programmes such as flexible commissioning, peer-led learning and integration with primary care networks.

Multimorbidity: a challenge and opportunity for the dental profession.

Multimorbidity (the coexistence of two or more chronic conditions) is common, is likely to be on the increase and has a major impact on quality of life, increased risk of mortality, and significant financial costs to the health and social care system. Multimorbidity is strongly associated with increasing age and is also directly linked to socioeconomic status. A substantial body of scientific evidence has shown an association between specific oral diseases and a range of other health conditions. Less is known, however, about the inter-relationships between oral diseases and multiple other health conditions. As multimorbidity is increasingly becoming the norm, rather than the exception, a profound shift is now needed in the training of oral health professionals, and the practice and delivery of dental care. A more integrated and coordinated approach to training and care is needed, which will require radical system-level reform and redesign of how health and dental services are commissioned, delivered and financed. Truly multidisciplinary teamwork requires system reform to facilitate effective joint working. The pattern of disease in society is changing and the dental profession needs to respond accordingly.

Dysbiotic Subgingival Microbial Communities in Periodontally Healthy Patients With Rheumatoid Arthritis.

OBJECTIVE: Studies that demonstrate an association between rheumatoid arthritis (RA) and dysbiotic oral microbiomes are often confounded by the presence of extensive periodontitis in these individuals. This study was undertaken to investigate the role of RA in modulating the periodontal microbiome by comparing periodontally healthy individuals with RA to those without RA. METHODS: Subgingival plaque was collected from periodontally healthy individuals (22 with RA and 19 without RA), and the 16S gene was sequenced on an Illumina MiSeq platform. Bacterial biodiversity and co-occurrence patterns were examined using the QIIME and PhyloToAST pipelines. RESULTS: The subgingival microbiomes differed significantly between patients with RA and controls based on both community membership and the abundance of lineages, with 41.9% of the community differing in abundance and 19% in membership. In contrast to the sparse and predominantly congeneric co-occurrence networks seen in controls, RA patients revealed a highly connected grid containing a large intergeneric hub anchored by known periodontal pathogens. Predictive metagenomic analysis (PICRUSt) demonstrated that arachidonic acid and ester lipid metabolism pathways might partly explain the robustness of this clustering. As expected from a periodontally healthy cohort, Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans were not significantly different between groups; however, Cryptobacterium curtum, another organism capable of producing large amounts of citrulline, emerged as a robust discriminant of the microbiome in individuals with RA. CONCLUSION: Our data demonstrate that the oral microbiome in RA is enriched for inflammophilic and citrulline-producing organisms, which may play a role in the production of autoantigenic citrullinated peptides in RA.