Adult Dental Health Survey 2009: implications of findings for clinical practice and oral health policy.

This is the final paper in a series reporting on the results of the 2009 Adult Dental Health Survey. Since 1968 national adult surveys have been repeated every decade with broadly similar methods providing a unique overview of trends in oral health over a 40-year period. This paper aims to explore the implications for dentists and oral health policy of the key results from the Adult Dental Health Survey 2009. Although repeat, cross-sectional, epidemiological surveys provide very valuable data on trends in disease patterns, they do not provide answers to test causal relationships and therefore cannot identify the causes for the significant improvements in oral health over the last 40 years. Evidence would indicate, however, that broad societal shifts in population norms and behaviours, combined with changes in clinical diagnostic criteria, treatment planning and clinical procedures are the main reasons for the changes that have taken place. Key implications of the survey results include the need to monitor, support and maintain the good state of oral health of the increasing proportion of younger adults with relatively simple treatment needs. A smaller number of young and middle aged adults but a significant proportion of older adults will have far more complex treatment needs requiring advanced restorative and periodontal care. Future oral health policy will need to address oral health inequalities, encourage skill mix and promote and facilitate the dental profession to deliver appropriate and high quality care relevant to the needs of their local population.

Adult Dental Health Survey 2009: transformations in British oral health 1968-2009.

This series of four papers reports and interprets the findings of the Adult Dental Health Survey (ADHS), 2009, published in early 2011. This is the fifth in a series of surveys repeated every decade since 1968. The evolution of the surveys and the way the supporting methodology has changed to meet the changing needs and circumstances over the last 40 years is described. In 1968, 37% of adults in England and Wales were edentate. By 2009, only 6% of the combined population of England, Wales and Northern Ireland were edentate. Among the dentate in 1968, there were a mean of 21.9 teeth. By 2009, not only had the dentate increased by 30 percentage points as a fraction of the population, but the number of teeth in this group had also increased by nearly four teeth on average to 25.7. There were significant variations in oral health according to geography and social variables and smaller differences according to sex. The retention of 21 or more teeth is widely used as a way of defining a minimum functional dentition. The proportion of adults with 21+ teeth increased from 73% in 1978 to 86% in 2009. Further huge improvements are projected as younger generations age, assuming future tooth loss continues at current low rates. We might expect that over 90% of those aged 35-44 in 2009 have a realistic prospect of retaining a functional natural dentition of 21 or more teeth by age 80.

A competing risk survival analysis model to assess the efficacy of filling carious primary teeth.

In recent years a strategy of selective, symptom-based intervention of carious primary teeth has been developed amongst some British general dental practitioners. Practice-based studies appear to provide evidence that policies of restoration of symptomless carious primary teeth do not confer any significant benefits above those associated with non-restorative care. However, results from these studies contrast with those of many clinical trials and prospective studies of primary molar restorations. In the current investigation, cohort study data from 5,168 carious primary molar teeth from 2,654 British children aged 4-5 years at baseline, augmented with Dental Practice Board treatment data, was utilised to assess the effect of restorative treatment on the likelihood of carious teeth subsequently progressing to either exfoliation or extraction. The effect of demographic and tooth level covariates on the fate of these teeth was also assessed. Multivariate multilevel parametric survival models were applied to the analysis of the carious-exfoliation and carious-extraction transitions to which the teeth were subject, assuming an underlying data hierarchy with teeth nested within individuals. Time of occurrence of caries affected survival experience, with teeth in which caries occurred later in life being associated with higher survival rates to extraction. Amongst filled teeth, later fillings were also associated with higher survival rates to extraction. Demographic and tooth level variables had a limited effect on survival experience. Treatment was found to be significantly associated with survival with respect to extraction, with survival rates of over 80% at 14 years, double those of untreated teeth.

Modelling childhood caries using parametric competing risks survival analysis methods for clustered data.

Caries in primary teeth is an ongoing issue in children's dental health. Its quantification is affected by clustering of data within children and the concurrent risk of exfoliation of primary teeth. This analysis of caries data of 103,776 primary molar tooth surfaces from a cohort study of 2,654 British children aged 4-5 years at baseline applied multilevel competing risks survival analysis methodology to identify factors significantly associated with caries occurrence in primary tooth surfaces in the presence of the concurrent risk of exfoliation, and assessed the effect of exfoliation on caries development. Multivariate multilevel parametric survival models were applied at surface level to the analysis of the sound-carious and sound-exfoliation transitions to which primary tooth surfaces are subject. Socio-economic class, fluoridation status and surface type were found to be the strongest predictors of primary caries, with the highest rates of occurrence and lowest median survival times associated with occlusal surfaces of children from poor socio-economic class living in non-fluoridated areas. The concurrent risk of exfoliation was shown to reduce the distinction in survival experience between different types of surfaces, and between surfaces of teeth from children of different socio-economic class or fluoridation status. Clustering of data had little effect on inferences of parameter significance.

Introducing a family case study to the dental undergraduate curriculum.

The 'Family Study' was introduced at Cardiff Dental School in the 2001/2 session. Students are paired with local families who they visit over three years to collect information about family structure, childhood development and health behaviours, which forms the basis of a major project in year 4. In this paper, data gained from the first cohort of students to complete the study are reviewed, together with a practical evaluation of the programme's delivery and teaching gains.

Sedation in Wales: a questionnaire.

AIM: To identify the current provision of sedation in primary dental care in Wales. DESIGN: Postal questionnaire survey. SETTING: Wales 2003. SUBJECTS AND MATERIALS: Questionnaires were sent to all dentists appearing on the Dentists Register with addresses in Wales (n = 1374). The questionnaires sought details on personal status, use of and training in conscious sedation techniques. RESULTS: In total 951 (69%) questionnaires were returned, 720 (90%) respondents worked in a primary dental care setting. Only 87 (12.1%) primary care dentists offered some form of sedation. CONCLUSIONS: The provision of conscious sedation services in primary dental care in Wales is poor.

Primary care research: difficulties recruiting preschool children to clinical trials.

OBJECTIVES: The aims of the present study were to report difficulties experienced recruiting preschool children to a clinical trial and to report the acceptability of a dental intervention to their parents. DESIGN: The study was a randomized controlled trial (RCT). SETTING: The study took place in community dental clinics, health centres and patient homes. SAMPLE AND METHODS: Health visitors were used to recruit 508 children aged between 18 and 30 months from high caries areas of South Wales. Children with caries-free first primary molars were entered into a placebo-controlled individual RCT of fissure sealants. All children received a standard package of dental health education. Children in the test group had their first primary molars sealed with glass ionomer. All children were reviewed once. Families were asked to rate the acceptability of procedures. RESULTS: Health visitors referred 1228 children for screening, but only 547 were seen (44.5%) and 508 subjects were recruited to the trial. Of these, 449 (88.4%) were seen at follow-up. Some 667 children missed 1610 visits at baseline, and 373 of those recruited missed an appointment. At follow-up, 1056 appointments were staffed to review 449 children. Three-quarters of parents reported the examination to be very easy. CONCLUSIONS: Preschool children are difficult to access for community trials. Dental examinations and sealant placement were acceptable to the majority of families who were seen.

A randomised controlled trial to determine the effectiveness of glass ionomer sealants in pre-school children.

BACKGROUND: Caries levels in pre-school children remain high in some areas of the UK. Studies of glass ionomer fissure sealants show their potential for caries prevention in permanent teeth, but their use in primary teeth has not been reported. AIM: To determine whether a glass ionomer fissure sealant placed on primary molars in pre-school children at high risk of developing dental caries can decrease the incidence of dental caries. MATERIAL: 508 children aged 18-30 months from high caries areas of South Wales with caries-free first primary molars were recruited to the trial after informed consent. METHODS: This was a placebo-controlled individual randomised controlled trial (RCT). All children (n = 508) received a standard package of dental health education. Children in the test group (n = 241) had their first primary molars sealed with glass ionomer. All the children were re-examined once at varying intervals between 12 and 30 months. RESULTS: Analysis of the caries data revealed no significant difference between test and control groups for any of the parameters examined. Examination of the confidence intervals showed no indication that there might be a difference even if the sample size had been increased. CONCLUSION: There is no evidence that the intervention as used in this population had any effect on caries incidence and it cannot be recommended as a clinical procedure.

The York review--a systematic review of public water fluoridation: a commentary.

Following the election of the British government in May 1997, a policy document outlining proposals to improve the health of the nation was published. This document placed a major emphasis on reducing inequalities in health and recognised the continuing poor state of oral health in deprived communities. However, whilst acknowledging the benefits of water fluoridation as a caries preventive measure, the Department of Health suggested that most of the research had been carried out some years ago and furthermore, recognised that strong views were held both for and against fluoridation.

Methods of stopping or reversing early carious lesions fluoride: a European perspective.

The purpose of this review was to discuss the findings of the systematic review of the management of the early carious lesion with fluoride from a European perspective. The review was checked, and the overall finding that the evidence was incomplete was confirmed. It was suggested that the reason that few data were available was that clinical trials had not been designed to answer this question and that the baseline of healthy teeth and surfaces with very early lesions were rarely quantified. The European perspective would want to identify a clinical method that could manage these lesions better than the home use of fluoride toothpaste. Future research was recommended in the form of several systematic reviews and re-analysis of existing data. Only then could further studies be recommended. In modern European dentistry, restoring these lesions is not an option.

Comparison of four composite deprivation indices and two census variables in predicting dental caries in 12-year-old children in Wales.

OBJECTIVE: To compare the explanatory power of four composite indices of social economic status in their ability to predict dental caries experience. BASIC RESEARCH DESIGN: A secondary analysis of Welsh BASCD survey data using ward aggregated dental data, census variables and composite measures of deprivation. CLINICAL SETTING: Examinations took place in schools. PARTICIPANTS: All 12-year-old children examined in the 1996/97 survey. MAIN OUTCOME MEASURES: The explanatory variables were Jarman index, Welsh Underprivileged Area score (WUPA), Carstairs and Townsend indices and the outcome measure was mean DMFT. RESULTS: The amount of the mean DMFT explained by the explanatory variables ranged from 62.9% with Welsh Underprivileged Area score (WUPA) in Bro Taf Health Authority to 4.2% with the Jarman index in Dyfed-Powys health authority. Of the constituent parts of the composite variables only the percentage with no car appeared in the 'top three' variables in all but one of six models. CONCLUSIONS: The composite indices explained very different amounts of the variation in mean DMFT between the different health authorities. It would be unwise to rely on any one as a method of predicting which sections of the population would be likely to have dental disease.

Dental attitudes and behaviours in 1998 and implications for the future.

The 1998 Adult Dental Health Survey included face to face interviews with participants to determine their dental attitudes and behaviours. This article considers reported oral hygiene practices, treatment choices, satisfaction with appearance of teeth, attitudes towards wearing dentures and how these have changed since previous surveys. Although overall there has been a steady improvement in dental health attitudes, adults from disadvantaged households are still lagging behind. This has implications for social equity.

Community dental officers' use and knowledge of restorative techniques for primary molars: an audit of two Trusts in Wales.

OBJECTIVE: A baseline audit of current levels of knowledge about, and use of, restorative techniques in children's primary molars. DESIGN: A survey of community dental officers. SETTING: Two large Trusts in Wales. SAMPLE: Eighteen dental officers (five from Trust A and 13 from Trust B) from a total of 23 (six from Trust A and 17 from Trust B). OUTCOME MEASURES: Dental officers' use of restorative materials in primary molars. Dental officers' participation in postgraduate training for restorative techniques. Dental officers' consideration of the research literature on 'best practice' in restorative techniques. RESULTS: Dental officers in these two Trusts were not using stainless steel crowns (SSCs) for restoring primary molars. All 18 dental officers reported using glass ionomer cement (GIC) and amalgam as restorative materials, whilst six reported using GIC exclusively. Only 11 dentists mentioned using stainless steel crowns and this was in conjunction with carrying out a pulpotomy. Fewer dentists had been taught to use GIC than either SSCs or amalgam for restoring primary teeth during undergraduate training. A hands-on, user-friendly, postgraduate training course is considered the most effective way of teaching dentists about restorative techniques. The research evidence on SSCs did not appear to influence these dental officers in their use of restorative materials. CONCLUSIONS: This study offers important baseline data about the acceptability of differing restorative techniques and about the type of intervention that could bring about change in pattern of use by community dental officers in two large Trusts in Wales. If a postgraduate course in the use of stainless steel crowns is to meet dental officers' needs, it should address their concerns about the use of crowns.

An investigation of the disposal of dental clinical waste in Bangkok.

This study investigated the disposal of clinical waste within dental surgeries in Bangkok, Thailand and followed the waste trail to the rubbish tips. A questionnaire was sent to all dental practices in the Bangkok Metropolitan Area. The response rate was 57.7 per cent. At the same time, rubbish collectors and scavengers were interviewed to see if they encountered clinical dental waste. Few dentists complied with all recommendations for the disposal of waste. Most waste was disposed of into the domestic rubbish stream. Rubbish collectors and scavengers knew what dental rubbish looked like and some had had needle-stick injuries. Although recommendations can be made to the dental profession to alter their behaviour, real improvement is unlikely without changes to legislation and social policy.

The EU manual of dental practice--a guide for dentists planning to practice abroad.

How does a dentist go about moving practice to another EU country? This article describes a new publication which aims to explain the dental practice arrangements in a number of European countries and clear up the EU red tape.

Dentistry and the National Health Service in the context of Europe.

Many British dentists consider that because of the NHS, oral healthcare provision in Europe is more comprehensive, less controlled and more remunerative than the UK, a view that is often shared by their European colleagues. In this article, the oral healthcare systems of most European countries are classified and compared, and some strengths, similarities and weaknesses are identified and discussed.

Oral health systems in Europe. Part II: The dental workforce.

OBJECTIVE: To describe and compare the practice of dentistry and the dental workforce in eighteen European countries. BASIC RESEARCH DESIGN: Semi-structured, in-depth validation interviews were carried out with key-informants from the main national dental associations of EU and associated countries. The interviews were structured around the responses to a previously completed questionnaire, whose topics and terminology had been agreed in advance with the collaborating associations. The resulting descriptions of dental practice and the dental workforce in each country were returned for further validation and correction by the collaborating associations. Ultimate editorial control over the review of each country's oral health system rested with the academic unit from which the associations jointly commissioned the study. RESULTS AND CONCLUSIONS: With the exception of Austria the primary training and registration of dentists is now more or less standard across Europe. However, wide international variation exists in the official recognition of dental specialists and auxiliaries. The Nordic countries of Sweden, Finland and Iceland recognise the broadest range of specialties. In contrast Spain, Portugal, Luxembourg and Belgium currently do not formally recognise any types of specialist practice. Fee-for-service is the dominant form of remuneration for dentists across Europe, but considerable variation exists in the level of fees, how they are decided and the proportion paid by the patient. When based upon standard questionnaires, semi-structured interviews with key informants are an effective method for capturing both the specifics of how an oral health system works, and the general similarities and differences between countries.