Deliberative Improvement of Oral Care Quality: The Horizon Europe DELIVER Project.

KNOWLEDGE TRANSFER STATEMENT: The EU DELIVER project aims to enhance the quality of oral health care through codevelopment and coproduction of solutions together with citizens/patients, providers, and policymakers. The unique multicountry nature of the project will facilitate fast-track prototype development and testing of innovative QI approaches in select countries. Reflective learning regarding the transferability of findings between different countries and settings offers unique opportunities to drive progress toward context-specific implementation of innovative oral health care QI approaches. The collective knowledge gained from the 7 European countries involved in DELIVER can also generate knowhow for improving the quality of oral health care in other countries around the globe.

Dental healthcare costs of children living in Amsterdam and associated socio-demographic characteristics.

OBJECTIVES: The aim of this study was to assess associations between socio-demographic characteristics and dental costs of children living in Amsterdam. Having incurred dental costs was an indicator for having visited the dentist. Having incurred low or high dental costs may indicate the type of dental care provided (periodic examination, preventive care or restorative treatment). METHODS: This study followed a cross-sectional, observational design. The research population contained all children up until 17 years living in Amsterdam in 2016. Dental costs from all Dutch healthcare insurance companies were obtained via Vektis, and socio-demographic data were obtained from Statistics Netherlands (CBS). The study population was stratified into age groups: 0-4 and 5-17 years. Dental costs were classified as no dental costs (0 euros), low dental costs (>0 to <100 euros) or high dental costs (≥100 euros). Univariable and multivariable logistic regression analyses were performed to study the distribution of dental costs and associations with socio-demographic child and parent variables. RESULTS: In the population of 142 289 children, 44 887 (31.5%) incurred no dental costs, 32 463 (22.8%) incurred low dental costs and 64 939 (45.6%) incurred high dental costs. Among children of 0-4 years, a much larger proportion (70.2%) incurred no dental costs, compared to those of 5-17 years (15.8%). In both age groups, migration background (adjusted Odds Ratio (aOR) range 1.23-1.98), low(er) household income (aOR range 0.45-0.93), low(er) parental educational level (aOR range 0.51-0.87) and living in a single-parent household (aOR range 0.89-0.91) were strongly associated with incurring high (vs. low) dental costs. Furthermore, in 5-17-year-old children, a lower level of secondary or vocational education (aOR range 1.12-1.17) and living in households receiving social benefits (aOR 1.23) were associated with incurring high dental costs. CONCLUSIONS: Among children living in Amsterdam in 2016, one in three children did not visit a dentist. For children that did visit a dentist, those with a migration background, low parental educational level and from a low household income were more likely to incur high dental costs, which could be indicative for additional restorative treatment. Hence, patterns of oral healthcare consumption, specified by type of dental care over time, and their association with oral health status, are targets for future research.

Whisker Sensing by Force and Moment Measurements at the Whisker Base.

We address the theoretical question which forces and moments measured at the base of a whisker (tactile sensor) allow for the prediction of the location in space of the point at which a whisker makes contact with an object. We deal with the general case of three-dimensional deformations as well as with the special case of planar configurations. All deformations are treated as quasi-static, and contact is assumed to be frictionless. We show that the minimum number of independent forces or moments required is three but that conserved quantities of the governing elastic equilibrium equations prevent certain triples from giving a unique solution in the case of contact at any point along the whisker except the tip. The existence of these conserved quantities depends on the material and geometrical properties of the whisker. For whiskers that are tapered and intrinsically curved, there is no obstruction to the prediction of the contact point. We show that the choice of coordinate system (Cartesian or cylindrical) affects the number of suitable triples. Tip and multiple point contact are also briefly discussed. Our results explain recent numerical observations in the literature and offer guidance for the design of robotic tactile sensory devices.

High fat diet-induced obesity prolongs critical stages of the spermatogenic cycle in a Ldlr-/-.Leiden mouse model.

Obesity can disturb spermatogenesis and subsequently affect male fertility and reproduction. In our study, we aim to elucidate at which cellular level of adult spermatogenesis the detrimental effects of obesity manifest. We induced high fat diet (HFD) obesity in low-density lipoprotein receptor knock-out Leiden (Ldlr-/-.Leiden) mice, and studied the morphological structure of the testes and histologically examined the proportion of Sertoli cells, spermatocytes and spermatids in the seminiferous tubules. We examined sperm DNA damage and chromatin condensation and measured plasma levels of leptin, testosterone, cholesterol and triglycerides. HFD-induced obesity caused high plasma leptin and abnormal testosterone levels and induced an aberrant intra-tubular organisation (ITO) which is associated with an altered spermatids/spermatocytes ratio (2:1 instead of 3:1). Mice fed a HFD had a higher level of tubules in stages VII + VIII in the spermatogenic cycle. The stages VII + VII indicate crucial processes in spermatogenic development like initiation of meiosis, initiation of spermatid elongation, and release of fully matured spermatids. In conclusion, HFD-induced obese Ldlr-/-.Leiden mice develop an aberrant ITO and alterations in the spermatogenic cycle in crucial stages (stages VII and VII). Thereby, our findings stress the importance of lifestyle guidelines in infertility treatments.

A de novo paradigm for male infertility.

De novo mutations are known to play a prominent role in sporadic disorders with reduced fitness. We hypothesize that de novo mutations play an important role in severe male infertility and explain a portion of the genetic causes of this understudied disorder. To test this hypothesis, we utilize trio-based exome sequencing in a cohort of 185 infertile males and their unaffected parents. Following a systematic analysis, 29 of 145 rare (MAF < 0.1%) protein-altering de novo mutations are classified as possibly causative of the male infertility phenotype. We observed a significant enrichment of loss-of-function de novo mutations in loss-of-function-intolerant genes (p-value = 1.00 × 10-5) in infertile men compared to controls. Additionally, we detected a significant increase in predicted pathogenic de novo missense mutations affecting missense-intolerant genes (p-value = 5.01 × 10-4) in contrast to predicted benign de novo mutations. One gene we identify, RBM5, is an essential regulator of male germ cell pre-mRNA splicing and has been previously implicated in male infertility in mice. In a follow-up study, 6 rare pathogenic missense mutations affecting this gene are observed in a cohort of 2,506 infertile patients, whilst we find no such mutations in a cohort of 5,784 fertile men (p-value = 0.03). Our results provide evidence for the role of de novo mutations in severe male infertility and point to new candidate genes affecting fertility.

Exploring Associations between Oral Health and Frailty in Community-Dwelling Older People.

BACKGROUND: In frail older people with natural teeth factors like polypharmacy, reduced salivary flow, a decrease of oral self-care, general healthcare issues, and a decrease in dental care utilization contribute to an increased risk for oral complications. On the other hand, oral morbidity may have a negative impact on frailty. OBJECTIVE: This study explored associations between oral health and two frailty measures in community-dwelling older people. DESIGN: A cross-sectional study. SETTING: The study was carried out in a Primary Healthcare Center (PHC) in The Netherlands. PARTICIPANTS: Of the 5,816 persons registered in the PHC, 1,814 persons were eligible for participation at the start of the study. MEASUREMENTS: Two frailty measures were used: 1. Being at risk for frailty, using Electronical Medical Record (EMR) data, and: 2. Survey-based frailty using 'The Groningen Frailty Indicator' (GFI). For oral health measures, dental-record data (dental care utilization, dental status, and oral health information) and self-reported oral problems were recorded. Univariate regression analyses were applied to determine the association between oral health and frailty, followed by age- and sex-adjusted multivariate logistic regressions. RESULTS: In total 1,202 community-dwelling older people were included in the study, 45% were male and the mean age was 73 years (SD=8). Of all participants, 53% was at risk for frailty (638/1,202), and 19% was frail based on the GFI (222/1,202). A dental emergency visit (Odds Ratio (OR)= 2.0, 95% Confidence Interval (CI)=1.33;3.02 and OR=1.58, 95% CI=1.00;2.49), experiencing oral problems (OR=2.07, 95% CI=1.52;2.81 and OR=2.87, 95% CI= 2.07;3.99), and making dietary adaptations (OR=2.66, 95% CI=1.31;5.41 and OR=5.49, 95% CI= 3.01;10.01) were associated with being at risk for frailty and survey-based frailty respectively. CONCLUSIONS: A dental emergency visit and self-reported oral health problems are associated with frailty irrespective of the approach to its measurement. Healthcare professionals should be aware of the associations of oral health and frailty in daily practice.

Usage and Scientific Properties of the ADVOCATE Oral Health Care Measures.

BACKGROUND: Feedback information about the quality of oral health care is important for reflective learning by oral health care professionals and the wider health system. To this end, a list of 48 topics describing oral health and oral health care was recently agreed as part of the EU H2020 ADVOCATE project. OBJECTIVE: This article reports on the formulation of measures based on the ADVOCATE topics and provides information on usage, reporting, validity, and reliability of the measures. METHODS: The AIRE instrument was used to guide the methodological approach adopted. The appropriateness of the measures was tested among 39 general dental practitioners (GDPs) in Denmark, Germany, and the Netherlands. Data were collected from a convenience sample of patients via a questionnaire deployed in an online application in their practice. Feasibility, acceptability, and usefulness of the measures were evaluated through focus group interviews with GDPs. Face validity and test-retest reliability of the measures were assessed. RESULTS: For 46 of the 48 topics, a measure could be defined by constructing a definition and a numerator and denominator. Data collection for all 46 measures was feasible and acceptable for patients using the online questionnaire. The practicalities of using claims data for the purpose of giving feedback to individual and groups of GDPs proved to be challenging in terms of timely access of such data, the granularity of the data, and matching the content of the data with the consented items on quality of oral health care. Face validity was considered appropriate, as the patients found the questionnaire easy to understand. Test-retest reliability was found to be acceptable for 36 of 46 measures. CONCLUSION: The broad range of the ADVOCATE oral health care measures could make a useful contribution to a more transparent, evidence-based, and patient-centered oral health care system. KNOWLEDGE TRANSFER STATEMENT: This study shows the usage, reliability, and validity of 46 oral health care measures. The measures, which include patient experience and health behaviors, were found to be useful to stimulate discussions about clinical practice. The measures can provide essential information for quality improvement strategies and useful and relevant feedback information for GDPs.

A comparison of international clinical practice guidelines on adult chronic rhinosinusitis shows considerable variability of recommendations for diagnosis and treatment.

OBJECTIVES: To compare international clinical practice guidelines on adult chronic rhinosinusitis (CRS). DESIGN: Extensive literature search in Embase, PubMed and the internet (Google, websites of well-known guideline organizations) on November 21st 2018. MAIN OUTCOME MEASURES: Guidelines' quality was measured by the AGREE II instrument. A summary and comparison of recommendations on diagnosis and treatment with harmonized levels of evidence (LoE) and grade of recommendations (GoR) is given. RESULTS: We selected ten guidelines on CRS. Five guidelines were of sufficient to high quality according to AGREE II, the remaining guidelines predominantly did not meet AGREE II criteria. We harmonized all guideline recommendations so we could compare them, although three guidelines did not provide a LoE. Five guidelines provided recommendations on diagnosis, all of them recommended performing nasal endoscopy, CT scan and allergy testing (with varying GoRs). All ten guidelines provided recommendations on therapy, one treatment, i.e., the use of intranasal steroids, was recommended by all guidelines (with varying GoRs). Recommendations for surgical treatment of CRS were provided by five guidelines. CONCLUSION: We performed an extensive search and included ten (inter)national guidelines on CRS for adults. According to AGREE II, five were of good or sufficient quality. Overall, there was much variation between guidelines in recommended diagnostic test or treatment, direction of evidence and GoR. We found consensus for nasal endoscopy, CT scan, allergy testing and intranasal steroids. We argue for standardization of guideline development, to increase their quality and improve comparability.

[Costs and financing of oral healthcare in the Netherlands]. / Kosten en financiering van de mondzorg.

In the Netherlands, dental diseases are the third most expensive category of healthcare costs. The total cost of the consumption of oral care gives, however, no insight into the content of the care. Data from health insurers do provide such insight, but due to limitations in reimbursements the data from health insurers represent only part of all the costs of oral care. In this study an attempt was made, by means of an estimation, to gain insight into the total cost of oral care, financed both by basic and supplementary health insurance and by the patients themselves . This estimation was made at the level of UPT clusters and is based on data from the health insurers and a large factoring company for the years 2011, 2013 and 2014. Based on this estimate, one can conclude that on average between 21% and 32% of oral care consumption is financed privately. A complete picture of the costs of oral care is important in determining the contribution of oral care to public health. The structure of the current financial system, however, impedes transparency concerning oral care consumed.

Caries Progression Rates Revisited: A Systematic Review.

Caries progression seems to follow universal, predictable rates, depending largely on the caries severity in populations: the higher the caries severity, the higher the progression rates. Quantification of these rates would allow prediction of future caries increments. Our aim was to describe caries progression rates in the primary and permanent dentition in Western populations (not in lesions) of children and adolescents. Therefore, we systematically searched MEDLINE-PubMed, Embase, CINAHL, and the Cochrane library for studies reporting caries progression data. Eligibility criteria were reporting empirical data from at least 2 full-mouth dental caries examinations in a closed cohort during a follow-up of at least 3 y, a first examination after 1974, a second examination before the age of 22 y, caries assessed as dentine caries (d3/D3), and caries reported in dmfs/DMFS (decayed, missing, and filled surfaces), dmft/DMFT (decayed, missing, and filled teeth), or caries-free participants. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, we described the results for the primary and permanent dentition in a systematic review, performed a meta-analysis for the caries incidence rate in the permanent dentition, and conducted multivariate, hierarchical meta-regression analyses for the caries incidence rate and the increments in DMFS and DMFT. Of the 6,343 unique studies retrieved, 43 studies (56,376 participants) were included for systematic review and 32 for meta-analyses (39,429 participants). The annual decline in caries-free children in the permanent dentition ranged from 0.8% to 10.2%. The annual increment ranged from 0.07 to 1.77 in DMFS and from 0.06 to 0.73 in DMFT. The pooled caries incidence rate was 0.11 (0.09-0.13) per person-year at risk. Meta-regression analyses showed that the methods of individual studies influenced pooled caries incidence rates and increments in DMFS and DMFT. This should be taken into account in planning and evaluation of oral health care services. However, the caries incidence rate is promising for prediction of future caries increments in populations.

Improving oral healthcare using academic detailing - design of the ADVOCATE Field Studies.

Background: Academic detailing (AD) is a defined form of educational outreach that can be deployed to intrinsically motivate practitioners towards improving quality of care. This paper describes the design of the ADVOCATE Field Studies. This proof of concept study aims to evaluate the feasibility, acceptability and usefulness of AD, reinforced with feedback information to promote prevention-oriented, patient-centred and evidence-based oral healthcare delivery by general dental practitioners (GDPs). Methods: Six groups of GDPs will be recruited; two groups of six to eight GDPs in each of three countries - the Netherlands, Germany and Denmark. GDPs will meet for four Academic Detailing Group (ADG) meetings for open discussions using comparative feedback data to stimulate debate about their dental practice performance and care delivery. Group meetings will be moderated using the AD methodology. Qualitative data will be collected through focus group interviews, an online discussion forum, field notes and debriefs of ADG meetings and analysed by conventional content analysis using MaxQDA software. Discussion: The results of the study will provide novel information on the feasibility, perceived acceptability and usefulness of AD and feedback data for GDPs to improve oral healthcare delivery.

[The content of publications in the Netherlands Journal of Dentistry - an analysis of patterns over time]. / De inhoud van publicaties in het Nederland Tijdschrift voor Tandheelkunde. Een patroonanalyse over de tijd.

In 2018, the Netherlands Journal of Dentistry (NTVT) had been published for 125 years: reason for a systematic look at the subjects that have received attention since 2000. These subjects were subsequently compared to those in Dutch dental publications in international literature and to leading fields in oral health care. The analysis revealed an increase in the attention given to certain fields in the Netherlands Journal of Dentistry, such as public dental health, during the past 18 years and a decrease in the attention given to other subjects, such as basic scientific research. In addition, there was a limited correlation between fields involving the greatest cost of care, such as cariology and preventive dentistry, and research activity. This held true both for international publications and publications in the Netherlands Journal of Dentistry.

Otolaryngologists adhere to evidence-based guidelines for chronic rhinosinusitis.

PURPOSE: To assess awareness of, opinion about and adherence to evidence-based guidelines on chronic rhinosinusitis among Dutch Otolaryngologists. METHODS: We assessed implementation of two guidelines, one Dutch and one European, that are both intended for diagnosis and treatment of patients with chronic rhinosinusitis. We invited 485 Otolaryngologists to fill out a questionnaire and report on their opinion on and adherence to the guidelines. The adherence was further tested by 4 clinical case scenarios, derived from guideline recommendations. RESULTS: 166 (34%) completed the questionnaire. 99% of the respondents was aware of one or both guidelines. Most respondents (90%) consider the guidelines as directing or supportive for their clinical practice based on the clinical case scenarios, between 62 and 99% of the respondents act according to guidelines. Concerning diagnosis, CT-imaging is performed more and allergy testing less than recommended. Where multiple treatment options are recommended, the responses are more heterogeneous as a result of this. Nonetheless, high recommended treatment was chosen more often. Otolaryngologists were reluctant in surgical treatment as a first option, which is according to the guidelines. CONCLUSIONS: Overall, both the EPOS and CBO guideline are well known among Dutch Otolaryngologists and 90% indicates that the guideline is important in their daily practice. Adherence to the guidelines is sufficient to high. If multiple treatment or diagnostic options are recommended this leads to a more heterogeneous response pattern. Recommendations with a high grade of recommendation were followed up most often.

Forceless Sadowsky strips are spherical.

We show that thin rectangular ribbons, defined as energy-minimizing configurations of the Sadowsky functional for narrow developable elastic strips, have a propensity to form spherical shapes in the sense that forceless solutions lie on a sphere. This has implications for ribbonlike objects in (bio)polymer physics and nanoscience that cannot be described by the classical wormlike chain model. A wider class of functionals with this property is identified.

Quality of reporting and risk of bias in therapeutic otolaryngology publications.

BACKGROUND: High-quality trials have the potential to influence clinical practice. METHODS: Ten otolaryngology journals with the highest 2011 impact factors were selected and publications from 2010 were extracted. From all medical journals, the 20 highest impact factor journals were selected, and publications related to otolaryngology for 2010 and 2011 were extracted. For all publications, the reporting quality and risk of bias were assessed. RESULTS: The impact factor was 1.8-2.8 for otolaryngology journals and 6.0-101.8 for medical journals. Of 1500 otolaryngology journal articles, 262 were therapeutic studies; 94 had a high reporting quality and 5 a low risk of bias. Of 10 967 medical journal articles, 76 were therapeutic studies; 57 had a high reporting quality and 8 a low risk of bias. CONCLUSION: Reporting quality was high for 45 per cent of otolaryngology-related publications and 9 per cent met quality standards. General journals had higher impact factors than otolaryngology journals. Reporting quality was higher and risk of bias lower in general journals than in otolaryngology journals. Nevertheless, 76 per cent of articles in high impact factor journals carried a high risk of bias. Better reported and designed studies are the goal, with less risk of bias, especially in otolaryngology journals.

A Consensus-Based Set of Measures for Oral Health Care.

Increasingly more responsive and accountable health care systems are demanded, which is characterized by transparency and explicit demonstration of competence by health care providers and the systems in which they work. This study aimed to establish measures of oral health for transparent and explicit reporting of routine data to facilitate more patient-centered and prevention-oriented oral health care. To accomplish this, an intermediate objective was to develop a comprehensive list of topics that a range of stakeholders would perceive as valid, important, and relevant for describing oral health and oral health care. A 4-stage approach was used to develop the list of topics: 1) scoping of literature and its appraisal, 2) a meeting of experts, 3) a 2-stage Delphi process (online), and 4) a World Café discussion. The aim was to create consensus through structured conversations via a range of stakeholders (general dental practitioners, patients, insurers, and policy makers) from the Netherlands, Germany, the United Kingdom, Ireland, Hungary, and Denmark. The study was part of the ADVOCATE project, and it resulted in a list of 48 topics grouped into 6 clusters: 1) access to dental care, 2) symptoms and diagnosis, 3) health behaviors, 4) oral treatments, 5) oral prevention, and 6) patient perception. All topics can be measured, as they all have a data source with defined numerators and denominators. This study is the first to establish a comprehensive and multiple-stakeholder consented topic list designed for guiding the implementation of transparent and explicit measurement of routine data of oral health and oral health care. Successful measurement within oral health care systems is essential to facilitate learning from variation in practice and outcomes within and among systems, and it potentiates improvement toward more patient-centered and prevention-oriented oral health care.

Toward More Patient-Centered and Prevention-Oriented Oral Health Care: The ADVOCATE Project.

ADVOCATE (Added Value for Oral Care) is a project funded by the European Commission's Horizon 2020 program, which aims to develop strategies for a system transition toward more patient-centered and prevention-oriented oral health care delivery within health care systems. This system should balance the restorative and preventive approaches in dental and oral health care. ADVOCATE is a partnership among 6 European Union member states, which involves collaboration among universities, state-funded health care providers, and private insurance companies in Denmark, Germany, Hungary, Ireland, the Netherlands, the United Kingdom, and Aridhia, a biomedical informatics company based in Scotland. There are 6 interrelated work packages, which aim to address the following objectives: 1) in-depth evaluation of oral health care systems in European Union member states to identify best system designs for oral disease prevention, 2) development of a set of measures to provide information on oral care delivery and oral health outcomes, 3) evaluation of a feedback approach in dental practice that aims to facilitate a change toward preventive oral health care delivery, and 4) economic evaluation of strategies to promote preventive oral health care and development of policy recommendations for oral health care systems. The project is novel in its use of data that are routinely collected by health insurance organizations, as well as the engagement of key stakeholders from dental teams, insurers, patients, and policy makers in guiding the development and progress of the project. This article outlines in detail the objectives and research methodology of the ADVOCATE project and its anticipated impact. Knowledge Transfer Statement: This commentary describes the development of policy options to promote a greater focus on disease prevention in general dental practice. The approach builds on identifying the comparative effectiveness of alternative incentive schemes, as well as methods to monitor clinical and patient-derived measures of success in creating health for patients. The article describes the development and application of the measures and the evaluation of their success in orienting clinical practice more toward disease prevention.

Associations of pain intensity and pain-related disability with psychological and socio-demographic factors in patients with temporomandibular disorders: a cross-sectional study at a specialised dental clinic.

The study assessed whether psychological and socio-demographic factors, including somatisation, depression, stress, anxiety, daytime sleepiness, optimism, gender and age, are associated with pain intensity and pain-related disability in patients with temporomandibular disorders (TMDs). In total, 320 TMD patients were involved in the study. The psychological status of each patient was assessed with questionnaires, including the Symptom Checklist-90 (SCL-90), Epworth Sleeping Scale (ESS), stress questionnaire and Life Orientation Test-Revised (LOT-R). TMD pain, including pain intensity and pain-related disability, was assessed with characteristic pain intensity (CPI) and disability points scales. The associations of psychological and socio-demographic factors with pain intensity and pain-related disability were assessed through logistic regression analyses. Higher pain intensity was significantly associated with more severe anxiety (P = 0·004), more severe somatisation (P < 0·001), more severe depression (P < 0·001), more severe stress (P = 0·001) and lower optimism (P = 0·025) in univariate regression analyses. However, multiple regression analysis showed that only somatisation was significantly associated with pain intensity (P < 0·001). Higher pain-related disability was significantly associated with more severe anxiety (P < 0·001), more severe somatisation (P < 0·001), more severe depression (P < 0·001), more severe stress (P < 0·001) and lower optimism (P = 0·003) in univariate regression analyses. However, multiple regression analysis showed that only depression was significantly associated with pain-related disability (P = 0·003). Among the psychological and socio-demographic factors in this study, somatisation was the best predictor of pain intensity, while depression was the best predictor of pain-related disability.

Improving oral healthcare: towards measurement?

In the last 30 years oral healthcare is increasingly being contested. Needs and expectations have evolved to a point of advanced restorative techniques, long term planning for preventative care and evidence-based practice, and patients and payers increasingly require more explicit demonstration of competence. However, relevant data are currently not routinely collected that would support approaches needed to further improve oral health and care. This paper sets out the case to collect and evaluate routinely available data. Variations in care and oral health could be described, which in turn would provide valuable insights for all wishing to further improve oral health and care.