Evaluation of UK paediatric nephrology teams' understanding, experience and perceptions of oral health outcomes and accessibility to dental care: a mixed-methods study.

BACKGROUND: Oral health conditions are common in children and young people (CYP) with kidney disorders. There is currently limited literature on how confident paediatric nephrology teams feel to identify and manage oral health concerns for their patients. METHOD: An exploratory mixed-method survey was distributed across all 13 UK specialist paediatric nephrology centres with responses received from consultants, registrars, specialist nurses and special interest (SPIN) paediatricians. RESULTS: Responses received from 109 multidisciplinary team members of 13/13 (100%) UK tertiary units. Ninety-two percent (n = 100) of respondents reported they had never received any training in oral health and 87% (n = 95) felt that further training would be beneficial to optimise care for patients and improve communication between medical and dental teams. Most respondents reported that they did not regularly examine, or enquire about, their patients' oral health. Only 16% (n = 17) reported that all their paediatric kidney transplant recipients underwent routine dental assessment prior to transplant listing. Severe adverse oral health outcomes were rarely reported and only 11% (n = 12) of respondents recalled having a patient who had a kidney transplant delayed or refused due to concerns about oral infection. Seventy-eight percent (n = 85) felt that joint working with a dental team would benefit patients at their unit; however, 17% (n = 18) felt that current infrastructure does not currently support effective joint working. CONCLUSIONS: Across the UK, paediatric kidney health professionals report lack of confidence and training in oral health. Upskilling subspecialty teams and creating dental referral pathways are recommended to maximise oral health outcomes for CYP with kidney diseases.

Young people's and adults' views and experiences of decision-making to manage compromised first permanent molars: a qualitative study.

BACKGROUND: Little information on young people's and adults' views and experiences on decision-making for managing compromised first permanent molars (cFPM) exists. AIM: To establish young people's and adults' views and experiences of decision-making for managing cFPM. DESIGN: Face-to-face (online) semi-structured interviews were undertaken using an iteratively designed topic guide. Participants aged 12-65 were purposively sampled with recruitment from different dental clinics (three primary care, an out-of-hours emergency and one dental hospital). Interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis. RESULTS: Three themes were generated from young people's interviews (n = 9): (i) influencing factors; (ii) long-term considerations; and (iii) shared decision-making. Three themes were generated from adults' interviews (n = 13): (i) influences that affect decisions; (ii) perceptions of the specialist's role; and (iii) importance of shared decision-making for children and young people. CONCLUSION: Several factors influenced decision-making; for young people, professional opinions were important, and parental/peer influences less so. For adults, it was based on decisions on their prior experiences. Adults felt young people were abnormal if referred to a specialist. Young people wanted autonomy in decision-making to be respected; in reality, their views were rarely heard. There is potential to increase young people's involvement in shared decision-making for cFPM, which aligns with their aspirations.

Molar incisor hypomineralisation: Teaching and assessment across the undergraduate dental curricula in the UK.

BACKGROUND: No consensus exists on how molar incisor hypomineralisation (MIH) should be covered by the undergraduate dental curricula. AIM: To assess the current teaching and assessment of MIH in the UK. DESIGN: A piloted questionnaire regarding the teaching and assessment of MIH was disseminated to paediatric, restorative and orthodontic teaching leads in each UK dental school (n = 16). Data were analysed using descriptive statistics, chi-squared and Kruskal-Wallis tests. RESULTS: Response rates from paediatric, restorative and orthodontic teams were 75% (n = 12), 44% (n = 7) and 54% (n = 8), respectively. Prevention of caries, preformed metal crowns, anterior resin composites and vital bleaching were taught significantly more by paediatric teams (p = .006). Quality of life and resin infiltration were absent from restorative teaching. Orthodontic teaching focussed on the timing of first permanent molar extractions. Paediatric teams were mainly responsible for assessment. Risk factors, differential diagnoses for MIH and defining clinical features were more likely to be assessed by paediatric teams than by others (p = .006). All specialities reported that students were prepared to manage MIH. CONCLUSION: Molar incisor hypomineralisation is primarily taught and assessed by paediatric teams. No evidence of multidisciplinary or transitional teaching/assessment existed between specialities. Developing robust guidance regarding MIH learning in the UK undergraduate curricula may help improve consistency.

Dental divisions: exploring racial inequities of dental caries amongst children.

DATA SOURCES: The search strategy involved three sequential stages. Initially, MEDLINE/PubMed was explored for relevant articles, identifying pertinent terms for formal searching. Using the terms ethnic, race, minoritised and dental caries, a strategy was formed and nine databases searched. Finally, hand-searching of reference lists of included articles and sourcing grey literature from relevant government reports, national oral health surveys, and registries which had comparative data for dental caries between racial groups, completed the search. STUDY SELECTION: Studies included were original primary research which reported dental caries and compared racially minoritised children, aged 5-11 years, to similarly aged from national, majority, or privileged populations. Dental caries had to be recorded from a clinical examination which assessed decayed, missing, and filled teeth (dmft) in primary dentitions. Studies were excluded if they used immigration status as a basis of racial status, or they were a case report, case series, in vitro study, or literature review. DATA EXTRACTION AND SYNTHESIS: After removing duplicates, two independent researchers screened abstracts, prior to extracting critical data following full-text reviews of included articles. Information collected included study and participant characteristics, definitions of race, and dental caries measurement. The authors of studies which had missing data were contacted, whilst those not written in the English language were translated. Methodological quality of each study was independently assessed by two reviewers using a modified version of the Newcastle-Ottawa scale. All studies were included in the review regardless of quality. A narrative overview of all included studies was conducted. Meta-analyses were completed using studies that reported the mean and standard deviation of the caries outcomes in both groups. Caries outcomes included severity (defined as mean dmft) or prevalence (percentage of teeth with untreated dental caries > 0%). Due to anticipated heterogeneity, statistical analyses approaches such as I2 statistics were used to estimate between-study variability. Additional sub-group analyses were conducted based on country of study and world income index. Contour-enhanced funnel plots and trim-and-fill analysis were completed to explore potential publication bias. Sensitivity analyses were performed to ensure robustness of the findings. RESULTS: Seventy-five studies were included from a variety of countries. A higher mean dmft score of 2.30 (0.45, 4.15) and prevalence of decayed teeth (d > 0) was 23% (95% CI: 16, 31) was noted amongst racially minoritised children compared to privileged children's populations. Notable disparities were reported in high-income countries, with minoritised children burdening the greatest distribution of caries incidence. The study faced challenges in consistent racial classification and encountered high heterogeneity in its findings, leading to varied GRADE assessment scores. CONCLUSIONS: The study calls for global, social, and political changes to tackle the substantial disparities in dental caries among minoritised children to achieve oral health equity.

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

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

A systematic review of the quality and scope of decision modelling studies in child oral health research.

BACKGROUND: Decision analytic models are often used in economic evaluations to estimate long-term costs and effects of treatment which span beyond the time-frame of a clinical trial, therefore providing a better understanding of the long-term implications of decisions that conventional trial-based economic evaluations fail to provide. This is particularly relevant for considering oral health interventions in children as treatments may affect adult oral health. However, in the field of child oral health there has not been an evaluation of the quality and scope of decision analytical models which extend into adulthood. The aim of this review is to examine the scope and quality of decision modelling studies, with horizons extending into adulthood, within the field of child oral health. METHODS: The following databases were searched: NHS Economic Evaluation Database (CRD York), MEDLINE, EMBASE, CINAHL, Web of Science, Scopus, the Cochrane Library and Econlit. Full economic evaluations, in the field of child oral health, published after 1997 which included a decision model with a horizon that extended beyond the age of 18 years old were included. Included studies were appraised against the Drummond checklist and the Consolidated Health Economic Evaluation Reporting Standards by calibrated reviewers. RESULTS: Four hundred studies were identified, of which nine met the inclusion criteria. Of the nine, eight were cost-effectiveness models. The majority focussed on the prevention or management of dental caries. The mean percentage of applicable Drummond checklist criteria met by the studies in this review was 82% (median = 85%, range = 54-100%). Discounting of costs and performing an incremental analysis were noted as key methodological weaknesses. The mean percentage of applicable CHEERS criteria met by each study was 82% (median = 87%, range = 32-96%). Justifying the type of model, analytical methods used, and sources of funding were most commonly unreported. CONCLUSIONS: There is a paucity of decision analytical models in the field of child oral health. Most of those that are available are of high methodological and reporting quality.

Success of endodontic management of compromised first permanent molars in children: A systematic review.

BACKGROUND: Endodontic therapies may be required in the management of compromised first permanent molar teeth; their success in children, however, is unknown. AIM: To determine the success of endodontic therapies used on first permanent molar teeth in children aged sixteen and under. DESIGN: MEDLINE, Embase, Cochrane library, CENTRAL, Clinicaltrials.gov, and the ISRCTN registry as well as relevant paediatric, endodontic, and traumatology journal were searched using a detailed search strategy. References of included studies were hand-searched. A PICOS question was formulated: (P): children aged sixteen and under; (I): endodontic therapies (not pulp capping) on a first permanent molar tooth; (C): no treatment; (O): clinical success of endodontic therapy; and (S): all study types included. Bias was assessed using the Cochrane and Robins-I risk tools. Quality of evidence was assessed using the GRADE approach. Significant heterogeneity precluded meta-analysis. RESULTS: 4172 studies were retrieved and eleven were included in the narrative review. Partial and coronal pulpotomies have high success rates in the short term and long term. Limited evidence is available for conventional pulpectomy or regenerative techniques. CONCLUSIONS: Partial and coronal pulpotomies are successful endodontic therapies for use in a compromised child's first permanent molar.

Children with type 1 diabetes and caries - are they linked?

Data sources PubMed, EMBASE and China National Knowledge Infrastructure. Manual review of reference list of included studies.Study selection Cross-sectional studies or the first evaluation of longitudinal studies that were conducted on patients (<18 years old) with a known diagnosis of type 1 diabetes mellitus (DM). The primary outcome was prevalence of dental caries.Data extraction and synthesis Selection of studies, data extraction and risk of bias assessment was performed, independently, by two members of the review team. Inter-rater reliability (kappa = 0.68) was provided. Disagreements were resolved by consensus. The modified Newcastle-Ottawa scale, modified specifically to this review, was used to assess study quality and bias. Where appropriate, data was pooled and analysed using a random-effects model. Subgroup analyses were carried out where possible.Results Four hundred and eighty-eight potential articles were screened; 83 full-text articles were reviewed, with ten (involving a total of 538 patients) included in the meta-analysis. Seven studies were adjudged to be of high quality and three of low quality using the modified Newcastle-Ottawa scale. Overall, pooled prevalence of dental caries, among children and adolescents with type 1 DM, was 67% (95%CI: 0.56-0.77%; I2 = 83%; p<0.01). Subgroup analyses (geographic location and diabetic control) highlighted pooled prevalence was highest at 84% (95%CI: 0.67-0.94%; I2 = 49%; p = 0.16) in South America and 66% (95%CI: 0.43-0.83%; I2 = 87%; p<0.01) in those with bad diabetic control.Conclusions Caries prevalence is high among children and adolescents with type 1 DM. Diabetic children and adolescents need to be regularly screened for dental disease. Consistent preventive measures are required, from all healthcare professionals involved in the care of these patients, to ensure a balance in struck between optimum oral health and diabetic control for these patients.

Medical emergency department attendance of under 16-year-olds with dental problems.

BACKGROUND: Medical emergency departments (MED) are under increasing pressure in the UK with suggestions that unnecessary attendances to MED, which may include dental problems, are to blame. OBJECTIVES: The aim of this cross-sectional study was to examine the period prevalence of under 16-year-olds attendance to medical emergency departments (MED) with oral and dental problems over a 5-year period and investigate reason for attendance. This cross-sectional study was carried out as part of a service evaluation at the Newcastle upon Tyne Hospitals NHS Foundation Trust. METHODS: Retrospective data were collected between 1 January 2012 and 31 December 2016 from the MED database using coding and a free text search of all paediatric attendances. The data were then analysed using descriptive statistics. RESULTS: Over the 5-year period, 135 760 under 16-year-olds attended the MED. Of these, 868 (0.6%) attended for dental problems. The most common dental reasons for attendance were as follows: Candida accounted for 22.6% of the 0- to 5-year-olds; dental trauma accounted for 29.5% of 6- to 11-year-olds; and mandibular fractures accounted for 18.9% of the 12- to 16-year-olds. Of those who attended the MED for dental problems, 28.5% resided in areas with an Index of Multiple Deprivation decile of 1, the areas of highest deprivation in the UK. CONCLUSION: Many of the diagnoses may have been appropriately managed elsewhere in the community, which may result in improved treatment provision and tailored care pathways, as well as reducing strain on the MED. Further research is needed to investigate why patients attend MED with dental problems.

Management of compromised first permanent molars in children: Cross-Sectional analysis of attitudes of UK general dental practitioners and specialists in paediatric dentistry.

BACKGROUND: It is unclear on how children with compromised first permanent molars (cFPMs) are currently managed in the UK by either general dental practitioners (GDP) or specialists in paediatric dentistry (SPD). AIM: Explore the current attitudes to the management of compromised first permanent molars amongst UK general dental practitioners and specialists in paediatric dentistry. DESIGN: Self-completed online questionnaire including three clinical vignettes of 7, 9, and 15 years old with cFPM. All registered SPDs (n = 236), as of May 2017, 500 randomly selected GDPs from England, selected from a national performers list, and 52 Scottish GDPs, part of Scottish dental practice research network, were invited to complete the questionnaire. RESULTS: About 71.6% (n = 53) of SPDs agreed that children with cFPM should be referred to a paediatric specialist for treatment planning, whereas the reverse for GDPs is true, as 86.8% (n = 138) believe they have a responsibility to treat these teeth. Responses to clinical vignettes suggest a slight preference amongst GDPs to restore cFPM, including root canal treatment, whereas SPDs have a slight preference towards extraction. CONCLUSION: Current pathways for cFPM, amongst UK general dental practitioners and specialists in paediatric dentistry, vary greatly between and within each professional group.

Aesthetic preformed crowns for primary teeth.

Data sourcesMedline, Cochrane central register of controlled trials, US National Institutes of Health Trials Register and the World Health Organization International Clinical Trials Registry Platform.Study selectionEnglish language randomised clinical trials comparing APCs with conventional restorative techniques for primary teeth.Data extraction and synthesisStudy selection and data abstraction were conducted independently by two reviewers. Risk of bias was assessed using the Cochrane risk of bias tool. Study characteristics and results were described qualitatively. Meta-analysis was not conducted.ResultsSeven studies were included, six reported on primary molars and one on primary incisors. There was great variety in the design of the RCTs, however, all compared pre-veneered stainless steel crowns (SSCs) with other crowns or two different pre-veneered SSCs. The risk of bias in all studies was high with significantly different outcome measures used.ConclusionsSSCs cannot be replaced by APCs for restoring decayed primary molar teeth due to the insufficient quality of evidence available. After a follow-up of only six months, zircon crowns gave significantly better results than the others regarding gingival health and crown fractures. Due to the small number of RCTs on this topic and their risk of bias, future RCTs should be carried out in primary teeth.

Molar incisor hypomineralisation.

Data sourcesThe Medline and Embase databases and hand searches in the journals International Journal of Paediatric Dentistry and European Archives of Paediatric Dentistry.Study selectionEnglish language cohort and case-control studies.Data extraction and synthesisStudy selection was carried out independently by two reviewers with data abstraction being conducted by a single reviewer and checked by a second reviewer. Risk of bias was assessed using a modified version of the Newcastle-Ottawa Scale (NOS). Adjusted (aOR) and unadjusted odds ratios (uOR), P-values and 95% confidence intervals (CI) were obtained from the studies. Meta-analysis was not conducted.ResultsTwenty-eight studies were included; 25 reported on MIH, three on hypomineralised second primary molars (HSPM). Nineteen of the studies were of cohort design (six prospective,13 retrospective) and nine were case controls. There was little evidence of an association between the most frequently investigated prenatal factors (smoking, maternal illness, maternal medication, maternal stress) and MIH. Similarly there was little evidence of an association between MIH and perinatal factors such as prematurity, low birth weight, caesarean delivery and birth complications. Early childhood illness, up to three or four years of age, was widely investigated, with six studies reporting a crude association. Associations between antibiotics, anti-asthma medication and breastfeeding were also evaluated. Only three studies looked at HSPM; one study suggested that maternal antibiotic use during pregnancy is unlikely to be associated with HSPM but maternal alcohol intake may be. Another study reported possible associations with a large number of factors, with perinatal factors and neonatal illness being most common, followed by prenatal factors.ConclusionsPrenatal and perinatal factors are infrequently associated with MIH. However, despite a lack of prospective studies, early childhood illness (in particular fever) appears to be associated with MIH. Further prospective studies that adjust for confounding based on biological principles, as well as genetic and epigenetic studies, are needed because the aetiology is likely to be multifactorial.

A clinical guide to needle desensitization for the paediatric patient.

Needle phobia is a common problem encountered by dental practitioners and it can pose a challenge, especially in the paediatric patient. Needle desensitization can be used for patients who have needle fear or phobia and help them overcome this by repeated, non-threatening and controlled contacts. This paper will describe an accepted technique of needle desensitization and work through the steps required to achieve a successful outcome of local anaesthesia being delivered in a calm, safe and controlled manner. Clinical Relevance: Needle desensitization is an effective technique which can be used to enable a needle phobic patient to receive a dental injection.

Fluoride varnish applications and caries incidence in pre-schoolers.

DESIGN: A two year placebo-controlled, double-blind, randomised control trial in 1-4-year-old children. INTERVENTION: Children were recruited from low income families in Rio de Janeiro, Brazil, with access to a fluoridated public water supply. Both groups received oral hygiene instruction along with provision of toothbrushes and 1450 ppm F- toothpaste. The control group had a placebo fluoride varnish applied every six months. The intervention group had 22,600 ppm F- varnish applied every six months. Clinical examinations for the presence of caries were conducted at baseline and at each subsequent six monthly visit. OUTCOME MEASURE: The primary outcome was the proportion of children in each group that went on to clinically develop any new carious surfaces using the ICDAS criteria. The number of new carious surfaces was assessed as a secondary outcome, both at the enamel and dentine level. The study also reported on the safety and acceptability of the varnish. RESULTS: Two hundred children participated in the trial, 91% were followed up at two years and adherence to the six-monthly applications was 84% in the intervention and 85% in control groups. The results did not show a significant difference for the development of new lesions between the two groups. In the fluoride varnish group 36% had developed new dentinal lesions compared to 47% in the placebo group, a difference of -10.8% (95% CI -24.9 to 3.3, p = 0.14). In relation to caries increment, at the enamel level, this was a mean of 2.0 teeth in the fluoride varnish group and 2.8 teeth in the placebo group, a difference of -0.8 (95% CI -2.0 to 0.4, p = 0.19). At the dentine level, caries increment was a mean of 1.8 teeth in the fluoride varnish group and 2.5 in the placebo group, a difference of -0.7 (95% CI -1.9 to 0.4, p = 0.23). Two minor complaints related to taste and appearance of the varnish were recorded and no safety events were reported. CONCLUSIONS: Whilst no significant difference was found, the authors note that this does not indicate ineffectiveness of fluoride varnish. Re-assessment of the power calculation following study completion demonstrated that a significantly larger sample size would have been indicated, preventing the drawing of any direct conclusions from the results of this study. The use of fluoride varnish amongst this group appears to be safe and overall well tolerated.

A CHANGE IN PRACTICE PROTOCOL: PREFORMED METAL CROWNS FOR TREATING NON-INFECTED CARIOUS PRIMARY MOLARS IN A GENERAL PRACTICE SETTING--A SERVICE EVALUATION.

Restoring non-infected carious primary molars can pose a challenge to the general dental practitioner. This paper aims to assess the effect on primary caries management and patient experience in a general dental practice setting, when restoring non-infected carious primary molars using a Hall preformed metal crown (PMC).