Brexit - Consequences for the UK's Oral Health Workforce?

On Friday, 20 December 2019, after three and a half years of discussion the Parliament of the United Kingdom (UK) voted decisively that this country should leave the European Union (EU). For many of us this was a sad day. However, this political decision has been made and intensive negotiations will now take place between the UK and the EU's negotiating teams to agree the details for the UK's future relationship with the EU. It is still far from clear exactly what the consequences of the resulting deal will be for both parties. A number of previous articles and editorials have speculated on the possible consequences for health and oral health in the UK. Key areas include workforce, research and regulations for medicines and medical and dental equipment. This editorial will consider the implications for the UK's Oral healthcare workforce.

Pathogenesis of Colitis in Germ-Free Mice Infected With EHEC O157:H7.

Enterohemorrhagic Escherichia coli (EHEC) are strains of E. coli that express Shiga toxins (Stx) and cause hemorrhagic colitis. In some cases, disease can progress to hemolytic uremic syndrome, a potentially fatal form of kidney disease. Both enteric and renal disease are associated with the expression of stx genes, which are often carried on lysogenic phage. Toxin is expressed following induction and conversion of the phage to lytic growth. The authors previously used a germ-free mouse model to demonstrate that toxin gene expression is enhanced during growth in vivo and that renal disease is dependent on both prophage induction and expression of Stx2. In the current study, the authors document and quantify necrotizing colitis, examine the progression of enteric and renal disease, and determine the role of Stx2, phage genes, and the type 3 secretion system (T3SS) in bacterial colonization and colitis and systemic disease. By 1 day after inoculation, EHEC-monocolonized mice developed colitis, which decreased in severity thereafter. Systemic disease developed subsequently. Infection with EHEC mutant strains revealed that renal failure and splenic necrosis were absolutely dependent on the expression of Stx2 but that T3SS function and prophage excision were not necessary for systemic disease. In contrast, colitis was only partly dependent on Stx2. This study demonstrates that in germ-free mice, like in human patients, EHEC causes early colitis followed by renal failure and that systemic disease but not colitis is Stx2 dependent.

Variation in methods used to determine national mean DMFT scores for 12-year-old children in European countries.

AIM: The aim of this study was to investigate the methods used to identify national mean DMFT scores for 12-year-old children in all the Member States of the European Union and European Economic Area, and in 11 other European countries. METHODS: The most recent national mean DMFT scores were accessed from the World Health Organisation Oral Health CAPP and the Council of European Chief Dental Officers databanks. A literature search was then performed to access the reports of the studies that had produced these DMFT scores, cited on these databanks. The reports were then analysed to determine: the year in which the survey/study that produced the score took place, the year the results were published, the geographical area (national, regional or local) covered, the number of children examined, how many examiners took part, how they were trained and calibrated, and the criteria used for the detection of caries. RESULTS: Data and information from 43 European countries were accessed. The years when the studies were performed ranged from 1990 to 2014. There were doubts over the representativeness of some samples. A wide range of different methods were used. Examiner training and calibration were very variable both in terms of duration and reported inter and intra-examiner consistency. There were important variations in the criteria employed for the detection of caries. CONCLUSIONS: These findings support the view that most of current national caries data for DMFT levels in 12-year-old children are not comparable across Europe.

A pilot project to improve the oral health of orphans and of the elderly in residential care in Constanta, Romania.

AIM: A pilot project to improve the oral health of Romanian orphans and elderly people in residential homes. MATERIAL AND METHODS: The orphanage and old persons' home were in Constanta. After training, 50 fifth-year dental students made 14 weekly residential home visits to improve carers' oral health knowledge and oral hygiene (OH) procedures and to monitor progress in one orphan and one old person. At baseline and after 14 weeks a local dental school staff member examined each orphan and old person's oral health using WHO (1997) criteria and the Simplified Oral Hygiene Index (OHI-S). The carers' knowledge of OH and attitudes to providing and the students' knowledge and attitudes were assessed at baseline and again after 14 weeks with a questionnaire. RESULTS: All 56 orphans (mean age 9.6 years, mean DMFT 2.39) living in the home participated and their mean OHI-S improved (1.40 to 0.80, p < 0.0001). Fifty old people (mean age 75.9 years) participated, of whom 22 (44%) were edentulous. There was no significant improvement in mean OHI-S (p < 0.10). The carers' oral health knowledge improved (mean scores from 65 to 88, p < 0.001) as did their attitude score (p < 0.013). Students noted changes in their understanding of the needs of the carers, orphans and elderly people. Their perception of their capability to provide OH education or train others to do so, or their inclination to do so remained substantially unchanged. CONCLUSIONS: This pilot study met its aims suggesting that with suitable management, senior dental students can play a significant role in residential homes for orphans and old people by training carers and improving the residents' oral hygiene. Further similar studies in other settings are indicated.

Introducing dental hygienists in general practice to research - an in-practice evaluation programme in the United Kingdom.

AIM: To introduce dental hygienists (DHs) in the UK to the principles of research through a practice-based product evaluation programme. METHODS: The programme consisted of an initial training and orientation day with presentations on evidence-based practice, research methods and the structure of research papers. The programme and its aims were explained in detail, and participants were briefed on the methods to be used. Participants then recruited seven to ten patients from their practices (offices), carried out a baseline assessment of: plaque, gingival health, calculus and staining at anterior teeth, and gave the patients a questionnaire asking about their teeth and then provided a 3-month supply of a test toothpaste. About 10 weeks later, a follow-up assessment of the same variables was performed and the questionnaire was repeated. A second training day followed during which the DHs provided feedback of their experiences and received training in literature searching and critical appraisal of literature including interpretation of results. RESULTS: Sixty-five DHs attended the first training day; 31 were able to recruit sufficient patients and attend the second training day. The DHs recruited 168 patients who received baseline and follow-up assessments. All the variables improved overall. Feedback from the DHs was very positive, and patients expressed delight with the care they had received. CONCLUSIONS: Qualitative feedback for participating DHs suggests the programme met its aim and could be used in the future as a mechanism for helping DHs who want to increase their understanding of research methodology.

How is research publishing going to progress in the next 20 years? Transcription of session for editors, associate editors, publishers and others with an interest in scientific publishing held at IADR meeting in Seattle on Wednesday, 20 March 2013.

On March 20th 2013, a one-hour session for Editors, Associate Editors, Publishers and others with an interest in scientific publishing was held at the IADR International Session in Seattle. Organised by Kenneth Eaton and Chris Lynch (Chair and Secretary, respectively, of the British Dental Editors Forum), the meeting sought to bring together leading international experts in dental publishing, as well as authors, reviewers and students engaged in research. The meeting was an overwhelming success, with more than 100 attendees. A panel involving four leading dental editors led a discussion on anticipated developments in publishing dental research with much involvement and contribution from audience members. This was the third such meeting held at the IADR for Editors, Associate Editors, Publishers and others with an interest in scientific publishing. A follow up session will take place in Cape Town on 25 June 2014 as part of the annual IADR meeting. The transcript of the meeting is reproduced in this article. Where possible speakers are identified by name. At the first time of mention their role/ position is also stated, thereafter only their name appears. We are grateful to Stephen Hancocks Ltd for their generous sponsorship of this event. For those who were not able to attend the authors hope this article gives a flavour of the discussions and will encourage colleagues to attend future events. Involvement is open to Editors, Associate Editors, Publishers and others with an interest in scientific publishing. It is a very open group and all those with an interest will be welcome to join in.

Outcome of infection of C57BL/6 IL-10(-/-) mice with Campylobacter jejuni strains is correlated with genome content of open reading frames up- and down-regulated in vivo.

Human Campylobacter jejuni infection can result in an asymptomatic carrier state, watery or bloody diarrhea, bacteremia, meningitis, or autoimmune neurological sequelae. Infection outcomes of C57BL/6 IL-10(-/-) mice orally infected with twenty-two phylogenetically diverse C. jejuni strains were evaluated to correlate colonization and disease phenotypes with genetic composition of the strains. Variation between strains was observed in colonization, timing of development of clinical signs, and occurrence of enteric lesions. Five pathotypes of C. jejuni in C57BL/6 IL-10(-/-) mice were delineated: little or no colonization, colonization without disease, colonization with enteritis, colonization with hemorrhagic enteritis, and colonization with neurological signs with or without enteritis. Virulence gene content of ten sequenced strains was compared in silico; virulence gene content of twelve additional strains was compared using a C. jejuni pan-genome microarray. Neither total nor virulence gene content predicted pathotype; nor was pathotype correlated with multilocus sequence type. Each strain was unique with regard to absences of known virulence-related loci and/or possession of point mutations and indels, including phase variation, in virulence-related genes. An experiment in C. jejuni 11168-infected germ-free mice showed that expression levels of ninety open reading frames (ORFs) were significantly up- or down-regulated in the mouse cecum at least two-fold compared to in vitro growth. Genomic content of these ninety C. jejuni 11168 ORFs was significantly correlated with the capacity to colonize and cause enteritis in C57BL/6 IL-10(-/-) mice. Differences in gene expression levels and patterns are thus an important determinant of pathotype in C. jejuni strains in this mouse model.

The platform for better oral health in Europe--report of a new initiative.

Public health practitioners are required to apply their competencies at a range of levels from governmental to small community groups. A recurring theme at BASCD conferences has been the need to influence policy at the highest level if improvements to oral health and better treatment of oral ill-health are to occur. This paper presents a clear example of such dental public health action at a European level. This report outlines the reasons why it is necessary to try to improve oral health within Europe, in general, and the European Union in particular. It goes on to describe how the newly formed Platform for Better Oral Health in Europe is trying to work at a macro level, and bring interested associations, groups and individuals together. Collectively they can then alert European institutions and national governments to oral health problems and promote policies to improve the current situation. It describes the current problems, their resource implications, the objectives of the Platform, its actions so far and its plans for the immediate future. It suggests that, if the problems are to be addressed, it will be necessary for all interested parties to work together at a European level to raise oral health issues higher on the E.U. agenda.

Ulcerative typhlocolitis associated with Helicobacter mastomyrinus in telomerase-deficient mice.

Telomerase deficiency induces early senescence and defects in proliferating cell populations, but in mice it has not been associated with inflammatory bowel disease. Genetically engineered mice lacking either telomerase reverse transcriptase (TERT) or telomerase RNA were examined for chronic diarrhea and wasting. Affected mice had pasty stools, thickened nondistensible colon walls, and contracted ceca. Histologically, the cecal mucosa was largely replaced by inflammatory infiltrate consisting of plasma cells, neutrophils, lymphocytes, and macrophages with marked widespread fibrosis and ulceration. Remaining epithelium was disorganized and hyperplastic, with multifocal dysplasia. Colonic mucosa was markedly hyperplastic with similar inflammation and epithelial dysplasia. Multifocal adenomatous hyperplasia, but no inflammation, was present in the small intestine. Microaerophilic spiral bacteria with 16S rRNA gene sequences identical to Helicobacter mastomyrinus were isolated from the colon and cecum. Severe granulomatous typhlocolitis without epithelial dysplasia developed in germ-free recombination-activating gene (RAG) knockout (KO) recipients of CD4+ T cells and inoculated with cecal contents from affected TERT KO mice and in specific pathogen-free recipient RAG KO mice and interleukin-10 KO mice inoculated with H mastomyrinus. Typhlocolitis in mice given H mastomyrinus was more severe than in mice given Helicobacter hepaticus. Telomerase-deficient mice are susceptible to helicobacter-associated typhlocolitis. H mastomyrinus causes severe disease in susceptible mouse strains.

Changes in dentist and dental hygienist numbers in the European Union and economic area.

AIM: To investigate the extent to which changes in the numbers of dental hygienists and dentists have occurred in the Member States of the European Union and Economic Area (EU/EEA) during the last ten years and discuss the changes in relation to the possibilities of sharing tasks between the two groups. METHODS: Numbers for active dentists, registered hygienists and EU/EEA member state populations in 2007 were taken from the website of the Council of European Chief Dental Officers (CECDO) (www.cecdo.org) and from CECDO records for the EU/EEA member states in 1998 and for the new EU member states (who joined in 2004 and 2007) in 2000. From these data, population: active dentists, population: registered dental hygienist and active dentists: registered dental hygienist ratios were calculated together with percentage changes in the number of dentists and dental hygienists by member state, between 1998 and 2007 for the old and between 2000 and 2007 for the new EU member states. RESULTS: In 2007, there were a total of 343,922 active dentists and 30,963 registered dental hygienists in the 30 EU/EEA member states plus Switzerland. The mean population to dentist ratio was about 1500:1 and the mean population to dental hygienist ratio (in the 25 states where dental hygienists were registered) was 13,454:1. During the study period, the population of the EU/EEA plus Switzerland increased by less that 3%, the number of dentists increased by 13% and the number dental hygienists by 42%. The overall ratio of active dentists: dental hygienists changed from 18:1 to 11:1. In six of the 30 member states plus Switzerland the population to dental hygienist ratio was between 2000:1 and 6000:1 and the dentist: dental hygienist ratio less than 1:3. CONCLUSIONS: Although, most member states educate dental hygienists and their numbers in the EU/EEA during the last 10 years have risen more than the dentist numbers, there are still only a handful countries where the hygienist numbers are great enough to make a significant difference to the delivery of oral health care.

Online learning in dentistry: an overview of the future direction for dental education.

This paper provides an overview of the diversity of tools available for online learning and identifies the drivers of online learning and directives for future research relating to online learning in dentistry. After an introduction and definitions of online learning, this paper considers the democracy of knowledge and tools and systems that have democratized knowledge. It identifies assessment systems and the challenges of online learning. This paper also identifies the drivers for online learning, including those for instructors, administrators and leaders, technology innovators, information and communications technology personnel, global dental associations and government. A consideration of the attitudes of the stakeholders and how they might work together follows, using the example of the unique achievement of the successful collaboration between the Universities of Adelaide, Australia and Sharjah, United Arab Emirates. The importance of the interaction of educational principles and research on online learning is discussed. The paper ends with final reflections and conclusions, advocating readers to move forward in adopting online learning as a solution to the increasing worldwide shortage of clinical academics to teach dental clinicians of the future.

Education in and the practice of dental public health in the United kingdom and Finland.

This paper describes and compares the education in and practice of dental public health in Finland and the United Kingdom. A brief introduction describes the populations of the two countries in terms of their geography, mean per capita, Gross Domestic Product (GDP), life expectancy, recent oral epidemiological data, oral health needs and the dental workforce. This is followed by a description of education in Dental Public Health in each country at undergraduate, postgraduate and continuing levels. The practice of Dental Public Health is then outlined. In both countries it includes: leadership and management of health organisations, teaching, training, research, advising and evaluating. A discussion follows. It considers the need for the provision of Dental Public Health at a time of changing oral health need and gives examples of problems that have arisen when such advice has not been sought or has been ignored. Finally, the paper considers how education in Dental Public Health could be developed to provide more flexible training whilst ensuring that the quality of knowledge and skills of specialists is maintained or improved.

Dental hygienists in Europe: trends towards harmonization of education and practice since 2003.

AIM: The aim of this study was to investigate the trends in dental hygienists' education and regulation in the European Union (EU) and European Economic Area (EEA) to examine whether, since 2003, there has been harmonization in dental hygiene education. METHODS: Information and data were obtained via piloted questionnaires and structured interviews with delegates from the International and European Dental Hygienists' Federations and representatives of the Council of European Chief Dental Officers and by literature review. RESULTS: In the EU/EEA, dental hygienists are legally recognized in 22 countries. Since 2003, there has been an increase in the number of Bachelor degree programmes and in autonomous practice. Entry to the profession is now exclusively via a Bachelor degree in five EU/EEA Member States and pending in two more. Ten Member States have adapted their degree programmes to the European Credit Transfer System. Two Member States combine education for dental hygienists and dental therapists. However, dental hygienists are not recognized by EU law and in five Members States, the introduction of the profession has been opposed by dental associations. CONCLUSIONS: For the reasons of wide variations in the standards of preventive care and periodontal therapies, the formal recognition of the dental hygiene profession by EU legislation and agreement on a pan-European curriculum for dental hygiene education leading to defined professional competencies and learning outcomes is required. To achieve this, there is a need for a better collaboration between competent authorities including governments, universities and dental and dental hygienists' associations.

Is there a need for a common framework of dental specialties in Europe?

This paper aims to promote discussion about dental specialties and post-graduate dental education in the European Union (EU). Previously, dental educators have concentrated their efforts of seeking Pan-EU convergence in undergraduate dental education. However, the impact of the enlargement of the EU, the new European Commission (EC) Directive of professional training and the Bologna Process all impact on post-graduate (specialist) just as much as on undergraduate dental education. The provisions of the new EC directive mean that, unlike new medical specialties, new Pan-EU dental specialties cannot be created purely because they exist in two-fifths of EU Member States. At present, some EU Member States recognise eight or more dental specialties, whereas others recognise none. It is suggested that changing needs and demands of patients, which reflect a general improvement in oral health, increased wealth and an aging population will place increasing demands on dentistry to provide more complex care and treatment and that the current undergraduate curriculum cannot be expanded to provide suitable training to meet these needs and demands. There is thus a need to expand dental specialist training in all EU Member States, to agree common standards for specialist education and to officially recognise a wider range of Pan-EU dental specialties. The paper concludes that in order to achieve these goals, there is a need of a better collaboration between competent authorities, including governments, universities, dental associations and the various Pan-European Scientific Specialist Organizations.

The healthcare system and the provision of oral healthcare in European Union member states. Part 9: Sweden.

Equally accessible and affordable dental services for all population groups have been a political goal in Sweden for almost a century. All political parties have shared the idea that a person's social background should not have consequences for his or her dental status. Strategic tools to achieve this ambitious goal have been the wide use of publicly provided oral healthcare services, covering even sparsely populated areas, focusing on preventive care and significant subsidies for necessary treatments. Besides free care for children and young adults, oral healthcare is reimbursed from public funds. The public subsidy was particularly generous in 1975-1999 when a 'full clearance' of adults' dentitions was undertaken both by the public and private providers under fixed prices and high reimbursement levels for all treatment measures. Today, preventive oral healthcare for the elderly is given higher priority as most Swedes have been able to keep their natural teeth.

The healthcare system and the provision of oral healthcare in European Union member states. Part 8: Italy.

In Italy healthcare is provided for all Italian citizens and residents and it is delivered mainly by public providers, with some private or private-public entities. Italy's public healthcare system - the Servizio Sanitario Nazionale (SSN) - is organised by the Ministry of Health and administered on a devolved regional basis. It is financed by general taxation that provides universal coverage, largely free of charge at the point of service. The central government establishes the basic national health benefits package, which must be uniformly provided throughout the country, through services guaranteed under the NHS provision called LEA - (Livelli Essenziali di Assistenza [Essential Level of Assistance]) and allocates national funds to the regions. The regions, through their regional health departments, are responsible for organising, administering and delivering primary, secondary and tertiary healthcare services as well as preventive and health promotion services. Regions are allowed a large degree of autonomy in how they perform this role and regarding decisions about the local structure of the system. Complementary and supplementary private health insurance is also available. However, as in most other Mediterranean European countries, in Italy oral healthcare is mainly provided under private arrangements. The public healthcare system provides only 5-8% of oral healthcare services and this percentage varies from region to region. Oral healthcare is included in the Legislation on Essential levels of care (LEAs) for specific populations such as children, vulnerable people (medically compromised and those on low income) and individuals who need oral healthcare in some urgent/emergency cases. For other people, oral healthcare is generally not covered. Apart from the national benefits package, regions may also carry out their own initiatives autonomously, but must finance these themselves. The number of dentists working in Italy has grown rapidly in the last few years. In December 2014, there were 59,324 practicing dentists with a ratio of one dentist every 1025 inhabitants, about 90,000 dental chair-side assistants, about 26,000 dental technicians and about 4000 dental hygienists. To enrol in an Italian dental school a student must pass a competitive national entrance examination after obtaining a high school leaving certificate. For entry in the 2015-2016 cycle, there were 792 places for dentistry. In comparison with dental schools in other EU member states, the number of dental students per school is low with an average of 20 students per year, per school and a range of 10 to 60. The aims of this paper are to give a brief description of the organisation of healthcare in Italy, to outline the system for the provision of oral healthcare in Italy and to explain and discuss the latest changes.

The healthcare system and the provision of oral healthcare in European Union member states. Part 7: Republic of Ireland.

The Irish oral healthcare system is a hybrid model with a public/private mix of service provision, predominantly organised on the basis of fee-per-item remuneration. The system is structured around three long standing publicly funded schemes: the Public Dental Service (PDS) for all children and adults with special needs and provided by salaried dentists, the Dental Treatment Services Scheme (DTSS) for low income adults, and the Dental Treatment Benefit Scheme (DTBS) for insured persons, the latter two both provided by private independent dental practitioners. Ireland introduced systemic water fluoridation in 1963 and currently 73% of the population has access to fluoridated water. Ireland currently has a dentist density ratio of 6.1 dentists per 10,000 inhabitants and on average, 43% of the population (30% for those aged 70+ years) visit a dentist annually. In 2014, 83% of expenditure on oral healthcare was from out-of-pocket payments by patients, with less than 1% of overall government expenditure on healthcare allotted to oral healthcare. After the economic downturn of 2008 and the severe recession that followed in Ireland, substantial cutbacks in government expenditure resulted in extensive cuts to the public sector supply of dental services and to the extent of cover provided by the publicly funded schemes. The Department of Health has recognised the major post recessionary challenges facing the Irish health system, not least, significantly reduced budgets and capacity deficits, and acknowledges the need for change in Ireland's health service. In 2014, a three-year project commenced at the Department of Health, to develop a new national oral health policy for Ireland.

Compliance of referral and hospital documentation with National Institute of Health and Care Excellence guidelines for the extraction of third molars: a comparative analysis of two NHS Trusts.

To find out whether documentation for the extraction of wisdom teeth complies with National Institute of Health and Care Excellence (NICE) guidelines, we reviewed the referral letters and hospital notes of patients treated at the maxillofacial unit of two NHS Trusts (A: 314 records and B: 280) over 12 months (1 September 2012 to 31 August 2013). Compliance was assessed as unsatisfactory ("indication for extraction not mentioned", "incorrect indication", "indication unclear") or satisfactory ("correct indication implied", "correct indication explicit"). The grade of the clinician who examined the patient was also recorded. A total of 194/314 (62%) referral letters in Trust A and 126/280 (45%) in Trust B were unsatisfactory (p<0.001). Hospital notes were unsatisfactory in 168/323 (52%) and 87/297 (29%) of cases, respectively (p<0.001). In Trust A, middle grades saw 23% (75/323) of the patients, as compared with 53% (157/297) in Trust B. In both, junior staff produced the highest percentage of satisfactory documentation, but in Trust A they were also responsible for most of the unsatisfactory examples. However, senior house officers saw 60% (195/323) of the patients in Trust A, and only 28% (83/297) in Trust B. Consultants were responsible for significantly more unsatisfactory documentation (p<0.001). One referral letter (0.2%) and seven hospital records (1%) explicitly and accurately complied with the guidelines. We conclude that compliance of documentation with the current NICE guidelines is poor and inconsistent.

NLRP6 function in inflammatory monocytes reduces susceptibility to chemically induced intestinal injury.

NLRP6 is a member of the Nod-like receptor family, whose members are involved in the recognition of microbes and/or tissue injury. NLRP6 was previously demonstrated to regulate the production of interleukin (IL)-18 and is important for protecting mice against chemically induced intestinal injury and colitis-associated colon cancer. However, the cellular mechanisms by which NLRP6 reduces susceptibility to colonic inflammation remain unclear. Here, we determined that NLRP6 expression is specifically upregulated in Ly6Chi inflammatory monocytes that infiltrate into the colon during dextran sulfate sodium (DSS)-induced inflammation. Adoptive transfer of wild-type (WT) Ly6Chi inflammatory monocytes into Nlrp6-/- mice was sufficient to protect them from mortality, significantly reducing intestinal permeability and damage. NLRP6-deficient inflammatory monocytes were defective in tumor necrosis factor α (TNFα) production, which was important for reducing DSS-induced mortality and was dependent on autocrine IL-18 signaling by inflammatory monocytes. Our data reveal a previously unappreciated role for NLRP6 in inflammatory monocytes, which are recruited after DSS-induced intestinal injury to promote barrier function and limit bacteria-driven inflammation. This study highlights the importance of early cytokine responses, particularly NLRP6-dependent and IL-18-dependent TNFα production, in preventing chronic dysregulated inflammation.