Interventions to improve oral health and related health behaviours of substance use, smoking, and diet in people with severe and multiple disadvantage: a systematic review of effectiveness and cost-effectiveness.

BACKGROUND: Homelessness overlapping with substance use and offending is described as severe and multiple disadvantage (SMD). People experiencing SMD have poor oral health along with high levels of related behaviours such as substance use, smoking, and poor diet. Existing evidence largely describes the prevalence of oral health problems, substance use, and smoking in SMD groups. Little is known about interventions that can address these conditions in SMD groups. We aimed to review the effectiveness and cost-effectiveness of interventions on oral health and related health behaviours in adults experiencing SMD. METHODS: For this systematic review, we searched bibliographic databases (MEDLINE, EMBASE, PsycINFO, CINAHL, EBSCO, Scopus) and grey literature for papers published from inception to February 2023. Two researchers independently reviewed the searches. Randomised controlled trials (RCTs), comparative studies and economic evaluations were included. Risk of bias was assessed. Population included adults experiencing SMD (including homelessness and substance use or repeat offending). Outcomes included oral health, and related behaviours (substance use, smoking, poor diet). Results were narratively synthesised. This review was registered with PROSPERO, CRD42020202416. FINDINGS: The review included 38 studies (published between 1991 and 2023), with 34 reporting effectiveness. These studies comprised of 23 RCTs and 11 quasi-experimental studies conducted in the USA (25 studies), Canada (seven studies), France (one study), and Spain (one study). The interventions involving multiple components, such as housing services with substance use and mental health support, effectively reduced substance use in SMD groups; these were mostly individual-level interventions. However, these studies had short follow-up periods and high attrition rates. Only one study addressed oral health outcomes, none focused on diet, and three RCTs covered smoking, with one intervention showing smoking abstinence at 4 weeks. Some limited evidence suggested cost-effectiveness of substance use interventions. INTERPRETATION: This review found that integrating services such as housing with other health-care services together could be effective in improving health behaviours, especially substance use among SMD groups. More evidence is needed specifically on oral health, smoking, and diet-related interventions. The generalisability of findings of this review is limited to high-income countries and shorter-term outcomes. FUNDING: National Institute for Health and Care Research (NIHR) Policy Research Programme.

Co-production of health and social science research with vulnerable children and young people: A rapid review.

BACKGROUND: The term 'care-experienced' refers to anyone who is currently in care or has been in care at any stage in their life. A complex interplay of factors leads to care-experienced children and young people (CECYP) experiencing poorer oral health and access to dental care than their peers. A rapid review of the co-production of health and social care research with vulnerable children and young people (CYP) was carried out to inform the development of a co-produced research project exploring the oral health behaviours and access to dental services of CECYP. Here, 'co-production' refers to the involvement of CYP in the planning or conduct of research with explicit roles in which they generate ideas, evidence and research outputs. AIM: To learn how to meaningfully involve vulnerable CYP in the co-production of health and social science research. OBJECTIVES: To identify: Different approaches to facilitating the engagement of vulnerable CYP in co-production of health and social science research; different activities carried out in such approaches, challenges to engaging vulnerable CYP in co-production of health and social science research and ways to overcome them and areas of best practice in relation to research co-production with vulnerable CYP. SEARCH STRATEGY: A rapid review of peer-reviewed articles was conducted in six databases (MEDLINE, Embase, SocINDEX, CINAHL, PsycINFO and Web of Science) and grey literature to identify studies that engaged vulnerable CYP in co-approaches to health and social research. MAIN RESULTS: Of 1394 documents identified in the search, 40 were included and analysed. A number of different approaches to co-production were used in the studies. The CYP was involved in a range of activities, chiefly the development of data collection tools, data collection and dissemination. Individual challenges for CYP and researchers, practical and institutional factors and ethical considerations impacted the success of co-production. DISCUSSION AND CONCLUSION: Co-production of health and social science with vulnerable CYP presents challenges to researchers and CYP calling for all to demonstrate reflexivity and awareness of biases, strengths and limitations. Used appropriately and well, co-production offers benefits to researchers and CYP and can contribute to research that reflects the needs of vulnerable CYP. Adherence to the key principles of inclusion, safeguarding, respect and well-being facilitates this approach. PATIENT AND PUBLIC CONTRIBUTION: Members of our patient and public involvement and stakeholder groups contributed to the interpretation of the review findings. This manuscript was written together with a young care leaver, Skye Boswell, who is one of the authors. She contributed to the preparation of the manuscript, reviewing the findings and their interpretation.

What is the evidence on the effectiveness of strategies to integrate oral health into primary care?

DATA SOURCES AND SEARCH STRATEGY: Seven databases (MEDLINE, CINAHL, Embase, Scopus, ProQuest, Cochrane and Google Scholar) were searched up to the third week in June 2022. Keyword search terms were based on four key concepts: oral health, primary health, strategies, and integration. STUDY SELECTION: Peer-reviewed studies that evaluated any strategies to integrate oral health into primary care (e.g., guidelines, policies, workforce programmes) were included in the review. Eligibility was restricted to papers written in English language. Papers in non-primary care settings or which did not describe an evaluation were excluded. Two reviewers independently screened titles and abstracts and thereafter full texts. Disagreements were resolved by consulting a third reviewer. DATA EXTRACTION AND SYNTHESIS: Data were extracted by one reviewer; a second person verified accuracy. Covidence was used for data extraction. Two independent reviewers critically appraised the papers using the relevant tools (e.g. Critical Appraisal Skills Programme, Cochrane Collaboration, and STrengthening the Reporting of Observational studies in Epidemiology). PRISMA flow diagram was used to present the study selection process. Review findings were reported using a narrative synthesis approach. The Health System Building Blocks (HSBB) was used as a basis for structuring the results/discussion. Heterogeneity among the included studies was high and therefore no meta-analysis was conducted. RESULTS: Forty-nine studies were included, of which two were RCTs. Most studies described oral healthcare delivered by non-dental primary care professionals within primary care services. Other settings included community, schools, and care homes. Outcomes of interest included: access to oral healthcare, knowledge/attitudes/perceptions, change in dental caries estimates. Almost all studies, except two studies which found no difference in the outcomes measured, favoured an integration strategy. Integration was achieved by enhancing competency (e.g. oral health promotion-trained educators), re-orientating responsibilities of health professionals at an organisation level and/or policy changes (e.g. expanded health insurance policy coverage to include oral health). Integration strategies enhanced access through improved referral pathways, documentation processes, operating efficiency, the number of health staff on hand, increased visits for oral health issues, higher fluoride varnish application rates for children, and more visits to dental health professionals. CONCLUSIONS: In this review, promoting an integrated approach for oral health was associated with improvements across a range of outcomes. Integrating oral health into primary care is complex but holds promise for reducing the burden of dental diseases. Identifying the best practice models of service integration requires further research and evaluation.

New Home, New You: A retrospective mixed-methods evaluation of a health-related behavioural intervention programme supporting social housing tenants.

BACKGROUND: Social housing tenants are at greater risk of engaging in unhealthy behaviours than the general population. Housing association employees are in an ideal position to contribute positively to their tenants' health. 'New Home, New You' (NHNY) is a joint venture between a social housing association, a city council and a community healthcare provider in the South West of England. It was designed with the aim of improving the health and well-being of social housing tenants. OBJECTIVES: The aim of this retrospective evaluation was to establish whether social housing tenants were benefiting from this health-related behavioural intervention in terms of their mental well-being and health-related behaviours. METHODS: This was a mixed-methods evaluation. The outcome evaluation was a secondary analysis of quantitative data collected during the NHNY project. The process of delivering and receiving the intervention was evaluated using qualitative, semi-structured interviews with housing officers and tenants who had participated in the programme. The development of the intervention was evaluated through a focus group and additional semistructured interviews with key stakeholders. Quantitative data were analysed using the Statistical Package for the Social Sciences. Qualitative interviews were analysed using thematic analysis. RESULTS: Six key stakeholders and a total of seven housing officers from several teams and seven tenants were interviewed. Of the 1016 tenants who were invited to participate in NHNY, 226 enroled in the programme. For participating tenants, the scope for health-related behaviour change was greatest in relation to eating and smoking. Small positive statistically significant changes in mental health were found between the 6- and 12-month mean score and between the baseline and the 12-month score. CONCLUSIONS: The findings indicate that NHNY may have been beneficial for some participating tenants. Housing officers can have a significant role in promoting health messages and embedding behaviour change among their tenants. Although the programme was implemented as a service improvement rather than a controlled trial and focused on a particular intervention and geographical area, other housing associations may find this evaluation useful for considering whether to adopt some of the principles applied in NHNY in other settings. PATIENT OR PUBLIC CONTRIBUTION: A social housing tenant representative provided input on the methodology and methods used to evaluate NHNY, as well as the information sheet.

Preprocedural mouth rinses for preventing transmission of infectious diseases through aerosols in dental healthcare providers.

BACKGROUND: Aerosols and spatter are generated in a dental clinic during aerosol-generating procedures (AGPs) that use high-speed hand pieces. Dental healthcare providers can be at increased risk of transmission of diseases such as tuberculosis, measles and severe acute respiratory syndrome (SARS) through droplets on mucosae, inhalation of aerosols or through fomites on mucosae, which harbour micro-organisms. There are ways to mitigate and contain spatter and aerosols that may, in turn, reduce any risk of disease transmission. In addition to personal protective equipment (PPE) and aerosol-reducing devices such as high-volume suction, it has been hypothesised that the use of mouth rinse by patients before dental procedures could reduce the microbial load of aerosols that are generated during dental AGPs. OBJECTIVES: To assess the effects of preprocedural mouth rinses used in dental clinics to minimise incidence of infection in dental healthcare providers and reduce or neutralise contamination in aerosols. SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest search date was 4 February 2022. SELECTION CRITERIA: We included randomised controlled trials and excluded laboratory-based studies. Study participants were dental patients undergoing AGPs. Studies compared any preprocedural mouth rinse used to reduce contaminated aerosols versus placebo, no mouth rinse or another mouth rinse. Our primary outcome was incidence of infection of dental healthcare providers and secondary outcomes were reduction in the level of contamination of the dental operatory environment, cost, change in mouth microbiota, adverse events, and acceptability and feasibility of the intervention. DATA COLLECTION AND ANALYSIS: Two review authors screened search results, extracted data from included studies, assessed the risk of bias in the studies and judged the certainty of the available evidence. We used mean differences (MDs) and 95% confidence intervals (CIs) as the effect estimate for continuous outcomes, and random-effects meta-analysis to combine data  MAIN RESULTS:  We included 17 studies with 830 participants aged 18 to 70 years. We judged three trials at high risk of bias, two at low risk and 12 at unclear risk of bias.  None of the studies measured our primary outcome of the incidence of infection in dental healthcare providers.  The primary outcome in the studies was reduction in the level of bacterial contamination measured in colony-forming units (CFUs) at distances of less than 2 m (intended to capture larger droplets) and 2 m or more (to capture droplet nuclei from aerosols arising from the participant's oral cavity). It is unclear what size of CFU reduction represents a clinically significant amount. There is low- to very low-certainty evidence that chlorhexidine (CHX) may reduce bacterial contamination, as measured by CFUs, compared with no rinsing or rinsing with water. There were similar results when comparing cetylpyridinium chloride (CPC) with no rinsing and when comparing CPC, essential oils/herbal mouthwashes or boric acid with water. There is very low-certainty evidence that tempered mouth rinses may provide a greater reduction in CFUs than cold mouth rinses. There is low-certainty evidence that CHX may reduce CFUs more than essential oils/herbal mouthwashes. The evidence for other head-to-head comparisons was limited and inconsistent.  The studies did not provide any information on costs, change in micro-organisms in the patient's mouth or adverse events such as temporary discolouration, altered taste, allergic reaction or hypersensitivity. The studies did not assess acceptability of the intervention to patients or feasibility of implementation for dentists.  AUTHORS' CONCLUSIONS: None of the included studies measured the incidence of infection among dental healthcare providers. The studies measured only reduction in level of bacterial contamination in aerosols. None of the studies evaluated viral or fungal contamination. We have only low to very low certainty for all findings. We are unable to draw conclusions regarding whether there is a role for preprocedural mouth rinses in reducing infection risk or the possible superiority of one preprocedural rinse over another. Studies are needed that measure the effect of rinses on infectious disease risk among dental healthcare providers and on contaminated aerosols at larger distances with standardised outcome measurement.

Factors influencing oral health behaviours, access and delivery of dental care for autistic children and adolescents: A mixed-methods systematic review.

BACKGROUND: Autistic children and young people (CYP) experience oral health (OH) inequalities. They are at high risk of dental disease and show significant levels of unmet need in relation to OH and access to dental care. AIM: This study aimed to gather evidence on the factors that influence OH behaviours, access to and delivery of dental care for autistic CYP. DESIGN: This was a mixed-methods narrative systematic review. DATA SOURCES: Embase, Web of Science, Dentistry & Oral Sciences Source, MEDLINE, Psychinfo, Scopus, CINAHL, SocINDEX and grey literature were the data sources for this study. REVIEW METHODS: A systematic search was conducted for qualitative, quantitative and mixed-methods research studies from countries with a High Development Index that related to OH behaviours, access to and delivery of dental care for autistic CYP. Results were analysed using narrative synthesis. RESULTS: From 59 eligible studies, 9 themes were generated: (1) affordability and accessibility; (2) autism-related factors and cognitive or motor skill differences; (3) the dental environment; (4) managing CYP's behaviour; (5) responding and adapting to the needs of the autistic CYP and their parent/carer; (6) attitude of dental health professionals (DHPs) towards autistic CYP and their parents/carers; (7) knowledge of how to care for and support CYP's OH; (8) empowerment of parents/carers and collaboration with DHPs; and (9) communication and building rapport. CONCLUSION: The adoption of healthy OH behaviours and access to dental care by autistic CYP is impacted by a range of factors including those intrinsically related to a diagnosis of autism, for example, communication and those often associated with autism, for example, sensory sensitivities. Access to better OH and dental care can be facilitated by responding to the individual needs of autistic CYP through accommodation, education and adaptation. This necessitates greater awareness and knowledge of autism amongst DHPs and the provision of appropriate services. More methodologically robust intervention studies are needed to identify effective ways to support autistic CYP in achieving good OH and access to dental care. PATIENT AND PUBLIC CONTRIBUTION: The review protocol was developed with members of the project patient and public involvement group who provided the autistic voice, contributing to the interpretation of the review findings and writing of the manuscript.

Barriers and facilitators to hepatitis C screening and treatment for people with lived experience of homelessness: A mixed-methods systematic review.

BACKGROUND: People experiencing homelessness have an increased risk of hepatitis C virus (HCV) infection, with rates higher than the general population. However, their access to HCV diagnosis is limited and treatment uptake is low. OBJECTIVES: To identify and describe the barriers and facilitators for HCV screening and treatment for adults with lived experience of homelessness in highly developed countries. METHODS: Bibliographic databases (Embase, MEDLINE, CINAHL and SocINDEX) and grey literature (Google, EThOS, the Health Foundation, Social Care Online, the World Health Organisation, Shelter, Crisis and Pathway) were searched. Two reviewers independently screened and appraised all studies. The Critical Appraisal Skills Programme tool and the Joanna Briggs Institute checklist were used. The analysis involved a three-stage process: coding, theme generation and theme mapping under Penchansky and Thomas's modified access model. RESULTS: Twelve papers/reports were included in the review. Several interacting factors influence access of people with lived experience of homelessness to HCV testing and treatment. Some mirror those identified for the general population. The precarious conditions associated with the lived experience of homelessness along with the rigidity of hospital settings and lack of awareness emerged as dominant barriers. Flexibility, outreach, effective communication, tailoring and integration of services were found to be important facilitators. Evidence from Black, Asian and minority ethnic groups is limited. CONCLUSIONS: People experiencing homelessness face multiple barriers in accessing and completing HCV treatment, relating to both their lived experience and characteristics of health systems. Although some barriers are readily amenable to change, others are more difficult to modify. The facilitators identified could inform future targeted measures to improve HCV diagnosis and treatment for people experiencing homelessness. Research is warranted into successful models to promote screening, diagnosis and treatment. PATIENT OR PUBLIC CONTRIBUTION: Our team includes a peer advocate, a hepatology nurse and a community volunteer, all with significant experience in promoting and engaging in HCV care and outreach for people experiencing homelessness. They contributed to the protocol, interpretation and reporting of the review findings.

Scoping review: Scope of practice of nurse-led services and access to care for people experiencing homelessness.

AIMS: To investigate the scope of practice of nurse-led services for people experiencing homelessness, and the influence on access to healthcare. DESIGN: A scoping review. DATA SOURCES: On 20 November 2020, the following databases were searched: CINAHL, Embase, MEDLINE, PubMed and Scopus. REVIEW METHODS: Included studies focused on people experiencing homelessness aged 18 years and over, nurse-led services in any setting and described the nursing scope of practice. Studies were peer-reviewed primary research, published in English from the year 2000. Three authors performed quality appraisals using the mixed methods assessment tool. Results were synthesized and discussed narratively and reported according to the PRISMA-ScR 2020 Statement. RESULTS: Nineteen studies were included from the United States (n = 9), Australia (n = 4), United Kingdom (n = 4) and Canada (n = 2). The total participant sample size was n = 6303. Studies focused on registered nurses (n = 10), nurse practitioners (n = 5) or both (n = 4), in outpatient or community settings. The nursing scope of practice was broad and covered a range of skills, knowledge and attributes. Key skills identified include assessment and procedural skills, client support and health education. Key attributes were a trauma-informed approach and building trust through communication. Important knowledge included understanding the impact of homelessness, knowledge of available services and the capacity to undertake holistic assessments. Findings suggest that nurse-led care facilitated access to healthcare through building trust and supporting clients to access services. CONCLUSION: Optimized nursing scope of practice can facilitate access to healthcare for people experiencing homelessness. Key factors in enabling this include autonomy in nursing practice, organizational support and education. IMPACT: The broad range of skills, knowledge and attributes reported provide a foundation from which to design an educational framework to optimize the nursing scope of practice, thereby increasing access to healthcare for people experiencing homelessness.

The benefits of an innovative community engagement model in dental undergraduate education.

Dental healthcare students at the Peninsula Dental School, University of Plymouth, UK undertake community engagement projects as a core part of their undergraduate curriculum. Students work with their peers to develop a student-led, evidence-based project working with target groups in the local community to address oral health needs. The aim of the programme is to further the students' understanding of health inequalities and the health needs of different groups in the community, while developing skills that will help them deliver holistic dental care as part of their future professional practice. This report highlights our model of education delivery in collaboration with the community, the student-learning outcomes and discusses some of the benefits of this approach including examples of projects that have benefitted the community. We highlight the further work needed to evaluate the longer-term impacts on students of undertaking social accountability programmes.

Mental health and wellbeing interventions in the dental sector: a systematic review.

Introduction UK dentists experience high levels of stress, anxiety and burnout. Poor mental health can lead practitioners to exit the profession, contributing to workforce and service loss. Therefore, there is a need to focus on interventions to protect the mental health and wellbeing of dental teams. Three levels of intervention can be deployed in the workplace to support mental health and wellbeing: primary prevention, secondary prevention, and tertiary prevention.Aim The aim of this systematic review was to identify evidence on interventions used to prevent, improve or tackle mental health issues among dental team members and dental profession students in countries of very high development.Methods This systematic review was conducted according to a predefined protocol and reported according to PRISMA guidelines. The MEDLINE, Embase CINAHL, DOSS, Scopus, and PsycINFO databases were searched. Prospective empirical studies were considered for inclusion. The Effective Public Health Practice Project Quality Assessment Tool (EPHPP) was used to assess the methodological quality of the included studies. The identified interventions were categorised according to level of prevention.Results The search yielded 12,919 results. Eight studies met the inclusion criteria. All of the studies concerned dentists or dental students. There were no studies for other groups of dental professionals. No primary prevention-level studies were identified. Secondary prevention-level studies (n = 4) included various psychoeducational interventions aiming to raise awareness and improve coping skills and led to significant improvements in stress levels and burnout of dentists and dental students. Tertiary prevention-level studies (n = 4) mainly employed counselling which was shown to be beneficial for dentists and students experiencing psychological ill-health.Conclusions Mental wellbeing awareness should be put at the centre of dental education and the workplace. Leadership and innovation are required to design primary-level interventions which can be implemented in the UK dental sector, with its distinct organisational and service characteristics.

Improving the sexual health of young people experiencing homelessness.

The sexual health needs of young people experiencing homelessness in the UK have not been researched adequately. This study aimed to examine knowledge and attitudes around sexual health and contraceptive use amongst this vulnerable group to develop suitable models of care in the community. A qualitative ethnographic case-study following Burawoy's extended case method was used. Semi-structured interviews with 29 young people experiencing homelessness and five key workers in London hostels were carried out together with ethnographic observations and analysis of documentary evidence. Thematic analysis was undertaken. Demographic data were collected. Three significant themes were identified: risks and extreme vulnerability, relationships and communication difficulties and emergence of a culture of homelessness. Young people experiencing homelessness require specialist delivery of sexual health care in safe surroundings. Initial care should focus on assessment of basic needs and current state of being. Establishing trusting relationships and considering ongoing vulnerability, can help promote meaningful and personalised sexual healthcare both at policy and practice level.

What is the global prevalence of dental healthcare needs and unmet dental needs among adolescents?

Data sources Databases searched included Web of Science, PubMed and Scopus.Study selection Cross-sectional studies that estimated dental healthcare needs and unmet dental needs in young people, aged 10-19 years were considered for inclusion. No limitations in terms of year of publication, language, location of the study, gender and race of the participants, or the type of dental health needs and unmet needs were applied. The papers were screened on title and abstract, and then on full text by two reviewers. Any disagreements were resolved through discussion and consultation with a third reviewer.Data extraction and synthesis Data were extracted by three reviewers. Critical appraisal was conducted by two reviewers using the Joanna Briggs Institute critical appraisal checklist. A PRISMA flowchart was used to present the study selection results. Summary measures on the prevalence of dental health needs and unmet needs were calculated. For the meta-analysis, the inverse variance method was used to obtain pooled summary measures.Results Fifty-seven studies were included in the review. The overall prevalence of dental healthcare needs was 49% (95% CI: 42-56) across all types of dental care. The highest prevalence was that for periodontal treatment needs (71%; 95% CI: 46-96 as reported in four studies), followed by that of general treatment needs (59.0%; 95% CI: 42-75 as reported in 12 studies), orthodontic treatment (46%; 95% CI: 38-53 as reported in 32 studies) and lastly that of malocclusion treatment needs (39%; 95% CI: 28-50 as reported in nine studies). The pooled prevalence of unmet dental needs as reported in nine studies was 34% (95% CI: 27-40) with the highest prevalence found in Southeast Asia (72.3%; 95% CI: 70.1-74.5) and the lowest in Europe (11.8%; 95% CI: 3.4-20.3).Conclusions The results of this review showed that the prevalence of dental healthcare needs was higher in America and Europe while unmet needs were more prevalent in Southeast Asia and Africa. The former could partly be explained by the lower number and sample sizes of studies conducted in developing countries.Commentary.

Is there an association between drug use and oral health conditions?

Data sources Databases searched included PsycINFO, PubMed, SciELO, Scopus and Web of Science.Study selection Cross-sectional, longitudinal and retrospective studies that compared caries, periodontal disease or tooth loss in people who use drugs as compared to those who do not. Studies that included psychiatric populations and alcohol or tobacco users were not included in the review. Qualitative studies, in vitro investigations, animal studies, reviews, case reports and series, letters to editor and conference abstracts were also excluded. The authors included only English studies published before 1 July 2019. Two independent reviewers screened the papers on title and abstract and then full text. In case of disagreements, these were discussed between the two reviewers and a third one was consulted if needed.Data extraction and synthesis Two reviewers extracted the data and contacted the primary authors for necessary clarifications, if needed. The unweighted kappa was applied to examine inter-examiner agreement. The Joanna Briggs Institute Critical Appraisal Checklist for observational studies was used to critically appraise the studies. The study selection results were presented through a flowchart. For the meta-analysis, the authors considered adjusted data. In some cases, crude estimates were used. Heterogeneity was estimated using the I2 statistic. The 'meta' package was used for the meta-analysis.Results Ten studies were included in the meta-analysis. Drug use was associated with higher risk of periodontal disease (OR 1.44; 95% CI 0.8-2.6) and higher DMFT index (OR 4.11; 95% CI 2.07-8.15).Conclusions The review showed high risk of periodontal disease and caries among people who use drugs. The authors concluded that this association may be explained by irregular tooth brushing and long history of drug use. It is important to develop programmes that aim to improve oral hygiene practices among people who use drugs.

Interventions to reduce contaminated aerosols produced during dental procedures for preventing infectious diseases.

BACKGROUND: Many dental procedures produce aerosols (droplets, droplet nuclei and splatter) that harbour various pathogenic micro-organisms and may pose a risk for the spread of infections between dentist and patient. The COVID-19 pandemic has led to greater concern about this risk. OBJECTIVES: To assess the effectiveness of methods used during dental treatment procedures to minimize aerosol production and reduce or neutralize contamination in aerosols. SEARCH METHODS: Cochrane Oral Health's Information Specialist searched the following databases on 17 September 2020: Cochrane Oral Health's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (in the Cochrane Library, 2020, Issue 8), MEDLINE Ovid (from 1946); Embase Ovid (from 1980); the WHO COVID-19 Global literature on coronavirus disease; the US National Institutes of Health Trials Registry (ClinicalTrials.gov); and the Cochrane COVID-19 Study Register. We placed no restrictions on the language or date of publication. SELECTION CRITERIA: We included randomized controlled trials (RCTs) and controlled clinical trials (CCTs) on aerosol-generating procedures (AGPs) performed by dental healthcare providers that evaluated methods to reduce contaminated aerosols in dental clinics (excluding preprocedural mouthrinses). The primary outcomes were incidence of infection in dental staff or patients, and reduction in volume and level of contaminated aerosols in the operative environment. The secondary outcomes were cost, accessibility and feasibility. DATA COLLECTION AND ANALYSIS: Two review authors screened search results, extracted data from the included studies, assessed the risk of bias in the studies, and judged the certainty of the available evidence. We used mean differences (MDs) and 95% confidence intervals (CIs) as the effect estimate for continuous outcomes, and random-effects meta-analysis to combine data. We assessed heterogeneity. MAIN RESULTS: We included 16 studies with 425 participants aged 5 to 69 years. Eight studies had high risk of bias; eight had unclear risk of bias. No studies measured infection. All studies measured bacterial contamination using the surrogate outcome of colony-forming units (CFU). Two studies measured contamination per volume of air sampled at different distances from the patient's mouth, and 14 studies sampled particles on agar plates at specific distances from the patient's mouth. The results presented below should be interpreted with caution as the evidence is very low certainty due to heterogeneity, risk of bias, small sample sizes and wide confidence intervals. Moreover, we do not know the 'minimal clinically important difference' in CFU. High-volume evacuator Use of a high-volume evacuator (HVE) may reduce bacterial contamination in aerosols less than one foot (~ 30 cm) from a patient's mouth (MD -47.41, 95% CI -92.76 to -2.06; 3 RCTs, 122 participants (two studies had split-mouth design); very high heterogeneity I² = 95%), but not at longer distances (MD -1.00, -2.56 to 0.56; 1 RCT, 80 participants). One split-mouth RCT (six participants) found that HVE may not be more effective than conventional dental suction (saliva ejector or low-volume evacuator) at 40 cm (MD CFU -2.30, 95% CI -5.32 to 0.72) or 150 cm (MD -2.20, 95% CI -14.01 to 9.61). Dental isolation combination system One RCT (50 participants) found that there may be no difference in CFU between a combination system (Isolite) and a saliva ejector (low-volume evacuator) during AGPs (MD -0.31, 95% CI -0.82 to 0.20) or after AGPs (MD -0.35, -0.99 to 0.29). However, an 'n of 1' design study showed that the combination system may reduce CFU compared with rubber dam plus HVE (MD -125.20, 95% CI -174.02 to -76.38) or HVE (MD -109.30, 95% CI -153.01 to -65.59). Rubber dam One split-mouth RCT (10 participants) receiving dental treatment, found that there may be a reduction in CFU with rubber dam at one-metre (MD -16.20, 95% CI -19.36 to -13.04) and two-metre distance (MD -11.70, 95% CI -15.82 to -7.58). One RCT of 47 dental students found use of rubber dam may make no difference in CFU at the forehead (MD 0.98, 95% CI -0.73 to 2.70) and occipital region of the operator (MD 0.77, 95% CI -0.46 to 2.00). One split-mouth RCT (21 participants) found that rubber dam plus HVE may reduce CFU more than cotton roll plus HVE on the patient's chest (MD -251.00, 95% CI -267.95 to -234.05) and dental unit light (MD -12.70, 95% CI -12.85 to -12.55). Air cleaning systems One split-mouth CCT (two participants) used a local stand-alone air cleaning system (ACS), which may reduce aerosol contamination during cavity preparation (MD -66.70 CFU, 95% CI -120.15 to -13.25 per cubic metre) or ultrasonic scaling (MD -32.40, 95% CI - 51.55 to -13.25). Another CCT (50 participants) found that laminar flow in the dental clinic combined with a HEPA filter may reduce contamination approximately 76 cm from the floor (MD -483.56 CFU, 95% CI -550.02 to -417.10 per cubic feet per minute per patient) and 20 cm to 30 cm from the patient's mouth (MD -319.14 CFU, 95% CI - 385.60 to -252.68). Disinfectants ‒ antimicrobial coolants Two RCTs evaluated use of antimicrobial coolants during ultrasonic scaling. Compared with distilled water, coolant containing chlorhexidine (CHX), cinnamon extract coolant or povidone iodine may reduce CFU: CHX (MD -124.00, 95% CI -135.78 to -112.22; 20 participants), povidone iodine (MD -656.45, 95% CI -672.74 to -640.16; 40 participants), cinnamon (MD -644.55, 95% CI -668.70 to -620.40; 40 participants). CHX coolant may reduce CFU more than povidone iodine (MD -59.30, 95% CI -64.16 to -54.44; 20 participants), but not more than cinnamon extract (MD -11.90, 95% CI -35.88 to 12.08; 40 participants). AUTHORS' CONCLUSIONS: We found no studies that evaluated disease transmission via aerosols in a dental setting; and no evidence about viral contamination in aerosols. All of the included studies measured bacterial contamination using colony-forming units. There appeared to be some benefit from the interventions evaluated but the available evidence is very low certainty so we are unable to draw reliable conclusions. We did not find any studies on methods such as ventilation, ionization, ozonisation, UV light and fogging. Studies are needed that measure contamination in aerosols, size distribution of aerosols and infection transmission risk for respiratory diseases such as COVID-19 in dental patients and staff.

Evaluation of a community dental clinic providing care to people experiencing homelessness: A mixed methods approach.

BACKGROUND: People who experience homelessness have higher dental treatment needs compared to the general population. However, their utilization of dental services and levels of treatment completion are low. Peninsula Dental Social Enterprise, a not-for-profit organization in the United Kingdom, established a community dental clinic to improve access to dental care for this population. OBJECTIVES: To evaluate the impact and acceptability of the community dental service for patients and examine the barriers and enablers to using and providing the service. METHODS: The evaluation included a retrospective assessment of anonymous patient data and thematic analysis of semi-structured interviews with patients, support staff and service providers. The interviews were thematically analysed. A cost analysis of the dental service was also conducted. RESULTS: By 18 February 2020, 89 patients had attended the clinic. These included 62 males (70%) and 27 females (30%), aged 38.43 years on average (SD ± 11.07). Of these, 42 (47%) patients have completed their treatment, 23 (26%) are in active treatment and 24 (27%) left treatment. In total, 684 appointments (541.5 hours clinical time) were given. Of these, 82% (562) of appointments were attended (452.5 hours clinical time). The 22 interviews that were conducted identified flexibility, close collaboration with support services and health-care team attitudes as key factors influencing service utilization and continuity of care. CONCLUSIONS: This study provides details of a highly acceptable and accessible dental care model for people experiencing homelessness, with recommendations at research, practice and commissioning levels.

Barriers and facilitators to dental care access among asylum seekers and refugees in highly developed countries: a systematic review.

BACKGROUND: Dental diseases are prevalent among asylum seekers and refugees (ASRs). Despite significant treatment needs, access to dental care in host countries is often limited. The aim of this systematic review was to identify the barriers and enablers to dental care access for ASRs in host countries of very high development. METHODS: Five health and social care databases and eight grey literature sources of information were searched. The Critical Appraisal Skills Programme tool was used to critically appraise included studies. Thematic analysis was undertaken to identify common themes. These were then deductively organised according to Penchansky and Thomas's modified access model. All review stages were conducted by two independent reviewers. RESULTS: Nine papers were included in the review. ASRs encounter significant challenges to accessing dental care in their host countries. These include affordability, communication difficulties, insufficient interpretation, limited knowledge of the healthcare systems and healthcare rights, and negative encounters with healthcare teams. The views and experiences of dental care teams providing care to ASRs were explored in only one study. CONCLUSIONS: Both population and healthcare characteristics influence access to dental care for ASRs. Affordability, awareness and accommodation are most frequently described as barriers to dental access for this population. The diverse needs of this population need to be recognised by policy makers, commissioners and practitioners alike. Cultural competence needs to be incorporated into dental services and any interventions to improve access to dental care for this population. Registration PROSPERO- International prospective register of systematic reviews (CRD42019145570).

Is there an association between oral health-related quality of life and Alzheimer's disease?

Data sources PubMed, Medline, Embase, CINAHL, Cochrane Library database and ProQuest databases were searched.Study selection Observational and non-randomised studies in English language were considered for inclusion. Two reviewers independently selected the relevant studies. Any disagreement was resolved by discussion with a third reviewer. The outcome of interest for this review was oral health-related quality of life (OHRQoL) in patients with Alzheimer's disease.Data extraction and synthesis Data extraction was conducted independently by two reviewers. Critical appraisal was conducted by two reviewers using the Joanna Briggs Institute 'Meta-Analysis of Statistics Assessment and Review Instrument'.Results Six studies were included in the review, of which five were cross-sectional and one was a non-randomised controlled trial. OHRQoL was measured by the Oral Health Impact Profile (OHIP) in one study and the Geriatric Oral Health Assessment Index (GOHAI) in the other five included studies. All six studies were judged as methodologically strong. When the results of four studies which used the GOHAI were pooled together in a meta-analysis, no statistically significant differences in the GOHAI scores between patients with Alzheimer's disease and controls were found (SMD = 0.09; 95%CI: -0.66 to 0.85).Conclusions The results of this review showed no significant difference in OHRQoL between patients with Alzheimer's disease and healthy controls.

Body mass index and dental caries in young people: a systematic review.

BACKGROUND: Obesity and caries in young people are issues of public health concern. Even though research into the relationship between the two conditions has been conducted for many years, to date the results remain equivocal. The aim of this paper was to determine the nature of the relationship between Body Mass Index (BMI) and caries in children and adolescents, by conducting a systematic review of the published literature. METHODS: A systematic search of studies examining the association between BMI and caries in individuals younger than 18 years old was conducted. The electronic bibliographic databases PubMed, MEDLINE, Embase, CINAHL, CENTRAL and Google Scholar were searched. References of included studies were checked to identify further potential studies. Internal and external validity as well as reporting quality were assessed using the validated Methodological Evaluation of Observational Research checklist. Results were stratified based on the risk of flaws in 14 domains 10 of which were considered major and four minor. RESULTS: Of the 4208 initially identified studies, 84 papers met the inclusion criteria and were included in the review; conclusions were mainly drawn from 7 studies at lower risk of flaws. Three main types of association between BMI and caries were found: 26 studies showed a positive relationship, 19 showed a negative association, and 43 found no association between the variables of interest. Some studies showed more than one pattern of association. Assessment of confounders was the domain most commonly found to be flawed, followed by sampling and research specific bias. Among the seven studies which were found to be at lower risk of being flawed, five found no association between BMI and caries and two showed a positive association between these two variables. CONCLUSIONS: Evidence of an association between BMI and caries was inconsistent. Based on the studies with a low risk lower risk of being flawed, a positive association between the variables of interest was found mainly in older children. In younger children, the evidence was equivocal. Longitudinal studies examining the association between different indicators of obesity and caries over the life course will help shed light in their complex relationship.

A dental student view on learning gained through Inter-Professional Engagement with people experiencing homelessness.

Community engagement is an important element of the undergraduate programme at the Faculty of Medicine and Dentistry, University of Plymouth, United Kingdom. This report presents a project that a group of second year dental students undertook with people experiencing homelessness, and provides an in-depth reflective account of its impact on the students' learning. The project formed part of the students' inter-professional engagement module and delivered an intervention to enable residents at a temporary accommodation centre to access dental treatment. As a result of the project, 14 residents received dental treatment. The groups' confidence in engaging with people experiencing homelessness and their understanding of the complex needs of this group also significantly improved. Community engagement modules can be an important learning tool for students' future practice and can help promote access to dental care for vulnerable populations.

Is there an association between children's screen use and cariogenic diet?

Data sources Databases searched included the International Database for Medical Research MEDLINE/Pubmed, ISI Web of Science, Scopus, Scientific Electronic Library Online (SciELO), and Latin American and Caribbean Health Sciences (LILACS).Study selection Studies of observational design that examined the association between any screen-time behaviour and dietary intake in preschool and school-aged children (younger than 12 years) were selected by two independent reviewers. If a consensus could not be reached, a third reviewer was consulted.Data extraction and synthesis Data were extracted independently by two reviewers using a pre-tested data extraction form. Risk of bias was assessed using an adapted version of the Newcastle-Ottawa Quality Assessment Scale for cross-sectional studies. A PRISMA flow chart was used to present the study selection results. The GRADE system was used to evaluate the strength of evidence. A qualitative synthesis was used to report the results. A meta-analysis was not conducted.Results Nineteen studies were included in the review, all of which were of cross sectional design or conducted cross-sectional analysis. Fourteen studies were assessed as high quality, three as moderate quality and two as low quality. All studies found a significant positive association between television and/or total screen-time viewing and poor quality diet including lower intake of fruit and vegetables and higher intake of unhealthy foods. Screen-based sedentary behaviour was positively associated with cariogenic foods consumption in 15 studies. Based on the GRADE rating, there was moderate evidence of an association between TV viewing and intake of potentially cariogenic diet.Conclusions Although there could be an association between TV viewing and poor quality cariogenic diet in preschool and school-aged children, the authors conclude that the strength of evidence is limited.Commentary.