Chapter 10: Oral Health-Related Quality of Life and Coronal Caries.

Dental caries is the most prevalent oral health disease and affects the health of individual and populations. The conventional disease metrics do not represent the impact of caries on people's lives. Oral-health-related quality of life measures were developed to help understand which aspects of dental caries have the greatest impact on well-being. How these measures were developed follows a standardized process of development and testing, with the ultimate aim of the entire process being that they be used in clinical dentistry, dental epidemiology, and health services research. There has been ongoing debate about whether these measures have adequate discriminative ability for the wide range of caries experience, and whether they are responsive to changes in disease experience. Whether these measures are "perfect" or not, what we do know after two decades is that numerous studies have found them to be sufficiently discriminative for caries in adults and children alike. There is also evidence for their responsiveness, chiefly from studies of children undergoing dental treatment under general anesthetic for early childhood caries. The influence of environmental, social, and psychological characteristics is another consideration in how people self-rate their oral health. Is there a need to improve the quality of these measures by refining existing ones or developing new ones which may represent those broader concepts? Regardless of the future, the most pressing challenge is the need for health systems work to ensure the routine use of these measures in clinical and public health practice.

Time to complain about pain: Children's self-reported procedural pain in a randomised control trial of Hall and conventional stainless steel crown techniques.

BACKGROUND: Children's pain in dentistry has undesirable short- and long-term consequences; therefore, less invasive treatments merit consideration. AIM: To investigate procedural pain scores for two treatments for carious primary molars in New Zealand primary care. DESIGN: This study was a split-mouth randomised control trial, with secondary outcome analysis. Children (4-8 years) with proximal carious lesions on matched primary molars had one tooth treated with the Hall technique (HT) and one treated with a conventional stainless steel crown (CT); treatment type and order of treatment were randomly allocated (allocation concealment). The Wong-Baker self-report pain scale measured pretreatment dental pain, procedural pain at each treatment and post-operative pain. RESULTS: Data were analysed for 103 children: 49 children had the HT first and 54 children had the CT first. Procedural pain scores did not differ by treatment type, with 71.8% and 76.7% of children reporting low pain for the HT and the CT, respectively. Fewer children reported low procedural pain for the second treatment than the first (p = .047). Most children reported low procedural pain for both treatments (58.3%), although 41.7% experienced moderate-high procedural pain with at least one treatment. CONCLUSIONS: The HT caused pain for as many children as the CT. There is an opportunity for better dental pain management in this setting.

Ultrastructure and properties of primary carious molars treated using the Hall Technique.

BACKGROUND: The Hall Technique (HT) is a method of restoring decayed primary teeth using stainless steel crowns (SSCs) without tooth preparation, caries removal, or local anaesthetic. AIM: To investigate the ultrastructural, biomechanical, and chemical characteristics of teeth managed with the Hall Technique in comparison with conventional SSC (controls). DESIGN: Twelve HT-treated primary molars and four controls were analysed. Teeth were dehydrated in ethanol, embedded in methylmethacrylate, mesio-distally sectioned, X-rayed, mounted, and polished. Biomechanical, ultrastructural, and chemical characterisation was performed for carious lesion and sound areas of each specimen. RESULTS: Pre-treatment and post-treatment X-rays showed evidence of little to no caries progression over time. In carious lesions, mean hardness and elastic modulus values were lower in HT-treated teeth than in controls. In both controls and HT-treated teeth, carious lesions had the lowest %wt of Ca and P of all tissues sampled. CONCLUSIONS: Although the retained carious tissue was biomechanically more compromised in HT-treated teeth, the Ca and P values were higher than reported elsewhere for carious lesions in primary molars, suggesting remineralisation may have occurred in caries in HT-treated teeth. Future investigations will help elucidate the processes involved with carious lesion arrest under SSC.

When to intervene in the caries process? A Delphi consensus statement.

Objectives To define an expert Delphi consensus on when to intervene in the caries process and existing carious lesions.Methods Non-systematic literature synthesis, expert Delphi consensus process and expert panel conference.Results Lesion activity, cavitation and cleansability determine intervention thresholds. Inactive lesions do not require treatment (in some cases, restorations may be placed for form, function, aesthetics); active lesions do. Non-cavitated carious lesions should be managed non- or micro-invasively, as should most cavitated lesions which are cleansable. Cavitated lesions which are not cleansable usually require minimally invasive management. In specific circumstances, mixed interventions may be applicable. Occlusally, cavitated lesions confined to enamel/non-cavitated lesions extending radiographically into deep dentine may be exceptions. Proximally, cavitation is hard to assess tactile-visually. Most lesions extending radiographically into the middle/inner third of dentine are assumed to be cavitated. Those restricted to the enamel are not cavitated. For lesions extending radiographically into the outer third of dentine, cavitation is unlikely. These lesions should be managed as if they were non-cavitated unless otherwise indicated. Individual decisions should consider factors modifying these thresholds.Conclusions Comprehensive diagnosis is the basis for systematic decision-making on when to intervene in the caries process and existing lesions.

Family Impact of Child Oro-Facial Cleft.

OBJECTIVE: To describe the association between children's orofacial cleft (OFC) and families' quality of life (QoL), using the short-form Family Impact Scale questionnaire (FIS-SF). Also assessed were the psychometric properties of the FIS-SF, as well as whether certain demographic and clinical variables impacted the family. DESIGN: Observational cross-sectional study. SETTING: Tertiary care public children's hospital in New South Wales, Australia. PARTICIPANTS: Parents/caregivers of children with OFC. MAIN OUTCOME MEASURE(S): The short-form Family Impact Scale questionnaire. RESULTS: Two hundred and fourteen parents completed the FIS-SF. Excellent convergent validity was evident, but discriminant validity was weaker. Those children with velopharyngeal insufficiency/submucous cleft reported lower scores on the family/parental activity, and lower overall family impact scores than those with cleft lip (CL) or cleft palate (CP). Those with cleft lip and palate (CL/P) had poorer family/parental activity scores than those with CP. There were no systematic differences in FIS-SF scores by the child's age, gender, private health insurance, living location, the number of cleft-related operations, or whether a child had commenced orthodontic treatment. CONCLUSIONS: The FIS-SF is a valid and reliable measure for determining the impact that OFC has on family QoL. The impact of OFC on children's families differs according to cleft type.

Psychosocial aspects of periodontal disease diagnosis and treatment: A qualitative study.

AIMS: Patient-reported outcomes have attracted interest as there has been a shift from clinician-centric endpoints. This qualitative study aimed to develop an understanding of the psychosocial impact of periodontitis and its treatment. MATERIALS AND METHODS: Fourteen adults were asked to document their experiences of untreated periodontitis and non-surgical periodontal therapy at a university clinic, using written or audio-recorded diaries. The diary data were then used as a framework for semi-structured qualitative interviews, conducted at the completion of initial non-surgical treatment. Inductive thematic content data analysis was employed. RESULTS: Three themes illustrated the detrimental impact of periodontitis: "concealment," "having a guilty conscience" and "patient comfort as paramount." These were related to a core underlying concept, "progression to a more positive outlook," which described a distinct shift in participants' attitudes and optimism after their periodontal treatment. Despite finding treatment unpleasant, the participants described profound positive influences on their social well-being, self-esteem, mood, work, relationships and outlook. CONCLUSIONS: This study illustrated the broad psychosocial impact of periodontitis. The findings suggest that the benefits of periodontal treatment extend beyond improvements in traditional biomedical indicators to those which are more relevant and desirable to patients.

Rasch model of the child perceptions questionnaire in multi-country data.

OBJECTIVE: To be fit-for-purpose, oral health-related quality of life instruments must possess a range of psychometric properties which had not been fully examined in the 16-item Short Form Child Perceptions Questionnaire for children aged 11 to 14 years (CPQ11-14 ISF-16). We used advanced statistical approaches to determine the CPQ's measurement accuracy, precision, invariance and dimensionality and analyzed whether age range could be extended from 8 to 15 years. METHODS: Fit to the Rasch model was examined in 6648 8-to-15-year-olds from Australia, New Zealand, Brunei, Cambodia, Hong Kong, Malaysia, Thailand, Germany, United Kingdom, Brazil and Mexico. RESULTS: In all but two items, the initial five answer options were reduced to three or four, to increase precision of the children's selection. Items 10 (Shy/embarrassed) and 11 (Concerned what others think) showed an 'extra' dependency between item scores beyond the relationship related to the underlying latent construct represented by the instrument, and so were deleted. Without these two items, the CPQ was unidimensional. The three oral symptoms items (4 Food stuck in teeth, 3 Bad breath and 1 Pain) were required for a sufficient person-item coverage. In three out of 14 items (21 %), Europe and South America showed regional differences in the patterns of how the answer options were selected. No differential item functioning was detected for age. CONCLUSION: Except for a few modifications, the present analysis supports the combination of items, the cross-cultural validity of the CPQ with 14 items and the extension of the age range from 8 to 15 years. CLINICAL SIGNIFICANCE: The valid, reliable, shortened and age-extended version of the CPQ resulting from this study should be used in routine care and clinical research. Less items and a wider age range increase its usability. Symptoms items are needed to precisely differentiate between children with higher and lower quality of life.

Risk Factors for Acute Rheumatic Fever: Literature Review and Protocol for a Case-Control Study in New Zealand.

Acute rheumatic fever (ARF) and its sequela, rheumatic heart disease (RHD), have largely disappeared from high-income countries. However, in New Zealand (NZ), rates remain unacceptably high in indigenous Maori and Pacific populations. The goal of this study is to identify potentially modifiable risk factors for ARF to support effective disease prevention policies and programmes. A case-control design is used. Cases are those meeting the standard NZ case-definition for ARF, recruited within four weeks of hospitalisation for a first episode of ARF, aged less than 20 years, and residing in the North Island of NZ. This study aims to recruit at least 120 cases and 360 controls matched by age, ethnicity, gender, deprivation, district, and time period. For data collection, a comprehensive pre-tested questionnaire focussed on exposures during the four weeks prior to illness or interview will be used. Linked data include previous hospitalisations, dental records, and school characteristics. Specimen collection includes a throat swab (Group A Streptococcus), a nasal swab (Staphylococcus aureus), blood (vitamin D, ferritin, DNA for genetic testing, immune-profiling), and head hair (nicotine). A major strength of this study is its comprehensive focus covering organism, host and environmental factors. Having closely matched controls enables the examination of a wide range of specific environmental risk factors.

Responsiveness of Oral Health-Related Quality of Life Questionnaires to Dental Caries Interventions: Systematic Review and Meta-Analysis.

This systematic review and meta-analysis were undertaken to assess the responsiveness of validated oral health-related quality of life (OHRQoL) questionnaires to dental caries interventions in children, adolescents, and young adults. Studies eligible were randomized clinical trials (RCTs), controlled clinical trials (CCTs), and prospective case series (PCS), which had OHRQoL questionnaires answered before and after caries intervention(s). The main outcome was improvement in OHRQoL mean scores following caries intervention. Twenty-six studies were selected for the quality assessment and 14 were selected for the meta-analysis. Most of the studies were PCS with a single group pretest and posttest study design (n = 19). Five studies were CCT and only 2 were RCT. The numbers of participants were 3,522 in the control group (baseline = 2,002; final = 1,520) and 5,917 in the test group (baseline = 3,102; final = 2,815). The age of the subjects ranged from 3 to 19 years. All studies showed significant improvement in OHRQoL following caries intervention. Most of nonrandomized studies (n = 15) had low or moderate risk of bias. The meta-analysis showed the effect of caries interventions (standardized weighted mean differences = -1.24; 95% CI: -1.68 to -0.81; p < 0.001). However, high heterogeneity between the studies was found. The Grading of Recommendations Assessment, Development and Evaluation approach classified the quality of evidence as very low and its strength weak. In conclusion, there is evidence that the OHRQoL of children and adolescents improved following caries intervention procedures, but the quality of the evidence was very low. In spite of that, caries interventions are highly recommended as abstaining from treatment is likely to result in a deterioration of OHRQoL.

A Comparison of Three Child OHRQoL Measures.

Comparing oral health-related quality of life (OHRQoL) measures can facilitate selecting the most appropriate one for a particular research question/setting. Three child OHRQoL measures Child Perceptions Questionnaire (CPQ11⁻14), the Child Oral Health Impact Profile (COHIP) and the Caries Impacts and Experiences Questionnaire for Children (CARIES-QC) were used with 335 10- to 13-year-old participants in a supervised tooth-brushing programme in New Zealand. The use of global questions enabled their validity to be examined. Assessments were conducted at baseline and after 12 months. All three measures had acceptable internal consistency reliability. There were moderate, positive correlations among their scores, and all showed differences in the impact of dental caries on OHRQoL, with children with the highest caries experience having the highest scale scores. Effect sizes were used to assess meaningful change. The CPQ11⁻14 and the CARIES-QC showed meaningful change. The COHIP-SF score showed no meaningful change. Among children reporting improved OHRQoL, baseline and follow-up scores differed significantly for the CPQ11⁻14 and CARIES-QC measures, although not for the COHIP-SF. The three scales were broadly similar in their conceptual basis, reliability and validity, but responsiveness of the COHIP-SF was questionable, and the need to compute two different scores for the CARIES-QC meant that its administrative burden was considerably greater than for the other two measures. Replication and use of alternative approaches to measuring meaningful change are suggested.

Personality, xerostomia and OHRQoL among 35-54-year-olds.

OBJECTIVE: Personality characteristics mean that people may interpret similar symptoms differently, complicating the measurement of self-reported oral health, and so we tested the hypothesis that controlling for aspects of personality makes a difference to the association between xerostomia and oral-health-related quality of life. MATERIAL AND METHODS: A cross-sectional study was conducted of a representative adult population sample in Dunedin (New Zealand). Data were collected on xerostomia, OHRQoL and personality characteristics, using (respectively) the 5-item Shortened Xerostomia Inventory (SXI), the OHIP-14 and the Positive and Negative Affect Schedule (PANAS). Negative binomial regression was used to model the association between the SXI and the OHIP-14 scores, and models with and without the PANAS score were compared. RESULTS: The participation rate was 51.3%, with complete OHIP-14 data available for 250 individuals (56.5% female). The SXI score (mean 6.9, sd 1.8) was strongly and positively associated with the OHIP-14 score (in both models), as was the PANAS negative affect score in the second model, which also explained slightly more of the observed variance than the first model. However, the difference in model deviance fell short of the amount required to reject the hypothesis that adding the PANAS variables to the model made a significant difference. CONCLUSIONS: Considering aspects of personality in investigating OHRQoL remains a theoretically important undertaking, but adjusting for it in analyses of associations between xerostomia and OHRQoL is unlikely to be necessary.

A survey of cariology teaching in Australia and New Zealand.

BACKGROUND: The Australian and New Zealand chapter of the Alliance for a Cavity Free Future was launched in 2013 and one of its primary aims was to conduct a survey of the local learning and teaching of cariology in dentistry and oral health therapy programs. METHODS: A questionnaire was developed using the framework of the European Organisation for Caries Research (ORCA)/Association of Dental Education in Europe (ADEE) cariology survey conducted in Europe in 2009. The questionnaire was comprised of multiple choice and open-ended questions exploring many aspects of the cariology teaching. The survey was distributed to the cariology curriculum coordinator of each of the 21 programs across Australia and New Zealand via Survey Monkey in January 2015. Simple analysis of results was carried out with frequencies and average numbers of hours collated and open-ended responses collected and compiled into tables. RESULTS: Seventeen responses from a total of 21 programs had been received including 7 Dentistry and 10 Oral Health programs. Key findings from the survey were - one quarter of respondents indicated that cariology was identified as a specific discipline with their course and 41% had a cariology curriculum in written format. With regard to lesion detection and caries diagnosis, all of the program coordinators who responded indicated that visual/tactile methods and radiographic interpretation were recommended with ICDAS also being used by over half them. Despite all respondents teaching early caries lesion management centred on prevention and remineralisation, many taught operative intervention at an earlier stage of lesion depth than current evidence supports. Findings showed over 40% of respondents still teach operative intervention for lesions confined to enamel. CONCLUSION: Despite modern theoretical concepts of cariology being taught in Australia and New Zealand, they do not appear to be fully translated into clinical teaching at the present time.

Cost-effectiveness of caries-preventive fluoride varnish applications in clinic settings among patients of low, moderate and high risk.

OBJECTIVES: The total body of evidence finds fluoride varnish effective to prevent caries. However, most trials were conducted in high-risk populations, with more recent trials on low-risk groups finding a lower efficacy. We aimed to assess the cost-effectiveness of fluoride varnish application in clinic setting in populations with different caries risk. METHODS: A mixed public-private-payer perspective in the context of German health care was performed using a lifetime Markov model. Effectiveness data were derived from an update of the most recent systematic Cochrane review and synthesized in three different risk groups according to control group caries increment via random-effects meta-analysis. Varnish was assumed to be applied twice yearly between age 6 and 18 years. Teeth with carious defects would be treated restoratively and could experience further follow-up treatments. Costs were deduced from German fee item catalogues. Monte Carlo microsimulations were used for to analyse lifetime treatment costs and caries increment (Euro/Decayed, Missing, Filled Teeth (DMFT)). RESULTS: In low-risk groups, fluoride varnish was nearly twice as costly and minimally more effective (293 Euro, 8.1 DMFT) than no varnish (163 Euro, 8.5 DMFT). The incremental cost-effectiveness ratio (ICER) was 343 Euro spent per avoided DMFT. The ICER was lower in medium-risk (ICER 93 Euro/DMFT) and high-risk groups (8 Euro/DMFT). CONCLUSIONS: Application of fluoride varnish in the clinic setting is unlikely to be cost-effective in low-risk populations. There is the need to either target high-risk groups or to provide fluoride varnish at lower costs, possibly in nonclinic settings.

New Zealand's School Dental Service over the Decades: Its Response to Social, Political, and Economic Influences, and the Effect on Oral Health Inequalities.

New Zealand's School Dental Service (SDS) was founded in 1921, partly as a response to the "appalling" state of children's teeth, but also at a time when social policy became centered on children's health and welfare. Referring to the Commission on Social Determinants of Health (CSDH) conceptual framework, this review reflects upon how SDS policy evolved in response to contemporary constraints, challenges, and opportunities and, in turn, affected oral health. Although the SDS played a crucial role in improving oral health for New Zealanders overall and, in particular, children, challenges in addressing oral health inequalities remain to this day. Supported by New Zealand's Welfare State policies, the SDS expanded over several decades. Economic depression, war, and the "baby boom" affected its growth to some extent but, by 1976, all primary-aged children and most preschoolers were under its care. Despite SDS care, and the introduction of water fluoridation in the 1950s, oral health surveys in the 1970s observed that New Zealand children had heavily-filled teeth, and that adults lost their teeth early. Changes to SDS preventive and restorative practices reduced the average number of fillings per child by the early 1980s, but statistics then revealed substantial inequalities in child oral health, with Ma¯ ori and Pacific Island children faring worse than other children. In the 1990s, New Zealand underwent a series of major structural "reforms," including changes to the health system and a degree of withdrawal of the Welfare State. As a result, children's oral health deteriorated and inequalities not only persisted but also widened. By the beginning of the new millennium, reviews of the SDS noted that, as well as worsening oral health, equipment and facilities were run-down and the workforce was aging. In 2006, the New Zealand Government invested in a "reorientation" of the SDS to a Community Oral Health Service (COHS), focusing on prevention. Ten years on, initial evaluations of the COHS appear to be mostly positive, but oral health inequalities persevere. Innovative strategies at COHS level may improve oral health but inequalities will only be overcome by the implementation of policies that address the wider social determinants of health.

Validity and reliability of the COHIP-SF in Australian children with orofacial cleft.

AIM: To measure the validity and reliability of the Child Oral Health Impact Profile-Short Form (COHIP-SF) in Australian children with orofacial cleft (OFC) and to evaluate the need for a proxy report. DESIGN: Children with OFC and their proxy completed a COHIP-SF questionnaire. Items were divided into oral health, functional and socio-emotional subscales, and scores on all subscales were compared between and within groups. RESULTS: A total of 222 children (average age 11.3, SD = 3.5, range 8.0-14.0) and 215 proxies completed the COHIP-SF, with similar mean scores of 50.8 (SD = 13.7) and 48.1 (SD = 14.0). Excellent internal consistency reliability (Cronbach's alpha 0.9) and convergent validity was evident (P < 0.001); however, discriminant validity was weaker. There was strong correlation between child and proxy reports (Pearson's r = 0.7), and intraclass correlation coefficients were high indicating good child/proxy agreement. Older children had poor socio-emotional well-being (P < 0.004), and children with bilateral cleft lip and palate (CL/P) and velopharyngeal insufficiency/submucous cleft (VPI/SMC) had poor functional well-being. Those with private health insurance reported better oral health-related quality of life (OHRQoL) (P < 0.05). CONCLUSION: The COHIP-SF is a valid and reliable measure for measuring OHRQoL in Australian children with OFC. Proxy reports did not add further information regarding a child's OHRQoL.

Untangling the Web of Influences on Dental Students' Participation in Interprofessional Education Programs.

The aim of this study was to explore how dental students involved in an experiential interprofessional education (IPE) program in New Zealand made sense of engaging in this unfamiliar learning environment. Qualitative data gathered from students during group interviews were analyzed to better understand how they assessed the IPE experience. Interviews were audiorecorded and transcribed before analysis of students' comments was undertaken, using constant comparison analysis and taking an inductive approach to the initial coding. Once each of the investigators had gone through his or her own transcripts, they reviewed each other's coding and agreed-upon categories before applying the 3-P model of student learning. Over a three-year period (2012-14), 16 focus groups were conducted with students from multiple health professions. In total, 24 dental students participated. Six categories of comments made in the focus groups were identified: expectations and realizations; not practicing; trade-offs/losses; learning with, from, and about each other; becoming open to a different clinical experience; valuing dental students' participation in IPE; and learning about what dentists do. From these categories, three main themes emerged: becoming a dentist, negotiating IPE experience, and valuing dentistry. The 3-P model highlighted the complexity of IPE, and the challenges suggested that dental students may need extra preparation prior to participating in IPE programs.

Caries Epidemiology and Community Dentistry: Chances for Future Improvements in Caries Risk Groups. Outcomes of the ORCA Saturday Afternoon Symposium, Greifswald, 2014. Part 1.

This paper reviews the first part of the outcomes of the ORCA Saturday Afternoon Symposium 2014 dealing with 'caries epidemiology and community dentistry: chances for future improvements in caries risk groups'. After the caries decline in many countries, there are remaining pockets of higher caries levels, mostly in the primary dentition and/or linked to a low socio-economic status (SES). The review into the evidence of caries-preventive measures clearly points to the use of fluorides, especially toothbrushing with fluoridated toothpaste and collective measures such as water fluoridation. In contrast to several unsuccessful high-risk approaches, community and public health programmes seem to be able to ensure a population-wide access and compliance in risk groups. Their simple and evidence-based measures mostly combine regular plaque removal and fluoride applications via toothbrushing, at least for children and adolescents. For the future, the common risk factor approach which addresses associations between oral health, social deprivation, diet, hygiene, smoking, alcohol use and stress should lead to combined efforts with other community health and education specialists. Further engagement with public policy, community leaders and administration is needed in order to strengthen healthy choices and behaviour, e.g. in 'healthy' schools and kindergartens. It seems advisable that these population programmes also aim at improving upstream factors.

Telomere length and periodontal attachment loss: a prospective cohort study.

AIM: The aim of the study was to examine the association between telomere erosion and periodontitis in a long-standing prospective cohort study of New Zealand adults. Specific hypotheses tested were as follows: (i) that exposure to periodontitis at ages 26 and 38 was associated with accelerated leucocyte telomere erosion and (ii) that accelerated leucocyte telomere erosion was associated with higher rates of periodontitis by ages 26 and 38. MATERIALS AND METHODS: Periodontal attachment loss data were collected at ages 26 and 38. Blood samples taken at the same ages were analysed to obtain estimates of leucocyte telomere length and erosion over a 12-year period. RESULTS: Overall, the mean telomere length was reduced by 0.15 T/S ratio (adjusted) from age 26 to 38 among the 661 participants reported on here. During the same period, the mean attachment loss increased by 10%, after adjusting for sex, socio-economic status and smoking. Regression models showed that attachment loss did not predict telomere length, and that telomere erosion did not predict attachment loss. CONCLUSIONS: Although both periodontitis and telomere length are age-dependent, they do not appear to be linked, suggesting that determination of leucocyte telomere length may not be a promising clinical approach at this age for identifying people who are at risk for periodontitis.

Measuring the attitudes of dental students towards social accountability following dental education - Qualitative findings.

BACKGROUND: The term social accountability has gained increased interest in medical education, but is relatively unexplored in dentistry. AIMS: The aim of this study is to explore dental students' attitudes towards social accountability. METHODS: A qualitative study utilizing focus groups with University of Otago final year (5th year) Bachelor of Dental Surgery (BDS) students was carried out. A questionnaire designed to measure medical students' attitudes towards social responsibility was used as a guide. Following data collection, framework analysis was used to analyze each of the three focus groups, and repeating themes were noted. RESULTS: Analysis of the focus groups discovered recurring themes, such that participants believed that dentists should be accountable to society in a professional context and that they are responsible for patients who present at their clinic but that there is no professional obligation to help reduce oral health inequalities by working with populations facing inequalities. There was strong agreement that there needs to be change to the dental health care system from a structural and political level to address oral health inequalities, rather than individual dentists assuming greater responsibility. CONCLUSION: Our findings show that dental education may not be accountable to society in the sense that it is not producing graduates who believe that they have an obligation to address the priority oral health concerns of society.

Can the Child Health Utility 9D measure be useful in oral health research?

BACKGROUND: Cost-utility analysis using the quality-adjusted life years (QALY) as an outcome measure to inform healthcare resource allocation is becoming more common. The Child Health Utility 9D (CHU9D) enables the calculation of utility values in children. Children were involved throughout its development to ensure it is child centred. AIM: To determine whether the CHU9D is responsive to the changing components of the dmfs+DMFS index score in children receiving dental care over a 1-year period. DESIGN: The study sample comprised children aged 6 to 9 years old who were enrolled in a split-mouth, placebo-controlled randomised controlled trial. All children had a comprehensive clinical examination including radiographs and health-related quality of life (HRQoL) was measured using the CHU9D at baseline and 1 year. Descriptive statistics was followed by bivariate analyses before effect sizes were calculated. A negative binomial model was fitted to assess whether the utility score predicted the components of decayed and filled teeth (combined primary and permanent teeth). RESULTS: Eighty (92%) children completed the CHU9D at baseline and follow-up. They presented with a mean baseline d3mfs+D3MFS of 6.7 (SD = 7.1), which rose to 7.3 (SD = 7.0) at follow-up. The mean CHU9D score improved from 0.88 to 0.90 from baseline to follow-up. No statistically significant relationships were found between caries status and the CHU9D score. CONCLUSION: The CHU9D was found to be unresponsive to the changing components of dental caries experience.