An empirically derived population-response model of the short form of the Oral Health Impact Profile.

OBJECTIVE: The aim of this paper was to model the consequences of dental conditions from an empirical basis and to test the model's ability to predict response combinations. METHODS: The model was derived from responses to the short-form Oral Health Impact Profile (OHIP14) obtained from a UK population sample of 5281 dentate adults. This model was then used to predict OHIP14 response combinations obtained from a sample of 3973 dentate and edentulous adults in Australia. FINDINGS: The empirically derived population-response model accounted for over 98% of response combinations of Australian dentate adults. CONCLUSIONS: The empirically derived model followed a similar hierarchical pattern to the base model underlying the long-form version of the measure (thereby supporting the validity of the OHIP14 measure) and was strongly predictive of the pattern of responses obtained from Australian adults.

The reported impact of oral condition on children in the United Kingdom, 2003.

BACKGROUND: The 2003 Children's Dental Health Survey is the fourth in a series of decennial national children's dental health surveys of the United Kingdom. AIMS: This paper is concerned with how children are reported to have been affected by their oral condition during the 12 month period immediately preceding the survey and how this relates to the children's experience of caries, their dental attendance behaviour and their social class. METHOD: The information was gathered by self-completion questionnaire distributed to the parents of half of the sample who were clinically examined in the dental survey. RESULTS: Some form of impact was reported by the parents of 22% of five-year-olds, 26% of eight-year-olds, 34% of 12-year-olds and 28% of 15-year-olds. The pattern of responses to the eight impact questions was broadly similar across age groups. The most frequently reported type of impact was pain in all age groups. Impacts on oral function, self-confidence, orally related activity and on the child's emotions were experienced by 4-10% of children of all ages. Fewer children (1-2%) were reported to have experienced more far reaching impacts affecting their social functioning, general health and life overall. CONCLUSIONS: Most children were reported not to have experienced any of the problems covered by the questionnaire. Of those who did, most reported a single problem and for most this was pain. Nevertheless there was a group of children for whom oral function, self-confidence, orally related activity, emotions, social functioning, their health or their life in general were reported to have been affected by their oral condition. The nature of dental care which is appropriate for such children needs to be determined.

Patterns of care and service use amongst children in the UK 2003.

BACKGROUND: The 2003 Children's Dental Health Survey is the fourth of the 10-yearly surveys of children's oral health in the United Kingdom. AIM: To detail the reported experience of dental services and dental treatment amongst children in the UK. METHOD: A self-completion questionnaire was distributed to a 50% sub-sample of parents or carers of the children who were clinically examined in the 2003 UK Child Dental Health Survey. This included questions relating to parental and child experience of dental services and dental treatment. RESULTS: The proportion of UK five-year-olds reported as not having visited the dentist fell from 14% in 1983 to 6% in 2003 and the proportion reported as having visited the dentist before the age of two rose from 7% in 1983 to 31% in 2003. Over 80% of all children were reported to seek regular dental check-ups. Around 10% were reported to have had some difficulty in accessing NHS dental care while 5% of five-year-olds were reported to have experienced a general anaesthetic for dental procedures in 2003. Dental attendance was associated with social class and mothers' reported attendance patterns. CONCLUSIONS: In line with previously reported trends, the 2003 survey of children in the United Kingdom shows improvements in several areas but some aspects of attendance pattern continue to be associated with social class and mothers' attendance pattern. It is of concern that 10% of five-year-olds reported having experienced extractions and 5% general anaesthesia for dental treatment.

Oral health habits amongst children in the United Kingdom in 2003.

BACKGROUND: The 2003 Children's Dental Health Survey is the fourth in a series of decennial national children's dental health surveys. AIMS: This paper presents data on parental attitudes towards the care of children's teeth and gums, reported oral hygiene behaviours and clinical measures of hygiene and periodontal health in 2003 and highlights trends since previous surveys. METHOD: A total of 10,381 children were examined in schools by trained and calibrated examiners. Four measures of hygiene and periodontal health were recorded as part of the clinical examination. In addition, 3,342 questionnaires were completed by parents of a sub-sample of these children. The questionnaire enabled information to be collected about reported oral health behaviours and parental attitudes. RESULTS: About three quarters of children across all age groups are reported to brush their teeth twice daily. A range of oral health products was reported as being used in addition to toothbrushes and toothpaste. There is a trend in parental preferences towards restoration of teeth rather than extractions and towards a better understanding of dental caries prevention. Although overall a higher proportion of children in this survey appeared to have gingival inflammation, plaque and calculus than 10 and 20 years ago, there was no change in the proportion of older children with gingivitis. CONCLUSIONS: Dental practitioners have a role to play in reinforcing these positive attitudes and encouraging appropriate and effective oral hygiene behaviours in their child patients.

The orthodontic condition of children in the United Kingdom, 2003.

BACKGROUND: The 2003 Children's Dental Health Survey is the fourth in a series of decennial national children's dental health surveys in the United Kingdom. AIMS: This paper reports on the orthodontic condition of children aged 12 and 15 years. METHODOLOGY: A representative sample of children across the UK were invited to participate in a clinical dental examination in school. Two thousand, five hundred and ninety-five 12-year-olds and 2,142 15-year-olds were examined. Current and past orthodontic treatment and type of appliance worn were recorded. Orthodontic treatment need was assessed by the Modified IOTN in those not undergoing treatment. A postal questionnaire sought parents' views on the orthodontic condition of their children and perceived need for treatment. RESULTS: At age 12, 35% were judged to have an orthodontic treatment need, 57% had no need and 8% were wearing an appliance. The corresponding figures at age 15 were, 21% (need), 65% (no need) and 14% (wearing appliance). A higher proportion of girls (p < 0.05) were wearing an appliance than boys. A greater proportion of 15-year-olds were undergoing treatment than in the 1993 and 1983 surveys and the use of fixed appliances had increased. CONCLUSIONS: In this representative sample of UK children, one in five were still judged as having an orthodontic treatment need at age 15 years, as determined by the modified index of orthodontic treatment need. However, considerable variation was observed between professional and lay perceptions of need.

Initial development of a scale to measure dental indifference.

Lack of concern about dental health contributes significantly to the reluctance of people to attend for dental check-ups and to implement preventive dental measures. The aim of this study was to develop and assess a questionnaire method of detecting this attitude which was described as dental indifference. The questionnaire was tested on 910 dentate adults in Scotland. A 62% response rate was obtained. Five hundred of the respondents were then sent a second copy of the questionnaire to assess its reliability, a 67% response rate was obtained. The Pearson correlation coefficient between the first and second completion of the dental indifference questionnaire was 0.79. The internal consistency measured by Chronbach's alpha was 0.71. High scores on the dental indifference questionnaire were significantly associated with being young, male and a manual worker. High scores had fewer teeth, on average, than the rest of the sample and more than half of them had no record of attending for dental care within 4 years. Those who did attend a dentist were more likely to have teeth filled or extracted. The dental indifference questionnaire may be useful for targeting groups who require oral health promotion activity and may prove to be a reliable means of identifying individuals who display behaviours which could be expected to be associated with a lack of interest in dental health, such as lack compliance with oral care instructions and failing to complete course of treatment.

Capability of a national epidemiological survey to predict general dental service treatment.

The aim of this investigation was to examine the relationship between the dental status of tooth surfaces, as recorded during the 1978 Adult Dental Health Survey, and the treatment dental attenders subsequently received. A year after the survey, almost twice as many surfaces had been filled than were predicted on the basis of the survey. After 3 yr, this had risen to a 3.5-fold difference. Despite this, 59% of the restorative need identified by the survey criteria remained unmet by the end of the 1st yr; 46% was unmet by the end of the 3rd yr. A surface that received a filling for the first time was three times more likely to have been identified as in need of filling during the survey than a surface which was refilled. These findings cast doubt upon the usefulness of the epidemiological survey as a tool for predicting restorative treatment, and show that maintenance of previous fillings was particularly poorly forecast by the survey data.

Characteristics of dentally successful and dentally unsuccessful adults.

A method is described for identifying two groups of people from a dentate sample according to the prognosis for their retaining their dentition. Dentally successful people were expected to retain teeth into old age. Dentally unsuccessful people were expected to lose all their teeth prematurely. The method appeared valid, as more of the dentally unsuccessful had teeth extracted at the course of treatment immediately prior to a dental survey than dentally successful adults. Furthermore, this trend was also observed in the 3 yr after the survey. A restoratively orientated dental service was unable to satisfactorily meet the treatment and psychological needs of many of the dentally unsuccessful.

Relationship between dentists' treatment attitudes and restorative decisions made on the basis of simulated bitewing radiographs.

The implicit valuations which dentists place on the outcomes of their treatment decisions may be a major contributory factor in dentists' decisions about when to restore teeth. This study sought to examine the relationship between dentists' treatment attitudes and restorative dental treatment decision making. A group of 20 dentists were asked to indicate teeth in need of filling from 15 simulated bitewing radiographs. The dentists graded their level of certainty about their treatment decision as "definite", "probable" or "possible". Afterwards, the teeth were sectioned and examined using a microscope in order to determine how far through the tooth the caries had penetrated. The gold standard treatment criterion was that caries extending into the dentine of the tooth would require restoration. Receiver Operator Characteristic (ROC) analysis was used to examine the apparent weighting the dentists were giving to decision errors when planning treatment on the basis of bitewing radiographs. The dentists also completed a treatment attitudes questionnaire to determine their views about the relative importance of false negative and false positive treatment decisions. The results suggest that the most appropriate operating point for most of these dentists to achieve an outcome which matched their views about the relative importance of the two types of treatment error would be the point at which a filling would "definitely" be required.

Assessment of reports by dentists of their restorative treatment thresholds.

Questionnaires have been used to determine the point when dentists think a filling ought to be placed (restorative treatment threshold). This study assesses the method. 211 general dental practitioners were interviewed and asked to identify the point at which they would instigate restorative treatment in a 12-yr-old patient from a list of descriptions of lesions affecting buccal/lingual, occlusal and approximal surfaces. They were also asked to judge the likely depth and lateral spread of the lesion they chose and to identify a photograph resembling it (buccal/lingual and occlusal surfaces) or a line drawing and description of its expected surface appearance (approximal surfaces). The Pearson correlation coefficients between reported treatment threshold and the characteristics expected to be associated with them were poor. This suggests that there may be considerable variation in opinion between dentists about the underlying condition of carious lesions of similar surface appearance. There was no evidence that the treatment opinions of these dentists have changed markedly between 1987 and early 1991.

Restorative treatment thresholds and agreement in treatment decision-making.

It has been recognised for many years that treatment decision-making among dentists often shows wide variation. This study sought to examine the effect of dentists' stated treatment thresholds as a source of variation between them. Twenty dentists made 360 treatment decisions about the approximal surface of extracted teeth seen in simulated bitewing radiographs. They also stated their personal treatment thresholds, i.e. the depth of lesion which they intended to restore. One hundred and ninety pairwise comparisons of treatment decisions showed that only 16% of the dentist pairs showed substantial agreement. Dentist pairs who reported that they held the same interventive threshold achieved exactly the same mean level of agreement in treatment decision-making as dentist pairs who disagreed about the appropriate threshold for restorative intervention. The study suggests that restorative thresholds which are reported to be used by dentists may be poorly correlated with the number of positive treatment decisions actually made.

Dental health services research in Scotland: a review of some 5-year results.

A longitudinal study of dental treatment carried out by the Dental Health Services Research Unit in Dundee has provided a unique opportunity to investigate a variety of aspects of dental care received by a sample of dentate individuals over 5 yr. The distribution of treatment indicated that frequent attenders, especially those who changed dentist, were particularly prone to having teeth filled and that two-thirds of the restorative cost was spent on restoring tooth surfaces that had previously been filled. A quarter of the sample had severe periodontal disease and they tended to visit a dentist less frequently than those with mild periodontal disease. They were also more likely to have teeth extracted but less likely to have a scaling or other periodontal treatment than the moderately diseased. The findings suggest that there is considerable scope for a less treatment-orientated approach to the management of dental caries for those who currently receive most of the restorative treatment. The majority of the population who receive little dental care, especially those with severe periodontal disease, would probably gain by visiting a dentist more frequently. Dentists need to acquire a more positive attitude towards prevention and an increased ability to make intellectually based decisions not to treat.

A proposed method for assessing the quality of sealants--the CCC Sealant Evaluation System.

OBJECTIVES: The aim of this paper is to introduce the C (colour) C (coverage) C (caries) Sealant Evaluation System and to present results of its use on a sample of adolescent patients in Scotland. METHODS: Baseline data are presented from a 3-year prospective study in general dental practices across Scotland. Subjects were examined under standardised conditions by one trained and calibrated examiner. RESULTS: 78.6% of the subjects had one or more sealed teeth, over half of these sealants being judged inadequate. There was a low prevalence of dentine caries associated with the sealed teeth (2.8%). The CCC sealant Evaluation System proved practical as demonstrated by its use during the project and had substantial intra-examiner reproducibility. CONCLUSIONS: There was a high level of sealant provision; however, this provision may not be optimal in terms of both targeting of provision and sealant maintenance. The CCC sealant Evaluation System appeared to be a useful assessment tool for assessing sealed surfaces.

Effect of diagnostic threshold on the validity and reliability of epidemiological caries diagnosis using the Dundee Selectable Threshold Method for caries diagnosis (DSTM).

OBJECTIVES: To develop a method for recording dental caries at the D1 (enamel and dentine) diagnostic threshold (without loss of D3 information) and assess its reliability, 'benchmark' validity and potential effects on reported caries prevalence and needs assessment. METHODS: Multi-examiner training, calibration and validation trial. Two groups of 10 dental examiners were trained to diagnose dental caries at the D1 (enamel and dentine) diagnostic threshold under the conditions of a caries prevalence survey, prior to a calibration trial being undertaken. RESULTS: Where 'experienced examiners' were trained to examine at the D1 (enamel and dentine) diagnostic threshold, under the conditions of a cross-sectional epidemiological survey, there was no significant deterioration in inter-examiner agreement on the assessment of teeth and a significant difference in one of two comparisons on the assessment of surfaces using the kappa statistic. Assessed against a benchmark examiner, there was no significant loss of sensitivity at the D1 diagnostic threshold compared with the D3 threshold and, although there was a significant loss of specificity at the D1 threshold, all specificity values could be considered to be high. CONCLUSIONS: Modifying the diagnostic criteria typically used in surveys of caries prevalence (to allow assessment of the levels of enamel caries which could benefit from preventive care as well as dentinal caries requiring restorative care) in adolescents does not adversely affect the reliability or benchmark validity of experienced examiners to a significant degree.

In vitro validity of the Dundee Selectable Threshold Method for caries diagnosis (DSTM).

OBJECTIVES: It is not generally possible to assess diagnostic accuracy in dental surveys as no histological 'gold standards' are available, therefore examiner agreement tends to be used as a proxy for accuracy. The aim of this study was to investigate, using extracted teeth in arch models, the in vitro validity of a diagnostic system to assess caries at the D1 (enamel and dentine) and D3 (dentine) diagnostic thresholds, for epidemiological purposes. METHOD: Two groups of 10 dental examiners trained in the use of the Dundee Selectable Threshold Method for caries diagnosis (DSTM) each examined (on two occasions) 160 extracted permanent molar and premolar teeth set in arch models in phantom heads according to the codes and criteria of the DSTM. The teeth were subsequently radiographed and sectioned to provide validation of the diagnoses. RESULTS: Intra-examiner agreement according to the kappa statistic was substantial. In general terms the results of the in vitro validation exercise demonstrated significantly higher sensitivity values at the D1 diagnostic threshold than were found at the D3 diagnostic threshold with a consequent loss of specificity. CONCLUSIONS: The results of this in vitro validation exercise demonstrate that at the D1 diagnostic threshold the sensitivity of the DSTM was greater than at the D3 threshold indicating no loss of diagnostic accuracy at the D1 threshold.

Knowledge of the human immunodeficiency virus among final year dental students.

A sound basis of knowledge about HIV infection and AIDS is essential to allow students to develop as dentists who undertake appropriate measures during clinical practice. In addition, it is also likely that possessing appropriate information may instil confidence in their own ability to diagnose and then manage patients infected by HIV. A questionnaire designed to test the knowledge of final year dental students in the UK was completed by 60.5% of students in 15 out of the 16 dental schools in the UK. Generally, the students rated the teaching they had received about cross-infection precautions, virology, sterilization practice and procedures and recognition of blood-borne virus risk groups as adequate or more than adequate. However, there was a lower degree of satisfaction expressed for instruction in the management of blood-borne virus carriers and the performance of barrier dentistry. Most dental students were aware of the association of hairy leukoplakia, oral Kaposi's sarcoma, oral candidiasis as a whole, and thrush as one clinical variant, with HIV infection but there was a much lower level of knowledge of erythematous candidiasis, HIV-associated salivary gland disease, oral melanotic hyperpigmentation and idiopathic thrombocytopenic purpura. This study highlights some important gaps in the knowledge of final year dental students about HIV and AIDS.

Final year dental students' views on cross-infection precautions.

This study was undertaken to determine the influence that undergraduate training currently has on the formation of clinical management strategies for minimizing cross-infection, among final year dental students. A 10-page questionnaire was sent to final year dental students attending 15 of the UK's 16 dental schools. A response rate of 60.5% was obtained. A large proportion of the students said they would be prepared to treat a known HBV carrier (90.4%) or HIV carrier (84.3%); a much higher proportion than has previously been found among qualified dental personnel. However, only 55.6% of the students agreed with current recommendations that they ought to adopt a universal cross-infection policy. Nevertheless, most students agreed with recommendations that they ought to wear gloves (96.6%), eye protection (84.3%) and a surgical mask (62.6%). Disparity between some responses suggested that some final year dental students might not have a fully thought out cross-infection strategy.

Assessing dental patients for their risk of being carriers of a blood-borne virus: the views of final year dental students.

A questionnaire was sent to final year dental students in all but one of the dental schools in the UK in 1991. The response was 447 out of 739 (60.5%). The students were asked about how they intended to approach various aspects of patient care once they were qualified and in practice. Almost half (44%) said they would use a cross-infection policy in which precautions would be stepped up for 'risky' patients. This study was undertaken to determine what they think are factors which might identify a patient who is infected, or at risk of being infected, by either hepatitis B virus or the human immunodeficiency virus. Those who said they would take personal histories to determine a patient's risk (30%) seemed prepared to ask about experiences which have relatively low predictive value for infection (e.g. blood transfusions), yet are reluctant to ask more pertinent questions, i.e. those concerning sexual activity. Those who would attempt to assess patients' risk status without asking 'intrusive questions' (14%) seem to have differing views about what sort of observable factors would be useful in framing such an assessment.

General dental practitioners diagnostic and treatment decisions related to fissure sealed surfaces.

OBJECTIVES: The purpose of this in-vitro study was to assess the validity and reproducibility of the diagnosis and treatment planned for occlusal surfaces prior to and following the placement of a clear sealant by a sample of general dental practitioners (GDPs). METHODS: 160 permanent posterior teeth were examined by 25 GDPs. The GDPs were not given any criteria and were therefore free to diagnose and plan care, as they felt appropriate. Each GDP conducted four examinations, two prior to and two after sealing. The teeth were serially sectioned to provide the validating criterion. RESULTS: After sealant placement, there was a statistically significant increase in specificity and decrease in sensitivity of both diagnostic and treatment decisions. The reproducibility expressed by the kappa-statistic was of the order of 0.5 prior to and after sealing with regard to diagnostic decisions. There was a general tendency to diagnose less disease after placement of a sealant (P<0. 001). There was also significantly less care (preventive or restorative) planned after sealant placement (P<0.001). CONCLUSIONS: The placement of a sealant resulted in the diagnosis of less disease and less restorative treatment. This may be appropriate as evidence exists to support the use of sealants as caries therapeutic agents.

An example of the application of Markov models in dentistry--a prediction of the fate of molar teeth in 12-year-old Scottish children.

Markov analysis is a mathematical modelling technique which is particularly useful for predicting prognoses and probabilities of chronic diseases within populations. This paper applies Markov analysis to data concerning the condition of upper left permanent first molars in a group of individuals who were surveyed at age 12 and 15 years in Scotland by the Office of Population Censuses and Surveys. The Markov analysis predicted that in 1998, when the group of individuals would be 27 years old, 3.6 per cent of upper left first permanent molar teeth would be sound, 2.6 per cent would be decayed, 58.4 per cent would be filled and 35.4 per cent would be missing. A comparison of the Markov prediction for 18 year-olds in Scotland in 1989 with United Kingdom data for 16-24 year-olds published in 1988 indicated that the observed health status of the teeth was considerably better than that predicted by the Markov technique. The applicability of the Markov method to tooth status may therefore lie less in its ability to predict events as in being able to provide 'baselines' for future dental states in particular groups. Such an application of the Markov method could be used to determine whether dental deterioration among a group is occurring at a faster or slower rate than in the past.