Predictors of oral healthcare utilization and satisfaction among Indian migrants and the host population in the Netherlands.

BACKGROUND: The aim of this study was to explore predictors associated with reasons for visiting an oral healthcare professional (OHP) and satisfaction with OHPs in the Netherlands among the Indian migrants and the host population. METHODS: A random sample was obtained for this cross-sectional questionnaire study. Variables were classified according to the Andersen Behavioural Model of Health Services Utilization. Multivariable binary logistic regression analysis was conducted to identify significant predictors for reasons for visiting an oral healthcare professional (OHP) (routine checkups and preventive care or visiting only for pain and/or treatment) and satisfaction with OHPs (satisfied or dissatisfied). RESULTS: The sample consisted of 391 participants (Indian migrants = 147 and host population = 244). Indian migrants with higher internal locus of control (LoC) [OR = 7.73 (95% CI: 2.13;27.99)], more trust in OHPs [OR = 4.12 (95% CI:1.68;10.14)] and higher integration level [OR = 1.09 (95% CI:1.03;1.17)] had higher odds of visiting an OHP for routine checkups and preventive care. In the host population, having dental insurance [OR = 2.64 (95% CI:1.00;6.95)] was significantly associated with increased odds of visiting an OHP for routine checkups and preventive care. For satisfaction, Indians with low paid jobs [OR = 16.26 (95% CI:2.83;93.36)] and those with higher integration levels [OR = 1.29 (95% CI:1.16;1.42)] had higher odds of being satisfied with the Dutch OHPs. Among the host population, those with more trust in OHPs [OR = 2.86 (95% CI:1.19;6.88)] had higher odds of being satisfied. CONCLUSION: Our study emphasize that integration levels and trust emerged as two crucial factors, policy makers can leverage upon to improve access to care for Indian migrants. CLINICAL TRIAL: N.A as this is a survey based cross sectional study.

Oral health of Dutch primary school children in relation to social and health aspects.

OBJECTIVE: This research investigated the oral health status of Dutch primary school children aged 10-12 years in Utrecht and its association with demographic characteristics, lifestyle factors, general psychosocial health, and dental treatment, to guide targeted interventions to improve children's oral and overall well-being. MATERIALS AND METHODS: A cross-sectional survey was conducted at 49 primary schools in Utrecht in 2017 and 42 schools in 2019. The questionnaire covered background characteristics (7 questions), psychosocial health (14 questions), nutrition and exercise (20 questions), school and leisure time (26 questions), home situation (23 questions), and oral health (4 questions). Associations were analyzed using multivariate logistic regression. RESULTS: Data from 5,426 children were analyzed. Prior to the survey, 11% did not visit a dentist, 23% had a toothache, 22% had a cavity filled, and 8% had a tooth extracted. Independent predictors for increased odds of oral health problems were migration background, poor general health, drinking more than two glasses of soft drinks per day, having ever drunk alcohol, having fear of failure, experiencing problems at home and/or coming from average or low socioeconomic position group. Factors associated with increased odds of dental treatment, such as cavity filled and tooth extracted, were migration background, fear of failure and home problems. CONCLUSIONS: These findings emphasize the need for targeted prevention to improve the oral health of children with a migration background, average or low socioeconomic position and/or with poorer general and psychosocial health, unhealthy diets and problems in the home situation, within a community-based and transdisciplinary approach.

The role of psychological distress in the relationship of financial strain with oral health and dental attendance in Dutch adults: A mediation analysis based on cross-sectional data.

OBJECTIVES: The study aimed to assess whether psychological distress mediates the association between financial strain and oral health and dental attendance in the Dutch adult population. METHODS: The study followed a cross-sectional design based on 2812 participants from the 2014 wave of the Dutch population-based GLOBE study. Financial strain was considered the exposure, while psychological distress measured with the Mental Health Inventory-5 (MHI-5) was the mediator. The outcomes included self-reported number of teeth, self-rated oral health, and self-reported dental attendance. Generalized regression analyses were used for the mediation analysis adjusted for several covariables. RESULTS: Greater financial strain was significantly associated with poorer self-rated oral health (total effect: 0.09, 95%CI: 0.05; 0.14) and restorative or no dental attendance (i.e. participants never visiting a dentist or only visiting a dentist for regular treatments or when they have complaints with their mouth, teeth, or prosthesis) (total effect: 0.05, 95%CI: 0.02; 0.09). Greater financial strain was not significantly associated with self-reported number of teeth (total effect: -0.14, 95%CI: -0.91; 0.64). Psychological distress significantly mediated the association of financial strain with self-rated oral health (average causal mediation effect [ACME]: 0.02, 95%CI: 0.01; 0.03) and self-reported dental attendance (ACME: 0.01, 95%CI: 0.00; 0.02), respectively. However, it did not significantly mediate the association of financial strain with self-reported number of teeth (ACME: -0.11, 95%CI: -0.25; 0.02). The estimated proportion of the total effect of financial strain on self-rated oral health and self-reported dental attendance that could be explained by psychological distress was respectively 24% (95%CI: 14%; 48%) and 19% (95%CI: 6%; 62%). CONCLUSIONS: Psychological distress partly explains the association of financial strain with self-rated oral health and dental attendance, but not with self-reported number of teeth. Future studies using longitudinal data are necessary to confirm the results.

Association of integration with oral health among Indian migrants living in the Netherlands.

BACKGROUND: Limited data exist about the relationship between acculturation and oral health. Hence, the aim of this study was to assess the association of integration with self-reported oral health, behaviours, and oral healthcare utilization among Indian migrants living in the Netherlands, a cross sectional survey study. METHODS: Between February and April 2021, a random sample from Dutch municipalities was obtained for the Indian migrants living in the Netherlands (n = 147). A validated questionnaire was used to collect information on independent variables, namely socio-demographic, integration assessment tool: Immigration Policy Lab (IPL-12) and everyday discrimination scale (EDS). The outcome variables were self-reported oral health, oral health behaviours, and oral healthcare utilization. Multiple regression analysis was used to assess the associations. RESULTS: Higher integration among Indian migrants was associated with longer stay in the Netherlands, having a Dutch passport, intention to settle in the Netherlands, and having a permanent residence. After adjusting for covariates such as age, gender, marital status, education, income, occupation, and dental insurance, regression analysis showed that Indians with higher integration had lower odds of reporting their oral health as fair to poor [OR = 0.92(95%CI:0.0.85;0.99)] than the Indians with low integration scores. Also, Indians with higher integration had lower odds of using a manual toothbrush as compared to an electric toothbrush or use of both [OR = 0.86(95%CI:0.76;0.97)]. Highly integrated Indians had lower odds of consuming Indian sweets than lower integrated Indians (OR = 0.91; 95%CI:0.86;0.97). Indians with higher integration had 1.15 times (95% CI:1.03;1.29) higher odds of visiting a Dutch dental professional than visiting a dentist in both places (India and the Netherlands). No significant association was found between discrimination and the three outcome variables. CONCLUSION: Integration is positively association with self-reported oral health outcomes among the Indian migrants. Measure to improve integration among Indian migrants may help to promote healthy oral health behaviours and improve their oral health care utilization.

Oral Health Status, Behaviours and Oral Healthcare Utilization among Indian Migrants Compared to the Host Population in the Netherlands: A Descriptive Cross-sectional Study.

The aim of this study was to assess the oral health status, oral health behaviours and oral healthcare utilization among Indian migrants living in the Netherlands and how they compare with the host population. Based on a random sample from Dutch municipalities, cross-sectional data were obtained for the Indian migrants living in the Netherlands (n = 148) and the host population (n = 244). A questionnaire was used to collect information on socio-demographic, self-reported oral health status, oral health behaviours and oral healthcare utilization. The distribution of self-reported oral health variables for both groups were tabulated and compared using logistic, ordinal and multinomial regression analysis. When adjusted for covariates such as age, gender, marital status, education, income, occupation and dental insurance, regression analysis for oral health status showed that the odds of reporting oral impact on daily performances (OIDP) was 5.87 times higher for Indians compared to the host population (95%CI:3.45;9.65). In contrast, the odds of Indians reporting bleeding gums [OR = 0.44 (95%CI:0.27;0.73)] and diagnosed with gum diseases [OR = 0.23(95%CI:0.13;0.39)] were lower than the host population. Also, the odds of consuming alcohol and cakes or chocolates was significantly lower among Indian migrants compared to the host population [(OR = 0.15(95%CI:0.09;0.25)] and [OR = 0.33(95%CI:0.21;0.52)], respectively. But the odds of consuming sugar in hot beverages were significantly higher among Indians [OR = 10.44(95%CI:5.99;18.19)]. The odds of Indians visiting a dental professional were 9.22 times (95%CI:4.62;18.40) lower compared to the host population. We found that oral health status and behaviours among Indian migrants were different in certain aspects compared to the host population. However, their oral healthcare utilization remained overall lower. The underlying determinants for such observations merit further research. Migrant friendly approach from both the dental professionals and policy makers can encourage dental visits and improve the utilization patterns among Indians migrants in the future.

Effectiveness of school-based strategies to prevent tooth decay in Filipino children: A cluster-randomized trial.

OBJECTIVES: Evidence for affordable and pragmatic programmes to address the burden of untreated tooth decay in children in low- and middle-income settings is limited. This study aimed to (1) assess the effect of a government-run, school-based daily group toothbrushing programme compared to standard school-based oral health education on the incidence of dental caries and odontogenic infections in Filipino children over a period of 3 years; and (2) assess the additional preventive effect of on-demand oral urgent treatment (OUT) and weekly fluoride gel application. METHODS: A cluster-randomized trial was conducted in Camiguin, Philippines. Schools in three regions were randomly assigned to one of three intervention groups: The Essential Health Care Programme (EHCP), which includes daily toothbrushing with fluoride toothpaste; EHCP plus twice-yearly access to on-demand urgent oral treatment (EHCP + OUT) and EHCP plus weekly application of high-concentrated fluoride gel (EHCP + Fluoride). Schools in a nearby province with a similar child population were selected as external concurrent control group. Clinical oral examinations were performed by calibrated dentists from a random sample of 682 seven-year-old students who were examined at baseline and over the following 3 years. Outcome variables were the number of decayed primary teeth, the number of decayed, missing and filled permanent teeth (DMFT) and surfaces (DMFS), and the number of permanent teeth with pulpal involvement, ulcerations, fistula or abscess (PUFA). Data were analysed using multilevel mixed-effects negative binomial regression. RESULTS: Three years after implementation, increments in dental caries and odontogenic infections in permanent teeth did not significantly differ between the EHCP and control group, yet the incidence of DMFT was lower by 22% in children receiving EHCP. Compared to controls, children receiving EHCP + Fluoride had a significantly lower increment of DMFT, DMFS and PUFA by 40%, 40% and 47%, respectively. Children receiving EHCP + OUT had lower incidence rates of DMFT and DMFS than control children by 23% and 28%, respectively. A lower incidence rate was also found for PUFA, but the effect was not statistically significant. CONCLUSIONS: Findings suggest that the weekly application of fluoride gel and urgent oral treatment, in addition to daily school-based toothbrushing with fluoride toothpaste, are realistic and effective strategies to lower the burden of dental caries in Filipino children. Implementation challenges may explain why no substantial caries-preventive benefits were demonstrated for school-based toothbrushing only. Intervention compliance should be considered in future programme implementation and evaluation research.

Improving Toilet Usability and Cleanliness in Public Schools in the Philippines Using a Packaged Operation and Maintenance Intervention.

This study evaluated the impact of packaged interventions for operation and maintenance (O&M) on the usability and cleanliness of toilets in public schools in the Philippines. In this cluster-randomized controlled trial, the divisions of Roxas City and Passi City were randomly assigned to the intervention or control group. Schools in Roxas City (n = 14) implemented the packaged O&M interventions; schools in Passi City (n = 16) formed the control group. Outcome variables were toilet usability-defined as accessible, functional and private-and toilet cleanliness, measured using the Sanitation Assessment Tool (SAT) and the Cleaner Toilets, Brighter Future (CTBF) instruments at baseline and at four months follow-up through direct observation of school toilets. SAT results showed that intervention schools had a 32.0% (4.6%; 59.3%) higher percentage of usable toilets than control schools at follow-up after full adjustment (p = 0.024). CTBF results found a similar result, although this was not statistically significant (p = 0.119). The percentage of toilets that were fully clean was 27.1% (3.7%; 50.6%) higher in intervention schools than in control schools after adjustment (p = 0.025). SAT results also showed an improvement in cleanliness of toilets in intervention schools compared to those in controls, but this did not remain significant after adjustment. The findings indicate that the additional implementation of O&M interventions can further stimulate progress towards reaching Water, Sanitation and Hygiene service levels aligned with the Sustainable Development Goals.

Oral Health Status, Oral Health Behaviours and Oral Health Care Utilisation Among Migrants Residing in Europe: A Systematic Review.

As the reported data on oral health status among the migrants in Europe is fragmented, we systematically reviewed the published literature on the oral health status, behaviours and care utilisation among migrants residing in Europe. For this, we retrieved publications from PubMed and EMBASE, supplemented by manual citation screening and grey literature search on Google scholars. Two independent reviewers screened the studies, extracted data and critically appraised the publications. A total of 69 studies included showed higher dental caries among migrant children. But some studies on adolescents and adults reported similar or even better oral health among migrants compared to the host population, while other reported the opposite. Poor oral health behaviours were generally reported among the migrants and they frequently made use of emergency service utilisation compared to the host population. We shed light on the gaps in dental literature and make some recommendations for the future.

Access to oral health care for undocumented migrants: Perspectives of actors involved in a voluntary dental network in the Netherlands.

OBJECTIVE: Undocumented migrants in Europe face multiple barriers in access to oral health care. This study aimed to explore the accessibility of a voluntary dental network providing dental treatments to undocumented migrants in the Netherlands, from the perspectives of patients, dentists and staff members of nongovernmental organizations involved. METHODS: This qualitative study used semi-structured interviews (n = 21) with undocumented migrants (n = 12), dentists (n = 7) and staff members of nongovernmental organizations (n = 2) during the implementation of a voluntary dental network. Interviews were analysed using a framework analysis method. RESULTS: As a temporary answer to problems in access to oral health for undocumented migrants, the voluntary dental network targeted initial barriers to dental care. Main challenges within the network were conflicting expectations and perceived treatment outcomes by patients, dentist and NGO staff members, limited financial resources, logistic and communication barriers and an increasing administrative burden. Furthermore, feelings of compassion for and trust of the patient affected the ethics of the professional relationship and influenced treatment decisions of dentists. CONCLUSION: Through the implementation of a voluntary dental network, treatments could be provided to undocumented migrants as a temporary solution. However, the voluntary nature of dental care in the network resulted in a fragmented provision of oral health care among undocumented migrants. To reduce inequalities in oral health on the long term, systemic barriers in access to oral health care need to be addressed.

Improving Oral Health care Using Academic Detailing-Reproducibility and Scalability of the Added Value for Oral Care Field Studies Approach.

OBJECTIVES: A proof-of-concept study has shown that the Added Value for Oral Care (ADVOCATE) Field Studies approach (academic detailing with feedback data) is considered a feasible, useful, and acceptable way to motivate general dental practitioners (GDPs) to reflect on and, if required, change their oral health-care delivery. The aims of this proof-of-principle study were to test whether such results were reproducible and to reach consensus among stakeholders on recommendations for wider implementation. METHODS: Eleven groups of GDPs were recruited in 6 countries (Denmark, England Germany, Hungary, Ireland, and The Netherlands). Each group had 3 academic detailing meetings, being stimulated by feedback data. Focus group interviews were held to evaluate the reproducibility of the Field Studies approach. A World Café session explored suggestions for the wider implementation of the approach. RESULTS: Replicable results on feasibility, acceptability, and usefulness of the Field Studies approach were seen; 7 out of 9 themes identified in the proof-of-concept study were validated. Directed content analyses identified that adjustments to procedures to collect and present feedback data were desirable. Overall, the approach can stimulate GDPs to reflect on and change aspects of their oral health-care delivery. CONCLUSIONS: The Field Studies approach, after some adjustments to data collection procedures, is ready for further testing in larger studies.

Impact of a school-based water, sanitation and hygiene programme on children's independent handwashing and toothbrushing habits: a cluster-randomised trial.

OBJECTIVES: To explore whether a school-based water, sanitation and hygiene programme, which includes group hygiene activities, contributes to the formation of independent handwashing and toothbrushing habits among Filipino children. METHODS: In this cluster-randomised trial, twenty primary schools were randomly allocated to the intervention or control arm. Intervention schools received group handwashing facilities and implemented daily group handwashing and toothbrushing activities. A soap use to toilet event ratio was calculated to measure children's independent handwashing behaviour after toilet use, and dental plaque accumulation on Monday morning was measured as a proxy indicator for children's independent toothbrushing behaviour at home. RESULTS: Four months after implementation, handwashing and toothbrushing behaviours did not significantly differ between intervention and control schools. The mean soap use in intervention schools and control schools was 0.41 g and 0.30 g per toilet event, respectively (p = 0.637). Compared to baseline, mean plaque scores reduced by 4.2% and 3.5% in intervention and control schools, respectively (p = 0.857). CONCLUSIONS: Although health benefits have been established, school-based group handwashing and toothbrushing may not be sufficient to increase children's uptake of independent hygiene behaviours.

Dutch oral health care quality measures: a modified Delphi study.

OBJECTIVES: Quality measures offer opportunities for evaluation and improvement of the quality of oral health care. This study describes the development of a core set of oral health care quality measures for adults in the Netherlands, which can be used in dental practice. MATERIALS AND METHODS: A comprehensive two-stage approach was used, consisting of: (1) identification of an initial set of measures based on appraised literature; and (2) a four-round modified RAND/UCLA Appropriateness Method to establish measures that are relevant, appropriate and important to oral health care. Measures were rated anonymously on a nine-point Likert scale, ranging from 1 (lowest rating) to 9 (highest rating), followed by a group discussion to reach consensus. Multiple key stakeholder groups in the Dutch oral health care field were involved in the Delphi rounds, including dental professionals, scientists and representatives from Dutch oral health care organisations. RESULTS: The study resulted in a core set of 13 oral health care quality measures. The measures cover domains related to oral disease outcomes, oral treatment and preventive services, patient experiences, patient safety, and organisational aspects of oral health care. In addition, the study led to the identification of 49 structural aspects of oral health care that are important to measure. DISCUSSION: To our knowledge, this is the first study combining appraised literature from a systematic review and a rigorous multi-stage procedure with extensive stakeholder involvement to develop a core set of oral health care quality measures. In the next phase, the measures will be tested on feasibility, reliability, and will be piloted and implemented in practice.

Academic detailing in oral healthcare - results of the ADVOCATE Field Studies.

Background: Academic detailing (AD) is a defined form of educational outreach that can be used to influence decision making and reduce unwarranted variation in healthcare delivery. This paper describes the results of the proof of concept phase of the ADVOCATE Field Studies. This study evaluated the feasibility, acceptability and usefulness of AD reinforced with feedback data, to promote prevention-oriented, patient-centred and evidence-based oral healthcare delivery by general dental practitioners (GDPs).Methods: In the Field Studies, six groups of GDPs (n = 39) were recruited in The Netherlands, Germany and Denmark. Each group had four meetings reinforced with feedback data for open discussions on dental practice and healthcare delivery. Conventional and directed content analysis was used to analyze the qualitative data collected from focus group interviews, debriefing interviews, field notes and evaluation forms.Results: A total of nine themes were identified. Seven themes related to the process of the Field Studies and covered experiences, barriers and facilitators to AD group meetings, data collection and the use of an electronic dashboard for data presentation and storage. Two themes related to the outcomes of the study, describing how GDPs perceived they made changes to their clinical practice as a result of the Field Studies.Conclusions: The ADVOCATE Field Studies approach offers a novel way of collecting and providing feedback to care providers which has the potential to reduce variation oral healthcare delivery. AD plus feedback data is a useful, feasible approach which creates awareness and gives insight into care delivery processes. Some logistic and technical barriers to adoption were identified, which if resolved would further improve the approach and likely increase the acceptability amongst GDPs.

The impact of an operation and management intervention on toilet usability in schools in the Philippines: a cluster randomised controlled trial.

BACKGROUND: Access to usable water, sanitation and hygiene provision in schools is included within indicators in the Sustainable Development Goals. Progress towards these indicators is dependent on developing an understanding of which intervention components are most effective to operate and maintain usable services. This study aimed to determine the impact of a school toilet operation and management intervention in the Philippines on toilet usability and student and teacher satisfaction, adjusted for clustering at school level. METHODS: In a non-blinded cluster randomised controlled trial, we compared improvements in usability and cleanliness of school toilets among those schools receiving a low-cost, replicable intervention. Toilet usability was measured based on Sustainable Development Goal indicators related to school sanitation defined by the UNICEF/WHO Joint Monitoring Programme for Water, Sanitation and Hygiene. Intervention schools received consumables, support kits, and structured tools designed to facilitate operation and maintenance of sanitation facilities. The primary outcome, toilet usability and cleanliness, was compared through a difference-in-difference analysis of toilet usability. Secondary outcomes of student and teacher satisfaction were measured through a survey at endline. All outcomes were adjusted for clustering at school level. RESULTS: 20 eligible schools in the Batangas region of the Philippines were randomly selected and allocated to either control or intervention group. We found that non-classroom toilets were 48% more likely to meet quality benchmarks in intervention schools, but this was not statistically significant. When including in-classroom toilets in the analysis, there were no significant differences in toilet usability - defined as accessible, functional, private and of high quality - between intervention and control schools. When stratified by toilet location, children in the intervention group clusters expressed a minor, but statistically significant increase in overall satisfaction with sanitation facilities (p = 0.035). CONCLUSION: Water, sanitation and hygiene interventions in schools focusing on operation and maintenance showed potential to improve toilet usability, but universal achievement of SDG targets may require additional efforts addressing toilet infrastructure. TRIAL REGISTRATION: ClinicalTrials.gov NCT03204175, June 2017 prior to participant enrolment.

Correction: Perspectives of general dental practitioners on preventive, patient-centred, and evidence-based oral healthcare-A Q-methodology study.

[This corrects the article DOI: 10.1371/journal.pone.0219931.].

Promoting parenting strategies to improve tooth brushing in children: design of a non-randomised cluster-controlled trial.

BACKGROUND: Tooth brushing with fluoride toothpaste is a key recommendation in evidence-based guidelines for caries prevention. Parents generally have sufficient knowledge to practice tooth brushing for their child, yet many experience barriers to actually implement the behaviour. Common barriers are associated with difficult child behaviour, stress, poor family organisation and management of routines. These underlying determinants of tooth brushing behaviour should be addressed in caries-preventive interventions. The 'Uitblinkers' intervention is a semi-structured interview method developed for oral healthcare professionals (OHPs), with the aim to improve the practice of twice daily tooth brushing in children. The interview method focusses on 1) identifying parents' barriers to tooth brushing, and 2) promoting parenting strategies (related to tooth brushing) to tackle the identified barriers. The intervention applies principles from learning theory, including stimulus control, operant conditioning and authoritative parenting. This paper describes a study protocol to evaluate the effect of the intervention. METHODS: This non-randomised cluster-controlled trial will be conducted in 40 general dental practices in The Netherlands. Intervention practices will implement the intervention in addition to care as usual, while control practices will only provide care as usual. From each dental practice, a random sample of 3 to 4-year-old children will be recruited. The intervention consists of three sessions between an OHP and parent, in which parenting strategies for identified barriers are discussed. The primary study outcome is children's dental caries experience after 24 months. Secondary outcomes include parents' self-efficacy in brushing their children's teeth, tooth brushing frequency in children and children's dental plaque scores. Differences in outcomes between the intervention and control group will be assessed using logistic and negative binomial regression. The feasibility of the intervention will be assessed through process evaluation. DISCUSSION: Findings of this study will ascertain whether promoting parenting strategies is a successful method to improve tooth brushing in children and to prevent childhood dental caries in a clinical dental setting. TRIAL REGISTRATION: This trial is registered with the Netherlands National Trial Register (registration date: 7 September 2018; trial registration number: NTR7469 ).

Perspectives of general dental practitioners on preventive, patient-centred, and evidence-based oral healthcare-A Q-methodology study.

OBJECTIVE: In the last 30 years, innovations in oral healthcare (OHC), such as advanced restorative techniques, shifts towards preventive and evidence-based care and changes in patients' expectations, have increased the complexity of clinical decision-making in OHC. Little is known about the perspectives of general dental practitioners (GDPs) on the value of providing preventive, patient-centred and evidence-based OHC. This study aimed to explore the range of perspectives present amongst GDPs on OHC. METHOD: Q-methodology was used to explore perspectives among 78 GDPs working in the Netherlands. Participants were asked to sort 50 statements representing three central domains in OHC: i.) restorative versus preventative OHC, ii.) disease-centred versus patient-centred OHC and iii.) expertise-based versus evidence-based OHC. Opinion statements about delivering OHC were formulated on the basis of published literature and input from OHC professionals. By-person factor analysis was used to reveal clusters of communality in statement rankings, which were interpreted and formed perspectives on OHC. RESULTS: Four perspectives, explaining 47% of variance, on OHC were identified amongst GDPs: 'the patient-focused dentist who values prevention', 'the outcome-oriented dentist who values learning from colleagues', 'the team player with ultimate care responsibility' and 'the dentist who considers oral health the responsibility of the patient.' CONCLUSION: Q-methodology can be effectively used to describe the different perspectives that GDPs have on the challenges of preventive, patient-centred and evidence-based OHC. GDPs should not be seen as a homogenous group; rather they have different views and approaches to the care they provide. This has implications for health systems; awareness of the heterogeneity of practitioners' perspectives can potentially be used to develop bespoke quality of care improvement strategies that constructively engage with each of these different groups.

Quality measures for dental care: A systematic review.

OBJECTIVES: This systematic review aimed to (a) provide an overview of existing quality measures in the field of oral health care, and to (b) evaluate the scientific soundness and applicability of these quality measures. METHODS: A systematic search was conducted in three electronic databases MEDLINE (via PubMed), EMBASE (via OVID) and LILACS (via BIREME). The search was restricted to articles published between 2002 and 2018. Publications reporting on the development process or clinimetric properties of oral health care quality measures for outpatient oral health care in dental practices were included. The identified publications reporting on oral health care quality measures were critically appraised with the Appraisal of Indicators through Research and Evaluation 2.0 (AIRE 2.0) instrument to evaluate the soundness and applicability of the measures. RESULTS: The search strategy resulted in 2541 unique and potentially relevant articles. In total, 24 publications were included yielding 215 quality measures. The critical appraisal showed a large variation in the quality of the included publications (AIRE scores ranging from 38 to 78 out of 80 possible points). The majority of measures (n = 71) referred to treatment and preventive services. Comparably, few measures referred to the domain patient safety (n = 3). The development process of measures often exhibited a lack of involvement of patients and dental professionals. Few projects reported on the validity (n = 2) and reliability (n = 3) of the measures. Four projects piloted the measures for implementation in practice. CONCLUSIONS: This systematic review provides an overview of the status quo with respect to existing quality measures in oral health care. Potential opportunities include the piloting and testing of quality measures and the establishment of suitable information systems that allow the provision of transparent routine feedback on the quality of oral health care.

Nutritional status, dental caries and tooth eruption in children: a longitudinal study in Cambodia, Indonesia and Lao PDR.

BACKGROUND: Untreated dental caries is reported to affect children's nutritional status and growth, yet evidence on this relationship is conflicting. The aim of this study was to assess the association between dental caries in both the primary and permanent dentition and nutritional status (including underweight, normal weight, overweight and stunting) in children from Cambodia, Indonesia and Lao PDR over a period of 2 years. A second objective was to assess whether nutritional status affects the eruption of permanent teeth. METHODS: Data were used from the Fit for School - Health Outcome Study: a cohort study with a follow-up period of 2 years, consisting of children from 82 elementary schools in Cambodia, Indonesia and Lao PDR. From each school, a random sample of six to seven-year-old children was selected. Dental caries and odontogenic infections were assessed using the World Health Organization (WHO) criteria and the pufa-index. Weight and height measurements were converted to BMI-for-age and height-for-age z-scores and categorized into weight status and stunting following WHO standardised procedures. Cross-sectional and longitudinal associations were analysed using the Kruskal Wallis test, Mann Whitney U-test and multivariate logistic and linear regression. RESULTS: Data of 1499 children (mean age at baseline = 6.7 years) were analyzed. Levels of dental caries and odontogenic infections in the primary dentition were significantly highest in underweight children, as well as in stunted children, and lowest in overweight children. Dental caries in six to seven-year old children was also significantly associated with increased odds of being underweight and stunted 2 years later. These associations were not consistently found for dental caries and odontogenic infections in the permanent dentition. Underweight and stunting was significantly associated with a lower number of erupted permanent teeth in children at the age of six to seven-years-old and 2 years later. CONCLUSIONS: Underweight and stunted growth are associated with untreated dental caries and a delayed eruption of permanent teeth in children from Cambodia, Indonesia and Lao PDR. Findings suggest that oral health may play an important role in children's growth and general development. TRIAL REGISTRATION: The study was restrospectively registered with the German Clinical Trials Register, University of Freiburg (trial registration number: DRKS00004485 ; date of registration: 26th of February, 2013).