Longitudinal assessment of undergraduate dental students: Building evidence for validity.

PURPOSE: To investigate the content and criterion validity, and reliability of longitudinal clinical assessment of undergraduate dental student clinical competence by determining patterns of clinical performance and comparing them with validated standalone undergraduate examinations. METHODS: Group-based trajectory models tracking students' clinical performance over time were produced from LIFTUPP© data for three dental student cohorts (2017-19; n = 235) using threshold models based on the Bayesian information criterion. Content validity was investigated using LIFTUPP© performance indicator 4 as the threshold for competence. Criterion validity was investigated using performance indicator 5 to create distinct trajectories of performance before linking and cross-tabulating trajectory group memberships with a 'top 20%' performance in the final Bachelor of Dental Surgery (BDS) examinations. Reliability was calculated using Cronbach's alpha. RESULTS: Threshold 4 models showed all students followed a single upward trajectory in all three cohorts, showing clear progression in competence over three clinical BDS years. A threshold 5 model produced two distinct trajectories, and in each cohort a 'better performing' trajectory was identified. Students allocated to the 'better performing' trajectories scored higher on average in the final examinations for cohort 2 (29% vs 18% (BDS4); 33% vs. 15% (BDS5)) and cohort 3 (19% vs. 16% (BDS4); 21% vs. 16% (BDS5)). Reliability for the undergraduate examinations was high for all three cohorts (≥0.8815) and did not change appreciably when longitudinal assessment was included. CONCLUSIONS: There is some evidence to support that longitudinal data have a degree of content and criterion validity for assessing the development of clinical competence in undergraduate dental students, which should increase confidence in decisions based on these data. The findings also provide a good foundation for subsequent research.

Selective Caries Removal in Permanent Teeth (SCRiPT) for the treatment of deep carious lesions: a randomised controlled clinical trial in primary care.

BACKGROUND: Dental caries is one of the most prevalent non-communicable disease globally and can have serious health sequelae impacting negatively on quality of life. In the UK most adults experience dental caries during their lifetime and the 2009 Adult Dental Health Survey reported that 85% of adults have at least one dental restoration. Conservative removal of tooth tissue for both primary and secondary caries reduces the risk of failure due to tooth-restoration, complex fracture as well as remaining tooth surfaces being less vulnerable to further caries. However, despite its prevalence there is no consensus on how much caries to remove prior to placing a restoration to achieve optimal outcomes. Evidence for selective compared to complete or near-complete caries removal suggests there may be benefits for selective removal in sustaining tooth vitality, therefore avoiding abscess formation and pain, so eliminating the need for more complex and costly treatment or eventual tooth loss. However, the evidence is of low scientific quality and mainly gleaned from studies in primary teeth. METHOD: This is a pragmatic, multi-centre, two-arm patient randomised controlled clinical trial including an internal pilot set in primary dental care in Scotland and England. Dental health professionals will recruit 623 participants over 12-years of age with deep carious lesions in their permanent posterior teeth. Participants will have a single tooth randomised to either the selective caries removal or complete caries removal treatment arm. Baseline measures and outcome data (during the 3-year follow-up period) will be assessed through clinical examination, patient questionnaires and NHS databases. A mixed-method process evaluation will complement the clinical and economic outcome evaluation and examine implementation, mechanisms of impact and context. The primary outcome at three years is sustained tooth vitality. The primary economic outcome is net benefit modelled over a lifetime horizon. Clinical secondary outcomes include pulp exposure, progession of caries, restoration failure; as well as patient-centred and economic outcomes. DISCUSSION: SCRiPT will provide evidence for the most clinically effective and cost-beneficial approach to managing deep carious lesions in permanent posterior teeth in primary care. This will support general dental practitioners, patients and policy makers in decision making. Trial Registration Trial registry: ISRCTN. TRIAL REGISTRATION NUMBER: ISRCTN76503940. Date of Registration: 30.10.2019. URL of trial registry record: https://www.isrctn.com/ISRCTN76503940?q=ISRCTN76503940%20&filters=&sort=&offset=1&totalResults=1&page=1&pageSize=10&searchType=basic-search .

The systemic inflammatory response following hand instrumentation versus ultrasonic instrumentation-A randomized controlled trial.

OBJECTIVE: This study sought to investigate whether the immediate systemic inflammatory response following full-mouth debridement differs following use of hand compared with ultrasonic instruments. METHODS: Thirty-nine periodontitis patients were randomized to treatment with full-mouth debridement using either hand or ultrasonic instrumentation completed within 24 hr. Serum and periodontal clinical parameters were collected at baseline, day 1, day 7 and day 90 post-treatment. Differences in systemic inflammatory markers were assessed using general linear models at each timepoint, corrected for age, gender, smoking status, body mass index and baseline levels of each marker. RESULTS: Across all patients, serum C-reactive protein increased at day 1, with no differences between hand and ultrasonic groups (p(adjusted) = .22). There was no difference between groups in interleukin-6 (p(adjusted) = .29) or tumour necrosis factor α (p(adjusted) = .53) at day 1. Inflammatory markers returned to baseline levels by day 7. Treatment resulted in equal and marked improvements in clinical parameters in both groups; however, total treatment time was on average shorter for ultrasonic instruments (p(adjusted) = .002). CONCLUSIONS: Ultrasonic instrumentation resulted in shorter treatment time with comparable clinical outcomes. Levels of serum C-reactive protein at day 1 were similar following debridement with hand or ultrasonic instruments.

The effectiveness of Dental Health Support Workers at linking families with primary care dental practices: a population-wide data linkage cohort study.

BACKGROUND: Link workers (lay health workers, health support workers) based in the community provide additional support to individuals and families to facilitate engagement with primary care and other services and resources. This additional support aims to tackle the wider socio-economic determinants of health that lead to inequalities. To date, there is no clear evidence of the effectiveness of these programmes. This study evaluates the effectiveness of Dental Health Support Workers (DHSW) at linking targeted families with young children to primary care dental practices. The DHSW role is one component of Childsmile, the national oral health improvement programme in Scotland. METHODS: A quasi-experimental approach captured the natural variation in the rollout of the DHSW intervention across Scotland in a cohort of children born between 2010 and 2013. Survival analysis explored "time to attendance" at primary care dental practice. Cox's regression models compared attendance rates and time until first attendance between those families who received support from the DHSW and those who did not. RESULTS: The cohort consisted of 35236 children. Thirty-three percent of the cohort (n = 11495) were considered to require additional support from a DHSW. Of these, 44% (5087) received that support. These families were more likely to attend a dental practice (Hazard Ratio [95% Confidence Interval] =1.87 [1.8 to 1.9]) and, on average, did so 9 months earlier (median time until first attendance: 8.8 months versus 17.8 months), compared to families not receiving additional support. CONCLUSIONS: Link workers (DHSW) within the Childsmile programme are effective at linking targeted children to primary care dental services and, most notably, at a younger age for prevention. This is the first study of its kind to evaluate the effectiveness of link-worker programmes using a robust quasi-experimental design on three, population-wide, linked datasets. These results will inform future health programmes which aim to improve health and reduce inequalities by reaching and supporting families from more disadvantaged backgrounds.

Obesity and dental caries in childhood: trends in prevalence and socioeconomic inequalities-a multicohort population-wide data linkage study.

OBJECTIVES: To quantify levels of coexisting obesity and caries experience in children in Scotland, and any associated socioeconomic inequalities over the years 2011/2012-2017/2018. DESIGN: A multicohort population-wide data linkage study. SETTING: Local authority primary schools in Scotland. PATIENTS: 335 361 primary 1 (approximately 5 years old) schoolchildren in Scotland between 2011/2012 and 2017/2018. MAIN OUTCOME MEASURES: Prevalence and inequalities in coexisting caries and obesity. RESULTS: The prevalence of coexisting obesity and caries experience was 3.4% (n=11 494 of 335 361) and did not change over the 7 years. Children living in the 20% most deprived areas had more than sixfold greater odds of coexisting obesity and caries experience than children from the 20% least deprived areas (adjusted OR=6.63 (95% CI=6.16 to 7.14; p<0.001)). There was a large persistent socioeconomic gradient across the Scottish Index of Multiple Deprivation groups, with the Slope and Relative Indices of Inequality remaining unchanged over the 7 cohort years. CONCLUSIONS: Despite improvements in oral health in children in Scotland, the prevalence of coexisting obesity and caries experience has remained static, with large persistent inequalities. These conditions are likely to signal increased risk of chronic conditions including multimorbidity in adulthood and therefore early identification of children most at risk and timely intervention tackling common risk factors should be developed and evaluated.

Effectiveness and reach of a directed-population approach to improving dental health and reducing inequalities: a cross sectional study.

BACKGROUND: Childsmile School adopts a directed-population approach to target fluoride varnish applications to 20% of the primary one (P1) population in priority schools selected on the basis of the proportion of enrolled children considered to be at increased-risk of developing dental caries. The study sought to compare the effectiveness of four different methods for identifying individuals most in need when a directed-population approach is taken. METHODS: The 2008 Basic National Dental Inspection Programme (BNDIP) cross-sectional P1 Scottish epidemiological survey dataset was used to model four methods and test three definitions of increased-risk. Effectiveness was determined by the positive predictive value (PPV) and explored in relation to 1-sensitivity and 1-specificity. RESULTS: Complete data was available on 43,470 children (87% of the survey). At the Scotland level, at least half (50%) of the children targeted were at increased-risk irrespective of the method used to target or the definition of increased-risk. There was no one method across all definitions of increased-risk that maximised PPV. Instead, PPV was highest when the targeting method complimented the definition of increased-risk. There was a higher percentage of children at increased-risk who were not targeted (1-sensitivity) when caries experience (rather than deprivation) was used to define increased-risk, irrespective of the method used for targeting. Over all three definitions of increased-risk, there was no one method that minimised (1-sensitivity) although this was lowest when the method and definition of increased-risk were complimentary. The false positive rate (1-specificity) for all methods and all definitions of increased-risk was consistently low (<20%), again being lowest when the method and definition of increased-risk were complimentary. CONCLUSION: Developing a method to reach all (or even the vast majority) of individuals at increased-risk defined by either caries experience or deprivation is difficult using a directed-population approach at a group level. There is a need for a wider debate between politicians and public health experts to decide how best to reach those most at need of intervention to improve health and reduce inequalities.

Periodontal instrumentation technique: an exploratory analysis of clinical outcomes and financial aspects.

Objective This exploratory post hoc analysis sought to investigate clinical outcomes comparing non-surgical treatment for periodontal disease using exclusively hand instruments, exclusively ultrasonic instruments or a combination approach. Differences in time efficiency and equipment use with each treatment method were evaluated.Methods In total, 55 patients with periodontitis were treated across two studies (randomised controlled trial and cohort study) with non-surgical periodontal therapy using hand instruments (HI), ultrasonic instruments (UI) or a combination approach (CI). All patients were re-evaluated 90 days after treatment. Clinical parameters, time taken and financial implications of non-surgical periodontal therapy were explored with a descriptive analysis within this post hoc analysis.Results There were no clinically relevant differences in clinical parameters across all groups at day 90. Inter-group comparisons showed no clinically relevant differences in treatment outcome between groups. UI required less time on average to complete treatment compared to HI. UI provided using a half mouth approach had fewest overall episodes of expenditure and lowest maintenance costs.Conclusions Comparison of clinical outcomes between HI, UI and CI yielded no clinically relevant differences. When comparing HI and UI, UI had a shorter treatment time on average. Full mouth treatment was associated with the least patient visits. UI was least costly on a recurring basis.

Child oral health and preventive dental service access among children with intellectual disabilities, autism and other educational additional support needs: A population-based record linkage cohort study.

OBJECTIVE: Inequalities in child oral health are a global challenge and the intersection of socioeconomic factors with educational additional support needs (ASN), including children with intellectual disabilities or autism, have thus far received limited attention in relatively small clinical studies. We aimed to address this evidence gap by investigating oral health and access to preventive dental services among children with ASN compared to the general child population. METHODS: Cohort study linking data from six Scotland-wide health and education databases compared: dental caries experience and tooth extraction via general anaesthetic; receipt of school-based dental inspection; access to primary care and hospital dental services; and access to the Childsmile national oral health improvement programme between children with a range of ASN (intellectual disabilities, autism, social and other) and their peers for the school years 2016/17-2018/19 (n = 166 781). RESULTS: Children with any ASN had higher rates of caries experience than those with no ASN, however, after adjustment for socioeconomic deprivation, sex, year, and school type only those with a social or other ASN remained at increased risk. Rates of tooth extraction under general anaesthesia in hospital were higher among children with intellectual disabilities (aRR = 1.67;95% CI = [1.16-2.37]). School-based dental inspection access improved for children with intellectual disability and/or autism from 2016/17 onwards, although higher rates of child refusal on the day were observed in these groups (no ASN refusal: 5.4%; intellectual disability: 35.8%; autism: 40.3%). Children with any ASN were less likely to attend primary dental-care regularly, and in those who attended, children with intellectual disability or autism were less likely than their peers to receive prevention (fluoride varnish, oral-hygiene instruction, or dietary advice). Childsmile nursery-supervised toothbrushing programme access among children with any ASN was similar to children with no ASN and children with intellectual disability (aRR = 1.27;95% CI = [1.12-1.45]) or autism (aRR = 1.32;95% CI = [1.19-1.45]) were more likely to receive support from Childsmile dental health support worker. CONCLUSIONS: We have identified inequalities in oral health and dental care for children with different ASN in Scotland with both a greater burden of disease among some groups and higher complexity of care; compounded by reduced and variable access to preventive dental services. Further efforts are needed to develop and improve preventive care pathways for children with ASN and integrate oral health to wider healthcare systems for these children to mitigate against oral health inequalities.

Estimated impact of the UK soft drinks industry levy on childhood hospital admissions for carious tooth extractions: interrupted time series analysis.

Introduction: Tooth extraction due to dental caries is associated with socioeconomic deprivation and is a major reason for elective childhood hospital admissions in England. Consumption of sugar-sweetened beverages is a risk factor for dental caries. We examined whether the soft drinks industry levy (SDIL), announced in March 2016 and implemented in April 2018, was associated with changes in incidence rates of hospital admissions for carious tooth extraction in children, 22 months post-SDIL implementation. Methods: Changes in incidence rates of monthly National Health Service hospital admissions for extraction of teeth due to a primary diagnosis of dental caries (International Classification of Diseases; ICD-10 code: K02) in England, between January 2012 and February 2020, were estimated using interrupted time series and compared with a counterfactual scenario where SDIL was not announced or implemented. Periodical changes in admissions, autocorrelation and population structure were accounted for. Estimates were calculated overall, by Index of Multiple Deprivation (IMD) fifths and by age group (0-4 years, 5-9 years, 10-14 years, 15-18 years). Results: Compared with the counterfactual scenario, there was a relative reduction of 12.1% (95% CI 17.0% to 7.2%) in hospital admissions for carious tooth extractions in all children (0-18 years). Children aged 0-4 years and 5-9 years had relative reductions of 28.6% (95% CI 35.6% to 21.5%) and 5.5% (95% CI 10.5% to 0.5%), respectively; no change was observed for older children. Reductions were observed in children living in most IMD areas regardless of deprivation. Conclusion: The UK SDIL was associated with reductions in incidence rates of childhood hospital admissions for carious tooth extractions, across most areas regardless of deprivation status and especially in younger children. Trial registration number: ISRCTN18042742.

Evaluating childsmile, Scotland's National Oral Health Improvement Programme for children.

In the early 2000s, a Scottish Government Oral Health Action Plan identified the need for a national programme to improve child oral health and reduce inequalities. 'Childsmile' aimed to improve child oral health in Scotland, reduce inequalities in outcomes and access to dental services, and to shift the balance of care from treatment to prevention through targeted and universal components in dental practice, community and educational settings. This paper describes how an embedded, theory-based research and evaluation arm with multi-disciplinary input helps determine priorities and provides important strategic direction. Programme theory is articulated in dedicated, dynamic logic models, and evaluation themes are as follows: population-level data linkage; trials and economic evaluations; investigations drawing from behavioural and implementation science; evidence reviews and updates; and applications of systems science. There is also a growing knowledge sharing network internationally. Collaborative working from all stakeholders is necessary to maintain gains and to address areas that may not be working as well, and never more so with the major disruptions to the programme from the COVID-19 pandemic and response. Conclusions are that evaluation and research are synergistic with a complex, dynamic programme like Childsmile. The evidence obtained allows for appraisal of the relative strengths of component interventions and the reach and impact of Childsmile to feed into national policy.

Inequalities in access to NHS primary care dental services in Scotland during the COVID-19 pandemic.

Introduction This study aimed to quantify the impact of the COVID-19 pandemic on access and inequalities in primary care dental services among children and adults in Scotland.Methods Access was measured as any NHS Scotland primary care dental contacts derived from administrative data from January 2019 to May 2022, linked to the area-based Scottish Index of Multiple Deprivation for children and adults, and related to population denominator estimates from National Record Scotland. Inequalities for pre-pandemic (January 2019-January 2020) and recent (December 2021-February 2022, and March 2022-May 2022) periods for both children and adults were calculated and compared using the slope index of inequality and relative index of inequality.Results Following the first lockdown (March 2020) there was a dramatic fall to near zero dental contacts, followed by a slow recovery to 64.8% of pre-pandemic levels by May 2022. There was initial widening of relative inequalities in dental contacts in early 2022, which, more recently, had begun to return to pre-pandemic levels.Conclusion COVID-19 had a major impact on access to NHS primary dental care, and while inequalities in access are apparent as services recover from lockdown, these inequalities are not a new phenomenon.

Periodontitis in non-smoking type 1 diabetic adults: a cross-sectional study.

AIM: To compare levels of periodontitis in non-smoking type 1 diabetic patients and controls. MATERIAL AND METHODS: Type 1 diabetic patients, aged 20-55 years, were recruited from outpatient clinics at five hospitals in Glasgow, UK. Control subjects were recruited from physiotherapy clinics, using the buddy system and through an advertisement in a free newspaper. The primary outcome was severe periodontitis defined by clinical attachment level ≥6 mm on ≥1 tooth. RESULTS: There were 34 well controlled patients (HbA1c ≤ 7.5%), 169 poorly controlled patients and 112 non-diabetic subjects. Prevalence of severe periodontitis was higher in all type 1 diabetic patients [24.1% (95% CI: 18.4-30.6%)] and poorly controlled patients [27.2% (20.7-34.6%)] than in controls [20.5% (13.5-29.2%)]. The fully adjusted odds ratios (ORs) in never smokers comparing the whole diabetic group, and the poorly controlled group, with the control group were 1.35 [0.66-2.8] (p = 0.41) and 1.58 [0.75-3.33] (p = 0.23), respectively. Mean clinical attachment level was higher in all type 1 diabetic and poorly controlled patients than in controls (both p < 0.001). CONCLUSIONS: These results indicate worse periodontal health in type 1 diabetic patients than in control subjects. TRIAL REGISTRATION: This study was registered with the UKCRN, ID: 9314 and Scottish Diabetes Research Network registration number: 128.

Improving the oral health of older people in care homes (TOPIC): a protocol for a feasibility study.

BACKGROUND: Evidence for interventions promoting oral health amongst care home residents is weak. The National Institute for Health and Care Excellence (NICE) guideline NG48 aims to maintain and improve the oral health of care home residents. A co-design process that worked with residents and care home staff to understand how the NG48 guideline could be best implemented in practice has been undertaken to refine a complex intervention. The aim of this study is to assess the feasibility of the intervention to inform a future larger scale definitive trial. METHODS: This is a protocol for a pragmatic cluster randomised controlled trial with a 12-month follow-up that will be undertaken in 12 care homes across two sites (six in London, six in Northern Ireland). Care homes randomised to the intervention arm (n = 6) will receive the complex intervention based on the NG48 guideline, whilst care homes randomised to the control arm (n = 6) will continue with routine practice. The intervention will include a training package for care home staff to promote knowledge and skills in oral health promotion, the use of the Oral Health Assessment Tool on residents by trained care home staff, and a 'support worker assisted' daily tooth-brushing regime with toothpaste containing 1500 ppm fluoride. An average of ten residents, aged 65 years or over who have at least one natural tooth, will be recruited in each care home resulting in a recruited sample of 120 participants. Assessments will be undertaken at baseline, 6 months and 12 months, and will include a dental examination and questionnaires on general health and oral health administered by a research assistant. A parallel process evaluation involving semi-structured interviews will be undertaken to explore how the intervention could be embedded in standard practice. Rates of recruitment and retention, and intervention fidelity will also be recorded. A cost-consequence model will determine the relevance of different outcome measures in the decision-making context. DISCUSSION: The study will provide valuable information for trialists, policymakers, clinicians and care home staff on the feasibility and associated costs of oral health promotion in UK care homes. TRIAL REGISTRATION: ISRCTN10276613. Registered on 17th April 2020. http://www.isrctn.com/ISRCTN10276613 .

Evaluation of a national complex oral health improvement programme: a population data linkage cohort study in Scotland.

OBJECTIVES: Child dental caries is a global public health challenge with high prevalence and wide inequalities. A complex public health programme (Childsmile) was established. We aimed to evaluate the reach of the programme and its impact on child oral health. SETTING: Education, health and community settings, Scotland-wide. INTERVENTIONS: Childsmile (national oral health improvement programme) interventions: nursery-based fluoride varnish applications (FVAs) and supervised daily toothbrushing, community-based Dental Health Support Worker (DHSW) contacts and primary care dental practice visits-delivered to the population via a proportionate universal approach. PARTICIPANTS: 50 379 children (mean age=5.5 years, SD=0.3) attending local authority schools (2014/2015). DESIGN: Population-based individual child-level data on four Childsmile interventions linked to dental inspection survey data to form a longitudinal cohort. Logistic regression assessed intervention reach and the independent impact of each intervention on caries experience, adjusting for age, sex and area-based Scottish Index of Multiple Deprivation (SIMD). OUTCOME MEASURES: Reach of the programme is defined as the percentage of children receiving each intervention at least once by SIMD fifth. Obvious dental caries experience (presence/absence) is defined as the presence of decay (into dentine), missing (extracted) due to decay or filled deciduous teeth. RESULTS: 15 032 (29.8%) children had caries experience. The universal interventions had high population reach: nursery toothbrushing (89.1%), dental practice visits (70.5%). The targeted interventions strongly favoured children from the most deprived areas: DHSW contacts (SIMD 1: 29.5% vs SIMD 5: 7.7%), nursery FVAs (SIMD 1: 75.2% vs SIMD 5: 23.2%). Odds of caries experience were markedly lower among children participating in nursery toothbrushing (>3 years, adjusted OR (aOR)=0.60; 95% CI 0.55 to 0.66) and attending dental practice (≥6 visits, aOR=0.55; 95% CI 0.50 to 0.61). The findings were less clear for DHSW contacts. Nursery FVAs were not independently associated with caries experience. CONCLUSIONS: The universal interventions, nursery toothbrushing and regular dental practice visits were independently and most strongly associated with reduced odds of caries experience in the cohort, with nursery toothbrushing having the greatest impact among children in areas of high deprivation.

Development of a core outcome set for oral health services research involving dependent older adults (DECADE): a study protocol.

BACKGROUND: Oral healthcare service provision for dependent older adults is often poor. For dental services to provide more responsive and equitable care, evidence-based approaches are needed. To facilitate future research, the development and application of a core outcome set would be beneficial. The aim of this study is to develop a core outcome set for oral health services research involving dependent older adults. METHODS: A multi-step process involving consensus methods and including key stakeholders will be undertaken. This will involve identifying potentially relevant outcomes through a systematic review of previous studies examining the effectiveness of strategies to prevent oral disease in dependent older adults, combined with semi-structured interviews with key stakeholders. Stakeholders will include dependent older adults, family members, carers, care-home managers, health professionals, researchers, dental commissioners and policymakers. To condense and prioritise the long list of outcomes generated by the systematic review and semi-structured interviews, a Delphi survey consisting of several rounds with key stakeholders, as mentioned above, will be undertaken. The 9-point Likert scale proposed by the GRADE Working Group will facilitate this consensus process. Following the Delphi survey, a face-to-face consensus meeting with key stakeholders will be conducted where the stakeholders will anonymously vote and decide on what outcomes should be included in the finalised core outcome set. DISCUSSION: Developing a core set of outcomes that are clinically and patient-centred will help improve the design, conduct and reporting of oral health services research involving dependent older adults, and ultimately strengthen the evidence base for high-quality oral health care for dependent older adults. TRIAL REGISTRATION: The study was registered with the COMET initiative on 9 January 2018 http://www.cometinitiative.org/studies/details/1081?result=true .

The effect of introducing a financial incentive to promote application of fluoride varnish in dental practice in Scotland: a natural experiment.

BACKGROUND: Financial incentives are often used to influence professional practice, yet the factors which influence their effectiveness and their behavioural mechanisms are not fully understood. In keeping with clinical guidelines, Childsmile (Scotland's oral health improvement programme) advocates twice yearly fluoride varnish application (FVA) for children in dental practice. To support implementation Childsmile offered dental practitioners a fee-per-item payment for varnishing 2-5-year-olds' teeth through a pilot. In October 2011 payment was extended to all dental practitioners. This paper compares FVA pre- and post-roll-out and explores the financial incentive's behavioural mechanisms. METHODS: A natural experimental approach using a longitudinal cohort of dental practitioners (n = 1090) compared FVA pre- (time 1) and post- (time 2) financial incentive. Responses from practitioners who did not work in a Childsmile pilot practice when considering their 2-5-year-old patients (novel incentive group) were compared with all other responses (continuous incentive group). The Theoretical Domains Framework (TDF) was used to measure change in behavioural mechanisms associated with the incentive. Analysis of covariance was used to investigate FVA rates and associated behavioural mechanisms in the two groups. RESULTS: At time 2, 709 74%, of eligible responders, were followed up. In general, FVA rates increased over time for both groups; however, the novel incentive group experienced a greater increase (ß [95% CI] = 0.82 [0.72 to 0.92]) than the continuous incentive group. Despite this, only 33% of practitioners reported 'always' varnishing increased risk 2-5-year-olds' teeth following introduction of the financial incentive, 19% for standard risk children. Domain scores at time 2 (adjusting for time 1) increased more for the novel incentive group (compared to the continuous incentive group) for five domains: knowledge, social/professional role and identity, beliefs about consequences, social influences and emotion. CONCLUSIONS: In this large, prospective, population-wide study, a financial incentive moderately increased FVA in dental practice. Novel longitudinal use of a validated theoretical framework to understand behavioural mechanisms suggested that financial incentives operate through complex inter-linked belief systems. While financial incentives are useful in narrowing the gap between clinical guidelines and FVA, multiple intervention approaches are required.

A systems approach using the functional resonance analysis method to support fluoride varnish application for children attending general dental practice.

BACKGROUND: All children attending General Dental Practice in Scotland are recommended to receive twice-yearly applications of sodium fluoride varnish to prevent childhood caries, yet application is variable. Development of complex interventions requires theorizing and modelling to understand context. This study applies the Functional Resonance Analysis Method (FRAM) to produce a sociotechnical systems model and identify opportunities for intervention to support application. METHODS: The FRAM was used to synthesise data which were: routine monitoring of fluoride varnish application in 2015/16; a longitudinal survey with practitioners (n = 1090); in-depth practitioner and key informant interviews (n = 43); and a 'world café' workshop (n = 56). RESULTS: We describe a detailed model of functions linked to application, and use this to make recommendations for system-wide intervention. CONCLUSIONS: Rigorous research is required to produce accessible models of complex systems in healthcare. This novel paper shows how careful articulation of the functions associated with fluoride varnish application can support future improvement efforts.

Use of the theoretical domains framework to further understanding of what influences application of fluoride varnish to children's teeth: a national survey of general dental practitioners in Scotland.

OBJECTIVES: Despite recent improvements in the oral health of Scotland's population, the persistence of childhood dental caries underscores a need to reduce the disease burden experienced by children living in Scotland. Application of fluoride varnish (FV) to children's teeth provides an evidence-based approach to achieving this goal. Despite policy, health service targets and professional recommendations supporting application, not all children receive FV in line with guidance. The objective of this study was to use the theoretical domains framework (TDF) to further an understanding of what may influence fluoride varnish application (FVA) in General Dental Practice in Scotland. METHODS: A postal questionnaire assessing current behaviour (frequency of FVA) and theoretical domains (TDs) was sent to all General Dental Practitioners (GDPs) in Scotland. Correlations and linear regression models were used to examine the association between FVA and the TDs. RESULTS: One thousand and ninety (53.6%) eligible GDPs responded. Respondents reported applying FV more frequently to increased risk and younger children (aged 2-5 years). Higher scores in eight TDs (Knowledge, Social/professional role and identity, Beliefs about consequences, Motivation and goals, Environmental context and resources, Social influences, Emotion and Behavioural regulation) were associated with greater frequency of FVA. Four beliefs in particular appear to be driving GDPs' decision to apply FV (recognizing that FVA is a guideline recommended behaviour (Knowledge), that FVA is perceived as an important part of the GDPs' professional role (Professional role/identity), that FV is something parents want for their children (Social influences) and that FV is something GDPs really wanted to do (Emotion). CONCLUSIONS: The findings of this study support the use of the TDF as a tool to understand GDPs application of FV and suggest that a multifaceted intervention, targeting dental professionals and families, and more specifically those domains and items associated with FVA may have the greatest likelihood of influencing the evidence-based behaviour.

The Oral Microbiome of Denture Wearers Is Influenced by Levels of Natural Dentition.

OBJECTIVES: The composition of dental plaque has been well defined, whereas currently there is limited understanding of the composition of denture plaque and how it directly influences denture related stomatitis (DS). The aims of this study were to compare the microbiomes of denture wearers, and to understand the implications of these towards inter-kingdom and host-pathogen interactions within the oral cavity. METHODS: Swab samples were obtained from 123 participants wearing either a complete or partial denture; the bacterial composition of each sample was determined using bar-coded illumina MiSeq sequencing of the bacterial hypervariable V4 region of 16S rDNA. Sequencing data processing was undertaken using QIIME, clustered in Operational Taxonomic Units (OTUs) and assigned to taxonomy. The dentures were sonicated to remove the microbial flora residing on the prosthesis, sonicate was then cultured using diagnostic colorex Candida media. Samples of unstimulated saliva were obtained and antimicrobial peptides (AMP) levels were measured by ELISA. RESULTS: We have shown that dental and denture plaques are significantly distinct both in composition and diversity and that the oral microbiome composition of a denture wearer is variable and is influenced by the location within the mouth. Dentures and mucosa were predominantly made up of Bacilli and Actinobacteria. Moreover, the presence of natural teeth has a significant impact on the overall microbial composition, when compared to the fully edentulous. Furthermore, increasing levels of Candida spp. positively correlate with Lactobacillus spp. AMPs were quantified, though showed no specific correlations. CONCLUSIONS: This is the first study to provide a detailed understanding of the oral microbiome of denture wearers and has provided evidence that DS development is more complex than simply a candidal infection. Both fungal and bacterial kingdoms clearly play a role in defining the progression of DS, though we were unable to show a defined role for AMPs.

Measuring socio-economic inequalities in edentate Scottish adults--cross-sectional analyses using Scottish Health Surveys 1995-2008/09.

OBJECTIVES: To investigate the appropriateness of different measures of socio-economic inequalities, in relation to adult oral health in Scotland, utilizing data from a series of large, representative population surveys. METHODS: The Scottish Health Surveys (SHeS) (1995; 1998; 2003; 2008/09) are cross-sectional national population-based surveys used to monitor health status in those living in private households. The age groups included in this study are as follows: 45-54; 55-64 years: all survey years; 65-74: 1998 onwards; 75+: 2003 onwards. Primary outcome was no natural teeth (edentulism). Three measures of socio-economic position: Occupational social class, Education, Carstairs deprivation score (2001) were used. Simple (absolute/relative differences) and complex measures (Slope Index, Relative Index, Concentration Index and c-index) of inequality were produced for each age group across all four surveys. RESULTS: Simple and complex (absolute) measures of inequality have both demonstrated narrowing disparities in edentulism over time in the 45- to 64-year-old group, a levelling off in those aged 65 and above, and a rise in those aged 75+. Complex relative measures (RII, Concentration Index and c-index), however, show an increasing trend in inequalities over time for all age groups, suggesting that rates of improvement in edentulism rates are not uniform across all social groups. CONCLUSIONS: Simple absolute inequality provides a quick and easy indication of the extent of disparities between extreme groups, whereas complex measures (absolute and relative) consider the gradient in health across all social groups. We have demonstrated that both are useful measures of inequality and should be considered complementary to one another. The appropriate choice of complex measure of inequality will depend on the audience to whom the results are to be communicated. This methodological approach is not confined to oral health but is applicable to other health outcomes that are socially patterned.