Silver diamine fluoride, atraumatic restorations, and oral health-related quality of life in children aged 5-13 years: results from the CariedAway school-based cluster randomized trial.

OBJECTIVE: Silver diamine fluoride (SDF) is a non-surgical treatment for the arrest and prevention of dental caries that results in irreversible black staining of dental decay. The objective of this study was to evaluate the short-term impact of SDF treatment on oral health-related quality of life (OHRQoL) relative to a standard package of glass ionomer sealants and atraumatic restorative treatment (ART) in children aged 5-13 years. METHODS: CariedAway is a pragmatic, longitudinal, cluster-randomized non-inferiority trial of non-surgical interventions for caries. Secondary study outcomes included OHRQoL and academic performance. Oral health-related quality of life was measured at each study visit using the Child Oral Health Impact Profile. Change in OHRQoL was assessed using linear regression and non-inferiority was determined using t tests. RESULTS: 160 children with an average age of 8.7 years completed quality of life assessments. Untreated decay at baseline (approximately 25%) was associated with significantly worse OHRQoL and treatment in both groups resulted in incremental improvement: children receiving SDF improved their OHRQoL scores from 16.44 (SD = 11.12) to 14.62 (SD = 11.90), and those receiving traditional sealants and atraumatic restorations slightly improved from 16.65 (SD = 10.56) to 16.47 (SD = 11.09). Quality of life in children receiving silver diamine fluoride was non-inferior to those receiving sealants and ART at least 6 months post-treatment (mean difference = 1.85, 95% CI = - 2.10, 5.80), and change in OHRQoL did not depend on the severity of baseline decay. CONCLUSIONS: OHRQoL is related to untreated dental caries, and observed changes following SDF treatment were non-inferior relative to standard preventive therapies.

What is the societal economic cost of poor oral health among older adults in the United States? A scoping review.

OBJECTIVE: To assess the state of the literature in the United States quantifying the societal economic cost of poor oral health among older adults. BACKGROUND: Proponents of a Medicare dental benefit have argued that addressing the growing need for dental care among the US older adult population will decrease costs from systemic disease and other economic costs due to oral disease. However, it is unclear what the current economic burden of poor oral health among older adults is in the United States. METHODS: We conducted a scoping review examining the cost of poor oral health among older adults and identified cost components that were included in relevant studies. RESULTS: Other than oral cancer, no studies were found examining the economic costs of poor oral health among older adults (untreated tooth decay, gum disease, tooth loss and chronic disease/s). Only two studies examining the costs of oral cancer were found, but these studies did not assess the full economic cost of oral cancer from patient, insurer and societal perspectives. CONCLUSIONS: Future work is needed to assess the full economic burden of poor oral health among older adults in the United States, and should leverage novel linkages between medical claims data, dental claims data and oral health outcomes data.

Periodontal disease as a possible cause for Alzheimer's disease.

Approximately 47 million people worldwide have been diagnosed with dementia, 60%-80% of whom have dementia of the Alzheimer's disease type. Unfortunately, there is no cure in sight. Defining modifiable risk factors for Alzheimer's disease may have a significant impact on its prevalence. An increasing body of evidence suggests that chronic inflammation and microbial dysbiosis are risk factors for Alzheimer's disease. Periodontal disease is a chronic inflammatory disease that develops in response to response to microbial dysbiosis. Many studies have shown an association between periodontal disease and Alzheimer's disease. The intent of this paper was to review the existing literature and determine, using the Bradford Hill criteria, whether periodontal disease is causally related to Alzheimer's disease.

The Effect of Silver Diamine Fluoride in Preventing Caries in the Primary Dentition: A Systematic Review and Meta-Analysis.

OBJECTIVES: To investigate whether silver diamine fluoride (SDF) is effective in preventing new caries lesions in primary teeth when compared to placebo or active treatments. METHODS: Systematic review (CRD42016036963) of controlled clinical trials. Searches were performed in 9 electronic databases, 5 registers of ongoing trials, and reference lists of identified review articles. Two researchers carried out data extraction and quality appraisal independently. The primary outcome was the difference in caries increment (decayed, missing, and filled surfaces or teeth - dmfs or dmft) between SDF and control groups. These differences were pooled as weighted mean differences (WMD) and prevented fractions (PF). RESULTS: Searches yielded 2,366 unique records; 6 reports of 4 trials that randomized 1,118 and analyzed 915 participants were included. Two trials compared SDF to no treatment, 1 compared SDF to placebo and sodium fluoride varnish (FV), and 1 compared SDF to high-viscosity glass ionomer cement (GIC). All studies had at least 1 domain with unclear or high risk of bias. After 24 months of follow-up, in comparison to placebo, no treatment, and FV, SDF applications significantly reduced the development of new dentin caries lesions (placebo or no treatment: WMD = -1.15, PF = 77.5%; FV: WMD = -0.43, PF = 54.0%). GIC was more effective than SDF after 12 months of follow-up but the difference between them was not statistically significant (WMD, dmft: 0.34, PF: -6.09%). CONCLUSION: When applied to caries lesions in primary teeth, SDF compared to no treatment, placebo or FV appears to effectively prevent dental caries in the entire dentition. However, trials specifically designed to assess this outcome are needed.

Comparative effectiveness of school-based caries prevention: a prospective cohort study.

BACKGROUND: Dental caries is the world's most prevalent childhood disease. School-based caries prevention can reduce the risk of childhood caries by increasing access to care. However, the optimal mix of treatment services, intensity, and frequency of care is unknown. METHODS: Data were derived from two prospective cohorts of US children participating in two caries prevention programs with different treatment intensities. One program provided primary and secondary prevention (glass ionomer sealants and interim therapeutic restorations) and one primary prevention only (glass ionomer sealants), both given twice yearly in six-month intervals. Primary study outcomes included untreated decay and the total observed caries experience. Analysis used generalized additive models to estimate nonlinear effects and trends over time. Results were compared to those estimated using generalized estimating equations and mixed-effects multilevel Poisson regression. RESULTS: Primary and secondary prevention combined did not significantly reduce total caries experience compared to primary prevention alone, but did reduce the risk of untreated decay on permanent dentition. Additionally, the rate of new caries experience was slower in the primary and secondary prevention group. Nonlinear trends for dental caries across both programs were statistically significant from zero (p < .001). CONCLUSION: Caries prevention consisting of primary and secondary prevention agents may be more effective than primary prevention alone in reducing the risk of tooth decay over time. Results suggest that the impact of caries prevention may not be constant over the medium- and long-term, suggesting reduced effectiveness with continued treatments.

Getting the Incentives Right: Improving Oral Health Equity With Universal School-Based Caries Prevention.

Despite significant financial, training, and program investments, US children's caries experience and inequities continued to increase over the last 20 years. We posit that (1) dental insurance payment systems are not aligned with the current best evidence, exacerbating inequities, and (2) system redesign could meet health care's triple aim and reduce children's caries by 80%. On the basis of 2013 to 2016 Medicaid and private payment rates and the caries prevention literature, we find that effective preventive interventions are either (1) consistently compensated less than ineffective interventions or (2) not compensated at all. This economic and clinical misalignment may account for underuse of effective caries prevention and subsequent overuse of restorative care. We propose universal school-based comprehensive caries prevention to address this misalignment. Preliminary modeling suggests that universal caries prevention could eliminate 80% of children's caries and cost less than one fifth of current Medicaid children's oral health spending. If implemented with bundled payments based on cycle of care and measurable outcomes, there would be an alignment of incentives, best evidence, care, and outcomes. Such a program would meet the Healthy People Oral Health goals for children, as well as health care's triple aim.

Preventable Tooth Loss in Hawai'i: The Role of Socioeconomic Status, Diabetes, and Dental Visits.

INTRODUCTION: Tooth preservation in adults and children is one of the Healthy People 2020 goals for oral health. Although the overall prevalence of tooth loss has been declining in the United States, substantial racial/ethnic differences in preventable tooth loss persist as a public health problem. We examined the strength of the association of health risk factors and tooth loss in Hawai'i. METHODS: We used data from the Hawai'i Behavioral Risk Factor Surveillance System survey collected from 2011 through 2014. Participant responses were included if they self-identified as Native Hawaiian, white, Japanese, or Filipino. Differences in excess tooth loss (6 or more teeth) and known risk factors (demographics, diabetes, and dental visits) were analyzed by using univariate analyses and adjusted stepwise, logistic regression models. RESULTS: We identified oral health inequity among the 4 ethnic groups studied; among the groups, Native Hawaiians had the largest proportion of excess tooth loss. The univariate analyses found differences in the strength of these associations among the 4 racial/ethnic groups. The stepwise analyses found that the associations of excess tooth loss and race/ethnicity were not significant after adjusting for demographics, diabetes status, and dental visits. CONCLUSION: Findings suggest a need for programs and policies that improve access to oral health care in Hawai'i for those with low levels of income and education and those with diabetes.

The concomitant administration of systemic amoxicillin and metronidazole compared to scaling and root planing alone in treating periodontitis: =a systematic review=.

BACKGROUND: The treatment of periodontitis begins with a non-surgical phase that includes scaling and root planing(SRP) and on occasion the use of systemic antibiotics. The goal was to systematically evaluate in systemic healthy adults the effect of the concomitant administration of amoxicillin (amx) and metronidazole (met) adjunctive to SRP compared to SRP alone. METHODS: The PubMed-MEDLINE, Cochrane-CENTRAL and EMBASE databases were searched up to November 2014 to identify appropriate studies. Probing Pocket Depth (PD), Clinical Attachment Level (CAL), Bleeding on Pocket Probing(BOP) and Plaque Indices(PI) were selected as outcome variables. Based on the extracted data a meta-analysis was conducted. RESULTS: A total of 526 unique articles were found, 20 studies met the eligibility criteria. A meta-analysis showed that SRP + amx + met provided significantly better effects overall and more pronounced PD reduction in periodontal pockets initially measuring ≥6 mm (DiffM:-0.86 mm, p < 0.00001) and gain in CAL(DiffM:+0.75 mm, p = 0.0001). The meta-analysis for the secondary inflammatory parameter BOP showed that SRP + amx + met provided full mouth significantly greater reduction in BOP than SRP alone (DiffM:-6.98 %, p = 0.0001). CONCLUSION: Adjunctive systemic amoxicillin and metronidazole medication to SRP significantly improved the clinical outcomes with respect to mean PD, CAL and BOP compared to SRP alone. There is moderate to strong evidence in support of the recommendation that adjunctive amx + met therapy to SRP significantly improves the clinical outcomes, with respect to mean PD and CAL compared to SRP alone especially in initially deep (≥6 mm) pockets. No major side effects associated with the intake of amx + met were reported. This treatment regimen is an efficacious, minimally invasive, practical and inexpensive approach for periodontitis therapy. The key components are mechanical tooth and pocket debridement, supportive treatment of the disease with systemic antibiotics and attention to proper self-care.

EVIDENCE BASED DENTISTRY AND CODA REQUIREMENTS.

Most of us assume that what we do, and teach, is evidence-based. The challenge is to insure that this is indeed the case. More to the point, how can we readily find the credible evidence we need to guide practice and teaching? And, can we differentiate high-quality evidence from less trustworthy reports? This paper presents a basic, three-step process for querying the literature, identifying levels of evidence, evaluating the evidence, and summarizes the early experiences of three dental schools in developing a curriculum that incorporates EBD and critical thinking.

Moderate quality evidence finds statistical benefit in oral health for powered over manual toothbrushes.

DATA SOURCES: The Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, CINAHL, National Institutes of Health Trials Register and the WHO Clinical Trials Registry Platform for ongoing trials. Reference lists of identified articles were also scanned for relevant papers. Identified manufacturers were contacted for additional information. STUDY SELECTION: Only randomised controlled trials comparing manual and powered toothbrushes were considered. Crossover trials were eligible for inclusion if the wash-out period length was more than two weeks. DATA EXTRACTION AND SYNTHESIS: Study assessment and data extraction were carried out independently by at least two reviewers. The primary outcome measures were quantified levels of plaque or gingivitis. Risk of bias assessment was undertaken. Standard Cochrane methodological approaches were taken. Random-effects models were used provided there were four or more studies included in the meta-analysis, otherwise fixed-effect models were used. Data were classed as short term (one to three months) and long term (greater than three months). RESULTS: Fifty-six trials were included with 51 (4624 patients) providing data for meta-analysis. The majority (46) were at unclear risk of bias, five at high risk of bias and five at low risk. There was moderate quality evidence that powered toothbrushes provide a statistically significant benefit compared with manual toothbrushes with regard to the reduction of plaque in both the short and long-term. This corresponds to an 11% reduction in plaque for the Quigley Hein index (Turesky) in the short term and a 21% reduction in the long term. There was a high degree of heterogeneity that was not explained by the different powered toothbrush type subgroups.There was also moderate quality evidence that powered toothbrushes again provide a statistically significant reduction in gingivitis when compared with manual toothbrushes both in the short and long term. This corresponds to a 6% and 11% reduction in gingivitis for the Löe and Silness indices respectively. Again there was a high degree of heterogeneity that was not explained by the different powered toothbrush type subgroups. The greatest body of evidence was for rotation oscillation brushes which demonstrated a statistically significant reduction in plaque and gingivitis at both time points. CONCLUSIONS: Powered toothbrushes reduce plaque and gingivitis more than manual toothbrushing in the short and long term. The clinical importance of these findings remains unclear. Observation of methodological guidelines and greater standardisation of design would benefit both future trials and meta-analyses. Cost, reliability and side effects were inconsistently reported. Any reported side effects were localised and only temporary.

School-based caries prevention using silver diamine fluoride: A pragmatic randomized trial in low-income rural children.

Background: Dental caries is the world's most prevalent noncommunicable disease, disproportionately affecting children from low-income families and rural geographic areas. Methods: The CariedAway 3.0 study was a cluster-randomized pragmatic non-inferiority trial comparing silver diamine fluoride (SDF) to sealants and atraumatic restorations (ART) for the prevention and control of dental caries. All participants also received fluoride varnish. Analysis consisted of mixed-effects logistic regression for caries prevalence and weighted least squares and mixed-effects negative binomial regression for caries incidence. A non-inferiority margin of 10% for the difference between groups was used. Dental caries was defined as an ICDAS score of four or greater. Results: A total of 3345 children were enrolled across 35 schools; however there was a large proportion of children who were noncompliant and received external dental care over the course of the trial. In adjusted analyses of compliant participants (n=1083; 543 in the SDF group and 540 in the sealant and ART group), there was no difference in the weighted risk difference between treatment groups (B=0.003, 95% CI = -0.0001, 0.0008). The odds of caries prevalence was elevated in the SDF group in longitudinal analyses (OR = 1.35, 95% CI = 0.86, 2.11) but was not significant and was below the non-inferiority margin. There were no significant differences between groups for caries incidence in adjusted models (IRR = 1.19, 95% CI = 0.81, 1.74). Results for intent to treat analyses were similar to that of per-protocol. Discussion: In this school-based clinical trial, the prevalence of dental caries in children treated with SDF and fluoride varnish was non-inferior compared to those treated with sealants, ART, and fluoride varnish, although the overall risk was slightly higher. Unfortunately, a high rate of dropout and participant noncompliance was observed, likely due to the impacts of COVID-19 on study procedures. As a result, observed effects may be unreliable beyond the short-term. Trial Registration: NCT03448107.

Noninferiority of Silver Diamine Fluoride vs Sealants for Reducing Dental Caries Prevalence and Incidence: A Randomized Clinical Trial.

Importance: Dental caries is the world's most prevalent noncommunicable disease and a source of health inequity; school dental sealant programs are a common preventive measure. Silver diamine fluoride (SDF) may provide an alternative therapy to prevent and control caries if shown to be noninferior to sealant treatment. Objective: To determine whether school-based application of SDF is noninferior to dental sealants and atraumatic restorative treatment (ART) in the prevalence of dental caries. Design, Setting, and Participants: The Silver Diamine Fluoride Versus Therapeutic Sealants for the Arrest and Prevention of Dental Caries in Low-Income Minority Children (CariedAway) study was a pragmatic noninferiority cluster-randomized clinical trial conducted from February 2018 to June 2023 to compare silver diamine fluoride vs therapeutic sealants for the arrest and prevention of dental caries. Children at primary schools in New York, New York, with at least 50% of the student population reporting as Black or Hispanic and at least 80% receiving free or reduced lunch were included. This population was selected as they are at the highest risk of caries in New York. Students were randomized to receive either SDF or sealant with ART; those aged 5 to 13 years were included in the analysis. Treatment was provided at every visit based on need, and the number of visits varied by child. Schools with preexisting oral health programs were excluded, as were children who did not speak English. Of 17 741 students assessed for eligibility, 7418 were randomized, and 4100 completed follow-up and were included in the final analysis. Interventions: Participants were randomized at the school level to receive either a 38% concentration SDF solution or glass ionomer sealants and ART. Each participant also received fluoride varnish. Main Outcomes and Measures: Primary study outcomes were the prevalence and incidence of dental caries. Results: A total of 7418 children (mean [SD] age, 7.58 [1.90] years; 4006 [54.0%] female; 125 [1.7%] Asian, 1246 [16.8%] Black, 3648 [49.2%] Hispanic, 153 [2.1%] White, 114 [1.5%] multiple races or ethnicities, 90 [1.2%] other [unspecified], 2042 [27.5%] unreported) were enrolled and randomized to receive either SDF (n = 3739) or sealants with ART (n = 3679). After initial treatment, 4100 participants (55.0%) completed at least 1 follow-up observation. The overall baseline prevalence of dental caries was approximately 27.2% (95% CI, 25.7-28.6). The odds of decay prevalence decreased longitudinally (odds ratio [OR], 0.79; 95% CI, 0.75-0.83) and SDF was noninferior compared to sealants and ART (OR, 0.94; 95% CI, 0.80-1.11). The crude incidence of dental caries in children treated with SDF was 10.2 per 1000 tooth-years vs 9.8 per 1000 tooth-years in children treated with sealants and ART (rate ratio, 1.05; 95% CI, 0.97-1.12). Conclusions and Relevance: In this school-based pragmatic randomized clinical trial, application of SDF resulted in nearly identical caries incidence compared to dental sealants and ART and was noninferior in the longitudinal prevalence of caries. These findings suggest that SDF may provide an effective alternative for use in school caries prevention. Trial Registration: ClinicalTrials.gov Identifier: NCT03442309.

Dental sealant knowledge, opinion, values and practice of Spanish dentists.

BACKGROUND: Multiple guidelines and systematic reviews recommend sealant use to reduce caries risk. Yet, multiple reports also indicate that sealants are significantly underutilized. This study examined the knowledge, opinions, values, and practice (KOVP) of dentists concerning sealant use in the southwest region of Andalusia, Spain. This is a prelude to the generation of a regional plan for improving children's oral health in Andalusia. METHODS: The survey's target population was dentists working in western Andalusia, equally distributed in the provinces of Seville, Cadiz, and Huelva (N=2,047). A convenience sample of meeting participants and meeting participant email lists (N=400) were solicited from the annual course on Community and Pediatric Dentistry. This course is required for all public health sector dentists, and is open to all private sector dentists. Information on the dentist's KOVP of sealants was collected using four-part questionnaire with 31, 5-point Likert-scaled questions. RESULTS: The survey population demographics included 190 men (48%) and 206 women (52%) with an average clinical experience of 10.6 (±8.4) years and 9.3 (±7.5) years, respectively. A significant sex difference was observed in the distribution of place of work (urban/suburb) (p=0.001), but no sex differences between working sector (public/private). The mean±SD values for each of the four KOVP sections for pit and fissure sealants were: knowledge=3.57±0.47; opinion=2.48±0.47; value=2.74±0.52; and practice=3.48±0.50. No sex differences were found in KOVP (all p>0.4). Independent of sex: knowledge statistically differed by years of experience and place of work; opinion statistically differed by years of experience and sector; and practice statistically differed by years of experience and sector. Less experienced dentists tended to have slightly higher scores (~0.25 on a Likert 1-5 scale). Statistically significant correlations were found between knowledge and practice (r=0.44, p=0.00) and between opinion and value (r=0.35, p=0.00). CONCLUSIONS: The results suggest that, similar to other countries, Andalusian dentists know that sealants are effective, have neutral to positive attitudes toward sealants; though, based on epidemiological studies, underuse sealants. Therefore, methods other than classical behavior change (eg: financial or legal mechanisms) will be required to change practice patterns aimed at improving children's oral health.

Pregnancy gingivitis and causal inference.

DATA SOURCES: The PubMed and Embase databases were searched together with hand searching of the Journal of Periodontology, Journal of Periodontal Research and Journal of Clinical Periodontology. The reference lists of identified articles were also searched. STUDY SELECTION: Prospective cohort or cross-sectional studies assessing the effect of pregnancy on gingival inflammation evaluated by the gingival index and/or bleeding on probing were included. Study quality was assessed using the Newcastle-Ottawa scale (NOS). DATA EXTRACTION AND SYNTHESIS: Study assessment and data extraction were carried out independently by two reviewers, with disputes resolved by a third reviewer. Mean values of primary and secondary outcomes were directly pooled and analysed with weighted mean differences (WMDs) and 95% confidence intervals (CIs), considering independently each study design (cohort and cross-sectional). Study specific estimates were pooled with both the fixed- and random-effect models. RESULTS: Forty-four articles representing 33 studies (14 cohort and 19 cross-sectional) were included. Meta-analyses revealed a significantly lower GI in pregnant women in the first term compared with those in their second or third term of pregnancy; a lower mean GI score in post-partum women compared with women in their second [WMD = 0.143; 95% CI (0.031; 0.255); p = 0.012] or third term [WMD = 0.256; 95% CI (0.151; 0.360); p < 0.001] of pregnancy, when considering cohort studies; non-pregnant women had lower mean GI values than women in their second or third term of pregnancy. Small changes in plaque levels were reported. CONCLUSIONS: The results of this systematic review confirm that gingival inflammation is significantly increased throughout pregnancy and when comparing pregnant versus post-partum or non-pregnant women, without a concomitant increase in plaque levels. However, this information should be considered with caution, due to the small number of studies included in the meta-analyses, the low quality of the included studies, differences in study design, absence of a periodontal diagnosis at baseline and performance of periodontal treatment in some cases. No conclusions could be drawn regarding secondary outcomes such as microbiological, immunological and patient-centred data, because no meta-analyses were possible for these factors. Future studies with higher quality should be designed to answer these questions.

Effect of Silver Diamine Fluoride on Caries Arrest and Prevention: The CariedAway School-Based Randomized Clinical Trial.

Importance: Dental caries is the most common global childhood disease. To control caries, the Centers for Disease Control and Prevention recommends school-based caries prevention, and the World Health Organization lists glass ionomer cement and silver diamine fluoride as essential medicines for oral disease. Objective: To determine the noninferiority of silver diamine fluoride with fluoride varnish vs traditional glass ionomer sealants with fluoride varnish after 2 years when provided to children via a school-based health care program. Design, Setting, and Participants: The CariedAway study is an ongoing single-blind, cluster randomized, noninferiority trial conducted between February 1, 2019, and June 1, 2023, among 2998 children in 47 New York City primary schools. Children aged 5 to 13 years of any race and ethnicity were recruited from block-randomized schools. Inclusion criteria for schools were a student population of at least 50% Hispanic or Latino or Latina ethnicity and/or Black race and at least 80% of students receiving free or reduced-cost lunch. Statistical analysis is reported through March 2022. Interventions: Children received a single application of silver diamine fluoride with fluoride varnish or an active comparator of glass ionomer sealants and atraumatic restorations with fluoride varnish. Main Outcomes and Measures: Primary outcomes were caries arrest and incidence after a 2-year follow-up, assessed using mixed-effects multilevel models and clustered 2-sample proportion tests. The noninferiority margin was 10%. Intention-to-treat analysis was performed using multiple imputation. Results: A total of 2998 children (1566 girls [52.2%]; mean [SD] age at baseline, 6.6 [1.2] years; 1397 Hispanic or Latino or Latina children [46.6%]; 874 [29.2%] with untreated dental caries) were recruited and treated from September 16, 2019, to March 12, 2020. Follow-up observations were completed for 1398 children from June 7, 2021, to March 2, 2022. The mean (SE) proportion of children with arrested caries was 0.56 (0.04) after experimental treatment and 0.46 (0.04) after control treatment (difference, -0.11; 95% CI, -0.22 to 0.01). The mean (SE) proportion of patients without new caries was 0.81 (0.02) after experimental treatment and 0.82 (0.02) after control treatment (difference, 0.01; 95% CI, -0.04 to 0.06). Analysis of imputed data for the full sample did not deviate from per-protocol analyses. There were no adverse events. Conclusions and Relevance: In this randomized clinical trial, silver diamine fluoride with fluoride varnish was noninferior to sealants and atraumatic restorations with fluoride varnish for caries arrest and prevention. Results may support the use of silver diamine fluoride as an arresting and preventive agent in school-based oral health programs. Trial Registration: ClinicalTrials.gov Identifier: NCT03442309.

The effectiveness of medical nurses in treating children with silver diamine fluoride in a school-based caries prevention program.

BACKGROUND: The sustainability of school-based oral health programs depends on the utilization of effective, efficient treatments and the availability of a trained clinical workforce. The objective of this study was to determine whether registered nurses are comparable to dental hygienists in the application and effectiveness of silver diamine fluoride (SDF) and fluoride varnish (FV) for the prevention of dental caries. METHODS: CariedAway was a school-based study of SDF and FV versus dental sealants and atraumatic restorations. Within the SDF + FV arm, participants were treated by either a licensed dental hygienist or a registered nurse, both under the supervision of a paediatric dentist. Although initial treatment assignment in CariedAway was randomized, assignment to provider was not. The proportion of children who remained caries free after 2 years was assessed for non-inferiority using two-group proportion tests, adjusting for the clustering effect of schools. RESULTS: A total of 417 children with no untreated caries at baseline were analysed including 298 treated by hygienists and 119 by nurses. The proportion of children who remained caries free after 2 years was 0.81 and 0.80 for those treated by hygienists and nurses, respectively, for a difference of 0.01 (95% CI = -0.07, 0.098) and within the pre-determined non-inferiority margin. CONCLUSIONS: Nurses may be effective in treating children with silver diamine fluoride and other fluoride varnishes in school-based oral health programs.

School-based caries prevention and the impact on acute and chronic student absenteeism.

BACKGROUND: Poor oral health is significantly associated with absenteeism, contributing to millions of lost school hours per year. The effect of school-based dental programs that address oral health care inequities on student attendance has not yet been explored. METHODS: CariedAway was a longitudinal, cluster-randomized, noninferiority trial of minimally invasive medicines for caries used in a school-based program. We extracted data on school absenteeism and chronically absent students from publicly available data sets for years before, during, and after program onset (2016-2021). Total absences and the proportion of chronically absent students were modeled using multilevel mixed-effects linear and 2-limit tobit regression, respectively. RESULTS: In years in which treatment was provided through a school-based caries prevention program, schools recorded approximately 944 fewer absences than in nontreatment years (95% CI, -1,739 to -149). Averaged across all study years, schools receiving either treatment had 1,500 fewer absences than comparator schools, but this was not statistically significant. In contrast, chronic absenteeism was found to significantly decrease in later years of the program (b, -.037; 95% CI, -.062 to -.011). Excluding data for years affected by COVID-19 removed significant associations. CONCLUSIONS: Although originally designed to obviate access barriers to critical oral health care, early integration of school-based dental programs may positively affect school attendance. However, the observed effects may be due to poor reliability of attendance records resulting from the closing of school facilities in response to COVID-19, and further study is needed. PRACTICAL IMPLICATIONS: School-based caries prevention may also improve educational outcomes, in addition to providing critical oral health care. This clinical trial was registered at ClinicalTrials.gov. The registration number is NCT03442309.

Sicily statement on classification and development of evidence-based practice learning assessment tools.

BACKGROUND: Teaching the steps of evidence-based practice (EBP) has become standard curriculum for health professions at both student and professional levels. Determining the best methods for evaluating EBP learning is hampered by a dearth of valid and practical assessment tools and by the absence of guidelines for classifying the purpose of those that exist. Conceived and developed by delegates of the Fifth International Conference of Evidence-Based Health Care Teachers and Developers, the aim of this statement is to provide guidance for purposeful classification and development of tools to assess EBP learning. DISCUSSION: This paper identifies key principles for designing EBP learning assessment tools, recommends a common taxonomy for new and existing tools, and presents the Classification Rubric for EBP Assessment Tools in Education (CREATE) framework for classifying such tools. Recommendations are provided for developers of EBP learning assessments and priorities are suggested for the types of assessments that are needed. Examples place existing EBP assessments into the CREATE framework to demonstrate how a common taxonomy might facilitate purposeful development and use of EBP learning assessment tools. SUMMARY: The widespread adoption of EBP into professional education requires valid and reliable measures of learning. Limited tools exist with established psychometrics. This international consensus statement strives to provide direction for developers of new EBP learning assessment tools and a framework for classifying the purposes of such tools.

Causal association between smoking and tooth loss is highly likely.

DATA SOURCES: Medline, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL) and hand searching of the journals; Community Dentistry and Oral Epidemiology, Gerodontology, Journal of Clinical Periodontology, Journal of Dental Research, Journal of Periodontology, Journal of Periodontal Research, Journal of Public Health Dentistry and Oral Diseases. Any potential studies in the reference lists of the identified articles read completely were also considered. STUDY SELECTION: Studies published in English investigating associations between smoking and tooth loss and reporting the effect size were included. Literature reviews and studies that combined former smokers with non-smokers or current smokers were excluded. DATA EXTRACTION AND SYNTHESIS: Data were extracted by one reviewer and verified independently by another with disagreements being resolved by discussion. Methodological quality of studies was assessed using the modified Newcastle-Ottawa Scale (NOS). A qualitative summary is presented. RESULTS: Six cross-sectional and two cohort studies were included examining 58,755 subjects in four countries. All studies reported significant associations, although the strength of the association was usually moderate. Four studies reported dose-response relationships between exposure to smoking and the risk of developing tooth loss. A decrease in the risk of tooth loss for former smokers was evident in six studies. Interpretation of evidence for each element was consistent, despite some shortcomings regarding study type and population. CONCLUSIONS: Based on the consistent evidence found with the existing biological plausibility, a causal association between smoking and tooth loss is highly likely. Further studies using a cohort design and different populations are necessary to confirm this association.

Are lasers as effective as scaling for chronic periodontitis?

DATA SOURCES: Medline, Cochrane Database of Systematic Reviews (CDSR), Database of Abstracts of Reviews of Effects (DARE), CINAHL, Science Direct, ISI Web of Science, and SCOPUS. The following journals were hand searched: Journal of Periodontology, International Journal of Periodontics and Restorative Dentistry, Journal of Clinical Periodontology, Journal of Dental Research, Journal of Periodontal Research, Periodontology 2000, Journal of Dentistry, Journal of American Dental Associations, Journal of Clinical Dentistry, Lasers in Medical Science, Lasers in Surgery and Medicine, Clinical Oral Investigations, and Photomedicine and Laser Surgery as well as the reference lists of included articles. STUDY SELECTION: Randomised controlled clinical trials (RCTs) comparing Er:YAG laser with manual or ultrasonic SRP alone were included. No language restrictions were applied. DATA EXTRACTION AND SYNTHESIS: Data were collected by two independent reviewers with only numeric data being extracted. Data were combined for meta-analysis with the effect size being estimated and reported as the mean difference (MD) for continuous variables using a random effects model. Heterogeneity was assessed using the ÷2-based Q-statistic method and I(2) measurement. RESULTS: Five trials met the inclusion criteria. Five trials (85 patients and 3,564 sites) were entered in the meta-analysis to investigate clinical attachment level (CAL) gain, pocket depth (PD) reduction and gingival recession (GR). All studies reported significant intragroup improvement in clinical and microbiological parameters in patients treated with the Er:YAG laser. However, three studies did not report a significant difference between Er:YAG laser and SRP groups in CAL gain, PD reduction or GR changes. The meta-analysis revealed no significant differences for any investigated parameters at six and 12 months. CONCLUSIONS: Significant heterogeneity, a high risk of bias in three of the five included studies, and methodological shortcomings indicate that the results should be considered with caution. Future long-term, well-designed RCTs are needed to assess the scientific evidence of Er:YAG laser efficacy as an alternative treatment strategy to SRP.