Health visitors' views on promoting oral health and supporting clients with dental health problems: a qualitative study.

BACKGROUND: Inequalities in dental decay in young children persist, resulting in high admission rates for general anaesthetics for tooth extractions. Health visitors have the potential to improve dental attendance and oral health in families least likely to engage with dental services. There is little evidence on health visitor views on this. METHODS: Semi-structured interviews were conducted with a purposive sample of 17 health visitors working in both affluent and deprived areas in a single UK city. Interviews were audio recorded, transcribed, anonymized and analysed following a constructivist grounded theory approach. RESULTS: Knowledge of oral health was high and health visitors requested oral health education specific to the communities they worked in. Health visitors reported effective, formal referral processes to other health services but not to primary NHS dental services even when dealing with infants in pain. Health visitors interviewed were largely unaware of specific NHS dental services which reduce barriers to dental care including interpreting services and dental services for children with additional needs. CONCLUSIONS: Health visitors interviewed were knowledgeable and enthusiastic about oral health but not about dental services. Inadequate links with NHS dental services may limit their effectiveness in oral health improvement and this needs to be addressed.

Use of programme budgeting and marginal analysis to set priorities for local NHS dental services: learning from the north east of England.

Background: Priority setting is necessary where competing demands exceed the finite resources available. The aim of the study was to develop and test a prioritization framework based upon programme budgeting and marginal analysis (PBMA) as a tool to assist National Health Service (NHS) commissioners in their management of resources for local NHS dental services. Methods: Twenty-seven stakeholders (5 dentists, 8 commissioners and 14 patients) participated in a case-study based in a former NHS commissioning organization in the north of England. Stakeholders modified local decision-making criteria and applied them to a number of different scenarios. Results: The majority of financial resources for NHS dental services in the commissioning organization studied were allocated to primary care dental practitioners' contracts in perpetuity, potentially constraining commissioners' abilities to shift resources. Compiling the programme budget was successful, but organizational flux and difficulties engaging local NHS commissioners significantly impacted upon the marginal analysis phase. Conclusions: NHS dental practitioners' contracts resemble budget-silos which do not facilitate local resource reallocation. 'Context-specific' factors significantly challenged the successful implementation and impact of PBMA. A local PBMA champion embedded within commissioning organizations should be considered. Participants found visual depiction of the cost-value ratio helpful during their initial priority setting deliberations.

Mechanisms of the placebo effect in pain and psychiatric disorders.

Placebo effect research over the past 15 years has improved our understanding of how placebo treatments reduce patient symptoms. The expectation of symptom improvement is the primary factor underlying the placebo effect. Such expectations are shaped by past experiences, contextual cues and biological traits, which ultimately modulate one's degree of response to a placebo. The body of evidence that describes the physiology of the placebo effect has been derived from mechanistic studies primarily restricted to the setting of pain. Imaging findings support the role of endogenous opioid and dopaminergic networks in placebo analgesia in both healthy patients as well as patients with painful medical conditions. In patients with psychiatric illnesses such as anxiety disorders or depression, a vast overlap in neurological changes is observed in drug responders and placebo responders supporting the role of serotonergic networks in placebo response. Molecular techniques have been relatively underutilized in understanding the placebo effect until recently. We present an overview of the placebo responder phenotypes and genetic markers that have been associated with the placebo effect in pain, schizophrenia, anxiety disorders and depression.

Barriers to Accessing Primary Dental Care in Adults with Alcohol Dependence: A Qualitative Study.

BACKGROUND: People with alcohol dependence (AD) frequently experience oral health problems, but their dental attendance is poor, with limited evidence to the reasons why from their perspective. OBJECTIVE: To explore perceived barriers, motivators, and facilitators to accessing primary dental care in people with AD. METHODS: Qualitative study consisting of remote one-to-one and group semistructured interviews with a convenience sample of adults with lived experience of AD in northern England. Data were audio-recorded, transcribed, and coded. A reflexive thematic analysis method was used; use of COM-B model informed data interpretation. RESULTS: Twenty adults with lived experience of AD participated in 18 one-to-one interviews and 1 group interview (of 3 participants). Barriers to access were fear and physical, social, and environmental factors (physical effects of AD, financial barriers, nonprioritization of oral health). Motivators to access were pain and prioritization of oral health. Facilitators to access were patterns of alcohol use (i.e., sobriety) and dental service provision within recovery services. CONCLUSIONS: Fear of "the dentist" is a major barrier to accessing dental care, and pain is the primary motivator, among people with AD, although neither are unique to this population. Fear and physical, social, and environmental barriers to access contribute to problem-oriented attendance, which negatively affect oral health outcomes. Opportunity to facilitate attendance increases when a person is in remission from AD through their physical capabilities improving. Increasing capability and opportunity can influence attendance beyond the automatic motivation of pain. Provision of dental care within recovery services could facilitate access to care. Understanding the "web of causation" is key to developing any intervention to improve dental access in people with AD. Further research is needed from the perspective of other adult populations with lived experience of AD, as well as of dental professionals, to gain deeper insight into barriers, facilitators, and possible solutions. KNOWLEDGE TRANSFER STATEMENT: The results of this study can help dental professionals understand factors affecting access to primary care in people with alcohol dependence to provide knowledge that may reduce stigma surrounding the disease. Results also demonstrate areas for intervention development for public policy.

Developing an assessment in dental public health for clinical undergraduates attending a primary dental care outreach programme.

BACKGROUND: This paper describes the development and implementation of a Dental Public Health (DPH) assessment within the Primary Dental Care Outreach (PDCO) course at Newcastle University. The assessment was piloted alongside the delivery of the Bachelor of Dental Surgery (BDS) curriculum in accordance with established learning outcomes. AIM: To design and implement a pilot summative assessment, incorporating patients' social histories obtained by undergraduate students attending primary dental care outreach clinics. METHOD: Undergraduates were tasked with obtaining a detailed social history from a patient seen during their two-year outreach attachment. Each student submitted a written account of their patient's social history and placed this in context by researching a number of demographic and social variables centred upon their patient's home residence. The final component involved writing a concise case feature for a nominated newspaper based upon the case history, where students were encouraged to identify one or more public health messages using language appropriate to a lay readership. RESULTS: Seventy one clinical undergraduates (98.6% of the year-group) subsequently submitted all components of the assessment. Eighty six per cent of the year-group was deemed to have passed the assessment with 9.9% achieving a 'Merit' grade and 76% a 'Satisfactory' grade. Following the assessment, students and clinical teachers were asked for their feedback through a focus group for staff, and a brief feedback form for students. CONCLUSION: Undergraduates subsequently reported greater awareness of the significance and importance of obtaining a detailed social history and its relevance when devising appropriate and realistic treatment plans.

Resource Allocation in a National Dental Service Using Program Budgeting Marginal Analysis.

INTRODUCTION: In any health system, choices must be made about the allocation of resources (budget), which are often scarce. Economics has defined frameworks to aid resource allocation, and program budgeting marginal analysis (PBMA) is one such framework. In principle, patient and public values can be incorporated into these frameworks, using techniques such as willingness to pay (WTP). However, this has not been done before, and few formal resource allocation processes have been undertaken in dentistry. This study aimed to undertake a PBMA with embedded WTP values in a national dental setting. METHODS: The PBMA process was undertaken by a panel of participant-researchers representing commissioners, dentists, dental public health staff, and academics. The panel reviewed current allocations and generated a set of weighted criteria to evaluate services against. Services to be considered for removal and investment were determined by the panel and wider discussion and then scored against the criteria. Values from a nationally representative WTP survey of the public contributed to the scores for interventions. Final decisions on removal and investment were taken after panel discussion using individual anonymous electronic voting. RESULTS: The PBMA process resulted in recommendations to invest in new program components to improve access to general dentists, care home dentistry, and extra support for dental public health input into local government decisions. Disinvestments were recommended in orthodontics and to remove routine scaling and polishing of teeth. DISCUSSION: The PBMA process was successful in raising awareness of resource allocation issues. Implementation of findings will depend on the ability of decision makers to find ways of operationalizing the decisions. The process illustrates practical aspects of the process that future dental PBMAs could learn from. KNOWLEDGE TRANSFER STATEMENT: This study illustrates a framework for resource allocation in dental health services and will aid decision makers in implementing their own resource allocation systems.

Colonic stool burden on computed tomography does not correlate with bowel habit: a cross-sectional study.

PURPOSE: Stool burden on abdominal radiographs is not reflective of constipation, perhaps because of variable fecal shadowing or limited inter-rater agreement. These limitations are hypothetically mitigated by computed tomography (CT). This research aimed (i) to evaluate whether bowel movement frequency, stool form, or a diagnosis of functional constipation correlate or associate with stool burden identified on CT, and (ii) to investigate whether physicians use CT in their assessment of a patients' bowel function. METHODS: Patients attending for non-emergent abdominal CT imaging were invited to participate by completing a bowel questionnaire. Stool burden identified on imaging was determined and inter-rater reliability was evaluated in a subgroup of patients (n = 20). Descriptive and comparative analyses were performed. An online questionnaire evaluated the use of abdominal imaging in assessing patients' bowel function in a cross-section of ordering physicians. RESULTS: The patient response rate was 19% (96/516). No clinically useful associations between fecal burden and stool form, bowel motion frequency, gastrointestinal symptoms or a diagnosis of constipation was identified. The physician response rate was 35% (33/94). Opportunistic use of data was more common than deliberate use. However, an abdominal radiograph or CT scan had been requested by 42% and 18% of physicians respectively to assess patient's chronic bowel habit. Approximately 30% of physicians believed evidence supported this practice. CONCLUSIONS: Physicians may use abdominal CT in their assessment of patients' chronic bowel habits. However, objective assessment does not support this practice. Colonic stool burden does not correlate with patient-reported symptoms or a criteria-based diagnosis of constipation.

Child Caries Management: A Randomized Controlled Trial in Dental Practice.

This multicenter 3-arm, parallel-group, patient-randomized controlled trial compared clinical effectiveness of 3 treatment strategies over 3 y for managing dental caries in primary teeth in UK primary dental care. Participants aged 3 to 7 y with at least 1 primary molar with dentinal carious lesion were randomized across 3 arms (1:1:1 via centrally administered system with variable-length random permuted blocks): C+P, conventional carious lesion management (complete carious tooth tissue removal and restoration placement) with prevention; B+P, biological management (sealing in carious tooth tissue restoratively) with prevention; and PA, prevention alone (diet, plaque removal, fluorides, and fissure sealants). Parents, children, and dentists were not blind to allocated arm. Co-primary outcomes were 1) the proportion of participants with at least 1 episode of dental pain and/or infection and 2) the number of episodes of dental pain and/or infection during follow-up (minimum, 23 mo). In sum, 1,144 participants were randomized (C+P, n = 386; B+P, n = 381; PA, n = 377) by 72 general dental practitioners, of whom 1,058 (C+P, n = 352; B+P, n = 352; PA, n = 354) attended at least 1 study visit and were included in the primary analysis. The median follow-up was 33.8 mo (interquartile range, 23.8 to 36.7). Proportions of participants with at least 1 episode of dental pain and/or infection were as follows: C+P, 42%; B+P, 40%; PA, 45%. There was no evidence of a difference in incidence of dental pain and/or infection when B+P (adjusted risk difference [97.5% CI]: -2% [-10% to 6%]) or PA (4% [-4% to 12%]) was compared with C+P. The mean (SD) number of episodes of dental pain and/or infection were as follows: C+P, 0.62 (0.95); B+P, 0.58 (0.87); and PA, 0.72 (0.98). Superiority could not be concluded for number of episodes between B+P (adjusted incident rate ratio (97.5% CI): 0.95 [0.75 to 1.21]) or PA (1.18 [0.94 to 1.48]) and C+P. In conclusion, there was no evidence of a difference among the 3 treatment approaches for incidence or number of episodes of dental pain and/or infection experienced by these participants with high caries risk and established disease (trial registration: ISRCTN77044005).

Systematic Review of Evidence Pertaining to Factors That Modify Risk of Early Childhood Caries.

INTRODUCTION: A systematic review of evidence on the impact of modifiable risk factors on early childhood caries (ECC) was conducted to inform recommendations in a World Health Organization manual on ECC prevention. OBJECTIVES: To systematically review published evidence pertaining to the effect of modifiable risk factors on ECC. METHODS: Twelve questions relating to infant feeding, diet, oral hygiene, and fluoride were addressed, as prioritized by a World Health Organization expert panel. Questions pertaining to the use of fluoride toothpaste were excluded due to its proven efficacy. The target population was children aged <72 mo. Data sources included Medline, Embase, CINAHL, and PubMed, and all human epidemiologic studies were included. The highest level of evidence was used for evidence synthesis and, where possible, meta-analysis. The review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) statement, with evidence assessed via the GRADE method. RESULTS: Of the 13,831 papers identified, 627 were screened in duplicate; of these, 139 were included. The highest-level evidence indicated that breastfeeding ≤24 mo does not increase ECC risk but suggested that longer-duration breastfeeding increases risk (low-quality evidence). Low-quality evidence indicated increased risk associated with consumption of sugars in bottles. Only 1 study had data on the impact of sugars in complementary foods, which increased risk. Moderate-quality evidence showed a benefit of oral health education for caregivers (odds ratio, 0.39; 95% CI, 0.19 to 0.80, P = 0.009). Meta-analysis of data on the impact on ECC from living in a fluoridated area showed a significant effect (mean difference, -1.25; 95% CI, -1.24 to -0.36; P = 0.006). Limited moderate- and low-quality data indicated a benefit of fluoride exposure from salt and milk, respectively. CONCLUSION: The best available evidence indicates that breastfeeding up to 2 y of age does not increase ECC risk. Providing access to fluoridated water and educating caregivers are justified approaches to ECC prevention. Limiting sugars in bottles and complementary foods should be part of this education. KNOWLEDGE TRANSFER STATEMENT: This research is being used by the World Health Organization in developing a toolkit on the prevention and management of early childhood caries. The information will guide 1) governments in developing national oral health plans and 2) clinicians when providing preventive advice, including that regarding infant feeding practices. It will help ensure that advice is in line with current World Health Organization guidelines and the best available evidence.

Patterns of care and service use amongst children in England, Wales and Northern Ireland 2013.

Background The 2013 Children's Dental Health survey is the fifth in a series of national surveys.Aims This paper describes children's reported use of dental services, their experience of receiving dental treatment and parental satisfaction with services.Methodology A representative sample of children (aged 5, 8, 12 and 15 years) in England, Wales and Northern Ireland were invited to participate in dental examinations. Older children and all parents were invited to complete a questionnaire about oral health behaviours and attitudes.Results Over 80% of 12- and 15-year-olds reported attending for a check-up. According to parents, 9 in 10 children of all ages had visited a dentist in the last year and 9 in 10 parents reported they were satisfied with the last dental practice their child had visited. There was some variation by country with respect to children's experiences of fillings and extractions.Conclusions There has been little change in the reported attendance patterns of children since the 2003 survey. Family deprivation (measured by children's eligibility for free school meals) negatively influenced dental attendance for regular check-ups, attendance within the last 12 months and the likelihood of having experienced difficulties accessing NHS dental services for children.

The impact of oral conditions on children in England, Wales and Northern Ireland 2013.

Background The 2013 Children's Dental Health survey is the fifth in a series of national surveys.Aim To summarise key findings on oral health perceptions, oral symptoms, and the impacts of oral conditions on the daily life of children and their families.Methodology A representative sample of children (aged 5, 8 12 and 15 years) and their parents in England, Wales and Northern Ireland completed relevant questionnaires.Results Oral symptoms, even more profound ones such as toothache, were prevalent among all age groups. Overall, 58% of 12- and 45% of 15-year-olds reported at least one oral impact in the past three months. The most prevalent oral impact was feeling embarrassed to smile or laugh, followed by difficulty eating. These symptoms and oral impacts were disproportionately high among children eligible for free school meals. Furthermore, one fifth to one third of parents reported that their children's oral conditions had some impact on their family life.Conclusion Oral symptoms were common and oral conditions had a negative impact on the quality of life of large proportions of children. There were clear and marked socioeconomic inequalities, with considerably worse oral health perceptions and higher levels of oral impacts among the more deprived children.

Forty years of national surveys: An overview of children's dental health from 1973-2013.

INTRODUCTION: The first national survey of children's dental health in England and Wales was carried out in 1973. Subsequent surveys, in 1983, 1993 and 2003, included all United Kingdom health departments. The 2013 survey involved England, Wales and Northern Ireland. AIM: To consider all five surveys, from 1973 to 2013, so as to summarise trends in the dental health of children in the UK over the last 40 years. MATERIALS AND METHOD: The 2013 survey was commissioned by the Health &Social Care Information Centre and all surveys used data collected during dental examinations conducted in schools on a random sample of children by NHS dentists, together with a questionnaire to parents of those children. In 2013, a pupil questionnaire for 12- and 15-year-olds was introduced, to complement information received from parents and carers. RESULTS: A total of 69,318 children, aged 5-15 years, were involved, from 1973-2013. Caries prevalence has reduced from 72% to 41% in 5-year-olds, and from 97% to 46% in 15-year-olds in 40 years. Changes in periodontal disease, orthodontic treatment, accidental damage to anterior teeth, tooth surface loss and enamel defects, are also summarised. Behavioural and attitudinal characteristics observed in the 2013 report are listed. CONCLUSIONS: Caries is now concentrated in a minority of children. The prevalence of gingivitis has not changed a great deal in 40 years. About half of those children assessed 'in orthodontic need' receive treatment.

Peroxisomal disorders: clinical commentary and future prospects.

Recent progress in the classification, biochemistry, and molecular biology of peroxisomal disorders is reviewed from a clinical perspective. Diseases such as Zellweger syndrome, neonatal adrenoleukodystrophy, infantile Refsum disease, hyperpipecolic acidemia, chondrodysplasia punctata, and Leber amaurosis share a common phenotype and involve deficiency of multiple peroxisomal enzymes. These disorders are associated with diverse metabolic abnormalities which are useful in pre- or postnatal diagnosis and distinguish these disorders from others such as X-linked adrenoleukodystrophy, adult Refsum disease, hyperoxaluria type I, and acatalasemia. Peroxisome structure is difficult to quantify histologically, since recent studies emphasize its developmental variability and tissue heterogeneity. The ability to manipulate this structure by dietary or pharmaceutical means provides a novel approach to therapy. At the molecular level, deficiency of peroxisomal enzymes responsible for fatty acid beta-oxidation or ether lipid synthesis reflects enhanced protein degradation due to abnormal peroxisomes; messenger RNA for the beta-oxidation enzymes is transcribed normally in peroxisomal disorders and can be increased by peroxisome proliferators. At least one integral structural protein of the peroxisome is synthesized normally in Zellweger syndrome. Hypotheses for the basic defect include defective regulation, uptake, or coenzyme stimulation of imported proteins, as well as defective biosynthesis. One clue to this defect may be a similar evolutionary history of peroxisomes and mitochondria which would explain their common alteration in Zellweger syndrome.

Dietary ether lipid incorporation into tissue plasmalogens of humans and rodents.

Chronic feeding of 1-O-octadecyl-sn-glycerol (batyl alcohol) to patients suffering from congenital deficiency in tissue ether glycerolipids showed an increase in the plasmalogens content of their erythrocytes. However, nothing is known about the ether lipid content of other tissues in these patients. Feeding 1-O-heptadecyl-sn-glycerol to young rats showed that this uncommon ether lipid was incorporated to a high extent into the plasmalogens of all tissues except brain. Comparative studies with other precursors, such as 3-O-heptadecyl-sn-glycerol, heptadecanol and heptadecanoic acid, indicated a stereospecific incorporation of the dietary 1-O-alkyl-sn-glycerols into tissue plasmalogens without cleavage of the ether bond. Dietary ether lipids were also shown to be transferred from mothers to suckling rats, but not from pregnant rats to fetuses. The implication of these results to possible dietary ether lipid therapy for patients suffering from peroxisomal disorders is discussed.

Continuing professional development and application of knowledge from research findings: a qualitative study of general dental practitioners.

OBJECTIVES: To explore general dental practitioners' opinions about continuing professional development (CPD) and potential barriers to translating research findings into clinical dental practice. DESIGN: Qualitative focus group and interviews. SUBJECTS, SETTING AND METHODS: Four semi-structured interviews and a single focus group were conducted with 11 general dental practitioners in North East England. OUTCOME MEASURE: Transcripts were analysed using the constant comparative method to identify emergent themes. RESULTS: The key theme for practitioners was a need to interact with colleagues in order to make informed decisions on a range of clinical issues. For some forms of continuing professional development the value for money and subsequent impact upon clinical practice was limited. There were significant practice pressures that constrained the ability of practitioners to participate in certain educational activities. The relevance of some research findings and the formats used for their dissemination were often identified as barriers to their implementation in general dental practice. CONCLUSIONS: There are a number of potential barriers that exist in general dental practice to the uptake and implementation of translational research. CPD plays a pivotal role in this process and if new methods of CPD are to be developed consideration should be given to include elements of structured content and peer review that engages practitioners in a way that promotes implementation of contemporary research findings.

Oral urgent treatment (OUT) - a volunteer led training programme in North West Tanzania.

Oral health is recognised as a fundamental contributor to general health. In many developing countries resources are scarce and access to oral healthcare is often limited, particularly in rural areas. An approach to solving the problem of providing oral healthcare in developing nations is the Basic Package of Oral Care (BPOC), which promotes the community-oriented promotion of oral health and affordable and effective interventions. The aim of this paper is to focus on one component of the BPOC, by presenting a model for the provision of a local training programme of oral urgent treatment (OUT), delivered by volunteers, in a region of North West Tanzania.

A soil ingestion pilot study of a population following a traditional lifestyle typical of rural or wilderness areas.

The relatively few soil ingestion studies underpinning the recommended soil ingestion rates for contaminated site human health risk assessments (HHRAs) that have been conducted to date assessed soil ingestion in children living in urban or suburban areas of the United States, and to a lesser extent, Europe. However, the lifestyle of populations living in North American urban and suburban environments is expected to involve limited direct contact with soil. Conversely, many populations, such as indigenous and Aboriginal peoples residing in rural and wilderness areas of North America and worldwide, participate in activities that increase the frequency of direct contact with soil. Qualitative exposure of Aboriginal populations inhabiting wilderness areas suggest that high levels of soil ingestion may occur that are many times greater than those recommended by regulatory agencies for use in HHRAs. Accordingly, a study of subjects selected from a wilderness community in Canada was conducted using mass balance tracer methods to estimate soil ingestion and the results compared with previous soil ingestion studies and regulatory guidelines for the soil ingestion rates used in HHRA of contaminated sites. A pilot study of 7 subjects living in the Nemiah Valley of British Columbia was conducted over a 3-week period. The mean soil ingestion rate estimated in this study using the 4 elemental tracers with the lowest food-to-soil ratios (i.e., Al, Ce, La, Si), was observed to be approximately 75 mg d(-1) (standard deviation 120 mg d(-1)), the median soil ingestion rate was 50 mg d(-1), and the 90th percentile was 211 mg d(-1). These soil ingestion rate estimates are higher than the soil ingestion estimates currently recommended for HHRAs of adults, and higher than those obtained in most previous studies of adults. However, the estimates are lower than the earlier qualitative assessments of subsistence lifestyles.

Managing resources in NHS dentistry: the views of decision-makers in primary care organisations.

OBJECTIVE: To investigate priority setting and decision-making in primary care organisations and to determine how resources are managed in order to meet the oral health needs of local populations. METHOD: This is a qualitative study. The purposive sample comprised twelve dental public health consultants and six senior finance representatives from contrasting care systems across the United Kingdom. Participants completed a written information sheet followed by a recorded semi-structured telephone interview. Conversations were professionally transcribed verbatim and analysed independently by two investigators using the constant comparative method. RESULTS: The emergent themes focused upon: the role of participants in decision-making; professional relationships; managing change; information needs; and identifying and managing priorities. There was wide interpretation with respect to participants' roles and perceived information needs for decision-making and commissioning. A unifying factor was the importance placed by participants upon trust and the influence of individuals on the success of relationships forged between primary care organisations and general dental practitioners. CONCLUSION: To facilitate decision-making in primary care organisations, commissioners and managers could engage further with practitioners and incorporate them into commissioning and resource allocation processes. Greater clarity is required regarding the role of dental public health consultants within primary care organisations and commissioning decisions.