Effect of fluoridated water on invasive NHS dental treatments for adults: the LOTUS retrospective cohort study and economic evaluation.

Background: Most water fluoridation studies were conducted on children before the widespread introduction of fluoride toothpastes. There is a lack of evidence that can be applied to contemporary populations, particularly adolescents and adults. Objective: To pragmatically assess the clinical and cost effectiveness of water fluoridation for preventing dental treatment and improving oral health in a contemporary population of adults, using a natural experiment design. Design: Retrospective cohort study using routinely collected National Health Service dental claims (FP17) data. Setting: National Health Service primary dental care: general dental practices, prisons, community dental services, domiciliary settings, urgent/out-of-hours and specialised referral-only services. Participants: Dental patients aged 12 years and over living in England (n = 6,370,280). Intervention and comparison: Individuals exposed to drinking water with a fluoride concentration ≥ 0.7 mg F/l between 2010 and 2020 were matched to non-exposed individuals on key characteristics using propensity scores. Outcome measures: Primary: number of National Health Service invasive dental treatments (restorations/'fillings' and extractions) received per person between 2010 and 2020. Secondary: decayed, missing and filled teeth, missing teeth, inequalities, cost effectiveness and return on investment. Data sources: National Health Service Business Services Authority dental claims data. Water quality monitoring data. Primary outcome: Predicted mean number of invasive dental treatments was 3% lower in the optimally fluoridated group than in the sub/non-optimally fluoridated group (incidence rate ratio 0.969, 95% CI 0.967 to 0.971), a difference of -0.173 invasive dental treatments (95% CI -0.185 to -0.161). This magnitude of effect is smaller than what most stakeholders we engaged with (n = 50/54) considered meaningful. Secondary outcomes: Mean decayed, missing and filled teeth were 2% lower in the optimally fluoridated group, with a difference of -0.212 decayed, missing and filled teeth (95% CI -0.229 to -0.194). There was no statistically significant difference in the mean number of missing teeth per person (0.006, 95% CI -0.008 to 0.021). There was no compelling evidence that water fluoridation reduced social inequalities in treatments received or missing teeth; however, decayed, missing and filled teeth data did not demonstrate a typical inequalities gradient. Optimal water fluoridation in England in 2010-20 was estimated to cost £10.30 per person (excluding original setup costs). Mean National Health Service treatment costs for fluoridated patients 2010-20 were 5.5% lower per person, by £22.26 (95% CI -£23.09 to -£21.43), and patients paid £7.64 less in National Health Service dental charges per person (2020 prices). Limitations: Pragmatic, observational study with potential for non-differential errors of misclassification in fluoridation assignment and outcome measurement and residual and/or unmeasured confounding. Decayed, missing and filled teeth data have not been validated. Water fluoridation cost estimates are based on existing programmes between 2010 and 2020, and therefore do not include the potentially significant capital investment required for new programmes. Conclusions: Receipt of optimal water fluoridation between 2010 and 2020 resulted in very small health effects, which may not be meaningful for individuals, and we could find no evidence of a reduction in social inequalities. Existing water fluoridation programmes in England produced a positive return on investment between 2010 and 2020 due to slightly lower National Health Service treatment costs. These relatively small savings should be evaluated against the projected costs and lifespan of any proposed capital investment in water fluoridation, including new programmes. Future work: National Health Service dental data are a valuable resource for research. Further validation and measures to improve quality and completeness are warranted. Trial registrations: This trial is registered as ISRCTN96479279, CAG: 20/CAG/0072, IRAS: 20/NE/0144. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: NIHR128533) and is published in full in Public Health Research; Vol. 12, No. 5. See the NIHR Funding and Awards website for further award information.

Fluoride is a natural mineral that prevents tooth decay. It is added to some drinking water and toothpastes to improve dental health. Water with fluoride added is known as 'optimally fluoridated'. Most research on water fluoridation was carried out before fluoride was added to toothpastes in the 1970s and only included children. We wanted to know if water fluoridation still produced large reductions in tooth decay, now that decay levels are much lower because of fluoride in toothpaste. We also wanted to look at its effect on adults and teenagers. Dental patients we spoke to told us they worried about needing treatment with the 'drill', or 'injection', losing their teeth and paying for their dental care. To see if water fluoridation helped with these concerns, we compared the National Health Service dental records of 6.4 million adults and teenagers who received optimally fluoridated or non-optimally fluoridated water in England between 2010 and 2020. We found water fluoridation made a very small difference to each person. Between 2010 and 2020, the number of NHS fillings and extractions was 3% lower per person for those who received optimally fluoridated water. We found no difference in the number of teeth lost per person and no strong sign that fluoridation reduced differences in dental health between rich and poor areas. Between 2010 and 2020, the cost of optimal water fluoridation was £10.30 per person (not including setup costs). National Health Service dental patients who received optimally fluoridated water cost the National Health Service £22.26 (5.5%) less and paid £7.64 (2%) less per person in National Health Service dental charges over the 10 years. The benefits we found are much smaller than in the past, when toothpastes did not contain fluoride. The cost to set up a new water fluoridation programme can be high. Communities may need to consider if these smaller benefits would still outweigh the costs.

How effective and cost-effective is water fluoridation for adults and adolescents? The LOTUS 10-year retrospective cohort study.

OBJECTIVE: To pragmatically assess the clinical and cost-effectiveness of water fluoridation for preventing dental treatment and improving oral health in a contemporary population of adults and adolescents, using a natural experiment design. METHODS: A 10-year retrospective cohort study (2010-2020) using routinely collected NHS dental treatment claims data. Participants were patients aged 12 years and over, attending NHS primary dental care services in England (17.8 million patients). Using recorded residential locations, individuals exposed to drinking water with an optimal fluoride concentration (≥0.7 mg F/L) were matched to non-exposed individuals using propensity scores. Number of NHS invasive dental treatments, DMFT and missing teeth were compared between groups using negative binomial regression. Total NHS dental treatment costs and cost per invasive dental treatment avoided were calculated. RESULTS: Matching resulted in an analytical sample of 6.4 million patients. Predicted mean number of invasive NHS dental treatments (restorations 'fillings'/extractions) was 3% lower in the optimally fluoridated group (5.4) than the non-optimally fluoridated group (5.6) (IRR 0.969, 95% CI 0.967, 0.971). Predicted mean DMFT was 2% lower in the optimally fluoridated group (IRR 0.984, 95% CI 0.983, 0.985). There was no difference in the predicted mean number of missing teeth per person (IRR 1.001, 95% CI 0.999, 1.003) and no compelling evidence that water fluoridation reduced social inequalities in dental health. Optimal water fluoridation in England 2010-2020 was estimated to cost £10.30 per person (excludes initial set-up costs). NHS dental treatment costs for optimally fluoridated patients 2010-2020 were 5.5% lower, by £22.26 per person (95% CI -£21.43, -£23.09). CONCLUSIONS: Receipt of optimal water fluoridation 2010-2020 resulted in very small positive health effects which may not be meaningful for individuals. Existing fluoridation programmes in England produced a positive return on investment between 2010 and 2020 due to slightly lower NHS dental care utilization. This return should be evaluated against the projected costs and lifespan of any proposed capital investment in water fluoridation, including new programmes.

The use of oral benzodiazepines for the management of dental anxiety: a web-based survey of UK dentists.

Background Oral benzodiazepines (OBZs) can facilitate treatment of dentally anxious patients and are widely used in countries such as Australia and the United States. Dentists in the UK prescribe them much less often.Aims To examine OBZ prescribing by dentists in the UK, including patterns of practice, barriers to use, and alternative anxiety management strategies.Methods An online mixed-methods survey was conducted utilising Qualtrics. Participants were recruited via the private Facebook group 'For Dentists, By Dentists' during April to June 2021. Quantitative data were analysed with descriptive statistics and qualitative data with thematic analysis.Results In total, 235 dentists participated, with 91% being general dentists. Half had previously prescribed OBZs, with 36% doing so in the last year. Only 18% were confident in their use. Diazepam was the anxiolytic preferred by respondents. Two-thirds of dentists who had never prescribed anxiolytics were interested in doing so in the future. Concerns about managing anxious patients with OBZs included: inadequate training; confusion about guidelines; medico-legal risk; and issues of general practitioners prescribing anxiolytics to dental patients unbeknown to their dentist.Conclusions A lack of confidence prescribing OBZs for anxiolysis exists among UK dentists. Guidelines should be clarified, and training provided.

One Full or Two Fractional Doses of Inactivated Poliovirus Vaccine for Catch-up Vaccination in Older Infants: A Randomized Clinical Trial in Bangladesh.

BACKGROUND: The polio eradication endgame called for the removal of trivalent oral poliovirus vaccine (OPV) and introduction of bivalent (types 1 and 3) OPV and inactivated poliovirus vaccine (IPV). However, supply shortages have delayed IPV administration to tens of millions of infants, and immunogenicity data are currently lacking to guide catch-up vaccination policies. METHODS: We conducted an open-label randomized clinical trial assessing 2 interventions, full or fractional-dose IPV (fIPV, one-fifth of IPV), administered at age 9-13 months with a second dose given 2 months later. Serum was collected at days 0, 60, 67, and 90 to assess seroconversion, priming, and antibody titer. None received IPV or poliovirus type 2-containing vaccines before enrolment. RESULTS: A single fIPV dose at age 9-13 months yielded 75% (95% confidence interval [CI], 6%-82%) seroconversion against type 2, whereas 2 fIPV doses resulted in 100% seroconversion compared with 94% (95% CI, 89%-97%) after a single full dose (P < .001). Two doses of IPV resulted in 100% seroconversion. CONCLUSIONS: Our study confirmed increased IPV immunogenicity when administered at an older age, likely due to reduced interference from maternally derived antibodies. Either 1 full dose of IPV or 2 doses of fIPV could be used to vaccinate missed cohorts, 2 fIPV doses being antigen sparing and more immunogenic. CLINICAL TRIAL REGISTRATION: NCT03890497.

Unlocking the potential of NHS primary care dental datasets.

Introduction Maximising the use of routinely collected health data for research is a key part of the UK Government's Industrial Strategy. Rich data are generated by NHS primary care dental services, but the extent of their use in research is unknown.Aims To profile the utility of the post-2006 NHS dental datasets for research, map how they have been used to date and develop recommendations to maximise their utility.Methods The content of and access to the four UK NHS dental datasets was collated using publicly available information and a free-text questionnaire, completed by the relevant data controllers. A scoping review was carried out to identify and map literature that has utilised NHS dental activity data.Results The contents of the UK NHS dental activity datasets are described, alongside how they may be accessed for research. Strengths and weaknesses of these datasets for research are highlighted. The scoping review identified 33 studies which had utilised NHS dental activity data since 2006. We classified 15 as public health practice, 11 as service evaluation and 7 as research.Conclusion In comparision to other NHS activity datasets, it appears that the UK dental datasets have been underutilised for research. We make 11 recommendations on how their utility for research may be increased.

How effective and cost-effective is water fluoridation for adults? Protocol for a 10-year retrospective cohort study.

BACKGROUND: Tooth decay can cause pain, sleepless nights and loss of productive workdays. Fluoridation of drinking water was identified in the 1940s as a cost-effective method of prevention. In the mid-1970s, fluoride toothpastes became widely available. Since then, in high-income countries the prevalence of tooth decay in children has reduced whilst natural tooth retention in older age groups has increased. Most water fluoridation research was carried out before these dramatic changes in fluoride availability and oral health. Furthermore, there is a paucity of evidence in adults. The aim of this study is to assess the clinical and cost-effectiveness of water fluoridation in preventing invasive dental treatment in adults and adolescents aged over 12. METHODS/DESIGN: Retrospective cohort study using 10 years of routinely available dental treatment data. Individuals exposed to water fluoridation will be identified by sampled water fluoride concentration linked to place of residence. Outcomes will be based on the number of invasive dental treatments received per participant (fillings, extractions, root canal treatments). A generalised linear model with clustering by local authority area will be used for analysis. The model will include area level propensity scores and individual-level covariates. The economic evaluation will focus on (1) cost-effectiveness as assessed by the water fluoridation mean cost per invasive treatment avoided and (2) a return on investment from the public sector perspective, capturing the change in cost of dental service utilisation resulting from investment in water fluoridation. DISCUSSIONS: There is a well-recognised need for contemporary evidence regarding the effectiveness and cost-effectiveness of water fluoridation, particularly for adults. The absence of such evidence for all age groups may lead to an underestimation of the potential benefits of a population-wide, rather than targeted, fluoride delivery programme. This study will utilise a pragmatic design to address the information needs of policy makers in a timely manner.

Does dental appearance impact on employability in adults? A scoping review of quantitative and qualitative evidence.

Background The importance of physical appearance in social and professional situations has been well studied. It has been suggested that improving dental appearance may increase employment prospects. This scoping review aims to map the current literature regarding the impact of dental appearance on employability.Methods A scoping review was carried out in accordance with guidance from the Joanna Briggs Institute. Inclusion and exclusion criteria were developed iteratively, databases were searched and decisions on inclusion made in duplicate. Data were charted in Excel and synthesised using a visual map, study summary table and narrative description.Results We identified 16 relevant articles: ten experimental simulation studies, two qualitative studies, one cross-sectional survey, one pre-/post-dental treatment survey, one retrospective cohort study and one narrative systematic review. Experimental simulations support the notion that visible dental conditions can negatively impact appraisals of employment-related personal characteristics. Negative impacts on job-seeking self-efficacy and willingness to apply for jobs have also been documented.Conclusions The applicability of this evidence base to the UK health system context is uncertain and demonstration of real-life impact on employment is lacking. Further research is needed before programmes to improve dental appearance could be justified on the basis of improving employment outcomes.

Is nicotine damaging to oral tissues?

Data sources The review included 42 pre-clinical in-vitro studies, published between 1995 and 2017. Study selection The study selected in-vitro studies which had assessed the effect of nicotine on human gingival and periodontal fibroblasts and epithelial cells. Typically, diluted pure nicotine was added to a cell culture medium in a variety of doses for a variety of time periods and the cells were then compared against a no-nicotine control. Outcomes assessed were: Cell viability, cell attachment or adhesion, cell proliferation or inflammatory mediator production. Studies were restricted to English language and full-text only.Data extraction and synthesis Two members of the review team screened abstracts and reviewed the full-texts independently. Disagreements regarding inclusion were resolved by discussion and consultation with the third author. Data were also extracted independently using a specifically designed data extraction form which included a quality assessment specifically designed for in-vitro studies. A narrative synthesis of the results was carried out.Results The included studies were heterogeneous in their designs, with a wide variety of cell types, concentrations of nicotine (1 nM to 100 mM), exposure times (30 minutes to four weeks), and assays used. All studies were assessed at being at high risk of bias due to lack of randomisation, allocation concealment, and blinding. No effect on cell viability was observed when the nicotine concentrations used were within the ranges observed in-vivo in smokers, nicotine replacement therapy users (NRT) and e-cigarette users. Cell viability was adversely affected only when concentrations of nicotine reached those observed in the saliva of smokeless tobacco users (>5 mM). However, periodontal ligament cells are not usually exposed to saliva in-vivo. Effects on cell attachment, cell proliferation and production of inflammatory mediators were reported at a wide range of concentrations, but the effects were contradictory. The authors make several recommendations for future research in this area, to improve the quality of the primary studies. Conclusions At the concentrations found in smokers and users of NRT including e-cigarettes, nicotine is unlikely to be toxic to human gingival and periodontal ligament cells in in-vitro. Higher concentrations of nicotine, of the levels observed in the saliva of smokeless tobacco users, have been shown to be cytotoxic in vitro.

Long-term variability in artificially and naturally fluoridated water supplies in England.

OBJECTIVES: To understand the potential impact of exposure misclassification on water fluoridation studies in England, this paper aims to describe the long-term variation in water fluoride concentrations in both artificially and naturally fluoridated water supplies. METHODS: Water fluoridation dose monitoring data were requested from all five English public water suppliers who artificially fluoridate their water, as well as from one water company that supplies naturally fluoridated water. Descriptive statistics were calculated, including annual means, standard deviations, minimum-maximum and absolute and relative frequencies. RESULTS: Data were made available by two of the five English water companies who supply artificially fluoridated water and one water company that supplies naturally fluoridated water (40 398 individual samples). The data for fluoridated water spanned 18-35 years, whilst the data on naturally fluoridated water spanned 14 years. The artificially fluoridated samples showed wide variation in fluoride dose control, both between different water treatment works and over time. Mean fluoride concentrations in the artificially fluoridated supplies ranged from 0.53 (SD 0.47) to 0.93 (SD 0.22) mg F/L and were within the optimal range of 0.7-1.0 mg F/L in 27.7%-77.8% of samples. The naturally fluoridated supplies had a higher mean fluoride concentration of 1.06 (SD 0.18) and 1.15 (SD 0.16) mg F/L than the artificially fluoridated supplies, with lower variation over time. The naturally fluoridated supplies were above the optimal range in 75.5% and 53% of samples. CONCLUSIONS: Assumptions that populations living in areas with a water fluoridation scheme have received optimally fluoridated water (0.7-1.0 mg F/L) are invalid. To support future research endeavours, as well as to provide 'external control' and facilitation of optimal dosing, it is recommended that a quarterly record of water fluoride concentrations (mean, standard deviation and minimum and maximum) are made available for every water supply in England, in a format that can be mapped against residential postcodes.

Does individual and neighbourhood social capital in early childhood influence oral health-related quality of life?

Design Prospective cohort study with seven years of follow-up. Cohort selection All children aged under six years, who attended one of 15 randomly selected health centres in the municipality of Santa Maria, a city in Southern Brazil on National Children's Vaccination Day in 2010. Exposure measurement Individual social support was measured by a questionnaire which asked parents if they had attended a volunteer group in the previous 12 months and if they participated in any groups related to the child's school. Neighbourhood social capital was measured for each of the 15 neighbourhoods, by indicating the presence or absence of each of the following three types of community assets: social-class associations; workers associations; and cultural community centres. Outcome measurement Oral health-related quality of life (OHRQofL) was assessed using the Brazilian version of the Child Perception Questionnaire, for 8-10-year-olds (CPQ8-10). This includes a 5-point Likert score across 25 questions relating to oral symptoms, functional limitations, emotional well-being, and social well-being. The total mean score for each exposure group was calculated, ranging from 0-100, where higher scores indicate poorer OHRQofL. Data analysis The association between individual and neighbourhood social capital at baseline and oral health-related quality of life at follow-up was assessed using a multi-level Poisson regression model to create incidence-rate-ratios where a ratio greater than 1 indicates poorer OHRQofL. Other variables included in the model were: sex; household income; household crowding; dental attendance behavior; presence of dental caries; and presence of increased maxillary overjet. Results Of the 639 children originally enrolled in the study, 449 children were included at follow up (70.3%). Children who lived in a community that had a social-class association (IRR 0.79, 95% CI 0.67-0.93) or workers association (IRR 0.79, 95% CI 0.78-0.93) at baseline had lower oral health impact scores (better oral health-related quality of life) seven years later. The presence of cultural community centres was not associated with OHRQofL. Parental involvement with school activities at baseline was also associated with better OHRQofL at follow up (IRR 1.23, 95% CI 1.14-1.34), but participation in a voluntary network was not. Other variables that had a significant association with OHRQofL were: sex; household income; household crowding; dental attendance pattern; caries incidence; and increased maxillary overjet.Conclusions Oral health-related quality of life was influenced by individual and neighbourhood social capital.

Seroprevalence of anti-polio antibodies in children from polio high risk area of Afghanistan: A cross sectional survey 2017.

BACKGROUND: Afghanistan is one of the remaining wild-poliovirus (WPV) endemic countries. We conducted a seroprevalence survey of anti-poliovirus antibodies in Kandahar Province. METHODS: Children in two age groups (6-11 months and 36-48 months) visiting Mirwais hospital in Kandahar for minor ailments unrelated to polio were enrolled. After obtaining informed consent, we collected venous blood and conducted neutralization assay to detect poliovirus neutralizing antibodies. RESULTS: A total of 420 children were enrolled and 409/420 (97%) were analysed. Seroprevalence to poliovirus type 1 (PV1) was 97% and 100% in the younger and older age groups respectively; it was 71% and 91% for PV2; 93% and 98% for PV3. Age group (RR = 3.6, CI 95% = 2.2-5.6) and place of residence outside of Kandahar city (RR = 1.8, CI 95% = 1.2-2.6) were found to be significant risk factors for seronegativity. CONCLUSIONS: The polio eradication program in Kandahar achieved high serological protection, especially against PV1 and PV3. Lower PV2 seroprevalence in the younger age group is a result of a withdrawal of live type 2 vaccine in 2016 and is expected. Ability to reach all children with poliovirus vaccines is a pre-requisite for achieving poliovirus eradication.

Effects of an Education Intervention about HPV Self-Testing for Healthcare Providers and Staff.

Human papillomavirus (HPV) self-testing is an emerging cervical cancer screening strategy, yet efforts to educate healthcare providers and staff about HPV self-testing are lacking. We report the findings of a brief education intervention about HPV self-testing for healthcare providers and staff. We conducted education sessions during 2015 with healthcare providers and staff (n = 33) from five federally qualified health centers located in Appalachian Ohio. Participants attended a one-time session and completed pre- and post-intervention surveys. Analyses for paired data assessed changes in knowledge and beliefs about HPV, HPV-related disease, and HPV self-testing. The intervention increased participants' knowledge and affected many of the beliefs examined. Participants answered an average of 4.67 of six knowledge items correctly on pre-intervention surveys and 5.82 items correctly on post-intervention surveys (p < 0.001). The proportion of participants who answered all six knowledge items correctly increased substantially (pre-intervention =9% vs. post-intervention =82%, p < 0.001). Compared to pre-intervention surveys, participants more strongly believed on post-intervention surveys that it is important to examine HPV self-testing as a potential cervical cancer screening strategy, that their female patients would be willing to use an HPV self-test at home by themselves, and that they have the knowledge to talk with their patients about HPV self-testing (all p < 0.05). A brief education intervention can be a viable approach for increasing knowledge and affecting beliefs about HPV self-testing among healthcare providers and staff. Findings will be valuable for planning and developing future HPV self-test interventions that include an education component for healthcare providers and staff.

Perspectives from health-care providers and women about completing human papillomavirus (HPV) self-testing at home.

Cervical cancer (CC) incidence and mortality rates are increased, and CC screening rates are low among Appalachian Ohio women. Mailing human papillomavirus (HPV) self-tests to women to complete at home is a potential new strategy to engage women in CC screening. The authors aimed to gain insights into the perceived acceptability of mailed HPV self-tests. Focus groups were conducted (August 2014-January 2015) among providers (physicians, nurse practitioners, nurses) and women in Appalachian Ohio. Providers (n = 28) and women (n = 15; age range: 32-62 years) reported general acceptance of HPV self-tests, however, for different reasons. Providers thought HPV self-testing would increase the proportion of under-screened women returning to the health-care system, while women thought self-testing would eliminate logistical and reduce psychological CC screening barriers. Findings provide insights into facilitators and barriers of completing an HPV self-test at home, returning it, reporting results, and providing needed follow-up care. To the authors' knowledge, no systematic research exists addressing providers' views regarding women's use of HPV self-tests and the relation of such use to fostering subsequent Pap testing. This information will be useful in developing CC screening programs that include mailed HPV self-tests, as well as encouragement of follow-up Pap testing to meet existing CC screening guidelines.

Cases of maternal cannibalism in wild bonobos (Pan paniscus) from two different field sites, Wamba and Kokolopori, Democratic Republic of the Congo.

Maternal cannibalism, whereby a mother consumes her own offspring, occurs in various animal taxa and is commonly explained by nutritional stress or environmental pressures. It is rare in nonhuman primates and is considered an aberrant behavior only observed under high-stress conditions. It was therefore surprising when, in the first reported case of cannibalism in wild bonobos, a mother consumed part of the dead infant at LuiKotale. Here we report two more cases of maternal cannibalism by wild bonobos at two different study sites, Wamba and Kokolopori. The dead infants' mothers participated in the cannibalism in both cases. At Kokolopori, although the mother did consume part of the carcass, it was held and shared by another dominant female. At Wamba, the mother was a dominant female within the community and was the primary consumer of the carcass. In both cases, cannibalism resembled other meat-eating events, with the dominant female controlling meat consumption. Infanticide was not observed in either case, but its occurrence could not be ruled out. Although rare, the occurrence of maternal cannibalism at three different study sites suggests that this may represent part of the behavioral repertoire of bonobos, rather than an aberrant behavior.

When Are Caregivers More Likely to Offer Sugary Drinks and Snacks to Infants? A Qualitative Thematic Synthesis.

Many children consume more sugar than is recommended, and caregivers often find it difficult to change this habit once established. This thematic synthesis aims to identify the "critical situations" where caregivers may be more likely to offer infants sugary drinks and snacks. This thematic synthesis is reported in accordance with the statement for enhancing transparency in reporting the synthesis of qualitative research (ENTREQ). Our confidence in the findings of our synthesis was assessed using the CERQual (Confidence in the Evidence From Reviews of Qualitative Research Approach). We included 16 studies from the United States, the United Kingdom, Australia, and Denmark. We identified eight "critical situations" when caregivers may be more likely to offer sugary drinks and snacks to infants. Interventions that seek to reduce sugar intake for caries prevention in infants and young children may be more successful if they provide caregivers with practical parenting strategies to replace the nonnutritive functions of sugary foods and drinks, as opposed to taking an information-giving approach.

Neutralization of Enterovirus D68 isolated from the 2014 US outbreak by commercial intravenous immune globulin products.

BACKGROUND: In 2014, an outbreak of Enterovirus D68 (EV-D68) was recorded as the largest in the US with cases confirmed in 49 states. Intravenous immune globulin (IVIG) has been used to treat enterovirus infections in neonates and is an accepted replacement therapy for immunodeficient patients. OBJECTIVES: This study aimed to detect the presence of neutralizing antibodies to EV-D68 viruses from the 2014 outbreak in commercially available IVIG products. STUDY DESIGN: Commercially available lots of IVIG preparations were obtained from five different manufacturers (2-10 preparations per manufacturer) and tested for neutralizing antibodies against the prototype EV-D68 virus and three EV-D68 isolates representing strains circulating during the 2014 outbreak. RESULTS: All lots of IVIG tested were positive for EV-D68 neutralizing antibodies, with high titers ranging from 9.5log2 to 17.5log2, and with comparable median titers to all four EV-D68 viruses. CONCLUSIONS AND DISCUSSION: Amino acid sequence differences in the regions of the predicted antigenic sites on the viral capsid may explain some of the differences in neutralization among the different strains. The neutralization titers suggests that the 2014 outbreak EV-D68 viruses share some antigenic sites with the prototype virus and also present some unique antigenic sites distinct from the prototype. However, the commercial IVIG lots tested all contained high levels of neutralizing antibodies against EV-D68.

Chlorhexidine treatment for the prevention of dental caries in children and adolescents.

BACKGROUND: Dental caries (tooth decay) is a common disease that is preventable by reducing the dietary intake of free sugars and using topical sodium fluoride products. An antibacterial agent known as chlorhexidine may also help prevent caries. A number of over-the-counter and professionally administered chlorhexidine-based preparations are available in a variety of formulations and in a range of strengths. Although previous reviews have concluded that some formulations of chlorhexidine may be effective in inhibiting the progression of established caries in children, there is currently a lack of evidence to either claim or refute a benefit for its use in preventing dental caries. OBJECTIVES: To assess the effects of chlorhexidine-containing oral products (toothpastes, mouthrinses, varnishes, gels, gums and sprays) on the prevention of dental caries in children and adolescents. SEARCH METHODS: We searched the Cochrane Oral Health Group Trials Register (25 February 2015), the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 12), MEDLINE via OVID (1946 to 25 February 2015), EMBASE via OVID (1980 to 25 February 2015) and CINAHL via EBSCO (1937 to 25 February 2015). We handsearched several journals placed no language restrictions on our search. After duplicate citations were removed, the electronic searches retrieved 1075 references to studies. SELECTION CRITERIA: We included parallel-group, randomised controlled trials (RCTs) that compared the caries preventive effects of chlorhexidine gels, toothpastes, varnishes, mouthrinses, chewing gums or sprays with each other, placebo or no intervention in children and adolescents. We excluded trials with combined interventions of chlorhexidine and fluoride or comparisons between chlorhexidine and fluoride interventions. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted trial data and assessed risk of bias. We resolved disagreements by consensus. We contacted trial authors for clarification or additional study details when necessary. The number of included studies that were suitable for meta-analysis was limited due to the clinical diversity of the included studies with respect to age, composition of intervention, and variation in outcome measures and follow-up. Where we were unable to conduct meta-analysis, we elected to present a narrative synthesis of the results. MAIN RESULTS: We included eight RCTs that evaluated the effects of chlorhexidine varnishes (1%, 10% or 40% concentration) and chlorhexidine gel (0.12%) on the primary or permanent teeth, or both, of children from birth to 15 years of age at the start of the study. The studies randomised a total of 2876 participants, of whom 2276 (79%) were evaluated. We assessed six studies as being at high risk of bias overall and two studies as being at unclear risk of bias overall. Follow-up assessment ranged from 6 to 36 months.Six trials compared chlorhexidine varnish with placebo or no treatment. It was possible to pool the data from two trials in the permanent dentition (one study using 10% chlorhexidine and the other, 40%). This led to an increase in the DMFS increment in the varnish group of 0.53 (95% confidence interval (CI) -0.47 to 1.53; two trials, 690 participants; very low quality evidence). Only one trial (10% concentration chlorhexidine varnish) provided usable data for elevated mutans streptococci levels > 4 with RR 0.93 (95% CI 0.80 to 1.07, 496 participants; very low quality evidence). One trial measured adverse effects (for example, ulcers or tooth staining) and reported that there were none; another trial reported that no side effects of the treatment were noted. No trials reported on pain, quality of life, patient satisfaction or costs.Two trials compared chlorhexidine gel (0.12% concentration) with no treatment in the primary dentition. The presence of new caries gave rise to a 95% confidence interval that was compatible with either an increase or a decrease in caries incidence (RR 1.00, 95% CI 0.36 to 2.77; 487 participants; very low quality evidence). Similarly, data for the effects of chlorhexidine gel on the prevalence of mutans streptococci were inconclusive (RR 1.26, 95% CI 0.95 to 1.66; two trials, 490 participants; very low quality evidence). Both trials measured adverse effects and did not observe any. Neither of these trials reported on the other secondary outcomes such as measures of pain, quality of life, patient satisfaction or direct and indirect costs of interventions. AUTHORS' CONCLUSIONS: We found little evidence from the eight trials on varnishes and gels included in this review to either support or refute the assertion that chlorhexidine is more effective than placebo or no treatment in the prevention of caries or the reduction of mutans streptococci levels in children and adolescents. There were no trials on other products containing chlorhexidine such as sprays, toothpastes, chewing gums or mouthrinses. Further high quality research is required, in particular evaluating the effects on both the primary and permanent dentition and using other chlorhexidine-containing oral products.

Xylitol-containing products for preventing dental caries in children and adults.

BACKGROUND: Dental caries is a highly prevalent chronic disease which affects the majority of people. It has been postulated that the consumption of xylitol could help to prevent caries. The evidence on the effects of xylitol products is not clear and therefore it is important to summarise the available evidence to determine its effectiveness and safety. OBJECTIVES: To assess the effects of different xylitol-containing products for the prevention of dental caries in children and adults. SEARCH METHODS: We searched the following electronic databases: the Cochrane Oral Health Group Trials Register (to 14 August 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2014, Issue 7), MEDLINE via OVID (1946 to 14 August 2014), EMBASE via OVID (1980 to 14 August 2014), CINAHL via EBSCO (1980 to 14 August 2014), Web of Science Conference Proceedings (1990 to 14 August 2014), Proquest Dissertations and Theses (1861 to 14 August 2014). We searched the US National Institutes of Health Trials Register (http://clinicaltrials.gov) and the WHO Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. SELECTION CRITERIA: We included randomised controlled trials assessing the effects of xylitol products on dental caries in children and adults. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the results of the electronic searches, extracted data and assessed the risk of bias of the included studies. We attempted to contact study authors for missing data or clarification where feasible. For continuous outcomes, we used means and standard deviations to obtain the mean difference and 95% confidence interval (CI). We used the continuous data to calculate prevented fractions (PF) and 95% CIs to summarise the percentage reduction in caries. For dichotomous outcomes, we reported risk ratios (RR) and 95% CIs. As there were less than four studies included in the meta-analysis, we used a fixed-effect model. We planned to use a random-effects model in the event that there were four or more studies in a meta-analysis. MAIN RESULTS: We included 10 studies that analysed a total of 5903 participants. One study was assessed as being at low risk of bias, two were assessed as being at unclear risk of bias, with the remaining seven being at high risk of bias.The main finding of the review was that, over 2.5 to 3 years of use, a fluoride toothpaste containing 10% xylitol may reduce caries by 13% when compared to a fluoride-only toothpaste (PF -0.13, 95% CI -0.18 to -0.08, 4216 children analysed, low-quality evidence).The remaining evidence on children, from small single studies with risk of bias issues and great uncertainty associated with the effect estimates, was insufficient to determine a benefit from xylitol products. One study reported that xylitol syrup (8 g per day) reduced caries by 58% (95% CI 33% to 83%, 94 infants analysed, low quality evidence) when compared to a low-dose xylitol syrup (2.67 g per day) consumed for 1 year.The following results had 95% CIs that were compatible with both a reduction and an increase in caries associated with xylitol: xylitol lozenges versus no treatment in children (very low quality body of evidence); xylitol sucking tablets versus no treatment in infants (very low quality body of evidence); xylitol tablets versus control (sorbitol) tablets in infants (very low quality body of evidence); xylitol wipes versus control wipes in infants (low quality body of evidence).There was only one study investigating the effects of xylitol lozenges, when compared to control lozenges, in adults (low quality body of evidence). The effect estimate had a 95% CI that was compatible with both a reduction and an increase in caries associated with xylitol.Four studies reported that there were no adverse effects from any of the interventions. Two studies reported similar rates of adverse effects between study arms. The remaining studies either mentioned adverse effects but did not report any usable data, or did not mention them at all. Adverse effects include sores in the mouth, cramps, bloating, constipation, flatulence, and loose stool or diarrhoea. AUTHORS' CONCLUSIONS: We found some low quality evidence to suggest that fluoride toothpaste containing xylitol may be more effective than fluoride-only toothpaste for preventing caries in the permanent teeth of children, and that there are no associated adverse-effects from such toothpastes. The effect estimate should be interpreted with caution due to high risk of bias and the fact that it results from two studies that were carried out by the same authors in the same population. The remaining evidence we found is of low to very low quality and is insufficient to determine whether any other xylitol-containing products can prevent caries in infants, older children, or adults.

Effect of multiple, simultaneous vaccines on polio seroresponse and associated health outcomes.

BACKGROUND: Administration of multiple simultaneous vaccines to infants, children, and military recruits is not uncommon. However, little research exists to examine associated serological and health effects, especially in adults. METHOD: We retrospectively examined 416 paired serum specimens from U.S. military subjects who had received the inactivated polio vaccine (IPV) alone or in combination with either 1 other vaccine (<3 group) or 4 other vaccines (>4 group). Each of the 2 groups was subdivided into 2 subgroups in which Tdap was present or absent. RESULTS: The >4 group was associated with a higher proportion of polio seroconversions than the <3 group (95% vs. 58%, respectively, p<0.01). Analysis of the <3 subgroup that excluded Tdap vs. the >4 subgroup that excluded Tdap showed no difference between them (p>0.1). However, the >4 subgroup that included Tdap had significantly more seroconversions than either the <3 subgroup that excluded Tdap or the >4 subgroup that excluded Tdap (p<0.01). Overall, at least 98% of subjects were at or above the putative level of seroprotection both pre- and post-vaccination, yet at least 81% of subjects seroconverted. In an analysis of 400 of the subjects in which clinic in- and outpatient encounters were counted over the course of 1 year following vaccinations, there was no significant difference between the 2 groups (p>0.1). CONCLUSION: A combination of >4 vaccines including IPV appeared to have an immunopotentiation effect on polio seroconversion, and Tdap in particular was a strong candidate for an important role. The dose of IPV we studied in our subjects, who already had a high level of seroprotection, acted as a booster. In addition, there appear to be no negative health consequences from receiving few versus more multiple simultaneous vaccinations.