Caries clusters at lesion-severity thresholds: A Sierra Leone case study.

OBJECTIVES: Despite being almost entirely preventable, globally, dental caries is extremely prevalent. Moreover, dental caries will continue to present an even larger challenge for lower income countries, particularly those in the African context, as they transition to a more Western diet. Hence, epidemiological data providing insight into disease patterns and trends is critical to inform public health action. The purpose of this study was to examine dental caries clusters by caries detection threshold among 15-year-old adolescents in Sierra Leone, using data from the latest national survey, and to explore associated sociodemographic factors. METHODS: This paper presents a secondary analysis of oral health data on 490 15-year-olds from the Sierra Leone national oral health survey of schoolchildren. Hierarchical cluster analysis of dental caries experience was conducted across all surfaces at four decay detection thresholds using the International Caries Detection and Assessment System (ICDAS) (clinical: ICDAS 2-6, cavitated: ICDAS 3-6, obvious: ICDAS 4-6 and extensive obvious: ICDAS 5-6 decay) across the four regions of Sierra Leone. Ordered logistic regression was used to estimate the association of sociodemographic factors with generated clusters relating to clinical and obvious decay experience. These are of both clinical and epidemiological relevance. RESULTS: A 3-cluster decay pattern representing a 'low' to 'high' decay experience distribution was observed under each decay detection threshold across surfaces. For clinical decay (including visual enamel caries), 28.8% had low, 55.1% medium and 15.9% high caries status. In the adjusted model, the only significant risk factor across obvious and clinical decay thresholds was region, with adolescents outside the Western region more likely to experience decay. CONCLUSION: This study suggests that adolescents in Sierra Leone fall into three distinct caries clusters: low, medium to high decay experience distribution, regardless of decay threshold. It reinforces the importance of recognizing dental caries detection thresholds and the use of contemporary epidemiological methodology. This suggests that adolescents outside the Western region are likely to have higher caries experience. The data also provides insight to the nature of adolescents in each cluster and should help to inform policy and planning of the integration of oral health into primary care and school systems.

Dentists' Perceptions of Personal Infection Control Measurements in Response to COVID-19.

OBJECTIVE: To explore through focus groups (FGs) the perceptions of dental practitioners (DPs) from different countries of the challenges of implementing coronavirus disease 2019 (COVID-19) related biosafety measures, especially personal protection equipment (PPE), during the COVID-19 pandemic period. METHODS: DPs from Colombia, Germany, the United Kingdom, and the United States were invited to participate in country-based FGs. These were facilitated by an experienced moderator who explored the factors that guided the implementation of COVID-19 related biosafety measures and PPE use. Data were analyzed through thematic analysis on the basis of categories defined by the researchers deductively and inductively. RESULTS: A total of 25 DPs participated in 3 FGs (Colombia:n = 8; United Kingdom: n = 7; United States: n = 9) and 1 in an in-depth interview (Germany). DPs described using several processes to judge which guidance document to adopt and which aspects of the guidance were important in their practice. These included making judgments concerning the views of any indemnity organization to which the DPs were responsible, the staff's views in the practice, and the views of patients. In the absence of a single overarching guidance document, DPs filtered the available information through several considerations to find a level of PPE that they deemed "implementable" in local practice. CONCLUSIONS: The findings suggest that the implementation of evidence-based practice is subject to modification through a lens of what is "feasible" in practice. KNOWLEDGE TRANSFER STATEMENT: Clinicians, educators, and policy makers can use the results of this study to understand the process through which guidance is transformed into implementable patient care pathways in the dental practice.

Making Cavities History: A Global Policy Consensus for Achieving a Dental Cavity-Free Future.

These global consensus recommendations on caries and cavities, as well as evidence that caries is the most prevalent noncommunicable disease (NCD) globally, should be shared throughout institutional, health care professional, industrial, civil society, and patient communities so that the recommendations can be incorporated into policies for achieving a dental cavity-free future. Appropriate inclusion within strategies and action plans globally and locally will accelerate progress toward Making Cavities History, as well as improving NCDs and wider health.

Reorienting Oral Health Services to Prevention: Economic Perspectives.

Despite the recognized need to change the emphasis of health services by shifting the balance from treatment to prevention, limited progress has been made in many settings. This is true in oral health, where evidence for preventive interventions that work has not been systematically exploited in oral health services. While reorienting health services is complex and context specific, economics can bring a helpful perspective in understanding and predicting the impact of changes in resource allocation, provider remuneration systems, and patient payments. There is an increasing literature on the economics of different prevention approaches. However, much of this literature focuses on the costs and potential savings of alternative approaches and fails to take into account benefits. Even where benefits are taken into account, these tend to be narrowly focused on clinical outcomes using cost-effectiveness analysis, which may be of little relevance to the policy maker, patient, and the public. Some commonly used economic approaches (such as quality-adjusted life years and incremental cost-effectiveness ratios) may also not be appropriate to oral health. Using alternative techniques, including wider measures of benefit and employing priority setting and resource allocation tools, may provide more comprehensive information on economic impact to decision makers and stakeholders. In addition, it is important to consider the effects of provider remuneration in reorienting services. While there is some evidence about traditional models of remuneration (fee for service and capitation), less is known about pay for performance and blended systems. This article outlines areas in which economics can offer an insight into reorientation of health systems toward prevention, highlighting areas for further research and consideration.

Caries de la primera infancia: La Declaración de Bangkok del IAPD

El propósito de esta declaración es obtener apoyo mundial para una definición basada en evidencia de la Caries de Primera Infancia (ECC), además de lograr un consenso en la comprensión de la etiología, factores de riesgo e intervenciones para reducir ECC, todas también basadas en evidencia. También presentará políticas y enfoques colaborativos para disminuir esta enfermedad crónica. Con estos antecedentes, 11 expertos de todo el mundo se reunieron bajo el auspicio de la Asociación Internacional de Odontopediatría (IAPD) para formular esta declaración.

Early Introduction of Sugar-Sweetened Beverages and Caries Trajectories from Age 12 to 48 Months.

Early exposure to sweet tastes predicts similar food preferences and eating behavior in later life and is associated with childhood obesity. The aim of this study was to explore the associations of early (during the first year of life) and subsequent intake of sugar-sweetened beverages (SSBs) with 4-y caries trajectories among Scottish young children. We used data from 1,111 Scottish children who were followed annually from age 12 to 48 mo (4 sweeps in total). SSB intake was reported by parents in every sweep. SSB intake was broken down into 2 components, the initial SSB intake and the deviation over time from that initial value. Childhood dental caries was clinically determined (including noncavitated and cavitated lesions) every year. The association of SSB intake with baseline decayed, missing, and filled tooth surfaces (dmfs) (intercept) and rate of change in dmfs over time (slope) was examined in 2-level linear mixed-effects models, with repeated observations nested within children. Both the initial SSB intake and the deviation from the initial SSB intake were positively associated with steeper caries trajectories. By sweep 4, the predicted mean dmfs difference was 1.73 between children with low and high initial SSB intake (1 standard deviation below and above the mean) and 1.17 between children with low and high deviation from their initial SSB intake (1 SD below and above the mean). The findings of this prospective study among Scottish young children provide evidence that the introduction of SSBs during the first year of life can put children in a trajectory of high levels of dental caries. They support current recommendations to avoid sugars for very young children and interventions targeting early feeding practices for caries prevention.

Shaping the future of dental education: Caries as a case-study.

This study reports on the full-day workshop "The Shape of The Future of Dental Education for Dental Caries-and how we get there" held immediately prior to the May 2017 ADEE/ADEA/King's College London meeting "Shaping the Future of Dental Education." A standardised, evidence-led Core Curriculum in Cariology (CCC) was developed jointly and systematically by ORCA and ADEE, starting in 2010. At the same time, the ICDAS Foundation was developing a comprehensive caries management system, ICCMS™. The workshop reported on what has been achieved on a global basis by many building on these initiatives. The CCC has been, or is currently being, localised in a number of places around the world and has, in some countries, been successfully implemented. There are also other areas which are struggling more with the logistics of introducing it. The workshop presented geographical perspectives and experiences on implementing the CCC from Colombia, the United States and Europe, as well as professional perspectives from hygienists, students and policymakers. The workshop then considered the future of the CCC and the roles of Interprofessional Education, Technology, Global Networking and Assessment in a Global Context in 4 breakout groups. Having had reports back and plenary discussion, it was concluded that the caries world has made good progress towards a "futuristic" curriculum with parallel development of a comprehensive, preventive and tooth-preserving caries management system-ICCMS™. The implementation challenge is now to share even more effectively in order to have these developments more widely accepted and adopted worldwide.

The Brussels Statement on the Future Needs for Caries Epidemiology and Surveillance in Europe.

Following debate and discussion prompted by a focussed, day long pre-ORCA Symposium in July 2015, the Alliance for a Cavity-Free Future Pan-European Chapter, the Platform for Better Oral Health in Europe, and the European Association of Dental Public Health have agreed this statement on the future needs for caries epidemiology and surveillance in Europe. Each organisation agreed to support the planned publication of the Statement, and will make it available on their Organisation's websites and strive to implement its recommendations.

Reminova and EAER: Keeping Enamel Whole through Caries Remineralization.

This article aims to outline the early development of a King's College London dental spinout company, Reminova, formed to commercialize a novel clinical method of caries remineralization: electrically accelerated and enhanced remineralization (EAER). This method is being developed to address the unmet clinical need identified by modern caries management strategies to keep enamel "whole" through remineralization of clinical caries as a form of nonoperative caries treatment for initial-stage and moderate lesions. A progressive movement within dentistry is shifting away from the restorative-only model, which, it is suggested, has failed. The high prevalence of initial-stage caries across populations provides a significant opportunity to prevent restorations and reduce repeat restorations over a patient's lifetime. Reminova has set out to provide a method to repair lesions without drilling, filling, pain, or injections. The article outlines the rationale for and the chronological stages of the technology and company development. It then outlines corroborative evidence to show that EAER treatment can, in this preliminary in vitro investigation, remineralize clinically significant caries throughout the depth of the lesion as measured by Knoop microhardness and corroborated by scanning electron microscopy. Furthermore, the presented data show that EAER-treated enamel is harder than the healthy enamel measured nearby in each sample and is very similar in appearance to healthy enamel from the subjective interpretation made possible by scanning electron microscopy imagery. The data presented also show that this more "complete" remineralization to a high hardness level has been achieved with 2 remineralizing agents via in vitro human tooth samples. The broad clinical potential of this new treatment methodology seems to be very encouraging from these results. Reminova will strive to continue its mission, to ensure that, in the future, dental teams will not need to drill holes for the treatment of initial-stage and moderate caries lesions.

The caries experience of 5 year-old children in Scotland in 2013-2014, and in England and Wales in 2014-2015. Reports of cross-sectional dental surveys using BASCD criteria.

OBJECTIVE: We report the findings from and comment on the surveys of the oral health of 5-year-old children undertaken in Scotland (2013-14), Wales (2014-15) and England (2014-15). This was the fourteenth survey in Scotland since 1988. In England and Wales it is the third survey since 2007 when changes were required in consent arrangements. METHOD: Representative samples were drawn within Health Boards across Scotland and local authorities across England and Wales. Consent was sought via opt-out parental consent in Scotland and opt-in parental consent in England and Wales. Children examined were those aged five in England and those in Primary 1 (school year aged 5 to 6) in Scotland and Wales. Examinations were conducted in schools by trained and calibrated examiners. Caries was visually diagnosed at the dentinal threshold. RESULTS: There is a continuing decline in d3mft in all three countries. d3mft was 1.27 (opt-out consent) for Scotland, 0.84 for England (opt-in consent) and 1.29 for Wales (opt-in consent). Tooth decay levels remain higher in more deprived areas across Great Britain, with clear inequalities gradients demonstrated across all geographies. Attempts to measure changes in dental health inequalities across the three countries show no conclusive trends. CONCLUSION: Inter-country comparisons provide further oral health intelligence despite differences in approach and timing. The third surveys in England and Wales using the new consent arrangements have enabled trend analysis. Dental health inequalities gradients were shown across all geographies and all of the indicators of inequality.

Birth Weight, Breastfeeding, Maternal Smoking and Caries Trajectories.

Evidence for the effects of low birth weight, breastfeeding and maternal smoking on childhood caries is mainly cross-sectional. We examined the association of these 3 putative early life factors with caries increment over a 4-y period among young children. We used data from a 4-y longitudinal caries-risk assessment study carried out among Scottish children. Early life factors were measured when children were aged 1 y (baseline). Caries assessment was repeated annually from ages 1 to 4, and the number of decayed, missing and filled primary tooth surfaces (dmfs) were used as a repeated outcome measure. The associations of low birth weight, breastfeeding and maternal smoking with dmfs at baseline and over time (trajectories) were assessed in linear mixed models. A total of 1,102 children were included in this analysis. Birth weight, breastfeeding and maternal smoking were not associated with dmfs at baseline. However, low birth weight and maternal smoking were associated with the rate of change in dmfs. By wave 4, the predicted mean difference in dmfs was 1.86 between children with low and normal birth weight, and 1.66 between children of smoking and non-smoking mothers. Children with low birth weight and smoking mothers had greater caries increments than those with normal weight and non-smoking mothers, respectively. There was no association between breastfeeding duration and childhood caries, either at baseline or over time.

Caries experience, the caries burden and associated factors in 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 To describe caries prevalence and severity and factors affecting these, in children in England, Wales and Northern Ireland in 2013.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. Caries was measured at both the dentine ('obvious caries') and dentine plus enamel ('clinical caries') levels and analysis included identifying those with indicators of significant burden of caries and identifying predictive factors.Results In 5-year-olds, 40% had obvious caries experience increasing to 56% when enamel lesions were included. In 15-year-olds, the respective figures were 46% and 63%. Fourteen percent of 5-year-olds and 15% of 15-year-olds had a least one indicator of significant levels of caries and those from deprived backgrounds were more likely to fall into this group.Conclusions Overall, the prevalence of caries in children is continuing to decrease, but the rate is slowing. The level of disease for those with disease is much higher than the average values might suggest and there remain a sizeable minority with a significant burden of caries, associated with deprivation. This complex picture poses significant clinical and public health challenges.

Global burden of oral diseases: emerging concepts, management and interplay with systemic health.

OBJECTIVES: This study presents the global burden of major oral diseases with an exegetical commentary on their current profiles, the critical issues in oral healthcare and future perspectives. METHODS: A narrative overview of current literature was undertaken to synthesise the contexts with critical elaboration and commentary. RESULTS: Oral disease is one of the most common public health issues worldwide with significant socio-economic impacts, and yet it is frequently neglected in public health policy. The oral data extracted from the Global Burden of Disease Study in 2010 (Murray et al, 2012) show that caries, periodontal disease, edentulism, oral cancer and cleft lip/palate collectively accounted for 18 814 000 disability-adjusted life-years; and the global burden of periodontal disease, oral cancer and caries increased markedly by an average of 45.6% from 1990 to 2010 in parallel with the major non-communicable diseases like diabetes by 69.0%. Oral diseases and non-communicable diseases are closely interlinked through sharing common risk factors (e.g. excess sugar consumption and tobacco use) and underlying infection/inflammatory pathways. CONCLUSIONS: Oral disease remains a major public health burden worldwide. It is of great importance to integrate oral health into global health agenda via the common risk factor approach. The long-term sustainable strategy for global oral health should focus on health promotion and disease prevention through effective multidisciplinary teamwork.

Variation in methods used to determine national mean DMFT scores for 12-year-old children in European countries.

AIM: The aim of this study was to investigate the methods used to identify national mean DMFT scores for 12-year-old children in all the Member States of the European Union and European Economic Area, and in 11 other European countries. METHODS: The most recent national mean DMFT scores were accessed from the World Health Organisation Oral Health CAPP and the Council of European Chief Dental Officers databanks. A literature search was then performed to access the reports of the studies that had produced these DMFT scores, cited on these databanks. The reports were then analysed to determine: the year in which the survey/study that produced the score took place, the year the results were published, the geographical area (national, regional or local) covered, the number of children examined, how many examiners took part, how they were trained and calibrated, and the criteria used for the detection of caries. RESULTS: Data and information from 43 European countries were accessed. The years when the studies were performed ranged from 1990 to 2014. There were doubts over the representativeness of some samples. A wide range of different methods were used. Examiner training and calibration were very variable both in terms of duration and reported inter and intra-examiner consistency. There were important variations in the criteria employed for the detection of caries. CONCLUSIONS: These findings support the view that most of current national caries data for DMFT levels in 12-year-old children are not comparable across Europe.

The caries experience of 5-year-old children in Scotland, Wales and England in 2011-2012: reports of cross-sectional surveys using BASCD criteria.

OBJECTIVE: This paper collates differences in methods and trends in caries prevalence in surveys of the oral health of young children undertaken in Scotland, Wales and England in 2011-12. For Wales and England this was the second survey carried out since changes were required in consent arrangements. METHOD: In compliance with BASCD criteria representative samples were drawn within the geographies of primary care organisations across the UK, and within Local Authorities across England and Wales. Consent was sought in two ways; via opt-in parental consent in England and Wales and opt-out parental consent in Scotland. Children aged five were examined in England and those aged 5 to 6 were examined in Wales and Scotland. Examinations were conducted in schools by trained and calibrated examiners and caries was diagnosed at the dentinal threshold using visual criteria. RESULTS: In Scotland there is a continuing decline in caries prevalence in young school children. Comparison with the previous survey using positive consent in England and Wales shows a decline in caries in both England and Wales although decay levels remain higher in more deprived areas. CONCLUSION: International comparisons assist in interpreting data and trends even if there are some differences in approach. A trend line is more useful than a single data point for monitoring of oral health. This second survey using positive parental consent in England and Wales has enabled trend analysis for the first time since the consent arrangements changed.

Consensus on domains, formation objectives and contents in cariology for undergraduate dental students in Colombia.

OBJECTIVE: To achieve a consensus for an undergraduate cariology teaching curriculum between Colombian dental schools in line with the 2015 Global Alliance for a Cavity-Free Future goal: '90% of dental schools adopting the current caries paradigm'. MATERIALS AND METHODS: First phase: Four-regional 2-day workshops were conducted with 4 representative teachers (cariology, clinics, basic-science, public health and specialisations) from each of the 24-ACFO schools (Colombian Dental Schools Association) as follows: Presentations: -Main Colombian cariology teaching barriers, -Caries and public health current paradigms; -Schools' cariology teaching descriptions; -European Cariology Curriculum. Five main-domain subgroup discussions: (i) the knowledge base; (ii) risk assessment, diagnosis and synthesis; (iii) decision-making, preventive non-surgical therapy; (iv) decision-making, surgical therapy; and (v) evidence-based cariology in clinical and public health practice, to adapt domains, objectives and contents to Colombian curriculum, public health and national health system needs. These 4-regional plus 24-school consensuses sent 1 month afterwards were adapted into a preliminary document. 2nd-phase: 10 peer review by national faculty in cariology, and 10 curriculum, basic sciences, research, clinical management and public health experts. School participants and deans reviewed the draft document and suggestions were discussed and adapted into a final consensus document officially presented to the academic community at the ACFO National-Research-Meeting (September, 2012). RESULTS: 24 schools and 92 teachers participated. The Colombian Cariology Curriculum was agreed by 23 schools. It positioned public health into one domain. A general focus on social determination was included, and more relevance was given to fluorosis than erosion. CONCLUSIONS: A consensus on cariology teaching for undergraduate dental students was achieved in Colombia and work to promote its adoption has commenced.

Incorporating new materials and techniques into clinical practice.

This article outlines the subjects presented and discussed at the December 2012 IADR Dental Materials Innovation Workshop held at King's College London. Incorporating new materials and techniques into clinical practice was considered from 4 perspectives: (1) Accelerating the "research to regulatory approval" process was presented with current developments in the United States, with the National Institutes of Health/Food and Drug Administration process as a working example; (2) intellectual property and regulatory requirements were discussed across the well-established US and EU frameworks, as well as the more recently developed procedures across Brazil, Russia, India, and China; (3) the challenges and opportunities of incorporating innovations into dental education were considered with reference to the future needs of both students and faculty; and (4) the key but difficult and unpredictable step of translating such innovations into routine dental practice was then explored. Constructive and far-ranging discussion among the broadly based Workshop participants (from dental research, education, practice, and industry, as well as environmental organizations and the World Health Organization) mapped out key issues for the future. The focus was on facilitating the more timely adoption of improvements in both materials and techniques to improve patient health and health systems, while minimizing environmental impact.

Adult Dental Health Survey 2009: implications of findings for clinical practice and oral health policy.

This is the final paper in a series reporting on the results of the 2009 Adult Dental Health Survey. Since 1968 national adult surveys have been repeated every decade with broadly similar methods providing a unique overview of trends in oral health over a 40-year period. This paper aims to explore the implications for dentists and oral health policy of the key results from the Adult Dental Health Survey 2009. Although repeat, cross-sectional, epidemiological surveys provide very valuable data on trends in disease patterns, they do not provide answers to test causal relationships and therefore cannot identify the causes for the significant improvements in oral health over the last 40 years. Evidence would indicate, however, that broad societal shifts in population norms and behaviours, combined with changes in clinical diagnostic criteria, treatment planning and clinical procedures are the main reasons for the changes that have taken place. Key implications of the survey results include the need to monitor, support and maintain the good state of oral health of the increasing proportion of younger adults with relatively simple treatment needs. A smaller number of young and middle aged adults but a significant proportion of older adults will have far more complex treatment needs requiring advanced restorative and periodontal care. Future oral health policy will need to address oral health inequalities, encourage skill mix and promote and facilitate the dental profession to deliver appropriate and high quality care relevant to the needs of their local population.

International Caries Detection and Assessment System (ICDAS) and its International Caries Classification and Management System (ICCMS) - methods for staging of the caries process and enabling dentists to manage caries.

OBJECTIVES: The aim of this article is to provide an overview of the International Caries Detection and Assessment System (ICDAS) and its associated International Caries Classification and Management System (ICCMS(™) ), explain the evolution of these systems over the past decade and outline how they are being used for staging of the caries process in order to enable dentists to manage caries appropriately. METHODS: the article outlines and references the key steps in development of these systems. RESULTS: ICDAS employs an evidence-based and preventively oriented approach, is a detection and assessment system classifying stages of the caries process on the basis of histological extent and activity, is designed for use in the four domains of clinical practice, education, research and public health and provides all stakeholders with a common language for staging caries. Over a decade ICDAS has evolved to comprise a number of approved, compatible 'formats', supports decision making at both individual and public health levels and has generated the ICCMS(™) to enable improved long-term caries outcomes. A range of further developments are in train, to assist with information capture and making clinical systems simpler and more practice friendly. CONCLUSION: ICDAS provides flexible and increasingly internationally adopted methods for classifying stages of the caries process and the activity status of lesions which can be incorporated into the ICCMS(™) . The ICCMS(™) provides options to enable dentists to integrate and synthesize tooth and patient information, including caries risk status, in order to plan, manage and review caries in clinical and public health practice.