Experiences and learnings from developing and implementing a co-designed value-based healthcare framework within Victorian public oral health sector.

Objective This study aimed to describe the development and implementation of a co-designed value-based healthcare (VBHC) framework within the public dental sector in Victoria. Methods A mixed-method study was employed. Explorative qualitative design was used to examine patient, workforce and stakeholder perspectives of implementing VBHC. Participatory action research was used to bring together qualitative narrative-based research and service design methods. An experience-based co-design approach was used to enable staff and patients to co-design services. Quantitative data was sourced from Titanium (online patient management system). Results Building a case for VBHC implementation required intensive work. It included co-designing, collaborating, planning and designing services based on patient needs. Evidence reviews, value-stream mapping and development of patient reported outcomes (PROMs) and patient reported experience measures (PREMs) were fundamental to VBHC implementation. Following VBHC implementation, a 44% lower failure to attend rate and 60% increase in preventive interventions was reported. A higher proportion of clinicians worked across their top scope of practice within a multi-disciplinary team. Approximately 80% of services previously provided by dentists were shifted to oral health therapists and dental assistants, thereby releasing the capacity of dentists to undertake complex treatments. Patients completed baseline International Consortium for Health Outcomes Measurement PROMs (n = 44,408), which have been used for social/clinical triaging, determining urgency of care based on risk, segmentation and tracking health outcomes. Following their care, patients completed a PREMs questionnaire (n = 15,402). Patients agreed or strongly agreed that: the care they received met their needs (87%); they received clear answers to their questions (93%); they left their visit knowing what is next (91%); they felt taken care of during their visit (94%); and they felt involved in their treatment and care (94%). Conclusion The potential for health system transformation through implementation of VBHC is significant, however, its implementation needs to extend beyond organisational approaches and focus on sustaining the principles of VBHC across healthcare systems, policy and practice.

Trends in social inequalities in early childhood caries using population-based clinical data.

OBJECTIVE: To assess the longitudinal trends in social inequalities in early childhood caries (ECC) using collected population-based data. METHODS: Clinical data on children were routinely collected from 2008 to 2019 in Victoria, Australia. ECC prevalence and severity (dmft) were quantified according to Indigenous status, culturally and linguistically diverse (CALD) status, concession cardholder status, geographic remoteness and area deprivation. The inverse probability weighting was used to quantify social inequalities in ECC. The weighted prevalence differences, and the ratio between the weighted prevalence of ECC and mean dmft and their 95% confidence interval, were then plotted. RESULTS: Absolute inequalities in ECC prevalence increased for children by 7% for CALD status and cardholder status between 2008 and 2019. Likewise, absolute inequalities in ECC severity in this time period increased by 0.6 for CALD status and by 0.4 for cardholder status. Relative inequalities in ECC increased by CALD (ratio: 1.3 to 2.0), cardholder status (1.3 to 2.0) and area deprivation (1.1 to 1.3). Relative inequalities in severity increased by CALD (1.5 to 2.8), cardholder (1.4 to 2.5) or area deprivation (1.3 to 1.5). Although children with Indigenous status experienced inequalities in ECC prevalence and severity, these did not increase on the absolute (ECC: 0.1-0.1 Severity: 1.0-0.1) or relative scale (ECC ratio: 1.3-1.3 Severity ratio: 1.6-1.1). CONCLUSIONS: Trends in inequalities in ECC were different according to sociodemographic measures. Oral health policies and interventions must be evaluated on the basis of reducing the prevalence of oral diseases and oral health inequalities between population sub-groups.

A Teledentistry Pilot Study on Patient-Initiated Care.

COVID-19 has challenged the public dental workforce in their ability to continue providing routine oral health care services. To mitigate the risk of COVID-19 transmission to staff and patients, Teledentistry was implemented in many parts of the world, mainly to provide remote consultations, undertake triage, and offer preventive educational sessions. The aim of this paper is to describe Dental Health Services Victoria's (DHSV) patient-initiated Teledentistry model of care implemented during peak COVID transmission in Victoria. The Teledentistry model supported patient-centered care involving active collaboration and shared decision making between patients, families, and clinicians in designing and managing remote care plans. DHSV's eligible patient cohort includes disadvantaged population groups with greater oral health needs. Strong emphasis was placed on the simplicity and user friendliness of the Telehealth platform, as well as the support for patients with low technology literacy. Consumers and dental workforce were consulted and modifications to the use of language and services were undertaken before the launch. A total of 2492 patients accessed Telehealth services between May 2020 and April 2021. Approximately 39% of patients were born in a country other than Australia. A total of 489 patient-reported experience measures (PREMs) were received. Patients agreed or strongly agreed that the care they received met their needs (87%); they received answers to their questions (89%); they left their visit knowing what is next (87%); they felt they were taken care of during their visit (90%); and they felt involved in their treatment (89%). Teledentistry enabled patients to initiate access to care and consult with dental workforce remotely and safely during peak pandemic.

Silver Diamine Fluoride Protocol for Reducing Preventable Dental Hospitalisations in Victorian Children.

INTRODUCTION: This study was designed to assess whether a dental caries management protocol combining a single application of 38% silver diamine fluoride (SDF) with comprehensive oral health education will successfully divert high-risk children from dental treatment under dental general anaesthesia (DGA), arrest active caries in primary teeth, and improve parent-reported child oral health-related quality of life (OHRQoL). METHODS: Children aged 2 to 10 years, who attended two public dental agencies in Victoria, Australia, and were unable to tolerate restorative treatments in the clinic setting, elected to participate in either a 38% SDF intervention protocol or, alternatively, referral for DGA. Follow-up examinations were completed at 6 months to assess caries progression, decayed missing filled tooth index, PUFA index (pulpal involvement, ulceration, fistula, abscess), DGA referral rates, and OHRQoL (Early Childhood Oral Health Impact Scale [ECOHIS]). RESULTS: Of the total sample, 89.5% of children (n = 102) [mean (SD) age, 4.1 (1.0) years] with 401 active carious lesions elected to participate in the 38% SDF protocol; 10.5% (n = 12) of parents opted for referral for treatment under DGA. The proportion of active caries subsequently arrested at follow-up (number of arrested lesions/number of lesions treated) was 0.78 (95% CI, 0.69 to 0.87). There was an 88% reduction in referrals for DGA in eligible children over the 6-month period. The 38% SDF intervention group showed a significant improvement in ECOHIS scores at follow-up (P < .001). DISCUSSION: Adoption of the 38% SDF intervention protocol resulted in a significant reduction in the rate of preventable dental hospitalisations. Most parents opted against referral for DGA. Parent-reported OHRQoL for children improved significantly.

Early Childhood Caries in Victorian Preschoolers: A Cross-Sectional Study.

AIM: The objective of this work was to determine the prevalence of early childhood caries (ECC) in children attending preschools that are enrolled in the Smiles 4 Miles health promotion program in Victoria and determine the sociodemographic variables associated with ECC. MATERIALS AND METHODS: A cross-sectional sample of 1,845 3- to 5-year-old children attending 61 preschools was selected by stratified cluster sampling. Dental caries was classified as non-cavitated/early lesions (d1-2), cavitated (d3-6) lesions, and cavitated/non-cavitated (d1-6) lesions using the International Caries Detection and Assessment System. A self-administered parental questionnaire captured sociodemographic and behavioural data. Multivariate logistic regression and Poisson mixed model analysis was used to examine associations amongst sociodemographic variables, child oral health behaviours, and decayed tooth surfaces. RESULTS: In all, 56.6% (n = 1,044) of the children had ECC; more than one-third (36.6%) presented exclusively non-cavitated/early lesions, 5.7% solely cavitated lesions, and 14.2% both. Children from socioeconomically disadvantaged backgrounds had higher levels of dental caries. Parental pensioner/health care card status (incidence rate ratio [IRR] = 1.76, 95% CI, 1.57-1.97), non-English-speaking background (IRR = 2.09, 95% CI, 1.80-2.43), and Indigenous status (IRR = 1.91, 95% CI, 1.50-2.43) were associated with higher rates of cavitated lesions. Children who consumed soft drinks once or more per week had 1.66 times more cavitated lesions (95% CI, 1.48-1.86) compared to children who never/rarely consumed soft drinks. Soft drink consumption of once or more per week was associated with parental health care/pensioner card status (odds ratio [OR] = 1.73, 95% CI, 1.36-2.18), non-English-speaking background (OR = 1.58, 95% CI, 1.11-2.27), and Indigenous status (OR = 1.92, 95% CI, 1.04-3.52). CONCLUSIONS: Higher levels of more severe caries rates in children from socioeconomically disadvantaged background highlight an opportunity for early preventive interventions targeting these groups.

Oral health surveillance in Australia: the need for ongoing data to inform public health decision-making.

Surveillance of people's health takes on an important meaning in the practice of public health because it allows monitoring of diseases and prompt response to change in proportions and rates at which diseases occur in populations. Improving health of populations requires establishment of an effective public health system. Population level data and analysis is critically important in government policy and program development and monitoring. Lack of or inadequate information about the health of populations leads to ineffective policies that may often attenuate health problems instead of solving them. Australia's current oral health surveillance is mostly through ad hoc sentinel surveys, which lack recency in time. This position paper is to present the need for real-time oral health surveillance in Australia, which can be used to inform health decision-making in a timely manner.

Settings-based Interventions at Primary, Secondary and Tertiary Prevention Levels May Significantly Improve the Oral Health of Older People.

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION: Gomez-Rossi J, Hertrampf K, Abraham J, Gaßmann G, Meyer G, Schlattmann P, Göstemeyer G, Schwendicke F. Interventions to improve oral health of older people: A scoping review. J Dent. 2020 Oct;101:103451. doi: 10.1016/j.jdent.2020.103451. Epub 2020 Aug 15. PMID: 32810577. SOURCE OF FUNDING: Government - the Innovationsfond des Gemeinsamen Bundesausschusses (01VSF18021). TYPE OF STUDY/DESIGN: Scoping review.

Developing a Standard Set of Patient-centred Outcomes for Adult Oral Health - An International, Cross-disciplinary Consensus.

OBJECTIVE: To develop a minimum Adult Oral Health Standard Set (AOHSS) for use in clinical practice, research, advocacy and population health. MATERIALS AND METHODS: An international oral health working group (OHWG) was established, of patient advocates, researchers, clinicians and public health experts to develop an AOHSS. PubMed was searched for oral health clinical and patient-reported measures and case-mix variables related to caries and periodontal disease. The selected patient-reported outcome measures focused on general oral health, and oral health-related quality of life tools. A consensus was reached via Delphi with parallel consultation of subject matter content experts. Finally, comments and input were elicited from oral health stakeholders globally, including patients/consumers. RESULTS: The literature search yielded 1,453 results. After inclusion/exclusion criteria, 959 abstracts generated potential outcomes and case-mix variables. Delphi rounds resulted in a consensus-based selection of 80 individual items capturing 31 outcome and case-mix concepts. Global reviews generated 347 responses from 87 countries, and the patient/consumer validation survey elicited 129 responses. This AOHSS includes 25 items directed towards patients (including demographics, the impact of their oral health on oral function, a record of pain and oral hygiene practices, and financial implications of care) and items for clinicians to complete, including medical history, a record of caries and periodontal disease activity, and types of dental treatment delivered. CONCLUSION: In conclusion, utilising a robust methodology, a standardised core set of oral health outcome measures for adults, with a particular emphasis on caries and periodontal disease, was developed.

Health promotion competencies for promoting child-oral health: Victorian multidisciplinary workforce perspectives.

ISSUE ADDRESSED: Population oral health (OH) improvements depend on successful, coordinated execution of oral health promotion (OHP) programs by both oral and general health professionals with key competencies (skills, abilities, knowledge and values). This study explored multidisciplinary professionals' perspectives of the competencies required for the successful implementation of a community-based OHP program called Smiles 4 Miles (S4M) in early childhood settings in Victoria, Australia. METHODS: Convenience sampling was used to recruit multidisciplinary professionals working in the S4M early childhood health promotion program in Victoria. Semi-structured focus groups were conducted with program managers/coordinators (n = 26) from 21 S4M sites and the state-wide program coordination team (n = 5). Focus groups explored OHP competency needs, capacity to promote child OH and strategies for enhancing OHP competencies. The competencies identified through focus groups were then compared to the International Union for Health Promotion and Education (IUHPE) competencies framework. RESULTS: Strategies to enhance individual and organisational OHP competencies included intersectoral collaborations; working in multidisciplinary teams; support networks and partnerships; sharing skills and expertise between health professionals. The OHP competencies identified by the participants were consistent with key IUHPE domains including ethical values and health promotion knowledge base underpinning, enabling change, advocacy for health, mediating through partnerships, communication, leadership, assessment, planning, implementation, evaluation and research. CONCLUSION: A multidisciplinary workforce based in community settings can play key and complementary roles in OHP and widen avenues for oral disease prevention. SO WHAT?: Integrated collaborative workforce models involving multidisciplinary professionals beyond the OH sector can more effectively support efforts to address the burden of oral disease.

Is there an association between body weight and early childhood caries experience?

Data sources PubMed, Cochrane Library, and Google Scholar. Study selection Papers reporting a primary study in non-syndromatic preschool children aged 0-6 years, reporting body weight and dental caries experience as outcomes.Data extraction and synthesis Two reviewers independently screened the titles and abstracts of the identified citations for relevance. The full text articles were subsequently assessed for eligibility for both qualitative and quantitative review. Body weight outcomes were standardised into four groups; 'underweight' (BMI-for-age percentile less than five), 'normal weight' (BMI-for-age percentile between five and 85), 'overweight' (BMI-for-age percentile between 85 and 95), and 'obese' (BMI-for-age percentile greater than 95). Dental caries outcomes were based on decayed, missing, and filled teeth/surfaces (dmft/dmfs) index. The risk of bias in individual studies were assessed based on the National Institute of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. The GRADE system was used to perform quality assessment for each outcome reported.Results Following screening of 293 articles, a total of 32 studies qualified for qualitative review and 12 of them reported data that was used to conduct a meta-analysis. All included studies were cross-sectional in nature and presented a high risk of bias. Findings from meta-analysis showed that children who are overweight have a significantly higher dmft index (95% CI -0.64 to -0.14, P = 0.002, I2 equals 62 percent). The quality of evidence was found to be moderate.Conclusions Overweight and obese preschool children are at a greater risk of developing caries. Public health prevention programmes must target both conditions together to reduce their burden and effectiveness of prevention strategies.

Which type of personal protective equipment (PPE) and which method of donning or doffing PPE carries the least risk of infection for healthcare workers?

Data sources CENTRAL, MEDLINE, Embase and CINAHL.Study selection Controlled studies (randomised or non-randomised) that evaluated the effect of full-body PPE on healthcare workers (HCW) exposed to highly infectious diseases, assessed which method of donning and doffing PPE was associated with reduced risk of contamination or infection for HCW, and which training methods increased compliance with PPE protocols.Data extraction and synthesis Two reviewers independently screened the titles and abstracts for inclusion of studies. Full text articles were subsequently assessed for eligibility and disagreements were resolved through consensus. Using criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions, pairs of review authors independently assessed risk of bias for each randomised study and rated each potential source of bias as high, low, or unclear.ROBINS-I tool was used for the assessment of risk of bias in non-randomised intervention studies. Where appropriate, random effects meta-analyses were conducted.Results A total of 24 studies (randomised controlled trials [RCT] [n = 14]; Quasi-RCT [n = 1] and non-randomised design [n=9]) with 2278 participants were included. Included studies compared types of PPE (n = 8), evaluated modified PPE (n = 6), procedures for donning and doffing PPE (n = 8), and types of training (n = 3). Twenty-two studies were simulation studies, of which 18 simulated exposure of HCW to contaminated body fluids using fluorescent markers or harmless microbes and measured contamination outcomes, and four studies provided modified PPE or procedures and measured compliance with donning and doffing procedures. Types of PPE Powered, air-purifying respirator with coverall may protect against the risk of contamination better than a N95 mask and gown (risk ratio [RR] 0.27, 95% confidence interval [CI] 0.17 to 0.43) but was more difficult to don (non-compliance: RR 7.5, 95% CI 1.81 to 31.1). Gowns compared to aprons may protect better against contamination (MD) -10.28, 95% CI -14.77 to -5.79). Breathable types of PPE are more comfortable and may increase user satisfaction, however with little impact on contamination. Modified PPE versus standard PPE Appropriate modifications to PPE design may lead to less contamination compared to standard PPE. For example, contamination can be reduced using a sealed gown and glove combination so that they can be removed together and cover the wrist area (RR 0.27, 95% CI 0.09 to 0.78), tight fitting gown around the neck, wrist area and hands (RR 0.08, 95% CI 0.01 to 0.55) and added tabs to facilitate doffing of masks (RR 0.33, 95%nCI 0.14 to 0.80) or gloves (RR 0.22, 95% CI 0.15 to 0.31).Guidance on PPE use: following the guidance and recommendations from the Centres for Disease Control and Prevention for doffing PPE compared to no guidance may reduce self-contamination (MD -5.44, 95% CI -7.43 to -3.45). One-step removal of gloves and gown compared to separate removal (RR 0.20, 95% CI 0.05 to 0.77), double gloving compared to single gloving (RR 0.34, 95% CI 0.17 to 0.66) and sanitising gloves before doffing with quaternary ammonium or bleach (but not alcohol-based hand rub) may decrease contamination. Additional verbal instructions may lead to fewer errors in doffing (MD -0.9, 95% CI -1.4 to -0.4). User training To a vast extent, face-to-face training may reduce non-compliance with doffing guidance (odds ratio 0.45, 95% CI 0.21 to 0.98) compared to solely providing folders or videos. In addition, computer simulation may lead to fewer errors in doffing (MD -1.2, 95% CI -1.6 to -0.7) and video lecture on donning PPE may lead to better skills scores (MD 30.70, 95% CI 20.14 to 41.26) compared to traditional lectures.Conclusions The more body parts are covered with PPE the better protection it offers. However, this is also associated and increased difficulty in donning and doffing PPE, and the PPE is less comfortable. Coveralls are the most difficult PPE to remove but may offer the best protection, followed by long gowns, gowns and aprons. The included studies had a high or unclear risk of bias, indirectness of evidence in simulation studies and small participant numbers. This increases the uncertainty about the estimates of effects, and it is likely that the true effects may be substantially different from the ones reported in this review.

Identifying predictors of early childhood caries among Australian children using sequential modelling: Findings from the VicGen birth cohort study.

OBJECTIVES: The aim of this birth cohort study was to identify concurrent associations between early childhood caries and putative risk and protective factors. METHODS: Data were collected in seven waves over five years. The study outcome measure, d3-6mfs, was modelled in a set of sequential negative binomial regressions that introduced the variables in steps starting from health determinants most distal to the child and ending with the more proximal ones. The goodness of fit of each model at each step was tested using the quasi-likelihood under independence model criterion (QIC). A final model included all significant factors identified in the sequential modelling. Bacterial composition of the child's saliva was determined by 16S RNA gene sequencing. RESULTS: Overall, 467 children (48.6 % female) participated, of whom 419 (89.7 %) had at least one follow-up visit after baseline. Of the 419 children included in the analyses, 133 (31.7 %) had their saliva samples sequenced for microbiomic determination. Independent protectors of surface cavitation included water fluoridation, and older age of mothers. Risk for d3-6mfs was significantly higher among children whose mothers were current smokers (IRR 3.29, 95 % CI 1.09-9.88, p = 0.034), children who went to bed with a bottle (IRR 2.67, 95-6.88, p = 0.041) and whose saliva sample sequencing over time showed higher percentages of Streptococcus mutans (IRR 1.39, 95 % CI 1.11-1.74, p = 0.005). Model fit was mostly improved by child's proximal variables. Household and mother covariates did not substantially improve model fit. CONCLUSION: This analysis highlights the relevance and importance of child-proximal risk factors in childhood dental cavitation. CLINICAL SIGNIFICANCE: The study findings inform clinical decision making for the management of early childhood caries at both the individual and population level. At an individual and family level these risk factors should be incorporated into caries risk assessment tools for more precise identification of risk and evidence-informed interventions by health professionals.

Family-centred oral health promotion through Victorian child-health services: a pilot.

Maternal and Child Health Services (MCHS) provide ideal settings for oral disease prevention. In Victoria (Australia), child mouth-checks (Lift-the-Lip) and oral health promotion (OHP) occur during MCHS child visits. This study trialled Tooth-Packs (OHP resources, toothbrushes, toothpastes) distribution within MCHS to (i) assess the impacts of Tooth-Packs distribution on child and family oral health (OH) behaviours and knowledge, including Maternal and Child Health Nurses (MCHN) child referral practices to dental services, and (ii) determine the feasibility and acceptability of incorporating Tooth-Packs distribution into MCHN OHP practices. A mixed-methods evaluation design was employed. MCHN from four high-needs Victorian Local Government Areas distributed Tooth-Packs to families of children attending 18-month and/or 24-month MCHS visits (baseline). Families completed a questionnaire on OH and dietary practices at baseline and 30-month follow-up. Tooth-Packs distribution, Lift-the-lip mouth-checks and child OH referrals were conducted. Guided discussions with MCHN examined intervention feasibility. Overall, 1585 families received Tooth-Packs. Lift-the-lip was conducted on 1493 children (94.1%). Early childhood caries were identified in 142 children (9.5%) and these children were referred to dental services. Baseline to follow-up behavioural improvements (n = 230) included: increased odds of children having ever seen an OH professional (OR 28.0; 95% CI 7.40-236.88; p < 0.001), parent assisted toothbrushing twice/day (OR 1.76; 95% CI 1.05-3.00; p = 0.030) and toothpaste use >once/day (OR 2.82; 95% CI 1.59-5.24; p < 0.001). MCHN recommendations included distribution of Tooth-Packs to at-risk children <12-months of age. MCHS provide an ideal setting to enable timely family-centred OHP intervention and adoption of good OH behaviours at an early age.

WITHDRAWN: Community-based population-level interventions for promoting child oral health.

BACKGROUND: Dental caries and gingival and periodontal disease are commonly occurring, preventable chronic conditions. Even though much is known about how to treat oral disease, currently we do not know which community-based population-level interventions are most effective and equitable in preventing poor oral health. OBJECTIVES: Primary • To determine the effectiveness of community-based population-level oral health promotion interventions in preventing dental caries and gingival and periodontal disease among children from birth to 18 years of age. Secondary • To determine the most effective types of interventions (environmental, social, community and multi-component) and guiding theoretical frameworks.• To identify interventions that reduce inequality in oral health outcomes.• To examine the influence of context in the design, delivery and outcomes of interventions. SEARCH METHODS: We searched the following databases from January 1996 to April 2014: MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Education Resource Information Center (ERIC), BIOSIS Previews, Web of Science, the Database of Abstracts of Reviews of Effects (DARE), ScienceDirect, Sociological Abstracts, Social Science Citation Index, PsycINFO, SCOPUS, ProQuest Dissertations & Theses and Conference Proceedings Citation Index - Science. SELECTION CRITERIA: Included studies were individual- and cluster-randomised controlled trials (RCTs), controlled before-and-after studies and quasi-experimental and interrupted time series. To be included, interventions had to target the primary outcomes: dental caries (measured as decayed, missing and filled deciduous teeth/surfaces, dmft/s; Decayed, Missing and Filled permanent teeth/surfaces, DMFT/S) and gingival or periodontal disease among children from birth to 18 years of age. Studies had to report on one or more of the primary outcomes at baseline and post intervention, or had to provide change scores for both intervention and control groups. Interventions were excluded if they were solely of a chemical nature (e.g. chlorhexidine, fluoride varnish), were delivered primarily in a dental clinical setting or comprised solely fluoridation. DATA COLLECTION AND ANALYSIS: Two review authors independently performed screening, data extraction and assessment of risk of bias of included studies (a team of six review authors - four review authors and two research assistants - assessed all studies). We calculated mean differences with 95% confidence intervals for continuous data. When data permitted, we undertook meta-analysis of primary outcome measures using a fixed-effect model to summarise results across studies. We used the I2 statistic as a measure of statistical heterogeneity. MAIN RESULTS: This review includes findings from 38 studies (total n = 119,789 children, including one national study of 99,071 children, which contributed 80% of total participants) on community-based oral health promotion interventions delivered in a variety of settings and incorporating a range of health promotion strategies (e.g. policy, educational activities, professional oral health care, supervised toothbrushing programmes, motivational interviewing). We categorised interventions as dietary interventions (n = 3), oral health education (OHE) alone (n = 17), OHE in combination with supervised toothbrushing with fluoridated toothpaste (n = 8) and OHE in combination with a variety of other interventions (including professional preventive oral health care, n = 10). Interventions generally were implemented for less than one year (n = 26), and only 11 studies were RCTs. We graded the evidence as having moderate to very low quality.We conducted meta-analyses examining impact on dental caries of each intervention type, although not all studies provided sufficient data to allow pooling of effects across similar interventions. Meta-analyses of the effects of OHE alone on caries may show little or no effect on DMFT (two studies, mean difference (MD) 0.12, 95% confidence interval (CI) -0.11 to 0.36, low-quality evidence), dmft (three studies, MD -0.3, 95% CI -1.11 to 0.52, low-quality evidence) and DMFS (one study, MD -0.01, 95% CI -0.24 to 0.22, very low-quality evidence). Analysis of studies testing OHE in combination with supervised toothbrushing with fluoridated toothpaste may show a beneficial effect on dmfs (three studies, MD -1.59, 95% CI -2.67 to -0.52, low-quality evidence) and dmft (two studies, MD -0.97, 95% CI -1.06 to -0.89, low-quality evidence) but may show little effect on DMFS (two studies, MD -0.02, 95% CI -0.13 to 0.10, low-quality evidence) and DMFT (three studies, MD -0.02, 95% CI -0.11 to 0.07, moderate-quality evidence). Meta-analyses of two studies of OHE in an educational setting combined with professional preventive oral care in a dental clinic setting probably show a very small effect on DMFT (-0.09 weighted mean difference (WMD), 95% CI -0.1 to -0.08, moderate-quality evidence). Data were inadequate for meta-analyses on gingival health, although positive impact was reported. AUTHORS' CONCLUSIONS: This review provides evidence of low certainty suggesting that community-based oral health promotion interventions that combine oral health education with supervised toothbrushing or professional preventive oral care can reduce dental caries in children. Other interventions, such as those that aim to promote access to fluoride, improve children's diets or provide oral health education alone, show only limited impact. We found no clear indication of when is the most effective time to intervene during childhood. Cost-effectiveness, long-term sustainability and equity of impacts and adverse outcomes were not widely reported by study authors, limiting our ability to make inferences on these aspects. More rigorous measurement and reporting of study results would improve the quality of the evidence.

Community-based population-level interventions for promoting child oral health.

BACKGROUND: Dental caries and gingival and periodontal disease are commonly occurring, preventable chronic conditions. Even though much is known about how to treat oral disease, currently we do not know which community-based population-level interventions are most effective and equitable in preventing poor oral health. OBJECTIVES: Primary • To determine the effectiveness of community-based population-level oral health promotion interventions in preventing dental caries and gingival and periodontal disease among children from birth to 18 years of age. Secondary • To determine the most effective types of interventions (environmental, social, community and multi-component) and guiding theoretical frameworks.• To identify interventions that reduce inequality in oral health outcomes.• To examine the influence of context in the design, delivery and outcomes of interventions. SEARCH METHODS: We searched the following databases from January 1996 to April 2014: MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Education Resource Information Center (ERIC), BIOSIS Previews, Web of Science, the Database of Abstracts of Reviews of Effects (DARE), ScienceDirect, Sociological Abstracts, Social Science Citation Index, PsycINFO, SCOPUS, ProQuest Dissertations & Theses and Conference Proceedings Citation Index - Science. SELECTION CRITERIA: Included studies were individual- and cluster-randomised controlled trials (RCTs), controlled before-and-after studies and quasi-experimental and interrupted time series. To be included, interventions had to target the primary outcomes: dental caries (measured as decayed, missing and filled deciduous teeth/surfaces, dmft/s; Decayed, Missing and Filled permanent teeth/surfaces, DMFT/S) and gingival or periodontal disease among children from birth to 18 years of age. Studies had to report on one or more of the primary outcomes at baseline and post intervention, or had to provide change scores for both intervention and control groups. Interventions were excluded if they were solely of a chemical nature (e.g. chlorhexidine, fluoride varnish), were delivered primarily in a dental clinical setting or comprised solely fluoridation. DATA COLLECTION AND ANALYSIS: Two review authors independently performed screening, data extraction and assessment of risk of bias of included studies (a team of six review authors - four review authors and two research assistants - assessed all studies). We calculated mean differences with 95% confidence intervals for continuous data. When data permitted, we undertook meta-analysis of primary outcome measures using a fixed-effect model to summarise results across studies. We used the I2 statistic as a measure of statistical heterogeneity. MAIN RESULTS: This review includes findings from 38 studies (total n = 119,789 children, including one national study of 99,071 children, which contributed 80% of total participants) on community-based oral health promotion interventions delivered in a variety of settings and incorporating a range of health promotion strategies (e.g. policy, educational activities, professional oral health care, supervised toothbrushing programmes, motivational interviewing). We categorised interventions as dietary interventions (n = 3), oral health education (OHE) alone (n = 17), OHE in combination with supervised toothbrushing with fluoridated toothpaste (n = 8) and OHE in combination with a variety of other interventions (including professional preventive oral health care, n = 10). Interventions generally were implemented for less than one year (n = 26), and only 11 studies were RCTs. We graded the evidence as having moderate to very low quality.We conducted meta-analyses examining impact on dental caries of each intervention type, although not all studies provided sufficient data to allow pooling of effects across similar interventions. Meta-analyses of the effects of OHE alone on caries may show little or no effect on DMFT (two studies, mean difference (MD) 0.12, 95% confidence interval (CI) -0.11 to 0.36, low-quality evidence), dmft (three studies, MD -0.3, 95% CI -1.11 to 0.52, low-quality evidence) and DMFS (one study, MD -0.01, 95% CI -0.24 to 0.22, very low-quality evidence). Analysis of studies testing OHE in combination with supervised toothbrushing with fluoridated toothpaste may show a beneficial effect on dmfs (three studies, MD -1.59, 95% CI -2.67 to -0.52, low-quality evidence) and dmft (two studies, MD -0.97, 95% CI -1.06 to -0.89, low-quality evidence) but may show little effect on DMFS (two studies, MD -0.02, 95% CI -0.13 to 0.10, low-quality evidence) and DMFT (three studies, MD -0.02, 95% CI -0.11 to 0.07, moderate-quality evidence). Meta-analyses of two studies of OHE in an educational setting combined with professional preventive oral care in a dental clinic setting probably show a very small effect on DMFT (-0.09 weighted mean difference (WMD), 95% CI -0.1 to -0.08, moderate-quality evidence). Data were inadequate for meta-analyses on gingival health, although positive impact was reported. AUTHORS' CONCLUSIONS: This review provides evidence of low certainty suggesting that community-based oral health promotion interventions that combine oral health education with supervised toothbrushing or professional preventive oral care can reduce dental caries in children. Other interventions, such as those that aim to promote access to fluoride, improve children's diets or provide oral health education alone, show only limited impact. We found no clear indication of when is the most effective time to intervene during childhood. Cost-effectiveness, long-term sustainability and equity of impacts and adverse outcomes were not widely reported by study authors, limiting our ability to make inferences on these aspects. More rigorous measurement and reporting of study results would improve the quality of the evidence.

Economic Models of Preventive Dentistry for Australian Children and Adolescents: A Systematic Review.

PURPOSE: To identify economic evaluation models and parameters that could be replicated or adapted to construct a generic model to assess cost-effectiveness of and prioritise a wide range of community-based oral disease prevention programmes in an Australian context. METHODS: The literature search was conducted using MEDLINE, ERIC, PsycINFO, CINHAL (EBSCOhost), EMBASE (Ovid), CRD, DARE, NHSEED, HTA, all databases in the Cochrane library, Scopus and ScienceDirect databases from their inception to November 2012. RESULTS: Thirty-three articles met the criteria for inclusion in this review (7 were Australian studies, 26 articles were international). Existing models focused primarily on dental caries. Periodontal disease, another common oral health problem, was lacking. Among caries prevention studies, there was an absence of clear evidence showing continuous benefits from primary through to permanent dentition and the long-term effects of oral health promotion. CONCLUSION: No generic model was identified from previous studies that could be immediately adopted or adapted for our purposes of simulating and prioritising a diverse range of oral health interventions for Australian children and adolescents. Nevertheless, data sources specified in the existing Australian-based models will be useful for developing a generic model for such purposes.

Unsafe abortion as a birth control method: maternal mortality risks among unmarried cambodian migrant women on the Thai-Cambodia border.

Reproductive health research and policies in Cambodia focus on safe motherhood programs particularly for married women, ignoring comprehensive fertility regulation programs for unmarried migrant women of reproductive age. Maternal mortality risks arising due to unsafe abortion methods practiced by unmarried Cambodian women, across the Thai-Cambodia border, can be considered as a public health emergency. Since Thailand has restrictive abortion laws, Cambodian migrant women who have irregular migration status in Thailand experimented with unsafe abortion methods that allowed them to terminate their pregnancies surreptitiously. Unmarried migrant women choose abortion as a preferred birth control method seeking repeat "unsafe" abortions instead of preventing conception. Drawing on the data collected through surveys, in-depth interviews, and document analysis in Chup Commune (pseudonym), Phnom Penh, and Bangkok, the authors describe the public health dimensions of maternal mortality risks faced by unmarried Cambodian migrant women due to various unsafe abortion methods employed as birth control methods.