The impact of COVID-19 on the well-being of Victorian children born with cleft lip and/or palate.

BACKGROUND: A longitudinal cohort study was established to investigate the well-being of children born with cleft lip and/or palate (CL/P) during the COVID-19 pandemic, in Victoria, Australia. MATERIALS AND METHODS: The Royal Children's Hospital cleft service database was used to identify children aged between 4 and 17 years old born with an isolated CL/P. Families of eligible children who consented to participate were asked to complete the Strengths and Difficulties Questionnaire (SDQ) between October and December 2020 and again 6-month later. SDQ results from typically developing Australian children during the COVID-19 pandemic were utilized from a previously published study. RESULTS: 63 parents completed the baseline questionnaire, with 44 completing the 6-month follow-up. For participants at baseline, the mean age was 8.9 years, with 55% male. All outcome domains of the SDQ improved between baseline and timepoint 2, with the difference in total difficulties scores being statistically significant, indicating a reduction in total difficulties at timepoint 2, associated with the easing of COVID-19 restrictions. When compared with the Australian population during the COVID-19 pandemic, Victorian children born with CL/P had lower SDQ scores for all difficulties outcome domains, with statistically significant results for conduct problems, hyperactivity, peer problems and total difficulties, indicating fewer difficulties for children born with CL/P. CONCLUSIONS: Children born with CL/P experienced fewer difficulties when compared with the typically developing Australian population during the COVID-19 pandemic. The level of restrictions imposed because of the pandemic also had little influence on the well-being of these children.

Utilising surface-level data to explore surface, tooth, individual and family influence on the aetiology of hypomineralised second primary molars.

OBJECTIVES: Hypomineralised second primary molars (HSPM) are common developmental enamel defects. The aims of this study were to use surface-level data to explore the clustering of HSPM at four levels (family, child, tooth, surface). METHODS: This study of 172 twin pairs was nested within the Peri/postnatal Epigenetic Twin Study. HSPM was measured by standardised oral examinations at age 6 years. Multilevel logistic regression models were fitted to assess the correlation structure of surface level data and variation in HSPM. The associations between surface level risk factors and HSPM were then explored using the multilevel logistic regression model using the best fitting correlation structure. RESULTS: The prevalence of HSPM was 68 (19.8%) children, with a total of 141 (10.3%) teeth and 264 tooth surfaces (6.3%) affected. Multilevel models revealed that a hierarchical structure accounting for correlation at the family, child and tooth level best accounted for the variation in HSPM. The estimated variances from the best fitting model (Model 3) were largest at the family level (12.27, 95% CI 6.68, 22.51) compared with 5.23 at the child level and 1.93 at the tooth level. Application of regression analysis utilising this three-level correlation structure identified tooth/surface level factors in addition to the previously identified familial and individual risk factors for HSPM. CONCLUSION: In addition to familial (environmental and genetic) and unique child-level factors, the aetiology of HSPM is likely to be influenced by local tooth-level factors.

A twin study of body mass index and dental caries in childhood.

Sub-optimal nutrition and dental caries are both common with significant short and long-term implications for child health and development. We applied twin statistical methods to explore the relationship between body mass index (BMI) and dental caries. We measured BMI at 18 months and six years of age and cumulative dental caries experience at six years in 344 twin children. Dental caries in primary teeth was categorised into 'any' or 'advanced' and BMI was analysed as both a continuous and categorical variable. Statistical analyses included multiple logistic regression using generalized estimating equations and within/between-pair analyses. There was no association between BMI and 'any' dental caries experience at either time-point, neither overall nor in within/between pair analyses. However, 'advanced' dental caries at six years was associated with a within-pair difference in BMI of -0.55 kg/m2 (95% CI -1.00, -0.11, p = 0.015). A within-pair increase of 1 kg/m2 in BMI was associated with a lower within-pair risk of advanced dental caries (OR 0.68, 95% CI 0.52, 0.90, p = 0.007). These findings reveal a possible causal relationship between lower BMI and dental caries. As dental outcomes were only measured at one time point, the direction of this potentially causal relationship is unclear.

Getting ahead of the oral health game: it starts before we're born?

Dental caries is one of the most common chronic diseases affecting individuals of all ages. Caries in the primary dentition is one of the main risk factors for caries in the permanent dentition. Preventing the development of the first carious lesion is fundamental not only to long term health and wellbeing but to reducing the burden of this disease on individuals, families and the community. Described as the developmental origins of health and disease, events from the prenatal period are increasingly recognised as having a significant impact on later health outcomes. While social and behavioural factors from this period have long been linked with oral health, emerging evidence of the influence of epigenetics and early life programming of microbiome and host response suggests that the prenatal period provides a timely opportunity for preventive interventions. Pregnancy is an ideal time to focus on health promoting activities as most women have regular interaction with health care professionals who can target risk factors before the onset of disease. This paper summarizes contemporary understanding of the role of pre- and perinatal factors on child oral health and describes how this evidence might be used by all health professionals to ensure infants start life ahead in the oral health game.

Etiology of Hypomineralized Second Primary Molars: A Prospective Twin Study.

The etiology of hypomineralized second primary molars (HSPM) is unclear, but genetic and environmental factors have been proposed. The aim of this study was to investigate the relative contribution of genes and environment to the etiology of HSPM and to identify potential environmental risk factors in a longitudinal twin cohort. Children from twin pregnancies ( N = 250) were recruited antenatally, and detailed demographic, health, and phenotypic data were collected at recruitment, 24- and 36-wk gestation, birth, and 18 mo of age. 25-Hydroxyvitamin D was quantified for mothers at 28-wk gestation and infants at birth. Dental examinations were conducted on the twins at 6 y of age to determine the presence, severity, and extent of HSPM per standardized criteria. To investigate associations of environmental risk factors with HSPM, multiple logistic regression models were fitted with generalized estimating equations to adjust for twin correlation. Within- and between-pair analyses were performed for unshared continuous variables: birthweight and birth 25-hydroxyvitamin D. Twin-twin concordance for monozygotic (MZ) and dizygotic (DZ) pairs was calculated and compared after adjusting for identified risk factors. A total of 344 twins underwent the 6-y-old dental assessment; HSPM occurred in 68 (19.8%). After adjusting for potential confounders, vitamin D levels at birth, infantile eczema, dizygosity, in vitro fertilization, socioeconomic position, and maternal smoking beyond the first trimester of pregnancy demonstrated the strongest associations with HSPM. Overall concordance for HSPM was 0.47 (95% CI, 0.32 to 0.62) with weak evidence ( P = 0.078) of higher concordance in MZ twins (0.63; 95% CI, 0.38 to 0.89) as compared with DZ twins (0.41; 95% CI, 0.24 to 0.58). After adjusting for known risk factors, there was no evidence ( P = 0.172) for an additive genetic influence. These findings suggest that shared and unshared environmental factors, such as maternal smoking later in pregnancy and infantile eczema, are important in the etiology of HSPM.

Midwives' and women's views on accessing dental care during pregnancy: an Australian qualitative study.

BACKGROUND: Maternal behaviours during pregnancy are likely to play a significant role in the development of dental caries in children. Although midwives are well placed to discuss oral health and provide information to women, dental attendance by women during pregnancy is minimal. This study aimed to explore midwives' experience of facilitating pregnant women's access to dental care and to document women's experience of receiving dental information and care during pregnancy. METHODS: Focus groups with midwives and telephone interviews with women who were referred to Monash Health Dental Services were conducted to explore their perspectives and experiences. The qualitative data was thematically analysed. RESULTS: Three focus groups with 13 midwives and telephone interviews with eight women who recently gave birth were conducted. Three key themes were identified: maternal oral health knowledge; barriers to accessing dental information and care during pregnancy; and suggested recommendations. CONCLUSIONS: This study highlighted the barriers that exist for midwives to discuss oral health with women and refer women to dental care, and women's experiences of accessing dental care during pregnancy. Ongoing collaboration between the maternity and dental services is required to strengthen midwives' knowledge, confidence and practise in supporting women to access dental care during pregnancy.

Facial morphology and growth following surgery for congenital midline cervical cleft patients.

Congenital midline cervical cleft (CMCC) is a rare condition that consists of a cutaneous midline neck lesion with a sinus extending inferiorly towards the sternum. A fibrous band that extends superiorly to the mandible is a consistent feature of the condition. Restriction of growth of the mandible, possibly due to incomplete removal of the band, is the most significant long-term problem. It remains unclear whether early removal of the fibrous band might allow catch-up growth of the mandible. This study utilized non-invasive three-dimensional photographs to objectively evaluate the facial growth of six CMCC patients. The growth of these CMCC patients was compared to the average growth of age- and sex-matched controls from a database of three-dimensional facial photographs of clinically normal subjects. After surgical removal of the fibrous cord, CMCC patients experience growth in the chin at the same rate as in the normal population; no evidence was found for catch-up growth. As a result, individuals with CMCC are likely to require further surgical intervention to correct the residual retrognathia on completion of facial growth. Early excision of the lesion including aggressive resection of the fibrous band is still recommended, as this should optimize the early growth of the mandible in infancy.

Secondary bone grafting of alveolar clefts: a review of outcome at two centres in Australia and the UK.

Secondary alveolar bone grafting is a key procedure in comprehensive cleft services, the main objective of which is to allow the canine to erupt through the bone. We have assessed the outcomes of the procedure at two units, one in Australia and one in the UK. Success was measured using standardised indexes for radiological assessment (Bergland and Kindelan) and clinically by noting eruption of canines through the grafted sites. The two-year review indicated that the two units had comparably high success rates. Canines erupted through cleft sites in 27/28 sites in patients in the UK, and 26/28 in patients in Australia, and the radiological success using the indexes was also high. These rates are in line with international benchmarks.

Refugee child oral health.

The number of people forced to flee their homes and move around the world is increasing rapidly. Such refugee populations are not only more likely to have poor physical, mental and social health outcomes but also to experience difficulties accessing health services in their new country. In particular, children from refugee backgrounds are at increased risk of poor oral health which in time is associated with poor adult oral health and impacts on child health (e.g. growth and development) and well-being. To date, there is little evidence about the nature and extent of their oral health problems nor interventions to improve their oral health status. This article summarises the evidence surrounding the oral health status of children from refugee backgrounds. In addition, a systematic review of the international literature over the past 10 years is presented which identifies interventions to improve the oral health of these vulnerable paediatric populations. Based on this evidence, potential strategies available to dental service providers to optimise provision of responsive dental care are discussed.

Hard to reach communities or hard to access services? Migrant mothers' experiences of dental services.

BACKGROUND: Good oral health is an important component of overall health which can help migrants settle in a new country. Infant oral health is intimately associated with maternal oral health knowledge and behaviours and therefore, encounters with dental services. This study aimed to explore the experiences of dental service use from the perspective of migrant mothers living in Melbourne, Australia. METHODS: A participatory research approach utilizing qualitative methods was adopted. Women from Iraq, Lebanon and Pakistan participated. Semi-structured focus groups and interviews were conducted and thematic analysis of the data was completed. RESULTS: Focus groups (n = 11) and interviews (n = 7) were conducted with 115 women. Despite an understanding that visiting the dentist was important for promoting oral health, the first dental contact for both the women and their children was typically for emergency care. Accessibility, cost and waiting lists were identified as significant barriers to attendance. Problematic interpreter encounters often led to negative experiences which were compounded by a perception that public services provided poorer quality of care. CONCLUSIONS: Despite evidence of poorer oral health, migrant women face significant barriers in accessing mainstream dental services. Reorientation of such services, to address the accessibility and experience for migrant communities may help reduce oral health inequalities.

Elective cesarean delivery in a parturient with Klippel-Feil syndrome.

Klippel-Feil syndrome is defined by congenital fusion of two or more cervical vertebrae and can be associated with abnormalities in multiple systems. Management poses challenges to the anesthesiologist, particularly in pregnancy. Cervical spine immobility and instability can make the management of the airway fraught with danger and vertebral column distortion may make neuraxial anesthesia unreliable. We present the management of a nulliparous patient with features consistent with Type I Klippel-Feil syndrome undergoing elective cesarean delivery. The patient had a potentially difficult airway and features consistent with an unstable cervical spine and severe thoracic and lumbar scoliosis. A combined spinal-epidural technique was used which initially provided satisfactory anesthesia, but ultimately proved inadequate despite use of the epidural component. Satisfactory anesthesia for surgery was eventually achieved with the addition of an intravenous remifentanil infusion. We review previous case reports discussing anesthetic management of parturients with Klippel-Feil syndrome, and describe the challenges encountered and lessons learned from management of this case.

A qualitative study of patients' motivations and expectations for dental implants.

OBJECTIVE: To explore patients' motivations and expectations for dental implants. DESIGN: Single-setting, qualitative interview study. SUBJECTS, SETTING AND METHOD: Semi-structured, telephone interviews were conducted with nine patients who had consulted a restorative dental practitioner with an interest in implantology about the possibility of replacing their missing teeth with dental implants. OUTCOME MEASURE: Interview transcripts were subjected to thematic analysis to identify relevant themes. RESULTS: The main theme to emerge was 'normality'. Participants expected implants to restore their oral-related quality of life to 'normal'. However, individual definitions of normality differed; some were appearance focused, while others were more concerned with functioning. Several participants who had completed implant treatment regarded their new prostheses as 'just like natural teeth'. CONCLUSIONS: Patients' belief that dental implants are just like natural teeth could be cause for concern if it leads them to treat them as such, and thereby not follow the recommended specialist care they require. The findings emphasise the importance of good dental practitioner-patient communication in assessing expectations of treatment and outcomes. Further studies should explore the expectations of patients of different ages and socioeconomic backgrounds and consider ways of eliciting patients' beliefs about implants before treatment takes place.

Dental admissions in children under two years--a total-population investigation.

BACKGROUND: There is a lack of literature describing dental admissions in children particularly very young children. This paper describes dental and oral cavity admissions and associated factors in children under two years of age using total-population databases. METHODS: The data used for this study were extracted from population-based databases which are linkable with midwives' data collected on all births in Western Australia. Children born from 1980 to 1998 inclusive (n = 459,831) were followed until two years of age including data on deaths, hospital admissions, birth defects and intellectual disability. Dental admissions (by ICD-9 category) and associated factors were investigated. RESULTS: There were 1513 dental admissions occurring in 1459 of the children up to the age of two years. Children were most frequently admitted under ICD-9 category 521, which includes a hospital admission for dental caries (39% of all oral cavity admissions), followed by ICD-9 category 528 (29%), which includes diseases of the oral soft tissues. Univariate analysis indicated that those with intellectual disability (OR 2.10, 95%CI 1.40-3.16), birth defect (1.74, 1.45-2.09), residing in a region without fluoridated water (2.15, 1.72-2.69) being male (1.14, 1.03-1.26), those from rural areas (2.29, 2.07-2.54) and Indigenous children (4.45, 3.91-5.05) were significantly more likely to have had a dental admission. CONCLUSION: Using total-population data allowed us to describe the admissions in children under two years and associated factors while able to identify children with intellectual disability or birth defects.

Using service rationalisation to build a research network: lessons from the centralisation of UK services for children with cleft lip and palate.

In the UK around a thousand children are born annually with a cleft lip and/or palate that requires treatment. In the last decade services have been centralised in the UK reducing the 57 centres operating on these children in 1998, down to 11 centres or managed clinical networks in 2011. While the rationale for centralisation was to improve the standard of care (and in so doing the outcome) for children born with cleft lip and/or palate, research was central to this process. We illustrate how research informed and shaped this service rationalisation and how it facilitated the emergence of a research culture within the newly configured teams. We also describe how these changes in service provision were linked to the development of a national research strategy and to the identification of the resources necessary to support this strategy.

Oral health inequalities in a national sample of Australian children aged 2-3 and 6-7 years.

BACKGROUND: While inequalities in oral health are generally well documented, it is less clear whether such patterns are evident from early childhood. Using four measures of potential inequality, this study examined patterns in oral health for Australian children at ages 2-3 and 6-7 years. METHODS: Cross-sectional data from two cohorts of children in the Longitudinal Study of Australian Children (LSAC) were used to explore associations between reported oral health and four indicators of social disadvantage: socio-economic position (SEP), residential remoteness, Indigenous status and non-English speaking background. RESULTS: For both cohorts, lower SEP and Indigenous status were associated with higher odds of poor oral health on all three indicators, and less accessible location was associated with increased odds for caries. Non-English speaking background was associated with increased odds for caries experience in 2-3 year olds and non-use of dental services in the older cohort. Inequalities were larger in the older cohort for socio-economic position and toothbrushing. CONCLUSIONS: Marked social disparities in oral health appear as early as 2 years of age and remain evident in school-age children. Interventions to reduce such disparities should start as early as possible.

Total population investigation of dental hospitalizations in indigenous children under five years in Western Australia using linked data.

BACKGROUND: The aim of this study was to compare dental hospital admissions in a total state birth population of Indigenous and non-Indigenous children aged under five years in Western Australia. METHODS: Midwives' notification data were linked to databases of deaths, admissions, birth defects and intellectual disability. Births during 1980-1995 were followed until five years of age (n = 383,665). Dental admissions were classified by ICD-9 principal diagnosis categories. RESULTS: There were 738 dental admissions for 665 children aged up to five years of Indigenous mothers (n = 20,921). Indigenous children comprised 6.3% of all children having a dental admission in this age group; 3.2% of children with Indigenous mothers had a dental admission compared with 2.7% of non-Indigenous children. Overall, 8.7% (n = 58) of Indigenous children with a dental admission had a birth defect and 5.5% (n = 23) had an intellectual disability (compared to 8.8% and 3.2%). Indigenous children were four times more likely to be diagnosed with oral soft tissue diseases than non-Indigenous children, and less likely to be categorized as having diseases of the dental hard tissues. Indigenous children were more likely to have a longer dental admission. CONCLUSIONS: These analyses provide important findings regarding hospital admissions for Indigenous children. Admissions for disorders of the soft tissues are more common in Indigenous children.

Why are multi-centre clinical observational studies still so difficult to run?

Despite the introduction of IRAS, obtaining R&D approvals for multicentre studies is a major rate limiting step. Our experience with cleft research demonstrates that this approvals process must be drastically and rapidly improved if we wish to continue attract clinical research to the UK.

State-level differences in the oral health of Australian preschool and early primary school-age children.

BACKGROUND: This study compares oral health outcomes and behaviours for young Australian children by residential state or territory to determine whether state differences arise from individual exposures to risk factors. METHODS: Cross-sectional data for 4606 2-3 year olds and 4464 6-7 year olds were obtained from the Longitudinal Study of Australian Children. Outcome measures were parent-reports of children's caries experience, frequency of toothbrushing and dental services use. RESULTS: For 2-3 year olds, children from the Australian Capital Territory were less likely to have parent-reported caries than children from other states, and more likely to brush their teeth twice daily and to have used dental services. For 6-7 year olds, optimal outcomes were observed in New South Wales for lowest caries experience, Western Australia for highest toothbrushing, and South Australia for highest dental services use. Adjustments for socio-demographic predictors did not eliminate state differences in oral health. CONCLUSIONS: Large state differences in the oral health of young children persisted after adjustment for individual socio-demographic determinants, suggesting these arise from variations in the systems to promote and care for children's oral health. Several states would benefit from a stronger emphasis on oral health promotion in young children, and disparities from a young age suggest the need for better engagement of early childhood professionals in oral health promotion.

Surface integrity governs the proteome of hypomineralized enamel.

Growing interest in the treatment and prevention of Molar/Incisor Hypomineralization (MIH) warrants investigation into the protein composition of hypomineralized enamel. Hypothesizing abnormality akin to amelogenesis imperfecta, we profiled proteins in hypomineralized enamel from human permanent first molars using a biochemical approach. Hypomineralized enamel was found to have from 3- to 15-fold higher protein content than normal, but a near-normal level of residual amelogenins. This distinguished MIH from hypomaturation defects with high residual amelogenins (amelogenesis imperfecta, fluorosis) and so typified it as a hypocalcification defect. Second, hypomineralized enamel was found to have accumulated various proteins from oral fluid and blood, with differential incorporation depending on integrity of the enamel surface. Pathogenically, these results point to a pre-eruptive disturbance of mineralization involving albumin and, in cases with post-eruptive breakdown, subsequent protein adsorption on the exposed hydroxyapatite matrix. These insights into the pathogenesis and properties of hypomineralized enamel hold significance for prevention and treatment of MIH.

Pathways to emergency dental care: An exploratory study.

AIM: To describe the pathways to care associated with acute dental infections in children. METHODS: Primary carers of children presenting with facial cellulitis completed a semistructured interview that sought to establish their pathway to the emergency department and definitive treatment. Descriptive statistics were used to describe the patterns of healthcare attendances, treatment received, medications prescribed and referrals made from the time the problem was first noted. RESULTS: Interviews were completed for 12 children presenting with acute cellulitis as a result of caries in the primary dentition (mean age of 6.8 + 2.6 years). The median time lapsed since carers first became aware of the problem was 15.5 days (range 3 to 63). The mean number of health service attendances made per child was 4.5 + 1.98. A total of 17 courses of oral antibiotics were prescribed prior to definitive treatment (mean 1.4 + 1.24, range 0 to 3). Half the teeth involved had been previously 'restored'. CONCLUSION: Children presenting with acute facial cellulitis represent the last stage in a pathway of failed clinical care that is associated with significant costs to both the individual family and the community. Further work is required to understand the barriers to children accessing timely and appropriate dental treatment.