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

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

Socioeconomic factors associated with risk of upper aerodigestive tract cancer in Europe.

INTRODUCTION: In the European Union, there are 180,000 new cases of upper aerodigestive tract (UADT) cancer cases per year--more than half of whom will die of the disease. Socioeconomic inequalities in UADT cancer incidence are recognised across Europe. We aimed to assess the components of socioeconomic risk both independently and through their influence on the known behavioural risk factors of smoking, alcohol consumption and diet. PATIENTS AND METHODS: A multicentre case-control study with 2198 cases of UADT cancer and 2141 controls from hospital and population sources was undertaken involving 14 centres from 10 countries. Personal interviews collected information on demographics, lifetime occupation history, smoking, alcohol consumption and diet. Socioeconomic status was measured by education, occupational social class and unemployment. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed using unconditional logistic regression. RESULTS: When controlling for age, sex and centre significantly increased risks for UADT cancer were observed for those with low versus high educational attainment OR=1.98 (95% CI 1.67, 2.36). Similarly, for occupational socioeconomic indicators--comparing the lowest versus highest International Socio-Economic Index (ISEI) quartile for the longest occupation gave OR=1.60 (1.28, 2.00); and for unemployment OR=1.64 (1.24, 2.17). Statistical significance remained for low education when adjusting for smoking, alcohol and diet behaviours OR=1.29 (1.06, 1.57) in the multivariate analysis. Inequalities were observed only among men but not among women and were greater among those in the British Isles and Eastern European countries than in Southern and Central/Northern European countries. Associations were broadly consistent for subsite and source of controls (hospital and community). CONCLUSION: Socioeconomic inequalities for UADT cancers are only observed among men and are not totally explained by smoking, alcohol drinking and diet.

Increasing breastfeeding and reducing smoking in pregnancy: a social marketing success improving life chances for children.

AIMS: The aim of this study is to evaluate an intervention using social marketing principles to increase breastfeeding and reduce smoking during pregnancy in a population to improve life chances for children born in a town in north east England. METHOD: Breastfeeding and smoking cessation attendance rates were measured against targets set in a government-local health authority agreement. RESULTS: Targets were bettered in both breastfeeding and smoking cessation. CONCLUSION: This social marketing-based approach is successful.

Hearts and mouths: perceptions of oral hygiene by at-risk heart surgery patients.

OBJECTIVE: To assess and use the attitudes of patients who are placed at risk after valvular heart surgery due to the connection between poor oral hygiene, valvular heart disease/surgery and the risk of developing infective endocarditis. DESIGN: A qualitative (focus group) design based study carried out on subjects three months post heart surgery. METHOD: There were five focus groups of five participants each convened by an experienced moderator. RESULTS: These portrayed an apparent pressing desire by most patients to talk about their experiences. However, patients did not accept the link between their oral health and their general health. Oral hygiene practices were not necessarily oral health related. CONCLUSIONS: The importance of the study in understanding the reasons for a patient's behaviour is evident when there is a clear need to modify the behaviour patterns of the patients effectively. Clinical trials can now be developed based on these results.

Using social marketing to increase recruitment of pregnant smokers to smoking cessation service: a success story.

OBJECTIVES: To explore what it is like to be a pregnant smoker in Sunderland and to inform the development of a Smoking Cessation Programme; to use qualitative techniques to develop a cessation programme tailored to pregnant smokers. STUDY DESIGN: The intervention follows years of social marketing research and development in Sunderland, Wearside, UK. METHODS: Information derived from nine focus groups (mainly with women from deprived areas, social class C2D and E) provided insights into the issues facing smoking pregnant women. This information was then used to overcome barriers to smoking cessation using the principles of social marketing. The number of women recruited into a specially designed smoking cessation support initiative was compared with women recruited into comparable groups in the North East. RESULTS: Recruitment of pregnant (and non-pregnant) smokers to the new NHS smoking cessation programme in Sunderland has increased during the intervention phase compared with neighbouring Primary Care Trust areas (in which different smoking cessation interventions targeted at pregnant women were being undertaken). CONCLUSIONS: This innovative intervention has been successful in generating ideas, guiding development of a customer-friendly service and encouraging women to come forward for smoking cessation support during their pregnancy. The target population have welcomed the approach, and health professionals have enjoyed and benefited from the role play with professional actors.

Attitudes to water fluoridation in general dental practice in the North East of England.

OBJECTIVE: To find out the knowledge of, and attitudes towards, water fluoridation of a sample of general dental practitioners working in the North East of England. DESIGN: Anonymous, self-completed postal questionnaire. SETTING: North East of England, both a fluoridated and non-fluoridated area. SUBJECTS AND METHODS: Following a small pilot survey, questionnaire to 79 general dental practitioners (44 in a non-fluoridated area, 35 in an area supplied with fluoridated water at one part per million) contracted to provide National Health Service (NHS) treatment in the North East of England. RESULTS: Fifty-five general dental practitioners returned questionnaires (a 70% response rate). Most respondents supported the principle of water fluoridation. Over half of the respondents indicated that they would benefit from more information and training on the issue of water fluoridation. There were marked differences in knowledge and attitudes to fluoridation between dental principals and associates. The sample was evenly split about what to do with a parent who was unsure about (whether to support) fluoridation even after the dentist had discussed the issue and answered questions. CONCLUSIONS: The majority of general dental practitioners support water fluoridation although some lack knowledge and expertise which might inhibit advocacy of it.

Oral cancer: material deprivation, unemployment and risk factor behaviour--an initial study.

Regional variations in the incidence of oral cancer may be related in some cases to material deprivation. The main aim of this study was to identify in cases (and controls matched for age and sex) an index of material deprivation, employment history, smoking and alcohol habits. This prospective study comprised 100 subjects in each group and was questionnaire based. Previous studies in relation to material deprivation in oral cancer have been population based. There was a statistically significant trend for patients to come from the most deprived groups. Sixty-six per cent of the cases had experience of long-term unemployment. Although a high proportion, this was not statistically significant after multi-variable analysis due to the confounding effects of smoking and alcohol use. Such a high proportion of cases with a history of long-term unemployment requires further study to examine in detail if there is a definite link with oral cancer once the confounding effects of smoking and alcohol are removed.

Blood pressure measuring equipment in the dental surgery: use or ornament?

OBJECTIVE: To survey the attitudes, knowledge and practice of general dental practitioners (GDPs) with regard to hypertension in dental patients and to assess opinion with regard to the concept of screening. SETTING: General dental practice. SUBJECTS AND METHODS: GDPs via a postal survey. To achieve an acceptable level of accuracy, at least 196 responses were required. RESULTS: Out of 300 questionnaires, 207 were returned (69% response rate). Most practitioners (98%) had received training in the measurement of blood pressure. Only 4.8% measured blood pressure routinely and this figure rose to 9.2% in patients with a known history of hypertension. Only 27.1% felt that the involvement of dentists in screening for hypertension was a good idea but 85.3% thought that education of practitioners about hypertension would be valuable. CONCLUSION: Most GDPs thought that education of practitioners about hypertension was a good idea. They did not, however, want to be involved with screening of patients for hypertension.

The changing patterns of drinking, illicit drug use, stress, anxiety and depression in dental students in a UK dental school: a longitudinal study.

OBJECTIVE: To investigate alcohol and illicit drug use in a cohort of dental undergraduates through to VT year. SETTING: A UK dental school (with a medical school comparison group). SUBJECTS AND METHODS: A cohort of dental students anonymously completed a lifestyle questionnaire about drinking and smoking, illicit drug use, stress, anxiety and depression in the spring of 1995 and 1998 as second and final year undergraduate students respectively, and in the summer of 1999 after one year working as qualified dentists. A parallel cohort of medical students also anonymously completed the questionnaire at the same time points in their undergraduate course as for the dental students, and at the end of a year working as Pre-Registration House Officers (PRHOs). RESULTS: The proportion of dental students in Newcastle drinking above the recommended low risk limits of alcohol declined from 47% as second year students to 25% as final year students and then it increased to 41% as qualified dentists, whilst in medical students it steadily increased over the three time points of the survey (33% to 43% to 54%). A greater proportion of dental students were drinking at hazardous levels at all three time-points, compared with medical students. Experimentation with illicit drugs ranged from 47% as second year students to 54% as final year students and to 51% as dentists. The prevalence of illicit drug use in medical students was similar to that in dental students. Forty seven per cent of the dental student cohort as second year students, 67% as final year students and 16% as dentists suffered from possible pathological anxiety, compared with 47%, 26% and 30% in the medical student cohort. The proportion of dentists suffering from stress decreased from 72% as final year students to 19% as dentists. In the medical student group, the proportion increased from 32% as final year students to 39% as PRHOs. CONCLUSION: This longitudinal study revealed that a high proportion of dental students from Newcastle continue to drink excessively and experiment with illicit drugs both as undergraduates and as practising dentists. A significant proportion also suffer from anxiety and stress. Further measures are needed in order to reduce alcohol and substance misuse and stress and anxiety among dental students and dentists.

Primary care clinicians' knowledge of oral cancer: a study of dentists and doctors in the North East of England.

OBJECTIVE: To compare the knowledge of oral cancer and related issues of general dental and general medical practitioners (GDPs and GMPs). DESIGN: A questionnaire was sent to 420 primary care clinicians, half to dentists and half to doctors. Responses to the questionnaire were analysed using odds ratios (OR) and 95% confidence intervals (CI). RESULTS: The response rate was 68.1% for GDPs and 71.9% for GMPs. Dental practitioners were significantly more likely to have diagnosed cases of oral cancer than medical practitioners (OR = 2.68, 95% CI 1.6,4.4). Important differences arose between the groups in terms of risk factor knowledge and clinical examination. CONCLUSION: This study demonstrates that whilst the knowledge level of both groups is generally good, there are some discrepancies. These relate mainly to risk factor knowledge and clinical examination techniques.

What the papers say: how does the United Kingdom press treat water fluoridation and does it matter?

This is a case study to investigate in an objective way how fluoridation is reported in the press. All press cuttings collected by a reputable national agency covering a 9-month period were studied; were rated as being profluoridation, antifluoridation or neutral. The rating system was calibrated before the study by comparing the scores given by the author and a selected group of experts. Overall, press article coverage was antifluoridation, though it is not clear how intentional this is.

How much do the general public want to be involved in decisions on implementing water fluoridation?

OBJECTIVE: Test general public view about how much they wish to be involved in water fluoridation implementation decisions. DESIGN: Qualitative research using focus group discussions led by an experienced moderator. SETTING: Among the general public living in three non-fluoridated areas in England. SUBJECTS: Members of the public more than 20 years of age and by social class. RESULTS: General public wish to be informed of water fluoridation plans but do not see themselves as being the appropriate implementation arbiters. CONCLUSIONS: In the public's eyes, it would be inappropriate and unwelcome to delegate to them the decision about whether to fluoridate the public water supply.

Smokers and drinkers awareness of oral cancer: a qualitative study using focus groups.

OBJECTIVE: To examine the perceptions and understanding of oral cancer among older male drinkers and smokers in the north east of England. DESIGN: Qualitative research using focus group discussions led by an experienced moderator. SETTING: Residents of the north east of England in their community. SUBJECTS: Male alcohol drinkers and tobacco smokers over the age of 44 years and by socio-economic grouping. RESULTS: There is a lack of knowledge and understanding of the risk of oral cancer in this whole at-risk population sample. Even those who have direct contact with the disease profess ignorance. Information on health is perceived as confusing or distrusted. Much of this is linked to a fatalistic approach to serious illness. CONCLUSIONS: There appears to be a large information gap to bridge, and we need to further understand the target group for oral cancer health promotion; and to use that knowledge to design effective health promotion initiatives.

The role of the public in water fluoridation: public health champions or anti-fluoridation freedom fighters?

OBJECTIVE: Using the opportunity of pretesting a leaflet for the general public on water fluoridation, their views were also sought on the issue as a whole. DESIGN: Qualitative research using focus group discussions led by an experienced moderator. SETTING: Among the general public living in north east England. SUBJECTS: Members of the public living in both fluoridated and non-fluoridated areas in three age bands (20-35, 36-50 and 50+) and by social class. RESULTS: The study found: the low priority given to dental health; how emotive the subject of water is; the variable knowledge of fluoride in relation to dental and general health; and the desire for information if new water fluoridation schemes are planned. CONCLUSIONS: The research confirmed public support for water fluoridation but highlighted the place of public health professionals in championing water fluoridation because of public apathy.

Oral cancer in the North-East of England: incidence, mortality trends and the link with material deprivation.

This study set out to determine the incidence of, and mortality from, oral cancer in the North-East of England between the mid-1970s and the early 1990s; to investigate its relation to material deprivation; and to test the completeness of cancer registry data. The Northern Region Cancer Registry provided details of registrations, deaths and population estimates. For analyses by deprivation, Small Area Statistics were obtained from the 1981 and 1991 censuses. In a selected sample district, 100% completeness and 89% accuracy of cancer registration of these conditions were found. For both tongue and mouth cancer, age- and sex-specific incidence and mortality rates rose with age and there was little change with time. When age-standardised registration and mortality ratios were compared between the Northern Region and England & Wales, only those for mouth cancer in males were significantly different. Crude survival from cancer of the tongue in males improved in the Northern Region from 1971-74 to 1983-86 but there was no improvement in females nor for cancer of the mouth in both sexes. In males for both tongue and mouth cancer, there was a graded increase in the standardised registration and mortality ratios from the most affluent to the most deprived areas but these differences were less marked in females. These differences in mouth cancer incidence found between England & Wales and the Northern Region probably reflect differences in lifestyles. The North ranks worst among the regions of England & Wales on a number of criteria of material deprivation, and long-term unemployment is one of the highest in the country. The analysis by deprivation has shown a clear relation to material deprivation. Whether socio-economic deprivation per se or a different risk factor behaviour associated with deprivation (smoking, alcohol consumption, poor diet) is the cause of these differences is not known. However, it is very likely that different risk factor behaviour plays a major part.

Under-registration for dental care of children with heart defects in the north-east of England: a comparative study.

The main aim of this study was to discover the number of children with heart defects registered for dental care under capitation in the north-east of England. Subsidiary aims were to compare percentage registrations of these children with those of a similar age in the general population and to investigate the involvement of the Hospital Dental Service (HDS) and Community Dental Service (CDS) in providing dental care for children with heart defects. A sample of all patients under the age of 18 years attending the northern regional cardiothoracic unit between 1st August 1990 and 31st July 1992 was obtained. Details were sent to the Dental Practice Board for analysis during September 1993. A separate analysis was undertaken to estimate the number of children receiving dental care at the dental hospital, Newcastle upon Tyne and within the CDS. A total of 930 children were identified during the study period. Only 38% of children were currently registered for capitation. Of the 930 patients 56 (6%) were registered at the dental hospital while 9% were estimated to be regularly attending the CDS. It is concluded that in the north-east of England, children with heart defects are registered under capitation at an unacceptably low level. They are less likely to be registered than children without this medical condition and it cannot be demonstrated that other dental services are making good the shortfall.

Putting Yiamouyiannis into perspective.

Few names crop up so often in the context of water fluoridation as that of John Yiamouyiannis, an American who has campaigned hard to stop this public health measure not only in the United States but in other countries such as Britain. During 1993, Yiamouyiannis was given considerable air time by the BBC, appearing on its prestigious You and yours and Nature programmes where he denigrated the efforts of local health authorities to reduce tooth decay by means of fluoridating their water supplies. His dramatic claims about fluoridation--in particular, that it increases people's risk of dying of cancer--must understandably alarm those who take them at face value. So just who is John Yiamouyiannis? And do his allegations hold up? This review of his career is based on publicly documented records and statements.