A pilot study on the global practice of informed consent in paediatric dentistry.

Background: Conducting oral treatment early in the disease course, is encouraged for better health outcomes. Obtaining informed consent is an essential part of medical practice, protecting the legal rights of patients and guiding the ethical practice of medicine. In practice, consent means different things in different contexts. Silver Diamine Fluoride (SDF) and Silver Fluoride (SF) is becoming popular and cost effective methods to manage carious lesions, however, cause black discolouration of lesions treated. Obtaining informed consent and assent is crucial for any dental treatment-and has specific relevance with SDF/ SF treatments. Methods: The aim of this paper is to describe informed consent regulations for dental care in a selection of countries, focusing on children and patients with special health care needs. An online survey was shared with a convenience sample of dental professionals from 13 countries. The information was explored and the processes of consent were compared. Results: Findings suggest that there are variations in terms of informed consent for medical practice. In Tanzania, South Africa, India, Kenya, Malaysia and Brazil age is the determining factor for competence and the ability to give self-consent. In other countries, other factors are considered alongside age. For example, in Singapore, the United Kingdom, and the United States the principle of Gillick Competence is applied. Many countries' laws and regulations do not specify when a dentist may overrule general consent to act in the "best interest" of the patient. Conclusion: It is recommended that it is clarified globally when a dentist may act in the "best interest" of the patient, and that guidance is produced to indicate what constitutes a dental emergency. The insights gathered provide insights on international practice of obtaining informed consent and to identify areas for change, to more efficient and ethical treatment for children and patients with special needs. A larger follow up study is recommended to include more or all countries.

Breastfeeding and Childhood Dental Caries: Results from a Socially Diverse Birth Cohort Study.

Previous studies showed that prolonged breastfeeding increases the risk of caries. However, the observed associations were mainly based on non-European populations, and important confounding and mediating factors like socioeconomic position (SEP) and diet were often neglected. The aim of this study was to investigate the role of breastfeeding and bottle-feeding practices on dental caries during childhood while accounting for SEP, ethnic background, and sugar intake. This study was part of the Generation R Study, a prospective multiethnic cohort study conducted in Rotterdam, The Netherlands. In total, 4,146 children were included in the analyses. Information about feeding practices was derived from delivery reports and questionnaires during infancy. Caries was measured via intraoral photographs at the age of 6 years and defined as decayed, missing, and filled teeth (dmft). Negative binomial hurdle regression analyses were used to study the associations between several infant feeding practices and childhood caries. The prevalence of dental caries at the age of 6 years was 27.9% (n = 1,158). Prolonged breastfeeding (for >12 months) was associated with dental caries (OR 1.35, 95% CI 1.04-1.74) and the number of teeth affected by dental caries (RR 1.27, 95% CI 1.03-1.56). Furthermore, nocturnal bottle-feeding was associated with dental caries (OR 1.52, 95% CI 1.20-1.93). All associations were independent of family SEP, ethnic background, and sugar intake. Results from this Dutch cohort study confirmed the previously observed associations between prolonged breastfeeding and nocturnal bottle-feeding and the increased risk of childhood dental caries, even after proper adjustments for indicators of SEP, ethnic background, and sugar intake. Future studies are encouraged to elaborate further on possible explanations for the observed relationships. Healthcare professionals should be aware and advise caregivers about the potential risk of prolonged breastfeeding on caries development by applying the current recommendations on breastfeeding, oral hygiene, and feeding frequency.

Foetal, neonatal and child vitamin D status and enamel hypomineralization.

OBJECTIVES: Recent literature suggested that higher vitamin D concentrations in childhood are associated with a lower prevalence of molar incisor hypomineralization (MIH). As tooth development already starts in utero, we aimed to study whether vitamin D status during foetal, postnatal and childhood periods is associated with the presence of hypomineralized second primary molars (HSPMs) and/or MIH at the age of six. METHODS: Our study was embedded in the Generation R Study, a population-based, prospective cohort from foetal life onwards in Rotterdam, the Netherlands. HSPMs and MIH were scored from intraoral photographs of the children at their age of six. Serum 25(OH)D concentrations were measured at three points in time, which resulted in three different samples; mid-gestational in mothers' blood (n = 4750), in umbilical cord blood (n = 3406) and in children's blood at the age of 6 years (n = 3983). RESULTS: The children had a mean (±SD) age of 6.2 (±0.5) years at the moment of taking the intraoral photographs. After adjustment for confounders, no association was found between foetal 25(OH)D concentrations and the presence of HSPMs (OR 1.02 per 10 nmol/L higher 25(OH)D, 95% CI: 0.98-1.07) or MIH (OR 1.05 per 10 nmol/L increase, 95% CI: 0.98-1.12) in 6-year-olds. A higher 25(OH)D concentration in umbilical cord blood resulted in neither lower odds of having HSPM (OR 1.05, 95% CI: 0.98-1.13) nor lower odds of having MIH (OR 0.95, 95% CI: 0.84-1.07) by the age of six. Finally, we did not find higher 25(OH)D concentrations at the age of six to be associated with a significant change in the odds of having HSPM (OR 0.97, 95% CI: 0.92-1.02) or MIH (OR 1.07, 95% CI: 0.98-1.16). CONCLUSIONS: 25(OH)D concentrations in prenatal, early postnatal and later postnatal life are not associated with the presence of HPSMs or with MIH at the age of six. Future observational research is required to replicate our findings. Furthermore, it is encouraged to focus on identifying other modifiable risk factors, because prevention of hypomineralization is possible only if the causes are known.

Social inequalities and dental caries in six-year-old children from the Netherlands.

OBJECTIVES: The purpose of our study was to investigate the association of different socioeconomic and sociodemographic factors with dental caries in six-year-old children. Furthermore, we applied a district based approach to explore the distribution of dental caries among districts of low and high socioeconomic position (SEP). METHODS: In our cross-sectional study 5189 six-year-olds were included. This study was embedded in a prospective population-based birth cohort study in Rotterdam, the Netherlands, the Generation R Study. Parental education level, parental employment status, net household income, single parenting, and teenage pregnancy were considered as indicators for SEP. Dental caries was scored on intraoral photographs by using the decayed, missing, and filled teeth (dmft) index. We compared children without caries (dmft=0) to children with mild caries (dmft=1-3) or severe caries (dmft >3). Multinomial logistic regression analyses and binary logistic regression analyses were performed to study the association between SEP and caries, and between district and caries, respectively. RESULTS: Only maternal education level remained significantly associated with mild caries after adjusting for all other SEP-indicators. Paternal educational level, parental employment status, and household income additionally served as independent indicators of SEP in children with severe caries. Furthermore, living in more disadvantaged districts was significantly associated with higher odds of dental caries. CONCLUSION: Dental caries is more prevalent among six-year-old children with a low SEP, which is also visible at the district level. Maternal educational level is the most important indicator of SEP in the association with caries. CLINICAL SIGNIFICANCE: Our results should raise concerns about the existing social inequalities in dental caries and should encourage development of dental caries prevention strategies. New knowledge about the distribution of oral health inequalities between districts should be used to target the right audience for these strategies.

Ethnic Disparities in Dental Caries among Six-Year-Old Children in the Netherlands.

The aim of this study was to investigate potential differences in caries prevalence of children from ethnic minority groups compared to native Dutch children and the influence of socio-economic status (SES) and parent-reported oral health behaviour on this association. The study had a cross-sectional design, embedded in a population-based prospective multi-ethnic cohort study. 4,306 children with information on caries experience, belonging to 7 different ethnic groups, participated in this study. The decayed, missing, and filled teeth (dmft) index was assessed at the age of 6 and categorized in two ways for analysis: children without caries (dmft = 0) versus any caries experience (dmft >0) and children without caries (dmft = 0) versus children with mild caries (dmft = 1-3) or severe caries (dmft >3). Compared to native Dutch children, children with a Surinamese-Hindustani, Surinamese-Creole, Turkish, Moroccan, and Cape Verdean background had significantly higher odds for dental caries. Especially the Surinamese-Hindustani, Turkish, and Moroccan group had significantly higher odds for severe dental caries. Household income and educational level of the mother explained up to 43% of the association between ethnicity and dental caries, whereas parent-reported oral health behaviour did not mediate the association. Alarming disparities in caries prevalence between different ethnic (minority) groups exist, which cannot be fully explained by social inequalities. Public health strategies can apply this new knowledge and specifically focus on the reduction of ethnic disparities in oral health. More research is needed to explain the high caries prevalence among different ethnic minority groups.

Early Caries Predicts Low Oral Health-Related Quality of Life at a Later Age.

Oral health-related quality of life (OHRQOL) is the perceived impact of one's own oral health on daily life. Oral diseases influence children's OHRQOL directly, but OHRQOL might also be related to oral health experiences from the past. We investigate the relation between dental caries at the age of 6 with OHRQOL assessed at the age of 10. This study was conducted within the Generation R Study, a population-based prospective cohort study. Caries experience was assessed with the decayed, missing, and filled teeth index (dmft) at a median age of 6.09 years (90% range: 5.73-6.80). OHRQOL was assessed with a short form of the Child Oral Health Impact Profile at the children's age of 9.79 years (9.49-10.44). In total, 2,833 children participated in this study, of whom 472 (16.6%) had mild caries (dmft 1-3) and 228 (8.0%) had severe caries (dmft >3). The higher the dmft score at the age of 6, the lower the OHRQOL at the age of 10 (p < 0.001). The children with severe caries at the age of 6 had significantly higher odds of being in the lowest OHRQOL quartile at the age of 10 (OR = 1.69; 95% CI: 1.17-2.45). Our study highlights the importance of oral health during childhood, because those who get a compromised start to oral health are much more likely to follow a trajectory which will lead to poor oral health (-related QOL) later. OHRQOL is not only related to current oral health experiences but also to oral health experiences from the past.

Pre- and postnatal determinants of deciduous molar hypomineralisation in 6-year-old children. The generation R study.

BACKGROUND: Deciduous Molar Hypomineralisation (DMH) and Molar Incisor Hypomineralisation (MIH) are common developmental disturbances in pediatric dentistry. Their occurrence is related. The same determinants as suggested for MIH are expected for DMH, though somewhat earlier in life. Perinatal medical problems may influence the prevalence of DMH but this has not been studied sufficiently. OBJECTIVE: This study aimed to identify possible determinants of DMH in a prospective cohort study among 6-year-old children. STUDY DESIGN: This study was embedded in the Generation R Study, a population-based prospective cohort study from fetal life until young adulthood. The the data were used to identify the determinants of DMH. Clinical photographs of clean, moist teeth were taken with an intra-oral camera in 6690 children (mean age 6.2 years; 49.9% girls). Data on possible determinants that had occurred during pregnancy and/or the child's first year of life were on the basis of manual standardized measurements (like length and weight) and questionnaires. Multivariate analyse with backward and forward selection was performed. RESULTS: A number of factors in the pre-, peri- and postnatal phase were found to be associated with DMH. After multivariate logistic regression analyses, Dutch ethnic background, low birth weight, maternal alcohol consumption during pregnancy, and fever episodes in the first year of the child's life were found to play a role in the development of DMH in 6-year-old children. CONCLUSION: This study shows that Dutch ethnicity, low birth weight, alcohol consumption by the mother during pregnancy and any fever in the first year of the child's life are associated with DMH. Not only childhood factors but also prenatal lifestyle factors need to be taken into account when studying determinants for DMH.

Is maternal use of medicines during pregnancy associated with deciduous molar hypomineralisation in the offspring? A prospective, population-based study.

BACKGROUND: The effects of maternal use of medicines during pregnancy on tooth development has scarcely been studied; only negative effects of tetracycline on tooth germs are known (irreversible tooth discoloration and enamel hypoplasia). OBJECTIVE: The aim of this study was to investigate whether antibacterials and anti-allergic and anti-asthma medicines, being the most frequently used medicines during pregnancy, are associated with deciduous molar hypomineralisation (DMH) and, if so, which specific medicines. MATERIALS AND METHODS: To clarify this possible association, the participants of the Generation R Study, a population-based prospective cohort study from fetal life until young adulthood, were studied. Data on medicine use during pregnancy were retrieved from pharmacies. Clinical photographs of the second primary molars, which were scored for DMH, were taken with an intra-oral camera in 6,690 children (mean age 6.2 years, standard deviation [SD] ± 0.53; 49.9 % girls). RESULTS: During pregnancy, 20.3 % of the mothers used antibacterials, 12.3 % anti-asthma medicines and 5.4 % anti-allergic medicines. The prevalence of DMH was 9.0 % in the study group. There was no association between the use of anti-asthma medicines, anti-allergic medicines (odds ratio [OR]: 0.97 [95 % CI 0.61-1.54]; OR: 1.04 [0.54-2.03]) or antibacterials (OR: 0.73 [0.49-1.09]) during pregnancy and DMH (all p-values >0.05). The study had sufficient power (80 %) to detect significant associations. CONCLUSION: Maternal use of antibacterials, anti-allergic medicines or anti-asthma medicines during pregnancy is not associated with the development of DMH in the offspring.

Factors increasing the caries risk of second primary molars in 5-year-old Dutch children.

BACKGROUND: Caries is still a prevalent condition in 5-year-old children. At present, knowledge regarding some aetiological factors, like deciduous molar hypomineralization (DMH), is limited. AIM: To investigate aetiological factors both directly and indirectly associated with caries in second primary molars. DESIGN: Of 974 children invited to participate in the study, 386 children were examined clinically with visual detection of caries. Only carious lesions determined to have reached the dentine were recorded. Information about tooth brushing frequency, education level of the mother, and country of birth of mother and child, was collected by means of a multiple-choice questionnaire. Parents of 452 children filled in the questionnaire. Complete clinical and questionnaire data were available for 242 children. Statistical analysis of the effect of the independent variables was undertaken using the Pearson's chi-squared test. RESULTS: Deciduous molar hypomineralization (P = 0.02) and the country of birth of the mother (P < 0.001) were positively associated with caries prevalence. CONCLUSIONS: Deciduous molar hypomineralization and the country of birth of the mother play a role in the prevalence of dental caries. These aetiological factors associated with childhood dental caries need to be investigated further in longitudinal clinical trials.