Dental Policy Lab 3: towards oral and dental health through partnership.

The third and last of the successful Alliance for a Cavity-Free Future (ACFF)/King's College London Dental Policy Lab series, held in 2019, focused on outlining how dental and oral health industries could benefit from enabling positive behaviour change in patients and the public, allowing progress towards caries reduction. During a two-day event, experts from across public health, dentists, global multi-national corporations and dental industry start-ups discussed the issue, collaboratively developing ideas around policy, technology, messaging and engagement for change. An analysis of the current trends in oral health laid out how the implications for industry and corporate social responsibility were identified as crucial. The report and accompanying infographic explored in this paper have been well received and acted as a catalyst for future developments in the area.

Intervention to enhance adherence to mandibular advancement appliance in patients with obstructive sleep apnoea: study protocol for a randomised clinical trial.

BACKGROUND: Obstructive sleep apnoea (OSA) is a sleep-related breathing disorder characterised by the repeated episodic collapse of the upper airway during sleep, resulting in sleep deprivation, giving rise to apnoeas and hypopnoeas. Based on the severity of OSA, there are two primary treatment modalities, continuous positive airway pressure (CPAP) and mandibular advancement appliances (MAA); both are adherence-dependent. MAA is offered to those with mild to moderate OSA and is prescribed as an alternative to patients intolerable to CPAP. However, adherence to MAA treatment is variable and declines over time. Hence, the current study aims to assess the effectiveness of the stage-matched intervention, the Health Action Process Approach (HAPA), on adherence to MAA in patients with OSA. METHODS: A single-centre randomised clinical trial will be undertaken at Bart's Health NHS Trust. Fifty-six participants with newly diagnosed OSA are planned to be enrolled in the study and randomised to intervention care (IC) and standardised care (SC) groups. Participants in the SC group will receive routine care whilst participants in the IC group will receive the stage-matched intervention, developed using the HAPA model. Data indicating MAA adherence will be collected both objectively and subjectively, from micro-sensors embedded in the MAA design and sleep diaries, respectively at 3, 6, 18 and 36 months. In addition, a range of questionnaires designed to assess risk perception, outcome expectancy, and self-efficacy (SEMSA) and quality of sleep (PSQI and ESS) and life (EQ-5DL), socio-economic and social support scales will be used. DISCUSSION: The currently available treatments for obstructive sleep apnoea depend entirely on the patient's acceptance and use. There are several factors that affect cooperation and wear for example patients' awareness of their condition, social support and psychological behaviour. In addition, mood, such as anxiety, stress, and depression, may affect wear. At the same time, we know that interventions involving more education and behaviour approaches can help patients adapt more easily to some treatments. As a result, the present trial aims to explore the potential role of these factors to maximise treatment success and minimise side effects. TRIAL REGISTRATION: ClinicalTrials.gov NCT04092660 . Registered on September 6, 2019.

Factors influencing adherence to oral appliance therapy in adults with obstructive sleep apnea: a systematic review and meta-analysis.

STUDY OBJECTIVES: The review aimed to identify the factors influencing adherence to oral appliance therapy in adults with obstructive sleep apnea. METHODS: The protocol was initially registered with the International Register of Systematic Reviews (Prospero: CRD42019122615) prior to undertaking a comprehensive electronic search of databases and references without language and date restrictions. Quality assessment was undertaken using the Cochrane Collaboration's risk of bias tool and Quality in Prognosis Studies (QUIPS) tool. RESULTS: Studies exhibited low or unclear risk of bias for the domains assessed by the respective quality assessment tools. The influence of independent variables such as disease characteristics, patient characteristics, appliance features, and psychological and social factors on adherence levels was also assessed. There was a total of 31 included studies, which consisted of 8 randomized controlled trials, 2 controlled clinical trial, 7 prospective cohorts, 11 retrospective cohorts, and the remaining 3 studies were a case-series, case-control, and a mixed-methods. All 31 included studies were subject to qualitative analysis, with only 4 studies included in the quantitative analysis. Results of the meta-analysis demonstrated increased adherence with custom-made appliances, with a pooled mean difference of -1.34 (-2.02 to -0.66) and low levels of heterogeneity (I² = 0%). CONCLUSIONS: A weak relationship was observed between objective adherence and patient and disease characteristics, such as age, sex, obesity, apnea-hypopnea index, and daytime sleepiness, to oral appliance therapy. Nonadherent patients reported more side effects with oral appliance therapy than users and tended to discontinue the treatment within the first 3 months. Custom-made oral appliances were preferred and increased adherence reported in comparison to ready-made appliances. Further research is imperative to examine the relationship between psychosocial factors and adherence to oral appliance therapy.

Brief Report: Analysis of Dental Treatment Provided Under General Anaesthesia for Children and Young Adults with Autistic Spectrum Disorder and Identification of Challenges for Dental Services.

Dental treatment provided under general anaesthesia (DGA) is an expectation for many children and young adults (CYA) diagnosed with Autistic Spectrum Disorder (ASD). Planning and delivery of DGA requires consideration of morbidity and mortality risks and implications for families and healthcare services. One hundred patient records of CYA with special healthcare needs were analysed to examine characteristics and experience of DGA revealing that 79% of CYA had a diagnosis of ASD. Forty-seven percent of CYA diagnosed with ASD had at least one previous hospital admission for DGA. For 24% of this repeat DGA group, the previous DGA was within a two-year period. Results highlight a high rate of DGA and need to investigate more effective primary dental care strategies.

How do you identify the patient with 'high expectations' of orthodontic treatment: An empirical approach.

OBJECTIVES: To identify an empirical method for identifying patients with 'high expectations' of orthodontic treatment with fixed appliances using a questionnaire-based approach. DESIGN: Secondary analysis of data from four studies which collected data on patients' expectations of orthodontic treatment using the same questionnaire. SETTING: Secondary care orthodontic services. PARTICIPANTS: All four datasets comprised new patients aged 12-15 years, with no history of orthodontic treatment, who fulfilled the criteria for NHS treatment using the Index of Orthodontic Treatment Need (IOTN). Unpublished dataset 1 comprised 100 participants, while dataset 2 had 70 participants, dataset 3 had 67 participants and dataset 4 comprised 40 participants. METHODS: The questionnaire utilised in all studies had a question which asked respondents to rate seven different expectations of outcome relating to straight teeth, better smile, ease of eating, speaking, cleaning teeth, improved career prospects and social confidence. Dataset 1 was analysed to determine the proportion of patients who had rated all seven outcome expectation items at a maximum score. Similar analyses were performed for the other three datasets to explore the trend in the proportion of patients with high expectations over time. RESULTS: For dataset 1, 2.0% of participants had high expectations, as defined by their scores on the questionnaire. The proportions for the datasets 2, 3 and 4 were 4.0%, 4.5% and 2.5%, respectively. CONCLUSION: The method outlined provides an empirical basis for identifying patients with statistically infrequent high expectations. This can potentially help clinicians in the management of such patients.

A curriculum for behaviour and oral healthcare management for dentally anxious children-Recommendations from the Children Experiencing Dental Anxiety: Collaboration on Research and Education (CEDACORE).

BACKGROUND: Dentists need training in the management of children's anxiety (DA), fear (DF) and behaviour management problems (DBMP) but little is known of their competence on this topic. AIM: To report dentists' opinions and attitudes about protective stabilisation and pharmacological techniques for the management of children with DA/DF/DBMP; to propose a postgraduate curriculum focussing on DA/DF/DBMP. DESIGN: A survey of 301 Brazilian dentists and later a modified Delphi process to outline the curriculum in two phases: (a) face-to-face discussions with 33 early career researchers mentored by six researchers, both from UK and Brazil; (b) online discussions by eight early and senior researchers on the knowledge, experience, and competencies necessary for a specialist in paediatric dentistry in Brazil that should be included in the core curriculum of postgraduate courses. RESULTS: Almost all (99.0%) of the survey respondents provide treatment to children with DA/DF/DBMP, and 91.2% do not systematically diagnose these conditions; 94.3% use protective stabilisation, and 20.0%-30.0% have training in pharmacological techniques. The four-domain framework supporting the proposed curriculum is as follows: DA/DF/DBMP assessment, non-pharmacological and pharmacological approaches, and decision-making. CONCLUSION: Dental curricula should be customised to solve the misconceptions and promote a comprehensive and positive attitude to DA/DF/DBMP by paediatric oral healthcare practitioners.

The effect of viewing idealised smile images versus nature images via social media on immediate facial satisfaction in young adults: A randomised controlled trial.

INTRODUCTION: The objective of this randomised controlled trial (RCT) is to investigate the effect of a social networking site (SNS) on body dissatisfaction, facial and smile dissatisfaction, and face-related discrepancy, and whether these effects differ from the use of appearance-neutral Instagram images. We also aimed to investigate whether there are trends in increased self-reported use of social media and increased body dissatisfaction, facial and smile dissatisfaction, and face-related discrepancy. METHODS: Undergraduate students were randomly allocated to an experimental group with idealised smile images or to a control group with neutral nature images. They completed pre-exposure questionnaires, then perused for 5 min their allocated images on individual Apple iPads via the Instagram application. Participants then completed the post-exposure surveys. The main outcome was facial dissatisfaction. Body dissatisfaction and total facial and body dissatisfaction were secondary outcomes. Simple randomisation was achieved with a computerised random number generator. Data were analysed using repeated measures ANOVA and multivariate regression analyses. RESULTS: A total of 132 participants (mean age = 20.50 ± 2.21 years) were randomised to either the experimental group with idealised smile images (n=71) or the control group with neutral nature images (n=61). Baseline characteristics were similar between groups and no participants were lost. Exposure to 'ideal' facial images on social media decreases facial satisfaction (95% confidence interval [CI] = 0.85-1.05; P < 0.0001). Individuals with high baseline self-discrepancy scores are less satisfied with their facial features and body appearance (95% CI = 0.04-1.16; P = 0.036). CONCLUSION: This study shows that viewing SNSs with high visual media reduces satisfaction with facial appearance in the short term in men and women. This effect is greater in those with high self-discrepancy scores. Increased media usage was not correlated with increased dissatisfaction. Wearing braces or having had braces was shown not to influence post-exposure dissatisfaction.

CariesCare practice guide: consensus on evidence into practice.

This CariesCare practice guide is derived from the International Caries Classification and Management System (ICCMS) and provides a structured update for dentists to help them deliver optimal caries care and outcomes for their patients. This '4D cycle' is a practice-building format, which both prevents and controls caries and can engage patients as long-term health partners with their practice. CariesCare International (CCI™) promotes a patient-centred, risk-based approach to caries management designed for dental practice. This comprises a health outcomes-focused system that aims to maintain oral health and preserve tooth structure in the long-term. It guides the dental team through a four-step process (4D system), leading to personalised interventions: 1st D: Determine Caries Risk; 2nd D: Detect lesions, stage their severity and assess their activity status; 3rd D: Decide on the most appropriate care plan for the specific patient at that time; and then, finally, 4th D: Do the preventive and tooth-preserving care which is needed (including risk-appropriate preventive care; control of initial non-cavitated lesions; and conservative restorative treatment of deep dentinal and cavitated caries lesions). CariesCare International has designed this practice-friendly consensus guide to summarise best practice as informed by the best available evidence. Following the guide should also increase patient satisfaction, involvement, wellbeing and value, by being less invasive and more health-focused. For the dentist it should also provide benefits at the professional and practice levels including improved medico-legal protection.

The oral health of dentally anxious five- and eight-year-olds: a secondary analysis of the 2013 Child Dental Health Survey.

Introduction Little research has been conducted into the relationships between dental anxiety and factors relating to oral health in small children. This research takes advantage of data from the Child Dental Health Survey 2013 to perform a secondary analysis for the five- and eight-year-old age groups. Aim To compare the oral health of groups of children aged five and eight years old, classified into three levels of anxiety.Design Secondary analysis of data from 2,289 children aged five and eight years in the Child Dental Health Survey 2013.Materials and methods Participants were divided into three groups, depending on the parent's report of their child's dental anxiety. Descriptive analyses compared the three groups on social demographic factors, clinical status, self-reported oral health status, oral health-related behaviours and oral health impact. Results Dentally anxious children were more likely to have active decay and decay experience. Parents of children with dental anxiety were more likely to report that the child's oral health had a negative effect on family life. Highly anxious children were less likely to attend the dentist or engage in oral health-related behaviours. Conclusions Dentally anxious children have more dental disease and their parents express that the child's oral health has a greater impact on their family's quality of life.

The impact of dental phobia on care planning: a vignette study.

Introduction A high percentage of people with dental phobia have poor oral health. This may be the result of delayed treatment or differences in care planning by the oral health care team.Aim This study sought to determine the effect, if any, of dental phobia and complexity of dental care on the proposed care plan devised by clinicians for patients.Design An experimental analogue study with independent variables of the presence of phobia and complexity of treatment need. Dependent variables included frequency of care planning elements such as periodontal treatment, prevention, restorations, root canal treatment, extraction and provision of crowns, bridges and prostheses.Participants Seventy-nine UK-based dental practitioners.Analysis The association between the case status (phobic versus non-phobic, simple versus complex) and the outcome variables were assessed using a chi-square test for association. Logistic regression analyses were also used to determine the predictors of care planning elements.Results There were no differences in care planning for phobic and non-phobic patients. Complexity of treatment need had significant effects on advanced periodontal treatment, restorations anterior and posterior, root canal treatment, provision of crowns, and extractions.Conclusions Care planning is influenced by patients' dental needs and not their phobic status.

The oral health of dentally phobic 12- and 15-year-olds: a descriptive analysis of the 2013 Child Dental Health Survey.

Introduction Dental anxiety has been shown to be related to poorer oral health. Limited data exist exploring the relationship between oral health status and dental anxiety in non-clinical populations in children.Aim To compare the oral health of phobic and non-phobic children aged 12 and 15 years.Design Secondary analysis of data from 12-year-old and 15-year-old children in the Child Dental Health Survey 2013.Materials and methods Participants were grouped into non-phobic and phobic groups, depending on their self-reported dental anxiety (MDAS). Descriptive analyses compared the two groups on social demographic factors, clinical status, self-reported oral health status, oral health-related behaviours and oral health impact.Results A total of 601 children were classed as dentally phobic with 4,144 classed as non-phobic. Dental phobic children were more likely to be female, had more active decay and untreated dental disease, and rated their dental health as poorer. Phobic children were more likely to report that their oral health had a negative effect on their everyday life. This group were less likely to brush their teeth regularly or attend the dentist for check-ups.Conclusions Dentally phobic children have more dental disease and express greater impact on their everyday life.

Body dysmorphic disorder: a guide to identification and management for the orthodontic team.

Body dysmorphic disorder (BDD) is a psychiatric disorder in which the individual has a disproportionate concern about a particular body part. With the increasing demand for aesthetic treatments, it is likely that individuals with BDD may present for orthodontic or combined orthodontic and orthognathic treatment. In this review, we shall outline the features of BDD and its prevalence, before discussing the best way for clinicians to identify and manage individuals with this disorder.

The role of social comparison in social judgments of dental appearance: An experimental study.

OBJECTIVE: The objective of this study was to examine the influence of social comparison on social judgments of dental malalignment in a sample of females. METHOD: In a Repeated measures design, N=218 female participants of which N=128 were orthodontic patients (mean age 31.4) and N=90 controls (mean age 26.1) rated their satisfaction with their facial appearance after viewing stereotypically beautiful images of faces (experimental condition) or houses (neutral condition). After 4-6 weeks participants returned to view an image of a female with severe crowding and were asked to make judgments of social competence (SC), intellectual ability (IA), psychological adjustment (PA) and attractiveness (A). RESULTS: The comparison of social judgments between high comparers (High SocComp) and low comparers (Low SocComp) was not statistically significant; (SC (t (204)=0.30, p=0.76), IA (t (204)=0.14, p=0.89) PA (t (204)=0.004, p=0.996), A (t(204)=1.26, (p=0.209). However, dentally induced social judgments (DISJ) was statistically significant in the clinical sample than the non-clinical sample SC (t (204)=0.784, p=0.434), IA (t (204)=0.2.15, p=0.033) PA (t (204)=-0.003, p=0.997) A (t (204)=1.58, p=0.116). CONCLUSION: Social comparison has little impact on DISJ. However, there are differences in DISJs between individuals who seek treatment for their malocclusion versus the nonclinical population; the reason for this is unclear but does not appear to be the result of adoption of societal standards of beauty and instead suggests individual ranking of important 'beauty areas' may play a role. CLINICAL SIGNIFICANCE STATEMENT: This paper uses social comparison theory to investigate the basis of judgments in regards to dental appearance. The findings of this research may help to identify individuals who are more susceptible to societal pressures towards non-ideal dentitions. This will help clinicians become more aware of the patient's comparison orientation, which seems to have an impact on satisfaction with treatment outcomes. This study may form the foundation for future behaviour studies seeking to alleviate the negative effects of social comparison.

Knowledge of behavioural management principles amongst specialist paediatric dental practitioners in the United Kingdom.

BACKGROUND: Paediatric specialist dental practitioners are often faced with the challenge of disruptive behaviour or refusal to comply with treatment. Behaviour management skills are an essential component of their role. However, little is known of the confidence or competence of practitioners in these approaches. AIM: To identify paediatric dentists' knowledge of behavioural management principles as applied to paediatric dentistry. METHOD: Postal questionnaire survey of all specialists in Paediatric Dentistry on the General Dental Council UK register (n = 234), using the Knowledge of Behavioural Principles as Applied to Children Questionnaire (KBPACQ; O'Dell, 1979) adapted for the dental setting. Information was also gathered on experience in using behavioural management techniques and demographics. RESULTS: Responses were received from 105 practitioners (45%). Participants gave the correct answer, on average, to 38% of the items (range 0 to 75%). CONCLUSION: Knowledge of behavioural principles amongst paediatric dentists in the United Kingdom is poor, despite their widespread reported use of such techniques.

The role of the general dental practitioner (GDP) in the management of abuse of vulnerable adults.

UNLABELLED: Abuse of vulnerable adults is largely under reported. The most common forms of abuse amongst this group are neglect and financial abuse, although an individual may be at risk of any or all forms of abuse. Certain individuals are at an increased risk of abuse due to their domestic environment and any physical or mental disability they may have. CLINICAL RELEVANCE: Vulnerable adults constitute a significant proportion of the population. GDPs should be aware of the signs of abuse, to be able to identify those individuals at risk, and how and when to raise concerns of abuse to social services.

Body dysmorphic disorder and aesthetic dentistry.

UNLABELLED: This paper outlines the features and presentation of body dysmorphic disorder (BDD), a psychological syndrome which results in patients seeking treatment for an imagined defect in appearance. The assessment of patients with suspected body dysmorphic disorder is outlined, as well as management strategies. CLINICAL RELEVANCE: Clinicians working in the field of aesthetic dentistry should be aware that some patients presenting for treatment may have body dysmorphic disorder. Aesthetic dental treatment for such patients is not beneficial and carries some risks. Advice for clinicians on assessment and management is outlined.

Reactions to cancer: communicating with patients, family and carers.

Effective communication has benefits for both patients and members of the health care team. Five main communication tasks in head and neck cancer are identified: Screening for head and neck cancer and communicating risk; Communicating the diagnosis of head and neck cancer; Providing information about treatment and pre-treatment; Communicating following treatment and dealing with fear of recurrence; Discussing the end of life. For each specific aspects of the communication situation are discussed. Underpinning each is the use of core communication skills.

Patterns of dental service use among homeless people using a targeted service.

OBJECTIVE: The objective of this study was to describe the patterns of dental service use among homeless people using a targeted dental service from 1992 to 2001. METHOD: A case-note review of a selection of patients (n = 204) was undertaken using a pre-designed data abstraction form. RESULTS: For those presenting at their first contact, 40 percent (n = 68) expressed need in relation to oral pain and disease/tissue damage, and 28 percent (n = 33) in relation to dental checking and oral prophylaxis. Most homeless people had normative need for dental treatment (93 percent: n = 153). The dental service was delivered using a mix of outreach and fixed site clinics, with 75 percent (n = 153) of all first contacts made at outreach clinics. The targeted service was moderately successful at getting people to attend the fixed site service for continuing care, with 51 percent (n = 87) attending for subsequent visits. Location of first contact with the targeted dental service did not predict subsequent attendance. Those who did attend for further care tended to have normative needs for periodontal disease and dental decay and have their presenting complaint met. Only 23 percent (n = 46) of people completed a treatment plan, over a mean of 8.2 (standard deviation +/- 9.4) visits. No factors appeared to predict completion of treatment. CONCLUSIONS: While the small sample limits the findings in this study, it is hypothesized that the presence of the dental service promoted uptake of dental care. Flexible attendance tended to result in multiple visits and delayed outcomes, which themselves could have acted as barriers to care.

The opinions of manufacturers of resin-based composite materials towards the repair of failing composite restorations.

AIM: To investigate the opinions of manufacturers of resin-based composite (RBC) towards the repair of their materials. METHODS: Representatives of 20 manufacturers of RBC were electronically mailed a questionnaire seeking information on aspects of the repair of direct composite restorations. RESULTS: The response rate was 100%. The findings indicated that although the majority of respondents regarded repair as a viable option for managing failing direct RBC restorations, marked variations were found to exist regarding recommendations for and contra-indications to performing repairs of RBC restorations. CONCLUSIONS: Within the limitations of the current study, the following conclusions can be drawn: (1) the majority of manufacturers of RBC materials are aware and in favour of repair as opposed to replacement of defective composite restorations; (2) there is a need for manufacturers to produce guidelines for repair of their materials; and (3) there is a need for robust randomised controlled dental practice-based clinical studies in the field of repair of composite restorations.

Anticipatory anxiety in children visiting the dentist: lack of effect of preparatory information.

AIM: This study sought to explore whether viewing a leaflet explaining the benefits of dental treatment would have a significant impact on children's anticipatory anxiety. METHOD: Fifty children aged 8-12, attending the paediatric dental clinic of King's College Hospital, London, took part in this triple-masked, randomized control study. The participants were randomly allocated to one of two groups and either shown an intervention leaflet containing child-friendly dental information (the experimental group) or a leaflet with child-friendly information on the benefits of healthy eating (the control group). Using the Facial Image Scale, anxiety was measured when the children arrived for their dental appointment, once before reading the leaflet and again after reading the leaflet. RESULTS: There was no statistically significant effect of the experimental leaflet on self-reported anxiety levels in this study, although anxiety levels did drop slightly in both groups after reading a leaflet. CONCLUSIONS: Providing paediatric patients with preparatory information about what to expect from a visit to the dentist had no effect on anticipatory anxiety in comparison to reading a leaflet about healthy eating. We speculate that reading, or cognitive processing, may have some beneficial effect. Future work should investigate this possibility.