What concentration of fluoride toothpaste should dental teams be recommending?

Data sources A total of 96 studies reported in peer reviewed journals between 1955 and 2014 Study selection The systematic review selected randomised controlled trials that compared toothbrushing with fluoride toothpaste with toothbrushing with a non-fluoride toothpaste or toothpaste of a different fluoride concentration, with a follow-up period of at least one year. The primary outcome was caries increment measured by the change from baseline in all permanent or primary teeth. Data extraction and synthesis Two members of the review team, independently and in duplicate, undertook the selection of studies, data extraction, and risk of bias assessment. They graded the certainty of the evidence through discussion and consensus. The primary effect measure was the mean difference or standardised mean difference caries increment. Where it was appropriate to pool data, they used random-effects pairwise or network meta-analysis. Results In the primary dentition of young children, 1500 ppm fluoride toothpaste was found to reduce caries increment when compared with non-fluoride toothpaste. In the adult permanent dentition, 1000 or 1100 ppm fluoride toothpaste was found to reduce DMFS increment when compared with non-fluoride toothpaste in adults of all ages, however, the evidence for DMFT was of low certainty. Conclusions This Cochrane Review supports the benefits of using fluoride toothpaste in preventing caries when compared to non-fluoride toothpaste. Evidence for the effects of different fluoride concentrations was found to be more limited, but a dose-response effect was observed for D(M)FS in children and adolescents. For many comparisons of different concentrations the caries-preventive effects and the confidence in these effect estimates are uncertain and could be challenged by further research.

Summary of: Mind the gap! A comparison of oral health knowledge between dental, healthcare professionals and the public.

INTRODUCTION: The importance of consistent, accurate and unambiguous messages are well documented in oral health promotion literature. Whether the reality of delivering messages in the field fulfils these principle is questionable. OBJECTIVE: This paper explores the perceptions of dental professionals, healthcare professionals and lay community members with regard to key oral health messages in order to highlight any inconsistencies and knowledge gaps between and within groups for disease risk factors. METHOD: A questionnaire was administered to individuals who belonged to three groups: dental professionals, healthcare professionals and lay community members. The questionnaire established knowledge regarding risk factors for caries, periodontal disease and erosion. RESULTS: Thirty-five (57.4%) of the dental group answered the whole questionnaire correctly, with 22 (27.8%) and 9 (5.1%) of the healthcare and lay community group answering the whole questionnaire correctly, respectively. The question of fluoride levels in children's toothpaste was the main reason for incorrect answers in the dental group. CONCLUSIONS: The results of this survey demonstrate a knowledge gradient from dental professionals through to healthcare professionals and then to lay members of the community. The knowledge base observed in the dental group is reflected in the other two groups as would be expected albeit with a significant gap between each group. As expected the dental professionals are generally well informed, but not as well informed as could be expected.

Obesity, diabetes and periodontitis--a triangular relationship?

The global rise of obesity, both adult and childhood, has been paralleled by a rise in type 2 diabetes, a trend predicted to continue for at least the next two decades. The combined effect will create a burden of direct and co-morbidities that will strain the physical and financial resources of all countries. While it is accepted that both type 1 and type 2 diabetes are major risk factors for the development and progression of periodontal disease, there is growing evidence that obesity is both an indirect risk factor because it affects glycaemic control and a direct risk factor because secretion of pro-inflammatory agents by adipose tissue modifies the periodontal reaction to the plaque biofilm. Recent research suggests that periodontitis may adversely affect glycaemic control, which can be improved by periodontal treatment with reduced risk of diabetic co-morbidity, thereby creating a two-way relationship. Furthermore it appears possible that periodontitis may stimulate inflammatory change in adipose tissue, creating a triangular self-generating cycle of morbidity linking obesity, diabetes and periodontal disease. Dentists should recognise these interlinked risk factors and consider including an assessment of glycaemic control and adiposity, possibly by waist-to-hip ratio, when periodontitis is diagnosed and in collaboration with medical practitioners provide treatment to help reduce the development of systemic disease.

Summary of: the impact of fluoride application training: survey of trained dental nurses from King's College Hospital NHS Trust.

OBJECTIVES: To explore the perceived benefits of a fluoride varnish training scheme, subsequent use of extended skills and any barriers that exist, in order to inform future training and practice. METHOD: Questionnaire survey of the first four cohorts of fluoride varnish training at one London dental hospital. RESULTS: Thirty-six (62%) nurses responded to the survey, 89% of whom were using fluoride varnishing. 'Personal development', 'NHS initiatives' and 'having a supportive principal' were key drivers for course attendance. Over 2,500 fluoride application treatments were carried out (range = 0-630) with six nurses providing 71% of the treatments. Twenty nurses (56%) worked in the salaried primary dental care service and provided 69% of treatments, the remaining 31% of treatments were provided by the 44% (n = 16) of nurses in general dental practice. Barriers were 'systems-related' and 'professional', including lack of community programmes, consultant oversight, referrals, materials and concerns regarding insurance and consent. The majority felt that the course contributed to their professional career (97%), and expressed their confidence in conducting fluoride application (80%). CONCLUSION: The findings highlight the potential for using extended roles to deliver evidence-based prevention and variation in their use; however, there is some evidence that organisational and professional barriers exist.

Identifying infants at risk of becoming obese: can we and should we?

OBJECTIVES: Increased understanding of the risk factors for childhood obesity has raised the possibility of identifying infants who are at risk of becoming overweight or obese, enabling early intervention for infants at high risk. This paper considers the known risk factors, describes statistical work aimed at identifying risk, and considers the ethical and practical issues of such a development. STUDY DESIGN AND METHODS: An overview of the published evidence for risk factors in the early development of overweight and obesity, and a statistical assessment of the practicality of developing a simple obesity risk assessment tool (ORT) for use in the primary care setting. RESULTS: Analysis of data from two currently available UK birth cohort studies suggests that an ORT based on these data does not provide acceptable levels of specificity and sensitivity for use in a primary care setting. CONCLUSION: Further development of an ORT using additional data and enhanced statistical analysis may lead to a practical tool. However the practical, ethical and legal issues involved in its use, and the public health policy considerations that follow must be resolved.

Weighing and measuring primary school children: evaluation of the TRENDS model for implementation of Department of Health guidelines.

BACKGROUND: The UK Department of Health for England and Wales has issued guidance to all local Primary Care Trusts (PCTs), who have responsibility for school nursing services, for the annual weighing and measuring of all children on entry to primary school and in Year 6 (age 5 and 11 years respectively), known as the National Child Measurement Programme. The guidance places the responsibility for implementation and funding of this scheme onto the PCTs. METHOD: This paper describes the conduct and evaluation of the 2006 monitoring exercise in a 10% sample of Leeds primary schools. RESULTS: The evaluation showed that the exercise can be carried out with little disruption in schools and minimal distress for children. CONCLUSIONS: Recommendations include: adequate staff training in measuring children, along with anticipation of the issues and problems they may encounter and best practice for dealing with them. A good working relationship must be established between the team and school before the measuring day. Schools need to ensure the availability of suitable accommodation and a screen to maintain privacy. Lightweight but robust and accurate scales conforming to the European Union standard should be used and routinely checked for accuracy. Where possible, children should not be lined up, but seen individually. This is considered essential for the older Year 6 children.

Monitoring trends in childhood obesity: a simple school-based model.

BACKGROUND: The UK Government has set a target of halting the rise in childhood obesity by 2010. However, at the time the target was set, no monitoring process existed. The English Department of Health has now issued guidelines to primary care trusts for the annual weighing and measuring of all children on entry to primary school and in year 6. AIM: Development of an inexpensive school-based monitoring scheme for trends in childhood obesity suitable for national implementation. METHOD: The methodology was developed in 10 pilot schools in 2004 and implemented in 25 primary schools and three secondary schools in 2005. Specially trained healthcare support workers (HCSWs) recorded height and weight measurements of primary school children in reception and year 4, and secondary school children in year 8 (aged 5, 8 and 13 years, respectively, on average). The ethnic and socio-economic profile of the sample was compared with census data, and the levels of obesity were calculated using standard age cut-offs. RESULTS: While monitoring in primary schools was achieved with no evidence of disruption to the schools or distress to the subjects, monitoring in secondary schools was deemed to be impractical. Cost analysis indicated an estimated cost of less than 1.50 UK pounds per primary school child measured. CONCLUSIONS: The model provides a viable means of monitoring childhood obesity trends. Monitoring should be confined to primary schools and should be conducted by specially trained HCSWs rather than school nurses.

Dietary patterns, toothbrushing habits and caries experience of schoolchildren in West Yorkshire, England.

OBJECTIVE AND METHOD: The present study followed a group of 608 children, aged 7-11 years from six primary schools, for whom detailed dietary information was available. These children were traced four years later when they were in secondary school. The aim of the study was to investigate the relationship between the original dietary pattern, current dietary pattern, toothbrushing habit and oral health. Of the original children, 500 were traced to 32 secondary schools over a wide geographic area. For logistical reasons those in 18 schools were selected and positive consent and full data was obtained for 315 together with an additional group of 122 of their classmates. Three-day, self-reported dietary data was obtained, together with information on toothbrushing habits. A dental examination was carried out using BASCD survey methodology. RESULTS: The children in this study had a lower DMFT (0.82) than found in the most recent survey for the area (1.39). No significant relationship was found between sugar-sweetened foods or drinks at age 7-11 and caries in the first permanent molar teeth at age 11-15 years, however a significant relationship was found between current sugar-sweetened drinks consumption and caries. Significantly less caries was associated with the reported moderate consumption of dairy products by the children when aged 11-15 years. The bedtime consumption of NMES drinks at 7-11 was significantly associated with an increase in caries as was the bedtime consumption of non-milk extrinsic sugars (NMES) foods at 11-15 years. A significant inverse relationship was found between claimed toothbrushing frequency and caries. Of those children aged 11-15 years claiming to brush at least once a day, 69% were caries-free with a mean DMFT of 0.69. Of the children who claimed to brush only occasionally or never, 52% were caries-free and they had a mean DMFT of 1.05. CONCLUSION: The reported consumption of sugar-sweetened drinks and the lack of regular toothbrushing were found to be the factors most strongly linked to caries and this finding is consistent with other recent studies.

Seat belt use among Hispanic ethnic subgroups of national origin.

OBJECTIVE: Findings from over a dozen studies of Hispanic/white disparities in seat belt use have been inconsistent, variably revealing that seat belt use prevalence among Hispanics is higher, lower, or comparable to use among non-Hispanics. In contrast to previous studies, this study investigates disparities in seat belt use by Hispanic subgroups of national origin. METHODS: Data from the US Fatality Analysis Reporting System were used to compare seat belt use among 60 758 non-Hispanic whites and 6879 Hispanics (Mexican American (MA), n = 5175; Central American/South American (CASA), n = 876; Puerto Rican (PR), n = 412; Cuban (CU), n = 416) killed in crashes from 1999-2003. Logistic regression was used to adjust for age, gender, seat belt law, seat position, urban/rural region, and income. RESULTS: Overall adjusted odds ratios for seat belt use among Hispanic subgroups, relative to non-Hispanic whites, were 1.04 (95% confidence interval (CI) 0.85 to 1.28) for CUs, 1.17 (95% CI 0.95 to 1.44) for PRs, 1.33 (95% CI 1.25 to 1.42) for MAs, and 1.66 (95% CI 1.44 to 1.91) for CASAs. Relative to their non-Hispanic white counterparts, odds ratios among MA and CASA Hispanics were highest for men, younger age groups, drivers, primary law states, rural areas, and lower income quartiles. CONCLUSION: Among all Hispanic subgroups, seat belt use was at least as prevalent as among non-Hispanic whites. In the CASA and MA subgroups, which have the most rapidly growing subpopulations of immigrants, seat belt use was significantly more common than among whites.

A mechanism of injury to the forefoot in car crashes.

OBJECTIVE: The purpose of this study was to determine a mechanism of injury of the forefoot due to impact loads and accelerations as noted in some frontal offset car crashes. METHODS: The impact tests conducted simulated knee-leg-foot entrapment, floor pan intrusions, whole-body deceleration, muscle tension, and foot/pedal interaction. Specimens were impacted at speeds of up to 16 m/s. To verify this injury mechanism research was conducted in an effort to produce Lisfranc type injuries and metatarsal fractures. A total of 54 lower legs of post-mortem human subjects were tested. Two possible mechanisms of injury were investigated. For the first mechanism the driver was assumed to be braking hard with the foot on the brake pedal and at 0 deg plantar flexion (Plantar Nominal Configuration) and the brake pedal was in contact with the foot behind the ball of the foot. The second mechanism was studied by having the ball of the foot either on the brake pedal or on the floorboard with the foot plantar-flexed 35 to 50 deg (Plantar Flexed Configuration). RESULTS: The Plantar Nominal injury mechanism yielded few injuries of the type the study set out to produce. Out of 13 specimens tested at speeds of 16 m/s, three had injuries of the metatarsal (MT) and tarsometatarsal joints. The Plantar Flexed Configuration injury mechanism yielded 65% injuries at high (12.5-16 m/s) and moderate (6-12 m/s) speeds. CONCLUSION: It is concluded that Lisfranc type foot injuries are the result of impacting the forefoot in the Plantar Flexed Configuration. The injuries were consistent with those reported by physicians treating accident victims and were verified by an orthopedic surgeon during post impact x-ray and autopsy. They included Lisfranc fractures, ligamentous disruptions, and metatarsal fractures.

History of diabetes mellitus and risk of prostate cancer in physicians.

Some studies have suggested that diabetes mellitus may decrease the risk of prostate cancer because of lower insulin levels. To further investigate the relation between diabetes and prostate cancer, a nested case-control study was conducted within the US Physicians' Health Study. Cases (n = 1,110) had been diagnosed with prostate cancer, confirmed on medical record review, during follow-up in 1982-1995. Controls (n = 1,110) were selected randomly from men free of prostate cancer and were matched on age and date of randomization. Information on personal history of diabetes and other diseases, lifestyle habits, and body weight/height was self-reported. Logistic regression analysis showed that the odds ratio for prostate cancer was 0.64 (95% confidence interval (CI): 0.43, 0.95) for men with diabetes, relative to those without the disease, after adjustment for potential confounders. Odds ratio estimates were 0.63 (95% CI: 0.35, 1.14), 0.77 (95% CI: 0.35, 1.72), 0.59 (95% CI: 0.21, 1.66), and 0.59 (95% CI: 0.27, 1.27) for diabetes diagnosed 1-5, 6-10, 11-15, and > or = 16 years prior to prostate cancer diagnosis (p for trend < 0.05). Adjusted odds ratios were 1.44 (95% CI: 0.34, 6.17) for stage A prostate cancer and 0.48 (95% CI: 0.28, 0.83) for stages B-D. Results suggest that history of diabetes may be associated with a decreased risk of prostate cancer, especially late-stage tumors.

Pain prediction for preventive non-operative management of dentinal caries in primary teeth in general dental practice.

OBJECTIVES: To provide a pain-predictive model for the non-operative management of carious deciduous teeth from the analysis of data from a retrospective analysis of clinical case notes of children regularly attending two general dental practices and receiving preventive care. DESIGN: A clearly defined protocol was used to determine the fate of deciduous teeth diagnosed as carious into dentine but symptomless and left unrestored from the sequential examination of the clinical records of 480 children attending at least annually. RESULTS: The age of the children at the first visit when carious teeth were diagnosed ranged from 008 to 12.3 years, with the majority of children (243/480) presenting by 6 years of age. In all, 250 teeth from 162 children were extracted because of pain or became painful and were treated. The remaining 318 children did not report pain on subsequent visits. The strongest predictor of pain was age on diagnosis, the other factors being tooth type and extent of the cavity when first seen. Data from the present study provides a model that enables a child with deciduous caries to be placed into one of six pain-predictive groups associated with a risk of pain or infection if the teeth are not restored but provided with preventive care only. CONCLUSIONS: In these patients, the majority of unrestored carious deciduous teeth remain symptomless until shed. A higher risk of subsequent pain or infection was associated with the development of caries in younger patients, disease extending beyond single surfaces, and disease in lower deciduous molars. The results provide evidence to aid the treatment planning of carious deciduous teeth in children receiving regular preventive dental care.

Using a nursing protocol to assure equitable delivery of cancer-related prevention services.

A nurse-administered, protocol-driven model (NP) for preventive services delivery was compared with a traditional physician reminder (PR) model with nursing back-up among 473 patients attending Internal Medicine and Family Medicine clinics. A total of 240 patients were randomized to the NP group and 233 to the PR group. Demographic characteristics including gender [71% female (NP) and 71% female (PR)], race (78% and 75% African American, respectively) and age (numbers of persons aged 18-54, 55-64 and 65+ years) were similar in each group. In the NP group 244/244 screening tests for breast, cervical and colon cancers and alcohol abuse were initiated or completed by nurses, while in the PR group 110/215 (51%) were initiated or completed by physicians. The NP group received 552/552 counseling services from nurses for tobacco, alcohol, nutrition, exercise and prostate screening, while in the PR group, physicians delivered 10% of the needed services (56/560). Aside from counseling for prostate cancer screening, which was 100% in both the NP and PR groups, all other between-group differences for each service were significant at the level of p<0.001. Results show the feasibility of a nursing protocol for initiating equitable cancer prevention services in a primary care setting.

The fate of 1,587 unrestored carious deciduous teeth: a retrospective general dental practice based study from northern England.

OBJECTIVE: To investigate the outcome of non-restoration of carious deciduous teeth by means of a retrospective analysis of clinical case notes of children regularly attending two general dental practices and receiving preventive care. DESIGN: Using a carefully defined protocol the fate of deciduous teeth diagnosed as carious into dentine but symptomless and left unrestored was determined from the sequential examination of the clinical records of 481 children attending at least annually. RESULTS: The age at initial diagnosis of carious teeth ranged from 1-12 years with the majority of cavities (1,005) presenting by 6 years of age. In all, 1,587 teeth were followed until loss from the mouth. Of these, 190 (12%) were extracted because of pain and a further 60 (4%) became painful and were treated, leaving 1,337 (84%) that remained symptomless until being lost. Of the 1,337 symptomless teeth, 178 were extracted under general anaesthesia at the same time as painful ones. The final group of 1,159 (74%) teeth were exfoliated without causing pain after a mean survival time of 1,332 days. Excluding from the analysis the 178 extracted, but symptomless teeth, leaves a total of 1,409 teeth of which 18% gave pain and were extracted or treated and the remaining 82% exfoliated. The strongest determinant of pain was age on diagnosis, the other factors being tooth type and extent of the cavity when first seen. The carious teeth most likely to cause symptoms were found to be molars that developed cavities with pulpal involvement by the age of 3 years, 34% of which caused pain. In contrast, those least likely to cause pain were carious molar teeth presenting without pulpal involvement after 8 years, only 6% of which produced symptoms. CONCLUSION: In these patients, the majority of unrestored carious deciduous teeth remain symptomless until shed. The results provide evidence to aid the treatment planning of carious deciduous teeth in children regularly receiving regular preventive dental care.

Risk factors for non-Hodgkin's lymphoma according to family history of haematolymphoproliferative malignancies.

BACKGROUND: Aetiological profiles of non-Hodgkin's lymphoma (NHL) may differ depending upon whether the disease is inheritance-related or sporadic. Because familial risk (a probable surrogate of inheritance-relatedness) of NHL is influenced by haematolymphoproliferative malignancies (HLPM), we evaluated whether non-familial risk factors differ between NHL with and without a family history of HLPM, using the Selected Cancers Study data. METHODS: Cases were 1511 men aged 31-59 and diagnosed with NHL during 1984-1988. Controls were men without NHL, frequency-matched to cases by age range and cancer registry (n = 1910). These groups were compared: cases with a family history of HLPM and without, and controls without such a family history. RESULTS: Polytomous logistic regression analyses showed that the odds ratio (OR) estimates of homosexual behaviour were 18.2 (95% confidence interval (CI) : 4.8-69.4) and 5.6 (95% CI : 3.3-9.5) for NHL with and without a family history of HLPM, respectively. The corresponding estimates were 3.9 (95% CI : 1.7-8.9) and 2.2 (95% CI : 1.5-3.1) for history of enlarged lymph nodes. Variables only related to NHL with a family history were use of heroin (OR = 15.6, 95% CI : 3.4-70.4), exposure to a chlorinated hydrocarbon pesticide (OR = 2.3, 95% CI : 1.0-5.0), occupational exposure to plywood, fibreboard or particleboard (OR = 2.0, 95% CI : 1.2-3.4) and history of liver diseases (other than hepatitis or cirrhosis) (OR = 6.5, 95% CI : 1.2-36.2). The association between homosexual behaviour and NHL among men with a family history was stronger for those aged 31-44, especially for B-cell type of the disease. CONCLUSIONS: This study suggests differences in the risk factor profiles between NHL with and without a family history of HLPM. The higher risks of NHL for homosexual behaviour and heroin use, surrogates of HIV infection, in men with a family history of HLPM imply that genetic susceptibility may be influential on the occurrence of HIV-related NHL.

Milk, flavoured milk products and caries.

The consumption of flavoured milk increased by 50% between 1992 and 1999 and dental health educators need to know if these and other sugar and fruit juice sweetened milk products, such as fruit yoghurts, are acceptable as snack items. Available evidence suggests that their cariogenicity is negligible to low and consumed in moderation they are a preferable alternative to similarly sweetened soft drinks.

Elevated serum homocysteine levels and increased risk of invasive cervical cancer in US women.

OBJECTIVES: To explore the relationship between serum homocysteine, a sensitive biomarker for folate inadequacy and problems in one-carbon metabolism, and invasive cervical cancer. METHODS: A large case-control study was conducted in five US areas with up to two community controls, obtained by random-digit dialing, individually matched to each case. Cervical cancer risk factors were assessed through at-home interview. Blood was drawn at least 6 months after completion of cancer treatment from 51% and 68% of interviewed cases and controls. Serum homocysteine was measured by high-performance liquid chromatography, and exposure to human papillomavirus (HPV) type 16, the most prevalent oncogenic type, was assessed using an enzyme-linked immunosorbent assay. Cases with advanced cancer and/or receiving chemotherapy were excluded, leaving 183 cases and 540 controls. RESULTS: Invasive cervical cancer risk was substantially elevated for women in the upper three homocysteine quartiles (> 6.31 micromol/L); multivariate-adjusted odds ratios ranged from 2.4 to 3.2 (all 95% CIs excluded 1.0). A trend was apparent and significant (p = 0.01). When cases were compared with HPV-16 seropositive controls only, odds ratios were comparable. CONCLUSIONS: Serum homocysteine was strongly and significantly predictive of invasive cervical cancer risk. This association could reflect folate, B12 and/or B6 inadequacy, or genetic polymorphisms affecting one-carbon metabolism.