How do dental practitioners, educators and students diagnose and manage caries risk and caries lesions? A COM-B analysis.

OBJECTIVE: The International Caries Classification and Management System (ICCMS™), a comprehensive, evidence-informed, best clinical practice system, comprises a 4D cycle: 1D-Determine risk; 2D-Detect and assess lesions; 3D-Decide on a personalized care plan; and 4D-Do preventive and tooth-preserving care. The aim of this study was to establish how Colombian dental practitioners, educators and students diagnose and manage caries risk and caries lesions using the COM-B model and the ICCMS™ system. METHODS: A total of 1094 participants (practitioners: n = 277; educators: n = 212; students: n = 605) completed a previously validated 79-item questionnaire which explores, based on the COM-B model, the practitioners' self-reported caries diagnosis and management behaviours. Descriptive statistics, Welch's ANOVAs and multiple linear regressions were computed. RESULTS: All groups generally performed the behaviours within the 4-D categories 'Most of the time' to 'Always' (students: 4.06 ± 0.95; educators: 3.94 ± 0.98; practitioners: 3.86 ± 1.01). The most frequently performed diagnosis behaviours (1D/2D) were for practitioners assessing initial/moderate lesions (4.09 ± 1.01) and for educators and students cleaning teeth before lesion assessment (4.41 ± 0.80 and 4.38 ± 0.77 respectively). The least frequently performed decision/management (3D/4D) behaviour was non-operative care for moderate-caries lesions (when applicable) (practitioners: 2.64 ± 1.23; educators: 2.68 ± 1.17; students: 3.22 ± 1.41). Opportunity (Resources and Relevance) was the best COM-B predictor for diagnostic behaviours, whereas capability and opportunity (Relevance) were the strongest predictors for management behaviours. CONCLUSION: Colombian practitioners, educators and students diagnose and manage caries risk and caries lesions implementing best practice with a high to very high frequency.

Reframing perceptions in operative dentistry relating evidence-based dentistry and clinical decision making: a cross-sectional study among Jordanian dentists.

BACKGROUND: The aim of the current study was to investigate current dental practice in operative dentistry in Jordan, and the relationship between evidence-based dentistry in caries research and decision making in clinical practice in operative dentistry. MATERIALS AND METHODS: This cross-sectional study was conducted through a survey of dentists in Jordan. The survey aimed to explore the degree of knowledge and practice of evidence-based dentistry in caries research the dentists possess regarding clinical decision making in operative dentistry. The sample size was composed of (5811) dentists whom registered in Jordan Dental Association database. Descriptive statistics were generated and Chi-square test was used to examine associations between the different variables and the significance level was set at P < 0.05. RESULTS: 4000 responses were collected from the web-survey, response rate (68.83%). Nearly half of the surveyed dentists focus on the chief complaint of their patients (n = 2032, 50.8%) rather than doing full mouth assessment. Nearly two-thirds of dentists (n = 2608, 65.2%) treat lesions confined to enamel with operative treatment. Half of dentists use operative treatment when asked about the routine management of radiographically detected proximal caries confined to enamel. When treating incipient lesions, the majority (n = 3220, 80.5%) use preventive treatment. Three-quarters of dentists (n = 2992, 74.8%) treat deep dentinal caries by removing just the soft infected carious dentin, and treated old failed restorations with replacement. CONCLUSION: In operative dentistry, the evidence-based research is not implemented clinically. To optimize relationship between evidence-based dentistry and clinical decision-making, dental curriculum has to be updated and modified constantly.

Refocusing dental care: A risk-based preventative oral health programme for dentate older people in UK care homes.

BACKGROUND: There is strong evidence for managing the risk of dental caries, notably dose-dependent use of fluoride based on risk. Specific guidance is lacking on higher fluoride use in older people in care homes and prevention is often omitted from dental care plans. OBJECTIVES: To introduce a risk-based preventative approach to existing routine dental care for older people in care homes. METHODS: Three mixed residential and nursing care homes for the frail and elder (>65 years) were selected to participate. All residents were risk assessed based on dependency, dentition status and self-care abilities and consequently placed on the appropriate evidence-based intervention (2800 ppm high dose fluoride toothpaste and/or quarterly fluoride varnish placement). Full mouth ICDAS dental examinations were completed at baseline, 6 months and 12 months. RESULTS: At baseline, 127 risk assessments were completed in which most dentate residents (58.2%, n = 74) were assessed as Risk Level 2/3 (mod/high) whilst edentulous residents were all Risk Level 1 (low) (41.7%, n = 53). Only 13 (26.5%) of the 49 eligible residents completed the 12-month preventative programme. There was a significant difference in root caries (P < .0001), with 17 (51.5%) root lesions changing from active at baseline to arrested at 12 months. CONCLUSIONS: The findings provide early indication of fluoride efficacy, especially on root caries in this vulnerable group, and highlight the challenges of delivering programme's in these complex, changing environments.

Caries and collaborations in context.

Dental caries is the most prevalent non-communicable disease globally and affects all age groups across the life course. Caries (and the dental cavities it produces) create very significant personal, societal and economic burdens across the world, despite dental cavities being largely preventable. This is why so many individuals and groups are collaborating to do something to improve the world landscape of avoidable cavities. Over the past 20 years, a series of international partnerships have been developed in caries research, education and management, which have paved the way for a shift towards collaborative, inter-disciplinary and multi-stakeholder approaches to caries. This paper: 1) discusses the motivation for individuals and organisations to collaborate towards 'service to society'/'making a difference'/'making the world a better place'; 2) explains that collaboration to make an impact is undeniably complicated, but highly desirable; 3) suggests that successful collaborations typically need to be sustainable and long-term; 4) provides some examples from the caries world of the range and depth of collaborations making a difference; and 5) suggests that we now seem to be at multiple 'tipping points' to accelerate the progress of integration, intersectoral and interprofessional collaboration and of aligning caries control with the broader context of oral health and general health globally.

Understanding dental caries as a non-communicable disease.

The recent developments in the science underpinning our knowledge of both the initiation of dental caries and the subsequent behaviour of lesions over time gives us a solid base to understand caries differently. Advances in understanding the human and oral microbiome have come in parallel with the recognition of the importance of balancing protective and pathological risk factors. Caries prevention and management is now about controlling risk factors to maintain a balanced intraoral biofilm ecology that guards against a continuing low pH driven by the frequent consumption of sugars. Thus, caries control is no longer about attempts at eradicating any specific microorganism. Further, the present knowledge leads to the classification of dental caries as a non-communicable disease (NCD), which is vitally important from a policy perspective (both globally and at the country level). Caries shares similar risk factors with other chronic/systemic diseases, which provides opportunities for developing common prevention strategies and promoting health equity through action on the social determinants of health. So, preventing and controlling caries should be integrated across the so-called upstream, midstream and downstream levels and these activities can also help to control other NCDs.

Dental Policy Lab 1 - towards a cavity-free future.

Although many dental professionals argue that prevention of oral diseases, including dental caries, will benefit both the patient and public finances, a paradigm shift has yet to happen in most countries. The literature has demonstrated that caries prevention and control is possible, but authorities have yet to implement health systems that allow patients to stay in a good health state. 'Policy Labs' are an innovative policy-making initiative that allow a positive collaboration between the many stakeholders around a given policy issue. In July 2017, 24 international experts, including representatives of both international and European Chief Dental Officers associations, were gathered for the first Alliance for a Cavity-Free Future/King's College London Dental Policy Lab to identify the main barriers for a change, and concrete actions to facilitate a policy shift towards increased resource allocation in prevention. A comprehensive report and well-received infographic summarising the key recommendations (explored in this paper) were produced to explain the situation and highlight the value of a cavity-free world to policymakers, demonstrating where change is needed. The first Dental Policy Lab proved to be an efficient way to generate new ideas and concrete ways to implement them, and has led to several subsequent initiatives worldwide.

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.

Dental Policy Lab 2 - towards paying for health in dentistry.

The first Alliance for a Cavity-Free Future (ACFF)/King's College London Dental Policy Lab, held in 2017, identified the need for a review of dental payment systems in order to see progress towards achieving improvements in caries and cavities. The lack of incentivisation for preventive intervention and care has long been a barrier to progress. The second Dental Policy Lab, held in July 2018, focused on this issue with the overarching question: 'How can we create and implement acceptable prevention-based dental payment systems to achieve and maintain health outcomes?' Using a design approach and participatory research, 29 participants from five stakeholder categories developed a blueprint report that aims to serve as a framework to adapt or create remuneration systems that are compatible with evidence-based dentistry with a focus on preventive care. Aimed at policymakers and policy entrepreneurs, this blueprint provides guidance and potential solutions using several international examples. The report and accompanying infographic explored in this paper have been well received and have helped to frame discussions in several country settings, with a direct implementation which is being trialled in France in 2021.

From 'ICDAS' to 'CariesCare International': the 20-year journey building international consensus to take caries evidence into clinical practice.

This paper charts the 20-year collaborative journey made by international teams of dental researchers, educators and practitioners. Following the initial development of the International Caries Detection and Assessment System (ICDAS) in 2002, the International Caries Classification and Management System (ICCMS) was collaboratively developed between 2010-2017 with several dental research and practice organisations, and influenced by best evidence judged via SIGN methodology, the UNEP Minamata Treaty (and linked phasing down of dental amalgam), three Dental Policy Labs and an international movement in operative dentistry to move towards minimally invasive dentistry. The FDI World Dental Federation publicised and advocated the ICCMS in 2019, when the 'CariesCare International' Consensus Guide and 4D caries management system was published to aid the delivery of ICCMS into practice. This system, which is designed to help practitioners deliver optimal caries care for patients, is now being adapted internationally for post-pandemic use in the 'Caries OUT' study. It is also being used as a vehicle for implementing the updated Delivering better oral health guidance on caries, as part of the minimum intervention oral healthcare delivery framework in the UK.

The Calcivis story - enamel caries activity assessment from technology to practice.

The Calcivis story is one of innovation and collaboration to deliver new technology capable of helping dentists improve patient care through solving an unmet clinical need in assessing the activity of caries lesions in enamel. Presently, there is no system routinely used in dental practice that can, in a single visit, determine whether a non-cavitated caries lesion is active or not. Calcivis has evolved since 2005, when a potential link between basic science in luminescence and differentiating initial-stage caries lesions that are actively demineralising and likely to progress, from other lesions which are inactive and currently do not need interventive care, was recognised. The 16-year journey has involved clinical academic dentists, scientists and entrepreneurs, general practitioners and their patients, together with serial investors and a core team working to patent, refine, assess and develop products to submit to regulatory approval and take to the international dental market. This journey has been made possible through effective long-term collaborations between disparate groups all sharing a common vision for the possibilities of harnessing new technology to help dental professionals provide better care for their patients.

New UK Chapter of the Alliance for a Cavity-Free Future.

The Alliance for a Cavity-Free Future (ACFF), started in 2010, has been based at King's College London since 2013. It is a dental caries-focused charity promoting integrated clinical and public health action. ACFF Chapters seek to improve caries prevention and management locally, based on best global evidence. The UK Chapter has been created in response to a continuing need combined with opportunities including the implementation of the latest UK version of the Delivering better oral health guidance on prevention (version 4). The Chapter has been formed through a coordinating committee with UKwide representation combining expertise in dental caries management across the patient life course. This committee co-created the Chapter Values Statement: 'in pursuit of a cavity-free future across the UK we value: collaboration and innovation; realistic and implementable prevention-based solutions; approaches that reduce health inequalities; action across both oral and general health settings; and working comprehensively from the population through to the individual level.' The agreed Chapter focus is on advocating for the implementation of appropriate, effective, pragmatic caries prevention and care across three themes: 1) in everyday dental practice; 2) in health and social care curricula; and 3) for vulnerable people across their life course on the basis of increased caries risk/susceptibility.

CariesCare International adapted for the pandemic in children: Caries OUT multicentre single-group interventional study protocol.

BACKGROUND: Comprehensive caries care has shown effectiveness in controlling caries progression and improving health outcomes by controlling caries risk, preventing initial-caries lesions progression, and patient satisfaction. To date, the caries-progression control effectiveness of the patient-centred risk-based CariesCare International (CCI) system, derived from ICCMS™ for the practice (2019), remains unproven. With the onset of the COVID-19 pandemic a previously planned multi-centre RCT shifted to this "Caries OUT" study, aiming to assess in a single-intervention group in children, the caries-control effectiveness of CCI adapted for the pandemic with non-aerosols generating procedures (non-AGP) and reducing in-office time. METHODS: In this 1-year multi-centre single-group interventional trial the adapted-CCI effectiveness will be assessed in one single group in terms of tooth-surface level caries progression control, and secondarily, individual-level caries progression control, children's oral-health behaviour change, parents' and dentists' process acceptability, and costs exploration. A sample size of 258 3-5 and 6-8 years old patients was calculated after removing half from the previous RCT, allowing for a 25% dropout, including generally health children (27 per centre). The single-group intervention will be the adapted-CCI 4D-cycle caries care, with non-AGP and reduced in-office appointments' time. A trained examiner per centre will conduct examinations at baseline, at 5-5.5 months (3 months after basic management), 8.5 and 12 months, assessing the child's CCI caries risk and oral-health behaviour, visually staging and assessing caries-lesions severity and activity without air-drying (ICDAS-merged Epi); fillings/sealants; missing/dental-sepsis teeth, and tooth symptoms, synthetizing together with parent and external-trained dental practitioner (DP) the patient- and tooth-surface level diagnoses and personalised care plan. DP will deliver the adapted-CCI caries care. Parents' and dentists' process acceptability will be assessed via Treatment-Evaluation-Inventory questionnaires, and costs in terms of number of appointments and activities. Twenty-one centres in 13 countries will participate. DISCUSSION: The results of Caries OUT adapted for the pandemic will provide clinical data that could help support shifting the caries care in children towards individualised oral-health behaviour improvement and tooth-preserving care, improving health outcomes, and explore if the caries progression can be controlled during the pandemic by conducting non-AGP and reducing in-office time. TRIAL REGISTRATION: Retrospectively-registered-ClinicalTrials.gov-NCT04666597-07/12/2020: https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S000AGM4&selectaction=Edit&uid=U00019IE&ts=2&cx=uwje3h . Protocol-version 2: 27/01/2021.

Protocol for A randomised feasibility trial comparing fluoride interventions to prevent dental decay in older people in care homes (FInCH trial).

BACKGROUND: The number and proportion of older people globally is growing faster than that of any other age group. At the same time the number of people retaining some of their own teeth is rising. There significant differences between those living in care and their community dwelling peers, with evidence showing those in care having fewer teeth and significantly higher levels of dental decay. There are numerous Cochrane reviews linking the use of fluoride to a reduction in dental decay, however, the majority of research on effectiveness has been conducted on children and consequently, children and adolescents tend to be the main recipients of fluoride interventions. There are to date no studies comparing the effectiveness of fluoride interventions in older people in care homes in the UK. However, prior to developing an appropriate protocol for full-scale trial comparing clinical effectiveness of fluoride interventions, there are a number of trial feasibility and statistical parameters that need to be clarified. METHODS: This trial is a single centre, multi-site randomised controlled assessor blind parallel group (three groups) trial, with the primary objective of establishing the feasibility, practicability and compliance of fluoride interventions to prevent dental decay in care homes. Secondary and tertiary objectives will aim to explore the acceptability of the interventions from resident, care home and dental services perspectives, and estimate the efficacy of the three different fluoride treatments. DISCUSSION: This feasibility trial will produce new knowledge and add value to a landscape that is under researched. Although the efficacy of fluoride interventions is proven, the feasibility of dental research and prevention in this vulnerable group and in the complex care home setting is novel. This work will not only add to our understanding of the interface of dental care and social care but will also contribute to our broader understanding on undertaking research in care home settings. Dental care for older people has been a longstanding issue, and the events of this past year has shone a light on the vulnerabilities of those residing in care homes and so this research is landing at a pivotal time. Trial registration EudraCT Registration 2017-002248-34. Registered 20th February 2018 https://www.clinicaltrialsregister.eu/ctr-search/search?query=2017-002248-34 .

Crisis in care homes: the dentists don't come.

AIM/OBJECTIVES: To present the findings of the challenges relating to access to dental care for older people in care homes from the Fluoride Interventions in Care Homes (FInCH) Trial. METHODS: Thematic analysis of 11 interviews / focus groups with care home managers and care staff were carried out against a framework informed by the literature drawing on lived experiences. RESULTS: The challenges identified mapped to Penchanksy and Thomas's (1981) five dimensions of access but also highlighted themes specifically relevant to the care home population. These include a lack of suitable services for routine and urgent domiciliary and clinic care, complex referral processes, operational challenges in the need for appropriate care chaperones, expectations of information for dental charge exemption and capacity / consent processes within the home. DISCUSSION: There is a malalignment of dental services offered to meet the needs of care home residents which has resulted in a reactive dental care system that is not fit for purpose and an entire generation of older people living in care with dental neglect. CONCLUSION: Urgent action is needed to commission not only the appropriate quantities of both routine and urgent dental care, but ensure it is delivered by clinicians who are appropriately skilled to meet the high levels of dental needs in an increasingly medically and behaviourally complex care home population. In line with eye tests and prescribing at the very least, free routine dental examinations should be offered to all care home residents, creating the opportunity for advice and prevention, and enabling care home residents to function and be free of pain. TRIAL REGISTRATION: The FinCH Trial registration EudraCT number 2017-002248-34.

Examining the effectiveness of different dental recall strategies on maintenance of optimum oral health: the INTERVAL dental recalls randomised controlled trial.

Objective To compare the clinical effectiveness of different frequencies of dental recall over a four-year period.Design A multi-centre, parallel-group, randomised controlled trial with blinded clinical outcome assessment. Participants were randomised to receive a dental check-up at six-monthly, 24-monthly or risk-based recall intervals. A two-strata trial design was used, with participants randomised within the 24-month stratum if the recruiting dentist considered them clinically suitable. Participants ineligible for 24-month recall were randomised to a risk-based or six-month recall interval.Setting UK primary dental care.Participants Practices providing NHS care and adults who had received regular dental check-ups.Main outcome measures The percentage of sites with gingival bleeding on probing, oral health-related quality of life (OHRQoL), cost-effectiveness.Results In total, 2,372 participants were recruited from 51 dental practices. Of those, 648 were eligible for the 24-month recall stratum and 1,724 participants were ineligible. There was no evidence of a significant difference in the mean percentage of sites with gingival bleeding on probing between intervention arms in any comparison. For those eligible for 24-month recall stratum: the 24-month versus six-month group had an adjusted mean difference of -0.91%, 95% CI (-5.02%, 3.20%); the 24-month group versus risk-based group had an adjusted mean difference of 0.07%, 95% CI (-3.99%, 4.12%). For the overall sample, the risk-based versus six-month adjusted mean difference was 0.78%, 95% CI (-1.17%, 2.72%). There was no evidence of a difference in OHRQoL (0-56 scale, higher score for poorer OHRQoL) between intervention arms in any comparison. For the overall sample, the risk-based versus six-month effect size was -0.35, 95% CI (-1.02, 0.32). There was no evidence of a clinically meaningful difference between the groups in any comparison in either eligibility stratum for any of the secondary clinical or patient-reported outcomes.Conclusion Over a four-year period, we found no evidence of a difference in oral health for participants allocated to a six-month or a risk-based recall interval, nor between a 24-month, six-month or risk-based recall interval for participants eligible for a 24-month recall. However, patients greatly value and are willing to pay for frequent dental check-ups.

Reframing Perceptions in Restorative Dentistry: Evidence-Based Dentistry and Clinical Decision-Making.

OBJECTIVES: The worldwide interest of both dentists and patients in esthetic dentistry has affected decision-making in dental practice. The aim of this study was to investigate contemporary dental practice in restorative dentistry and the relationship between evidence-based dentistry in caries research and decision-making in clinical practice in restorative dentistry. METHODS: The study was conducted through a structured questionnaire distributed randomly at the Jordanian Dental Association registered dentists in Jordan. The questionnaire aimed to clarify the degree of knowledge and practice of evidence-based dentistry in caries research the dentists hold regarding clinical decision-making in restorative dentistry. RESULTS: The majority of the surveyed dentists (77%) treat teeth with irreversible pulpitis with root canal treatment rather than vital pulp therapy. 13.8% routinely insert a post and 23% routinely crown the tooth after root canal treatment regardless of the remaining tooth structure. Badly damaged teeth are treated with full crowns in 72% of the cases. Regarding Hollywood smile or smile makeover, the majority of dentists choose conservative approaches, and implants were the first choice to replace missing teeth for 93.8% of the surveyed dentists. CONCLUSION: A higher degree of implementation of evidence-based dentistry in clinical decision-making was found in Prosthetic Dentistry than in Endodontics. Yet, the gap between evidence-based data and clinical practice needs bridging. More emphasis on communicating these data to educators to integrate them into the dental curriculum is a must.

Risk-based, 6-monthly and 24-monthly dental check-ups for adults: the INTERVAL three-arm RCT.

BACKGROUND: Traditionally, patients are encouraged to attend dental recall appointments at regular 6-month intervals, irrespective of their risk of developing dental disease. Stakeholders lack evidence of the relative effectiveness and cost-effectiveness of different recall strategies and the optimal recall interval for maintenance of oral health. OBJECTIVES: To test effectiveness and assess the cost-benefit of different dental recall intervals over a 4-year period. DESIGN: Multicentre, parallel-group, randomised controlled trial with blinded clinical outcome assessment at 4 years and a within-trial cost-benefit analysis. NHS and participant perspective costs were combined with benefits estimated from a general population discrete choice experiment. A two-stratum trial design was used, with participants randomised to the 24-month interval if the recruiting dentist considered them clinically suitable. Participants ineligible for 24-month recall were randomised to a risk-based or 6-month recall interval. SETTING: UK primary care dental practices. PARTICIPANTS: Adult, dentate, NHS patients who had visited their dentist in the previous 2 years. INTERVENTIONS: Participants were randomised to attend for a dental check-up at one of three dental recall intervals: 6-month, risk-based or 24-month recall. MAIN OUTCOMES: Clinical - gingival bleeding on probing; patient - oral health-related quality of life; economic - three analysis frameworks: (1) incremental cost per quality-adjusted life-year gained, (2) incremental net (societal) benefit and (3) incremental net (dental health) benefit. RESULTS: A total of 2372 participants were recruited from 51 dental practices; 648 participants were eligible for the 24-month recall stratum and 1724 participants were ineligible. There was no evidence of a significant difference in the mean percentage of sites with gingival bleeding between intervention arms in any comparison. For the eligible for 24-month recall stratum: the 24-month (n = 138) versus 6-month group (n = 135) had an adjusted mean difference of -0.91 (95% confidence interval -5.02 to 3.20); the risk-based (n = 143) versus 6-month group had an adjusted mean difference of -0.98 (95% confidence interval -5.05 to 3.09); the 24-month versus risk-based group had an adjusted mean difference of 0.07 (95% confidence interval -3.99 to 4.12). For the overall sample, the risk-based (n = 749) versus 6-month (n = 737) adjusted mean difference was 0.78 (95% confidence interval -1.17 to 2.72). There was no evidence of a difference in oral health-related quality of life between intervention arms in any comparison. For the economic evaluation, under framework 1 (cost per quality-adjusted life-year) the results were highly uncertain, and it was not possible to identify the optimal recall strategy. Under framework 2 (net societal benefit), 6-month recalls were the most efficient strategy with a probability of positive net benefit ranging from 78% to 100% across the eligible and combined strata, with findings driven by the high value placed on more frequent recall services in the discrete choice experiment. Under framework 3 (net dental health benefit), 24-month recalls were the most likely strategy to deliver positive net (dental health) benefit among those eligible for 24-month recall, with a probability of positive net benefit ranging from 65% to 99%. For the combined group, the optimal strategy was less clear. Risk-based recalls were more likely to be the most efficient recall strategy in scenarios where the costing perspective was widened to include participant-incurred costs, and in the Scottish subgroup. LIMITATIONS: Information regarding factors considered by dentists to inform the risk-based interval and the interaction with patients to determine risk and agree the interval were not collected. CONCLUSIONS: Over a 4-year period, we found no evidence of a difference in oral health for participants allocated to a 6-month or a risk-based recall interval, nor between a 24-month, 6-month or risk-based recall interval for participants eligible for a 24-month recall. However, people greatly value and are willing to pay for frequent dental check-ups; therefore, the most efficient recall strategy depends on the scope of the cost and benefit valuation that decision-makers wish to consider. FUTURE WORK: Assessment of the impact of risk assessment tools in informing risk-based interval decision-making and techniques for communicating a variable recall interval to patients. TRIAL REGISTRATION: Current Controlled Trials ISRCTN95933794. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme [project numbers 06/35/05 (Phase I) and 06/35/99 (Phase II)] and will be published in full in Health Technology Assessment; Vol. 24, No. 60. See the NIHR Journals Library website for further project information.

Traditionally, dentists have encouraged both patients at low risk and patients at high risk of developing dental disease to attend their dental practices for regular 6-month 'check-ups'. There is, however, little evidence available for either patients or dentists to use when deciding on the best dental recall interval (i.e. time between dental check-ups) for maintaining oral health. In this study, we wanted to find out, for adult patients who regularly attend the dentist, what interval of time between dental check-ups maintains optimum oral health and represents value for money. A total of 2372 adults who regularly attended 51 different dental practices across Scotland, Northern Ireland, England and Wales were involved. Patients aged 18 years or over who received all or part of their care as NHS patients were randomly allocated to groups to receive a check-up either every 6 months, at an individualised recall interval based on their own risk of oral disease (risk-based recall), or every 24 months (if considered at low risk by their dentist). The recruited adults completed questionnaires at their first trial appointment and then every year of the 4-year study. Their attendance at recall appointments was recorded and they received a clinical assessment taken by study staff at the end of their involvement at year 4. After 4 years, there was no evidence of a difference in the oral health of patients allocated to a 6-month or variable risk-based recall interval. For patients considered by their dentists to be suitable for a 24-month recall interval, there was no difference between those in the 24-month, 6-month or risk-based recall intervals. However, people greatly value and are willing to pay for frequent dental check-ups. The recall strategy that offers the best value for money to patients and the NHS, therefore, depends on what people and decision-makers wish to value within a health-care system.

2018 French dental contracts: On the road to achieving universal dental health coverage?

Following the failure of earlier negotiations, the new French Government decided not to go ahead with a unilateral decision to define fees in the dental contracts, and to reopen the negotiations. This in a bid to satisfy the providers' requests, as well as to negotiate Emmanuel Macron's presidential campaign promise of no out-of-pocket expenses on dental prosthetics. The three stakeholders, the National Health Insurance System, Dental Trade Unions and Complementary Health Insurers, started another round of negotiations which lead to an agreement. This new convention, which will be phased in from the 1 st of April 2019, will exclude 90 % of dental procedures from out-of pocket payments for patients. Though economic models were controversial between the stakeholders, this reform is likely to engage France in a system where the dental medical divide is narrowing, quasi-universal dental coverage is achieved and policy making processes are adaptable to the evolution of evidence-based medicine and economic realities. This reform, supported by more than 95 % of the French population, is likely to serve as an example for its impact on: political campaigns; the role of comprehensive data collection systems; economic models; and adaptive policies in order to overcome barriers to reforms.

Terminology of Dental Caries and Dental Caries Management: Consensus Report of a Workshop Organized by ORCA and Cariology Research Group of IADR.

A 2-day workshop of ORCA and the IADR Cariology Research Group was organized to discuss and reach consensus on definitions of the most commonly used terms in cariology. The aims were to identify and to select the most commonly used terms of dental caries and dental caries management and to define them based on current concepts. Terms related to definition, diagnosis, risk assessment, and monitoring of dental caries were included. The Delphi process was used to establish terms to be considered using the nominal group method favored by consensus. Of 222 terms originally suggested by six cariologists from different countries, a total of 59 terms were reviewed after removing duplicates and unnecessary words. Sixteen experts in cariology took part in the process of reaching consensus about the definitions of the selected caries terms. Decisions were made following thorough "round table" discussions of each term and confirmed by secret electronic voting. Full agreement (100%) was reached on 17 terms, while the definitions of 6 terms were below the agreed 80% threshold of consensus. The suggested terminology is recommended for use in research, in public health, as well as in clinical practice.

Caries classification and management in the context of the CariesCare International (CCI™) consensus: a clinical case study.

The objective of this clinical case study is to illustrate the caries management four-step structured process, leading to personalised interventions specific for each individual patient's risks and needs, according to CariesCare International, derived from the International Caries Classification and Management System (ICCMS) for clinical practice. An 18-year-old female was diagnosed with higher caries risk at the individual level, and with several caries lesions at different severity stages, some likely active and others likely inactive. A care plan was co-created with the patient and delivered to obtain optimal health outcomes. Several issues pertinent to patient-centred care are discussed, including caries management at the individual and the tooth surface level, the preservation of tooth structure, patient's caries risk management, and prevention and control of caries lesions. The patient's perspective is taken into account and the health outcome focus of the system is highlighted.