General dental practitioner's views on dental general anaesthesia services.

OBJECTIVE: Policy has recently changed on provision of dental general anaesthetic services in England. The aim of this study was to investigate general dental practitioners' views about dental general anaesthetics, the reduction in its availability and the impact on care of children with toothache. RESEARCH DESIGN: Qualitative study using semi-structured interviews and clinical case scenarios. PARTICIPANTS: General dental practitioners providing NHS services in the North West of England. RESULTS: 93 general dental practitioners were interviewed and 91 answered a clinical case scenario about the care they would provide for a 7-year-old child with multiple decayed teeth presenting with toothache. Scenario responses showed variation; 8% would immediately refer for general anaesthesia, 25% would initially prescribe antibiotics, but the majority would attempt to either restore or extract the tooth causing pain. Interview responses also demonstrated variation in care, however most dentists agree general anaesthesia has a role for nervous children but only refer as a last resort. The responses indicated an increase in inequalities, and that access to services did not match population needs, leaving some children waiting in pain. CONCLUSIONS: Most general dental practitioners support moving dental general anaesthesia into hospitals but some believe that it has widened health inequalities and there is also a problem associated with variation in treatment provision. Additional general anaesthetic services in some areas with high levels of tooth decay are needed and evidence based guidelines about caring for children with toothache are required.

A survey of school dental screening practise in community dental services of England and Wales in 2003.

OBJECTIVE: To describe the school dental screening process in Community Dental Services across England and Wales. BASIC RESEARCH DESIGN: Cross-sectional study using a postal questionnaire. CLINICAL SETTING: Community Dental Services. PARTICIPANTS: Clinical Directors of Community Dental Services in England and Wales. MAIN OUTCOME MEASURES: Respondents answers about the objectives of school dental screening, criteria used for referring a child, methods of informing parents of screening results, and methods used to confirm subsequent dental attendance. RESULTS: The response rate for this study was 92.1%. Respondents identified dental registration (75.2%) and attendance at a dentist (82.9%) as objectives of school dental screening. Less than one third (29.5%) saw the activity as having a preventive role. Caries in the primary and secondary dentitions and soft tissue lesions were reported as key criteria for referral. Methods of follow-up of screened positive children differed and were often inadequate; approximately one third of respondents used a letter carried home by the child that did not allow parents to inform the CDS of action taken. Half of the respondents routinely collected data on the number of screened positive children who subsequently visit a dentist. CONCLUSIONS: School dental screening is delivered in a similar fashion throughout England and Wales but methods of informing parents of a positive screen and follow-up mechanisms for children with positive screens vary. Most school dental screening programmes do not collect sufficient data to evaluate the impact of their programmes on children's oral health.

The effectiveness of school dental screening: dental attendance and treatment of those screened positive.

OBJECTIVE: To determine dental attendance and treatment outcomes following two models of dental screening. DESIGN: An observational prospective cohort study. SETTING: Infant, primary and junior schools in the North West of England. SUBJECTS: Children aged six to nine years at the start of the study. INTERVENTIONS: Subjects received a screening examination according to either a 'Traditional model' or 'New model' of school dental screening. MAIN OUTCOME MEASURES: Attendance at a dentist within four months of the intervention and treatment received by children referred via the 'New model' with caries in their permanent teeth. RESULTS: In the 'New model' of school dental screening 46% of screened positive and 41% of screened negative children attended a dentist during the study period. Some 44% of children referred with caries in permanent teeth attended a dentist and 53% of those attending received treatment for the referred condition. Larger proportions of children from disadvantaged backgrounds were screened positive but higher proportions of children from more affluent backgrounds attended the dentist and subsequently received treatment. CONCLUSION: School dental screening has a minimal impact on dental attendance and only a small proportion of screened positive children receive appropriate treatment. The programme fails to reduce inequalities in utilisation of dental services.

Fluoridated milk for preventing dental caries.

BACKGROUND: Dental caries remains a major public health problem in most industrialised countries, affecting 60% to 90% of school children and the vast majority of adults. Milk provides a relatively cost-effective vehicle for fluoride in the prevention of dental caries. OBJECTIVES: To determine the effectiveness of fluoridated milk, as a means of delivering fluoride on a community basis, for preventing dental caries. SEARCH STRATEGY: We searched Cochrane Oral Health Group Trials Register (28 April 2005), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2005), MEDLINE (1966 to 17 May 2005), OLDMEDLINE (1950 to 1965), EMBASE (1980 to 2005 week 20), LILACS (1982 to 17 May 2005), BBO (1986 to 17 May 2005), SIGLE (1980 to 17 May2005), Digital Dissertations (1861 to 17 May 2005) and reference lists of relevant articles. Attempts were made to identify both unpublished and ongoing studies. There were no language restrictions. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials (RCTs), with an intervention or follow-up period of at least 3 years, comparing fluoridated milk with non-fluoridated milk. Primary outcome was change in caries experience, as measured by changes in decayed, missing and filled figures on tooth (dmft/DMFT) and surface (dmfs/DMFS). DATA COLLECTION AND ANALYSIS: Inclusion decisions, data extraction and quality assessment were carried out independently and in duplicate. Study authors were contacted for additional information where necessary. MAIN RESULTS: Two RCTs involving 353 children were included. For permanent teeth, after 3 years there was a significant reduction in the DMFT (78.4%, P < 0.05) between the test and control groups in one trial, but not in the other. The latter study only showed a significant reduction in the DMFT until the fourth (35.5%, P < 0.02) and fifth (31.2%,P < 0.05) years. For primary teeth, again there was a significant reduction in the dmft (31.3%, P< 0.05) between the test and control groups after 3 years in one study, but not in the other. The results could not be pooled because of the difference in concentration of fluoride in the milk. AUTHORS' CONCLUSIONS: There are insufficient studies with good quality evidence examining the effects of fluoridated milk in preventing dental caries. However, the included studies suggested that fluoridated milk was beneficial to school children, especially their permanent dentition. The data need to be supplemented by further RCTs to provide the highest level of evidence for practice.

General dental practitioners' views on the use of stainless steel crowns to restore primary molars.

AIM: To ascertain general dental practitioners' views on the use of stainless steel (pre-formed metal) crowns to restore carious primary molars. METHOD: Ninety-three general dental practitioners were selected at random from those practising in Lancashire, Cheshire and Greater Manchester in 2003 and interviewed separately about the clinical care they provide to the primary dentition. Before the interview participants recorded the care they would provide for a case scenario, describing a child with a carious lesion that the British Society of Paediatric Dentistry (BSPD) guidelines indicate should be treated with a stainless steel crown. RESULTS: In answering the case scenario only six (7%) of the dentists reported that they would fit a stainless steel crown. Of the 93 dentists interviewed 71% knew of the BSPD guidelines, but only 18% had ever fitted a stainless steel crown in general practice. Reasons given for not using stainless steel crowns were they are inappropriate for many children, time consuming to fit, difficult to manipulate, expensive, and ugly. CONCLUSION: The BSPD guidelines on the use of stainless steel crowns do not reflect the views of the majority of general dental practitioners who consider these crowns unsuitable for most children and an impractical restorative technique in busy daily practice.

Possible link between extraction of wisdom teeth and temporomandibular disc displacement with reduction: matched case control study.

We undertook a case control study that compared 220 patients diagnosed with disc displacement with reduction at the Dental Hospital of Manchester with 1100 controls drawn from participants in the 1998 Adult Dental Health Survey. We found that patients were not significantly more likely to have had extraction of third molars than controls; odds ratio: 1.28, 95% CI: 0.96-1.71. Also only 21 patients (9.5%) reported having had extraction of third molars in the 5 years before their diagnosis. We conclude that for most patients extraction of third molars is unlikely to have caused disc displacement with reduction.

Screening by mammography, women with a family history of breast cancer.

The aim of this study was to describe the experience of screening women under the age of 50 years with a family history of breast cancer. 1259 women attended the Family History Clinic in Manchester for their first and subsequent consultations between 30 September 1992 and 30 April 1997. All women were under the age of 50 years at the initial consultation and had a lifetime risk of breast cancer of 1 in 6 or greater. Seven prevalent, seven incident and two interval cancers were detected. The number of invasive cancers expected to occur if this high risk population had not been screened was 8.45 (in 2722 person years at risk). 12 invasive cancers were detected, giving a ratio of 1.42 (95% confidence interval 0.73-2.48). The overall cancer detection rates in this young, at risk population were similar to those in older women in the National Health Service Breast Screening Programme. The number of cancers detected in the study was greater than expected in this population. As the numbers were small, a national trial needs to be undertaken to confirm these results and to determine the long term effects of screening.

Reliability of underlying incidence rates for estimating the effect and efficiency of screening for breast cancer.

The process of setting screening performance targets requires an estimate of what the incidence of breast cancer would have been in the population invited for screening if there had not been a screening programme. Before the introduction of the National Health Service breast screening programme in 1988 the incidence of breast cancer was already increasing in the population targeted for screening. To establish the incidence before screening the most recent complete data from all the regional cancer registries were collated. An age-period model was constructed to predict what these incidence rates might now have been if the screening programme had not been introduced. The model predicted that if prescreening trends continued (between 1987 and 1995) underlying incidence over this period would increase by 2.3 per 10,000 in women aged 50-54, 2.6 per 10,000 in women aged 55-59, and 2.9 per 10,000 in women aged 60-64. If the prescreening trends have continued then the use of a universal rate, applied across all calendar years and age groups, would seem to be inappropriate when setting targets.

Is the three year breast screening interval too long? Occurrence of interval cancers in NHS breast screening programme's north western region.

OBJECTIVE: To report the detection rate of interval cancers in women screened by the NHS breast screening programme. DESIGN: Detection of interval cancers by computer linkage of records held by the screening centres in the North Western Regional Health Authority with breast cancer registrations at the regional cancer registry. SETTING: North Western Regional Health Authority. SUBJECTS: 137,421 women screened between 1 March 1988 and 31 March 1992 who had a negative screening result. RESULTS: 297 invasive interval cancers were detected. The rate of detection of interval cancers expressed as a proportion of the underlying incidence was 31% in the first 12 months after screening, 52% between 12 and 24 months, and 82% between 24 and 36 months. CONCLUSION: The incidence of interval cancers in the third year after breast screening approaches that which would have been expected in the absence of screening and suggests that the three year interval between screens is too long.

Approaches taken to the treatment of young children with carious primary teeth: a national cross-sectional survey of general dental practitioners and paediatric specialists in England.

AIM: To measure the distribution of choices for the treatment of a child with differing severities of caries in a primary molar tooth among specialists in paediatric dentistry and general dental practitioners (GDPs) in England. METHOD: Two surveys were undertaken using the same tool. The populations invited to take part in the study were confined to dentists practising in England in 2004. They were 500 GDPs selected at random from the list of all GDPs with a National Health Service (NHS) contract identified by the Dental Practice Board (DPB) and all 148 specialists in paediatric dentistry appearing on the General Dental Council specialist register. The selected dentists were sent a questionnaire containing four hypothetical clinical case scenarios in which the severity of dental caries in a single primary molar differed. Each clinical case scenario had a list of possible treatment options and participants were asked to select their single most preferred treatment option. To maximise the response rate there were three mailing rounds. RESULTS: Of the 500 GDPs and 148 paediatric specialists sent a questionnaire, 322 (64%) GDPs and 115 (78%) specialists responded. The answers to each of the case scenarios indicate differences of opinion both between and among GDPs and specialists in the care they would recommend for a child with caries in a primary molar tooth. This variation in opinion about care was more pronounced for a single deep carious lesion than for a less severe lesion. The spread of treatment options chosen in each scenario indicates disagreement among GDPs and specialists about restorative techniques and philosophy of care. CONCLUSION: In England there is wide variation among GDPs and specialists in paediatric dentistry about the best way to treat a young child with caries in a primary molar tooth. Well designed studies are urgently needed to provide strong evidence for the most effective way to manage the dental care of children.

Exploring factors that influence general dental practitioners when providing advice to help prevent caries in children.

OBJECTIVE: To increase understanding about how and to whom general dental practitioners provide preventive advice to reduce caries in young children. DESIGN: Qualitative study using semi-structured interviews. SETTING: The North West of England. Interviews took place between March and September 2003. SUBJECTS AND METHODS: Ninety-three general dental practitioners practising within the general dental service were interviewed about the care they provide to young children. The interviews were recorded, transcribed and analysed using a constant comparative method. RESULTS: Children with caries were more likely to be questioned about diet and oral hygiene and if dentists believed parents to be motivated they were more inclined to spend time providing advice. Most dentists seemed to believe that education was the key to preventing caries and gave preventive advice in the form of a short educative talk. There was little use of visual aids or material for parents to take home. CONCLUSION: Preventive advice is given in an ad hoc way with no formal targeting. Most dentists deliver preventive advice as a short educative talk with no props or additional materials. Use of visual aids, providing materials for parents to take home and greater emphasis on partnership might help improve the impact of advice.

Exploring the content of the advice provided by general dental practitioners to help prevent caries in young children.

OBJECTIVES: To increase understanding about the content of preventive advice and care offered by general dental practitioners to young children. DESIGN: Qualitative study using semi-structured interviews. Setting The North West of England. Interviews took place between March and September 2003. SUBJECTS AND METHODS: Ninety-three general dental practitioners practising within the general dental service were interviewed about the care they provide to young children. The interviews were recorded, transcribed and analysed using a constant comparative method. RESULTS: Preventive advice given to parents of young children is usually about sugar consumption and tooth brushing behaviour but the emphasis and specific messages provided varies among general dental practitioners. Use of fluorides varied considerably, suggesting that some dentists either have reservations or are unclear about the appropriate use of fluorides. The study indicates important variation in the content of preventive care. CONCLUSION: There is important variation in the approach of general dental practitioners to the core activity of preventing caries in young children and some views expressed are not supported by the evidence base.

Impact of NHS breast screening on advanced disease and mortality from breast cancer in the North West of England.

A cohort study was undertaken to describe outcomes from breast cancer in women who were aged 54 years or younger when they were first invited for NHS breast screening. The analysis included 5125 women invited for multiple rounds of breast screening by the Wigan screening programme and 10 750 women invited by the Manchester programme. The main outcome measures were rates of advanced disease and mortality from breast cancer. In Wigan 4028 (78.6%) and in Manchester 5485 (51.0%) women accepted all of their invitations for screening. The incidence of invasive cancer was higher in Wigan than in Manchester (24.78 vs 21.11 per 10 000 person-years; chi(2)=2.11, 1 df, P=0.15), but the rate of advanced disease was significantly lower (2.49 vs 4.73 per 10 000 person-years; chi(2)=4.36, 1 df, P=0.04). Mortality was lower in Wigan than in Manchester (2.46 vs 4.31 per 10 000 person-years; chi(2)=3.25, 1 df, P=0.07). In the first report of long-term outcomes in women invited for NHS breast screening, we demonstrated that it is possible to evaluate the impact of screening by comparing programmes with different proportions of regular attenders; a significant difference was shown in the rate of advanced disease between two programmes with different cancer detection and attendance rates.