Richard D. Holmes

The Adult Oral Health Survey 2023 comprised a questionnaire (interview) and clinical oral examination of a nationally representative epidemiological sample of adults aged 16 years and older conducted in participants’ homes. This paper provides an overview of the prevalence and severity of periodontal disease and erosive tooth wear among dentate adults in England based on the clinical examination of participants carried out by dental examiners. Indicators of periodontal disease were common; of the 1,585 dentate adults examined, 40.6% had at least one site with periodontal pocketing 3.5mm or greater in depth and interdental recession affected 20.4%. Indicators of more advanced disease were less common; 12.2% had pocketing greater than 5.5mm but this was present in 22.6% of those aged 65–74 years. Erosive tooth wear (BEWE Codes 1–3) affected 71.2% of adults, hard tissue loss < 50% (BEWE Code 2) as the worst score affected 22.2% and hard tissue loss ≥ 50% (BEWE Code 3) affected 4.5%. The prevalence of periodontal disease and all grades of severity of erosive tooth wear increased with age. Inequalities in experience of periodontal disease and erosive tooth wear were apparent, especially for more advanced disease/ disorder.

Background: Social accountability relates to the obligation of a health professional school to align education, research, and services with community health priorities. Limited research has examined the role of social accountability in dental education and its potential for addressing oral health inequalities. Aim: The aim of this narrative review is to describe current research of relevance to social accountability in dental education and identify gaps in the literature. Method: A systematic search of the electronic databases PubMed, Medline, Embase, Web of Science, and Scopus, using the terms “social accountability”, “social responsibility”, and “dental education” was undertaken. Articles included in the review were those published between January 1995 and May 2024 which were related to dental professional education and deemed relevant to social accountability. Results and conclusions: Four themes of relevance to social accountability were identified in the literature (curriculum design and delivery, attitudes, social responsiveness, and cultural competence). This review highlights challenges in measuring the community impact of socially accountable approaches in dental education. There is a need for more longitudinal research to assess the long-term impacts of social accountability in dental education. There are also potential implications for policy and research to influence the working environment of dental graduates to enable and support the workforce to apply and embed social accountability in the practice of dentistry.

Data sources: Databases included Embase, Medline (via OVID) and PsycINFO (via EBSCO). Studies referenced within included review articles were additionally screened for relevance. Study selection: This review focused upon qualitative research studies and their use of dental behaviour support (DBS) tools to support dental care. Included studies were restricted to those in English and published since 1997. Screening of studies involved several authors according to pre-agreed inclusion and exclusion criteria. In the event of disagreement, a third author mediated the collaborative discussion. Data extraction and synthesis: Included studies first provided baseline study information including the type of qualitative research, the population studied and details of the type(s) of DBS under investigation. Then the qualitative data generated by each study, together with any interpretation provided by the authors, was entered onto bespoke data collection forms. A thematic synthesis approach was adopted. The authors generated new themes supported by selected quotations. The methodological quality of each included study was explored through a recognised tool and the level of confidence provided by each study was informed by the GRADE-CERQual assessment process. Results: Twenty-three studies were included. Most studies used semi-structured interviews, followed by focus groups and a small number of video diaries. For most studies, the focus was upon the dental care of children with a good proportion of these exploring dental general anaesthesia (DGA). Indeed, DGA was the most studied DBS technique. Whilst some studies explored adults’ experiences of DBS, none of the included studies centred upon medically compromised or older adults. The review authors identified five themes following data synthesis. These themes included the following areas (abridged and modified from the review paper): trust; information sharing; control and autonomy; perceived treatment success and failure of DBS techniques; and the longer-term impact of DBS techniques upon patients. Conclusions: Qualitative research has more to offer our understanding of DBS techniques and the impact they have upon patient care experience. There is a need for research to explore a wider range of DBS techniques used in isolation or in combination. Patient reported experiences of care should be considered in the development of outcome measures and any related DBS Core Outcome Set.

Data sources: Eight electronic databases including APA PsycINFO, CINAHL, Embase, LILACS, PubMed, Ovid, Scopus and Web of Science were searched from date of inception to November 2021. An updated search was conducted in August 2022. Google Scholar was accessed including Open Grey and ProQuest. Reference lists of the included studies were analysed for potentially eligible studies. Study selection: Observational studies (cross-sectional, case-control and cohort) that evaluated the association between dental caries and food insecurity were eligible for analysis. Qualitative studies, reviews and meeting abstracts were excluded. There were no restrictions on language or publication date. Data extraction and synthesis: Two reviewers independently screened titles and abstracts. A third experienced researcher was consulted if there was disagreement. Food insecurity status was the exposure with dental caries the outcome. The authors retrieved effect measures, 95% CI’s and P values where available. Heterogeneity was assessed via I² and R². A total of 514 records were initially identified. Once duplicates were removed, 19 references were assessed in full. The association between food insecurity and dental caries were presented as odds-ratios, relative risks and prevalence ratios with 95% CIs. A random-effects model was fitted to all meta-analyses. Results: Evaluation identified 14 studies for the qualitative synthesis and 7 studies for the quantitative synthesis. The total sample size for the 14 studies was 150,546 individuals. Quantitative data merged from two studies found food-insecure individuals more prone to dental caries than food-secure individuals (OR = 1.62; 95% CI, 1.01–2.60; P = 0.045). In two studies that used binary data to compare food security or insecurity, food insecure individuals were more likely to exhibit dental caries (OR = 1.66; 95% CI, 1.36–2.02; P < 0.0001). Conclusions: People experiencing food insecurity are more likely to exhibit dental caries than those who have food security.

Introduction: In any health system, choices must be made about the allocation of resources (budget), which are often scarce. Economics has defined frameworks to aid resource allocation, and program budgeting marginal analysis (PBMA) is one such framework. In principle, patient and public values can be incorporated into these frameworks, using techniques such as willingness to pay (WTP). However, this has not been done before, and few formal resource allocation processes have been undertaken in dentistry. This study aimed to undertake a PBMA with embedded WTP values in a national dental setting. Methods: The PBMA process was undertaken by a panel of participant-researchers representing commissioners, dentists, dental public health staff, and academics. The panel reviewed current allocations and generated a set of weighted criteria to evaluate services against. Services to be considered for removal and investment were determined by the panel and wider discussion and then scored against the criteria. Values from a nationally representative WTP survey of the public contributed to the scores for interventions. Final decisions on removal and investment were taken after panel discussion using individual anonymous electronic voting. Results: The PBMA process resulted in recommendations to invest in new program components to improve access to general dentists, care home dentistry, and extra support for dental public health input into local government decisions. Disinvestments were recommended in orthodontics and to remove routine scaling and polishing of teeth. Discussion: The PBMA process was successful in raising awareness of resource allocation issues. Implementation of findings will depend on the ability of decision makers to find ways of operationalizing the decisions. The process illustrates practical aspects of the process that future dental PBMAs could learn from. Knowledge Transfer Statement: This study illustrates a framework for resource allocation in dental health services and will aid decision makers in implementing their own resource allocation systems.

Introduction: A systematic review of the evidence on the impact of dental caries on malnutrition risk in children was conducted. Objectives: To systematically review published evidence pertaining to the effect of dental caries severity and prevalence on risk of wasting or stunting in children. Methods: Four questions relating to caries of the permanent dentition, primary dentition, early childhood caries (ECC), and severe ECC as a risk factor for undernutrition were set. The target population was children aged 0 to 18 y from any country. Data sources included MEDLINE and Embase. All human epidemiological studies were included. Quality assessment excluded lowest-quality studies. Evidence synthesis by vote counting was depicted using harvest plots. A best available evidence approach was applied to narrative synthesis. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Results: Of the 2,690 studies identified, 447 were screened in duplicate; of these, 117 underwent quality assessment, resulting in 46 included studies, of which 38 were included in vote counting (3 quasi-experimental, 1 cohort, 1 case control, and 33 cross-sectional studies). For the permanent dentition, findings were mixed; the balance of data showed no association between caries prevalence (7/11 studies) or severity (8/17 studies) with wasting. For the primary dentition, the balance of data showed a positive association between caries prevalence (10/15 studies) and severity (12/15 studies) with wasting, as well as between-caries prevalence (4/5 studies) and severity (6/6 studies) with stunting. Considering ECC only did not alter this pattern of findings. Conclusion: The balance of evidence suggests that dental caries in the primary dentition is associated with undernutrition. There is a need for well-designed trials on the impact of caries rehabilitation on growth trajectories of children from low- and middle-income countries and for prospective studies of the impact of caries severity on both stunting and wasting to confirm causality. Knowledge Transfer Statement: The results of this study can be used by policy makers when considering the importance of oral health in addressing the United Nations Sustainable Development Goal to end all forms of malnutrition. The findings suggest that dental caries in the primary dentition may impair children’s healthy weight gain. The findings indicate that higher-quality data are required to confirm a causal relationship and thus inform funding bodies of the need for research, especially in low- and middle-income countries, to substantiate the current knowledge and inform clear and accurate policy statements.

Background: The association between Free Sugars intake and non-communicable diseases such as obesity and dental caries is well documented and several countries are taking measures to reduce sugars intakes. Public Health England (PHE) instigated a range of approaches to reduce sugars, including a national health marketing campaign (Sugar Smart). The campaign aimed to raise awareness of the amount of sugars in foods and drinks and to encourage parents to reduce their children’s intake. The aim of this study was to determine whether the campaign was effective in altering dietary behaviour, by assessing any impact of the campaign on sugars intake among children aged 5–11 years. Parental perceptions of the campaign and barriers to reducing sugars intake were also explored. Methods: Parents of 873 children aged 5–11 years, identified from an existing PHE database, were invited to take part. Dietary information was collected online using Intake24 before, during, and at 1, 10 and 12 months following the campaign. Change in sugars intake was assessed using mixed effects linear regression models. One-to-one telephone interviews were conducted with a purposive sample of parents to explore perceptions of the campaign and identify barriers and facilitators to reducing children’s sugars intake. Results: Completion rates for dietary assessment ranged from 61 to 72% across the follow up time points. Qualitative telephone interviews were conducted with 20 parents. Total sugars intake decreased on average by ~ 6.2 g/day (SD 43.8) at peak campaign and the percentage of energy from total sugars significantly decreased immediately and 1 year post campaign. The percentage of energy from Free Sugars significantly decreased across all time points with the exception of the long term follow up at 12-months post campaign. The percentage of energy intake from total fat increased. Parents expressed a willingness to reduce sugars intakes, however, identified barriers including time constraints, the normalisation of sugary treats, and confusing information. Conclusions: A health marketing campaign had a positive impact in reducing sugars intake but reductions in sugars were not sustained. Parents want to reduce their child’s sugars intake but societal barriers and confusion over which sources of sugars to avoid hamper efforts to change.

Background: The Filling Children’s Teeth: Indicated Or Not? (FiCTION) randomised controlled trial (RCT) aimed to explore the clinical- and cost-effectiveness of managing dental caries in children’s primary teeth. The trial compared three management strategies: conventional caries management with best practice prevention (C + P), biological management with best practice prevention (B + P) and best practice prevention alone (PA)-based approaches. Recently, the concept of treatment acceptability has gained attention and attempts have been made to provide a conceptual definition, however this has mainly focused on adults. Recognising the importance of evaluating the acceptability of interventions in addition to their effectiveness, particularly for multi-component complex interventions, the trial design included a qualitative component. The aim of this component was to explore the acceptability of the three strategies from the perspectives of the child participants and their parents.Methods: Qualitative exploration, based on the concept of acceptability. Participants were children already taking part in the FiCTION trial and their parents. Children were identified through purposive maximum variation sampling. The sample included children from the three management strategy arms who had been treated and followed up; median (IQR) follow-up was at 33.8 (23.8, 36.7) months. Semi-structured interviews with thirteen child-parent dyads. Interviews were transcribed verbatim and analysed using a framework approach.Results: Data saturation was reached after thirteen interviews. Each child-parent dyad took part in one interview together. The participants were eight girls and five boys aged 5–11 years and their parents. The children’s distribution across the trial arms was: C + Pn = 4; B + Pn = 5; PAn = 4. Three key factors influenced the acceptability of caries management in primary teeth to children and parents: i) experiences of specific procedures within management strategies; ii) experiences of anticipatory dental anxiety and; iii) perceptions of effectiveness (particularly whether pain was reduced). These factors were underpinned by a fourth key factor: the notion of trust in the dental professionals – this was pervasive across all arms.Conclusions: Overall children and parents found each of the three strategies for the management of dental caries in primary teeth acceptable, with trust in the dental professional playing an important role.

Background: The lack of evidence for the effective management of carious lesions in children’s primary teeth has caused uncertainty for the dental profession and patients. Possible approaches include conventional and biological management alongside best practice prevention, and best practice prevention alone. The FiCTION trial assessed the effectiveness of these options, and included a qualitative study exploring dental professionals’ (DPs) experiences of delivering the different treatment arms. This paper reports on how DPs managed children with carious lesions within FiCTION and how this related to their everyday experiences of doing dentistry.Methods: Overall, 31 DPs from FiCTION-trained dental surgeries in four regions of the UK participated in semi-structured interviews about their experiences of the three treatment arms (conventional management of carious lesions and prevention (C + P), biological management of carious lesions and prevention (B + P) or prevention alone (PA)). A theoretical framework, drawing on social practice theory (SPT), was developed for analysis.Results: Participants discussed perceived effectiveness of, and familiarity with, the three techniques. The C + P arm was familiar, but some participants questioned the effectiveness of conventional restorations. Attitudes towards the B + P arm varied in terms of familiarity, but once DPs were introduced to the techniques, this was seen as effective. While prevention was familiar, PA was described as ineffective. DPs manage children with carious lesions day-to-day, drawing on previous experience and knowledge of the child to provide what they view as the most appropriate treatment in the best interests of each child. Randomisation undermined these normal choices. Several DPs reported deviating from the trial arms in order to treat a patient in a particular way. Participants valued evidence-based dentistry, and expect to use the results of FiCTION to inform future practice. They anticipate continuing to use the full range of treatment options, and to personally select appropriate strategies for individual children.Conclusions: RCTs take place in the context of day-to-day practices of doing dentistry. DPs employ experiential and interpersonal knowledge to act in the best interests of their patients. Randomisation within a clinical trial can present a source of tension for DPs, which has implications for assuring individual equipoise in future trials.