Background: Inequalities in oral health disproportionately affect low and middle income countries and a pattern of increased prevalence of dental caries in children has been reported. Objectives: To determine the burden of disease and behavioural and toothache history of six- and 12-year-old Malawi schoolchildren. Methods: Ethical approval was granted by Malawi's National Health Sciences Research Committee. The survey was undertaken by nine Malawian dental therapists and three UK dentists in 24 schools. Stratified cluster sampling ensured that the children were representative of Malawi's three Regions. Dental caries (into dentine), fluorosis, oral hygiene and PUFA index data were collected via a dental examination. Questionnaires were completed by each child and by the Head Teacher from each school. Results: A total of 1,330 six-year-old and 1,611 12-year-old children were examined, evenly split between the sexes. Dental caries was identified in 47% of six-year-olds and 23% of 12-year-olds. None of the children had filled teeth. The mean dmft/DMFT for children with caries experience was 3.0 for six-year-olds and 1.8 for 12-year-olds. Dental fluorosis was recorded for 7% of 12-year-olds. A history of toothache was reported by 29% of six-year-olds and 42% of 12-year-olds. Conclusions: The prevalence of caries and absence of signs of past clinical care highlight the need to implement activities identified in Malawi's National Oral Health Policy around the provision of appropriate preventive and treatment services for children.

OBJECTIVES:This scoping review aimed to map global evidence on upstream interventions which promote oral health and reduce socioeconomic inequalities in oral health. METHODS:A review was undertaken in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist. A multistranded comprehensive search strategy was employed to identify relevant studies. Article texts were retrieved and assessed for eligibility against the inclusion criteria. Key findings were extracted and summarised. RESULTS:A total of 99 articles (74 empirical studies and 25 systematic, scoping and umbrella reviews) were included in the scoping review. The review findings revealed a limited number of upstream interventions specifically focused on promoting oral health and reducing oral health inequalities. Legislative and regulatory measures (e.g., advertising controls), fiscal measures (e.g., sugar-sweetened beverage taxation) and specific oral health interventions (e.g., water fluoridation) have shown a positive impact on promoting oral health. In addition, fiscal measures, food subsidies targeted at low-income groups and improvements to housing/work environments have proven effective in reducing socioeconomic inequalities in general health outcomes. CONCLUSIONS:Despite a very detailed and thorough search of the global literature, this scoping review identified a limited number of upstream interventions that specifically focused on improving oral health, and an even smaller number of upstream interventions that tackled oral health inequalities. However, the review did identify three levels of upstream intervention including: policies tackling the broader socio-political determinants of health; policies combating non-communicable diseases (NCDs) linked to oral health; and some specific interventions (e.g., water fluoridation) focusing on oral health. The upstream approach to prevention remains highly relevant to public health policy and provides a guiding principle for future strategic action to promote oral health and tackle oral health inequalities.

An increase in the prevalence of caries has been reported in many low- and middle-income countries. However, limited data are available in Sub-Saharan Africa. Aims: The aims were to conduct a national oral health survey in six- and 12-year-old schoolchildren in Malawi, to determine the burden of disease and any history of toothache, and to collect behavioural information from the children, together with current health promoting practices within schools. Methods: Ethical approval was granted by Malawi’s National Health Sciences Research Committee. The survey was undertaken by nine Malawian dental therapists and three UK dentists, in 24 schools. Stratified cluster sampling ensured that the children were representative of Malawi’s three regions. Dental caries (into dentine), fluorosis, oral hygiene and PUFA index data were collected via a dental examination. The WHO pathfinder methodology and BASCD criteria were followed for caries. Questionnaires were completed by each child with support when needed, and by the Head Teacher from each school. Results: A total of 1,330 six-year-old and 1,611 12-year-old children were examined, evenly split between the sexes. Dental caries was identified in 629 (47%) of six-year-olds and 367 (23%) of 12-year-olds. None of the children examined had filled teeth. The mean dmft/DMFT for children with caries experience was 3.0 for six-year-olds and 1.8 for 12-year-olds. Dental fluorosis was recorded for 37 (3%) six-year-olds and 109 (7%) for 12-year-olds. A history of toothache was reported by 391 (29%) of six-year-olds and 690 (42%) 12-year-olds. A lack of PUFA signs was recorded in 1252 (94%) of six-year-olds and 1570 (97%) of 12-year-olds. Conclusions: In the population studied, the prevalence of caries and absence of signs of past clinical care highlight the need to implement activities identified in Malawi’s National Oral Health Policy around the provision of appropriate preventive and treatment services for children.

Introduction: An economic evaluation (EE) was conducted alongside a randomized controlled trial (the Protecting Teeth @ 3 Study [PT@3]), exploring the additional preventive value of fluoride varnish (FV) application at 6-monthly intervals in nursery schools compared to treatment as usual (TAU) in the same nurseries. TAU represented a multicomponent national child oral health improvement intervention, the Childsmile program, apart from nursery FV. Methods: The EE was a within-trial cost-utility analysis (CUA) comparing the FV and TAU groups. The CUA was conducted from a National Health Service perspective and followed relevant methods guidance. Within-trial costs included intervention costs and health care resource use costs. Health outcomes were expressed in quality-adjusted life years (QALYs) accrued over the 2-y follow-up period. The Child Health Utility 9 Dimensions questionnaire was used to obtain utility scores. National reference costs were used, a discount rate of 1.5% for public health interventions was adopted, multiple imputation methods for missing data were employed, sensitivity analyses were conducted, and incremental cost-utility ratios were calculated. Results: Data from 534 participants from the 2014–2015 PT@3 intake were used in the EE analyses, n = 265 (50%) in the FV arm and n = 269 (50%) in the TAU arm. Mean incremental cost per child in the FV arm was £68.37 (P = 0.382; 95% confidence interval [CI], –£18.04 to £143.82). Mean incremental QALY was −0.004 (P = 0.636; 95% CI, −0.016 to 0.007). The probability that the FV intervention was cost-effective at the UK £20,000 threshold was 11.3%. Conclusion: The results indicate that applying FV in nurseries in addition to TAU (all other components of Childsmile, apart from nursery FV) would not be deemed cost-effective given current UK thresholds. In view of previously proven clinical effectiveness and economic worthiness of the universal nursery toothbrushing component of Childsmile, continuation of the additional, targeted nursery FV component in its pre–COVID-19 form should be reviewed given its low probability of cost-effectiveness. Knowledge Transfer Statement: The results of this study can be used by child oral health policy makers and dental public health professionals. They can form part of the evidence to inform the Scottish, UK, and international guidance on community-based child oral health promotion programs.

Progression of dental caries can result in irreversible pulpal damage. Partial irreversible pulpitis is the initial stage of this damage, confined to the coronal pulp whilst the radicular pulp shows little or no sign of infection. Preserving the pulp with sustained vitality and developing minimally invasive biologically based therapies are key themes within contemporary clinical practice. However, root canal treatment involving complete removal of the pulp is often the only option (other than extraction) given to patients with irreversible pulpitis, with substantial NHS and patient incurred costs. The European Society of Endodontology’s (ESE 2019) recent consensus statement recommends full pulpotomy, where the inflamed coronal pulp is removed with the goal of keeping the radicular pulp vital, as a more minimally invasive technique, potentially avoiding complex root canal treatment. Although this technique may be provided in secondary care, it has not been routinely implemented or evaluated in UK General Dental Practice. This feasibility study aims to identify and assess in a primary care setting the training needs of general dental practitioners and clinical fidelity of the full pulpotomy intervention, estimate likely eligible patient pool and develop recruitment materials ahead of the main randomised controlled trial comparing the clinical and cost-effectiveness of full pulpotomy compared to root canal treatment in pre/molar teeth of adults 16 years and older showing signs indicative of irreversible pulpitis. The feasibility study will recruit and train 10 primary care dentists in the full pulpotomy technique. Dentists will recruit and provide full pulpotomy to 40 participants (four per practice) with indications of partial irreversible pulpitis. The Pulpotomy for the Management of Irreversible Pulpitis in Mature Teeth (PIP) study will address the lack of high-quality evidence in the treatment of irreversible pulpitis, to aid dental practitioners, patients and policymakers in their decision-making. The PIP feasibility study will inform the main study on the practicality of providing both training and provision of the full pulpotomy technique in general dental practice. ISRCTN Registry, ISRCTN17973604 . Registered on 28 January 2021. Protocol version Protocol version: 1; date: 03.02.2021

BACKGROUND Supporting patients to access community-based support may be a key intervention to address the wider determinants of health. There is a lack of evidence synthesis around the most effective methods for linking individuals from health services to organizations within communities, especially those aimed at supporting families with young children. METHODS Papers were identified from seven databases covering peer-reviewed and grey literature. The Effective Public Health Practice Project and the Critical Appraisal Skills Programme Qualitative quality appraisal tools were used to assess methodological quality. Thematic narrative data synthesis based on study quality was performed. RESULTS Twenty-four unique publications were included in the review with a range of study designs and variable methodological quality. A broad typology of intervention processes for undertaking linking was developed defining three distinct approaches: signposting, referral and facilitation. Active processes, such as facilitation, appeared more successful at linking families to community support. CONCLUSIONS This was the first systematic review to focus on interventions that link families with young children to community-based support organizations. It identified a typology for linking interventions, and whilst there were limitations in the quality of evidence available, it showed a tendency for more active interventions to be more effective in linking families to community support.

Objective To compare the clinical effectiveness and cost benefit of different frequencies of scale and polish (S&P) treatments in combination with different types of oral hygiene advice (OHA). Design Multi-centre, multi-level cluster randomised factorial open trial with blinded outcome evaluation. UK dental practices were cluster randomised to deliver OHA as usual or personalised. In a separate randomisation, patients were allocated to receive S&P 6-monthly, 12-monthly or never. Setting UK primary dental care. Participants Practices providing NHS care and adults who had received regular dental check-ups. Main outcome measures The percent of sites with bleeding on probing, patient confidence in self-care, incremental net benefits (INB) over three years. Results Sixty-three practices and 1,877 adult patients were randomised and 1,327 analysed (clinical outcome). There was no statistically significant or clinically important difference in gingival bleeding between the three S&P groups (for example, six-monthly versus none: difference 0.87% sites, 95% CI: 1.6 to 3.3, p = 0.48) or between personalised or usual OHA groups (difference -2.5% sites, -95%CI: -8.3 to 3.3, p = 0.39), or oral hygiene self-efficacy (cognitive impact) between either group (for example, six-monthly versus none: difference -0.028, 95% CI -0.119 to 0.063, p = 0.543). The general population place a high value on, and are willing to pay for, S&P services. However, from a dental health perspective, none of the interventions were cost-effective. Conclusion Results suggest S&P treatments and delivering brief personalised OHA provide no clinical benefit and are therefore an inefficient approach to improving dental health (38% of sites were bleeding whatever intervention was received). However, the general population value both interventions.

“Oral health matters” was the clear and emphatic message on the front cover of The Lancet on July 20, 2019. In this single issue of The Lancet, in addition to the front cover, oral health was the focus of an editorial (The Lancet 2019), an Oral Health Series comprising 2 major papers (Peres et al. 2019; Watt et al. 2019), 2 associated commentaries (Beaglehole and Beaglehole 2019; Kearns and Bero 2019), a perspective piece on the historical origins of modern dentistry (Barnett 2019), and a profile of a dental public health researcher (Davies 2019). Never before in the 196-year history of The Lancet—one of the most prestigious medical journals in the world—has oral health been given such a high profile. This is, without doubt, a watershed moment for global oral health. It is also, however, a profoundly important opportunity for the oral and dental research community. This commentary highlights the key messages from The Lancet Oral Health Series and considers the implications for the oral and dental research agenda globally.

OBJECTIVES:To describe and summarize evidence on economic evaluations (EEs) of primary caries prevention in preschool children aged 2 to 5 years and to evaluate the reporting quality of full EE studies using a quality assessment tool.METHODS:A systematic literature search was conducted in several databases. Full and partial EEs were included. The reporting quality of full EE studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.RESULTS:A total of 808 studies were identified, and 39 were included in the review. Most papers were published between 2000 and 2017 and originated in the United States and the United Kingdom. The most common type of intervention investigated was a complex multicomponent intervention, followed by water fluoridation. Cost analysis and cost-effectiveness analysis were the most frequently used types of EE. One study employed cost-utility analysis. The proportion of full EEs increased over time. The parameters not reported well included study perspective, baseline year, sensitivity analysis, and discount rate. The CHEERS items that were most often unmet were characterizing uncertainty, study perspective, study parameters, and estimating resources and costs.CONCLUSIONS:Within the past 2 decades, there has been an increase in the number of EEs of caries prevention interventions in preschool children. There was inconsistency in how EEs were conducted and reported. Lack of preference-based health-related quality-of-life measure utilization in the field was identified. The use of appropriate study methodologies and greater attention to recommended EE design are required to further improve quality.

BackgroundThere is a paucity of research concerning paediatric dental consultations in primary care. This is potentially due to the difficulty of measuring the communication behaviours in the complex triadic consultations. The present study aims to describe the development and refinement of a coding scheme to record the triadic communication between dental professionals, child patients and parents.MethodsThe PaeD-TrICS was developed from video observation of triadic communications and refined through an iterative process. Its practical applicability was assessed via implementation of the scheme on specialised behavioural coding software. Reliability was calculated using Cohen's Kappa.ResultsThe PaeD-TrICS contains 45 codes. Forty-four dental professional-child-parent communications were successfully coded through administering the scheme on The Observer XT 10.5 system. Cohen's Kappa was 0.83 (inter-coder) and 0.90 (intra-coder). Parental verbal facilitation (mean=1.68/min) was the most frequent behaviour. Dental professionals' dentally engaging talk (mean=1.24/min), praise (mean=1.10/min) and instruction (mean=0.62/min) were frequently seen. Children's common behaviours included speech other (mean=0.66/min) and non-verbal behaviour i.e. non-verbal agreement and verbal behaviour speech yes (mean=0.26/min).ConclusionsThe PaeD-TrICS is developed to capture the communication behaviour of the triadic consultations in a preventive dental setting. It demonstrates satisfactory intra- and inter-coder reliability and has been successfully used in paediatric dental consultations.

Aim To explore the time taken and the types of communication strategies used by dental health professionals (DHPs) when interacting with and providing fluoride varnish and oral health advice to children with their parents. Methods A video observational study was conducted to explore the types of communication strategies used by DHPs when interacting with child patients and their parents during preventive oral healthcare appointments. Three dentists and two extended duty dental nurses (EDDNs) from four general dental practices were recruited in East of Scotland. Forty-four child-parent dyads participated in the study. Verbal and non-verbal behaviours were coded with Observer XT 10.5 using the PaeD-TrICS coding scheme. Frequencies of communication behaviours were compared using Mann-Whitney U-tests. Results The communication during the preventive care appointment ranged in time from 130 seconds to 1,756 seconds with an average of 736 seconds. The total number of communication strategies (verbal and non-verbal behaviours) based on 44 video observations was 7,299. DHPs used different communication strategies when providing fluoride varnish application (FVA) and oral health advice. Dentists used more direct communication strategies to elicit child patients' cooperation in FVA. EDDNs used communication behaviours to maintain a balanced relationship with children. Consequently, children exhibited different responses to the two different dental professional groups. Conclusions Differences in the style of communication strategies existed between the participating DHPs when interacting with children during preventive dental appointments. Further work is required to confirm these initial findings.

Background: All children attending General Dental Practice in Scotland are recommended to receive twice-yearly applications of sodium fluoride varnish to prevent childhood caries, yet application is variable. Development of complex interventions requires theorizing and modelling to understand context. This study applies the Functional Resonance Analysis Method (FRAM) to produce a sociotechnical systems model and identify opportunities for intervention to support application. Methods: The FRAM was used to synthesise data which were: routine monitoring of fluoride varnish application in 2015/16; a longitudinal survey with practitioners (n = 1090); in-depth practitioner and key informant interviews (n = 43); and a 'world cafe' workshop (n = 56). Results: We describe a detailed model of functions linked to application, and use this to make recommendations for system-wide intervention. Conclusions: Rigorous research is required to produce accessible models of complex systems in healthcare. This novel paper shows how careful articulation of the functions associated with fluoride varnish application can support future improvement efforts.

Low public awareness of oral cancer and delays in symptomatic patients presenting to health services have been identified as contributing factors to poor survival rates. In order to promote diagnosis and treatment of oral cancer at an earlier stage, public awareness campaigns have been recommended, encouraging those with signs and symptoms to attend primary care services at an earlier stage. This article provides an overview of the evidence of effectiveness of interventions aimed at raising cancer awareness and explores the use of mass media for health behaviour change. The use of awareness campaigns to promote earlier diagnosis of oral cancer is also explored from both a patient and health professional perspective. The findings of the overview suggest that while awareness raising campaigns can increase knowledge of the disease and attendance at health services in the short-term, those at lesser risk often respond, and evidence of longer-term impact is very limited. The translation of knowledge into behaviour change is likely to require a more comprehensive, longer-term, multi-faceted approach, acknowledging the social determinants of health and health behaviour theory. More work is required to understand what needs to be included in campaigns to make them effective. Availability and access to appropriately trained and informed primary care personnel is important, particularly for high-risk groups. This is relevant for: supporting those with signs and symptoms to attend services; promoting opportunistic screening; enabling referral of patients to secondary care in a timely manner; and for provision of advice on the major risk factors associated with oral cancer.

The promotion of twice yearly application of fluoride varnish (FVA) to the teeth of pre-school children in the dental practice is one component of Scotland’s child oral health improvement programme (Childsmile). Nevertheless, evidence shows that application rates of FVA are variable and below optimal levels. The reasons are complex, with many contextual factors influencing activity. However, we propose that one possible reason may be related to the communication challenges when interacting with younger children. Therefore, the primary aim of the study is to assess the feasibility of conducting a video observational study in primary dental care. The secondary aim is to assess the communication behaviours of dental professionals and those of the parents to predict child cooperation when receiving FVA using this video observational study design.