Martin Tickle

The relationship between anxiety and dental treatment experience in 5-year-old children.

Objectives To examine the relationship between dental anxiety, dental attendance and past treatment history in 5-year-old children after taking into account confounding influences.Methods A cross sectional study of all 5-year-old children living in Ellesmere Port and Chester. All children were clinically examined and dmft and its components were recorded. A postal questionnaire was sent to parents of participating children to identify whether children attended the dentist on a regular asymptomatic basis or only when experiencing problems. Additionally parents were asked to judge whether they and their child were anxious about dental treatment. The socio-economic status of the family was measured using the Townsend Material Deprivation Index of the electoral ward in which they resided. The bivariate relationships between anxiety and reported attendance, caries experience, past extraction and restoration history were assessed using chi-square and t-tests. Multiple logistic regression analyses were used to identify predictors for dental anxiety.Results A total of 1,745 children received both a clinical examination and a questionnaire and 1,437 parents responded, a response rate of 82.3%. One in ten parents (10.8%) judged their child to be dentally anxious. Anxious children had significantly (p<0.001) more caries experience (dmft 2.58 vs 1.12). Multiple logistic regression analyses confirmed that anxious children were more likely to be irregular attenders (OR 3.33, 95% CI 2.22, 5.00), have anxious parents (OR 1.60, 95% CI 1.09, 2.36), and to have undergone dental extraction in the past (OR 3.50, 95% CI 2.10, 5.85), after controlling for gender and socio-economic status. A past history of restoration was not a significant predictor of anxiety after controlling for other factors.Conclusions Dental anxiety is a fairly common condition in 5-year-old children in the North West of England. It is closely associated with a symptomatic, irregular attendance pattern, a history of extraction and having a dentally anxious parent. The cause and effect dynamics of these relationships need to be determined.

A Cluster-randomized Controlled Trial: Fluoride Varnish in School Children

We conducted a school-based parallel cluster randomized controlled trial with 36-month follow-up of children aged 7 to 8 years. Primary schools were randomly assigned to 2 groups: 3 applications of fluoride varnish (22,600 ppm) each year or no intervention. The primary outcome was DFS increment in the first permanent molars, with the hypothesis that 9 applications of varnish over 3 years would result in a lower increment in the test group. Follow-up measurements were recorded by examiners blind to the allocation. Ninety-five schools were randomized to the test and 95 to the reference groups; 1473 (test) and 1494 (reference) children participated in the trial. An intention-to-treat analysis was carried out with random effects models. The DFS increment was 0.65 (SD 2.15) in the test and 0.67 (SD 2.10) in the reference groups, respectively. There was no statistically significant difference between the groups. We were unable to demonstrate an effect for fluoride varnish when it was used as a public health intervention to prevent caries in the first permanent molar teeth (Inter-national Standard Randomized Controlled Trial Registration: ISRCTN: #72589426)

Population attributable risk of tobacco and alcohol for upper aerodigestive tract cancer.

Tobacco and alcohol are major risk factors for upper aerodigestive tract (UADT) cancer and significant variation is observed in UADT cancer rates across Europe. We have estimated the proportion of UADT cancer burden explained by tobacco and alcohol and how this varies with the incidence rates across Europe, cancer sub-site, gender and age. This should help estimate the minimum residual burden of other risk factors to UADT cancer, including human papillomavirus. We analysed 1981 UADT cancer cases and 1993 controls from the ARCAGE multicentre study. We estimated the population attributable risk (PAR) of tobacco alone, alcohol alone and their joint effect. Tobacco and alcohol together explained 73% of UADT cancer burden of which nearly 29% was explained by smoking alone, less than 1% due to alcohol on its own and 44% by the joint effect of tobacco and alcohol. Tobacco and alcohol together explained a larger proportion of hypopharyngeal/laryngeal cancer (PAR=85%) than oropharyngeal (PAR=74%), esophageal (PAR=67%) and oral cancer (PAR=61%). Tobacco and alcohol together explain only about half of the total UADT cancer burden among women. Geographically, tobacco and alcohol explained a larger proportion of UADT cancer in central (PAR=84%) than southern (PAR=72%) and western Europe (PAR=67%). While the majority of the UADT cancers in Europe are due to tobacco or the joint effect of tobacco and alcohol, our results support a significant role for other risk factors in particular, for oral and oropharyngeal cancers and also for UADT cancers in southern and western Europe.

Dental pain and dental treatment of young children attending the general dental service.

Objectives: The objective was to examine the relationship between dental pain (and its sequaelae), and the extent of restorative care provided for primary molars, amongst children who regularly attend a general dental practitioner.Methods: A retrospective review of the clinical case notes of 677 children with caries who attended 50 general dental practitioners on a regular basis. Analyses were performed at the subject level. Logistic regression models were fitted for the dependent variables whether or not pain, a dental extraction for pain or sepsis and a course of antibiotics was recorded, after taking into account the proportion of carious teeth that were restored, the total number of carious teeth, the age caries was first recorded, gender and the clustering of the subjects within dental practices.Results: Almost half of the children in the study (48%) were recorded as having at least one episode of pain. Total decay experience in the primary molars was a significant predictor of pain, extraction due to pain or sepsis and prescription of antibiotics. There was no significant association between the proportion of carious teeth restored and each of the three dependent variables.Conclusions: For those children who regularly attend their general dental practitioner and who have decay in their primary molars, dental pain is a common finding. Total decay experience in primary molars is the principal predictor of pain, extraction due to pain and the need for antibiotics, whilst the level of restorative care in the primary dentition is less important. In order to reduce the incidence of dental pain in young children, effective methods of preventing caries at the individual and public health levels need to be expanded.

Paying for the wrong kind of performance? Financial incentives and behaviour changes in National Health Service dentistry 1992–2009

BACKGROUND There is a tension between financial incentives and professional codes and norms, both of which are believed to influence the behaviour of health care professionals. This study examined the impact of changes to financial incentive structures on the behaviour of dentists working in the English National Health Service (NHS) as a result of a new national contract. METHODS Comparison of six reference treatments delivered by all NHS dentists in England for the period 1992-2009. RESULTS Large and abrupt changes in the provision of the reference treatments coincided with the introduction of changes in the incentive structure in 2006. Treatments which can be provided in the least amount of time (and therefore costs to dentists) such as extractions increased and treatments which are time consuming or have significant additional materials costs such as bridgework, crowns, root fillings and radiographs reduced substantially. CONCLUSIONS Changes to financial incentive structures can produce large and abrupt changes in professional behaviours. In the context of multiple and conflicting goals, greater thought needs to be given to policies to change incentive structures to mitigate their unintended consequences.

A prospective study of dental anxiety in a cohort of children followed from 5 to 9 years of age.

BACKGROUND The development of dental anxiety in children is poorly understood. AIMS The aims of this study were to measure changes in dental anxiety over time and to examine the relationship between anxiety, dental care, and other factors. DESIGN A prospective cohort study of children in the north-west of England followed from 5 to 9 years of age. The participants were clinically examined and their parents completed the same questionnaire at 5 and 9 years. RESULTS The majority (54.3%N = 38) of participants who were anxious at 5 years were no longer anxious at 9 years, but a large proportion of children who were anxious at 5 remained anxious at 9 years of age (45.7%N = 32). During the follow-up period, a larger proportion of children developed anxiety (11.7%N = 85) than the proportion of children who were reported as being anxious at baseline (8.8%N = 70). At 9 years of age, dental anxiety was significantly associated with girls; parental anxiety; a history of extraction; and irregular, asymptomatic dental visiting. These factors were also significantly associated with dental anxiety at 5 years old. CONCLUSIONS Dental anxiety was cumulative in the study population over time, and its development influenced by multiple variables. Results suggest that adverse conditioning and vicarious learning are both important in the development of this condition.

The incidence of dental caries in the primary molar teeth of young children receiving National Health Service funded dental care in practices in the North West of England

Introduction A prospective cohort study was undertaken to describe the incidence of dental caries, as recorded by GDPs, in the primary molar teeth of children aged approximately 3-6 years attending general dental practices in the North West of England.Method Detailed dental records of children aged 3-6 years attending 50 general dental practices were assembled over a period of three years. Data from these records were analysed to estimate caries incidence rates at the subject and tooth level.Results The study population consisted of 739 children aged between 2.8 and 6.2 years; 620 children (84%) were caries free at recruitment. The incidence of developing a first carious (into dentine) lesion in caries free children increased with age. At age four the incidence of the first carious lesion was 9.5 per 100 person years and at age seven it was 19.6 per 100 person years. The tooth specific incidence of caries was found to be approximately 5-6 times greater in children with caries at recruitment than in caries free children. A sub-analysis on 566 children that were followed for more than two years revealed that of 486 children caries free at recruitment 132 (27%) developed caries in their primary molar teeth. By contrast, of the 80 children that had caries in their molar teeth at recruitment, one had eight carious molar teeth and 57 (72%) of the remaining 79 developed new cavities during the follow up period.Conclusions Caries incidence increases with age. There is a 5-6 times difference in the incidence of new cavities between caries free children and children with caries, irrespective of when a child developed the disease. As a consequence children with the disease and without the disease should be considered as two different populations; this has implications for care strategies applied to each population.

The Effectiveness of School Dental Screening: a Cluster-randomized Control Trial

Dental screening of children in schools is undertaken in many countries. There is no evidence that this activity is effective. The objective of our study was to determine if school dental screening of children reduces untreated disease or improves attendance at the population level. A four-arm cluster-randomized controlled trial was undertaken in the northwest of England. In total, 16,864 children aged 6–9 years in 168 schools were randomly allocated to 3 test groups, which received screening according to different models, and a control, which received no intervention. There were no significant differences in caries increment in the primary and secondary dentitions or in the proportions of children attending a dentist after screening between the control group and the 3 intervention arms. School dental screening delivered according to 3 different models was not effective at reducing levels of active caries and increasing attendance in the population under study.

The failure rate of NHS funded molar endodontic treatment delivered in general dental practice

Objective To describe the quality and record the outcomes of root canal therapy on mandibular, first permanent molar teeth provided by GDPs working according to NHS contracts.Design Descriptive, retrospective cohort study.Setting Twelve general dental practices in Salford, North West England.Subjects and method All patients aged 20-60 years attending the practices who had received a NHS-funded root filling in a mandibular first permanent molar between January 1998 and December 2003. The radiographic quality of root fillings in the teeth was assessed by an endodontic specialist and categorised into optimal, suboptimal and teeth which had no radiograph, or an unreadable radiograph. Teeth were also dichotomised into those restored with a crown and those restored with an intracoronal restoration. Failure as an outcome was defined as if a tooth was extracted, the root filling was replaced or periradicular surgery was performed on the tooth. Crude failure rates per 100 years were calculated for optimally, sub-optimally root filled teeth and for those with no or an unreadable radiograph, and according to how the tooth was coronally restored. Survival was assessed using Kaplan-Meier curves and Cox proportional hazards were used to determine factors linked with increased failures.Results One hundred and seventy-four teeth were included in the study, of which 16 failed. The crude failure rates per 100 years with a root filled tooth were very low and differed little (p = 0.9699) for optimally (2.6), sub-optimally (2.5) root filled teeth and for those with no or an unreadable radiograph (2.9), with approximately one in 37 root filled mandibular first molar teeth failing each year. The majority of root fillings fail within the first two years (N = 10, 62.5%). Some 67 teeth (38.5%) were restored with a crown, none of which failed during the follow up period compared to those with a plastic restoration (p = 0.0004).Conclusions The very low failure rates have significant implications for the design of research studies investigating outcomes of endodontic therapy. The similar failure rates for teeth that had optimal and suboptimal root fillings suggest that endodontic treatment is not as technique sensitive as previously thought. The results also support the notion that the coronal restoration is more important than radiographic appearance of the root filling.

Is skill mix profitable in the current NHS dental contract in England

The use of skill mix in medicine is now widespread, yet it appears that its use in dentistry is not as prominent. Unlike doctors, dentists are required to mitigate the financial risk produced by their capital investment and ensure an adequate cash flow to cover their annual running costs. Examining the financial incentives for employing dental care professionals is therefore an important step to understand why dentistry appears to lag behind medicine in skill mix. It is also apposite, given the announcement of the coalition government to develop a new contract, which could introduce incentives for the use of dental care professionals in this way. The purpose of this short paper is to examine whether skill mix is profitable for general dental practices under the existing NHS contract in England.