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1 Annual Clinical Journal of Dental Health | No. 2 December 2012

Study to measure the clinical effectiveness of a dental hygienist in a cleft lip and palate unit.

Bulimia nervosa: The role of the dental hygienist in the care of the bulimic patient.

Determining the best method of applying CPP-ACP containing pastes and fluoride to eroded enamel in order to limit the amount of tooth wear in vitro.

A Survey of Dental Hygienists in the United Kingdom in 2011 – Part 5 Critical appraisal, research and continuing professional education.

Telomere length, chronic inflammation and oral health: implications for supportive therapy.

How effective are specific dentifrices in reducing or controlling plaque and gingivitis in adults?

Does evidence suggest that the use of mouthwash that contains alcohol increase the risk of oral cancer?

Parental consent and fluoride varnish schemes: lessons from dental screening.

Do motivational interviewing techniques contribute to improving the oral health of primary dental care patients?

Evaluation of the impact and effectiveness of safeguarding children training on dental practice.

T H E B r i T i S H S O C i E T Y O F D E N T A L H Y G i E N E A N D T H E r A P Y

Annual Clinical Journal of

Dental Health

www.bsdht.org.uk5 hours verifiable CPD

No. 2 December 2012


contents

1. Study to measure the clinical effectiveness of a dental hygienist in a cleft lip and palate unit.

Rhiannon Jones Page 5

2. Bulimia nervosa: The role of the dental hygienist in the care of the bulimic patient

Alison Lowe Page 8

3. Determining the best method of applying CPP-ACP containing pastes and fluoride to eroded enamel in order to limit the amount of tooth wear in vitro

Alison Chapman Page 11

4. A Survey of Dental Hygienists in the United Kingdom in 2011 – Part 5 Critical appraisal, research and continuing professional education

Marina Harris Page 16

5. Telomere length, chronic inflammation and oral health: implications for supportive therapy

Juliette Reeves 1

6. How effective are specific dentifrices in reducing or controlling plaque and gingivitis in adults?

Nicola Gough Page 28

7. Does evidence suggest that the use of mouthwash that contains alcohol increase the risk of oral cancer?

Sue Bagnall Page 33

8. Parental consent and fluoride varnish schemes: lessons from dental screening

Charlotte Jeavons Page 38

9. Do motivational interviewing techniques contribute to improving the oral health of primary dental care patients? A literature review.

Maggie Nash Page 43

10. Evaluation of the impact and effectiveness of safeguarding children training on dental practice

Kevin Hogan Page 48

11. Abstracts Page 53

12. CPD Page 56

iSSN 2049-0682

www.bsdht.org.ukEditorHeather L Lewis19 Cwrt-y-Vil roadPENArTHVale of GlamorganCF64 3HNEmail: [email protected]/fax: 02920 710042

BSDHT National Enquiry LineTel: 01452 886365Fax: 01452 886468Email: [email protected]

Publications CommitteeSue AdamsHayley LawrenceAlastair LomaxAlison LowePatricia MacphersonElaine TillingHelen WestleyPippa StewartEmma Pacey

Editorial BoardJennifer HughesJiann KhawMatt PerkinsAnthony robertsAndrew GouldAmit Patel

© Annual Clinical Journal of Dental Health - The British Society of Dental Hygiene and Therapy 2012. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying or otherwise without the prior permission of Dental Health. Views and opinions expressed in Annual Clinical Journal of Dental Health are not necessarily those of the Editor or The British Society of Dental Hygiene and Therapy.

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Tel: 01983 524885, e-mail: [email protected]

Annual Clinical Journal of Dental Health | No. 2 December 2012 3

Editor’s comments

Welcome to the second issue of the Annual Clinical Journal of Dental Health. As i described in my Editor’s comments in the first issue, the aim of this publication is to highlight clinically relevant research being undertaken by dental hygienists and dental hygienist-therapists. i hope that readers will agree that once again the journal contains a collection of high quality and clinically relevant contributions.

i am delighted that it has been possible to increase the number of papers this year which, i am sure, is a reflection of the increased research activity being undertaken by members of the British Society of Dental Hygiene and Therapy (BSDHT). As can be seen from the list of contents, the research topics cover a spectrum of our professional activity, all of which provides further evidence of the wide reaching role that dental hygienists and dental hygienist–therapists are providing in the delivery of dental healthcare within the United Kingdom. The performance and publication of quality research by members of BSDHT can only further enhance our position as key members of the dental team. The finding of such research also provides essential information for the formation of evidence-based practise within our profession.

i have also once again included a section that contains the abstracts of the research posters presented for display at BSDHT’s annual Oral Health Conference & Exhibition. i think that inclusion of this section provides an opportunity for early researchers to gain additional feedback to that obtained during their poster presentations at the annual meeting, before writing a full paper for submission to the journal. As more individuals are required to undertake a research based project as a component of their undergraduate course, i hope that many students will consider submitting their findings to this journal. Guidelines for authors can be found on the BSDHT website.

Despite the present difficult financial climate there are still, perhaps surprisingly, quite a number of opportunities to attract industrial funding from the larger dental companies to sponsor research. i would advise making contact with representatives from companies at any of the trade exhibitions that you visit. There is no harm in asking.

i hope that the Annual Clinical Journal becomes the vehicle that our profession uses to engage in research activity and as such the publication becomes the platform by which BSDHT demonstrates its commitment to development of evidence-based practise. The papers could well inspire you to consider some aspect of clinical research in an area of activity that you have a particular interest. Please use the contact details provided by corresponding authors to either gain further information or make comments. it is also a lot easier to initiate your own research by contacting and working with others. All researchers welcome feedback and would be more than happy to collaborate with interested colleagues.

As always, i welcome correspondence from readers on any aspect of the journal. in the meantime, i hope that you enjoy the papers presented here and find the content not only a thought provoking aspect of your CPD but that it also inspires you to continue to question our clinical behaviour to ensure that we provide the highest quality treatment to our patients.

Heather Lewis

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Maria P

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it is with great pleasure that i write this Guest Editorial for the Annual Clinical Journal of Dental Health, 2012. Fundamentally, the goal of the journal is to provide a showcase for British Dental Hygienists’ and Therapists’ clinical research. i have been asked to encourage dental hygiene colleagues to get involved in research. What is research? research is the investigation of a particular topic using a variety of reliable, scholarly resources. The three major goals of research are establishing facts, analyzing information, and reaching new conclusions. The three main acts of doing research are searching for, reviewing, and evaluating information1.

The international Federation of Dental Hygienists (iFDH) aims to promote and coordinate the exchange of knowledge and information about the profession, its education, and its practice. One of the 2010-2013 goals of the iFDH is to: “Support the dissemination of research by dental hygienists”, a goal this publication shares. in addition to the iFDH Education and research Committee, we have a research page on our website2. i urge you to visit it!

Dental hygiene research has become an increasingly important aspect of achieving the goal of advancing the art and science of dental hygiene globally. research facilitates the development of new clinical techniques, materials and treatments modalities. it also impacts access to care, education, and public and private policies on oral health. it is incumbent on the profession to increase its involvement in a variety of oral health research initiatives, and support projects that rely on research or statistical expertise.

The American Dental Hygienists’ Association (ADHA) has a National Dental Hygiene research Agenda (NDHrA). This agenda promotes the profession of dental hygiene, and seeks to acquire data that supports the educational goals of the profession, and the public and private policies that advance the profession. The NDHrA provides directions to hygienists on priority research areas that can help advance the profession. it is the hope of the ADHA that the professional community will commit to using the NDHrA to guide research, enhance patient-centred care, improve the quality of services, and foster other professional efforts. You can view the NDHrA, which was updated in 20073.

research career opportunities exist in a variety of settings, such as in the corporate arena, universities, or private research companies. There is even an effort to promote practice-based research. One way to begin this journey is to take courses offered in research methodology, medical terminology, and statistics. You can offer to volunteer to be a research subject or to assist in a clinical trial at your university. research projects in your community, at your school or at local hospitals, are others means of getting involved in research.

There are key databases for dental hygiene research, and basic tools for searching bibliographic databases4. The dhnet serves as the home base for the National Centre for Dental Hygiene research & Practice (NCDHrP or Centre) and is a good connection to research resources that support dental hygiene education, practice and research5. Within each of the sections there are several categories and quick links to major resources for your convenience. Also, each section has links to training programmes, many of which are online and can be accessed at your convenience.

And lastly, i would like to invite you to attend the Dental Hygiene research Meeting “Non Surgical Periodontal Treatment: How to Conciliate Scientific Evidences and Clinical Practice”. Pisa, December 14th -15th 2012.6,7

“Dental hygienists and dental therapists are ideally placed to undertake and support clinical research”.8

Maria Perno Goldie, RDH, MSPresident, International Federation of Dental HygienistsSeminars for Women’s Health

references1. http://www.edison.edu/library/researchskills/Unit1/1whatisresearch.php.2. http://www.ifdh.org/research.html. 3. http://www.adha.org/downloads/research_agenda%20-ADHA_Final_report.pdf. 4. http://research.ewu.edu/dental.5. http://dent-web01.usc.edu/dhnet/.6. E-mail: [email protected]. 7. [email protected] - www.tueor.it. 8. Annual Clinical Journal of Dental Health, No.1, December 2011, page 6.

Guest editorial


Study to measure the clinical effectiveness of a dental hygienist in a cleft lip and palate unit

AbstrAct

objective:To assess the clinical effectiveness of a dental hygienist within a Cleft Lip and Palate Unit by measuring oral hygiene at each visit.

Design:A prospective cohort study with data collected at each visit and plaque recorded using a modified Turesky index. Specific oral hygiene instruction would be given at each appointment.

setting:The dental clinic at the South West Cleft Unit, Frenchay Hospital, Bristol. All consenting patients with a Cleft Lip and/or Palate that were attending the Cleft Unit between September 2010 and September 2011 and were subsequently referred to the dental hygienist.

results:28 patients had a second appointment to allow for comparison. Of these, 23 had a reduction in score, 2 remained the same and 3 increased.

conclusion:Different types of periodontal diseases are prevalent in the cleft population. Oral hygiene improved significantly in most cases after referral to a dental hygienist.

Key words: Cleft lip and palate, dental hygienist, clinical effectiveness, oral health

Rhiannon F Jones

Scott A Deacon

Deborah Franklin

Rosemarie Winter

Authors’ affiliations:

South West Cleft Unit,

Frenchay Hospital

Bristol

BS16 1LE.

Correspondence to:

[email protected]

CLEFT LIP AND PALATE

BackgroundCraniofacial anomalies are amongst the most common of all birth defects.1 The mean prevalence rate of facial clefting in Europe is between 1 in 500-700 births with the ratio of boys to girls being 3:2.2 There are several different types of cleft varying from unilateral cleft lip to a bilateral cleft lip and palate. in addition, it is estimated that up to 21% of clefts occur as part of a wider syndrome.3 Feeding, hearing, speech and the alignment of the teeth are often affected, particularly where a cleft palate is present. The shape of the nose and jaws may be affected and often require surgery as the patient matures.

Although treatment is not continuous, it is punctuated by episodes of intervention by a multidisciplinary team over a 20 year period from birth. The team ideally consists of plastic and maxillo-facial surgeons, specialist nurses, orthodontists, speech and language therapists, audiologists, dentists and clinical psychologists as recommended by the CSAG (Clinical Standards Advisory Group) report 1998. 4

research has shown that patients with clefts present with poorer oral hygiene, greater levels of decay and poorer oral clearance. 5 Children with a cleft lip and/or palate are at a higher risk of development of caries in the deciduous dentition, compared with children without clefts. 6 Children with cleft lip and/or palate present particular characteristics that may influence their oral health. Anatomy of the cleft area, dental anomalies of shape, structure, number and position, and the scar fibrosis secondary to lip surgery impair proper oral hygiene.7

With this knowledge, the South West Cleft Unit decided to appoint a dental hygienist to join their team based at Frenchay Hospital near Bristol. This centre cares for patients from the whole of the south west region. Very few studies have been conducted to assess the effectiveness of a dental hygienist in a cleft team setting. Following the first year in post, the dental hygienist conducted a study to assess the possible effectiveness of her intervention. This study demonstrated that it could be effective but further studies were required.


Statistics Data was recorded using a MS Excel spread sheet and analysis was completed by the audit facilitator using Excel and SPSS.

DemographicsForty five cases were included in the study, including the five non-cleft, craniofacial children. The ratio of boys to girls was 2:1, a slightly higher prevalence rate than the general population. The majority (49%) fell in the 11 – 15 age group. 69% of the cohort had been referred by the lead consultant orthodontist. Of the 40 patients with a cleft, 37 (93%) had palatal involvement, the most predominant cleft type being that of unilateral cleft lip and palate. 11% had a syndrome which is only half of the general cleft population prevalence of approximately 21%.

Oral hygieneThe oral hygiene score was recorded for 42 patients and ranged from 0.7 – 2.8 (the higher the score the poorer the oral hygiene). Of these, 28 had a second visit, with scores ranging from 0.4 – 2.2. in total, 23 of the patients showed a reduction in score from first to second appointment, two remained the same and three increased. There was a statistically significant difference in score as indicated by the Wilcoxon test (p < 0.05).

Dental diseaseA total of 23% of cases presented with gingival inflammation. 42% presented with bleeding on

A disclosed mouth. Note the mixed dentition and low lip line. (Hygienist’s own, consented photograph)

Mouth with the lowest overall score of 0.4 (4%). Note the obvious difficulties in effective oral hygiene. (Hygienist’s own, consented photograph)

A disclosed mouth in upper fixed appliance therapy in an attempt to expose a buried canine. (Hygienist’s, own consented photograph)

MethodThe study ran for approximately one year. The objectives were to measure and record oral hygiene at each visit using a modified version of a recognised and well established index. The Turesky modification of the Quigley – Hein was adapted for it to be more suitable for use with cleft patients as they commonly have missing or heavily restored teeth. The aim was to calculate the difference between visits and compare. Other data was collected such as brushing frequency and fluoride use.

The dental hygienist was assisted by the lead consultant orthodontist and the consultant in paediatric dentistry, who provided advice and guidance, and two specialist dental nurses. The dental hygienist holds two sessions per week with chair side assistance and sees approximately four to six patients per session. A criterion for inclusion in this study was any consenting patient attending the hygienist’s clinic. referrals came from the consultant orthodontist, paediatric dentist and the maxillo-facial surgeon of the cleft team. Patients were seen and then recalled three months later.Prior to the appointment each patient was given a qualitative questionnaire to complete in the waiting area. They had the option to remain anonymous and the questionnaires were collected and collated by the audit facilitator at North Bristol NHS trust. Once in surgery, a series of questions was asked by the hygienist in an interview. Questions included; registration with a GDP, brushing habits, bleeding on brushing and product preferences. An intra-oral examination was carried out which recorded mobility, bleeding and inflammation.

The teeth of each patient were disclosed using a two tone solution and the patient was shown the results in a mirror. With the aid of the dental nurse a score was given for both the buccal and lingual/palatal surface of each tooth using the modified index. These scores were added up and calculated. The final score was discussed with the patient and recorded in the notes. Specific instructions were given with regards to improving oral hygiene and suitable products were provided thanks to the generosity of many companies. There were some caveats to be considered: a few patients were unwilling to be included and some were unable due to time restraints; five patients were craniofacial but non-cleft and some had been seen previously, which will have affected the results to some degree.

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probing at their first visit and 38% had noticed some bleeding on brushing. 11% of adults had some sign of active periodontal disease even though they were seen regularly by their general dental practitioner. 67% used a manual toothbrush, 18% an electric and the remainder used a combination of the two. 20% were only brushing once a day and two patients admitted that they did not brush every day. The majority of patients were using a high fluoride toothpaste but not using interdental aids. Other findings were that 44% were seen outside of the Cleft Unit by a dentist but 76% had never seen a dental hygienist before.

A more worrying incidental finding was that 73% of children under the age of 14 years had no parental support, supervision or verbal reminder to brush their teeth.

The qualitative questionnaire demonstrated that patients were more comfortable about visiting the hygienist if the referring clinician had explained the purpose of the visit. All patients were less anxious at the second visit.

DiscussionA literature review was conducted to determine what other studies had been completed on dental hygienists’ intervention with cleft patients. The search yielded one pilot study, conducted by Juliana Brasil of the University of Sao Paulo, Brazil in 2007.8 This study concluded that an oral hygiene programme seems to be effective. it also concluded that more research in this area was required.

Cleft children often have more treatment, such as surgery and orthodontics and are more at risk of dental diseases. High risk patients should be identified and suitable preventative advice and treatment provided. This study highlighted the lack of parental involvement at home. it was hoped that the results would offer direction on the most effective clinical techniques and the most sensible use of clinic time.

The results may have been affected by the fact that some of the patients included in this study had previously seen a dental hygienist. Their first score may have been lower to begin with or the advice they previously received may have enabled them to improve their oral hygiene more effectively than others. Overall the results were statistically significant but do indicate that more research in this area is required.

Recommendations The study should be continued and the patients reassessed after one year in order to determine whether the improvement has been sustained and if not, how this could be best addressed. it is hoped that the results will also enable an effective recall interval to be implemented.

Parental involvement, both at home and at clinic appointments, has a positive impact on children’s oral hygiene and should be encouraged.

This study confirmed the value of having a dental hygienist in the cleft team and this post has been recommended to other cleft networks, as most do not currently employ such.

The findings were presented at the Annual Tri-centre Conference of Regional Cleft Networks and the Paediatric Dentistry SIG (special interest group) at Guys, London in 2011. It was accepted and displayed at the Great Britain and Irelands Craniofacial Society Annual Conference 2012 as a poster presentation.

References1. reiter r, Haase S, Brosch S. Oro-facial clefts. Laryngorhinootololgie

2012; 91(2): 84-95.

2. Sohan K, Freer M, Mercer N et al. Prenatal detection of facial clefts. Fetal Diagn Ther 2001; 16(4): 196–99.

3. Fitzsimmons KJ, Mukarram S, Copely LP et al. Centralisation of services for children with cleft lip or palate in England: a study of hospital episode statistics. BMC Health Serv Res 2012; 12(1): 148.

4. Sandy J, Williams A, Mildinhall S et al. The Clinical Standards Advisory Group (CSAG) Cleft Lip and Palate Study. Br J Orthod 1998; 25(1): 21-30.

5. Ahluwalia M, Brailsford Sr, Tarelli E et al. Caries, oral hygiene and oral clearance in children with craniofacial disorders. J Dent Res 2004; 83(2): 175-9.

6. Johnsen DC, Dixon M. Dental caries of primary incisors in children with a cleft lip and palate. Cleft Palate J 1984; 21(2): 104–109.

7. Mc Donagh S, Pinson r, Shaw AJ. Provision of general dental care for children with cleft lip and palate–parental attitudes and experiences. Br Dent J 2000; 189(8): 432– 34.

8. Brasil JM, de Almeida Pernambuco r, da Silva Dalben G. Suggestion of an oral hygiene program for orthodontic patients with cleft lip and palate: findings of a pilot study. Cleft Palate Craniofac J. 2007; 44(6):

595-7.

Graph to demonstrate difference between first and second appointment. Y axis = Modified Turesky score X = Patient identification number.1st appointment = ( M = 1.84, SD = 0.43), 2nd appointment = (M = 1.32, SD = 0.27, p < 0.05)

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Bulimia nervosa: The role of the dental hygienist in the care of the bulimic patient

Alison Lowe


Orthodontic DepartmentUniversity Dental HospitalHeath Park Cardiff

CF14 4XY

Correspondence to:

[email protected]

BULIMIA NERVOSA

Introductionit is estimated that 6.4% of people in the UK suffer from an eating disorder and of these 40% are bulimic1. it is generally agreed that society’s preoccupation with body image and thinness has resulted in an increased prevalence of this disorder. Although raised awareness of such problems promotes the misconception that they are new, evidence from historical references and detailed case studies suggest that bulimia was documented as early as the mid-18th century. indeed, the disease is referred to in The Talmud –a collection of Jewish law which is thousands of years old 2.

Bulimia literally means ‘ox-hunger’ which is an accurate description of this abnormal craving for food. Bulimic rituals include eating large amounts of food followed by attempts to eliminate it from the body to avoid weight gain. The bulimic individual will employ a variety of methods in order to do this, including self-induced vomiting, use of enemas or diuretics and excessive exercise. Most health professionals are aware of the compulsive behaviour associated with this debilitating disease, and yet only a small percentage of patients are ever diagnosed3. This is

AbstrAct

Aim:To outline the diagnostic features and characteristics of bulimia nervosa and the impact of bulimic rituals on oral health. To consider the role of the dental hygienist in both preventing and managing the harmful effects of this psychiatric eating disorder and improve our understanding of the role the dental hygienist can play in the management of the bulimic patient.

objectives:• Identifyoralmanifestationsassociatedwithbulimia• Describesystemiccomplicationsthatcanariseassequalaetobulimicbehaviour• Outlinedentalhygieneinterventionstobeconsideredformanifestationsassociated with this eating disorder• Discusspsychologicalandphysicalcharacteristicsofthebulimicpatient• Valuetheroleofthehygienistinidentificationandreferralofpatientswitheatingdisorders.

Materials and methods:A systematic literature review of recent English language publications using the Medline Database.

results:The literature review revealed many papers relating to psychiatric disorders but few specific to bulimia nervosa. The results indicate that the dental team are often the first to identify bulimia nervosa based on clinical evidence and that dental hygienists have a key role in highlighting the oral implications of this debilitating condition.

conclusion:During the course of their careers dental hygienists are likely to encounter many patients who are battling eating disorders such as bulimia. Having an understanding of this condition may well be fundamental in ensuring successful treatment outcomes.

Key words: Bulimia nervosa, dental hygienist

attributed to the fact that their compensatory behaviours do not get rid of all the extra calories consumed and therefore, unlike anorexics, typical bulimics are of normal weight, appear healthy and also go to great lengths to protect and deny their purging behaviour, all of which makes diagnosis difficult. However, because the oral manifestations of bulimia are often so apparent dental professionals are in a prime position to address this multi-disciplinary pathology that has such severe oral and systemic ramifications4.

The role of the dental hygienistOf all the eating disorder rituals, those who purge through vomiting display the most obvious oral signs. There is evidence to suggest that provided they have the knowledge dental hygienists are adept in recognising these symptoms and discussing eating disorders with their patients5. Their ability to explain the aetiology of bulimia, oral complications and physical complications, whilst encouraging the patient to seek help, may be fundamental to successful treatment of the disease.

Diagnostic criteriaDiagnosis of bulimia is made on clinical grounds. The


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SCOFF screening tool, developed by Professor John Morgan at Leeds Partnership NHS Foundation Trust, can be helpful in indicating a possible problem as can use of the GErD questionnaire6. Criteria include:

• Eatingmorethanmostpeopleinashort period of time• Ritualisticeatinghabits-alternatingfood gorging with discrete evidence of purging (such as disappearing after meals)• Asenseoflossofcontroloverbehaviouranda consistent concern with body image and weight• Excessiveexercise• Engagingininappropriatecompensatory behaviours to prevent weight gain, such as self- induced vomiting or misuse of laxatives, diuretics, enemas or other medications (purging)• Persistentconcernsaboutbodyshapeandweight

Oral complicationsThe oral and facial signs and symptoms associated with bulimia are largely the result of self-induced vomiting and the consequent action of hydrochloric acid regurgitated from the stomach into the mouth. Other complications are usually as a result of actions taken to induce vomiting (i.e. swallowing items such as spoons and toothbrushes).

Oral characteristics• The most consistent sign of bulimia is Perimolysis (erosion)7. Erosion can occur after six months of regular vomiting although the severe levels of erosion characterising perimolysis are often only evident after two years8. Typically it follows a distinctive pattern tending to occur on surfaces that have maximum exposure to the regurgitated acid; the palatal surfaces of the upper teeth and the occlusal surfaces of the lower posterior teeth (this is easily distinguished from erosion arising from other causes). Subsequent mechanical erosion then occurs when the tongue or toothbrush moves against the teeth.• Painless parotid gland enlargement - sialosis (indicative of self- induced vomiting) often referred to as nutritional mumps.• Varicositiesbeneaththedorsumofthetongue9

• Palatalpetechiae• Commissure lesions (resembling angular cheilitis) /dry cracked lips• Attrition/abrasion• Palataltrauma• Trauma to the teeth and soft tissues can occur if an individual is using objects to induce vomiting. The gag reflex often becomes desensitised as a result of repeated self-induced vomiting which results in individuals pushing objects further down the throat to induce retching. There is literary evidence of injuries caused by foreign objects including toothbrushes that have been used for this purpose as well as reports of accidental swallowing of objects10.• Thermal sensitivity (as a result of exposed dentine following erosion of the enamel layer)• Attrition• Anterior open bite (often with pitted or

sheared incisal edges)• Absenceoftoothstain• Distinguishedtaste(acuity)• Raisedappearanceofrestorations• Smooth and dished out appearance of lingual surfaces of teeth• Dry mouth and anomalous symptoms that are related to dry mouth e.g. problems chewing and swallowing, difficulty speaking and sore gums (often as a result of excessive vomiting, diuretic or laxative abuse). Patients undergoing psychiatric or psychological treatment for eating disorders are often prescribed medication such as Selective Serotonin re-uptake inhibitors (Sris) of which xerostomia is a common side effect. • Soft tissue lesions – nutritional deficiencies often have oral presentations i.e. Vitamin B deficiency is associated with recurrent aphthous ulceration, Vitamin C and or iron deficiency with bleeding gums and Vitamin B12 with glossitis11

• Oropharyngealinflammation• Increased caries as a result of two factors- a dysfunction of the parotid glands and associated lack of saliva and eventual systemic dehydration, leading to a lowered buffering capacity and the frequent ingestion of sugars during binges. Some studies have shown that individuals with eating disorders have higher than expected levels of dental caries but the most comprehensive review to date suggests that individuals with eating disorders are at no greater or lesser risk of dental caries12: it is likely that the theoretical caries risk is balanced by oral hygiene related behaviours.

Systemic factorsThe effects of bulimia on the general well-being of an individual are significant. Possible health complications include: • Hypotension• Hypokalaemia• Lowpulserate• Hypothermia• Peripheralcyanosisandcoldnesswithbrachycardia• Esophagitis• Reflux• Pancreatitis• Gastricrupture• Electrolyte imbalances (which may result in cardiac arrest)13

• Endocrineimbalances• Menstrualdysfunctionorirregularities• Urinaryinfections• Renaldamage• Cardiomyopathy/cardiacarrest -10%ofuntreated bulimics suffer from cardiac arrest. it is particularly common following misuse of ‘Syrup of ipecac’, an emetic thought to be responsible for Karen Carpenter’s death in 198314

• Peripheralmyopathy• Constipation/abdominalpain

Physical characteristics• Abrasions on finger knuckles (Russell’s sign)


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which occur as a result of repeated self-induced vomiting (it is estimated that between 8 & 29% of bulimics exhibit abrasions)3

• Bloodshoteyes

Psychosocial factorsEating disorders often co-exist with psychiatric problems such as: • Depression• Anxietydisordersincludingfeelingsofpersonal helplessness, loss of control and low self esteem Many sufferers have a family history of alcoholism and disturbed interpersonal relationships which may occur as a result of a failure to progress through appropriate developmental stages during childhood and adolescence3. The typical bulimic is female, from an upper socioeconomic stratum and adolescent, although it now affects an increasing number of older women. Just 1% of diagnosed bulimics are male.

Dental managementAwareness of the psychodynamics of eating disorders is critical when treating the bulimic patient. if dental erosion is the most obvious finding, asking questions that eliminate other possibilities for tooth wear permit the dental hygienist to gain valuable information whilst acclimatising the patient to more direct questions. However, it is important to ensure that confidentiality is maintained whilst meeting oral health needs.

Once tooth surface loss has been diagnosed, the primary goal is to prevent further loss of tooth structure. This involves:1. Advice about the deleterious effects that repeated vomiting has on the oral cavity and health in general.2. Demonstration of prominent intra-oral findings (using hand mirror/intra-oral camera)3. Advice on protective mechanisms for the teeth including: •Provisionofamouthguardtowearduringpurging4

•Avoidance of toothbrushing following vomiting to inhibit erosion and abrasion of hard tooth structures •Pitandfissuresealantsifappropriate •Study models to monitor progression of tooth structure loss •Rinsingwithasolutionofsodiumbicarbonate, magnesium hydroxide (milk of magnesia) or slightly alkaline mineral water to raise the pH level in the mouth immediately post-vomiting •Daily rinse with a neutral pH 0.5% sodium fluoride rinse (home fluoride use is proven to be effective in reducing sensitivity)7 • If the patient has a dry mouth, they can be advised to chew on sugar free mints, gum or paraffin wax to stimulate salivary flow (the patient should be reassured that they have no calorific value) •Applicationoftopicalfluoride •Useofinterdentalcleaningaids •Useofasofttoothbrushandarecommended fluoridated, non-abrasive, desensitising toothpaste •Local anaesthesia may be required for scaling •Selective polishing or use of a low abrasive

polishing agent should be considered when patients have had extensive enamel erosion resulting in dentine exposure10

•Nutritional counselling - diet advice including the importance of decreasing erosive foods i.e. fizzy drinks, citrus fruits •Regular dental hygienist appointments (due to compromised hard tissues and the importance of reinforcing an effective oral hygiene regime) are important. Bulimics often respond positively to specific oral hygiene instructions as it gives them a feeling of control over one aspect of their life.

ConclusionSuccessful treatment of bulimia involves intensive therapy followed by several years of aftercare. The dental team need to be aware that patients may relapse and for this reason complex restorative treatment should be avoided until purging behaviours are controlled. Continual evaluation of the patient’s oral health status is therefore critical when maintaining the bulimic patient - this may call for liaison with their medical team since patients frequently over or under-estimate their recovery. it is important that we avoid placing emphasis on the value of thinness with all patients and instead focus on the importance of a healthy well balanced diet.Finally, the effects of bulimia can be life threatening. Therefore, we have an ethical duty to broach the subject with a patient who has obvious signs of an eating disorder and recommend referral for medical or psychological care.

DiscussionAs a profession we frequently encounter patients who have a suspected bulimic condition. improving our knowledge of this debilitating illness will not only give us a better understanding of appropriate educational and clinical interventions but may also provide the opportunity to liaise with other health professionals who can offer lifesaving therapies to the bulimic patient.

References1. About Eating Disorders. www.b-eat.co.uk

2. Bouquot JE, Seime rJ. Bulimia nervosa: dental perspectives. Pract Periodontics Aesthet Dent. 1997; 9(6): 655-63.

3. Fellona MO. A rare case of a male bulimic patient – identification, education and referral. Oral-B Case Studies in Dental Hygiene. Vol. 1, No 2, Fall 2003.

4. McCreedy KS. Bulimia and its implications for oral health. November 2006 ADHA Publications.

5. Ashcroft A, Milosevic A. The eating disorders 1. Current scientific understanding and dental implications. Dent Update. 2007; 34(9): 544-54.

6. The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ 1999; 319 doi: 10.1136/bmj.319.7223.1467 (Published 4 December 1999) http://www.bmj.com/content/319/7223/1467.full

7. Newton T, Travess H. Eating disorders: diagnosis, prevention and management. Preventive Dentistry. 2006; 1(1): 17-19.

8. Altshuler BD, Dechow PC, Waller DA. et al. An investigation of the oral pathologies occurring in bulimia nervosa. International Journal of Eating Disorders. 1990; 9: 191-199.

9. Studen-Pavlovich D, Elliott MA. Eating disorders in women’s oral health. Dent Clin North Am. 2001; 45(3): 491-11.

10. Darby ML, Walsh MW. Dental Hygiene Theory and Practice. London: W.B. Saunders Company 1994.

11. Faine MP. recognition and management of eating disorders in the dental office. Dent Clin North Am 2003; 47(2): 395-410.

12. Scully C. Aspects of human disease. Dent Update. 2010; 37(5): 341-43.

13. roberts MW, Li SH. Oral findings in anorexia nervosa and bulimia nervosa: a study of 47 cases. J Am Dent Assoc. 1987; 115(3): 407-10.

14. Schmidt r. Karen Carpenter’s tragic story. The Guardian 24th Oct 2010.


Determining the best method of applying CPP-ACP containing pastes and fluoride to eroded enamel in order to limit the amount of tooth wear in vitro

Alison Chapman

Nicola X West

Siân Bodfel Jones


Clinical Trials GroupSchool of Oral and Dental SciencesUniversity of BristolBristolUK

Correspondence to:

[email protected]

TOOTH WEAR

AbstrAct

Aim:The aim of this study was to determine how effective different ways of applying two CPP-ACP containing pastes and fluoride to pellicle coated enamel are at reducing tooth wear.

Methods:Human enamel specimens were immersed in 14 mM citric acid for 10 minutes prior to developing a 2 h pellicle. Four treatment solutions were investigated (tooth mousse, GCMi paste plus, 225 µg/g fluoride and artificial saliva). Treatment solution was applied either by soaking, rubbing or brushing onto the specimen surface for 3 minutes. Specimens were soaked in citric acid for a further 10 minutes and the cycle repeated five times. The amount of tissue loss was measured using non-contact profilometry following the first, third and fifth cycle.

results:Applying treatment solution by soaking showed a significant (p<0.05) reduction in tooth wear for specimens treated with fluoride and GCMi paste plus. There was no significant difference in the amount of tooth wear following any of the three applications when treated with Tooth Mousse or Artificial Saliva. Treatment with fluoride presented the least amount of tooth wear irrespective of the application method.

conclusion:This study provides useful advice to patients who are susceptible to tooth wear in that applying by soaking or swishing causes the least amount of tooth wear.

Key words: Fluoride, CPP-ACP, erosion

IntroductionDental erosion is defined as the loss of tooth substance by chemical processes (acid exposure) not involving bacteria. Acid attack can lead to irreversible loss of dental hard tissue, and or softening. This softened zone is more susceptible to mechanical forces, such as abrasion. The chemical and mechanical processes can occur individually or together often resulting in tooth wear. Tooth wear from erosion has been an issue concerning dental professionals for many years. in the 2003 child dental health survey it was noted that 33% of 15 year olds had evidence of erosion affecting their permanent molar teeth surfaces 1.

The mechanism of dental erosion is more aggressive on the enamel surface than the mechanism that causes dental caries. Caries develops as a consequence of demineralisation that takes place sub surface, whereas an erosive attack causes demineralisation of the enamel surface. Dental erosion softens the enamel surface making it very susceptible to mechanical forces 2.

Fluoride is widely used for the prevention of caries because it can incorporate into the hydroxyapatite structure making enamel less soluble, as well as forming calcium fluoride on the enamel surface. As erosion has a different mechanism it cannot be assumed that fluoride will have the same effectiveness against tooth wear. Previous studies investigating the effectiveness of fluoride on reducing erosion have found that toothpastes and mouthrinses containing fluoride have a limited effect on the erosive process3 and that high quantities of sodium fluoride4 or pastes containing stannous or amine fluoride5 may be required to provide a protective effect. Due to the limited effect of fluoride, the industry still seeks other forms of treatment to supplement fluoride or replace it completely. To this end newer products are being developed and examples of such products currently on the market are GC pastes containing casein phosphopetide-amorphous calcium phosphate (CPP-ACP). GC Tooth Mousse contains 10% CPP-ACP whereas GCMi Paste Plus contains 10% CPP-ACP as well as 900 µg/g fluoride. There are several publications that highlight the remineralising potential of


CPP-ACP using caries models 6-8. CPP-ACP provides a source of bioavailable calcium and phosphate at the enamel surface that act as a reservoir to remineralise demineralised enamel. Previous work has also been carried out to investigate the effectiveness of CPP-ACP on reducing enamel erosion and tooth wear9-11.The GC marketed pastes are not conventional daily use toothpastes and are specifically recommended for use with patients who demonstrate a potential problem of demineralisation. recommended methods of using the paste are to apply it by rubbing a finger over the demineralised area and leave in place overnight, fill a plastic stent tray to wear overnight or, for an orthodontic patient wearing fixed appliances, to swish the paste in between the orthodontic brackets. it is very difficult to maintain good oral hygiene in areas around orthodontic appliances and therefore the area is more easily demineralised due to a reduced flow of saliva 12.

AimThe aim of this study was to identify any differences in the potential of CPP-ACP containing pastes and fluoride solution to reduce the amount of tooth wear when applied using three different application techniques to pellicle coated enamel.

Materials and methodsSpecimen preparation A total number of 72 specimens were prepared using human enamel from extracted 3rd molars which were checked visually for defects, demineralisation and extraction damage. The crowns were obtained from an ethically approved human tissue bank (NHS rEC ref: 11/Ni/0145) collected following HTA (Human Tissue Authority) guidelines. Specimens were sectioned from crowns using a water cooled high-speed diamond saw (MicroSlice, Metal research, Cambridge, UK). The specimens were sectioned into 3 × 2 mm sections. Each section was mounted in Stycast resin (Hitek Electronic Materials, Scunthorpe, UK) and polished using silicon carbide (SiC) discs followed by 3 µm SiC grit powder and finished by

polishing with 0.3 µm alumina powder to ensure a smooth, flat surface. Specimens were ultrasonicated in deionised water following each polishing stage to remove polishing debris. Each specimen was scanned using a non-contact profilometer (Proscan 2000, Scantron, Taunton, UK) to ensure that the surface was flat within the range of ±3 µm over a 2 × 1 mm area. Both ends of the specimen were covered with tape leaving a window approximately 1 mm in width.

Saliva collectionStimulated saliva was collected using an ethically approved saliva bank (rEC ref: 08/H0606/87) where healthy donors had provided informed written consent. Donors were supplied with a piece of Parafilm to chew and expectorate into a universal pot. The saliva was pooled and used as whole saliva.

Experimental All specimens were immersed in 14 mM citric acid gently stirred at 100 rpm using an orbital shaker (Bibby Scientific Limited, Staffordshire UK) for 10 minutes at 36 ºC to form a softened enamel surface. The specimens were then rinsed in deionised water before being gently stirred at 100 rpm using an orbital shaker in pooled stimulated whole human saliva for 2 hours at 36 ºC to form an acquired pellicle. Specimens were again rinsed in deionised water. Three groups of six specimens were allocated to four different treatment solutions. The four different treatment solutions were GCMi paste plus, Tooth Mousse, 225 µg/g fluoride solution (as sodium fluoride) and artificial saliva (0.103 g L-1 calcium chloride dihydrate, 0.019 g L-1 magnesium chloride anhydrous, 0.544 g L-1 potassium dihydrogen phosphaste, 4.77 g L-1 HEPES buffer (acid form), 2.24 g L-1 potassium chloride, 1.80 ml of 1mol hydrochloric acid and enough potassium hydroxide to attain pH 6.8). The pastes were used as a 1:3 slurry with artificial saliva. The four treatment solutions and the application methods are highlighted in Table 1. Each treatment solution was applied to the specimens in three different ways. The specimens that were soaked in solution were placed in 20 ml of solution in a 100 ml beaker and placed

Table 1. Treatment

solutions and its means of

application to the specimen surface. N=6

for each application within each

treatment group.

treatment groups Application

GCMi paste plus(GC, Buckinghamshire, UK)

Active ingredients: CPP-ACP and 900 µg/g F

Soaking

Brushing

Finger rubbing

GC tooth mousse(GC, Buckinghamshire, UK)Active ingredients: CPP-ACP

Soaking

Brushing

Finger rubbing

225 µg/g Fluoride (NaF) in Artificial Saliva

(All ingredients; SigmaAldrich, Dorset, UK)

Soaking

Brushing

Finger rubbing

Artificial Saliva

Soaking

Brushing

Finger rubbing

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onto an orbital shaker (Bibby Scientific Limited, Staffordshire UK) set at 100 rpm for 3 minutes. The brushed specimens were mounted in a custom built brushing machine with enough slurry to cover them and brushed using an Oral B advantage 30 (Procter and Gamble, Surrey, UK) tooth brush (180 times over a 3 minute period with an evenly applied weight of 200g. The brushing stroke was in line with the applied tape to reduce danger of removal. During application by rubbing, the specimen was held in place at the bottom of a weighing boat using sticky wax. 20 ml of treatment solution was added and a finger wearing clean laboratory gloves was used to rub the specimen surface. The force used to apply the paste by rubbing was standardised by using a balance to weigh the force being applied. The force used was approximately 200g.

Following treatment, the specimens were rinsed with deionised water and immersed in 20 ml of 14mM citric acid in a 100 ml beaker and gently agitated on an orbital shaker at 100 rpm for 10 minutes at 36 ºC. The specimens were rinsed with deionised water following acid exposure and the tape removed.

MeasurementThe amount of tooth wear was measured using non-contact profilometry. The difference in height between the control areas and the base of the eroded area was recorded following the second acid exposure. The above cycle of exposure to saliva, treatment solution and citric acid was repeated for five cycles in total and the amount of tooth wear was also recorded following the third and fifth cycle.

Statistical analysisStatistical comparisons were made using iBM SPSS version 19. Following a Levene test of homogeneity, a one way analysis of variance was carried out comparing the amount of tooth wear following the three different ways of applying a single solution. A one way analysis of variance was also carried out to compare the amount of tooth wear from each of the four solutions following one application method. Tukey post hoc test was performed in each case where significant differences are quoted where p < 0.05.

ResultsFollowing the first cycle, there was no significant difference in the amount of tooth wear between any of the application methods apart from following application by soaking in fluoride solution, which was significantly less than when applied by brushing (p=0.029) and that soaking in GCMi paste plus was significantly less than when applied by both brushing and rubbing (p=0.004 and 0.001 respectively).

Following the third cycle, there were no significant differences in the way that the treatment solutions were applied apart from that the amount of tooth wear following soaking in GCMi paste plus was again significantly less than when applied by both brushing and rubbing (p<0.001 for both).

Application by soaking

Application by brushing

Application by rubbing

cycle 1 3.76 (0.64) 5.18 (0.42) 5.28 (0.69)

cycle 3 19.23 (1.74) 26.56 (1.23) 24.58 (2.38)

cycle 5 32.88 (4.45) 46.21 (2.81) 39.57 (3.32)




cycle 1 6.79 (1.52) 5.86 (1.00) 6.11 (0.65)

cycle 3 21.11 (1.77) 20.83 (3.89) 23.08 (2.67)

cycle 5 35.32 (2.91) 39.26 (5.10) .03 (4.79)




cycle 1 3.09 (0.55) 4.86 (1.68) 4.17 (0.25)

cycle 3 16.06 (2.85) 18.89 (2.26) 16.98 (2.08)

cycle 5 29.59 (2.32) 36.87 (2.15) .25 (5.20)




cycle 1 5.56 (0.45) 6.61 (0.99) 5.60 (0.19)

cycle 3 22.69 (2.57) 25.71 (2.30) 22.78 (9.39)

cycle 5 40.16 (2.98) 42.89 (3.34) 41.75 (3.07)

Table 2. Amount of tooth wear recorded in µm following exposure to a) GCMI paste plus, b) Tooth Mousse, c) 225 µg/g Fluoride Solution and d) Artificial Saliva using various application methods. Standard deviations shown in brackets. a) GCMI paste plus

b) Tooth Mousse

c) 225 µg/g Fluoride Solution

d) Artificial Saliva

Again, following the fifth cycle there were no significant differences between the amount of tooth wear following the different applications when treated with either tooth mousse or artificial saliva. Specimens that were treated with fluoride solution showed that the amount of tooth wear following soaking was significantly less than following brushing (p=0.007). Specimens that were treated with GCMi paste plus showed that the amount of tooth wear following application by soaking was significantly less than following rubbing (p=0.015), which was also significantly less than following application by brushing (p=0.015).

The amount of tooth wear recorded following soaking the specimens in different treatment solutions showed that treating the specimens with fluoride solution presented the least amount of surface loss followed by GCMi paste plus following each cycle but these were not significantly different to each other. Soaking the specimens in fluoride solution showed significantly less tooth wear than soaking the specimens in tooth


Alison

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mousse or artificial saliva.Brushing the specimens in different treatment solutions showed that the amount of tooth wear was smallest following brushing in fluoride solution but following the first cycle, this was not significantly

different to any of the other treatment solutions. Following the third and fifth cycles, brushing the specimens with fluoride showed significantly less tooth wear compared to when brushed with GCMi paste plus and artificial saliva.

rubbing the specimens in different treatment solutions again highlighted that treatment with fluoride showed the least amount of tooth wear, which was significantly less than rubbing with all other treatment solutions apart from rubbing with GCMi paste plus following 5 cycles.

The amount of tooth wear recorded following each treatment solution and each application method are highlighted in Table 2 and in Figure 1.

DiscussionThis study investigated the erosion reducing potential of CPP-ACP containing pastes and fluoride solution using various application methods. Application by soaking showed a significantly lower amount of tooth wear when compared to the two other applications when treated with either fluoride solution or GCMi paste plus. Application by soaking was the least aggressive method as both rubbing and brushing could physically damage the already softened enamel surface, which could have led to the greater amount of tooth wear recorded. Prior to exposure to the treatment solutions, the specimens were soaked in whole human saliva to develop an acquired pellicle. Pellicle itself has previously been found to reduce the rate of erosion13,14 and that a pellicle developed over two hours has the potential to significantly reduce the amount of erosion measured15.

An undisturbed pellicle could protect the enamel surface to a greater degree than a brushed pellicle, as brushing does effect the thickness of the pellicle layer16. Brushing or rubbing and damaging the pellicle surface could allow CPP-ACP and fluoride

Figure 1. Amount of tooth wear

for each treatment

solution following a)

application by soaking, b)

application by brushing and c) application

by rubbing.

a) Soaking

b) Brushing

c) Rubbing


Alison

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to penetrate the softened enamel easier than when the pellicle was left undisturbed during soaking. in this study there was no evidence that brushing or rubbing the pellicle allowed any benefit in allowing ions to diffuse through to the hydroxyapatite with greater ease. it is therefore concluded that soaking was the most effective way of applying the treatment solutions whilst limiting the amount of tooth wear experienced.

Fluoride as well as calcium and phosphate are ions that interact with hydroxyapatite to remineralise or strengthen the demineralised surface following acid attack. CPP-ACP forms a reservoir of bioavailable calcium and phosphate at the enamel surface that has the potential to diffuse into the enamel surface to remineralise the surface. Fluoride also has the ability to diffuse into the porous enamel surface but can also protect the enamel surface as it forms calcium fluoride. Calcium fluoride is effective at reducing erosion by preventing the protons from an acid attack reaching the enamel surface as well as forming a reservoir of fluoride to penetrate into the hydroxyapatite to form a less soluble fluorapatite surface3. The results from this study showed that irrespective of the application technique, the least amount of tooth wear was observed when specimens had been treated with a solution of sodium fluoride. This is in agreement with a previous study5 that also found fluoride in the form of sodium fluoride at a similar concentration was able to reduce the amount of mineral loss. The GCMi paste plus also contained 900 µg/g fluoride as sodium fluoride but as the specimens were treated with a paste slurry rather than the paste, the fluoride concentration was reduced to 225 µg/g. A previous study by Wang et al10 also investigated the erosion reducing potential of tooth mousse and GCMi paste and found that after acidifying the paste and detecting the amount of available fluoride the total available fluoride was only 445 µg/g, which when extrapolated to this study suggests that only approximately 100 µg/g of fluoride was available from the GCMi paste plus slurry. The low level of fluoride could explain why there was no significant difference between Tooth Mousse and GCMi paste plus than there was for the 225 µg/g fluoride solution.

There was only one incidence where the amount of tooth wear following treatment with Tooth Mousse was significantly reduced when compared to the negative control of artificial saliva. This was following three cycles of application by rubbing. Currently, there is no explanation for this result so it is concluded that under the limitations of this study, Tooth Mousse was no more effective than artificial saliva at reducing tooth wear, irrespective of the application method and it was only following application by soaking after the first cycle that GCMi paste plus performed significantly better than Tooth Mousse. This result is in agreement with previous research10,11 that could also not detect any erosive reducing potential of CPP-ACP in vitro. Previous studies have found that CPP-ACP is effective in reducing enamel erosion when added to beverages17,18 or when investigated in situ19

ConclusionWithin the limits of this in vitro study, soaking specimens was shown to be the most effective method of applying solution to pre softened enamel to limit the amount of tooth wear. A 225 µg/g fluoride solution was found to be more effective than the CPP-ACP containing pastes at reducing tooth wear. This result is especially important to patients who are susceptible to tooth wear so that they understand the best method of applying oral care products to limit the amount of tooth wear that could be caused.

References1. Lader D, Chandwick B et al. Children’s Dental Health in the United Kingdom, 2003; Summary report. Office for National Statistics, 2005. http://www.dh.gov.uk/prod_ consum_dh/groups/dh_digitalassets/@dh/@en/documents/ digitalasset/dh_4107310.pdf Accessed 27 August 2012.

2. Lussi A. Erosive tooth wear – a multifactorial condition of growing concern and increasing knowledge. Monogr Oral Sci 2006; 20: 1-8.

3. Magalhães AC, Wiegand A, rios D et al. Fluoride in dental erosion. Monogr Oral Sci 2011; 22: 158-170. Epub 2011 Jun 23

4. Ganss C, Klimek J, Brune V et al. Effects of two fluoridation measures on erosion progression in human enamel and dentine in situ. Caries Res 2004; 38(6): 561-66.

5. Ganss C, Schlueter N, Hardt M et al. Effect of fluoride compounds on enamel erosion in vitro: a comparison of amine, sodium and stannous fluoride. Caries Res. 2008; 42(1): 2-7. Epub 2007 Nov 27

6. reynolds EC. remineralization of enamel subsurface lesions by casein phosphopeptide-stabilized calcium phosphate solutions. J Dent Res 1997; 76(9): 1587–95.

7. Cai F, Manton DJ, Shen P et al. Effect of citric acid and casein phosphopeptide-amorphous calcium phosphate to a sugar- free chewing gum on enamel remineralization in situ. Caries Res 2007; 41(5): 377–83.

8. Cochrane NJ, Saranathan S, Cai F et al. Enamel subsurface lesion remineralisation with casein phosphopeptide stabilised solutions of calcium, phosphate and fluoride. Caries Res. 2008; 42(2): 88-97. Epub 2008 Jan 15.

9. rees J, Loyn T, Chadwick B. Pronamel and tooth mousse: an initial assessment of erosion prevention in vitro. J Dent. 2007; 35(4): 355-7. Epub 2006 Nov 20.

10. Wang X, Megert B, Hellwig E et al. Preventing erosion with novel agents. J Dent. 2011; 39(2): 163-70. Epub 2010 Nov 30.

11. Wegehaupt FJ, Attin T. The role of fluoride and casein phosphopeptide/amorphous calcium phosphate in the prevention of erosive/abrasive wear in an in vitro model using hydrochloric acid. Caries Res 2010; 44(4): 358-63. Epub 2010 Jul 29.

12. Sudjalim Tr, Woods MG, Manton DJ et al. Prevention of demineralization around orthodontic brackets in vitro. Am J Orthod Dentofacial Orthop. 2007; 131(6): 705. e1-9.

13. Amaechi BT, Higham SM, Edgar WM et al. Thickness of acquired salivary pellicle as a determinant of the sites of dental erosion. J Dent Res. 1999; 78(12): 1821-28.

14. Hannig C, Becker K, Häusler N et al. Protective effect of the in situ pellicle on dentin erosion - an ex vivo pilot study. Arch Oral Biol. 2007; 52 (5): 444-9. Epub 2006 Nov 28

15. Wetton S, Hughes J, West N et al. Exposure time of enamel and dentine to saliva for protection against erosion: a study in vitro. Caries Res 2006; 40(3): 213-17.

16. Joiner A, Schwarz A, Philpotts CJ et al. The protective nature of pellicle towards toothpaste abrasion on enamel and dentine. J Dent 2008; 36(5): 360-8. Epub 2008 Mar 4.

17. Manton DJ, Cai F, Yuan Y et al. Effect of casein phosphopeptide-amorphous calcium phosphate added to acidic beverages on enamel erosion in vitro. Aust Dent J 2010; 55(3): 275-9.

18. ramalingam L, Messer LB, reynolds EC. Adding casein phosphopeptide-amorphous calcium phosphate to sports drinks to eliminate in vitro erosion. Paediatr Dent 2005; 27(1): 61-7.

19. Srinivasan N, Kavitha M, Loganathan SC. Comparison of the remineralization potential of CPP-ACP and CPP-ACP with 900ppm fluoride on eroded human enamel: An in situ study. Arch Oral Biol 2010 Jun 1. [Epub ahead of print)


A Survey of Dental Hygienists in the United Kingdom in 2011 – Part 5. Critical appraisal, research and continuing professional education

AbstrAct

Aim:The aims of this part of the survey were to investigate whether

or not Dental Hygienists (DHs) and Dental Hygienist/Therapists

(DH/Ts) in the United Kingdom (UK) in 2011 had been trained in

critical appraisal of scientific literature, were interested in taking

part in research and their preferred medium for the delivery of

Continuing Professional Education (CPE).

Methods: A 10% sample of all those registered with the General Dental

Council as DHs or DH/Ts in April 2011 were sent a pre-piloted

questionnaire, explanatory letter and stamped addressed

envelope. The questionnaire contained a total of 100 questions,

3 of which related to the questions set out above in the aims.

Three mailings were distributed between May and July 2011.

results: 561 DHs and DH/Ts were sent the questionnaire and by the third

mailing 371 (66.1%) had responded and returned completed

questionnaires. The respondents were 288 DHs, 79 DH/Ts and

four who did not specify which category they were. Overall

104 (28%) of the respondents reported that they had been

trained to critically appraise scientific literature and 184 (50%)

that they were interested in research. Traditional lectures and

interactive and hands on workshops were the most highly

ranked forms of CPE.

conclusions: The survey has provided a snapshot in the summer of 2011 of

UK DHs skills in critical appraisal of scientific literature, interest

in research and preferred media for the delivery of their CPE.

its findings will help to inform all those involved in the pre-

qualification education and CPE of DHs, including the BSDHT,

the FGDP(UK) and other royal Colleges.

Key Words: Dental hygienists, critical appraisal skills, interest

in research, preferred medium for CPE delivery

Kenneth A. Eaton1

Marina Harris2

Margaret K. Ross3

Carolina Arevalo4

Authors affiliations:

1Visiting Professor, University College London Eastman and King’s College London Dental institutes, Honorary Professor University of Kent.

2University of Portsmouth Dental Academy, William Beatty Building, Hampshire Terrace, Portsmouth, PO1 2QG.

3Edinburgh Postgraduate Dental institute, Lauriston Building (4th Floor), Lauriston Place, Edinburgh, EH3 9HA.

4Centre for Flexible Learning, King’s College London, 46 Aldwych, London, WC2B 4LL.

Correspondence to:

[email protected]

SURVEY OF DENTAL HYGIENISTS


Introductionin the summer of 2011, the British Society of Dental Hygiene and Therapy (BSDHT), in collaboration with the Faculty of General Dental Practice (UK) [FGDP(UK)], carried out a survey of dental hygienists (DHs) in the United Kingdom. The survey investigated DHs and dually qualified dental hygienist/therapists’ (DH/Ts) working patterns, dental hygienist (and dental therapist) skills usage, whether or not they had been trained in critical appraisal of scientific literature, their interest in taking part in research and their preferred medium for continuing professional education (CPE)*. The preliminary results from the survey were reported during the 2011 BSDHT conference1. Subsequently, five papers have been, or are in the process of being, produced. They present and discuss the results of the survey. This paper, the fifth in the series, reports the findings of the survey with regard to training in critical appraisal of scientific literature, the interest in taking part in research and the preferred medium for CPE.

All members of the dental professions are encouraged to base their practise on evidence. Such evidence comes from research. Along with all other Dental Care Professionals (DCPs) DHs therefore need to be able to critically appraise evidence from research and other sources. However, until recently, critical appraisal of scientific literature was not taught during the pre-qualification training of DHs and there appear to be very few opportunities for most DHs to acquire this skill.

relatively little is known about the effectiveness of CPE as far as all members of the dental team are concerned. The General Dental Council (GDC) recognised this deficiency and in 2011 commissioned a literature review of the impact of continuing professional development in dentistry2. The findings of this review confirmed the paucity of evidence with regard to most aspects of CPE. Subsequently, a study relating to continuing professional development of UK dental nurses has been published3.

AimsAgainst this background, the aims of this part of the survey were to investigate whether or not DHs and DH/Ts in the United Kingdom in 2011 had been trained in critical appraisal of scientific literature, were interested in taking part in research and their preferred medium for the delivery of CPE.

MethodsThis survey was conducted using a self-reported questionnaire. The questionnaire had been piloted amongst a random sample of 20 dental hygienists in Edinburgh and Portsmouth. Following the collating of the results of the pilot scheme some of the original questions were revised. The questionnaire consisted of 100 questions with sections on: practice profile, assessment skills, prevention skills, operative skills, the demography of the respondents and their

continuing professional education.

Statistical advice was that a 10% sample of all those registered as a DH or DH/T would be sufficient to achieve an error rate of 5% and 90% confidence level, if there was at least a 66% response rate. The GDC provided an electronic version of the register for Dental Care Professionals, from which the names and addresses of those registered as DH or DH/T were extracted. The sample was drawn by selecting every tenth name from the resulting list of 561 names and addresses.

This paper reports on the responses to the questions on critical appraisal of scientific literature, the interest in taking part in research and the preferred medium for CPE. The full, 100 question, questionnaire can be viewed on the News webpage for March/April 2012 of www.bsdht.org.uk

Who received the questionnaire?Full details of how DHs and DH/Ts were selected and contacted with the questionnaire and justification for the methods used have been published in the first paper in the series4. in summary, 10% of all DHs and DH/Ts on the General Dental Council register at the beginning of May 2011 were mailed the questionnaire. Statistical advice was that a 10% sample of all those registered as a DH or DH/T would be sufficient to achieve an error rate of 5% and 90% confidence level, if there was at least a 66% response rate. After the first mailing in May 2011, two further mailings were performed in June and July.

An editorial in Dental Health5 advised dental hygienists that the survey was to take place and encouraged them to respond. At a local level, dental hygienists who attended continuing professional development courses, run by the BSDHT, were reminded of the survey and encouraged to respond.

The anonymity of respondents was guaranteed and advice from the South East Scotland research Ethics Committee was that ethics approval was not required for the survey.

The questions The questions relevant to this paper were:

• Haveyoubeentrainedtocriticallyappraise scientific literature? Yes/no• Wouldyoubeinterestedintakingpart in research? Yes/no• Whatisyourpreferredmediumforyour continuing professional education? (Please rank all of the following from 1 to 7, where 1 is your most preferred and 7 is your least preferred)• Readingjournalsand/orbooks• Traditionallectures• Interactiveandhandsonworkshops• Online• Webinars• ViaCDsand/orUSBsticks• Other(pleasespecify)

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ResultsAfter three mailings, 371 of the 561 in the sample (66.1%) had responded, of whom 288 were DHs, 79 were DH/Ts and four did not specify whether they were DHs or DH/Ts.

Throughout the results, when percentages are given they are based on 371 and not the number who responded to each question.Twelve respondents reported that they were taking a career break and five that they had retired from work as a DH.

Training in critically appraising scientific literatureOverall 104 (28%) respondents reported that they had been trained to critically appraise scientific literature, 248 (67%) that they had not been trained and 19 (5%) did not answer this question. There was a difference in responses between DH and DH/Ts in that 63% (50 out of 79) DH/Ts reported that they had been trained whereas less than 20% (54 out of 288) DH gave this response (Table 1).

Interest in researchOverall 184 (50%) of those who answered this question responded that they were interested in research, 164 (42%) that they were not interested and 23 (6%) did not respond. There was some difference between responses from DH and DH/Ts, in that 136 DH expressed an interest and 132 did not, whereas 45 DH/Ts expressed an interest but 31 did not (Table 2).

Preferred medium for the delivery of CPEOverall 297 of the 371 respondents to the questionnaire answered this question. However, of these 297, 3 did not include interactive hands-on workshops, 4 did not include online learning, 15 did not include via CDs and/or USB sticks, 16 did

not include webinars and 118 did not include other when awarding ranking from 1 to 7 (Table 3).

Of those who responded, 228 ranked traditional lectures as either 1 or 2. This ranking of 1 or 2 was also given by 161 to interactive and hands on workshops, 141 to reading journals and or books. However, only 49 ranked online learning as 1 or 2 and even fewer to the other media - 11 to via CDs and/or USB sticks, 9 to webinars, and 5 to other (Table 4 and Figure1).

Twenty nine respondents specified other forms of CPE of which 8 suggested in-house training and 3 “bouncing ideas” from colleagues. Other suggestions were given by only either one or two respondents.

DiscussionThere are always some doubts about the validity of results obtained from postal questionnaire surveys. The 66.1% response rate can be viewed as satisfactory as advice was that this level of response from a 10% sample should have been sufficient for no more than 5% error at a 90% confidence level. it should be remembered that although the overall response rate was 66.1%, the response rate and useable responses to individual questions were slightly lower. The response rates to the recent surveys of DHs and DH/Ts in the UK6 and England7 were 65%6 and 56% for DH/Ts7 and 48% for DHs7 respectively. The response rate for the current survey was therefore slightly better than that of other recent surveys of DH and DH/Ts. The editorial in Dental Health5 and reminders during regional DH meetings may well have contributed to the satisfactory response rate.Prior to the current millennium, the skill of critically appraising scientific literature was rarely taught during DH and DH/T pre-qualification training. it was therefore not surprising that overall only 28%

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Figure 1.


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Registration Yes No Did not respond Total

Dental Hygienist 54 215 19 288

Dental Hygienist/Therapist 50 29 0 79

Respondents who did not indicate DH/DHT registration 0 4 0 4

Total 104 (28%) 248 (67%) 19 (5%) 371

Registration Yes No Did not respond Total

Dental Hygienist 136 132 20 288

Dental Hygienist/Therapist 45 31 3 79

Respondents who did not indicate DH/DHT registration 3 1 0 4

Total 184 (50%) 164 (42%) 23 (6%) 371

RankReading Journals and/or books

Traditional Lectures

Interactive and

hands on workshops

Online learning Webinars

Via CDs and/

or USB sticks

Other

Dental Hygienist 226 226 223 222 211 214 153

Dental Hygienist/Therapist 68 68 68 68 67 68 34

Respondents who did not indicate DH/DHT registration 3 3 3 3 3 2 2

Total number of respondents 297 297 294 293 281 282 179

Did not respond 74 74 77 78 90 87 182

Ranking A B C D E F G

1 63 (17%) 137 (36.9%) 78 (21%) 18 (4.9%) 3 (0.8%) 1 (0.3%) 2 (0.5%)

2 78 (21%) 91 (24.5%) 83 (22.4%) 31 (8.4%) 6 (1.6%) 10 (2.7%) 3 (0.8%)

3 97 (26.1%) 32 (8.6%) 83 (22.4%) 56 (15.1%) 6 (1.6%) 8 (2.2%) 1 (0.3%)

4 36 (9.7%) 22 (5.9%) 21 (5.7%) 141 (38%) 21 (5.7%) 38 (10.2%) 8 (2.2%)

5 13 (3.5%) 8 (2.2%) 15 (4%) 32 (8.6%) 92 (24.8%) 111 (29.9%) 14 (3.8%)

6 7 (1.9%) 4 (1.1%) 12 (3.2%) 11 (3%) 128 (34.5%) 107 (28.8%) 6 (1.6%)

7 3 (0.8%) 3 (0.8%) 2 (0.5%) 4 (1.1%) 25 (6.7%) 9 (2.4%) 155 (41.8%)

Table 1. Critical appraisal of scientific literature

Table 2. Interest in research

Table 3. Details of respondents to questions on preferred medium for CPE

Table 4. Respondents’ rankings for the seven media for CPE delivery

Key A - Reading journals and/or text books B - Traditional lectures C - Interactive and hands on workshops D - Online learning E - Webinars F - Via CDs and/or USB sticks G - Other

of respondents reported that they had been trained in this skill. it was also not surprising that a far higher percentage of DH/Ts than DHs reported that they had been trained in this skill, as in the last 10 years, most dental hygienists have also been dually trained as dental therapists.

in view of the efforts of the BSDHT and the FGDP(UK) to

promote DH interest in research, it was encouraging to see that 50% of respondents expressed an interest in research. The difference in responses to this question between DH and DH/Ts was less marked than for possession of the skill of critical appraisal. Although a slightly higher percentage of DH/Ts expressed interest than DHs. This may reflect the fact that the DH/Ts who responded to the


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survey had in general qualified more recently then the DHs4 . As more DHs and DH/Ts qualify with a Bachelor degree, it seems likely that they will have had training in both critical appraisal and an understanding of the importance of research, particularly those graduates from dental schools which have incorporated the new GDC learning outcomes8 relating to evidence based approach into their curriculum. in this respect it is interesting to note that for the last ten years, all DHs qualifying in the Netherlands9 and at most DH schools in the UK have been trained in critical appraisal and have been required to perform a small research project during their pre-qualification training.

it was also interesting to note that respondents rated traditional lectures most highly as their preferred medium for their CPE and also rated journal and book reading highly. This contrasts with the findings of a systematic review of systematic reviews of the literature on the effectiveness of different types of continuing medical education10 which found that: The literature is also clear on the least-effective education methods - didactic lectures and distributed print materials alone. The same review stressed the importance of interactive education and feedback and combining techniques. Others have stressed the importance of multiple exposures to a topic, rather than just one lecture and the use of multimedia11 . it seems likely that only a minority of respondents had taken part in a webinar and that many may not have access to high quality electronically based educational material in the format of CDs etc. Hence these modes of delivery were ranked poorly.

ConclusionsThe survey has provided a snapshot in the summer of 2011 of UK DHs skills in critical appraisal of scientific literature, interest in research and preferred media for the delivery of their CPE. its findings will help to inform all those involved in the pre-qualification education and CPE of DHs, including the BSDHT, the FGDP(UK) and other royal Colleges.

*Because the term Continuing Professional Education (CPE) was used in the questionnaire this term and not Continuing Professional Development (CPD) is used throughout this paper.

AcknowledgementsThe authors wish to thank: Oral B for sponsoring the costs of this survey, the BSDHT and the FGDP(UK) for their collaboration and promotion of the survey, Sue Adams and her team from the Adams Partnership for distributing the questionnaire and data input to an Excel spreadsheet, the General Dental Council for making an electronic version of the Dental Care Professionals register available to the Principal investigator and all the DHs and DH/Ts who responded to the survey.

Contribution of AuthorsKenneth Eaton conceived the survey, obtained sponsorship and wrote the first draft of this paper.

Marina Harris co-planned the study co-ordinated the piloting of the questionnaire and contributed to drafts of this paper and checked the final version.

Margaret ross co-planned the study, sought advice from the South East Scotland research Ethics Committee, contributed to drafts of this paper and checked the final version.

Carolina Arevalo produced the tables of results and the figures, performed all the statistical analyses, contributed to drafts of this paper and checked the final version.

References

1. Harris M. report of preliminary results of BSDHT/FGDP(UK) dental hygienists’ skills survey. BSDHT Conference, 19 November 2011.

2. General Dental Council. The impact of continuing professional development in dentistry; a literature review. Available at www.gdc-uk.org accessed on 19 August 2012.

3. Turner S, ross MK, ibbetson rJ. The impact of the General Dental Council registration and continuing professional development on UK dental care professionals: (1) dental nurses. Br Dent J. 2012 Jul 27; 213(2): E2. doi: 10.1038/sj.bdj.2012.664.

4. Eaton KA, Harris M, ross MK, Arevalo C. A survey of Dental Hygienists in the United Kingdom in 2011. Part 1 - Demographics and working patterns as dental hygienists. Br Dent J. 2012 Accepted for publication.

5. Lewis H. Editorial: The personal is political. Dental Health. 2011; 50 (3): 4.

6. Turner S, ross MK, ibbetson rJ. Dental hygienists and therapists: how much professional autonomy do they have? How much do they want? results from a UK survey. Br Dent J. 2011; 210(10): E16.

7. robinson PG, Patrick A, Newton T. Modelling the dental workforce supply in England. The University of Sheffield 2011. accessed from www. mee.nhs.uk/PDF/Dental_Workforce_ Supply.pdf accessed on 10 February 2012.

8. General Dental Council. Preparing for practice. Dental team learning outcomes for registration. Available at www.gdc-uk.org. accessed on 24 August 2012.

9. Van den Heuvel J, Jongbloed-Zoet C, Eaton K. The new style dental hygienist: changing oral healthcare professionals in the Netherlands. Dental Health 2005; 44(6): 3-10.

10. Bloom B. Effects of continuing medical education on improving physician clinical care and patient health: a review of systematic reviews. Int J Technol Assess Health Care. 2005; 21(3):380-5.

11. Marinopoulos SS, Dorman T, ratanawongsa N et al. Effectiveness of continuing medical education. Evidence report/Technology Assessment Number 149 (prepared by the John Hopkins Evidence-based Practice Center, under contract No. 290-02-0018). Agency for Healthcare research and Quality Publication N0. 07-E006, rockville,MD. Agency for Healthcare research and Quality, January 2007.


Telomere length, chronic inflammation and oral health: implications for supportive therapy

AbstrAct

Over the last ten years there has been an increasing body of evidence establishing an association between inflammatory periodontal disease and other age related inflammatory diseases such as CVD, rheumatoid arthritis, diabetes and lung function. The causal link between these diseases is poorly understood and remains to be established. Oxidative stress and chronic inflammation are features of all these diseases. More recently telomere shortening has also been implicated in age related, inflammatory diseases, including periodontal disease.

New research from the UK has found that shorter leukocyte telomere length is associated with the diagnosis of periodontitis and their measures correlate with the severity of periodontitis, systemic inflammation and oxidative stress.

Could these factors be part of the causal link that could explain the association between periodontitis and chronic inflammatory diseases? it may be that it is the critical shortening of telomeres that triggers inflammation in a bi-directional manner. Are there any preventive measures that could be taken to attenuate oxidative stress and degradation of telomere length? With the evidence base we currently have, can we now begin to draw together evidence based nutritional protocols for implementation in supportive periodontal therapy?

Whist associations do not imply causation, this report examines the effect of chronic periodontal disease, oxidative stress and additional lifestyle factors on telomere length, oral health and chronic inflammation. Novel treatment protocols are explored, questions raised and the need for further study in this exciting and rapidly developing area of research is highlighted.

Keywords: Telomeres, chronic inflammation, oxidative stress, periodontal health, nutrition, lifestyle factors.

Juliette Reeves


Secretary to the Eastern regional Group BSDHT

ADi member

A spokesperson for the Wrigley Oral Healthcare Programme

Key Opinion Leader to Philips Oral Healthcare

Post graduate trainer with ivoclar Vivadent and EMS

Correspondence to:

[email protected]

SUPPORTIVE THERAPY


IntroductionNew research from the UK has found that shorter leukocyte telomere length is associated with the diagnosis of periodontitis and their measures correlate with the severity of periodontitis, systemic inflammation and oxidative stress. This piece of research from Masi et al1 examined telomere length, systemic inflammation and oxidative stress in periodontal disease. Whilst associations do not explain causality, this paper considers the implications of this research and reviews the wider picture concerning telomere length relative to periodontal disease and systemic health.

Oxidative stressOxidative stress is thought to make a significant contribution to all inflammatory diseases, including inflammatory periodontal disease. For the majority of our patients variations in plaque levels provide the most significant determinant of the disease. An increasing body of evidence is emerging to implicate free radical activity in the pathogenesis of periodontal breakdown2. inadequate antioxidant availability could either predispose the host to the disease, or modify the progression of a pre-existing disease.

Adequate host defence activity critically depends upon the micronutrient status of an individual, particularly the oxidant-antioxidant balance3. Oxidative burst is part of the physiological function of phagocytes, which results in a massive production and release of reactive oxygen free radicals which are needed to destroy invading micro-organisms, but which over a prolonged period exert oxidative stress on otherwise healthy tissues. (Fig 1)

The antioxidant micronutrients are important not only for limiting oxidative damage and tissue damage, but also in preventing increased cytokine production, which is a result of prolonged activation of the immune response. Dietary antioxidants, and other enzymatic antioxidants such as glutathione peroxidase, superoxide dismutase and catalase, protect the lipids of lipoproteins and other biomembranes against oxidative damage by intercepting oxidants before they can attack the tissues.

TelomeresTelomeres have been likened to the protective ends of a shoelace. A telomere is a repeated DNA sequence found at the ends of chromosomes. Telomeres cap the ends of chromosomes and protect them from degradation and end-to-end fusion. DNA sequences become shorter and undergo telomere erosion with each cycle of replication and cell division (mitosis). Each time a cell divides it loses 25-200 DNA base pairs from the telomere ends. Once this process has taken place about 100 times, then cellular senescence is induced (“senescence” is the process of cellular exhaustion), the cell ages and finally dies (apoptosis). research shows that oxidative stress enhances this process4,5 and that telomere attrition can serve as

a marker of the cumulative oxidative stress and inflammation. Telomere length therefore has been associated with ageing, chronic inflammation, oxidative stress and systemic disease6.

Telomerase (also referred to as telomerase reverse transcriptase TErT) is an enzyme that adds telomeric sequences to telomeres. its role is to elongate chromosomes by adding telomeric sequences to the end of existing chromosomes, thus protecting telomere length and allowing the cell to continue dividing past its normal lifespan. in the absence of telomerase or when this enzyme is expressed at very low levels, DNA synthesis during cell division results in the progressive shortening of telomeric DNA. This erosion eventually compromises telomere integrity, triggering cellular senescence and blocking further cell replication7.

Telomere length, oxidative stress and ageingit was the russian biologist Alexei Olovnikov who in the late 1960s first predicted the shortening of telomeres as an explanation for finite cell division in cells grown in culture. it took more than 20 years to show experimentally that telomeric DNA declines with the ageing of human fibroblasts.

Oxidative stress and shortened telomere length have been shown to have important implications for the onset of other age related systemic diseases such as cardiovascular disease, hypercholesterolemia, diabetes mellitus and chronic inflammation8. Kurtz et al9 demonstrated that long-term exposure of human endothelial cells to mild oxidative stress caused by disruption of the glutathione redox-cycle results in accelerated telomere erosion, loss

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Figure 1. Oxidative Stress


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of telomeric integrity and the premature onset of cell senescence and apoptosis. This confirmed the results of an earlier study, indicating that oxidative stress can induce or accelerate the development of cell senescence and ageing10.

Implications for periodontal healthOver the last ten years the impact of periodontal disease on systemic health has been established, with research showing an increasing association between periodontal inflammation and cardiovascular disease11, diabetes12, rheumatoid arthritis13 and impaired lung function14. The association between periodontal inflammation and systemic disease has yet to be fully understood. it appears to be based on systemic inflammation and elevated levels of pro-inflammatory cytokines in the general circulation15. Other risk factors include the presence of C reactive Protein (CrP)16, intrinsic genetic factors and lifestyle factors such as stress, smoking and the absence of health enhancing behaviour17. All of these factors collectively may increase the risk of inflammatory disease and reduce the inflammation pro-resolving mechanisms of the body, thus increasing the risk of systemic disease.

This latest piece of research from Masi et al1 has found that telomere length is inversely associated with periodontitis and this also correlates with systemic inflammation and oxidative stress.

The protective enzyme TErT in human cells extends both the lifespan of the cell and telomere length to those typical of young cells18. inflammation is also thought to contribute to telomere attrition in the cells of the immune system through increasing the rate of leucocyte turnover. An increased expression of pro-inflammatory cytokines has been shown to adversely affect telomerase activity and telomere length19. in addition, research has demonstrated that increased generation of reactive oxygen species (rOS) stimulates the loss of the protective enzyme TErT from the nucleus of the cell, thus increasing the

rate of cell senescence and subsequently apoptosis 20.Could these factors be part of the causal link that could explain the association between periodontitis and chronic inflammatory diseases? it may be that the critical shortening of telomeres triggers inflammation in a bi-directional manner (Fig 2.). Are there any preventive measures that could be taken to attenuate oxidative stress and degradation of telomere length?

Lifestyle factors and telomere lengthThere is evidence that telomere degradation, chronic inflammation and oxidative stress may be attenuated by modulating certain lifestyle factors such as nutrition, smoking, stress and obesity 21. Ornish et al 22 conducted a three months comprehensive lifestyle intervention programme (including nutrition and physical activity) in 24 low-risk prostate cancer patients and demonstrated an increase of 29% in peripheral blood mononuclear cell telomerase activity. This suggests that telomere attrition is not genetically determined but can be attenuated by modification of lifestyle factors.

Micronutrient statusAn increasing body of evidence suggests that several micronutrients, such as antioxidant vitamins and minerals, can modulate the states of oxidative stress and chronic inflammation and therefore may affect telomere length. These include vitamin C23, alpha tocopherol24 vitamin D25 and Omega three fatty acids26. Multivitamin supplements contain large amounts of many vitamins and minerals and therefore represent a major source of micronutrient intake.

Xu et al27 examined whether multivitamin use was associated with increased telomere length among 586 women from the Sister Study. The researchers found that after age and other potential confounders were adjusted for, multivitamin use was associated with longer telomeres. in the analysis of micronutrients, higher intakes of vitamins C and

Figure 2. Model suggesting how telomere attrition may be the bi-directional link in the association of periodontal disease with other systemic diseases and inflammatory conditions


E from foods were each associated with longer telomeres, even after adjustment for multivitamin use. Furthermore, intakes of both nutrients were associated with telomere length among women who did not take multivitamins. intervention studies are required to further determine the evidence base for dietary and/or supplemental intake of these nutrients as a potential long term preventive strategy.

Glutathione (GTH) and the redox cycleThere is an increasing body of evidence demonstrating the effect of nutrition on antioxidant status and periodontal health. research has suggested that low levels of the endogenous antioxidant reduced glutathione (GSH) may be implicated in the susceptibility and progression of chronic periodontal disease28. The researchers have suggested that high concentrations of GSH in health may represent an important anti-inflammatory defence system in the progression of inflammatory periodontal disease.

The effect of N-acetylecysteine (NAC) on telomere length has also been investigated. NAC can elevate glutathione synthesis, a key component of the glutathione redox cycle. The glutathione redox cycle is an endogenous antioxidant enzyme system, which plays a pivotal role in the protection of the cell membrane from oxidative damage 29 (Fig 3). Haendler et al 30 found that NAC reduced intracellular rOS formation and prevented mitochondrial DNA damage. NAC also reduced the loss of TErT from the cell and inhibited cellular senescence. They suggested that the prevention of intracellular reactive oxygen species (rOS) activity and loss of TErT from the cell, also prevents telomere shortening and subsequent cell senescence. Similar effects were reported by the authors with statins (Atorvastatin). The results with statins were dose dependant with lower concentrations able to delay the onset of senescence, and higher concentrations increasing rOS formation in endothelial cells.NAC has been used for about thirty years as a mucolytic in patients with broncho- pulmonary diseases31. Other therapeutic uses of GTH and NAC appear to be mainly employed in the treatment of paracetamol overdose32, inflammatory diseases of the lung33, and in HiV

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and AiDS34 therapy. NAC is well absorbed, readily passes through cellular membranes, resists enzymatic breakdown and stimulates glutathione production in the cells35. it appears to be well tolerated and does not raise blood or tissue levels above the desired ranges36. The case for NAC as an important inhibitor of the pro inflammatory transcription factor NFkB, as a potential glutathione-preserving therapy for periodontitis, was first proposed by Chapple in 199637. The use of NAC as an adjunctive therapy in the treatment of chronic periodontal disease has yet to be established and provides an intriguing basis for further investigation and clinical trials.

Obesity and smokingObesity and cigarette smoking are important risk factors for many age-related and inflammatory diseases. Both factors are associated with increased oxidative stress, inflammation and periodontal disease38.

ObesityObesity has been associated with the development of periodontal disease39. An association between obesity, periodontal infections and diabetes has been suggested as being mediated by increased levels of tumour necrosis factor (TNF) which may lead to a systemic inflammatory state, thereby increasing susceptibility to inflammatory periodontal disease40.

research has also shown an association between shorter telomere length in obesity, with lean individuals (BMi <20) having significantly longer telomeres than obese (BMi>30) individuals41. Consistent with earlier studies, particularly amongst women, Kim et al42 demonstrated an inverse association between BMi and telomere length. Shorter telomere length was associated with higher hip and waist circumferences. in addition higher BMi at ages 30-49, adult weight gain and frequent weight cycling were also inversely associated with telomere length.Exploring the possibility of a bi-directional effect between elevated levels of circulating pro inflammatory mediators and telomere attrition may therefore, provide additional insight into the incidence of periodontal disease in obese individuals and subsequent supportive treatment protocols.

Figure 3. Diagram showing the crucial role of glutathione in the intracellular detoxification of peroxides and how alterations in the redox cycle may affect telomere status.


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SmokingAs dental professionals we are only too aware of the effects of smoking on the periodontium and oral mucosa. Smoking is recognised as a major factor in the aetiology of periodontitis43. Smoking is typically associated with increased inflammation, oxidative stress and telomere attrition44. Valedes et al41 reported that cigarette smoking enhances telomere loss and subsequent telomere shortening. A dose dependent relationship with smoking was recorded, with each pack year smoked, equivalent to an additional 18% loss of telomere length when compared to the rest of the cohort. individuals who had never smoked had longer age adjusted telomeres than former smokers and both had longer telomeres than current smokers. Smoking a pack per day for 40 years corresponded to an additional 7.4 years of ageing. This was also confirmed by Moria et al45 in patients with chronic obstructive pulmonary disease (COPD). This may provide further insight into the effect of smoking on the periodontal tissues and subsequent systemic disease.

StressThe effects of stress on periodontal health, is now widely recognized as having a significant physiological effect on the periodontal tissues via the activity of the stress hormones adrenaline and cortisol. Stress is recognized as a contributing risk factor in both the incidence of periodontal disease

46 and negative outcome of periodontal treatment47.

More recently psychological and life stress have been shown to be significantly associated with higher levels of oxidative stress, lower telomerase activity and increased leukocyte telomere attrition48. An early study from Epel and Blackburn et al49 reported accelerated telomere shortening as a biological response to chronic life stress and, more recently, in women who have experienced chronic stress related to intimate partner violence50. The modification of lifestyle factors

has been suggested as having a buffering effect on chronic stress and telomere attrition51.

Oestrogen and telomere lengthThere is a substantial body of evidence linking oestrogen status and the onset of menopause with an increased risk of periodontal disease and alveolar bone loss52,53. Clinical observations include more frequent and more exaggerated responses to oral bacteria, which initiate gingival and periodontal lesions and includes bleeding on probing, or with tooth brushing, inflamed gingivae, hyperplastic gingivae, pyogenic granuloma, tooth mobility and bone loss54. These clinical observations coupled with tissue specificity of hormone localisation, have strongly suggested that periodontal tissues are targets for androgens55, oestrogens56 and progesterone57.

Earlier investigations have shown that the risk of tooth loss during menopause is smaller in women using HrT58 and that circulating levels of oestrogen influence alveolar bone density 53.

More recent research has shown decreasing numbers of Porphyromonas gingivalis and Tannerella forsythia in periodontal pockets with HrT use59. in addition a significant association between the levels of oestrogen and telomerase activity has been shown under physiological conditions60. Decreased leukocyte telomere length has also been associated with osteoblast senescence, decreased bone mineral density and osteoporosis61.

Taking into account the known associations between periodontal bacteria and systemic diseases, coupled with the anti-inflammatory effects of oestrogen62, the role of this steroid hormone in telomere length, periodontal inflammation and systemic disease deserves some attention.

Menopause usually begins at approximately 45-55

Figure 4. Telomere location and structure


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years of age, unless accelerated by hysterectomy or ovariectomy. At this stage there is a dramatic decrease of oestrogen and progesterone production. Whereas the pre menopausal woman has cycling plasma levels of oestrodiol and progesterone of 50 – 500 pg/ml and 0.5- 20 ng/ml respectively, the post menopausal woman has non cycling, circulating levels of 5 – 25pg/ml and 0.5ng/ml respectively63.

Oestrogen has been linked to leukocyte telomere length through anti-inflammatory and antioxidant effects and its ability to stimulate TErT64. Oestrogen lowers the production of pro inflammatory cytokines including TNF65 and stimulates the activity of mitrochondrial superoxide dismutase (SOD) and glutathione peroxidase (Gpx)66, two powerful antioxidant enzyme systems. it has been suggested that oestrogen may stimulate telomerase expression and exert some of its antioxidant effects through the same cellular pathways67.

Sato et al68 were able to show that the administration of exogenous oestradiol in hepatic cells can attenuate telomere shortening by up-regulation of telomerase activity, thereby prolonging the lifespan of these cells. A concentration dependent increase in TErT protein expression by oestradiol induction was observed. The fact that women exhibit a significantly lower rate of age-dependent telomere attrition compared with men69 may possibly be due to the stimulating properties of oestrogen on telomerase.

it may also be possible that the anti-inflammatory and antioxidant effects of oestrogen may have an additional effect on the periodontal tissues, thus preserving telomere length. A drop in oestrogen production consistent with the onset of menopause may therefore alter leukocyte telomere attrition and affect periodontal inflammation. This may further add to our understanding of menopause as a risk factor for periodontal disease, alveolar bone loss and chronic inflammation. Further research is required to establish whether the modification of nutrition and lifestyle factors relative to oestrogen status, may also provide significant attenuation of chronic inflammation and bone loss of the periodontal tissues.

ConclusionChronic inflammation is involved in the pathogenesis of many systemic diseases and involving the release of pro-inflammatory mediators that may cause persistence of the disease process. Periodontal disease is highly prevalent in the population and therefore presents a marked inflammatory burden in this regard. Over the last ten years there has been an increasing body of evidence establishing an association between inflammatory periodontal disease and other age related inflammatory diseases such as CVD, rheumatoid arthritis, diabetes and COPD. The causal link between these diseases is poorly understood and remains to be established. Oxidative stress and chronic inflammation are features of all these diseases. More recently telomere attrition has also been implicated in age related, inflammatory diseases, including periodontal disease.

The glutathione redox cycle is pivotal to the protection of the cell from rOS and oxidative stress. research has confirmed that GSH concentrations are inversely related to the inflammatory periodontal diseases. NAC increases glutathione availability for the redox cycle and prevents telomere shortening and subsequent cell senescence.

The rate of telomere attrition is significantly affected by diet and lifestyle choices. A growing body of evidence supports the clinical effectiveness of lifestyle changes including a diet enhanced with key nutrients to minimise oxidative stress and inflammation and thus telomere attrition.

More research and clinical trials are needed to draw together and continue to asses the effects of nutrition and lifestyle intervention as a supportive therapy in the treatment of periodontal disease. Would supporting the glutathione redox cycle with supplemental glutathione precursors (such as NAC), in addition to dietary antioxidants, provide a therapeutic/preventive measure in attenuating telomere loss and oxidative stress? if this is the case perhaps we can now begin to draw together nutritional protocols as supportive therapy in the treatment of chronic inflammatory diseases including periodontal disease.

This paper was presented at Europerio 7 Vienna 2012.

References1. Masi S, Salpea K, Li K, et al. Oxidative stress, chronic inflammation, and telomere length in patients with periodontitis. Free Radic Biol Med 2011; 50(6):730-5.

2. Waddington rJ, Moseley r, Embery G. reactive oxygen species: a potential role in the pathogenesis of periodontal diseases. Oral Dis. 2000; 6(3): 138-51.

3. Schmidt. K. interaction of antioxidative micronutrients with host defence mechanisms. A critical review. Int J Vitam Nutr Res 1997; 67(5): 307-11.

4. Tchirkov A, Lansdorp PM. The role of oxidative stress in telomere shortening in cultured fibroblasts from normal individuals and patients with ataxia-telangiectasia. Hum Mol Genet 2003; 12(3): 227-232.

5. Houben JM, Moonen HJ, van Schooten FJ et al. Telomere length assessment: biomarker of chronic oxidative stress? Free Radic Biol Med 2008; 44(3): 235–46.

6. von Zglinicki T, Martin-ruiz CM. Telomeres as biomarkers for ageing and age-related diseases. Curr Mol Med 2005; 5(2):197–203.

7. Smogorzewska, A, de Lange T. Different telomere damage signaling pathways in human and mouse cells. EMBO J 2002; 21(16): 4338-48.

8. Saretzki G, Von Zglinicki T. replicative aging, telomeres, and oxidative stress. Ann N Y Acad Sci 2002; 959: 24 –9.

9. Kurz DJ, Decary S, Hong Y et al. Chronic oxidative stress compromises telomere integrity and accelerates the onset of senescence in human endothelial cells. J Cell Sci 2004; 117(11): 2417-26.

10. Serrano M, Blasco, MA. Putting the stress on senescence. Curr Opin Cell Biol 2001; 13(6): 748-753.

11. Mealey BL. influence of periodontal infections on systemic health. Periodontol 2000 1999; 21: 197-209.

12. Saito T, Shimazaki Y, Kiyohara Y, et al. The severity of periodontal disease is associated with the development of glucose intolerance in non-diabetics: the Hisayama Study. J Dent Res 2004; 83(6): 485-90.

13. dePablo P, Dietrich T, McAlindon TE. Association of periodontal disease and tooth loss with rheumatoid arthritis in the US population. J Rheumatol 2008; 35(1): 70-76.

14. Garcia ri, Nunn ME, Vokonas PS. Epidemiologic associations between periodontal disease and chronic obstructive pulmonary Disease. Ann Periodontol 2001; 6(1): 71-77.

15. iacopino AM, Cutler CW. Pathophysiological relationships between periodontitis and systemic disease: recent concepts involving serum Lipids. J Periodontol 2000; 71(8): 1375-84.


Juliette R

eeves • S

up

portive T

herap

y

16. Noack B, Genco rJ, Trevisan M et al. Periodontal infections contribute to elevated systemic C-reactive protein levels. J Periodontol 2001; 72(9): 1221-27.

17. Beck JD, Offenbacher S, Williams r et al. Periodontitis: a risk factor for coronary heart disease? Ann Periodontol 1998; 3: 127-41.

18. Yang J, Chang E, Cherry AM et al. Human endothelial cell life extension by telomerase expression. J Biol Chem. 1999; 274(37): 26141–48.

19. Xu D, Erickson S, Szeps M et al. interferon down regulates telomerase reverse transcriptase and telomerase activity in human malignant and nonmalignant hematopoietic cells. Blood 2000; 96(13): 4313-18.

20. Haendeler J, Hoffmann J, Brandes rP et al. Hydrogen peroxide triggers nuclear export of telomerase reverse transcriptase via Src kinase family- dependent phosphorylation of tyrosine 707. Mol Cell Biol. 2003; 23(13): 4598–610.

21. Gilley D, Herbert BS, Huda N et al. Factors impacting human telomere homeostasis and age-related disease. Mech Ageing Dev 2008; 129(1-2): 27-34.

22. Ornish D, Lin J, Daubenmier J et al. increased telomerase activity and comprehensive lifestyle changes: a pilot study. Lancet Oncol 2008; 9(11): 1048-57.

23. Furumoto K, inoue E, Nagao N et al. Age-dependent telomere shortening is slowed down by enrichment of intracellular vitamin C via suppression of oxidative stress. Life Sci 1998; 63(11): 935–48.

24. Tanaka Y, Moritoh Y, Miwa N. Age-dependent telomere-shortening is repressed by phosphorylated alpha-tocopherol together with cellular longevity and intracellular oxidative-stress reduction in human brain microvascular endotheliocytes. J Cell Biochem 2007; 102(3): 689–703.

25. richards JB, Valdes AM, Gardner JP, et al. Higher serum vitamin D concentrations are associated with longer leukocyte telomere length in women. Am J Clin Nutr 2007; 86(5): 1420–25.

26. Farzaneh-Far r, Lin J, Epel E et al. Association of marine omega-3 fatty acid levels with telomeric aging in patients with coronary heart disease. JAMA 2010; 303(3): 250-7.

27. 25.Xu Q, Parks C, Deroo LA et al. Multivitamin use and telomere length in women. Am J Clin Nutr 2009; 89(6): 1857–63.

28. Chapple iL, Brock G, Eftimiadi C et al. Glutathione in gingival crevicular fluid and its relation to local antioxidant capacity in periodontal health and disease. Mol Pathol 2002; 55(6): 367-73.

29. Suttorp N, Toepfer W, roka L. Antioxidant defence mechanisms of endothelial cells: glutathione redox cycle versus catalase. Am J Physiol 1986; 251: C671-80.

30. Haendeler J, Hoffmann J, Diehl JF. Antioxidants inhibit Nuclear Export of Telomerase reverse Transcriptase and Delay replicative Senescence of Endothelial Cells. Circ Res 2004; 94(6): 768-775.

31. No Authors Listed: Long-term oral acetylcysteine in chronic bronchitis: A double-blind controlled study. Multicenter Study Group Eur J Respir Dis Suppl 1980; 111: 93-108.

32. Corcoran GB, Wong BK. role of glutathione in prevention of acetaminophen-induced hepatotoxicity by N-acetyl-L-cysteine in vivo: studies with N-acetyl-D-cysteine in mice. J Pharmaco Exp Ther 1986; 238(1): 54-61.

33. rahman i, MacNee W. Oxidative stress and regulation of glutathione in lung inflammation. E Resp J 2000; 16(3): 534-54.

34. Herzenberg LA, De rosa SC, Dubs JG et al. Glutathione deficiency is associated with impaired survival in HiV disease. Proc Natl Acad Sci USA 1997; 94(5): 1967-72.

35. DeCaro, L ,Ghizzi A, Costa r et al. Pharmacokinetics and bioavailability of oral acetylcysteine in healthy volunteers. Arzneimittelforschung 1989; 39(3): 382-6.

36. No Authors Listed. Acetylcysteine. Lancet 1991; 337(8749): 1069-70.

37. Chapple iL. role of free radicals and antioxidants in the pathogenesis of the inflammatory periodontal diseases. Clin Mol Path 1996; 49(5): M247-255.

38. Nishida N, Tanaka M, Hayashi N, et al. Determination of smoking and obesity as periodontitis risks using the classification and regression tree method. J Periodontol 2005; 76(6): 923-28.

39. Al-Zahrani MS, Bissada NF, Borawskit EA. Obesity and periodontal disease in young, middle-aged, and older adults. J Periodontol 2003; 74(5): 610-15.

40. Genco rJ, Grossi SG, Ho A et al. A proposed model linking inflammation to obesity, diabetes and periodontal infections. J Periodontol 2005; 76(11-s): 2075-84.

41. Valedes AM, Andrew T, Gardener JP et al. Obesity, cigarette smoking and telomere length in women. Lancet 2005; 366(9486): 622-64.

42. Kim S, Parks C, Deroo LA, et al. Obesity and Weight Gain in Adulthood and Telomere Length. Cancer Epidemiol Biomarkers Prev 2009; 18(3): 816-20.

43. Heasman L, Stacey F, Preshaw PM et al. The effect of smoking on periodontal treatment response: a review of clinical evidence. J Clin Periodontol 2006; 33(4): 241-53.

44. Nawrot TS, Staessen JA, Holvoet P et al: Telomere length and its associations with oxidised-LDL, carotid artery distensibility and smoking. Front Biosci 2010; 2: 1164-68.

45. Morla M, Busquets X, Pons J. Telomere shortening in smokers with and without COPD. Eur Respir J 2006; 27(3): 525–28.

46. Genco rJ, Ho AW, Grossi SG et al. relationship of stress,

distress, and inadequate coping behaviours to periodontal disease. J Periodontol 1999; 70(7): 711-23.

47. Elter Jr, White BA, Gaynes BN et al. relationship of clinical depression to periodontal treatment outcome. J Periodontol 2002; 73(4): 441-49.

48. Huzen J, van der Harst P, de Boer rA et al. Telomere length and psychological well-being in patients with chronic heart failure. Age Ageing 2010; 39(2): 223-27.

49. Epel ES, Blackburn EH, Lin J, et al. Accelorated telomere shortening in response to life stress. Proc Natl Acad Sci USA 2004; 101(49): 17312-15.

50. Humphreys J, Epel ES, Cooper BA et al. Telomere Shortening in Formerly Abused and Never Abused Women. Biol Res Nurs 2012; 14(2): 115-23. doi: 10.1177/1099800411398479. Epub 2011 Mar 8.

51. Putterman E, Lin J, Blackburn E et al. The Power of exercise: Buffering the Effect of Chronic Stress on Telomere Length. PLoS ONE 2010; 5(5):e10837.

52. Mariotti A. Sex steroid hormones and cell dynamics in the periodontium. Crit Rev Oral Biol Med 1994; 5(1): 27-53.

53. Payne JB, Zachs Nr, rinehart rA et al. The association between oestrogen status and alveolar bone density changes in post menopausal women with a history of periodontitis. J Periodontol 1997; 68: 24-31.

54. Halling A, Bengtsson C. The number of children, use of oral contraceptives and menopausal status in the relationship to the number of remaining teeth and periodontal bone height. Community Dent Health 1989; 6(1): 39-45.

55. Vittek J, Hernandez Mr, Wenk EJ et al. Binding of 3H-methyltrienolone (3H-r1881) to androgen receptors in human gingiva. J Periodontal Res 1985; 20(1): 41-46.

56. Leuko WM, Anderson A. Oestrogen receptors and growth response in cultured periodontal ligament cells. Life Sci 1986; 39(13): 1201-06.

57. Vittek J, Gordon GG, rappaport SC et al. Specific progesterone receptors in rabbit gingiva. J Perio Res 1982; 17(6): 657-61.

58. Grodstein F, Colditz GA, Stampfer MJ. Post-menopausal hormone use and tooth loss: a prospective study. J Am Dent Assoc 1996; 127(3): 370-77.

59. Tarkkila L, Kari K, Furuholm J et al. Periodontal disease- associated micro-organisms in peri-menopausal and post- menopausal women using or not using hormone replacement therapy. A two-year follow-up study. BMC Oral Health 2010; 10: 10.

60. Yokoyama Y, Takahashi Y, Morishita S et al. Telomerase activity in the human endometrium throughout the menstrual cycle. Mol Hum Reprod 1998; 4(2): 173-77.

61. Pignolo rJ, Suda rK, McMillan EA et al. Defects in telomere maintenance molecules impair osteoblast differentiation and promote osteoporosis. Aging Cell 2008; 7(1): 23-31.

62. Pfeilschifter J, Koditz r, Pfohl M et al. Changes in pro inflammatory cytokine activity after menopause. Endocr Rev 2002; 23(1): 90-119.

63. Mishell Dr. Menopause: Physiology and Pharmacology. in Mishell Dr: Menopause: Physiology and Pharmacology Chicago Book Medical Pubs inc. 1988 pp75.

64. Kyo S, Takakura M, Kanaya T et al. Estrogen activates telomerase. Cancer Res 1999; 59(23): 5917-21.

65. Dantas AP, Sandberg K. Estrogen regulation of tumor necrosis factor alpha: a missing link between menopause and cardiovascular risk in women? Hypertension 2005; 46(1): 21-22.

66. Vina J, Borras C, Gambini J et al. Why females live longer than males? importance of the up-regulation of longevity- associated genes by oestrogenic compounds. FEBS Lett 2005; 579(12): 2541-45.

67. Aviv A, Valdes A, Gardner JP et al. Menopause modifies the association of leukocyte telomere length with insulin resistance and inflammation. J Clin Endocrinol Metab 2006; 91(2): 635-40.

68. Sato r, Maesawa C, Fujisawa K et al. Prevention of critical telomere shortening by oestradiol in human normal hepatic cultured cells and carbon tetrachloride induced rat liver fibrosis. Gut 2004; 53(7): 1001-09.

69. Bekaert S, DeMeyer T, rietzschel Er et al. Telomere length and cardiovascular risk factors in a middle-aged population free of overt cardiovascular disease. Aging Cell 2007; 6(5): 639-47.


How effective are specific dentifrices in reducing or controlling plaque and gingivitis in adults?A review of the literature

AbstrAct

Aims:To conduct a literature review to undertake a comparison of dentifrices containing triclosan and copolymer, triclosan and zinc citrate and stabilised stannous fluoride.

Materials and methods: Pub Med, Cochrane Oral Health Group Database of Abstracts of review of Effectiveness (DArE) and Google Scholar were systematically searched for literature relating to the subject area. The set criteria for the inclusion of papers were peer-reviewed literature in the English language and randomised controlled trials of at least six months duration. in addition, all test dentifrices had to be related to the research question and compared with each other or a fluoride control.

results: The titles and abstracts of 973 papers were screened and 36 potentially relevant full text papers were retrieved. Of these, 22 papers fulfilled the set criteria outlined for inclusion. Analysis of the papers found heterogeneity in the results of the studies, which made it difficult to quantify the effectiveness of a dentifrice for the reduction or control of plaque and gingivitis.

conclusion: Despite heterogeneity in the results, analysis of the papers identified that triclosan/copolymer, triclosan/zinc citrate and stabilised stannous fluoride dentifrices have the ability to reduce or control dental plaque and gingivitis when compared to a fluoride control. However, stabilised stannous fluoride dentifrices may not have such an effect on the reduction of plaque when compared to dentifrices containing triclosan. it was proposed that a triclosan/copolymer dentifrice may be more effective in reducing or controlling gingivitis in those areas demonstrating the most gingival inflammation.

Key Words: Dentifrice, triclosan, stannous fluoride.

Nicola Gough


The Grand Avenue Dental Practice

104 Grand Avenue

Worthing

West Sussex

Correspondence to:

[email protected]

PLAQUE AND GiNGiViTiS

IntroductionThe widespread use of dentifrices has played an important role in the practise of good oral hygiene and promotion of improved oral health.1 The Oxford English Dictionary (cited by Stamm2) dates the usage of the term dentifrice to 1558, defining it as ‘a powder or other preparation for rubbing and cleaning the teeth’.2 Since this original definition, dentifrices have evolved and they now provide a vehicle for delivering potential cosmetic, hygienic and therapeutic effects to the teeth and oral mucosa.3 These therapeutic agents, with anti-plaque and anti-gingivitis effects, are incorporated into dentifrices to act as adjuncts to self-performed mechanical plaque removal.4,5

Dental Care Professionals (DCPs) may be required to advise patients in choosing an appropriate dentifrice to aid the patient in reducing plaque and gingivitis levels. Due to the variety of dentifrices available on the market,

evidence-based information may be sought to ensure the patient selects the most appropriate dentifrice to aid in the improvement of their oral health.2

The Department of Health (DH) publication, Delivering Better Oral Health: An evidence-based tool kit provides dental professionals with the latest evidence-based recommendations for patient care.6 The DH advises dental professionals to recommend dentifrices containing triclosan in combination with copolymer or zinc citrate to improve plaque control, or dentifrices containing stannous fluoride (SnF2) to reduce gingivitis.6 A systematic review is considered the highest level of evidence6 (Figure.1).

However, when assessing the evidence that supports the DH publication, the systematic reviews presented conflicting results. Systematic reviews of the literature have all concluded that dentifrices containing triclosan and a copolymer not only have an anti-plaque effect, but


also an anti-gingivitis effect.8,9,10 A review on the effects of SnF2 demonstrated a small effect on the reduction and control of plaque and gingivitis. However, heterogeneity in the results was reported 8,11 which could not be attributed to clinical or methodological factors.8

Furthermore, researching the evidence-base behind using triclosan and zinc citrate elicited conflicting views. One meta-analysis reported no evidence of efficacy in the reduction of plaque and gingivitis for triclosan products containing zinc citrate.9 However, one study reported triclosan and zinc citrate products as having a small but significant effect on the reduction of plaque and gingivitis.10 Consequently, a need was identified to obtain the primary source of research in order to assess how effective specific dentifrices are in reducing or controlling plaque and gingivitis in order to improve the evidence based advice that can be given to patients.

Literature review The proposed research question was addressed through a literature review, which consisted of locating, critically appraising and synthesising scholarly information on a selected subject.12,13,14 Within the nursing profession, the ability to critically appraise and synthesise research on a particular topic is of prime importance to evidence-based patient care.15 This observation is transferrable to dentistry, as dental professionals have a responsibility to provide treatment for patients based on current evidence-based research and guidelines.16

MethodologyA systematic approach was applied to search and review available literature related to the literature review question. Pub Med, Cochrane Oral Health Group Database of Abstracts of review of Effectiveness and Google Scholar were initially searched using the keywords, ‘plaque’, ‘gingivitis’ and ‘dentifrices’. Boolean logic was applied to systematically reduce references to a manageable level. Table 1 demonstrates how Boolean logic was applied and references were reduced.

No set time frame was planned when retrieving the literature so that the literature represented all of the research that was available on the specific dentifrice. However, it was ensured that the dentifrice formulation was currently available for patients

to purchase. The literature obtained from the systematic

search dated from 1988–2010 and included primary

and secondary sources of research, anecdotal

reports, letters and recommendations.

inclusion criteria was applied

in order to reduce the

references in a systematic

way and Figure 1: The Hierarchy of evidence7

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SystematicReviews

Randomized Control Trials

Cohort Studies

Case-Control Studies

Case Series, Case Reports

Editorials, Expert Opinions

to demonstrate the validity and reliability of the literature review so that it could be used to improve patient care.

randomised Controlled Trials (rCTs) are the most valid source of primary research if the effectiveness of an intervention is to be measured.17 Therefore, it was appropriate to apply rCTs as criteria for inclusion. Moreover, only studies of at least six months duration were considered for inclusion, as this is the minimum requirement for the assessment of a product that claims to be effective in reducing plaque and gingivitis.11 in addition, studies were only included if all the test dentifrices were directly related to the literature review question. Furthermore, only peer reviewed literature printed in the English language was eligible for inclusion.

Search resultsThe number of full articles obtained after the application of inclusion criteria can be seen in Table 2.

Analysisin order to make observations on the internal and external validity of the studies18 a modified version of the Critical Appraisal Skills Programme tool for rCTs19 was applied to critique the literature. This tool was modified to make the appraisal tool specific to the rCTs related to the research question and study design, thus aiding the rigorous appraisal of the literature. Each paper was systematically assessed for sample selection; randomisation; blinding; bias; methodology, which included methods of baseline assessment and oral hygiene procedures; clarity of results; and completeness of follow-ups.

Study resultsAll 22 studies identified for inclusion were randomised, longitudinal, stratified and parallel group clinical trials of a minimum of six months duration. However, the method of randomisation was only clear in five of the studies 4,20-23. Dental industry involvement was noted in all of the studies in terms of dentifrice provision, funding, or co-authors being involved in the research centres.

Participants were assessed for mean baseline plaque and gingival index scores, stratified into balanced groups and randomly assigned the use of one of the test dentifrices or a control dentifrice. The dentifrice formulations and method of baseline assessment varied amongst the studies. The majority of the studies identified for the literature review were double-blinded to minimise the risk of bias. However, one triclosan/copolymer study24 was single-blinded as the participants in the control group used their own dentifrice.

Participants were re-examined at least twice during the study period. At the end of a period of at least six months, the results tables (Tables 3-5) demonstrate the statistically significant greater reduction in the mean plaque index, gingival index and gingival bleeding scores when the test dentifrice was compared to a fluoride control.


in the comparative trials, at the end of the six month test period, one study concluded there were no statistically significant differences in mean plaque and gingival indexes between a dentifrice containing triclosan/copolymer and a dentifrice containing triclosan/zinc citrate.45 However, the studies comparing dentifrices containing triclosan/copolymer and stabilised SnF2 produced conflicting results.

Two studies demonstrated that SnF2 was more effective in reducing gingivitis than triclosan/copolymer 22,5 and one demonstrated that triclosan/copolymer was more effective at reducing plaque and gingivitis than SnF2.46

DiscussionVariations in the results were found when the test dentifrices were compared to a fluoride control. in addition, conflicts were found when triclosan/copolymer and SnF2 were placed in direct comparative trials. This made it difficult to quantify the effectiveness of a specific dentifrice. Patient compliance is an important factor in clinical trials47. in addition, analysis of the literature uncovered differences in the study methodology that may partly explain some of the variation noted in the results.

The first difference identified was in the formulations of the specific dentifrices. it has been reported that, due to the importance of maintaining the bioavailability and, in some cases, to increase the substantivity of the active ingredients in dentifrices, different formulations may have different levels of efficacy9. Therefore, the differences in dentifrice formulations make a direct comparison of results difficult and thus may partly explain the variations in reported levels of effectiveness of the dentifrices.

The second factor noted was the lack of reported examiner calibration. Although the majority of the studies stated that participants were re-examined by the same examiner, only three studies reported that the examiners were calibrated. 35,37,39 Differences in the grading of indices can be expected between examiners therefore, lack of examiner calibration may have affected the results.22,48

The analysis of the studies demonstrated that there were differences in the plaque and gingival indices used to assess plaque and gingivitis levels in the studies, which made it difficult to make a direct comparison of all the results. However, eighteen of the studies utilised the Talbott, Mandel and Chilton 27 modification of the Löe-Silness Gingival index 29. Therefore the mean baseline scores of this index were analysed in relation to the results.

in all of the triclosan/copolymer studies, the participants required a minimum mean baseline Talbott, Mandel and Chilton27 modification of the Löe-Silness Gingival index29 score of 1.0 to enter into the study. The mean baseline gingival index score for the triclosan/copolymer studies and comparative studies using this criteria ranged from 1.16 33 to 1.72.40 in contrast, the mean baseline gingival index scores for the stabilised SnF2 and remaining comparative studies were also analysed. The mean baseline gingival index score of participants included in these studies ranged from 0.515 to 0.71.20,21 This observation uncovered a limitation of the studies, which may have implications on the results and application to clinical practice.

The limitation of the studies related to the dental industry involvement. As previously stated, dental

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Table 1. Initial search results

Table 2. Papers included in the

literature review

Data base searched and search results September 2010

Search Terms Pub Med DARE Cochrane Oral Health Group

Google Scholar Comments

1) Plaque, gingivitis, clinical trials. 952 2 0 7940

retrieval included oral hygiene aids as well as dentifrices and mouth rinses and therefore refinement was required. Boolean logic applied using ‘AND’.

2) Plaque, gingivitis, clinical trials AND dentifrices.

306 2 0 3780

Therapeutic agents identified and search re- run to separate into sections for easier appraisal and to refine search to the research question.

3) Triclosan, plaque, gingivitis, clinical trials AND dentifrices.

73 1

1 (not published at time of writing this paper but was in review process)

486Abstracts reviewed to consider eligibility for inclusion in literature review.

4) Stannous fluoride, plaque, gingivitis, clinical trials AND dentifrices.

38 0 0 365 As above.

Dentifrice Number of papers included in the literature review

Triclosan and copolymer 10

Triclosan and zinc citrate 4

Stabilised stannous fluoride (SnF2) 4

Comparative clinical trials 4


industry involvement was identified in all of the studies. in the triclosan/copolymer studies, Colgate provided the dentifrices and funding or the co-authors were involved in the Colgate Palmolive Technology Centre. in the triclosan/zinc citrate studies, Unilever provided funding or the co-authors were involved in the Unilever research laboratory. in the stabilised SnF2 studies, Proctor and Gamble provided dentifrices and funding or the co-authors were involved in the Proctor and Gamble technical or oral health care research centres. in the comparative trials, two studies had funding provided by Colgate or the co-authors were involved in the Colgate Palmolive Technology Centre 45,46 and two trials had funding provided by Proctor Gamble or the co-authors were involved in the Proctor and Gamble technical or oral health care research centres. 5,22

in the comparative studies with Proctor and Gamble involvement, a lower mean Talbott, Mandel and Chilton modification27 of the Löe-Silness Gingival index 29 baseline was noted and the stabilised SnF2 dentifrices resulted in a statistically significant

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Reference % Greater reduction in mean plaque index*

% Greater reduction in mean gingival index #

% Greater reduction in gingival bleeding ##

Cubells et al. (1991)32 24.9% 19.7% 57.5%

Deasy et al. (1991)33 32.3% 25.6% 57.1%

Garcia-Godoy et al. (1991)34 58.9% 30.2% 87.6%

Bolden et al. (1992)35 17.0% 29.0% 47.6%

Denepitiya et al. (1992)36 18.4% 31.5% 57.1%

Mankodi et al. (1992)37 11.9% 19.7% 73%

Lindhe et al. (1993)38 31.3% 26.7% Not available

Kanchanakamol et al.

(1995)2412.1%

Not statistically significant

Not available

Allen et al. (2002)39 27.9% 21.4% 69.2%

Triratana et al. (2002)40 34.9% 25.7% 40.3%

* Turesky modification25 of the Quigley Hein plaque index 26

# Talbott, Mandel and Chilton27 modification of the Löe-Silness Gingival index 28

## Talbott, Mandel and Chilton27 modification of the Löe-Silness Gingival index 28 (sites grading 2 or 3)

≠ Silness and Löe plaque index 29

∞ Ainamo and Bay gingival index 30

≠ Silness and Löe plaque index 29

* Turesky modification25 of the Quigley Hein plaque index 26

# Talbott, Mandel and Chilton27 modification of the Löe-Silness Gingival index 28

× Modified gingival index (Lobene et al.)31

Table 3. Results of the triclosan/copolymer studies

Table 4. Results of the triclosan/zinc citrate studies

Table 5. Results of the stabilised stannous fluoride studies

Reference % Greater reduction in mean plaque index ≠

% Greater reduction in gingival bleeding ∞

Svatun et al.(1987)41 50.0% 78.0%

Svatun et al. (1989)42 37.04% 33.6%

Stephen et al. (1990)4 Not significant 50.2%

Svatun et al. (1993)23 28.0% 50.0%

Reference % Greater reduction in mean plaque index

% Greater reduction in mean gingival index

% Greater reduction in mean number of gingival bleeding sites.

Beiswanger et al. (1995)20 Not significant ≠ 18.0 % # Not significant

Perlich et al. (1995)21 Not significant * 20.5% # 33.4%

Mankodi et al. (2005)43 6.9% * 21.7% × 57.1%

Mallatt et al. (2007)44 8.5% * 16.9% × 40.8%

greater reduction in the mean gingival index over the triclosan/copolymer dentifrice.5,22 Conversely, in the study with involvement from Colgate, a higher mean baseline gingival index score was noted and the triclosan/copolymer dentifrice demonstrated a statistically significant greater reduction in the mean gingival index over the stabilised SnF2 dentifrice.46 This observation demonstrates how a clinical trial may be designed to influence an outcome through the potential bias in the selection of participants.

Additionally, this observation may be applicable to practice as it may add to the argument that triclosan containing dentifrices are most effective in patients demonstrating higher levels of gingivitis.

ConclusionDespite the variation in the results, analysis of the papers identified that triclosan/copolymer, triclosan/zinc citrate and stabilised stannous fluoride dentifrices have the ability to reduce or control dental plaque and gingivitis when compared to a fluoride control. However, stabilised stannous fluoride


dentifrices may not have such an effect on the reduction of plaque when compared to dentifrices containing triclosan. it was proposed that a triclosan/copolymer dentifrice may be more effective in reducing or controlling gingivitis in those areas demonstrating the most gingival inflammation.

Implications for future researchDespite the variations in the ranges of percentages of effectiveness, the facts gleaned from the literature provided enough information to improve the evidence-based advice that can be given to patients. However, the literature review uncovered potential areas for future research. it is suggested that future research should be:

• Performed in an impartial manner, as all of the studies identified for the review had dental industry involvement from the manufacturers of the specific dentifrices.• Performed on specific dentifrices with the same formulation, on the same population sample using the same method of assessment and with fully calibrated examiners.• Performed on populations across a range of backgrounds and ages and across a range of specific disease levels, so dental professionals can recommend a specific dentifrice to aid the patient in the improvement of his or her oral health.

This paper is based on the author’s dissertation submitted as part of her BSc (Hons) in Primary Dental Care for the University of Kent.

References1. 1. Baig A, He T. A novel dentifrice technology for advanced oral health protection: A review of technical and clinical data. Compend Contin Educ Dent. 2005; 26(9): 4-11.

2. Stamm JW. Multi-function toothpastes for better oral health: a behavioural perspective. Int Dent J 2007; 57(s5): 351-63.

3. Darby ML, Walsh MM. Dental Hygiene Theory and Practice. Canada: Saunders Elsevier (2010).

4. Stephen KW, Saxton CA, Jones CL. et al. Control of gingivitis and calculus by a dentifrice containing zinc salt and triclosan. J Periodontol 1990; 61(11): 674-79.

5. Archila L, Bartizek rD, Winston JL. et al. The comparative efficacy of stabilized stannous fluoride/sodium hexametaphosphate dentifrice and sodium fluoride/triclosan/copolymer dentifrice for the control of gingivitis: A 6-month randomised clinical study. J Periodontol 2004; 75(12): 1592-99.

6. Department of Health. Delivering Better Oral Health: An Evidence- Based Toolkit for Prevention. Available at: http://www.dh.gov.uk/en/ Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/ DH_102331 (accessed 20th April 2010), 2009.

7. Hierarchy of Evidence image. Available at: www. mirakelbutik.dk (accessed April 20th 2011).

8. Davies rM, Ellwood rP, Davies GM. The effectiveness of a toothpaste containing triclosan and polyvinyl-methyl ether maleic acid copolymer in improving plaque control and gingival health: a systematic review. J Clin Periodontol 2004; 31(12): 1029-33.

9. Gunsolley JC. A meta-analysis of six-month studies of antiplaque and antigingivitis agents. J Am Dent Assoc 2006; 137(12): 1649-57.

10. Hioe KP, van der Weijden GA. The effectiveness of self- performed mechanical plaque control with triclosan containing dentifrices. Int J Dent Hyg 2005; 3(4): 192-204.

11. Paraskevas S, van der Weijden GA. A review of the effects of stannous fluoride on gingivitis. J Clin Periodontol 2006; 33(1): 1-13.

12. Garrard J. Health Sciences Literature review Made Easy. Available at: http://books.google.co.uk/books?id=XZ8w2wjQa3 MC&printsec=frontcover&dq=literature+review&cd=3#v=o nepage&q&f=false (accessed 19th April 2010), 2007.

13. Carnwell r, Daly W. Strategies for the construction of a critical review of the literature. Nurse Educ Pract, 2001; 1(2): 57-63.

14. Gerrish, K, Lacey A. The research Process in Nursing. 5th edn. Oxford: Blackwell Publishing (2006).

15. Timmins F, McCabe C. How to conduct an effective literature search. Nurs Stand, 2005; 20(11): 41-47.

16. General Dental Council Standards Guidance. Standards for Dental Professionals. London: The General Dental Council (2006).

Nicola G

ough

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ingivitis

17. Greenhalgh T. How to read a Paper: the Basics of Evidence- Based Medicine. 3rd ed. London: Blackwell Publishing (2006).

18. Brunette D. Critical Thinking. Understanding and Evaluating Dental research. London: Quintessence Publishing Co. (2007).

19. Public Health resource Unit. Critical Appraisal Skills Programme. Available at: http://www.phru.nhs.uk/casp/casp.htm (accessed 4th December 2010).

20. Beiswanger BB, Doyle PM., Jackson rD. et al. The clinical effect of dentifrices containing stabilised stannous fluoride on plaque formation and gingivitis. A 6-month study with ad libitum brushing. J Clin Dent 1995; 6 (special edition): 46-53.

21. Perlich MA, Bacca LA, Bollmer BW et al. The clinical effect of a stabilised stannous fluoride dentifrice on plaque formation, gingivitis and gingival bleeding: a 6-month study. J Clin Dent 1995; 6 (special number): 54-58.

22. McClanahan SF, Beiswanger BB, Bartizek rD et al. A comparison of stabilised stannous fluoride dentifrice and triclosan/copolymer dentifrice for efficacy in the reduction of gingivitis and gingival bleeding: six month clinical results. J Clin Dent 1997; 8(2) 39-45.

23. Svatun B, Saxton CA, Huntingdon E et al. The effects of a silica dentifrice containing triclosan and zinc citrate on supragingival plaque and calculus formation and the control of gingivitis. Int Dent J 1993; 43(4): 431-39.

24. Kanchanakamol U, Umpriwan r, Jotikasthira N. et al. reduction of plaque formation and gingivitis by a dentifrice containing triclosan and copolymer. J Periodontol 1995; 66(2): 109-12.

25. Turesky S, Gilmore ND, Glickman i. reduced plaque formation by the chloromethyl analogue of victamine C. J Periodontol 1970; 41: 41-43.

26. Quigley GA, Hein JW. Comparative cleansing efficiency of manual and power brushing. J Am Dent Assoc 1962; 65: 26-29.

27. Talbott K, Mandel iD, Chilton NW. reduction of baseline gingivitis scores with repeated prophylaxis. J Prev Dent 1977; 4(6): 28-29.

28. Löe H, Silness J. Periodontal disease in pregnancy 1: Prevalence and severity. Acta Odontol Scand 1963; 21: 531-51.

29. Löe H. The gingival index, the plaque index and retention index system. J Periodontol 1967; 38(6): 610-16.

30. Ainamo J, Bay i. Problems and proposals for recording gingivitis and plaque. Int Dent J 1975; 25(4): 229-35.

31. Lobene rr, Weatherford T, ross NM et al. A modified gingival index for use in clinical trials. Clin Prev Dent 1986; 8(1): 3-6.

32. Cubells AB, Dalmau LB, Petrone ME et al. The effect of a triclosan/copolymer/fluoride dentifrice on plaque formation and gingivitis: a six month clinical study. J Clin Dent 1991; 2(3): 63-69.

33. Deasy MJ, Singh SM, rustogi KN et al. Effect of a dentifrice containing triclosan and copolymer on plaque formation and gingivitis. Clin Prev Dent 1991; 13(6): 12-19.

34. Garica-Godoy F, De Vizio W, Volpe Ar et al. Effect of a triclosan/ copolymer/fluoride dentifrice on plaque formation and gingivitis: a 7-month clinical study. Am J Dent 1990; 3 (special number): s15-26.

35. Bolden TE, Zambon JJ, Sowinski J et al. The clinical effect of a dentifrice containing triclosan and a copolymer in a sodium fluoride/silica base on plaque formation and gingivitis: a six month clinical study. J Clin Dent 1992; 3(4): 125-31.

36. Denepitiya JL, Fine D, Singh S et al. Effect upon plaque formation and gingivitis of a triclosan/copolymer/fluoride dentifrice: a 6-month clinical study. Am J Dent 1992; 5(6): 307-11.

37. Mankodi S, Walker C, Conforti N et al. Clinical effect of a triclosan-containing dentifrice on plaque and gingivitis: a 6-month study. Clin Prev Dent 1992; 14(6): 4-10.

38. Lindhe J, rosling B, Socransky SS et al. The effect of a triclosan-containing dentifrice on established plaque and gingivitis. J Clin Periodontol 1993; 20(5): 327-34.

39. Allen Dr, Battista GW, Petrone DM et al. The clinical efficacy of Colgate Total Plus Whitening Toothpaste containing a special grade of silica and Colgate Total Fresh Stripe Toothpaste in the control of plaque and gingivitis: a six-month clinical study. J Clin Dent; 2002; 13(2): 59-64.

40. Triratana T, rustogi KN, Volpe Ar et al. Clinical effect of a new liquid dentifrice containing triclosan/copolymer on existing plaque and gingivitis. J Am Dent Assoc 2002; 133(2): 219-25.

41. Svatun B, Saxton CA, van der Ouderaa F et al. The influence of a dentifrice containing zinc salt and nonionic antimicrobial agent on the maintenance of gingival health. J Clin Periodontol 1987; 14(8): 457-61.

42. Svatun B, Saxton CA., rölla G et al. One-year study of the efficacy of a dentifrice containing zinc citrate and triclosan to maintain gingival health. Scand J Dent Res 1989; 97(3): 242-46.

43. Mankodi S, Bartizek rD, Winston JL et al. Anti-gingivitis efficacy of a stabilised 0.454% stannous fluoride/sodium hexametaphosphate dentifrice. J Clin Periodontol 2005; 32(1): 75-80.

44. Mallatt M, Mankodi S, Bauroth K, et al. A controlled 6-month clinical trial to study the effects of a stannous fluoride dentifrice on gingivitis. J Clin Periodontol 2007; 34(9): 762-7. Epub 2007 Jul 23.

45. Conforti NJ, Smith i, Davies r et al. Comparative efficacy of two commercially available dentifrices containing Triclosan in the control of plaque and ingivitis: a six-month clinical study in Scotland. J Clin Dent 1994; 5(3):70-73.

46. Mankodi S, Lopez M, Smith i, et al. Comparison of two dentifrices with respect to efficacy for the control of plaque and gingivitis, and with respect to extrinsic tooth staining: a six-month clinical study on adults. J Clin Dent 2002; 13(6): 228-33

47. Wolff LF, Pihlstrom BL., Bakdash MB et al. Effect of brushing with 0.4% stannous fluoride and 0.22% fluoride gel on gingivitis for 18 months. J Am Dent Assoc 1989; 119(2): 283-89

48. Giannobile WV, Burt BA, Genco rJ. Clinical research in Oral Health. iowa: Wiley Blackwell (2010).


Does the use of mouthwash which contains alcohol increase the risk of oral cancer? A review of the literature

AbstrAct

objective: To carry out a literature review to address the question, “Does scientific evidence

indicate that the use of mouthwash that contains alcohol increases the risk of

oral cancer?”

Methods: Studies were identified through a systematic search using bibliographic

databases and relevant websites. These included; Pubmed, Cochrane, Database

of abstracts of reviews of Effectiveness (DArE), Cancer research UK and the

National research register. Only case controlled studies written in the English

language and published since 1983 were included in the review.

results: Ten case-controlled studies were identified. Analysis of the studies showed

widespread disparity and shortcomings in the methodology of the studies.

There was a variation in results and conflicting outcomes.

conclusions: Although controversy exists regarding increased risk of oral cancer when using

a mouthwash containing alcohol, a review of the literature does not support

a causal association between alcohol mouthwash and increased risk of oral

cancer.

Key Words: mouthwash, mouth rinses, alcohol, oropharyngeal and oral cancer.

Susan Bagnall


Co-director of

www.CPD4dentalhygienists.co.uk ,

www.CPD4dentalnurses.co.uk and

www.CPD4dentaltechnicians.co.uk

Dental hygienist at:

Albert road Dental Practice,

Evesham, Worcestershire.

Marble Alley Dental Practice,

Studley, Warwickshire.

Correspondence to:

[email protected]

MOUTHWASH

IntroductionDental hygienists and dental hygienist-therapists have historically recommended the use of a variety of mouthwashes, some containing alcohol, to help patients improve plaque control. Haffagee et al. conducted an investigation to examine if mouthwashes with different formulations affect the composition of subgingival microbiota and concluded that microbial changes were accompanied by improvement in clinical parameters of periodontal maintenance in their subject group1. This finding is supported by a review of studies performed by Silverman and Wilder, who concluded that mouth rinses were an important method of reducing plaque and gingivitis2.

However, the safety of alcohol-containing mouthwashes has been questioned due to a possible link to oral cancer3. Cole, rodu, and Mathisen conducted a review of the epidemiology of oropharyngeal cancer with respect to alcohol-containing

mouthwashes and concluded that “practicing dentists may recommend to their patients that they use the mouthwashes of their choice, including those that contain alcohol.”4 McCullough and Farah, on the other hand, conducted a review of epidemiological evidence studies that showed a link between alcohol and development of oral cancer and concluded that “sufficient evidence was available to accept the proposition that developing oral cancer is increased or contributed to by the use of alcohol-containing mouthwashes.”5 These conflicting opinions led the author to question the advice provided to patients regarding the use of mouthwash.

The General Dental Council states that dental professionals should “provide a good standard of care based on available up-to-date evidence and reliable guidance”6. The aim of the review was to inform the author’s professional practise to provide patients with evidence-based information regarding mouthwashes that are a suitable adjunct to oral hygiene.


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Risk factors of oral cancer The National Cancer institute (NCi) defines oral cancer as “Cancer that forms in the tissues of the oral cavity (mouth) or the oropharynx (the part of the throat at the back of the mouth).”7 The prevalence of oral cancer is increasing in the United Kingdom (UK). Cancer research UK reports that from 1989 to 2006 the incidence of oral cancer in males has steadily risen to reach 11 cases per 100,000 of the population; this is an increase of 51%. in females the rates are significantly lower. Nevertheless, over the same period the rate has increased by 2.7% each year, approximately 50%8.

it is documented that the major risk factors for oral and pharyngeal cancer in developed countries are tobacco smoking and alcohol consumption9,10. A positive correlation has also been identified between low intake of fresh fruit and vegetables and increased risk of oral cancer3. in addition, poor oral health and hygiene have been considered a contributing risk factor11. Other aetiological factors that have been associated with increased risk in oral and pharyngeal cancer include human papilloma virus, Epstein-Barr virus and Candida albicans12.

Tobacco in any form, cigarettes, pipes, cigars and smokeless tobacco have all been associated with increased risk of oral cancer13,14 Chewing tobacco, which is usually mixed with betel quid, is also considered a contributing risk factor and is more commonly used by the Asian ethnic minority group3.

The risk of oral cancer associated with alcohol varies depending on the alcohol content of the beverage, with wine reported to present a lower risk15,16. A meta-analysis of published case-control and cohort studies of alcohol drinking and cancer risk observed strong trends in risk of cancers of the oral cavity, pharynx, oesophagus and larynx 17. However, smoking and drinking in combination suggest cumulative increased risk in oral and pharyngeal cancer14.

MouthwashesMouthwashes contain a variety of constituents including: water, antiseptics, antibiotics, antifungals, astringents, anti-inflammatories and alcohol 18. Alcohol is mainly used in mouthwashes as a solvent for other ingredients, but can also act as a preservative5,19. Some brands of mouthwash have an alcohol content that is equal to, or exceeds, the alcohol content of many alcoholic beverages; the alcohol content can be as high as 26%5,20. Furthermore, Weaver et al suggest mouthwash is generally held in the oral cavity for longer periods of time than alcoholic beverages20. Kowitz et al reported epithelial peeling, mucosal ulceration, gingivitis, and petechiae in a study of dental and dental hygiene students who used 20 ml of mouthwash with a 25% alcohol content twice a day for five-second intervals over a two-week period21.

Literature reviewA comprehensive review of pre-existing literature was conducted using a systematic, evidence-based approach in order to gain a comprehensive understanding of mouthwashes, and specifically the potential link (or lack thereof) of mouthwashes with alcohol and oral cancer. The literature review was undertaken with a positivist approach, which entailed a scientific approach to quantitative research that could produce knowledge reasonably considered to be unbiased.

MethodologyA search was conducted using bibliographic databases and relevant websites, including Pubmed, Cochrane, Database of Abstracts of reviews of Effectiveness (DArE), Cancer research UK, and the National research register. Specific search terms were used both individually and with Boolean logic operators in order to capture all the relevant information.

To focus the literature search and enable it to be completed within the set time frame, inclusion and exclusion criteria were used. Aveyard states “inclusion and exclusion criteria enable the literature reviewer to identify the literature that addresses the research question and that which does not.”22 Houser suggests that inclusion and exclusion criteria help to control extraneous variables23. The inclusion criteria included articles written in the English language, primary research that was relevant to the research question and, initially, literature which was published since 1990. This date was set in an effort to restrict the number of articles located in order to allow completion of the literature review within the set time scale. Following a citation search of the literature, this date was extended to 1983 in order to allow inclusion of research that was cited in a number of articles and which the author acknowledged was relevant to the research question. The exclusion criteria included literature that was written in languages other than English, primary research that was not relevant to the research question, and literature published before 1990 (this was changed to literature published before 1983, as noted earlier). Grey literature and anecdotal reports were excluded due to the lack of evidence they provided 23.

Reduction of the searchThe initial search yielded 351 articles which was reduced to 29 by the inclusion/exclusion criteria. Melnyk et al suggest that to provide answers to clinical questions it is necessary to use evidence which ranks higher in the hierarchy of evidence24. The highest level of confidence can be found in systematic reviews, followed by randomised control trials and then other controlled trials. A systematic review of mouthwashes containing alcohol, or a review of their role with respect to oral cancer risk, was not found.


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randomised controlled studies and controlled clinical trials on this topic were not available due to the ethical issue of conducting such studies. in addition, Werner and Seymour note that oral cancer is a chronic disease, and a randomised controlled study would be difficult to carry out as it would require a large follow-up population19.

Denscombe suggests “case studies work best when the researcher wants to investigate an issue in depth and provide an explanation that can cope with the complexity and subtlety of real life situations”. Therefore, as the author considered case-controlled studies as the highest level of evidence available for inclusion in the literature review, the inclusion criteria were adjusted to include only case-controlled studies. A total of ten papers were included in the literature review.

Flow summary of the search reduction

Critical appraisal of literatureA systematic approach was taken to critically appraise each paper using explicit, systematic, and clearly identified methods in order to reach an unbiased conclusion26. An appraisal tool adapted by combining key questions from the Critical Appraisal Skills Program (CASP) qualitative research tool for case studies 27 with key questions from Critical Appraisal/reviewers Checklist for research Papers28 was used to analyse the literature. Adapting critical appraisal tools can facilitate rigorous appraisal of literature29. Literature included in the literature review was examined critically to assess its validity and reliability. This was important to demonstrate the credibility of the research. Confirmation of whether ethical approval was gained for studies included in the review was examined, as ethical approval

can be considered a fundamental feature of all good research 25.

Analysis and resultsThe ten studies accessed in the systematic search were analysed for geographical distribution, study characteristics, and inclusion/exclusion criteria for the cases and controls. The quality of the studies was assessed for criteria specific to the research question by examining the following: interview technique and examiner calibration; assessment of mouthwash use and oral hygiene status; assessment of smoking status and alcohol intake; and other covariates (race, religion, fruit and vegetable intake). These factors were assessed to examine the risk of bias of the studies.

Multiple logistic regression (a statistical prediction of probability) was used to estimate the association between the risk factor and oral cancer in eight of the studies30. Kabat et al used Miettinen’s method (a method used to construct confidence intervals) to estimate the association between the risk factor and oral cancer31.

The papers were divided almost equally, with five papers reporting that the use of alcohol-containing mouthwash increased the risk of oral cancer, and four papers reporting no increased risk. Garrote et al provided a vague, nonspecific reference to the concept that mouthwash provides a protective factor against oral cancer32. However, no details of types of mouthwash used, or questions asked of subjects were provided.

Kabat et al reported that mouthwash use was not associated with increased oral cancer risk in terms of frequency, duration of use or rinsing practices31. However, it was found that cases did report taking more mouthwash mouthfuls than the controls. Mashberg et al reported a similar proportion of patients and controls reported using mouthwash. in the groups of patients that reported similar smoking habits no statistical difference was associated with mouthwash use33. No statistically significant link was found after adjusting for the variables of smoking and drinking habits between oral and pharyngeal cancer and mouthwash use in categories of alcohol consumption that were studied. No statistical differences were found between different brands of mouthwash or mouthwashes with different alcohol content.

The overall results of the study by Winn et al showed no association between mouthwash use and oral cancer with greater exposure of frequency or duration of use, or with alcohol content of the mouthwash34. However, an elevated risk that was not felt to be significant was reported in non-smokers and abstainers from alcohol.

The rest of the studies demonstrated some level of increased risk of oral cancer associated with mouthwash use. Divaris et al reported marginally elevated estimates of risk for oral cancer with


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consistent mouthwash use among African Americans who had never smoked or drank35.

Guha et al 11 and Marques et al36 reported a higher risk for oral cancer when mouthwash was used twice a day. Winn et al34 and Wynder et al37 reported a significantly increased risk of cancer associated with mouthwash use in males and a significantly higher increased risk in females. This risk was not found to be less in individuals who did not smoke or drink. Wynder et al also found females who used mouthwash for the previous one to four years appeared to be the highest risk37.

Guha et al reported that poor oral hygiene in combination with use of a mouthwash twice a day were risk factors for head and neck cancer across all cancer sites; the strongest association was with oral cancer11. Wynder et al reported that cancer site distribution was similar in males and females, and did not differ with different frequency of mouthwash use in males or females37.

DiscussionGeographical distributionThe incidence of oral cancer is highest in developing countries such as: india, Sri Lanka, Bangladesh, and Pakistan the countries included in the studies with the exception of Cuba were described as developed countries. Therefore, it could be considered that conclusions drawn from the analysis of the literature is biased towards developed countries and not globally representative.

AgeHistorically, the risk increases for oral cancer with age, specifically starting at the age of 40 years38. Only three of the studies restricted the sample to only include case and control subjects who were more than 40 years of age11,33,36. The results of these studies could be considered more representative, as they are specific to the age group at risk.

Brand informationThe research question specifically dealt with alcohol-containing mouthwash. Brand information is essential to confirm the alcohol content of the mouthwash. However, the brand information provided in the studies was limited or not available.

Mouthwash useMost of the studies failed to report on all aspects of mouthwash use, such as: information regarding use, including age at which the subject started to use mouthwash; whether mouthwash was being used at diagnosis; if they had stopped, how many years ago they stopped using mouthwash; frequency of mouthwash use in the year preceding diagnosis; brand used for longest period; dilution; rinsing; and number of mouthfuls. Failing to report on these aspects could potentially introduce bias into the data.

Other ingredients of mouthwashit is widely acknowledged that mouthwashes that contain alcohol also contain a variety of other

ingredients 18. These ingredients have not been considered in any of the studies that were reviewed. Therefore, the causal effect of these ingredients as a risk factor for oral cancer cannot be eliminated.

Interview techniqueAlthough the analysis highlights that a considerable amount of heterogeneity existed in the methods of information collection for the studies, the majority of the studies did fail to report if calibration of the examiners took place.

Confounder risksVariability existed between the covariates in the studies; this makes it difficult to draw comparisons between the studies. A covariate can be defined as “a continuous variable that is not part of the main experimental manipulation but can have an effect on the dependent variable”39. Covariates could include: a diet rich in fruit and vegetables; smokeless tobacco; snuff and betel quid.

AcetaldehydeA personal thought considered by the author was a potential risk of recommending a mouthwash containing alcohol to patients with poor oral hygiene due to a potential increase in metabolism of ethanol into acetaldehyde in the oral cavity in these patients.

Candida albicansThe author also considered a link, albeit tenuous, between alcohol in mouthwash increasing the risk of oral colonisation with Candida albicans. The presence of candida species in the epithelium has been suggested as a risk factor for oral cancer12.

DiscussionA comprehensive search of the current published literature was conducted with the aim of providing a comprehensive unbiased view of the subject. The search was undertaken with a systematic approach, and inclusion/exclusion criteria were applied to focus the search and provide literature relevant to the research question. The search resulted in the location of ten articles that were critically appraised and analysed using an adapted critical appraisal tool.

Analysis of the literature identified the key themes which included: geographical distribution, age, brand information, mouthwash use, interview technique, other mouthwash ingredients, confounder risks, acetaldehyde, and the presence of Candida albicans.

Exploration of the key themes highlighted a variety of issues that could be addressed in the methodology of future research in order to improve the study designs for future research efforts.

Conclusionit is highly unlikely that alcohol in mouthwash increases the risk of oral cancer due to the variation in results and conflicting outcomes across the literature reviewed. However, until further research becomes


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available the author will recommend alcohol-free mouthwash or a mouthwash low in alcohol for short term use and continue to strive to assist patients in improving their oral hygiene.

Recommendations

• Further research is needed to examine the efficacy of mouthwashes that contain alcohol compared to mouthwashes that are alcohol-free.

• The associated risk of oral cancer with the use of alcohol-containing mouthwash warrants further investigation that could include a systematic review and meta- analysis of the world literature and (ideally) a pooled analysis of the individual patient data.

• Further research is needed to explore the metabolism of alcohol in the oral cavity into acetaldehyde and the association with poor oral health.

• Further research could be conducted to explore the possibility that alcohol containing mouthwash could increase the risk of development of Candida albicans in immuno-compromised patients, which could ultimately increase the risk of oral cancer.

• Further research is needed to produce guidelines for recommending alcohol- containing mouthwashes in dental practice.

References

1. Haffajee AD., roberts C., Murray L et al. Effect of herbal, essential oil, and chlorhexidine mouthrinses on the composition of the subgingival microbiota and clinical periodontal parameters. J Clin Dent 2009; 20(7): 211-217.

2. Silverman, S, Wilder, r. Antimicrobial mouthrinse as part of a comprehensive oral care regimen. Safety and compliance factors. J Am Dent Assoc.2006; 137: 22s-26s.

3. Warnakulasuriya, S. Causes of oral cancer – an appraisal of controversies. Brit Dent J 2009; 207(10): 471-475.

4. Cole P, rodu D, Mathisen A. Alcohol-containing mouthwash and oropharyngeal cancer a review of the epidemiology. J Am Dent Assoc 2003; 134(8): 1079-87.

5. McCullogh MJ, Farah CS. The role of alcohol in oral carcinogenesis with particular reference to alcohol- containing mouthwashes. Austr Dent J 2008; 53(4): 302-5.

6. General Dental Council (2005) Standards for Dental Professionals. London: General Dental Council.

7. National Cancer institute (2010) Available from: http://www. cancer.gov/cancertopics/types/oral (accessed 17/3/2011)

8. Cancer research UK (2010) Available from: http://info. cancerresearchuk.org/cancerstats/types/oral/incidence/ (accessed 09/04/10).

9. Talamini r., Vaccarella S., Barbone F et al. Oral hygiene, dentitition, sexual habits and risk of oral cancer. Brit J Cancer 2000; 83(9): 1238-42.

10. Negri E., La Vecchia C., Franceschi S et al. Attributable risk of oral cancer in Northern italy. Cancer Epidemiol, Biomarkers and Prev 1993; 2(3): 189-193.

11. Guha N., Boffetta P., Wünsch Filho V. et al. Oral health and risk of squamous cell carcinoma of the head and neck and esophagus: results of two multicentric case-control studies. Am J Epidemiol. 2007; 166(10): 1159-73.

12. McCullough M., Jaber M., Barrett AW et al. Oral yeast carriage correlates with presence of oral epithelial dysplasia. Oral Oncol. 2002; 38(4): 391-93.

13. National Cancer institute (2010) Available from: http://www. cancer.gov/cancertopics/types/oral (accessed 17/3/2011).

14. Blot WJ., McLaughlin JK., Winn DM et al. Smoking and drinking in relation to oral and pharyngeal cancer. Cancer Res 1988; 48(11): 3282-87.

15. Altieri A., Bosetti C., Gallus S. et al. Wine, beer and spirits and risk of oral and pharyngeal cancer: a case-control study from italy and Switzerland. J Oral Oncol. 2004; 40(9): 904-9.

16. Macfarlane GJ, Zheng T., Marshall Jr et al. Alcohol, tobacco, diet and the risk of oral cancer: a pooled analysis of three case- control studies. Eur J Cancer B Oral Oncol. 1995; 31B(3): 181-7.

17. Bagnardi V., Blangiardo M., La Vecchia C. et al. A meta-analysis of alcohol drinking and cancer risk. Brit J Cancer 2001; 85(11): 1700-5.

18. Carretero Peláez MA, Esparza Gómez GC, Figuero ruiz E, et al. Alcohol-containing mouthwashes and oral cancer. Critical analysis of literature. Med Oral. 2004; 9(2):120-3, 116-20. [Article in English, Spanish]

19. Werner CW, Seymour rA. Are alcohol containing mouthwashes safe? Brit Dent J 2009; 207(10): E19; discussion 488-9.

20. Weaver AM., Fleming SB., Smith D et al. Mouthwash and oral cancer: carcinogen or coincidence. J Oral Surg 1979; 37(4): 250-3.

21. Kowitz GM, Lucatorto FM, Cherrick HM. Effects of mouthwashes on the oral soft tissues. J Oral Med 1976; 31(2): 47-50.

22. Aveyard H. Doing a Literature Review in health and social care. A Practical Guide. Maidenhead: Open University Press (2007).

23. Houser J. Nursing research. London: Jones and Bartlett Publishers international (2008).

24. Melynk, B. and Fineout-Overholt, E. Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice. 2nd Edn. New York: Lippincott, Williams and Wilkins (2010).

25. Denscombe, M. The Good research Guide. 4th Edn. Maidenhead: Open University Press (2010).

26. Hek G. and Moule P. Making Sense of Research an Introduction for Health and Social Care Practitioners. 3rd Edn. London: Sage Publications Ltd. (2006).

27. Solutions for Public Health (2010) Available from: http://www. sph.nhs.uk/sph-fi les/caspappraisaltools/Case%20 Control%2011%20Questions.pdf (accessed 16/2/11).

28. Faculty of General Dental Practice (UK) (2011) Reviewer checklist for research papers. Available from: http://www.fgdp. org.uk/_assets/pdf/publications/pdcchecklistresearch.pdf (accessed 27/3/11).

29. Gambrill, H. Critical Thinking in Clinical Practice Improving the Quality of Judgements and Practice. 2nd Edn. New Jersey: John Wiley &Sons (2005).

30. Lee J. An insight on the use of multiple logistic regression to estimate association between risk factor and disease occurrence. Int J Epidemiol. 1985; 15(1): 22-29.

31. Kabat GC., Hebert Jr, Wynder EL. risk factors for oral cancer in women. Cancer Res. 1989; 49(10): 2803-6.

32. Garrote LF. Herrero r., reyes r et al. risk factors for cancer of the oral cavity and oro-pharynx in Cuba. Brit J Cancer. 2001; 85(1): 46-54.

33. Mashberg A., Barsa P, Grossman, M. A study of the relationship between mouthwash use and oral and pharyngeal cancer. J Am Dent Assoc. 1985; 110(5): 731-4.

34. Winn DM., Blot WJ., McLaughlin JK et al. Mouthwash use and oral conditions in the risk of oral and pharyngeal cancer. Cancer Res.1991; 51(11): 3044-7.

35. Divaris K., Olshan A., Smith J et al. Oral health risk for head and neck squamous cell carcinoma: the Carolina Head and Neck Cancer Study. Cancer Causes Control.2010; 21(4): 567-75.

36. Marques LA., Eluf-Neto J., Figueiredo rA et al. Oral health, hygiene practices and oral cancer. Rev Saúde Publica. 2008; 42(3): 471-9.

37. Wynder E., Kabat G., rosenber S et al. Oral cancer and mouthwash use. J Natl Cancer Institute 1983; 70(2): 255-60

38. Oral Cancer Foundation (2010) Available from: http://www. oralcancerfoundation.org/facts/index.htm (accessed 19/3/11).

39. Oxford English Dictionary Oxford English Dictionary for Students. 4th Edn. Oxford: Oxford University Press (2006).


Parental consent and fluoride varnish schemes: lessons from dental screening

AbstrAct

in 2006 the Department of Health issued guidance reversed the consent mechanisms that could be used for dental public health programmes, i.e. from negative to positive. The implications of this change have been significant for some programmes.

objective: To explore and critically evaluate the published literature in relation to dental public health programmes that specifically require consent and to draw on any concepts found and to apply them to the implementation processes of fluoride varnish programmes.

Methods: A literature search was conducted using two electronic data basis. Literature was systematically compared against specified criteria before rigorous assessment using the CASP tool. Literature was required to meet a 50% threshold of positive answers prior to detailed analysis via thematic extraction.

results: Little evidence exists that details consent procedures for Fluoride varnish programmes. Ten articles were finally assessed and evidence from epidemiological programmes proved a useful proxy indicator. There appears to have been a simple transfer of implementation methods from one programme to another without consideration of appropriateness or effectiveness.

conclusions: Currently there is little understanding amongst the dental profession of the implications of using specific consent mechanisms, and more importantly, what knowledge and evidence there is available is being overlooked.

Key Words: Positive consent, consent processes, Fluoride varnish programmes, dental epidemiology.

Charlotte Jeavons


University of Greenwich

School of Health and Social Care

Mary Seacole Building, 2nd Floor

Southwood Site

Avery Hill Campus

Avery Hill road

Eltham

London

SE9 2PQ

Correspondence to:

[email protected]

DENTAL SCrEENiNG


IntroductionDental Public Health Dental Public Health is the branch of dentistry that is primarily concerned with preventing oral disease and improving the quality of life for whole populations.1 in 2005 a dental strategy was published that placed greater emphasis on the need for public health interventions to address oral health inequalities.2

Dental epidemiological screening Since 1918 dental examinations of school children have been mandatory, and this statutory duty remained until November 2006.3 Prior to 2006, this function was the responsibility of NHS Primary Care Salaried Dental Services (PCSDS)and dental epidemiological programmes were carried out across the country, with various implementation methods. Many areas reported high levels of participation with some regularly reporting 96% uptake.4 However, changes in Department of Health (DH) guidance that states that positive consent must be obtained for all dental examination for screening or surveys, has resulted in most programmes now ceasing to exist.5 Previously programmes had operated a negative consent system.6 Those that remained experienced a dramatic reduction in the numbers of participants.4

Fluoride varnish programmes Extensive research has been conducted to examine the efficacy and safety of fluoride use by humans both on an individual and population level and its use as advocated by the Department of Health.7-9 in 2006/7, a programme was initiated in Scotland, which involved the application of fluoride varnish to children’s teeth.10 This was the first major population based dental treatment programme of its type in the UK. The programme, called ChildSmile, was delivered via a setting based approach where Dental Care Professionals (DCPs) visited nurseries and schools to apply fluoride.10,11 Since 2006/7 several similar programmes have started across the country.

The concentration of fluoride recommended to be effective (2.2% fl-) renders its classification as a ‘prescription only medicine’.12 As a result, it is a legal, and possibly moral, requirement that individuals, or those with parental responsibility, provide their consent before a child receives treatment.13 The majority of the fluoride varnish (FV) programmes now in operation are aimed at young primary-school-aged-children and require parents to provide written positive consent.14,15

Parental consent Western society places importance on autonomy, especially in relation to medical treatment. The concept of autonomy is considered so important it is a founding ethical principal of health promotion.16 Furthermore, respect for autonomy is entrenched in British law.17 One way to prove that autonomy has been respected is for patients, or those who are considered responsible for them, such as parents of young children, to be asked to sign a consent form.

This is considered good practise by many healthcare regulators of medical or dental personnel, such as the General Dental Council (GDC).18

As illustrated by the 2006 DH guidance there has been a move in recent years to apply the medico-ethical principal of autonomy and its practical application of positive consent to the field of public health dental programmes.5 The result has had a significant impact on programmes not least through the clear demonstration of the inverse care law, which has led some PCSDS Managers to rethink the allocation of resources delivering these programmes, particularly if the outcome may contribute to greater oral health inequalities.14,19-21

Research questionWhat lessons can be learnt from dental epidemiology programmes with regards to consent process that can be applied to the design and delivery of fluoride varnish programmes?

Objective• To explore and critically evaluate the published literature in relation to dental public health programmes that specifically require consent and to draw on any concepts found, and to apply them to the implementation processes of fluoride varnish programmes.

Methods The broad topic area of ‘impact of consent procedures used for dental public health programmes’ was used for the initial exploratory search. The purpose was to ascertain if anecdotal evidence, i.e. that current consent procedures appeared to result in a demonstration of the inverse care law, had been examined and published by others.14,19

Electronic data basis searched included Pubmed and Web of Knowledge. Articles were located from here via the UK Access Management Federation gateway. The Cochrane Collaboration data base was also consulted for citations included in systematic reviews that could be followed up.22

Inclusion and exclusion criteriaFrom the articles generated, particular attention was paid to those that documented consent procedures, therefore both quantative and qualitative studies were deemed acceptable if they satisfied the inclusion and exclusion criteria. The inclusion and exclusion criteria used are listed below. The criteria were all given equal importance i.e. there was no hierarchy between criterions.

Inclusion criteria• PublishedintheEnglishlanguage• Publishedsince2001 Literature must be related to dental

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public health programmes • If the literature is research, it was carried out in the UK, Europe, Canada or USA• Provides information on dental epidemiology, fluoride varnish programmes and, or consent, whether research article or literature from another source

Exclusion criteria• Thetextisitselfaliteraturereview• Theliteratureisnotaboutschoolagechildren• Literature content is about clinical dentistry in a surgery setting and not related to a dental public health programme• A letter to an editor and / or editor’s published response• Literature content includes predominantly secondary sources of information• Literature is an editorial / opinion style article or paper

The flow chart, right, is a pictorial demonstration of the literature search and reduction processArticles were reviewed against the inclusion and exclusion criteria and abstraction tables completed. Once saturation point had been reached a summary table of all articles was compiled. The Critical Appraisal Skills Programme (CASP) for qualitative studies developed by the Public Health resource Unit was used to make a further detailed assessment.23 A threshold of 50% of positive answers was set prior to assessment using the CASP tool.

ResultsLiterature identifiedinitial scooping and subsequent searches showed a large volume of irrelevant literature, outside the realms of dental public health, was routinely identified by both data basis. research papers consistently focused on large scale clinical programmes with few results looking at the effectiveness of implementation procedures i.e. methods for gaining consent. The pattern of articles sourced via Pubmed and Web of Knowledge was similar in both volume and category. Searches for publications about fluoride varnish schemes and consent processes, showed there was synergy between facilities with data basis locating 0 articles. Some studies did included descriptions of the procedures used but this rarely, if ever, included details of consent processes.24,25 No prominent

Literature reduction process &

results for full text papers using

CASP after the initial online filtering and

reduction process

Literature sourceNumber of selected full text articles /papers

Number excluded after detailed read and abstraction table completed

Number assessed using CASP questions

Number excludedafter CASP

Total submitted for detailed analysis

Pubmed 7 3 4 3 1

Web of knowledge 9 4 5 1 4

Citations followed up 10 4 6 1 5

Total 26 11 15 5 10

and consistent authors were identified on this subject but ‘Childsmile’ was consistently cited in articles.10

No publications were identified when the search terms ‘School fluoride varnish programmes AND consent’, were combined. Therefore no articles solely related to this subject were submitted for further scrutiny. Equally, no systematic reviews were included in the Cochrane Collaboration library with which to consult possible new sources of literature. Furthermore, no forward citations were identified during the searching period of this review.

Data resultsThe majority of publications (six) analysed

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conclusively stated that the introduction of written positive consent has negatively impacted on the uptake and therefore validity of epidemiological surveys of the dental health of school children in England.26-32 A further two anticipated this requirement to have a detrimental effect on the participation of children in surveys, and on the inclusion of some families in dental public health programmes that include provision of fluoride varnish.32,33 The remaining two articles clearly indicate that communication with parents in written format has little or no impact with regards to the oral health of their children.20,31

Five of the studies that focus specifically on consent as a core point of analysis recommend further detailed work in this complex area to better understand parents’ response behaviour to consent and the possible implications that the changes have had.26-30 An additional two articles also indicate more research is required surrounding the subject of communication with parents about their children’s dental health, which both found to be ineffective when using the common method of sending letters to parents.31,33

The academic discussion paper published in 2009 addresses moral and ethical issues with regards to dental public health programmes.34 This paper specifically applies ethical view points to Childsmile, the fluoride varnish programme in Scotland. However, although it touches on the requirement for parents to ‘opt in’ to such programmes it mostly focuses on the tensions between being universal and targeted in its delivery. One other article demonstrates consideration of ethics with regards to the methods used to gain consent.28 However, in none of the papers included do the authors discuss in detail the ethical appropriateness of methods employed to gain written positive consent.

The acceptability and application of consent procedures for public health programmes is discussed in at least two of the publications.27,28 On both occasions the authors cite the Department of Health guidance use of negative consent, as part of the national programme to measure and monitor obesity trends in school children, as inconsistent and confusing in light of the opposing guidance regarding dental surveys.35 Equally, the fact that the Scottish National Dental inspection Programme continues under negative consent in line with the Education (Scotland) Act 1980, was also raised by one author.27,36,37 More specifically no publications in this review discussed the concerns or negative outcomes resulting from changes to consent processes for epidemiological programmes in relation to similar methods employed for fluoride varnish programmes. However two discuss the need to gain written positive consent for children to be included in future programme design due to the low levels of participation they have witnessed. Furthermore, one researcher states he ‘cannot recommend fluoride varnish as a public health measure to reduce caries as a result of the poor positive consent rate achieved which significantly affected the research outcome, particularly for those most likely to

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benefit’.31 in this study over 50% of children were excluded due to non-response to consent requests.31

Out of all the papers included in this review six provide brief and largely speculative details why the uptake of dental public health programmes are low when written positive consent is required. But, some evidence was found to support the view that using letters as a means of gaining consent for dental public health programmes from parents was ineffective.

DiscussionImpact of positive / negative consent on participation All papers reviewed demonstrate a large number of parents are not actively objecting to their children’s participation and deliberately refusing to provide consent. The drop in participation appears to be largely down to non-response, which results in the passive exclusion of children from epidemiological surveys. This parental behaviour pattern of non response has also been witnessed when consent is requested for participation in school based fluoride varnish programmes. Furthermore, the evidence suggests that there is a relationship between increasing levels of non response and decreasing levels of socio-economic status.

it could be argued that if those in the greatest need have the highest levels of non participation any programme that is delivered will be inequitable. Dental epidemiological programmes are carried out to collect data and to stimulate uptake of dental services. Whilst these are important ends in themselves, non-participation at an individual level could be seen to have minimal impact on a child’s oral health. However, if we look at this scenario in terms of participation in Fluoride Varnish programmes, individual children from disadvantaged communities may miss out on the increased protection against caries that this intervention affords and will be further disadvantaged.

Professional understanding of barriers to respondingin the literature reviewed it would appear that there is little professional understanding of why a large number of parents do not respond to requests for consent. This is demonstrated not only in the lack of research that appears to have looked in any depth at the reasons for this phenomenon but also in statements made by some in the discussion and conclusion sections of these publications, for example, phrases such as ‘…not bothering to read’, were cited. This seems a rather simplistic explanation and indicates that some professionals who deliver such programmes are more willing to cite lazy parenting as a reason for non response than to admit that the implementation methods that they have employed may not be suitable. However, in defence of the dental profession, several of the papers reviewed highlighted the need for further


research exploring the reason behind non response to written communication.

it appears that methods for gaining consent for epidemiological programmes are being employed by dental services when implementing fluoride varnish programmes. To date the potential for these new programmes to increase oral health inequalities as a result of non-response to written requests for positive parental consent does not appear to be of concern, despite this point being made repeatedly in the literature regarding delivery of dental epidemiological programmes. The evidence indicates that it is the method of request that creates a barrier for some sections of society. Therefore repeated use of written requests for consent is likely to increase oral health inequalities as non response is more prevalent in disadvantaged communities.

The impact of this may be detrimental to the long term future of similar programmes if efficacy can not be conclusively established. in recent years we have seen a decline in the number dental epidemiological programmes being implemented on a local level for exactly the reasons discussed above. if the implementation methods used to elicit positive written responses from parents are ineffective for epidemiological surveys, rendering the programmes themselves ineffective and worse still, contributing to the oral health divide, it could be said that the fate of Fluoride varnish programmes may be sealed.

Conclusion From the papers identified it is evident that there has been a transference of the techniques used to gain positive consent from epidemiological to fluoride varnish programmes, at least in some programmes, if not all. But it would appear that this has been done with little heed to recent evidence over the last five years that indicates sending letters home to parents to sign and return to school is ineffective. implementation of this method to gain consent has repeatedly shown to have a negative impact on the uptake of programmes, particularly in some sections of society.

References1. Pine C, Harris r. Principals and Practice of Public Health. in: Pine C, Harris r. (Eds) Community Oral Health. 2nd ed. England: Quintessence Publishing Co. 2007. (pp 1-103).

2. Department of Health. Choosing Better Oral Health. Department of Health, 2005.

3. Milsom K, Tickle M, Jenner A et al. Community dental health: The identification of agreed criteria for referral following the dental inspection of children in the school setting. Brit Dent J 1999; 186(1): 37-40.

4. Gizzi C. School Dental Health Assessment. Haringey Community Health Service-Dental 2010.

5. Department of Health. GUiDANCE: dental screening (inspection) in schools and consent for undertaking screening and epidemiological surveys. [Online] Available from: http://www.dh.gov.uk/en/ Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/ DH_064173 [Accessed 27th November2010].

6. Functions of Primary Care Trusts (Dental Public Health) (England) regulations 2006 (OPSi, 2006).

7. Marinho VCC et al. Fluoride toothpastes for preventing dental caries in children and adolescents. Cochrane Database of Systematic reviews. 2003. issue 2. Art. no: CD002278 DOi: 10.1002/14651858

8. NHS Centre for reviews and Dissemination. A systematic review of Public Water Fluoridation. [Online] Available from: www.nhs.uk/

Conditions/Fluoride/Documents/crdreport18.pdf [Accessed 27th November 2010].

9. Department of Health. Delivering Better Oral Health: an evidence based toolkit for prevention. [Online] Available from: http://www.dh.gov. u k / e n / P u b l i c a t i o n a n d s t a t i s t i c s / P u b l i c a t i o n s / PublicationsPolicyAndGuidence/DH_102331 [Accessed 27th November 2010].

10. NHS Scotland. Childsmile. [Online] Available from: http:// www.child-smile.org.uk/ [Accessed 22nd November 2010].

11. Simnett i. Evidence Base of Work in Setting. in: Perkins E, Simnett i, Wright L. (eds.) Evidence Based Health Promotion. Chichester: Wiley & Sons 1999 (pp 161-172).

12. Primary Care Commissioning. The use of Fluoride varnish by dental nurses to control caries. [Online] Available from: http:// wwwpcc.nhs.uk [Accessed 27th November 2010].

13. Matthews K. Dental Therapy Manager. Personal Communication. 1st April 2011.

14. Central London Community Healthcare. Bigger Smiles [Online] Available from http://www.biggersmiles.nhs.uk [Accessed 22nd November 2010].

15. Salford NHS. Healthier Mouths and Happier Smiles. An oral health strategy for people in Salford 2007-2012 [Online] Available from: http://www.salford-pct.nhs.uk/documents/PnS/OralHealthStrategyNew. pdf [Accessed 22nd November 2010].

16. Holland S. Public Health Ethics. 2nd Edition. Cambridge: Polity Press 2010.

17. Shokrollahi K. request for treatment: the evolution of consent. Ann R Coll Surg Eng. 2010; 92(2): 93-100.

18. General Dental Council. Principles of patient consent. [Online] Available from: http://www.gdc-uk.org/Dentalprofessionals/ Standards/Pages/default.aspx [Accessed 20th April 2011].

19. Watt G. The inverse care law today. [Online] Available from: www.lwms. ac.uk/resources/.../wkbk/watt_inversecarelaw_lancet.pdf [Accessed 25th May 2011].

20. Milson KM, Threlfall AG, Blinkhorn AS et al. The effectiveness of school dental screening: dental attendance and treatment of those screened positive. Brit Dent J. 2006; 200(12): 687-90.

21. Milson KM, Blinkhorn AS, Worthington HV et al. The effectiveness of school dental screening: a cluster-randomised control trial. J Dent Res. 2006; 85(10): 924-28.

22. Evidence-based medicine. What is a systematic review? [Online] Available from: www.medicine.ox.ac.uk/bandolier/ painres/.../whatis/Syst-review.pdf [Accessed 21st April 2010].

23. Critical Appraisal Skills Programme. 10 questions to help you make sense of qualitative research. [Online] Available from: www.pdptoo lk i t . co .uk / . . . /C r i t i ca l%20Appra i sa l / . . . /new%20 10%20qual%20questions.doc - [Accessed 21st April 2011].

24. Macpherson LM, Ball GE, Brewster L et al. Childsmile: the national child oral health improvement programme in Scotland. Part 1: establishment and development. Brit Dent J. 2010; 209(2): 73-78.

25. Turner S, Brewster L, Kidd J et al. Childsmile: the national child oral health improvement programme in Scotland. Part 2: monitoring and delivery. Brit Dent J. 2010; 209(2): 79-83.

26. Monaghan NP, Jones SJ, Morgan MZ. Do parents of children with caries choose to opt out of positive consent dental surveys in Wales? Brit Dent J.2011; 210(2): E1.

27. Dyer TA, Marshman Z, Merrick D et al. School-based epidemiological surveys and the impact of positive consent requirements. Brit Dent J. 2008; 205(11): 589-92.

28. White DA, Morris AJ, Hill KB et al. Consent and school-based surveys. Brit Dent J 2007; 202(12): 715-17.

29. Morgan MZ, Monaghan NP. Trends in childrens’ ability to consent to a dental examination and the potential impact on reported caries indices. Community Dent Health. 2010; 27(4): 200-05.

30. Monaghan N, Morgan MZ. Consent of older children participating in BASCD coordinated dental epidemiology surveys in Wales. Community Dent Health. 2009; 26(3): 157-161.

31. Hardman MC, Davis GM, Duxbury JT et al. A cluster randomised controlled trial to evaluate the effectiveness of fluoride varnish as a public health measure to reduce caries in children. Caries Res.2007; 41(5): 371-76.

32. Cunningham CJ, Elton r, Topping GV. A randomised control trial of the effectiveness of personalised letters sent subsequent to school dental inspections in increasing registration in unregistered children. BMC Oral Health 2009, 9: 8.

33. Tickle M, Milsom KM, Buchanan K et al. Dental Screening in schools: the views of parents, teachers and school nurses. Brit Dent J 2006; 201(12): 769-73.

34. Shaw D, Macpherson L, Conway D. Tackling socially determined dental inequalities: ethical aspects of Childsmile, the national child oral health demonstration programme in Scotland. Bioethics.2009; 23(2): 131-39

35. Department of Health. Measuring childhood obesity: guidance to Primary Care Trusts. Gateway reference 5990 (rOCr/Or/0027/FT6/009) 2006. [Online] Available from: http://www.dh.gov.uk/prod_consum_dh/ groups/dh_digitallassets/@dh/@en/documents/digitallasset/dh_4126406. pdf [Accessed 12th July 2011]

36. Dental Health Services research Unit (2008) Scotland’s National Dental inspection Programme, 2003. [Online] Available from: http://www.dundee. ac.uk/dhsru/publications/ndip/DiP2003.htm [Accessed 12th July 2011]

37. Department of Education. Education (Scotland) Act 1980. [Online] Available from: http://www.legislation.gov.uk/ ukpga/1980/44/enacted [Accessed 19th July 2011].

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Do motivational interviewing techniques contribute to improving the oral health of primary dental care patients? A literature review.

AbstrAct

Aim: This literature review explored the evidence for Motivational interviewing (Mi) in relation to Oral Health Education (OHE). The purpose was to determine whether Mi techniques contribute to improving the oral health of patients in a primary dental care (PDC) setting.

Method: A documented, systematic search of literature, published from 1995 – 2011, was undertaken. The approach was positivist, incorporating quantitative data, but inductive, to generate conclusions regarding the validity of Mi in OHE. The search incorporated inclusion and exclusion criteria, and the key words: ‘Motivational interviewing’, ‘Oral Health’ and ‘Dentistry’. Primary and secondary data were included and prioritised according to a hierarchy of evidence. The resulting studies were critically appraised and analysed using a data extraction matrix, specifically populated to address validity and the project question.

results: The ten studies that met the selection criteria suggested that issues of reliability and validity in these studies rendered the findings insufficient for changing policy or practise in favour of Mi intervention. A common theme relating to the Hawthorne Effect emerged in many of the studies. However, Mi was found to be an acceptable intervention for both patients and professionals. Cost of delivery and training for fidelity were found to be further potential barriers for implementation of the intervention.

conclusion: The evidence from this literature review was found to be insufficient for supporting or opposing the use of Mi techniques to contribute to improving the oral health of patients. However, it does suggest that there may be some limited potential for effective application. Further, methodologically rigorous research into the topic is required, and should focus on long-term benefits, or deficits, and what external influences may compromise, or alter, the intervention.

Key Words: Motivational interviewing, oral health, dentistry.

Maggie Nash


University of Kent

Dental Divison

Canterbury

Kent

CT2 7NZ

Correspondence to:

[email protected]

MOTiVATiONAL iNTErViEWiNG


IntroductionOral Health (OH) shares a Common risk Factor Association (CrFA) with chronic health conditions1,2. High risk behaviours including poor oral hygiene, diet choices, smoking and alcohol consumption, particularly in vulnerable or lower socio-economic groups, are significant contributors1,2,3. Targeted Oral Health Promotion (OHP) public policy interventions aim to encourage a reduction in high risk behaviours at population level2,4. in contrast, Oral Health Education (OHE) interventions undertaken in the Primary Dental Care (PDC) setting tend towards promoting healthy behaviour changes among individuals or small groups5. Such interventions are underpinned by the 1986 Ottawa Charter the Department of Health and Delivering Better Oral Health; An Evidence-based Toolkit for Prevention2,6. The hope is for current, and future, NHS dental services to contribute to the prevention of oral diseases and promote improved general health7.

Unfortunately, evidence to support the sustained efficacy of traditional methods of OHE delivery is poor4,5. it is argued that eliciting patient motivation to adopt and sustain autonomous self-care through healthy behaviours, requires innovative communication approaches which acknowledge a patient’s perception and health beliefs5.

Motivational interviewing (Mi) is proposed as a communication skill that can elicit a patient’s intrinsic motivation for adopting a change in behaviour. Motivation intrinsic to the patient is more powerful than extrinsic motivation, or instruction, from a health professional9,10.

The review

AimPrompted by the author’s personal observations of the inefficiency of traditional techniques, the literature review aimed to perform a critical review of the evidence relating to Mi, to determine whether or not it may be a more effective approach for OHE in the PDC setting.

Search methods The literature was reviewed methodically and periodically between June and December 201111,12. The search area was extensive and incorporated specific search terms with Boolean Logic to refine the search 12,13. inclusion / exclusion criteria were applied to promote access and understanding and account for the recent evolution of Mi as a theory. Details of the search are available at Table 1.

Search outcomeThe initial sample identified 107 articles for review8,14 . Scanning for relevance led to the exclusion of 65

articles which did not specifically relate to OH and Mi15.

The remaining 42 articles were categorised according to research design. Further reduction was based on the hierarchy of evidence15,16 duplication and overall relevance16,17. The final number of articles for review was ten, and included eight randomised Controlled Trials (rCTs) and two Systematic reviews (Table 2).

Critical appraisal, data extraction and synthesisCritical appraisal and data extraction were undertaken by a single reviewer using frameworks or matrices designed to promote a systematic and iterative examination of each article 18,19. The author acknowledges the potential for selection and secondary interpretation bias within this process 20,21,22.

Critical Appraisal Skills Programme (CASP) tools were adapted for greater depth and breadth17,23. Each article was then questioned critically and iteratively against the framework and the results recorded. A data extraction matrix (Table 3) was created and populated with questions to establish the validity of the research methods and answer the project question15. The matrix was then systematically applied to provide further analysis and meta-synthesis of data15,24 .

Synopsis of the main resultsAnalysis of the eight rCTs revealed issues of reliability and external validity 15, 25. Each of the rCTs was revealed as being ‘quasi-experimental’, failing to conform to the most rigorous methodology8,14. Analysis of the relationship between cause and effect was difficult to establish without blinding 14,

16. issues of validity were also apparent in the two Systematic reviews and related to the ability to replicate, or failure to acknowledge methodological or author bias, or conflict8, 15.

However, content analysis revealed four emerging themes:• Adolescentoralhealthriskbehaviours• Early childhood caries and risky behaviours of parents / carers• Oralhygieneandself-careinadults• TheeffectivenessofMIinclinicalencounters

Emerging themesAdolescent oral health risk behavioursAlthough the Mi interventions were not delivered in a clinical setting, a significant finding was the ability of the dental team to deliver the Mi intervention. Credibility, deemed to be a good predictor of outcome, was high within Mi intervention groups. Smoking prevalence of former and susceptible smokers after twelve months was lower in the Mi intervention group26,27.

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Both studies also recognised the significance of readiness to change 28,29. Analysis further suggested that study design incorporating self-reporting may have exposed limitations associated with Espoused Theory, or what participants say and what they actually do30, 31.

With high attrition rates, both studies acknowledged that recruitment and retention in this participant group was a challenge that requires addressing in future studies 26,27.

Early childhood caries (ECC) and risky behaviours of parents / carersThe Mi interventions were not delivered in a clinical setting, but each aimed at facilitating autonomy of behaviour choice 32, 33, 34. Harrison et al. indicated that the intervention group showed 46% fewer decayed, missing, filled or white spot (dmfs) at two years, possibly linked to a higher mean attendance for fluoride application32.

The ECC risk behaviour of sharing utensils reduced, and brushing frequency increased in the Mi intervention group33. One other significant change in behaviour was the increased likelihood of checking for pre-cavities34. However, with data collection from self-reporting via pre- and post-test questionnaires, the reliability of these results may be undermined 21,35.

Oral hygiene and self-care in adultsThe delivery of the Mi intervention varied, with only one study delivering it as part of a clinical encounter36. Each of the studies recorded reduced plaque levels in both intervention and control groups. The biggest reduction in Plaque indices (Pi) occurred in the Mi intervention groups36,37, 38.

Greater compliance with inter-dental cleaning and autonomous regulation was also recorded in the intervention group in each of the studies. With

treatment satisfaction an indicator of future compliance, greater satisfaction with, or value for, the intervention was recorded in two cases 36,38. However, the short duration of the studies was acknowledged in each case as rendering the findings insignificant for establishing any contribution to sustained autonomous care36,37,38.

The effectiveness of MI in clinical encountersBoth Systematic reviews assessed the effectiveness of Mi in clinical encounters. in each case, the Mi intervention was found to be effective in promoting health behaviour change and acceptable to the health professional and/or patient39.40. in one study, Mi was described as having potential for caries prevention and overcoming dental avoidance40.Both studies suggested that the time and attention given to participants may reflect a Hawthorne Effect thus pre-determining the outcomes of an Mi intervention29. A lack of methodological rigour and confounding factors in existing Mi research is acknowledged in each study39,40. Additional, rigorous research is suggested.

DiscussionSince Mi intervention is a recent theory, the reviewed literature was contemporaneous. However, the weaknesses associated with the methodologies, such as blinding, participant numbers and study duration, suggested potential limitations in validity. A variety of sources of bias, such as methods of data gathering, were identified by the literature review, and contributed to undermining the reliability of the studies21, 35.

Nonetheless, study participants appeared to be representative of patients seen in Primary Dental Care (PDC) settings17. Thus, if participants share similar characteristics to PDC patients, the positive clinical outcomes of the Mi intervention may yet provide pertinent information15,16.

Table 1

SEARCH TERMS(WITH BOOLEAN LOGIC)

PUB MED

EBSCO host

SCO PUS

OVI DSP

COCH RANE

PSYCH INFO COMMENTS

Motivational interviewing AND Oral Health

17 12 19 4*-5 4 4returned theses and articles detailing Mi in dental and non-dental sectors.

Motivational interviewing AND Oral Health AND Dentistry

12 7 10 4*-0 4 4

Still returned many non-dental results particularly smoking cessation and HiV related papers.

Motivational interviewing AND Oral Health AND Dentistry NOT HiV NOT Smoking NOT Tobacco

6 4 3 4*-0 4 4Pattern of results emerging. Same articles being returned as in previous searches.

individual search of online journals: returned 0 additional articles.

individual search of article and textbook reference lists: returned 4 additional articles for scrutiny.

Google Scholar search: returned 42 articles for scrutiny

inclusion criteria: 1995 – 2011: English Language: Published.


Positive findings included evidence that Mi appears to be well-received and applicable in primary care settings39,40. Smoking prevalence was lower in adolescents receiving an Mi intervention27, the incidence of caries in children was lower32 and Pi reduced in adults36, 37, 38. However, as stated previously, the association between Mi and these positive outcomes was difficult to ascertain 14, 16.

The difficulty with establishing a cause and effect relationship arose due to the potential influence of other factors. For example, combining interventions such as Mi intervention and fluoride application led to confusion over the cause of any dmfs reduction32. Similarly, the influence of the Hawthorne Effect29, may have led to altered behaviour in response to being studied14,35. However, by giving extra time and attention, the clinical dental team may be able to exploit this effect within the PDC setting and achieve similar positive clinical outcomes.

ConclusionsThe evidence from this literature review suggested that Mi techniques do not necessarily contribute to long-term improvements in oral health. However, the short-term improvements seen in some studies may be at least equivalent to traditional methods of OHE. Moreover, the Mi intervention may not be the most significant factor in any improvements in oral health status, despite it being intended as the means of eliciting a patient’s intrinsic motivation.

The patient’s intrinsic motivation may have a variety of sources and be linked to existing health-related beliefs, which are determinants of oral health status41,42. For dental professionals to work within any framework of the behavioural sciences, it is argued that dental education requires a paradigm shift43. Moreover, the health-related beliefs of both patient and professional may require a shift from treatment to prevention, before an intervention such as Mi can prove successful.

Table 2

Table 3

AUTHORS DATE TITLE

Skaret, E., Weinstein, P., Kvale, G. & raadal, M. 2003‘An intervention Program to reduce Dental Avoidance Behaviour Among Adolescents: A Pilot Study’

Harrison, r., Benton, T., Everson-Stewart, S., & Weinstein, P.

2007‘Effects of Motivational interviewing on rates of Early Childhood Caries: A randomised Trial’

Lando, H., Hennrikus, D., Boyle, r., Lazovich, D., Stafne, E. & rindal, B.

2007‘Promoting Tobacco Abstinence Among Older Adolescents in Dental Clinics’

Yevlahova, D. & Satur, J. 2009‘Models for individual Oral Health Promotion and Their Effectiveness; A Systematic review’

Martins, r. & McNeil, D. 2009‘review of Motivational interviewing in Promoting Health Behaviours’

Almomani, F., Williams, K., Catley, D. & Brown, C

2009‘Effects of an Oral Health Programme in People with Mental illness’

Jonsson, B., Ohrn, K., Oscarson, N. & Lindberg, P.

2009

‘The Effectiveness of an individually Tailored Oral Health Education Programme on Oral Hygiene Behaviour in Patients with Periodontal Disease: A Blinded randomised Controlled Clinical Trial (One Year Follow-up)’

Freudenthal, J. & Bowen, D. 2010‘Motivational interviewing to Decrease Parental risk-related Behaviours of Early Childhood Caries’

ismail, A., Ondersma, S., Willem Jedele, J., Little, r. & Lepkowski, J.

2011‘Evaluation of a Brief Tailored Motivational interview to Prevent Early Childhood Caries’

Godard, A., Dufour, T., & Jeanne, S. 2011‘Application of Self-regulation Theory and Motivational interview for improving Oral Hygiene: A randomised Controlled Trial’

RCT SYSTEMATIC REVIEW CONTENT

Date , Abstracts, Ethics Blinded or Quasi-experimental Duration Stratification Sample size and power calculation Attrition Methods of data collection Calibration

Date , Abstracts, Ethics Study design Search area and search terms inclusion / exclusion criteria Selection procedure Quality assessment

research Paradigm Major focus e.g. ECC Context e.g. Caries prevalence Aims and themes Who and how recruited - bias How intervention delivered / measured Common theories recommendations Acknowledgments of issues Limitations / confounding factors

Maggie N

ash •

Motivation

al Interview

ing


Maggie N

ash •

Motivation

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importantly, caution is required in drawing firm conclusions based on research which appeared to have several limitations. This review therefore did not provide the strength of evidence to recommend either implementing or rejecting this intervention in practise. The presence of some positive outcomes suggests that Mi techniques may have some applicability in practise that would benefit from further, methodologically sound research.

Recommendations• Further research is required to explore the nature of Mi: what it is, how and why it works, and whether clinician and patient characteristics affect the outcomes.• Priortofurtherrobustresearch,MIshouldonly be viewed as a model for encouraging effective patient communication, and eliciting a patient’s own motivation for change. • MI should be viewed within the context of other communication, health behaviour change and health belief theories. • Education and service commissioning should continue to encourage a paradigm shift, or change in attitude, towards healthy lifestyle choices and proactive prevention of dental disease.• Promote education and understanding of a variety of health behaviour change models.

References

1. Blinkhorn A., Downer M., Fuller S et al. Notes on Oral Health. Manchester: Eden Bianchi Press (2001).

2. GB. DH. Choosing Better Oral Health: An Oral Health Plan for England. London: DH (2005).

3. WHO. (2011) Oral Health. Available at: http://www.who.int/mediacentre/ factsheets/fs318/en/index.html (Accessed: 25 October 2011).

4. HDA. (1997) Effectiveness of Oral Health Promotion. [Online] Available at: http://www.nice.org.uk/nicemedia/documents/effectivenessoralhealth. pdf (Accessed: 25 October 2011).

5. Levine r, Stillman-Lowe C. The Scientific Basis of Oral Health Education. London: British Dental Association (2009).

6. GB. DH. Delivering Better Oral Health: An Evidence-Based Toolkit for Prevention. 2nd edn. London: DH (2009).

7. GB. DH. (2010) NHS Dental Contract: Proposal for Pilots. [Online] Available at: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@ dh/@en/@ps/documents/digitalasset/dh_122789.pdf (Accessed: 12 February 2012).

8. Whittaker A. & Williamson G. Succeeding in Project Plans and Literature reviews for Nursing Students. Exeter: Learning Matters Limited (2011).

9. rollnick S., Miller W, Butler,C. Motivational interviewing in Healthcare: Helping Patients Change Behaviour. London: The Guildford Press (2008).

10. Catley D, Goggin K. Lynam i. ‘Motivational interviewing (Mi) and its Basic Tools’, in ramseier, C. & Suvan, J. (eds.) Health Behaviour Change in the Dental Practice. Oxford: Wiley-Blackwell (2010).

11. ridley D. The Literature review: A Step-by-Step Guide for Students. London: Sage Publications Ltd. 2008.

12. Machi L, McEvoy B. The Literature review: Six Steps to Success. California: Corwin Press (2009).

13. Colville-Stewart, S. ‘How to do a Literature Search,’ in Tarling, M. & Crofts, L. (ed.) The Essential researcher’s Handbook for Nurses and Health Care Professionals. 2nd edn. Oxford: Bailliere Tindall (2002).

14. Moule P, Hek G. Making Sense of research: An introduction for Health and Social Care Practitioners. 4th edn. London: Sage Publications (2011).

15. Jesson J, Matheson L, Lacey F. Doing Your Literature review: Traditional and Systematic Techniques. London: Sage Publications Limited (2011).

16. Brunette D. Critical Thinking: Understanding and Evaluating Dental research. 2nd Edn. Hanover Park: Quintessence Publishing Company inc.

(2007).

17. Gomm r, Needham G, Bullman A. Evaluating research in Health and Social Care. London: Sage Publications Limited (2000).

18. Booth A. ‘Making the Most of Existing Knowledge’, in Crookes, P. & Davies, S. (eds.) research into Practice: Essential Skills for reading and Applying research in Nursing and Health Care. 2nd edn. Oxford: Bailliere Tindall (2004).

19. Burls A. (2009) What is Critical Appraisal? [Online] Available at: http:// www.medicine.ox.ac.uk/bandolier/painres/download/whatis/What_is_ critical_appraisal.pdf (Accessed: 28 November 2011).

20. Bradley, P. ‘Evidence-based Practice and Critical Appraisal of Quantitative review Articles (Systematic reviews)’, in Crookes, P. & Davies, S. (eds.) research into Practice: Essential Skills for reading and Applying research in Nursing and Health Care. 2nd edn. Oxford: Bailliere Tindall (2004).

21. Parahoo K. Nursing research: Principles, Process and issues. 2nd edn. Basingstoke: Palgrave Macmillan (2206).

22. Bell J. Doing Your research Project: A Guide for First-Time researchers in Education, Health and Social Science. 5th edn. Maidenhead: Open University Press (2010).

23. CASP. (2010) Critical Appraisal Skills Programme. Available at: http:// www.sph.nhs.uk/what-we-do/public-health-workforce/resources/critical- appraisals-skills-programme (Accessed: 18 April 2011).

24. Davies S. reviewing and interpreting research: identifying implications for Practice’, in Crookes, P. & Davies, S. (eds.) research into Practice: Essential Skills for reading and Applying research in Nursing and Health Care. 2nd edn. Oxford: Bailliere Tindall (2004).

25. rees A., Beecroft C,Booth A. ‘Critical Appraisal of the Evidence’, in Gerrish, K. & Lacey, A. (eds.) The research Process in Nursing. 6th edn. Oxford: Wiley-Blackwell (2010).

26. Skaret E, Weinstein P, Kvale G et al. An intervention program to reduce dental avoidance behaviour among adolescents: a pilot study. Euro J Paediatr Dent 2003; 4(4): 191 – 196.

27. Lando H, Hennrikus D, Boyle r et al. Promoting tobacco abstinence among older adolescents in dental clinics. Journal of Smoking Cessation 2007; 2(1): 23 – 30.

28. Prochaska JO, DiClemente CC. Stages and processes of self-change of smoking: toward an integrative model of change. J Consult Clin Psychol. 1983; 51(3): 390-5.

29. Mayo, E. (1971) Hawthorne and the Western Electric Company. [Online] Available at: http://74.125.155.132/scholar?q=cache:jyHo36OasEAJ:schol ar.google.com/&hl=en&as_sdt=0,5&as_vis=1 (Accessed: 6 March 2011).

30. Argyris M, Schön D. Theory in Practice: increasing Professional Effectiveness. San Francisco: Jossey-Bass (1992).

31. Ghaye T, Lillyman S. (2010) reflection: Principles and Practice for Healthcare Professionals. Quay Books Division, MA Healthcare Ltd: London (2010).

32. Harrison r, Benton T, Everson-Stewart S et al. Effects of motivational interviewing on rates of early childhood caries: a randomised trial. Paediatr Dent, 2007; 29(1): 16 – 22.

33. Freudenthal JJ, Bowen DM. Motivational interviewing to decrease parental risk-related behaviours of early childhood caries. J Dent Hyg 2010; 84(1): 29 – 34.

34. ismail Ai, Ondersma S, Jedele JM et al. Evaluation of a brief tailored motivational interview to prevent early childhood caries. Community Dent Oral Epidemiol 2011; 39(5): 433 – 48.

35. Gerrish K, Lacey, A.. The research Process in Nursing. 6th edn. Oxford: Wiley-Blackwell. (2010).

36. Godard A, Dufour T, Jeanne S. Application of self-regulation theory and motivational interview for improving oral hygiene: a randomised controlled trial. J Clin Periodontol 2011; 38(12): 1099 – 105.

37. Almomani F, Williams K., Catley D et al. Effects of an oral health programme in people with mental illness. J Dent Res 2009; 88(7): 648 – 52.

38. Jonsson B, Ohrn K., Oscarson N et al. The effectiveness of an individually tailored oral health education programme on oral hygiene behaviour in patients with periodontal disease: a blinded randomised controlled clinical trial (one year follow-up). J Clin Periodontol (2009); 36(12): 1025-34.

39. Yevlahova D, Satur J. Models for individual oral health promotion and their effectiveness: a systematic review. Aust Dent J (2009), 54(3): 190 – 97.

40. Martins,rK, McNeil DW. review of motivational interviewingin promoting health behaviours. Clin Psychol Rev (2009); 29(4): 283 – 93.

41. Gross r, Kinnison N. Psychology for Nurses and Allied Health Professionals. London: Hodder Arnold (2007).

42. Walker J., Payne S., Smith P et al. Psychology for nurses and the caring professions. 3rd edn. Maidenhead: Open University Press (2007).

43. richards P. Health Behaviour Change Education’, in ramseier, C. & Suvan, J. (eds.) Health Behaviour Change in the Dental Practice. Oxford: Wiley-Blackwell (2010).


Evaluation of the impact and effectiveness of safeguarding children training on dental practice

AbstrActAim: The study aimed to evaluate whether safeguarding children training improves dental professionals’ and non-professionals’ knowledge of the types of abuse and neglect children and young people can experience and knowledge of the actions to follow to safeguard children.

Methods: The group studied for the research study were a sample of mainly dental professionals who attended four postgraduate training sessions across Wales. Training participants were asked to complete a training evaluation questionnaire pre and post training and again six-weeks later. Data generated from completed questionnaires was analysed to measure change in mean scores and test for statistical significance.

conclusions: Study results indicate an improvement in mean scores compared to the start of training. improvement in mean scores was statistically significant, although some differences are indicated in mean scores and significance values between professionals and non-professionals. As with the original NSPCC study there was a low follow up response six-weeks following training. Study results indicate an evidence based approach to training evaluation can capture whether knowledge was gained and retained, although larger studies are recommended.

Key Words: Safeguarding children

Kevin Hogan1

Alastair Tomlinson2


1Public Health Wales

2 Cardiff School of Health

Sciences, Cardiff Metropolitan

University

Correspondence to:

[email protected]

SAFEGUArDiNG CHiLDrEN

impact of training in regards to knowledge of the different types of child maltreatment and the actions to follow if holding such concerns. The study also served to add to the knowledge base in this area as there is a dearth of literature on the topic of safeguarding children in relation to dental practice and even less literature available regarding the evaluation of safeguarding children training for dental practice.

MethodologyFour safeguarding children postgraduate training sessions, held at venues across Wales, were evaluated using an adapted version of a NSPCC/Promoting inter-agency training [Piat] evaluation toolkit6,7. The questionnaire developed for the study provided a complex evaluation approach which involved the administration of the questionnaires at different time points i.e. start of training [T1], end of training [T2] and a six-week follow-up [T3]. The research design approach was therefore a repeated-measures design taking measurements on the same subjects over time, pre and post-training. The study was also designed to test the hypothesis that at the end of training there would be an improvement in mean scores compared to the start of training, attributed to the training intervention, and at follow-up, six-weeks later, this improvement would be sustained.

IntroductionDental professionals and staff are well placed to identify cases of child maltreatment1, although dentists acknowledge their lack of awareness of the signs and symptoms of physical child abuse and express fears regarding the outcome of reporting concerns, with little knowledge of local child protection mechanisms2. But, despite high profile child maltreatment cases and the development of relevant legislation and guidance, questions remain regarding how consistently full ownership of safeguarding children and young people is delivered by all parties3, including health professionals, such as dental professionals. More specifically, there are indications only a small proportion of paediatric dentists regularly communicate with other health and social care professionals4. Further evidence suggests a significant proportion of dentists have suspected abuse in one or more patients during their career, although only eight per cent have reported their suspicions, with those who had received postgraduate training more likely to report their suspicions5.

The purpose of this research study was to evaluate the impact and effectiveness of safeguarding children training delivered to dental professionals and non-professionals in postgraduate training settings. This included measuring the


Planning and deliveryThe study was coordinated through Cardiff University dental postgraduate department, who organised the training sessions and Children in Wales, a children’s organisation, who provided the subject specialist trainers. Ethical approval for the study was sought and approved via NHS Wales and Cardiff Metropolitan University.

Prior to attendance at training none of the training participants were aware they would be participating in the research study. On attendance at training each participant was given a copy of a letter of explanation and training evaluation questionnaire6. Participation in the study included completion of the questionnaire pre and post-training and again six-weeks post-training. The same questionnaire was distributed pre and post-training and the follow-up questionnaire was sent to training participants by post and email and made available via a Public Health Wales web link to increase the number of questionnaires returned. Email and postal reminders were sent to all training participants to optimise questionnaire response rates.

Training evaluation questionnaire designThe training evaluation questionnaire was divided into three sections.

The first section captured training participants’ demographic data i.e. professional status, decade of graduation, gender, age and motivation for attending training. The second section incorporated four of the available nine ‘Defining Child Abuse Scenarios’ [CAS] provided with the Piat/NSPCC toolkit 6. The CAS case scenarios required training participants to complete rating scales designed to assess attitudes, knowledge and self-efficacy in relation to safeguarding children. The rating scales consisted of ‘Action knowledge’ and ‘Type knowledge’ tests. in all four of the CAS case scenarios the action option ‘Initiate a Common Assessment Framework’ [CAF] was changed to ‘Child in Need Referral’ [CiN], as CiN is the safeguarding children terminology and approach mainly used across Wales and CAF is the safeguarding children terminology and approach used in England.

The third and final section included a Likert psychometric scale scoring system, devised by the principal investigator, consisting of a series of questions requiring training participants to provide responses on a scale from 1 to 5 [“Strongly agree” to “Strongly disagree”]. The Likert psychometric scale was selected as it is widely used in social research and is the form of scaling most often seen on questionnaires and instruments used in research 8.

Data results and analysisMean scores were calculated for each training participant pre and post-training. The means were calculated as data collected for the research study and did not include extreme scores. Data was generated from training participants’ responses

to the four child abuse case scenarios [CAS] in Section 2 of the training evaluation questionnaire. Total mean scores were calculated for each training participant’s responses to the case scenarios. Any change in mean scores was also calculated [T2-T1]. To establish whether change in mean scores was statistically significant, paired *t-tests were performed and calculated using SPSS [Statistical Package for the Social Sciences]. Mean scores for the six-week follow-up responses to the training questionnaire were also calculated but not t-tested due to the low number of responses. The Likert scale scores in Section 3: Learning objectives of the questionnaire were calculated using percentages for the total data set of responses pre-training and post-training.

*Note: The t-test assesses whether the means of two groups are statistically different from each other. This analysis is appropriate whenever you want to compare the means of two groups.

Section 1 of training evaluation questionnaire: DemographicsAll training participants [n=108] who attended the four postgraduate training sessions consented to participate in the study. During the data cleaning process 88 training participants’ questionnaire responses were included in the research study as 20 questionnaires were incomplete. The data set included 75 responses from dental professionals [Dentists; n=31 and Dental Care Professionals; n=44] and 13 responses from non-professionals [Other dental staff or Other]. Table 1 includes descriptive data for the full data set.

Section 2 of training evaluation questionnaire: Child Abuse Case Scenarios (CAS)Action knowledge mean scores:As illustrated in Figure 1, the total Action Knowledge mean score indicates a change in mean value [T2-T1] of 1.08 which was highly statistically significant [p< 0.001]. As the probability value, or **p-value, was very small it was likely training made a highly significant change in improving Action Knowledge to safeguard children. The mean score of 3.43 for the six-week follow-up also indicates training participants Action Knowledge was retained and almost consistent with the post-training [T2] mean score [3.56].

**Note: A p-value is calculated to assess whether trial results are likely to have occurred simply through chance.

Professional status: (Action Knowledge)As illustrated in Figure 2, there was an increase in Action Knowledge mean score for both sets of dental professionals [Dentists=1.38; DCPs=1.05] and a highly significant p-value [p< 0.001] for all dental professionals. For the six-week follow up, responses from both sets of dental professionals generated the same mean score [3.40] which indicates Action Knowledge had largely been retained.

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Type Knowledge Mean scoresAs illustrated in Figure 3 the total Type Knowledge mean score indicates a change in mean value [T2-T1=1.04] very similar to the change in total Action Knowledge mean score [1.08]. This was considered highly statistically significant [p< 0.001]. The mean score for the six-week follow-up questionnaire responses [2.63] also indicates training participants total Type Knowledge had increased when compared with the post-training mean score [2.37]. Although due to the low number of follow-up responses this was not confirmed by t-test as being statistically significant.

Professional status: (Type Knowledge)As illustrated in Figure 4, Type Knowledge mean scores for both sets of dental professionals indicate an increase in mean scores [Dentists=0.97; DCPs=1.13] and a highly significant p-value for all dental professionals [p< 0.001]. This was a similar statistical result as indicated by the Action Knowledge t-test output. Follow-up mean scores indicate dentists’ Type Knowledge had not only been retained but increased six-weeks following training [3.27], compared to their post-training mean scores [2.58], although again this could not be tested for statistical significance due to the small number included in the data set. in comparison, DCPs mean scores indicate Type Knowledge had almost been retained six-weeks following training [2.20] compared to their post-training mean score [2.29].

Section 3 of training evaluation questionnaire: Likert scale scores/Learning objectivesThe Likert scale data results were generated by analysing the full data sets’ response to Section 3: Learning objectives of the training questionnaire, distributed pre and post-training. Data from the six-week follow-up questionnaires was not included. The following five statements developed for the purpose of the questionnaire were based on the learning objectives for the training session that training participants were about to attend or had attended. Training participants were directed to answer each of the five Likert scale statements, or questions, by selecting one of five set responses, ranging from Strongly disagree through to Strongly agree. The five statements or questions were:

Question 1: ‘I am aware of the main legislation and guidance to safeguard children and young people’

Question 2: ‘I am able to list the main categories of child abuse, including signs and symptoms’

Question 3: ‘I feel confident in dealing with child protection issues’

Question 4: ‘I am aware of my roles and responsibilities to safeguard children in dental practice’

Question 5: ‘I would know how to refer child abuse and where to access advice’

Likert Psychometric Scale Results Pre-training a significant number of training participants indicated they were Not sure or disagreed pre-training with the five statements, but post-training percentage scores were more favourable with the majority of training participants indicating they Agree or Strongly agree with all five statements. The results indicate a large percentage of training participants had changed their pre-training responses of Not sure, Disagree or Strongly disagree, to post-training responses of Agree or Strongly agree, as illustrated in the training participants responses to Question 2 and Question 5.

Attrition rate for six-week follow-up questionnaires The attrition rate for the six-week follow-up questionnaire (T3) was appreciably high with only 34% (n=30) of training participants responding. Of these follow-up responses the majority (83.3%; n=25) were received from dental professionals.

Discussion Low follow-up responses resulted in only mean scores being generated due to the relatively small data set. This limited the scope of the study to measure whether knowledge was retained over time. Due to the low follow-up response rate a deeper level of statistical analysis was limited to an interrogation of pre and post-training questionnaire responses.

Additional study limitations included: different

Table 1

Data results for the four postgraduate training sessions (n=88)

Number (n) Percentage (%)

Professional status

Dentist 31 35.2

DCP 44 50.0

Other Dental Staff 11 12.5

Other 2 2.3

Decade of graduation

Pre-1980 5 5.7

1980-1989 15 18.2

1990-1999 19 20.4

Since 2000 28 31.8

Not applicable 21 23.9

GenderMale 18 20.4

Female 70 79.5

Age

20 and under 2 2.3

21-30 22 23.9

31-40 23 26.1

41-50 18 20.4

51-60 18 21.6

61 and over 5 5.7

Motivation to attend training

recommended 2 2.3

improve Performance 8 9.1

CPD 67 76.1

Told to attend 7 7.9

Do not know 0 0

Other 4 4.5

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training facilitators at each of the four postgraduate training sessions, a possible confounding factor; as may be validity of altering one of the child abuse scenarios (CAS) action options from Initiate a Common Assessment Framework (CAF) to Child in Need Referral.

Future studies should also consider the validity of using only four of the possible nine CAS/child abuse case scenarios from the original Piat/NSPCC toolkit and report 6,7 and altering the timing of the follow-up questionnaires from three months to six-weeks, as these changes may affect the validity of the study.

Furthermore, it is difficult to state with certainty that improvement in mean scores was attributable to training as there was no control group, although the study approach could not be realistically challenged due to practical and ethical considerations as safeguarding children training is mandated by government 7.

it is also difficult to compare and contrast the findings from this research study with the original source material i.e. the NSPCC/Piat report findings 7; as the NSPCC/Piat study approach focused on the evaluation of interagency courses, in partnership with eight Local Safeguarding Children Boards (LSCBs); as opposed to the uni-disciplinary (single agency) approach employed in this evaluation study of dental training. Nevertheless, the analyses of the research study of dental training and the original NSPCC/Piat study both indicate a large majority of participants attending these courses significantly increased their knowledge concerning the recognition of neglect and abuse in its various forms and also of what action to take 7. in addition when compared to the original NSPCC/Piat evaluation toolkit 6, the research design is more robust than those previously employed in this area, which have used simple pre- and post-test designs. indeed only four other studies 7 attempted a follow-up beyond the immediate post-training period.

in addition, with the Likert psychometric scale, care should be taken not to read too much into ranked scales as the Likert scale may also be subject to distortion from several causes i.e. central tendency bias, where respondents may avoid using extreme response categories; acquiescence response bias, where respondents agree with statements as presented or social desirability bias, where respondents try to portray themselves or their organisation in a more favourable light.

Conclusion Study results indicate that following training dental professionals retained significant knowledge and understanding regarding their roles and responsibilities. results of the study also indicate dental professionals increased confidence in dealing with safeguarding children issues and retained knowledge regarding the categories and types of child abuse. Furthermore, although dental training participants did not retain all they had learned, study results suggest they knew more about the subject of safeguarding children six-weeks following training than they did before attending training. This is

an important research finding as similar studies addressing dental professionals’ knowledge and awareness of child protection indicate uncertainty about diagnosing child protection issues 9 or have highlighted uncertainty amongst dental practitioners regarding how to respond if they became suspicious of child abuse 10.

The study also supports the message that the dental team are an increasingly important aspect and resource in cases of child maltreatment; although to avoid misunderstandings, increase sensitivity and raise awareness, more training for dental professionals and non-professionals is recommended11. To assist in progressing this recommendation the training evaluation tool 6,7, implemented for this research study, can be evidenced as a means of supporting more effective, evidence based evaluations of training for dental professionals and non-professionals. More broadly, a study of evidenced based approaches to evaluate safeguarding children training appears to be timely and relevant; a recent all Wales report 12 states that more robust safeguarding children training evaluation approaches are required as there is little evidence of training needs assessment and evaluation being conducted.

Finally, recent publications on child protection training experiences of dentists13 and the

Figure 1: Comparison of pre and post-course changes: Total Action Knowledge Mean Scores (n=88)

Figure 2: Comparison of pre and post-course changes and increase in scores: Action Knowledge Mean Scores by Professional Status (n=88)

Note: In both Figure 2 and Figure 4 Other dental staff refers to non-professional, unqualified dental staff.

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Figure 3: Comparison of Pre and Post-course changes: Total Type Knowledge Mean Scores

Question 2: ‘I am able to list the main categories of child abuse, including signs and symptoms’

Question 5: ‘I would know how to refer child abuse and where to access advice’

Figure 4: Comparison of Pre and Post-course changes and increase in mean scores: Type Knowledge Mean Scores by Professional Status (n=88)

development and review of an auditing tool for inter-professional safeguarding children training14 both indicate that research into the area of evidence based approaches is gathering pace in health and social care arenas, including within the dental profession. Therefore consideration should be given by organisations and professional groups in adopting an evidenced based approach to the evaluation of safeguarding children training programmes, with the intention of safeguarding the working practices of dental professionals and dental staff and to safeguard the welfare of children and young people.

Acknowledgements:This article is based on a dissertation completed in partial fulfilment of the requirements for the MSc in Applied Public Health degree at Cardiff Metropolitan University.

The author would like to thank members of Cardiff University Dental Postgraduate Department, Children in Wales, Public Health Wales and Cardiff Metropolitan University for their guidance and support in this study.

References1. NiCE (2009) When to suspect child maltreatment - NiCE clinical guideline 89. National institute for Health and Clinical Excellence/ National Collaborating Centre for Women’s and Children’s Health/ royal College of Obstetricians and Gynaecologists. July 2009. www. nice.org.uk/CG89

2. Welbury rr, MacAskill SG, Murphy JM et al. General dental practitioners’ perception of their role within Child Protection - a qualitative study. Eur J Paed Dent 2003; 4(2): 89-95. http://www.ejpd.eu/

3. Health inspectorate Wales (2009) Welsh National Health Service for Safeguarding and Protecting Children in Wales. Health inspectorate Wales. October 2009 http://www.hiw.org.uk/

4. Harris JC, Elcock C, Sidebotham PD et al. (2009) Safeguarding children in dentistry: 2. Do paediatric dentists neglect child dental neglect? Br Dent J 2009; 206(9): 465-70.

5. Soldani F, robertson S, Foley S. (2008) An audit of a child protection basic awareness programme within the dental hospital setting: are we effective or not? Child Abuse Review 2008; 17: 55-63. www.interscience.wiley.com

6. Carpenter J, Patsios D, Szilassy E et al. (2011) Connect, share and learn: Evaluating the outcomes of inter-agency training to safeguard children. Promoting inter-agency training. Piat/ NSPCC. January 2011 www.nspcc.org.uk/piat

7. Carpenter J, Patsios D, Szilassy E et al. (2010) Outcomes of interagency training to safeguard children: final report to the Department for Children, schools and families and the Department of Health. Piat/NSPCC. February 2010. University of Bristol www.education.gov.uk/publications/ standard/publicationDetail/Page1/DCSF-rr209

8. Punch KF. (2005) introduction to Social research-Quantitative and Qualitative Approaches. 2nd edition. London: SAGE Publications Ltd. (2005).

9. Chadwick BL, Davies J, Bhatia SK et al. Child Protection: training and experiences of dental therapists. Br Dent J 2009; 207(3): 130-31 http://www.nature.com/bdj

10. Cairns AM, Mok JY, Welbury rr. The dental practitioner and child protection in Scotland. Br Dent J 2005; 199(8): 517-20. http://www.nature.com/bdj

11. Nuzzolese E, Lepore M, Montagna F et al. Child abuse and dental neglect: the dental team’s role in identification and prevention. Int J Dent Hyg 2009; 7(2): 96-101 http://www. wiley.com/bw/journal.asp?ref=1601-5029

12. CSSiW (2011) Joint inspection of Local Safeguarding Children Boards 2011: Overview. Care and Social Services inspectorate Wales (CSSiW), Estyn (the office of Her Majesty’s inspectorate for Education and Training), Health inspectorate Wales (HiW), Her Majesty’s inspectorate of Probation (HMi Probation), and Her Majesty’s inspectorate Constabulary (HMiC)

http://wales.gov.uk/docs/cssiw/report/111004overviewen.pdf

13. Laud A, Gizani S, Maragkou S et al. Child protection training, experience and personal views of dentists in the prefecture of Attica, Greece. int J Paediatr Dent 2012; Mar 16. doi: 10.1111/j.1365-263X.2012.01225.x. [Epub ahead of print]

14. Dugdale D, Wells C. The development of an auditing tool to support the delivery of inter-professional training within the field of safeguarding children. Child Abuse Review. 2012; 21: 141-50. http:// onlinelibrary.wiley.com/doi/10.1002/car.v21.2/issuetoc

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The introduction to practice for therapists (ITP) scheme in Wales: an evaluation of the first three yearsBarnes E1, Hannington D1, Moons K1, Cowpe J1, Bullock A2, rockey A1 1Dental Section, PGMDE Wales, Cardiff University, United Kingdom2Cardiff Unit for research and Evaluation in Medical and Dental Education (CUrEMeDE) Cardiff University, Wales.Email: [email protected]

Aim: The Wales Deanery (School of Postgraduate Dental and Medical Education, Cardiff University) runs a foundation (vocational) training scheme for newly qualified dental therapists. The introduction to Practice for therapists (iTP) scheme runs for 12 months, beginning in January each year and commenced in 2004. The programme was originally open to both therapists and hygienists but since 2009, following the changes in NHS contracts, the scheme is open to therapists only. The purpose of this study was to evaluate the scheme with ‘current’ trainees and to follow-up previous trainees (since 2009) to gather their retrospective views and their career history.

Materials & methods: Following a group discussion with 2011 trainees (n=7) on their last study day, individuals completed questionnaires. Portfolio extracts were also gathered, with permission. Previous trainees (3 from the 2009 and 6 from the 2010 intakes) completed an online survey. Current and past trainers completed a postal questionnaire (n=11).

Results: reflections on the scheme were positive. All past-trainees had remained in dentistry as practising therapists and felt that the scheme had been useful in developing their career. respondents reported that the scheme aided their transition from student to unsupervised dental professional. Data suggested trainees gained confidence in their skills and valued working in a supported way. All would recommend the scheme to others. The majority of trainers was supportive of the scheme, would recommend it to others and would advocate the scheme being mandatory.

Conclusions: This scheme is an effective training programme that contributes to the skill mix agenda in dentistry. it provides therapists with an avenue to further develop as practising clinicians in a supportive environment. At the same time, it provides a platform to promote their clinical skills in primary dental care and raises awareness of their contribution to the dental health of patients.

Bigger smiles: a dental public health pilot projectCharlotte Jeavons, University of Greenwich, School of Health and Social Care, Mary Seacole Building, 2nd Floor, Southwood Site, Avery Hill Campus, Avery Hill road, Eltham, London SE9 2PQ

Email: [email protected]

Objectives: •increase exposure to fluoride for children attending the pilot school •Introducethechildrentodentalcareinafamiliarenvironment •Disseminatememorableoralhealtheducationmessages •Learnstrengthsandweaknessesoftheprojectinterventionbeforeroll-outtoallprimaryschoolsintheborough

Methods: •Themodesofintervention,viaaschool,includedclinicalpreventionandhealtheducation •ParentswereaskedtoprovideconsentforFluoridevarnishtreatments,deliveredinschool • Performers were used in the playground generate interest from parents and increase consent for the Fluoride treatments •Atheatrecompanydeliveredhealtheducationmessages •Childrenwereprovidedwithtoothbrushandtoothpastepacks •Projectbrandingwasdevelopedforallpublicity

Results: •106outof124(85.5%)responsestoconsentrequestswerereceived •Ofresponders,91.5%providedpositiveconsent •Over90%ofchildrenshowedanincreaseinoralhealthknowledge •Anincreaseof52%ofchildrenreportedcleaningtheirteethtwiceadayConclusions:•A number of key messages appear to have been successfully absorbed by the children •Themajorityofchildrenreceivedfluoridevarnishtreatment • The high % of consent forms returned demonstrates the use of characters to generate interest was effective to achieve parental engagement. •Datacollectedcanbeusedtoreviewtheprocessesinvolvedintheimplementationofthispilot • Success has been demonstrated in the purpose of a pilot to test and streamline intervention methods before roll – out

Funding for this pilot project was supplied by Kensington and Chelsea Primary Care Trust. Character costumes were loaned for use by GlaxoSmithKline

BSDHT ORAL HEALTH CONFERENCE & EXHIBITION 9th & 10th November 2012, ACC, Liverpool

Abstracts submitted for poster demonstration


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Do oral bacteria contribute to obesity? Elaine Taylor, Centre for Nutrition Education and Lifestyle Management, (CNELM), 2 Edward Court, Wellington road, Wokingham, Berks rG40 2AN


Aim: The aim of this mechanism review was to examine potential links between oral bacteria and obesity via the possible influence of the gut flora and the possible effects of periodontal disease (PD) systemically. An understanding of the potential influence oral bacteria may impact on the pathogenesis of obesity was considered to be of value.

Methods: The initial electronic search conducted using Pubmed, Google Scholar and Highwire, using the search terms ‘obesity’ and ‘periodontal disease’ resulted in 221 papers, which were further defined to papers published between the years 2000-2011. Additional publications were obtained by searching the citation listings of included studies and reviews. As the network diagram developed, more leads were uncovered and further search terms added. Critical analysis of papers was followed according to SiGN50 guidelines.

Results: Many potential associations between PD and obesity have been suggested but it is important to consider the enormous amount of confounding variables, as each chronic disease is independently associated with other factors and also with those common to both, such as diet and insulin resistance (ir). The opinion of the author is that the evidence so far is weak in relation to the systemic effects of PD. However, PD does appear to influence glycaemic control and ir. At this point the direction appears to change with adipocyte activity contributing to ir and PD. research into the possible association of oral bacteria contributing to the gut microbiota of obese individuals is inconclusive, is it cause or effect? Further research on how it may affect leptin and ghrelin levels would be of value.

Conclusions: This mechanism review identifies many potential systemic pathways between PD and obesity. However, it is not possible to say oral bacteria contribute to obesity based on the research so far. The network diagram is a useful tool for research to expand the links further.

Clinical outcomes for preformed metal crowns in a hospital setting: a therapist-led auditCowlam J, North S, rodd HD. Paediatric Dentistry Department, Charles Clifford Dental Hospital, Sheffield.


Objectives: This audit sought to determine clinical outcomes of preformed metal crowns (PMCs) placed on primary molars in a hospital setting. it also explored whether success was influenced by: i) the technique used (conventional tooth preparation versus non-invasive Hall Technique); ii) operator status (therapist versus dentist); iii) the child’s compliance.

Methods: Clinical data were collected for children who had previously received a PMC and who were subsequently reviewed by a single operator. Outcomes were simply categorised as ‘successful’ (PMC present with no problems); ‘minor failure’ (intervention required but tooth retained) and ‘major failure’ (tooth required extraction).

Results: Data were obtained for 610 PMCs provided for 184 children, whose mean age was 5.9 years (range=2-15). Children had an average of 3.3 crowns (1-8) and the mean follow-up period was 21 months. The Hall Technique had been used for 60% of crowns, and 72% of all crowns had been placed by a single therapist. Overall, 88% of PMCs were categorised as successful, 8.3% as having a minor failure and 3.7% as having a major failure. The most common problem was a worn crown, accounting for 31% of all failed PMCs. Further statistical analysis (chi squared test and independent t-test as appropriate) revealed that a significantly higher proportion of Hall crowns were successful (91.4%) compared to conventional crowns (83.4%) (P=0.02). Success rates for therapist-placed crowns were also significantly higher (89%) than those placed by dentists (83%) (P=0.01). Finally, there was no significant difference in outcome according to the child’s observed acceptance of treatment, including those who had a PMC placed under GA.

Conclusions: These findings support the growing evidence-base for the use of PMCs for young children with caries. Therapists clearly have a role in achieving high quality outcomes. Further analysis is needed to more closely identify clinical predictors of success or failure.


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Evaluation of the addition of a water flosser to sonic toothbrushing: effect on plaque, bleeding and gingivitisLyle DM1, ram Goyal C2, Qaqish JG2, Schuller r3 1Water Pik, inc., 2BioSci research Canada, 3reinhard Schuller Consulting.


Objectives: The primary objective of this study was to compare the effectiveness of a water flosser plus sonic toothbrush to a sonic toothbrush alone on clinical parameters. The secondary objective was to compare the effectiveness of different sonic toothbrushes on clinical parameters.

Methods: One hundred and thirty-nine subjects were randomized into four groups in this, four-week, single-masked, parallel clinical study. Group i used a water flosser plus sonic toothbrush (WPS), Group ii used a sonic toothbrush (SPP), Group iii used a sonic toothbrush (SF), and Group iV used a manual toothbrush (MT). Subjects were provided written and verbal instructions for all power products and the MT group continued with their normal brushing method. Data was evaluated at baseline, two-weeks, and four weeks for bleeding on probing (BOP), gingivitis (MGi), and plaque using the rustogi Modification of the Navy Plaque index (rMNPi).

Results: The reduction of whole mouth BOP scores was significantly higher for the WFS group; 34% more effective than the SPP group (p=0.008), 70% more effective than the SF group (p<0.001) and 1.59 times more effective than the MT group (p<0.001) at four-weeks. The whole mouth reduction of MGi was significantly higher for the WFS group; 23% more effective than SPP, 48% more effective than SF, and 1.35 times more effective than MT at four-weeks (p<0.001). The WFS group showed significantly better reductions for whole mouth rMNPi scores at four-weeks compared to all other groups. The SPP toothbrush was significantly better than the SF toothbrush for whole mouth BOP scores (26%), MGi scores (20%), and rMNPi scores (29%) (p<0.001).

Conclusions: The water flosser plus sonic toothbrush is an effective regimen for improving oral health indices and significantly more effective than sonic brushing alone. The SPP toothbrush is significantly more effective at improving oral health indices than the SF toothbrush.

This study was funded by a research grant from Water Pik, inc.

Study published: Goyal Cr, Lyle DM, Qaqish JG, Schuller r. The addition of a water flosser to power tooth brushing: effect on bleeding, gingivitis, and plaque. J Clin Dent 2012; 23:57-63.

The use of a Miswak compared to the use of a manual toothbrushUmama Begum, Lucy Bellfield, Maryan Khalif , Marium Khan and Vanessa Miller University of Portsmouth Dental Academy, William Beatty Building, Hampshire Terrace, Portsmouth, PO1 2QG

Email: [email protected] Or [email protected]

Aim: To undertake a randomised controlled trial to ascertain whether the use of a miswak or manual toothbrush would result in a greater reduction in plaque levels.

Methods: The A total of 200 subjects, adult male and female, aged between 21 and 50 were recruited to the study. A professional scale and polish was carried out on all participants. The study was single blind and six external clinicians measured the O’Leary plaque scores one week following treatment, as a baseline. The O’Leary plaque score provided a percentage (%) of plaque covered tooth surfaces for each participant.

Each subject was given either a miswak or a manual toothbrush depending on which group they were allocated to.

O’Leary plaque scores were recorded again one month later. All clinicians examined the same patients at baseline and again after one month. An average percentage of the participants’ increase or decrease in plaque levels, obtained from both groups, determined the results of this experiment.

Control variables: minimum of 20 permanent teeth, all subjects, in both groups, used identical toothpaste and all were non-smokers.

Results: The research indicated a significant difference in plaque levels between those subjects who used a miswak and those who used a manual toothbrush.

Conclusions: There were variations in plaque levels in both groups.


CPD

Q1. A number of individuals in the UK suffer from an eating disorder. Of this group what percentage suffers from bulimia? a) 6% b) 10% c) 40% d) 55%

Q2. Diagnosis of the bulimic patient can be difficult. What acronym is used for the screening tool developed to aid diagnosis?

Q1. What do the letters CPP stand for? a) Casein-phosphopeptide b) Casein-phosphatec) Casein–phosphoric acid d) Casein-peptide phosphate

Q2. What excipients did the study compare?a) CPP-ACP and fluoride solutionb) CPP-ACP and fluoridated pastec) CPP-ACP and standard fluoridated toothpasted) Fluoride tablets and CPP paste

Q3. What was the study seeking to establish? a) The efficacy of CPP-ACP in treating root cariesb) The efficacy of CPP-ACP in relation to fluoride in the prevention of toothbrush abrasion

Q1. What were the objectives of the study?a) To measure and record the oral hygiene status of participants at each visitb) To measure and record the oral hygiene status of participants at every second visitc) To measure and record the oral hygiene status of participants at three monthly intervalsd) To measure and record the oral hygiene status of participants at the start and end points of the trial.

Q2. How many cases were included in the study?a) 15 b) 25 c) 45 d) 50

Q3. What percentage of clefts occur as part of a wider syndrome? a) 2% b) 12% c) 21% d) 22%

Q4. How many studies did the literature review yield?a) One b) Threec) Five d) Ten

Q5. What percentage of cases presented with gingival inflammation? a) 23% b) 35% c) 56% d) 72%

Q6. Which well-established index was used to record data?a) An adapted version of the Tureskey modification of the

Quigley – Heineman indexb) An adapted version of the Turesky modification of the Quigley – Heimlich indexc) An adapted version of the Turesky modification of the Quigley – Heinrich indexd) An adapted version of the Turesky modification of the Quigley – Hein index

CPD paper 2: Bulimia nervosa: The role of the dental hygienist in the care of the bulimic patient pages 8-10

CPD paper 3: Determining the best method of applying CPP-ACP containing pastes and fluoride to eroded enamel in order to limit the amount of tooth wear in vitro. pages 11-15

CPD paper 1: Study to measure the clinical effectiveness of a dental hygienist in a cleft lip and palate unit. pages 5-7

Self Assessment for CPDSelect one correct answer in each question: Each paper is worth 30 minutes verifiable CPDTo take your CPD log onto the website www.bsdht.org.uk

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a) SCOFF b) TrOFFc) ENUFF d) STUFF

Q3. Self induced frequent vomiting results in dental erosion. What term is used to describe erosion specifically associated with chronic regurgitation of gastric contents? a) Perimolysisb) Perigynousc) Peristalsisd) Peritonitis

Q4. Which vitamin deficiency is associated with Glossitis?a) Vitamin Eb) Vitamin B12c) Vitamin Cd) Vitamin K

Q5. Typically, bulimic sufferers tend to be female. What percentage of sufferers is male? a) 1% b) 2% c) 3% d) 5%

Q6. Which of the following was not an objective of this study? a) Value the role of the dentist in identification and

referral of patients with eating disordersb) Outline dental hygiene interventions to be considered for manifestations associated with this eating disorderc) Describe systemic complications that can arise as sequelae to bulimic behaviourd) identify oral manifestations associated with bulimia


Self Assessment for CPDSelect one correct answer in each question:

Each paper is worth 30 minutes verifiable CPD To take your CPD log onto the website www.bsdht.org.uk

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Q1. How many mailings of this questionnaire were carried out?a) One b) Three c) Six d) Ten

Q2. What was the response rate?a) 5% b) 10% c) 66% d) 90%

Q3. In preferred medium of delivery how many respondents did not include hands on workshop?a) 3 b) 15 c) 16 d) 118

Q4. How was the response rate of this questionnaire rated?a) Good b) Very goodc) Satisfactory b) Unsatisfactory

Q5. What percentage of respondents indicated an interest in research?a) 28% b) 42% c) 50% d) 65%

CPD paper 4: A Survey of Dental Hygienists in the United Kingdom in 2011 – Part 5. Critical appraisal, research and continuing professional education pages 16-20

CPD Paper 5: Telomere length, chronic inflammation and oral health: implications for supportive therapy pages 21-27

Q1. What is senescence?a) Cellular ageing b) Cellular deathc) Cellular exhaustion d) Cellular maturation

Q2. What is the role of telomerase? a) To elongate chromosomesb) To shorten telomeric DNAc) To compromise telomere integrityd) To block cell replication

Q3. What causes oxidative stress? a) Dietary antioxidants intercepting oxidants b) Prolonged phagocytic production of free radicalsc) inflammatory periodontal diseased) Poor micronutrient status of an individual

Q4. Which micronutrients have increasing evidence to support their ability to modulate oxidative stress and chronic inflammation? a) Vitamin C, Alpha Tocopherol, Vitamin D and Omega three fatty acidsb) Vitamin B complex, Vitamin K, Beta Carotene and Calcium c) Vitamin E, Magnesium, Potassium and Glucosamined) Lutein, Alpha Carotene, Fluoride and Theanine

Q5. What effect may low levels of endogenous antioxidant reduced glutathione (GSH) have on periodontal health? a) Decrease the host responseb) increase the host responsec) Decrease susceptibility and progressiond) increase susceptibility and progression

Q6. How can Hormone Replacement Therapy affect the microbiology of the periodontal pocket?a) increase numbers of Aggregatibacter actinomycetemcomitans

and Streptococcus oralisb) Decrease numbers of Aggregatibacter actinomycetemcomitans and Streptococcus oralisc) Decrease numbers of Porphyromonas gingivalis and Tannerella forsythiad) increase numbers of Porphyromonas gingivalis and Tannerella forsythia

c) The relative efficacy of CPP-ACP compared with fluoride in the reduction of tooth weard) The correct way to apply CPP-ACP to minimise tooth surface loss

Q4. What did the study report regarding the efficacy of CPP-ACP when incorporated into beverages?a) That it was effective in reducing root surface cariesb) That it was effective in reducing enamel erosionc) That it provided effective protection against enamel hyperplasiad) That it was effective in reducing sensitivity

Q5. What was the reason suggested for the lack of significant difference between Tooth Mousse and GCMI paste when compare to the fluoride solution?a) Low level of available calciumb) Low level of available fluoride c) Low level of phosphopeptidesd) Low level of saliva

Q6. What did this study conclude was the best way to apply treatment solutions?a) Brushing b) Brushing and rinsingc) Soaking d) irrigation

Q6. What was the respondents preferred medium for delivery of CPE?a) Workshops b) Webinarsc) Lectures b) Journals


Q1. How many case controlled studies were identified, for the review? a) 5 b) 10 c) 15 d) 20

Q2. In a review of studies performed by Silverman and Wilder, it was found that mouth rinses were? a) Of no clinical valueb) Of little valuec) An important method of reducing plaque and gingivitisd) An important method of reducing calculus

Q1. Systemic reviews of the literature have all concluded that dentifrices containing triclosan and a copolymer have? a) No effect b) An anti plaque effectc) An anti gingivitis effect d) An anti plaque and anti gingivitis effect

Q2. Dental professionals have a responsibility to provide treatment to patients based on? a) The professional’s experienceb) Practice protocolsc) Current evidence based research and guidelinesd) Training undertaken at dental school

Q3. What is the highest level of evidence, as considered by the Department of Health?a) Case controlled studies b) Systematic reviewc) Cohort studies d) Expert opinion

Q4. In the author’s methodology, studies were included if they had been running for what period of time? a) Six days b) Six weeksc) Six months d) Six years

Q5. Of the 22 studies included in the review how many of the examiners were calibrated? a) 3 b) 9 c) 13 d) 22

Q6. Stabilised stannous fluoride dentifrices may not have such an effect on the reduction of plaque when compared to dentifrices containing?a) Triclosan b) Triclosan and zinc citratec) Triclosan and copolymer d) Sodium fluoride

Q3. Which of the following is not a risk factor for oral cancer?a) Tobacco smoking b) Alcohol consumptionc) Poor oral hygiene d) Caffeine consumption

Q4. The incidence of oral cancer in males in the UK rose between 1989 and 2006. By what percentage? a) 21% b) 31% c) 41% d) 51%

Q5. A fundamental feature of good research is that it should always include? a) Ethical approval b) A large sample groupc) A small sample group d) A large range of issues

Q6. After review of the studies, it is concluded that alcohol in mouthwashes is?a) Likely to increase the risk of oral cancerb) Highly likely to increase the risk of oral cancerc) Highly unlikely to increase the risk of oral cancerd) Unlikely to increase the risk of oral cancer

CPD paper 7: Does the use of mouthwash which contains alcohol increase the risk of oral cancer? A review of the literature pages 33-37

CPD paper 6: How effective are specific dentifrices in reducing or controlling plaque and gingivitis in adults? pages 28-32

Q1. In 2005 the Department of Health published an important dental public health strategy aimed at addressing inequalities in oral health. What was it called?a) Choosing Better Oral Healthb) Promoting Good Oral Healthc) Delivering Better Oral Healthd) Encouraging Good Oral Health

Q2. In which year did the Department of Health issue guidance to reverse consent mechanisms for dental public health programmes from negative to positive? a) 2005 b) 2006 c) 2007 d) 2008

Q3. What is the name of the population based dental treatment programme, initiated in Scotland in 2006/2007, which involved the application of fluoride varnish to children’s teeth?a) ChildLine b) ChildStartc) ChildSmile d) ChildCare

Q4. How can it be proved that autonomy has been respected in children’s dental treatment, such as receiving an application of fluoride varnish?a) A consent form is signed after treatment by the patient or by those with parental responsibilityb) A consent form is signed prior to treatment by the patient or by those with parental responsibilityc) No consent is required to apply fluoride varnish to children’s teethd) None of the above

CPD paper 8: Parental consent and fluoride varnish schemes: lessons from dental screening pages 38-42

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Self Assessment for CPDSelect one correct answer in each question: Each paper is worth 30 minutes verifiable CPDTo take your CPD log onto the website www.bsdht.org.uk


Q1. Motivational interviewing is a communication skill that…? a) rewards a patient with praiseb) Motivates a patient intrinsicallyc) Motivates a patient extrinsicallyd) Provides a patient with specific instructions

Q2. What is the The Hawthorne effect? a) Altered behaviour in response to being studiedb) Statistically inconsistent resultsc) The difference between what participants say and what they actually dod) B & C

Q3. Which of the following may be considered to be a confounding factor for the validity of MI?a) The Hawthorne theory b) The Espoused theoryc) Cost of training and delivery d) All of the above

Q4. Which of the following did not appear improved by MI?a) Smoking cessationb) DMF in childrenc) Pi in adultsd) improvements in periodontal condition

Q5. The findings of the literature review reached the following conclusion…?a) Mi should be incorporated into all OH adviceb) Mi is not cost effective to provide for patientsc) insufficient evidence was discovered to either support or oppose Mi

Q1. What percentage of dentists has reported their suspicion of child abuse?a) 8% b) 12% c) 18% d) 25%

Q2. For several reasons, it is often difficult to voice your concerns regarding suspected child maltreatment. Which of the following statements should not be considered a justifiable reason for not reporting suspected child maltreatment?a) Not my professional responsibilityb) A lack of awareness of signs and symptomsc) Fears of the outcomes of reporting concernsd) Little knowledge of local child protection mechanisms

Q3. Which dental professional is more likely to report child abuse?a) Dentist b) Dental Nurses c) Dental Hygienistd) Those who have received postgraduate training

Q4. In which of the following categories was there no increase in post- training percentage scores?a) i am able to list the main categories of child abuse, including signs and symptomsb) i know how to refer child abuse and where to access advicec) i lack confidence in dealing with child protection issuesd) All of the above

Q5. How many participants responded to the six week follow-up questionnaire?a) 25 b) 30 c) 34 d) 83

Q6. Undertaking training sessions in safeguarding children helps dental professionals…?a) retain knowledge regarding the categories and types of child abuseb) retain significant knowledge and understanding regarding their roles and responsibilities c) increase confidence in dealing with safeguarding children issuesd) All of the above

CPD paper 9: Do motivational interviewing techniques contribute to improving the oral health of primary dental care patients? A literature review pages 43-47

CPD paper 10: Evaluation of the impact and effectiveness of safeguarding children training on dental practice pages 48-52

d) Mi was proved to be unsuccessful in a Primary Dental care setting

Q6. Which of the following are not to be considerations into further research into the effects of MI?a) Length of studies b) Gender of participantsc) Data reporting from self reporting questionnairesd) External influences

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Q5. The introduction of written positive consent has shown…?a) Communication with parents in written format has little or no impact with regards to the oral health of their childrenb) To negatively impact on the uptake and therefore validity of epidemiological surveys of the dental health of school children in Englandc) it is anticipated that this requirement will have a detrimental effect on the participation of children in surveysd) All of the above

Q6. What main factor has contributed to a drop in participation in epidemiological studies?a) Parents are deliberately refusing to provide written consentb) Non-response of parents to provide written consent c) increasing levels of socio-economic status of parentsd) Large number of parents are actively objecting to their children’s participation

Self Assessment for CPDSelect one correct answer in each question:

Each paper is worth 30 minutes verifiable CPD To take your CPD log onto the website www.bsdht.org.uk


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