Publications by authors named "Richard G Watt"

127 Publications

Global Neglect of Dental Coverage in Universal Health Coverage Systems and Japan's Broad Coverage.

Int Dent J 2021 Feb 19. Epub 2021 Feb 19.

WHO Collaborating Centre for Oral Health Inequalities and Public Health, Department of Epidemiology and Public Health, University College London, UK.

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http://dx.doi.org/10.1016/j.identj.2020.12.027DOI Listing
February 2021

Developing a Standard Set of Patient-centred Outcomes for Adult Oral Health - An International, Cross-disciplinary Consensus.

Int Dent J 2021 Feb 16;71(1):40-52. Epub 2021 Jan 16.

ICHOM Adult Oral Health Working Group, Boston, MA, USA; FDI Vision 2020 Think Tank, Geneva, Switzerland; Bart's and The London, School of Medicine and Dentistry, Queen Mary, University of London, London, UK.

Objective: To develop a minimum Adult Oral Health Standard Set (AOHSS) for use in clinical practice, research, advocacy and population health.

Materials And Methods: An international oral health working group (OHWG) was established, of patient advocates, researchers, clinicians and public health experts to develop an AOHSS. PubMed was searched for oral health clinical and patient-reported measures and case-mix variables related to caries and periodontal disease. The selected patient-reported outcome measures focused on general oral health, and oral health-related quality of life tools. A consensus was reached via Delphi with parallel consultation of subject matter content experts. Finally, comments and input were elicited from oral health stakeholders globally, including patients/consumers.

Results: The literature search yielded 1,453 results. After inclusion/exclusion criteria, 959 abstracts generated potential outcomes and case-mix variables. Delphi rounds resulted in a consensus-based selection of 80 individual items capturing 31 outcome and case-mix concepts. Global reviews generated 347 responses from 87 countries, and the patient/consumer validation survey elicited 129 responses. This AOHSS includes 25 items directed towards patients (including demographics, the impact of their oral health on oral function, a record of pain and oral hygiene practices, and financial implications of care) and items for clinicians to complete, including medical history, a record of caries and periodontal disease activity, and types of dental treatment delivered.

Conclusion: In conclusion, utilising a robust methodology, a standardised core set of oral health outcome measures for adults, with a particular emphasis on caries and periodontal disease, was developed.
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http://dx.doi.org/10.1111/idj.12604DOI Listing
February 2021

Oral health and depressive symptoms: findings from the English Longitudinal Study of Ageing.

Br Dent J 2021 Feb 11. Epub 2021 Feb 11.

Department of Epidemiology and Public Health, UCL, 1-19 Torrington Place, WC1E 6BT, London, UK.

Aim We assessed the cross-sectional association between depressive symptoms and oral health using a nationally representative sample of older adults aged 50 years and older living in England.Methods Data came from wave 7 (2014-2015) of the English Longitudinal Study of Ageing. Multiple logistic regression analyses were conducted to assess the association between depressive symptoms, measured through the eight-item Centre for Epidemiologic Studies Depression Scale and three oral health outcomes, namely self-rated oral health, edentulousness and oral impacts.Results The analytical sample comprised 3,617 individuals. The proportion of participants that reported poor self-rated oral health, being edentate and having at least one oral health impact in the last six months was 19.8%, 7.7% and 8.9%, respectively. Around a tenth of the participants reported having depressive symptoms (10%). All unadjusted associations between depressive symptoms and the oral health measures were statistically significant. However, after accounting for potential confounders, only the relationship between depressive symptoms and self-rated oral health remained significant (OR = 1.38; 95% CI 1.01-1.89). Socioeconomic and general health-related variables appeared to influence the associations between depressive symptoms and oral health, particularly edentulousness and oral impacts.Conclusion Depressive symptoms were associated with poor self-rated oral health in older English adults.
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http://dx.doi.org/10.1038/s41415-021-2603-1DOI Listing
February 2021

Cross cultural adaptation and psychometric properties of the Bengali version of the Scale of Oral Health Outcomes for 5-year-old children (SOHO-5).

Health Qual Life Outcomes 2021 Feb 5;19(1):46. Epub 2021 Feb 5.

Research Department of Epidemiology and Public Health, University College London (UCL), 1-19 Torrington Place, London, WC1E 6BT, UK.

Background: The oral health related quality of life (OHRQoL) of children in Bangladesh has not yet been measured, as there is no validated OHRQoL measure for that population. The aim of this study was to cross-culturally adapt the child self-report and parental proxy report versions of the Scale of Oral Health Outcomes for 5-year-old children (SOHO-5) into Bengali and test their psychometric properties: face validity, construct validity (convergent and discriminant validity) and reliability (internal consistency and test-retest reliability), among 5-9-year-old children and their parents in Bangladesh and assess associations between dental caries/sepsis and OHRQoL in this population.

Methods: The forward-backward translated Bengali SOHO-5 was piloted among 272 children and their parents to test its face validity. The questionnaire was administered to 788 children and their parents to evaluate its psychometric properties. Internal consistency of Bengali SOHO-5 was assessed using Cronbach's alpha, and test-retest reliability was assessed using Kappa. Convergent and discriminant validity were assessed through nonparametric tests. The calculation of effect sizes and standard error of measurement facilitated the assessment of minimally important difference (MID) for SOHO-5. The associations of reporting an oral impact with caries and sepsis were assessed via logistic regression models.

Results: Both child self-report and parental proxy report questionnaires showed good face validity. Cronbach's alpha scores were 0.79 and 0.87 for child and parental questionnaire, respectively. A weighted Kappa score of 0.85 demonstrated test-retest reliability of child questionnaire. SOHO-5 scores were significantly associated with subjective oral health outcomes and discriminated clearly between different caries severity and sepsis groups. These differences were considerably higher than the MID. After adjusting for child's age, sex, setting, maternal education and family income, the odds of reporting an oral impact were 2.25 (95% CI 1.98-2.56) and 4.44 (95% CI 3.14-6.28) times higher for each additional tooth with caries and sepsis, respectively.

Conclusion: This study provided strong evidence supporting the validity and reliability of both versions of Bengali SOHO-5 as OHRQoL measures. Dental caries and sepsis were associated with poor OHRQoL in this population. The Bengali SOHO-5 is expected to be a useful outcome measure for research and clinical purposes in Bengali speaking child populations.
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http://dx.doi.org/10.1186/s12955-021-01681-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7866745PMC
February 2021

Causal Effect of Tooth Loss on Functional Capacity in Older Adults in England: A Natural Experiment.

J Am Geriatr Soc 2021 Jan 26. Epub 2021 Jan 26.

Department of Epidemiology and Public Health, University College London, London, United Kingdom.

Background/objectives: Tooth loss is associated with reduced functional capacity, but so far, there is no relevant causal evidence reported. We investigated the causal effect of tooth loss on the instrumental activities of daily living (IADL) among older adults in England.

Design: Natural experiment study with instrumental variable analysis.

Setting: The English Longitudinal Study of Aging (ELSA) combined with the participants' childhood exposure to water fluoride due to the community water fluoridation.

Participants: Five thousand six hundred and thirty one adults in England born in 1945-1965 participated in the ELSA wave seven survey (conducted in 2014-2015; average age: 61.0 years, 44.6% men).

Measurements: The number of natural teeth predicted by the exogenous geographical and historical variation in exposure to water fluoride from age 5 to 20 years old (instrumental variable) was used as an exposure variable. The outcome, having any limitations in IADL (preparing a hot meal, shopping for groceries, making telephone calls, taking medications, doing work around the house or garden, or managing money), was assessed by self-reported questionnaires.

Results: Linear probability model with Two-Stage Least Squares estimation was fitted. Being exposed to fluoridated water was associated with having more natural teeth in later life (coefficient: 0.726; 95% confidence interval (CI) = 0.311, 1.142; F = 11.749). Retaining one more natural tooth reduced the probability of having a limitation in IADL by 3.1 percentage points (coefficient: -0.031; 95% CI = -0.060, -0.002).

Conclusion: Preventing tooth loss maintains functional capacity among older adults in England. Given the high prevalence of tooth loss, this effect is considerable. Further research on the mechanism of the observed causal relationship is needed.
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http://dx.doi.org/10.1111/jgs.17021DOI Listing
January 2021

Poor sleep quality and oral health among older Brazilian adults.

Oral Dis 2020 Nov 26. Epub 2020 Nov 26.

Department of Epidemiology & Public Health, University College London, London, UK.

Objectives: This study evaluates the association between normative and subjective oral health measures and poor self-reported sleep quality among community-dwelling older adults in Brazil.

Methods: This was a cross-sectional study with data from the Brazilian Longitudinal Study of Aging. The dependent variable was the poor sleep quality. Independent variables of interest included number of teeth and self-reported impact of oral health on eating/chewing and on maintaining emotional stability.

Results: Poor sleep quality was reported by 17.8 (95% CI 16.6; 19.2) of the participants, 29% of the participants were edentulous, and 30% had 20 or more teeth. Impacts of oral health on eating and maintaining emotional stability was found among 33.3% and 20% of the older adults, respectively. After adjusting for all oral health measures and covariates, the magnitude of the associations between the number of teeth and sleep quality was attenuated. Sleep quality was related to oral health impacts on eating (OR 1.19 [95% CI 1.00; 1.41]) and on emotional stability (OR 1.51 [95% CI 1.21; 1.87]).

Conclusions: This study found an association between oral health and sleep quality emphasizing the importance of oral health to general health.
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http://dx.doi.org/10.1111/odi.13734DOI Listing
November 2020

Multimorbidity: a challenge and opportunity for the dental profession.

Br Dent J 2020 09 11;229(5):282-286. Epub 2020 Sep 11.

School of Dentistry, University of Leeds, Clarendon Way, Leeds, LS2 9LU, UK.

Multimorbidity (the coexistence of two or more chronic conditions) is common, is likely to be on the increase and has a major impact on quality of life, increased risk of mortality, and significant financial costs to the health and social care system. Multimorbidity is strongly associated with increasing age and is also directly linked to socioeconomic status. A substantial body of scientific evidence has shown an association between specific oral diseases and a range of other health conditions. Less is known, however, about the inter-relationships between oral diseases and multiple other health conditions. As multimorbidity is increasingly becoming the norm, rather than the exception, a profound shift is now needed in the training of oral health professionals, and the practice and delivery of dental care. A more integrated and coordinated approach to training and care is needed, which will require radical system-level reform and redesign of how health and dental services are commissioned, delivered and financed. Truly multidisciplinary teamwork requires system reform to facilitate effective joint working. The pattern of disease in society is changing and the dental profession needs to respond accordingly.
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http://dx.doi.org/10.1038/s41415-020-2056-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7485176PMC
September 2020

Socioeconomic Inequalities in Clustering of Health-Compromising Behaviours among Indian Adolescents.

Indian J Community Med 2020 Apr-Jun;45(2):139-144. Epub 2020 Jun 2.

Department of Epidemiology and Public Health, University College London, London, United Kingdom.

Background: The simultaneous occurrence of health-compromising behaviors can accentuate the risk of noncommunicable diseases (NCDs). This study aimed to examine the existence and patterns of clustering of four NCD risk behaviors among adolescents and its association with social position. In addition, socioeconomic inequalities in the occurrence of clustering of NCD risk behaviors were also assessed.

Methods: A cross-sectional study was undertaken among 1218 adolescents (14-19 years old) in the city of New Delhi, India. An interviewer-administered questionnaire was used to assess health-compromising behaviors (tobacco and alcohol use, fruit/vegetable intake, and physical inactivity). Clustering was assessed using pairwise correlations, counts of clustering of health-compromising behaviors, comparison of observed/expected ratios, and hierarchical agglomerative cluster analysis. Multivariable logistic regressions were used to test the associations of clustering with social position (education and wealth). The relative and slope indices of inequalities in the presence of clustering of behaviors according to education and wealth were estimated.

Results: Three major clusters of health behaviors emerged: (a) physical inactivity + lower fruit and vegetable intake, (b) tobacco + alcohol use, and (c) lower fruit and vegetable intake + tobacco + alcohol use. Pronounced clustering of health-compromising behaviors was observed with lower educational attainment and wealth.

Conclusion: The presence of clustering of health-compromising behaviors was considerably higher among adolescents with lower educational attainment and wealth. The area of residence has an important influence on socioeconomic inequalities in clustering of NCD risk factors.
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http://dx.doi.org/10.4103/ijcm.IJCM_349_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7467189PMC
June 2020

COVID-19 is an opportunity for reform in dentistry.

Authors:
Richard G Watt

Lancet 2020 08;396(10249):462

Department of Epidemiology and Public Health, University College London, London WC1E 6BT, UK. Electronic address:

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http://dx.doi.org/10.1016/S0140-6736(20)31529-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7426102PMC
August 2020

Wider Dental Care Coverage Associated with Lower Oral Health Inequalities: A Comparison Study between Japan and England.

Int J Environ Res Public Health 2020 07 31;17(15). Epub 2020 Jul 31.

Department of International and Community Oral Health, Tohoku University, Sendai 980-8575, Japan.

Countries with different oral health care systems may have different levels of oral health related inequalities. We compared the socioeconomic inequalities in oral health among older adults in Japan and England. We used the data for adults aged 65 years or over from Japan ( = 79,707) and England ( = 5115) and estimated absolute inequality (the Slope Index of Inequality, SII) and relative inequality (the Relative Index of Inequality, RII) for edentulism (the condition of having no natural teeth) by educational attainment and income. All analyses were adjusted for sex and age. Overall, 14% of the Japanese subjects and 21% of the English were edentulous. In both Japan and England, lower income and educational attainment were significantly associated with a higher risk of being edentulous. Education-based SII in Japan and England were 9.9% and 26.7%, respectively, and RII were 2.5 and 4.8, respectively. Income-based SII in Japan and England were 9.2% and 14.4%, respectively, and RII were 2.1 and 1.9, respectively. Social inequalities in edentulous individuals exist in both these high-income countries, but Japan, with wider coverage for dental care, had lower levels of inequality than England.
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http://dx.doi.org/10.3390/ijerph17155539DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7432332PMC
July 2020

Developing a standard set of patient-centred outcomes for adult oral health - an international, cross-disciplinary consensus.

Int Dent J 2020 Jul 5. Epub 2020 Jul 5.

ICHOM Adult Oral Health Working Group, Boston, MA, USA.

Objective: To develop a minimum Adult Oral Health Standard Set (AOHSS) for use in clinical practice, research, advocacy and population health.

Materials And Methods: An international oral health working group (OHWG) was established, of patient advocates, researchers, clinicians and public health experts to develop an AOHSS. PubMed was searched for oral health clinical and patient-reported measures and case-mix variables related to caries and periodontal disease. The selected patient-reported outcome measures focused on general oral health, and oral health-related quality of life tools. A consensus was reached via Delphi with parallel consultation of subject matter content experts. Finally, comments and input were elicited from oral health stakeholders globally, including patients/consumers.

Results: The literature search yielded 1,453 results. After inclusion/exclusion criteria, 959 abstracts generated potential outcomes and case-mix variables. Delphi rounds resulted in a consensus-based selection of 80 individual items capturing 31 outcome and case-mix concepts. Global reviews generated 347 responses from 87 countries, and the patient/consumer validation survey elicited 129 responses. This AOHSS includes 25 items directed towards patients (including demographics, the impact of their oral health on oral function, a record of pain and oral hygiene practices, and financial implications of care) and items for clinicians to complete, including medical history, a record of caries and periodontal disease activity, and types of dental treatment delivered.

Conclusion: In conclusion, utilising a robust methodology, a standardised core set of oral health outcome measures for adults, with a particular emphasis on caries and periodontal disease, was developed.
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http://dx.doi.org/10.1111/idj.12604DOI Listing
July 2020

Development of a core outcome set for oral health services research involving dependent older adults (DECADE): a study protocol.

Trials 2020 Jul 1;21(1):599. Epub 2020 Jul 1.

Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK.

Background: Oral healthcare service provision for dependent older adults is often poor. For dental services to provide more responsive and equitable care, evidence-based approaches are needed. To facilitate future research, the development and application of a core outcome set would be beneficial. The aim of this study is to develop a core outcome set for oral health services research involving dependent older adults.

Methods: A multi-step process involving consensus methods and including key stakeholders will be undertaken. This will involve identifying potentially relevant outcomes through a systematic review of previous studies examining the effectiveness of strategies to prevent oral disease in dependent older adults, combined with semi-structured interviews with key stakeholders. Stakeholders will include dependent older adults, family members, carers, care-home managers, health professionals, researchers, dental commissioners and policymakers. To condense and prioritise the long list of outcomes generated by the systematic review and semi-structured interviews, a Delphi survey consisting of several rounds with key stakeholders, as mentioned above, will be undertaken. The 9-point Likert scale proposed by the GRADE Working Group will facilitate this consensus process. Following the Delphi survey, a face-to-face consensus meeting with key stakeholders will be conducted where the stakeholders will anonymously vote and decide on what outcomes should be included in the finalised core outcome set.

Discussion: Developing a core set of outcomes that are clinically and patient-centred will help improve the design, conduct and reporting of oral health services research involving dependent older adults, and ultimately strengthen the evidence base for high-quality oral health care for dependent older adults.

Trial Registration: The study was registered with the COMET initiative on 9 January 2018 http://www.cometinitiative.org/studies/details/1081?result=true .
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http://dx.doi.org/10.1186/s13063-020-04531-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7329504PMC
July 2020

Down syndrome and oral health: mothers' perception on their children's oral health and its impact.

J Patient Rep Outcomes 2020 Jun 16;4(1):45. Epub 2020 Jun 16.

Special Care Dentistry, Dublin Dental University Hospital, Dublin, Ireland.

Background: Individuals with Down syndrome exhibit particular oro-facial characteristics that may increase their risk of oral health problems. However, there is little research on the oral health of children and adults with Down syndrome and the way that oral health may affect Quality of Life (QoL). This study explored mothers' perceptions of the oral health problems experienced by their children with Down syndrome and how these reported problems impacted the lives of the children and their families.

Methods: The study involved 20 in-depth, semi-structured interviews with mothers of children and adolescents aged 12-18 years with Down syndrome attending special care centres in Riyadh, Saudi Arabia.

Results: The predominant oral-health related problem reported by mothers was difficulty in speaking. Mothers also reported that tooth decay and toothache were problems that had undesirable effects on different aspects of their children's QoL including: performing daily activities, emotional wellbeing, and social relationships. Poor oral health and functional problems had direct and indirect impacts on the family's QoL as well.

Conclusion: Mothers perceived an array of QoL impacts from oral conditions, which affected their child with Down syndrome and the wider family.
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http://dx.doi.org/10.1186/s41687-020-00211-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7297886PMC
June 2020

Authors' Response.

J Am Dent Assoc 2020 06;151(6):384-385

Professor, Dental Public Health, World Health Organization Collaborating Centre for Oral Health, Inequalities and Public Health, Department of Epidemiology and Public Health, University College London, London, UK.

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http://dx.doi.org/10.1016/j.adaj.2020.04.019DOI Listing
June 2020

IADR and AADR applaud the Lancet Oral Health Series - Authors' reply.

Lancet 2020 02;395(10224):564

WHO Collaborating Centre for Quality-Improvement, Evidence-Based Dentistry, Department of Epidemiology and Health Promotion, New York University College of Dentistry, New York, NY, USA.

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http://dx.doi.org/10.1016/S0140-6736(19)32991-5DOI Listing
February 2020

A call for action to improve US oral health care.

J Am Dent Assoc 2020 02;151(2):73-75

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http://dx.doi.org/10.1016/j.adaj.2019.12.003DOI Listing
February 2020

Oral diseases: a global public health challenge - Authors' reply.

Lancet 2020 01;395(10219):186-187

WHO Collaborating Centre for Oral Health Inequalities and Public Health, Department of Epidemiology and Public Health, University College London, London WC1E 6BT. Electronic address:

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http://dx.doi.org/10.1016/S0140-6736(19)32997-6DOI Listing
January 2020

Student Loans and Psychological Distress: A Cross-sectional Study of Young Adults in Japan.

J Epidemiol 2020 Oct 31;30(10):436-441. Epub 2019 Aug 31.

Department of International and Community Oral Health, Tohoku University Graduate School of Dentistry.

Background: Levels of student loan debt have been increasing, but very little research has assessed if this is associated with poor health. The aim was to examine the association between student loans and psychological distress in Japan.

Methods: We conducted a cross-sectional web-based self-administered questionnaire survey in 2017. The sample comprised of 4,149 respondents aged 20-34, with 3,170 graduates and 979 current university students. The independent variables were whether or not current students had student loans, and for graduates, the total amount of their student loan debt. The dependent variable was severe psychological distress assessed using the Kessler Psychological Distress Scale (K6; the cut-off point was 12/13). Covariates were demographic and parents' socioeconomic variables. A Poisson regression analysis with a robust error variance was conducted to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs). Because there was a significant interaction between current student status and the status of borrowing student loans, stratified analyses were conducted.

Results: The percentage of those with student loans was 33.8% among graduates and 35.2% among current university students. Among graduates, student loan debt was significantly associated with a high possibility of having severe psychological distress after adjusting for covariates (PR of ≥4 million yen, 1.44; 95% CI, 1.02-2.03). Among current university students, there was no significant association (PR of borrowing student loans, 0.91; 95% CI, 0.60-1.37).

Conclusions: There was a significant association between student loan debt and psychological distress among graduates but not current university students.
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http://dx.doi.org/10.2188/jea.JE20190057DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7492703PMC
October 2020

Ending the neglect of global oral health: time for radical action.

Lancet 2019 Jul;394(10194):261-272

WHO Collaborating Centre for Quality-Improvement, Evidence-Based Dentistry, Department of Epidemiology and Health Promotion, New York University College of Dentistry, New York, NY, USA; New York University College of Global Public Health, New York, NY, USA.

Oral diseases are a major global public health problem affecting over 3·5 billion people. However, dentistry has so far been unable to tackle this problem. A fundamentally different approach is now needed. In this second of two papers in a Series on oral health, we present a critique of dentistry, highlighting its key limitations and the urgent need for system reform. In high-income countries, the current treatment-dominated, increasingly high-technology, interventionist, and specialised approach is not tackling the underlying causes of disease and is not addressing inequalities in oral health. In low-income and middle-income countries (LMICs), the limitations of so-called westernised dentistry are at their most acute; dentistry is often unavailable, unaffordable, and inappropriate for the majority of these populations, but particularly the rural poor. Rather than being isolated and separated from the mainstream health-care system, dentistry needs to be more integrated, in particular with primary care services. The global drive for universal health coverage provides an ideal opportunity for this integration. Dental care systems should focus more on promoting and maintaining oral health and achieving greater oral health equity. Sugar, alcohol, and tobacco consumption, and their underlying social and commercial determinants, are common risk factors shared with a range of other non-communicable diseases (NCDs). Coherent and comprehensive regulation and legislation are needed to tackle these shared risk factors. In this Series paper, we focus on the need to reduce sugar consumption and describe how this can be achieved through the adoption of a range of upstream policies designed to combat the corporate strategies used by the global sugar industry to promote sugar consumption and profits. At present, the sugar industry is influencing dental research, oral health policy, and professional organisations through its well developed corporate strategies. The development of clearer and more transparent conflict of interest policies and procedures to limit and clarify the influence of the sugar industry on research, policy, and practice is needed. Combating the commercial determinants of oral diseases and other NCDs should be a major policy priority.
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http://dx.doi.org/10.1016/S0140-6736(19)31133-XDOI Listing
July 2019

Oral diseases: a global public health challenge.

Lancet 2019 Jul;394(10194):249-260

WHO Collaborating Centre in Oral Health Inequalities and Public Health, Department of Epidemiology and Public Health, University College London, London, UK. Electronic address:

Oral diseases are among the most prevalent diseases globally and have serious health and economic burdens, greatly reducing quality of life for those affected. The most prevalent and consequential oral diseases globally are dental caries (tooth decay), periodontal disease, tooth loss, and cancers of the lips and oral cavity. In this first of two papers in a Series on oral health, we describe the scope of the global oral disease epidemic, its origins in terms of social and commercial determinants, and its costs in terms of population wellbeing and societal impact. Although oral diseases are largely preventable, they persist with high prevalence, reflecting widespread social and economic inequalities and inadequate funding for prevention and treatment, particularly in low-income and middle-income countries (LMICs). As with most non-communicable diseases (NCDs), oral conditions are chronic and strongly socially patterned. Children living in poverty, socially marginalised groups, and older people are the most affected by oral diseases, and have poor access to dental care. In many LMICs, oral diseases remain largely untreated because the treatment costs exceed available resources. The personal consequences of chronic untreated oral diseases are often severe and can include unremitting pain, sepsis, reduced quality of life, lost school days, disruption to family life, and decreased work productivity. The costs of treating oral diseases impose large economic burdens to families and health-care systems. Oral diseases are undoubtedly a global public health problem, with particular concern over their rising prevalence in many LMICs linked to wider social, economic, and commercial changes. By describing the extent and consequences of oral diseases, their social and commercial determinants, and their ongoing neglect in global health policy, we aim to highlight the urgent need to address oral diseases among other NCDs as a global health priority.
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http://dx.doi.org/10.1016/S0140-6736(19)31146-8DOI Listing
July 2019

Understanding and tackling oral health inequalities in vulnerable adult populations: from the margins to the mainstream.

Br Dent J 2019 Jul;227(1):49-54

Division of Public and Child Dental Health, School of Dental Science, Trinity College Dublin and Dublin Dental University Hospital, Lincoln Place, Dublin 2, Ireland.

Vulnerable and socially excluded groups in society persistently experience significantly worse oral health and poorer access to dental services than the mainstream population. Action to tackle these unfair, unjust and avoidable inequalities in oral health needs to be informed by an understanding of the broad range of interacting factors that ultimately influence oral health across society and specifically the most vulnerable and marginalised. Failure to understand the underlying factors that create and perpetuate the oral health equity gap risks the development and implementation of ineffective interventions that do not achieve meaningful improvements in oral health for the most vulnerable. This paper presents a theoretical framework that combines a broad public health perspective on oral health inequalities, combined with more specific factors determining the oral health of vulnerable and marginalised groups. Actions to improve access to dental services and policies to combat oral health inequalities among vulnerable adult populations are then presented.
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http://dx.doi.org/10.1038/s41415-019-0472-7DOI Listing
July 2019

Income or education, which has a stronger association with dental implant use in elderly people in Japan?

Int Dent J 2019 Dec 27;69(6):454-462. Epub 2019 Jun 27.

Department of International and Community Oral Health, Graduate School of Dentistry, Tohoku University, Sendai, Japan.

Objectives: Although inequalities in dental implant use based on educational level have been reported, no study has used income as a proxy for the socioeconomic status. We examined: (i) income inequalities in implant use; and (ii) whether income or education has a stronger association with implant use in elder Japanese.

Methods: In 2016, a self-reported questionnaire was mailed to participants aged 65 years or older living across Japan as part of the ongoing Japan Gerontological Evaluation Study. We used data from 84,718 respondents having 19 or fewer teeth. After multiple imputation, multi-level logistic regression estimated the association of dental implant use with equivalised income level and years of formal education. Confounders were age, sex, and density of dental clinics in the residential area.

Results: 3.1% of respondents had dental implants. Percentages of dental implant use among the lowest (≤ 9 years) and highest (≥ 13 years) educational groups were 1.8 and 5.1, respectively, and among the lowest (0 < 12.2 '1,000 USD/year') and highest (≥ 59.4 '1,000 USD/year') income groups were 1.7 and 10.4, respectively. A fully adjusted model revealed that both income and education were independently associated with dental implant use. Odds ratios for implant use in the highest education and income groups were 2.13 [95% CI = 1.94-2.35] and 4.85 [95% CI = 3.78-6.22] compared with the lowest education and income groups, respectively. From a model with standardised variables, income showed slightly stronger association than education.

Conclusion: This study reveals a public health problem that even those with the highest education but low income might have limited accessibility to dental implant services.
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http://dx.doi.org/10.1111/idj.12491DOI Listing
December 2019

Health insurance and education: major contributors to oral health inequalities in Colombia.

J Epidemiol Community Health 2019 08 16;73(8):737-744. Epub 2019 May 16.

Department of Epidemiology and Public Health, University College London, London, UK.

Background: Health inequalities, including inequalities in oral health, are problems of social injustice worldwide. Evidence on this issue from low-income and middle-income countries is still needed. We aimed to examine the relationship between oral health and different dimensions of socioeconomic position (SEP) in Colombia, a very unequal society emerging from a long-lasting internal armed conflict.

Methods: Using data from the last Colombian Oral Health Survey (2014), we analysed inequalities in severe untreated caries (≥3 teeth), edentulousness (total tooth loss) and number of missing teeth. Inequalities by education, income, area-level SEP and health insurance scheme were estimated by the relative index of inequality and slope index of inequality (RII and SII, respectively).

Results: A general pattern of social gradients was observed and significant inequalities for all outcomes and SEP indicators were identified with RII and SII. Relative inequalities were larger for decay by health insurance scheme, with worse decay levels among the uninsured (RII: 2.57; 95% CI 2.11 to 3.13), and in edentulousness (RII: 3.23; 95% CI 1.88 to 5.55) and number of missing teeth (RII: 2.08; 95% CI 1.86 to 2.33) by education, with worse levels of these outcomes among the lower educated groups. Absolute inequalities followed the same pattern. Inequalities were larger in urban areas.

Conclusion: Health insurance and education appear to be the main contributors to oral health inequalities in Colombia, posing challenges for designing public health strategies and social policies. Tackling health inequalities is crucial for a fairer society in a Colombian post-conflict era and our findings highlight the importance of investing in education policies and universal health care coverage.
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http://dx.doi.org/10.1136/jech-2018-212049DOI Listing
August 2019

Alcohol Screening and Brief Advice in NHS General Dental Practices: A Cluster Randomized Controlled Feasibility Trial.

Alcohol Alcohol 2019 May;54(3):235-242

Department of Epidemiology and Public Health, UCL, UK.

Aim: To assess the feasibility and acceptability of screening for alcohol misuse and delivering brief advice to eligible patients attending NHS dental practices in London.

Methods: A two-arm cluster randomized controlled feasibility trial was conducted. Twelve dental practices were recruited and randomized to intervention and control arms. Participants attending for a dental check were recruited into the study and were eligible if they consumed alcohol above recommended levels assessed by the AUDIT-C screening tool. All eligible participants were asked to complete a baseline socio-demographic questionnaire. Six months after the completion of baseline measures, participants were contacted via telephone by a researcher masked to their allocation status. The full AUDIT tool was then administered. Alcohol consumption in the last 90 days was also assessed using the Form 90. A process evaluation assessed the acceptability of the intervention.

Results: Over a 7-month period, 229 participants were recruited (95.4% recruitment rate) and at the 6 months follow-up, 176 participants were assessed (76.9% retention rate). At the follow-up, participants in the intervention arm were significantly more likely to report a longer abstinence period (3.2 vs. 2.3 weeks respectively, P = 0.04) and non-significant differences in AUDIT (44.9% vs. 59.8% AUDIT positive respectively, P = 0.053) and AUDIT C difference between baseline and follow-up (-0.67 units vs. -0.29 units respectively, P = 0.058). Results from the process evaluation indicated that the intervention and study procedures were acceptable to dentists and patients.

Conclusions: This study has demonstrated the feasibility and acceptability of dentists screening for alcohol misuse and providing brief advice.
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http://dx.doi.org/10.1093/alcalc/agz017DOI Listing
May 2019

Review and analysis of Chilean dental undergraduate education: curriculum composition and profiles of first year dental students.

Hum Resour Health 2018 09 17;16(1):48. Epub 2018 Sep 17.

Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London, WC1E 6BT, United Kingdom.

Background: In Chile, dentistry has become a very popular career choice for students, which has resulted in a substantial increase in both, the number of dental graduates and dental schools. Nonetheless, there is a need for change in the way dental schools select and educate their students to keep pace with the rapidly changing nature of societal needs and to tackle the marked health inequalities that exist in the country. The aim of this study was to review and critique dental undergraduate education in Chile, with a particular focus on the curriculum composition and profiles of students admitted to dental schools from 2010 to 2014.

Methods: A descriptive and retrospective design was utilised. Two different methods were undertaken: primary data collection regarding curriculum and secondary data analysis in relation to students' profiles. Descriptive statistics were used to assess the relative proportions of subject modules within the undergraduate dental curriculum and in particular the public health components. The analysis of the student profiles described specific background factors, namely, gender, age, secondary school type, location, rural-urban status and student's year of admission. Also, trends of dental students' intake between 2010 and 2014 were investigated. Logistic regression analysis was undertaken to assess potential associations between the aforementioned background factors and students' choice of dental school.

Results: Regarding the curriculum review, a 67% response rate was obtained. The most dominant component of Chilean dental curriculum was the clinical subjects (33%), followed by the basic and biological sciences (16%) and then medical and dental sciences (13%). In relation to the admission of students, the majority attended private schools (72%); most were females (62%); aged 19 years or less (74%); had an urban origin (99%); and came from subsidised private secondary schools (48%). Significant differences were found between students admitted to traditional and private dental schools.

Conclusions: Clinical sciences are the most dominant subjects in the Chilean dental curriculum. Overall, traditional and private institutions had a broadly similar composition in their curriculum with the exception of the public health component. Students from disadvantaged backgrounds were the minority in dental schools across Chile.
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http://dx.doi.org/10.1186/s12960-018-0314-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6142632PMC
September 2018

Oral Health Disparities in Children: A Canary in the Coalmine?

Pediatr Clin North Am 2018 10;65(5):965-979

Division of Oral Epidemiology and Dental Public Health, Center to Address Disparities in Children's Oral Health (Known As CAN DO), Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, Box #1361, San Francisco, CA 94143, USA.

Despite being largely preventable, oral diseases are still a major public health problem in child populations in many parts of the world. Increasingly, however, oral diseases disproportionately affect socially disadvantaged groups in society. It is unjust and unfair that children and families from disadvantaged backgrounds experience high levels of oral diseases. This article analyzes oral diseases through a health disparities lens. Action to combat oral health disparities requires a radical multifaceted strategy that addresses the shared underlying root causes of oral diseases, the social determinants of health inequality.
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http://dx.doi.org/10.1016/j.pcl.2018.05.006DOI Listing
October 2018

Explaining oral health inequalities in European welfare state regimes: The role of health behaviours.

Community Dent Oral Epidemiol 2019 02 13;47(1):40-48. Epub 2018 Sep 13.

Department of Epidemiology and Public Health, University College London, London, UK.

Objective: To assess the extent to which behavioural factors, including those related to dental care, account for oral health inequalities in different European welfare state regimes.

Methods: Data from the Eurobarometer 2009 survey were analysed. Nationally representative samples of dentate adults aged ≥45 years (n = 9979) from 21 European countries classified into the five welfare regimes (Scandinavian, Anglo-Saxon, Bismarckian, Southern, Eastern) were considered. Inequalities in no functional dentition (having <20 natural teeth) by education and occupation were identified using the Relative and Slope Indices of Inequality (RII and SII, respectively). The percentage reduction in RII and SII was calculated from regression models before and after adjustment for behaviours, first one at a time and then all together.

Results: Behaviours explained 21.0% (95% CI 8.7, 31.4) and 13.1% (95% CI 7.9, 33.2) of educational inequalities in no functional dentition (RII) in the Scandinavian and Eastern regimes, respectively. For occupational inequalities, the attenuations in RII in these welfare regimes were 19.3% (95% CI 7.1, 24.2) and 10.5% (95% CI 3.4, 22.5), respectively. Attenuations were weaker and nonsignificant in the Bismarckian, Anglo-Saxon and Southern regimes. Among the behaviours analysed, alcohol consumption was particularly relevant in explaining inequalities in the Scandinavian regime, and this was confirmed in sensitivity analyses through three-way cross-level interaction terms in multilevel models. Behaviours related to dental care produced similar, consistent attenuations in the Scandinavian and Eastern regimes for both socioeconomic indicators. SII findings showed a similar picture.

Conclusion: The role of particular behaviours in explaining oral health inequalities could be heterogeneous across European welfare regimes, indicating that their importance might be influenced by the general approach to social policies.
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http://dx.doi.org/10.1111/cdoe.12420DOI Listing
February 2019

Dentistry's future.

J Am Dent Assoc 2018 09;149(9):752-753

Professor, University College, London, United Kingdom.

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http://dx.doi.org/10.1016/j.adaj.2018.07.011DOI Listing
September 2018

Dental caries and anthropometric measures in a sample of 5- to 9-year-old children in Dhaka, Bangladesh.

Community Dent Oral Epidemiol 2018 10 6;46(5):449-456. Epub 2018 Aug 6.

Research Department of Epidemiology and Public Health, University College London (UCL), London, UK.

Aim: This study aimed to assess associations between dental caries and anthropometric measures among a sample of children aged 5-9 years in Dhaka, Bangladesh.

Methods: A cross-sectional observational study was conducted among 5- to 9-year-old children in Dhaka, Bangladesh. Data were collected from children and their parents attending the Dhaka Dental College Hospital and from three nearby primary schools. The outcome measures were as follows: age and sex adjusted height-z-scores (HAZ), weight-z-scores (WAZ) and BMI-z-scores (BAZ). Multiple linear regressions were used to assess the associations between caries and anthropometric measures, adjusted for maternal education, family income, study setting, birth weight and childhood diseases as potential confounders.

Results: The final sample comprised 788 children, and the overall response rate was 96.7%. The majority (73.2%) had experience of dental caries. The mean dmft + DMFT score was 2.84 (95% CI 2.64, 3.03) and 35.8% experienced dental sepsis. Dental caries and sepsis were negatively associated with HAZ, WAZ and BAZ scores. After adjustment for potential confounders, children with severe levels of caries had lower HAZ scores (coefficient: -0.40; 95% CI -0.69, -0.10), lower WAZ scores (coefficient: -0.59; 95% CI -0.94, -0.24) and lower BAZ scores (coefficient: -0.50; 95% CI -0.87, -0.13) than those who were caries free. Children with moderate levels of caries also had lower WAZ scores (coefficient: -0.43; 95% CI -0.72, -0.15) and lower BAZ scores (coefficient: -0.43; 95% CI -0.72, -0.13) than caries-free children. Children with dental sepsis had lower HAZ (coefficient: -0.23; 95% CI -0.42, -0.03), WAZ (coefficient: -0.33; 95% CI -0.56, -0.10) and BAZ scores (coefficient: -0.29; 95% CI -0.53, -0.05) than dental sepsis-free children.

Conclusions: Dental caries was associated with lower height, weight and BMI among this sample of Bangladeshi children, even after adjusting for age and sex and a number of potential confounders.
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http://dx.doi.org/10.1111/cdoe.12412DOI Listing
October 2018

Breastfeeding practices in the United Kingdom: Is the neighbourhood context important?

Matern Child Nutr 2018 10 17;14(4):e12626. Epub 2018 May 17.

Research Department of Epidemiology and Public Health, University College London, Torrington Place, London, UK.

Breastfeeding is an important public health issue worldwide. Breastfeeding rates in the United Kingdom, particularly for exclusive breastfeeding, are low compared with other OECD countries, despite its wide-ranging health benefits for both mother and child. There is evidence that deprivation in the structural and social organisation of neighbourhoods is associated with adverse child outcomes. This study aimed to explore whether breastfeeding initiation, exclusive breastfeeding for at least 3 months, and any type of breastfeeding for at least 6 months were associated with neighbourhood context measured by neighbourhood deprivation and maternal neighbourhood perceptions in a nationally representative U.K.

Sample: A cross-sectional analysis was conducted using data from the Millennium Cohort Study. Logistic regression was carried out on a sample of 17,308 respondents, adjusting for individual- and familial-level socio-demographic characteristics. Neighbourhood deprivation was independently and inversely associated with breastfeeding initiation. Compared with the least deprived areas, the likelihood of initiating breastfeeding was 40% lower in the most deprived neighbourhoods (OR: 0.60, 95% CI [0.50, 0.72]). The relationship between both exclusive and any type of breastfeeding at 3 and 6 months respectively with neighbourhood deprivation after adjustment for potential confounders was not entirely linear. Breastfeeding initiation (OR: 0.78, 95% CI [0.71, 0.85]), exclusivity for 3 months (OR: 0.84, 95% CI [0.75, 0.95]), and any breastfeeding for 6 months (OR: 0.82, 95% CI [0.73, 0.93]) were each reduced by about 20% among mothers who perceived their neighbourhoods lacking safe play areas for children. Policies to improve breastfeeding rates should consider area-based approaches and the broader determinants of social inequalities.
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http://dx.doi.org/10.1111/mcn.12626DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6865869PMC
October 2018