The burden of oral ill health for children

Gamification and Oral Health in Children and Adolescents: Scoping Review

BACKGROUND

Oral health is a determinant of overall well-being and quality of life. Individual behaviors, such as oral hygiene and dietary habits, play a central role in oral health. Motivation is a crucial factor in promoting behavior change, and gamification offers a means to boost health-related knowledge and encourage positive health behaviors.

OBJECTIVE

This study aims to evaluate the impact of gamification and its mechanisms on oral health care of children and adolescents.

METHODS

A systematic search covered multiple databases: PubMed/MEDLINE, PsycINFO, the Cochrane Library, ScienceDirect, and LILACS. Gray literature, conference proceedings, and WHOQOL internet resources were considered. Studies from January 2013 to December 2022 were included, except for PubMed/MEDLINE, which was searched until January 2023. A total of 15 studies were selected following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The eligibility criteria were peer-reviewed, full-text, and empirical research related to gamification in oral health care, reports of impact, and oral health care outcomes. The exclusion criteria encompassed duplicate articles; unavailable full texts; nonoriginal articles; and non-digital game-related, non-oral health-related, and protocol studies. Selected studies were scrutinized for gamification mechanisms and outcomes. Two main questions were raised: "Does gamification in oral health care impact oral health?" and "Does oral health care gamification enhance health promotion and literacy?" The PICO (Patient, Intervention, Comparison, Outcome) framework guided the scoping review.

RESULTS

Initially, 617 records were obtained from 5 databases and gray literature sources. After applying exclusion criteria, 15 records were selected. Sample size in the selected studies ranged from 34 to 190 children and adolescents. A substantial portion (11/15, 73%) of the studies discussed oral self-care apps supported by evidence-based oral health. The most clearly defined data in the apps were "brushing time" (11/11, 100%) and "daily amount brushing" (10/11, 91%). Most studies (11/15, 73%) mentioned oral health care behavior change techniques and included "prompt intention formation" (11/26, 42%), "providing instructions" (11/26, 42%), "providing information on the behavior-health link" (10/26, 38%), "providing information on consequences" (9/26, 35%), "modeling or demonstrating behavior" (9/26, 35%), "providing feedback on performance" (8/26, 31%), and "providing contingent rewards" (8/26, 31%). Furthermore, 80% (12/15) of the studies identified game design elements incorporating gamification features in oral hygiene applications. The most prevalent gamification features were "ideological incentives" (10/12, 83%) and "goals" (9/16, 56%), which were found in user-specific and challenge categories, respectively.

CONCLUSIONS

Gamification in oral health care shows potential as an innovative approach to promote positive health behaviors. Most studies reported evidence-based oral health and incorporated oral health care behavior change techniques.

Awareness and Attitude of General and Specialist Dentists in Providing Oral Health-related Quality of Life for Children with Special Healthcare Needs

Special healthcare needs children (SHCNC) requires specialized knowledge acquired by additional training, as well as increased awareness and accommodative measures on part of general practitioners and specialist dentists beyond what is considered routine. Most dentists face challenges in treating these children, due to lack of awareness and insufficient training regarding the management of such children in a dental operatory.

Effectiveness of Silver Diammine Fluoride Applications for Dental Caries Cessation in Tribal Preschool Children in India: Study Protocol for a Randomized Controlled Trial

Introduction: Silver Diammine Fluoride (SDF) is an emerging caries preventive treatment option that is inexpensive, safe, and easily accessible. The evidence is clear that the use of SDF at concentrations of 38% is effective for arresting caries in primary teeth. However, the determination of an optimal SDF application frequency for a cavitated lesion in pragmatic settings is warranted especially among high dental caries risk groups. Hence, the primary objective of this clinical trial is to compare the effectiveness of annual, bi-annual, and four times a year application of 38% SDF application in arresting active coronal dentinal carious lesions on primary teeth among tribal preschool children aged 2–6 years. Methods and Analysis: This study is designed as a randomized, controlled trial consisting of three parallel arms with an allocation ratio of 1:1:1. The trial will enroll 480 preschool tribal children with a cavitated carious lesion (2–6 years) attending a primary health care Centre in Wayanad district, India. Each arm will receive 38% SDF application on an annual (baseline), bi-annual (baseline and 6 months), and four times a year (baseline, 2nd, 4th, and 8th week), respectively. The analysis will be performed both at the tooth- and person-level. Ethics and Dissemination: This trial will be conducted following the principles of the Declaration of Helsinki and local guidelines (Indian Council of Medical Research). The protocol has been approved by Institutional Review Committee (IRB). This trial has been registered prospectively with the Clinical Trial Registry of India [Registration No: CTRI/2020/03/024265].

The Effects of Gamification and Oral Self-Care on Oral Hygiene in Children: Systematic Search in App Stores and Evaluation of Apps

Background

Poor oral hygiene is a great public health problem worldwide. Oral health care education is a public health priority as the maintenance of oral hygiene is integral to overall health. Maintaining optimal oral hygiene among children is challenging and can be supported by using relevant motivational approaches.

Objective

The primary aim of this study was to identify mobile smartphone apps that include gamification features focused on motivating children to learn, perform, and maintain optimal oral hygiene.

Methods

We searched six online app stores using four search terms (“oral hygiene game,” “oral hygiene gamification,” “oral hygiene brush game,” and “oral hygiene brush gamification”). We identified gamification features, identified whether apps were consistent with evidence-based dentistry, performed a quality appraisal with the Mobile App Rating Scale user version (uMARS), and quantified behavior scores (Behavior Change score, uMARS score, and Coventry, Aberdeen, and London-Refined [CALO-RE] score) using three different instruments that measure behavior change.

Results

Of 612 potentially relevant apps included in the analysis, 17 met the inclusion criteria. On average, apps included 6.87 (SD 4.18) out of 31 possible gamification features. The most frequently used gamification features were time pressure (16/17, 94%), virtual characters (14/17, 82%), and fantasy (13/17, 76%). The most common oral hygiene evidence-based recommendation was brushing time (2-3 minutes), which was identified in 94% (16/17) of apps. The overall mean uMARS score for app quality was high (4.30, SD 0.36), with good mean subjective quality (3.79, SD 0.71) and perceived impact (3.58, SD 0.44). Sufficient behavior change techniques based on three taxonomies were detected in each app.

Conclusions

The majority of the analyzed oral hygiene apps included gamification features and behavior change techniques to perform and maintain oral hygiene in children. Overall, the apps contained some educational content consistent with evidence-based dentistry and high-quality background for oral self-care in children; however, there is scope for improvement.

The relative frequency of paediatric oral and maxillofacial pathology in New Zealand: A 10-year review of a national specialist centre

BACKGROUND

There has been no previous report of the prevalence of paediatric oral and maxillofacial pathology in a New Zealand oral pathology diagnostic service.

AIM

The aim of this study was to review cases of paediatric oral pathology to determine relative frequencies of oral lesions in this age group.

DESIGN

Paediatric oral pathology cases (≤15 years of age) received between 2007 and 2016 were retrieved from the electronic database of the Oral Pathology Centre, University of Otago. Data collected included diagnoses (categorised into 12 groups), age at diagnosis, and gender. The prevalence of each diagnosis was calculated in terms of percentage of all diagnoses made. Male-to-female ratio and mean age at diagnosis were also determined.

RESULTS

A total of 1139 paediatric cases were identified representing 5.2% of all cases. The most common diagnostic group was salivary gland pathology (25.4%), followed by dental (24.8%) pathology. The most prevalent lesion was mucocoele (23%), followed by dental follicle (14.1%). Malignancies were rare with only two cases identified.

CONCLUSION

The findings provide an insight into the prevalence of paediatric oral pathology for clinicians. Mucocoele was the most common diagnosis made, suggesting a high prevalence of soft tissue injury as a main presenting concern warranting diagnosis and management through biopsy.

Flora colonization and oral care in high-risk newborns

PURPOSE

A randomized intervention study was conducted to explore the impact of oral care with sterile normal saline to oral flora colonization of high-risk newborns at the third day after birth.

DESIGN AND METHODS

Ninety-two newborns were allocated to either intervention or control group. After obtaining oral secretion for prepoint data, the intervention group received oral care with sterile normal saline only. Oral secretions for postpoint data were obtained 8 hr after the prepoint. Total 179 specimens were obtained during the study period.

RESULTS

Among the total 92 newborns, 44.6% were female and 57.6% were premature. Mean gestational age and weight was 35.9 ± 3.2 weeks and 2,545 ± 697.5 g. The most common colonized flora included Streptococcus (26.3%), methicillin-resistant Staphylococcus aureus (MRSA, 16.2%), and coagulase-negative Staphylococci (CNS, 13.4%). The oral care with normal saline did not change the number of flora type of newborns. The statistic results were not significant by group (F = 0.918, p = 0.514), time (F = 0.322, p = 0.672), and the interaction between time and group (F = 0.519, p = 0.472).

PRACTICE IMPLICATIONS

Oral care with sterile saline did not change oral flora colonization among high-risk newborns at early period of life. This intervention can be safely delivered to high-risk newborns when they are at risk of infection and particularly breast milk is not available.

Suitability of ART approach for managing caries lesions in people with disability-Experts' opinion

OBJECTIVE

This study aimed to obtain the opinions of experts in Special Care Dentistry (SCD) regarding the suitability of the Atraumatic Restorative Treatment (ART) approach for the treatment of carious lesions in persons with disability.

MATERIAL AND METHODS

Thirty expert participants from around the world, joining the SCD Task Force meeting, Education Committee of the International Association of Disability and Oral Health (Antalya, Turkey, 2011), completed a questionnaire survey. Frequency distributions of variables were analysed using Chi-Square test for differences between variables.

RESULTS

All respondents reported having full or moderate knowledge of ART (23.3% and 63.3%, respectively) and 66.7% indicated that they felt the technique was useful for this population. However, only 50% of respondents used the technique regularly in their practice and five (16.7%) replied that they would never use it, even if a favourable evidence base for ART use in this population became available. The barriers to the introduction of ART to SCD are discussed and the need for training and further research highlighted.

CONCLUSIONS

Barriers to the implementation of ART in practice were placement of the restoration under difficult conditions and the dentist's pre-conception of the technique as being 'lower quality dentistry'. Experts suggested that some of these barriers might be overcome by improving the evidence base in favour of the technique, specifically in the population with disability.

Primary school-based behavioural interventions for preventing caries

BACKGROUND

Dental caries is one of the most common global childhood diseases and is, for the most part, entirely preventable. Good oral health is dependent on the establishment of the key behaviours of toothbrushing with fluoride toothpaste and controlling sugar snacking. Primary schools provide a potential setting in which these behavioural interventions can support children to develop independent and habitual healthy behaviours.

OBJECTIVES

To assess the clinical effects of school-based interventions aimed at changing behaviour related to toothbrushing habits and the frequency of consumption of cariogenic food and drink in children (4 to 12 year olds) for caries prevention.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Oral Health Group's Trials Register (to 18 October 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 4), MEDLINE via OVID (1948 to 18 October 2012), EMBASE via OVID (1980 to 18 October 2012), CINAHL via EBSCO (1981 to 18 October 2012) and PsycINFO via OVID (1950 to 18 October 2012). Ongoing trials were searched for using Current Controlled Trials (to 18 October 2012) and ClinicalTrials.gov (to 18 October 2012). Conference proceedings were searched for using ZETOC (1993 to 18 October 2012) and Web of Science (1990 to 18 October 2012). We searched for thesis abstracts using the Proquest Dissertations and Theses database (1950 to 18 October 2012). There were no restrictions regarding language or date of publication. Non-English language papers were included and translated in full by native speakers.

SELECTION CRITERIA

Randomised controlled trials of behavioural interventions in primary schools (children aged 4 to 12 years at baseline) were selected. Included studies had to include behavioural interventions addressing both toothbrushing and consumption of cariogenic foods or drinks and have a primary school as a focus for delivery of the intervention.

DATA COLLECTION AND ANALYSIS

Two pairs of review authors independently extracted data related to methods, participants, intervention design including behaviour change techniques (BCTs) utilised, outcome measures and risk of bias. Relevant statistical information was assessed by a statistician subsequently. All included studies contact authors were emailed for copies of intervention materials. Additionally, three attempts were made to contact study authors to clarify missing information.

MAIN RESULTS

We included four studies involving 2302 children. One study was at unclear risk of bias and three were at high risk of bias. Included studies reported heterogeneity in both the intervention design and outcome measures used; this made statistical comparison difficult. Additionally this review is limited by poor reporting of intervention procedure and design. Several BCTs were identified in the trials: these included information around the consequences of twice daily brushing and controlling sugar snacking; information on consequences of adverse behaviour and instruction and demonstration regarding skill development of relevant oral health behaviours.Only one included study reported the primary outcome of development of caries. This small study at unclear risk of bias showed a prevented fraction of 0.65 (95% confidence interval (CI) 0.12 to 1.18) in the intervention group. However, as this is based on a single study, this finding should be interpreted with caution.Although no meta-analysis was performed with respect to plaque outcomes (due to differences in plaque reporting between studies), the three studies which reported plaque outcomes all found a statistically significant reduction in plaque in the intervention groups with respect to plaque outcomes. Two of these trials involved an 'active' home component where parents were given tasks relating to the school oral health programme (games and homework) to complete with their children. Secondary outcome measures from one study reported that the intervention had a positive impact upon children's oral health knowledge.

AUTHORS' CONCLUSIONS

Currently, there is insufficient evidence for the efficacy of primary school-based behavioural interventions for reducing caries. There is limited evidence for the effectiveness of these interventions on plaque outcomes and on children's oral health knowledge acquisition. None of the included interventions were reported as being based on or derived from behavioural theory. There is a need for further high quality research to utilise theory in the design and evaluation of interventions for changing oral health related behaviours in children and their parents.

Using the International Classification of Functioning, Disability and Health (ICF) to describe children referred to special care or paediatric dental services

Children in dentistry are traditionally described in terms of medical diagnosis and prevalence of oral disease. This approach gives little information regarding a child’s capacity to maintain oral health or regarding the social determinants of oral health. The biopsychosocial approach, embodied in the International Classification of Functioning, Disability and Health - Child and Youth version (ICF-CY) (WHO), provides a wider picture of a child’s real-life experience, but practical tools for the application of this model are lacking. This article describes the preliminary empirical study necessary for development of such a tool - an ICF-CY Core Set for Oral Health. An ICF-CY questionnaire was used to identify the medical, functional, social and environmental context of 218 children and adolescents referred to special care or paediatric dental services in France, Sweden, Argentina and Ireland (mean age 8 years ±3.6yrs). International Classification of Disease (ICD-10) diagnoses included disorders of the nervous system (26.1%), Down syndrome (22.0%), mental retardation (17.0%), autistic disorders (16.1%), and dental anxiety alone (11.0%). The most frequently impaired items in the ICF Body functions domain were ‘Intellectual functions’, ‘High-level cognitive functions’, and ‘Attention functions’. In the Activities and Participation domain, participation restriction was frequently reported for 25 items including ‘Handling stress’, ‘Caring for body parts’, ‘Looking after one’s health’ and ‘Speaking’. In the Environment domain, facilitating items included ‘Support of friends’, ‘Attitude of friends’ and ‘Support of immediate family’. One item was reported as an environmental barrier – ‘Societal attitudes’. The ICF-CY can be used to highlight common profiles of functioning, activities, participation and environment shared by children in relation to oral health, despite widely differing medical, social and geographical contexts. The results of this empirical study might be used to develop an ICF-CY Core Set for Oral Health - a holistic but practical tool for clinical and epidemiological use.

The value of education in special care dentistry as a means of reducing inequalities in oral health

People with disability are subject to inequality in oral health both in terms of prevalence of disease and unmet healthcare needs. Over 18% of the global population is living with moderate to severe functional problems related to disability, and a large proportion of these persons will require Special Care Dentistry at some point in their lifetime. It is estimated that 90% of people requiring Special Care Dentistry should be able to access treatment in a local, primary care setting. Provision of such primary care is only possible through the education and training of dentists. The literature suggests that it is vital for the dental team to develop the necessary skills and gain experience treating people with special needs in order to ensure access to the provision of oral health care. Education in Special Care Dentistry worldwide might be improved by the development of a recognised academic and clinical discipline and by providing international curricula guidelines based on the International Classification of Functioning, Disability and Health (ICF, WHO). This article aims to discuss the role and value of promoting and harmonising education in Special Care Dentistry as a means of reducing inequalities in oral health.

Oral health promotion for children with disabilities in the Republic of Ireland: independent qualitative evaluation of a multi-sectoral oral health promotion intervention for children with disabilities

Children with disabilities are a marginalized group in relation to health in the Republic of Ireland, and oral health is frequently relegated to a position of little or no importance by parents, paid carers, and non-dental professionals. Subsequently, there is often a higher need for treatment and inpatient procedures that could be prevented. Introducing a health promotion intervention which aimed to reduce the need for dental treatment was envisioned as being the way forward. A qualitative evaluation of the context for implementation highlighted barriers in achieving the aims of the plan.

Barriers to oral health promotion in the Republic of Ireland

Aims: This paper discusses the evaluation of a multi-sector oral health promotion intervention in the Republic of Ireland for children with disabilities. It argues that a lack of awareness about the context of interventions means that sometimes people’s health concerns remain unaddressed through a lack of participation. This may actually increase rather than decrease health inequalities. Implementing qualitative methods to provide a context before proceeding with interventions may assist in providing approaches that are fit for purpose when trying to include people in health promotion. Methods: A purposive sample of 15 parents or carers of children with disabilities and 18 non-dental professionals were interviewed in either focus groups or on a one-to-one basis. Results: The qualitative analysis indicated that budget constraints were affecting joint working because non-dental professionals were overstretched, feeling that they only had the capacity to carry out day-to-day work with parents and children. The daily demands of caring for a child with disabilities for many parents meant that they were tied to a day-to-day existence. Conclusions: The qualitative evaluation suggested that an initial lack of knowledge about structural, procedural, and budgetary barriers, coupled with insight into the daily demands on parents caring for children with disabilities, meant that all parents were not enabled. Therefore, achieving the aims of the plan could not be a total success for all parents and children from the outset.

Cannabinoid receptor CB1-immunoreactive nerve fibres in painful and non-painful human tooth pulp

The cannabinoid receptor CB1 is involved in modulation of neuronal hypersensitivity and pain. The aim of this study was to evaluate CB1 receptor levels for the first time in dental pain. A total of 19 patients due for molar extraction were divided into two groups, those with existing dental pain (n=9), and those with no history of pain (n=10). Immunohistochemistry and computer image analysis was used to evaluate CB1-positive nerve fibres in tooth pulp, with neurofilament-immunostaining as a structural nerve marker. CB1-immunoreactive nerve fibres were scattered throughout the tooth pulp and often seen in nerve bundles, but the fibres did not penetrate the subodontoblastic layer. There was no statistically significant change in the CB1 nerve fibre percentage area in the painful group compared to the non-painful group (p=0.146); the neurofilament fibres were significantly reduced in the painful group compared to the controls (p=0.028), but there was no difference in the ratio of CB1 to neurofilaments between the two groups. Thus, CB1 expression is maintained by nerve fibres in painful human dental pulp, and peripherally-restricted CB1 agonists currently in development may advance the treatment of dental pain.

Effects of Dental Caries on Nutritional Status Among First-Grade Primary School Children

The aim of this study was to explore association between caries prevalence and nutritional status among first-grade primary school children. A cross-sectional study of 212 students was conducted. All students were weighed and measured and then the body mass index (BMI) was calculated. Each student underwent dental examination and was interviewed. Overall, caries prevalence was 80.2% and the average decayed, missing, and filled surfaces (dmfs) were 12.4 ± 12.3. Although none of the students was in the underweight category, 45.8% were in low percentile (5th < BMI-for-age < 15th). Multiple logistic regression showed that each extra carious surface (dmfs) increased the odds of being at risk for underweight (5th < BMI-for-age < 15th) by 3.1% after adjusting for gender and dental visits. Our findings stressed that caries has significant implications on overall child health and health personnel should increase awareness of negative impacts and promote healthy nutritional choices for children.

Differential regulation of immune responses by odontoblasts

Odontoblasts (OBs) are cells lining the inner surface of the tooth. Their potential role in host defenses within the tooth is suggested by their production of antimicrobial beta-defensins, but their role needs confirmation. The present study sought to define the roles of human OBs in microbial recognition and innate host responses. Toll-like receptor 2 (TLR2) and TLR4, as well as CCR6, were immunolocalized in human OBs and their dentinal processes in situ. To examine OB function we used organotypic tooth crown cultures to maintain human OBs within their dentin scaffold. Cells in the OB layer of cultured and non-cultured crown preparations expressed mRNA for several markers of innate immunity including chemokine CCL20, chemokine receptor CCR6, TLR2, TLR4 and the OB marker dentin sialophosphoprotein (DSPP). Expression of human beta-defensin 1 (hBD1), hBD2, hBD3, interleukin-8 (IL-8), and CCL20 increased with time in culture. Tooth crown odontoblast (TcOB) cultures were stimulated with agonist that was specific for TLR2 (Pam3CSK4) or TLR4 [Escherichia coli lipopolysaccharide (LPS)]. Nuclear factor-kappaB assays confirmed the TLR2 activity of Pam3CSK4 and the TLR4 activity of LPS. LPS up-regulated IL-1beta, tumor necrosis factor-alpha (TNF-alpha), CCL20, hBD2, IL-8, TLR2 and TLR4; however, Pam3CSK4 down-regulated these mRNAs. IL-1beta, TNF-alpha, CCL20 were also up-regulated from six-fold to 30-fold in TcOB preparations from decayed teeth. Our results show for the first time that OBs express microbial pattern recognition receptors in situ, thus allowing differential responses to gram-positive and gram-negative bacteria, and suggest that pro-inflammatory cytokines and innate immune responses in decayed teeth may result from TLR4 signaling.