Global incidence, prevalence, years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Detailed, comprehensive, and timely reporting on population health by underlying causes of disability and premature death is crucial to understanding and responding to complex patterns of disease and injury burden over time and across age groups, sexes, and locations. The availability of disease burden estimates can promote evidence-based interventions that enable public health researchers, policy makers, and other professionals to implement strategies that can mitigate diseases. It can also facilitate more rigorous monitoring of progress towards national and international health targets, such as the Sustainable Development Goals. For three decades, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) has filled that need. A global network of collaborators contributed to the production of GBD 2021 by providing, reviewing, and analysing all available data. GBD estimates are updated routinely with additional data and refined analytical methods. GBD 2021 presents, for the first time, estimates of health loss due to the COVID-19 pandemic.

METHODS

The GBD 2021 disease and injury burden analysis estimated years lived with disability (YLDs), years of life lost (YLLs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries using 100 983 data sources. Data were extracted from vital registration systems, verbal autopsies, censuses, household surveys, disease-specific registries, health service contact data, and other sources. YLDs were calculated by multiplying cause-age-sex-location-year-specific prevalence of sequelae by their respective disability weights, for each disease and injury. YLLs were calculated by multiplying cause-age-sex-location-year-specific deaths by the standard life expectancy at the age that death occurred. DALYs were calculated by summing YLDs and YLLs. HALE estimates were produced using YLDs per capita and age-specific mortality rates by location, age, sex, year, and cause. 95% uncertainty intervals (UIs) were generated for all final estimates as the 2·5th and 97·5th percentiles values of 500 draws. Uncertainty was propagated at each step of the estimation process. Counts and age-standardised rates were calculated globally, for seven super-regions, 21 regions, 204 countries and territories (including 21 countries with subnational locations), and 811 subnational locations, from 1990 to 2021. Here we report data for 2010 to 2021 to highlight trends in disease burden over the past decade and through the first 2 years of the COVID-19 pandemic.

FINDINGS

Global DALYs increased from 2·63 billion (95% UI 2·44-2·85) in 2010 to 2·88 billion (2·64-3·15) in 2021 for all causes combined. Much of this increase in the number of DALYs was due to population growth and ageing, as indicated by a decrease in global age-standardised all-cause DALY rates of 14·2% (95% UI 10·7-17·3) between 2010 and 2019. Notably, however, this decrease in rates reversed during the first 2 years of the COVID-19 pandemic, with increases in global age-standardised all-cause DALY rates since 2019 of 4·1% (1·8-6·3) in 2020 and 7·2% (4·7-10·0) in 2021. In 2021, COVID-19 was the leading cause of DALYs globally (212·0 million [198·0-234·5] DALYs), followed by ischaemic heart disease (188·3 million [176·7-198·3]), neonatal disorders (186·3 million [162·3-214·9]), and stroke (160·4 million [148·0-171·7]). However, notable health gains were seen among other leading communicable, maternal, neonatal, and nutritional (CMNN) diseases. Globally between 2010 and 2021, the age-standardised DALY rates for HIV/AIDS decreased by 47·8% (43·3-51·7) and for diarrhoeal diseases decreased by 47·0% (39·9-52·9). Non-communicable diseases contributed 1·73 billion (95% UI 1·54-1·94) DALYs in 2021, with a decrease in age-standardised DALY rates since 2010 of 6·4% (95% UI 3·5-9·5). Between 2010 and 2021, among the 25 leading Level 3 causes, age-standardised DALY rates increased most substantially for anxiety disorders (16·7% [14·0-19·8]), depressive disorders (16·4% [11·9-21·3]), and diabetes (14·0% [10·0-17·4]). Age-standardised DALY rates due to injuries decreased globally by 24·0% (20·7-27·2) between 2010 and 2021, although improvements were not uniform across locations, ages, and sexes. Globally, HALE at birth improved slightly, from 61·3 years (58·6-63·6) in 2010 to 62·2 years (59·4-64·7) in 2021. However, despite this overall increase, HALE decreased by 2·2% (1·6-2·9) between 2019 and 2021.

INTERPRETATION

Putting the COVID-19 pandemic in the context of a mutually exclusive and collectively exhaustive list of causes of health loss is crucial to understanding its impact and ensuring that health funding and policy address needs at both local and global levels through cost-effective and evidence-based interventions. A global epidemiological transition remains underway. Our findings suggest that prioritising non-communicable disease prevention and treatment policies, as well as strengthening health systems, continues to be crucially important. The progress on reducing the burden of CMNN diseases must not stall; although global trends are improving, the burden of CMNN diseases remains unacceptably high. Evidence-based interventions will help save the lives of young children and mothers and improve the overall health and economic conditions of societies across the world. Governments and multilateral organisations should prioritise pandemic preparedness planning alongside efforts to reduce the burden of diseases and injuries that will strain resources in the coming decades.

FUNDING

Bill & Melinda Gates Foundation.

Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations.

METHODS

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds.

FINDINGS

The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles.

INTERPRETATION

Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere.

FUNDING

Bill & Melinda Gates Foundation.

Theories, Models, Frameworks, Guidelines, and Recommendations for Trauma-Informed Oral Healthcare Services: A Scoping Review

BACKGROUND

Traumatic life experiences (TLE) are common and can affect a person's physical being and health-related behaviors, including those related to oral health. This scoping review aimed to identify evidence exploring the implementation and provision of trauma-informed care (TIC) in oral health services delivery.

METHODS

Arksey and O'Malley's framework with enhancements proposed by Levac et al. and Peters et al. was used. Studies were selected based on a preset inclusion and exclusion criteria and the population/concept/context framework. Primary charting of descriptive data was conducted, followed by thematic analysis to identify ideas common within the included literature. Searches were conducted in Medline (via Ovid), APA PsycINFO (via Ovid), Embase (Elsevier), Scopus, CINAHL (via EBSCO), and Cochrane databases. Google Scholar and ProQuest were used to identify grey literature.

RESULTS

The search identified 251 records, with fifteen records meeting the inclusion criteria. Limited models, frameworks, and recommendations for trauma-informed practices in oral health services were identified. Recommendations for TIC practices were identified, and clinical practice adjustments for dental practitioners were described to improve service delivery for patients who may have experienced trauma. Avenues for future research were identified.

CONCLUSIONS

Limited evidence exists to guide trauma-informed practice in oral health service delivery. This scoping review highlights the need for further research into approaches and practices of TIC for oral health services delivery to assess their efficacy and the need to develop evidence-based TIC frameworks to meet the unique needs of oral health service providers and populations.

Do dental anxiety and satisfaction with dental professionals modify the association between affordability and dental service use? A population-based longitudinal study of Australian adults

OBJECTIVES

This study aimed to assess the association between affordability in terms of difficulty paying dental bills in Australian dollars and dental service use in the presence of sociodemographic confounders, and to assess the role of dental anxiety and satisfaction with dental professionals as mediators. The second aim was to investigate how dental anxiety and satisfaction with dental professionals modify the association between affordability and use of dental services in Australian adults.

METHODS

Longitudinal data from the Australian National Study of Adult Oral Health (2004-06 and 2017-18) was used. Poisson regression and path analysis were conducted to determine the association between affordability and frequency of use of dental services. Effect measure modification (EMM) analysis was performed by stratification of dental anxiety and satisfaction with dental professionals.

RESULTS

The study included 1698 Australian adults and identified that the prevalence of low frequency of dental visits was 20% more for those who had difficulty paying dental bills. Adults with dental anxiety (prevalence ratio [PR] = 1.14) and those who were dissatisfied with dental professionals (PR = 1.17) had a higher prevalence of low frequency of dental visits in the presence of difficulty paying dental bills. This indicated that dental anxiety and dissatisfaction with dental professionals were effect modifiers on this pathway.

CONCLUSIONS

Adults who experience dental anxiety and dissatisfaction with dental professionals are more likely to avoid dental visits when faced with difficulty paying dental bills. However, it is important to note that these associations do not necessarily imply a causal relationship.

Assessing the status of oral health integration in South East Asian Regional Office countries' Universal Health Coverage-A scoping review

BACKGROUND

Oral diseases affect close to 3.5 billion people worldwide and there has been a call by the World Health Organization (WHO) to integrate oral health into the Universal Health Coverage (UHC) agenda.

OBJECTIVES

To collate and synthesise information regarding the status of integration of oral health into the health systems covered by UHC across the 11 countries in the South East Asian Regional Office.

METHODS

Drawing on the framework of the six building blocks of health systems as devised by WHO, we compared the public dental care coverage models, with a focus on outpatient dental care in these countries. We gathered this information from publicly available resources, databases and peer-reviewed publications to populate the template guided by the WHO Health System Building Blocks.

RESULTS

We found a poor access to oral health care, lopsided distribution of manpower, rickety health information systems, and private sector domination and inadequate or absent financing mechanisms for outpatient procedures. The private sector was dominant in all countries except Thailand and Srilanka. Financing was absent in most countries and deficient in Thailand and Indonesia. Dental workforce was deficient in most countries except India, Srilanka, and Thailand. Health information systems were weak with no dental items under price control. Better UHC indicators did not guarantee a lower oral disease burden.

CONCLUSIONS

Our review highlighted the close connection between service quality and human resources, governance, and finance. There is a need to establish standardised dental treatment guidelines that are uniformly adopted across countries, integrate oral health into national health and development programs, push for functional oral health research through collecting robust surveillance, economic, and social impact data and the development of cost-effective strategies tailored to each country's unique needs.

Assessment of usefulness and reliability of YouTube™ videos on denture care

INTRODUCTION

The world's population is in a demographic transition with a rising ageing population. Tooth loss is frequent among older people resulting in the replacement of natural teeth using complete or partial dentures. YouTube™ is the second most popular website in the world and is being increasingly used to access health care information. The aim of this study is to evaluate the usefulness and reliability of the information in YouTube™ videos regarding denture care.

METHODS

The YouTube™ website was used to systematically search for videos using the keyword 'denture care'. Videos meeting the eligibility criteria were assessed separately by two independent researchers. The usefulness of the videos was assessed using the Global Quality Assessment Scale and a customized usefulness scoring scheme. Based on these scores, the usefulness of the videos was categorized as low, medium and high. A modified DISCERN tool (mDISCERN) was used for assessing reliability with scores ranging from 0 to 5. Other video characteristics like source/ownership of the videos, duration, views, likes, dislikes, number of days posted, like ratio, view ratio, interaction index and Video Power Index were also obtained. Statistical analysis was carried out using the Kruskal-Wallis test, Spearman correlation test and multiple linear regression analysis.

RESULTS

A total of 120 videos were included. Based on the usefulness score, the usefulness of 65.8% of videos were classified as low, 32.5% were medium and 1.6% had high usefulness. The mDISCERN score for 74.2% of videos was 2 or below 2 indicating that the majority of videos had low reliability. Video characteristics did not differ significantly according to the usefulness of videos. Videos uploaded by dentists or dental hygienists had significantly higher usefulness scores (p < 0.001) in comparison to videos uploaded by other sources. However, reliability scores did not differ based on the sources of the videos. Video reliability was found to have a significant (B = 2.08, p < 0.001) positive association with video usefulness.

CONCLUSION

YouTube™ cannot be recommended as the only source of information for denture care as most videos received low usefulness and reliability ratings in our study. Dentists and dental health professionals could take an active part in enhancing denture care-related content on YouTube™ and enable patients to have adequate and reliable knowledge of denture hygiene practices.

Trueness assessment of additively manufactured maxillary complete denture bases produced at different orientations

STATEMENT OF PROBLEM

The trueness of the intaglio surface of an additively manufactured maxillary denture base may be influenced by the build orientation and the inclusion of support struts.

PURPOSE

The purpose of this in vitro study was to compare the trueness of a photopolymer additively manufactured maxillary complete denture base created at different orientations with different support strut designs. Optimizing the build is critical for adopting best practice when fabricating maxillary complete dentures through additive manufacturing techniques.

MATERIAL AND METHODS

Denture bases (N=70) were additively manufactured at 5 different build orientations (0-, 15-, 45-, 60-, and 90-degrees) with 10 specimens per orientation. Another 2 groups of 10 were manufactured by using the optimal printing orientation with and without support struts. The denture bases were scanned after storage in artificial saliva at 37 °C, and the scan data were analyzed with a 3D metrology software program. Statistical differences were determined with 1-way analysis of variance (ANOVA) and the Kruskal-Wallis test (α=.05). Color deviation heat maps were used to determine areas of clinically significant dimensional errors.

RESULTS

Significant differences were found among groups for positive mean deviation (F=44.09, P<.001), negative mean deviation (F=11.69, P<.001), and root mean square deviation (F=17.11, P<.001) for the different orientations. One-way ANOVA revealed significant differences with the use of support struts in relation to negative mean deviation (F=3.857, P<.001) and RMSE (F=11.215, P<.001) and positive mean deviation (Kruskal-Wallis H=0.070, P=.007). The color deviation maps showed that a 45- to 90-degree print orientation was truest overall and that the addition of support struts to the cameo and intaglio surfaces improved the trueness of the maxillary denture bases.

CONCLUSIONS

The build orientation and inclusion of support struts influenced the accuracy of the intaglio surface of additively manufactured maxillary denture bases. A 45- to 90-degree build orientation with support struts on the cameo and intaglio surfaces resulted in the truest denture base.

Radiographic evaluation of secondary dentin formation in lower premolars for forensic age diagnosis of 18 years in a sample of south Indian adolescents and young adults

There has been an increase in the need for alternate methods of dental age assessment, especially for the forensic age diagnosis of the 18th year of life. This is due to the completion of the third molar development before 18 years or the agenesis or therapeutic extractions of the third molars. The present study aimed to verify whether the secondary dentin formation in lower premolars can be used to determine the completion of the 18th year of life in a sample of South Indian adolescents and young adults. For this purpose, 800 orthopantomograms of 400 male and 400 female South Indian subjects aged 14- 22 were evaluated. The characteristics of the secondary dentin formation were determined in all mandibular premolars using the stage classification according to Olze et al (Int J Legal Med 126(4):615-21). The results showed that when stage 3 of secondary dentin formation was reached in the first premolars, the probability of the subject completing the 18th year of life was very high. However, only a few individuals in the studied population were at stage 3. Therefore, proceeding cautiously with this degenerative change in lower premolars is advised due to the higher inter-examiner differences. It is also recommended to use this method in conjunction with other age estimation methods. Further research should investigate other degenerative characteristics in the studied population.

Comparison of Oral Health-Related Quality of Life scores in children treated for early childhood caries under general and local anesthesia: a quasi-experimental study

PURPOSE

The purpose of this study was to compare the changes in oral health-related quality of life (OHRQoL) scores in children treated for Early Childhood Caries (ECC) under general (GA) and local anesthesia (LA).

METHODS

A quasi-experimental study was carried out on 73 children, with 37 in the GA group and 36 in the LA group. The early childhood oral health impact scale (ECOHIS) was used to measure OHRQoL, with the type of anesthesia (LA or GA) serving as the explanatory variable. A Friedman test was used to assess the difference between the LA and GA groups at baseline, one-week, and one-month follow-up points.

RESULTS

The results showed a significant difference in the overall mean ECOHIS scores between the LA and GA groups at 1-week (LAmean ± SD = 6.12 ± 1.11, GAmean ± SD = 5.50 ± 0.88; P = 0.01) and 1-month (LAmean ± SD = 5.87 ± 1.12, GAmean ± SD = 4.96 ± 0.99; P < 0.001) follow-up points. Irrespective of the administered anesthesia, a significant (P < 0.001) reduction in the mean score for dental pain was observed at both 1-week (mean ± SD = 1.30 ± 1.16) and 1-month (mean ± SD = 0.81 ± 0.89) timepoints after the treatment, as compared to the baseline assessment (mean ± SD = 2.02 ± 1.02).

CONCLUSION

Early treatment for ECC reduces pain, restore normal activities, and improves the quality of life of affected children. Specifically, GA was found to be more beneficial for both children and parents. However, further studies using more robust study designs and carefully considering related factors are necessary to confirm these findings.

Dental referrals for patients with diabetes: survey of barriers and enablers for medical and health professionals

BACKGROUND

Oral health care improves diabetes management; however, medical and other health practitioners do not commonly refer their patients with diabetes for oral health care. This study aimed to understand barriers to and enablers of dental referrals for patients with diabetes.

METHODS

Quantitative data were collected from a cross-sectional survey of health care providers attending a virtual Grand Rounds on the relationship between oral health and diabetes. Attendees were invited to complete and share a Forms survey. Barriers to and enablers of dental referrals were compared for 18 health professionals working in inpatient/ward settings to 23 working in community/primary care settings using the chi-square test.

RESULTS

Across both work settings, only 12% of respondents often or always discussed the importance of oral health and only 8% often or always referred their patients with diabetes for dental care. Time barriers, awareness and knowledge of how/where to send dental referrals were significant barriers, while online referral pathways, more education and availability of brochures for the patient to take home were identified as key enablers for dental referrals.

CONCLUSIONS

Online referral pathways, targeted oral health education and resources for medical and health professionals caring for patients with diabetes may increase the number of patients being referred for dental care as part of their diabetes managements. © 2023 Australian Dental Association.

A meta-analysis to evaluate the prevalence of maxillofacial trauma caused by various etiologies among children and adolescents

AIMS

Children and adolescents who are affected by trauma may have complications that are more serious and dangerous. Herein, a meta-analysis to evaluate the prevalence of maxillofacial trauma caused by various etiologies according to the geographic regions of the world among children and adolescents was conducted.

MATERIALS AND METHODS

A comprehensive search was performed in four databases of PubMed/MEDLINE, Web of Science, Cochrane Library, and Scopus from January 1, 2006 until July 7, 2021. To evaluate the quality of included articles, an adapted version of the Newcastle-Ottawa scale was used. The prevalence of maxillofacial trauma was estimated by event rates and 95% confidence intervals in relation to etiology and geographic region of study population.

RESULTS

Through search in the databases and the electronic sources, 3071 records were identified, and 58 studies were eligible for inclusion in the meta-analysis. A total of 264,433 maxillofacial trauma cases were reported by all included studies. Globally, the overall prevalence of maxillofacial trauma was highest due to Road Traffic Crashes (RTC) (33.8%) followed by falls (20.7%), violence (9.9%), and sports (8.1%) in children/adolescents. The highest prevalence of maxillofacial trauma were observed in African population (48.3%) while trauma due to falls was most prevalent in Asian population (44.1%). Maxillofacial trauma due to violence (27.6%) and sports (13.3%) were highest in North Americans.

CONCLUSION

The findings demonstrate that RTC was the most prevalent etiology of maxillofacial trauma in the world. The prevalent causes of maxillofacial trauma differed between the regions of study population.

Oral and Maxillofacial Injuries Associated With E-Cigarette Explosions: A Systematic Review and Management Guidelines Proposal

PURPOSE

E-cigarettes have become increasingly popular devices used to consume nicotine in recent years. There is a growing body of evidence regarding the risk of spontaneous explosion of these devices causing burn and projectile injuries. The primary purpose of this review was to summarize all injuries to the oral and maxillofacial region secondary to explosion of e-cigarettes. The secondary purpose was to propose an initial management algorithm for such injuries based on the findings in the literature. This review also aims to test the hypothesis that e-cigarette explosive injuries to the oral region were associated with an increased risk of intubation and surgery and examine whether any other injury pattern was associated with an increased risk of intubation or surgery.

METHODS

A cohort study based on identifying cases in the literature was conducted to summarize injuries to the oral and maxillofacial region and examine the associations between injury types and location and management. A literature search of the major biomedical databases was conducted in September 2022 using terms such as e-cigarette, explosion, blast, trauma, and burn, among others, which yielded 922 studies. Nonclinical studies, review articles, and studies without injuries to the facial region were excluded. Study subjects were recorded for demographics, device characteristics, injury mechanism, injury location, management, and complications. Chi-squared analysis was used to determine if the predictor variables of type of injury (burn or projectile) and its associated location (ocular, facial, or intraoral for burns and facial thirds for projectile) were associated with the outcomes of intubation and surgical management. The collected data were then used as a guide to propose an initial management algorithm for these injuries.

RESULTS

Twenty eight studies, including 20 case reports and 8 case series met the inclusion criteria. A total of 32 explosions of e-cigarettes to 32 patients caused 105 recorded injuries to the facial region. Projectile injuries made up 73.3% (n = 77) of all facial injuries, while burn injuries made up of 26.7% (n = 28). There were 14 (43.8%) patients who suffered both projectile and burn injuries. Burn injuries mostly involved the face (64.3%, n = 18), oral cavity (25%, n = 7), and eye (10.7%, n = 7). The majority (81.8%, n = 63) of projectile injuries occurred in the lower facial third. There were 20 (62.5%) patients who suffered a bone or tooth fracture. Management of injuries involved surgery in 62.5% (n = 20) of patients, which included open reduction and internal fixation of fractures, dental extraction, bone and skin grafts, and ocular surgery. A complication rate of 44.4% (n = 8) was observed across studies that reported on follow-up. There was no statistically significant association between explosive injury to the oral region and intubation or surgical management. There was also no other statistically significant association between any other injury type and location with intubation or surgical management.

CONCLUSIONS

E-cigarettes are at risk for spontaneous combustion that can cause serious oral and maxillofacial injuries, particularly to the lower facial third and commonly requiring surgical management. Safety of these devices should be improved through increased user education and regulation.

AValidation of radiographic visibility of root pulp in mandibular first, second and third molars in the prediction of 21 years in a sample of south Indian population: A digital panoramic radiographic study

This study examines the radiographic visibility of root pulp (RPV) in lower first, second and third molars to validate the completion of 21 years. RPV in all lower three molars of both sides was assessed using a sample of 930 orthopantomograms of individuals aged between 15 and 30. The scoring of RPV was done using the Olze et al. four-stage classification (Int J Legal Med 124(3):183-186, 2010). Cut-off values were determined for each molar using the receiver operating characteristic (ROC) curve and the area under the ROC curve (AUC). The selected cut-off values were stage 3 for the first molar, stage 2 for the second molar and stage 1 for the third molar. For lower first molar, the AUC was 0.702, and the sensitivity, specificity and posttest probability (PTP) were 60.1%, 98.8% and 98.1% in males, and 64.5%, 99.1% and 98.6% in females. For lower second molar, the AUC was 0.828, and the sensitivity, specificity and PTP were 75.5%, 97% and 96.2% in males, and 74.4%, 96.3% and 95.3% in females. For the lower third molar, the AUC was 0.906; the sensitivity was 74.1% and 64.4% in males and females, while specificity and PTP were 100% in both sexes. The accuracy of predictions for the completion of 21 years was high. However, the greater percentage of false negatives and inapplicability of this method in one-third of lower-third molars have been recommended for using this method in conjunction with other dental or skeletal methods.

Prevalence of Dental Anomalies and Its Role in Sex Estimation among Children of Jazan Region, Saudi Arabia

BACKGROUND

This study aimed to ascertain the prevalence of dental anomalies and their ability to estimate sex status.

MATERIAL AND METHODS

This cross-sectional radiographic study was based on the evaluation of dental anomalies of Saudi children aged between 5 and 17 years. A total of 1940 orthopantomograms (OPG) were screened, of which 1442 were included. All the OPGs were digitally evaluated with ImageJ software. The demographic variables and dental anomaly findings were subjected to descriptive and comparative statistical analysis. Discriminant function analysis was conducted for sex estimation. p value < 0.05 was considered as significant.

RESULTS

The mean age of the children in this study was 11.35 ± 0.28 years. At least one dental anomaly was detected in 161 children (11.17%), including 71 males and 90 females. Only 13 children (8.07%) presented with more than one anomaly. The most common dental anomaly detected was root dilaceration (47.83%) followed by hypodontia (31.68%). The least common dental anomaly was infraocclusion (1.86%). The sex prediction accuracy using discriminant function analysis was 62.9% (p < 0.01).

CONCLUSION

The prevalence of dental anomalies was 11.17% with root dilaceration and hypodontia being the most common. The role of dental anomalies in sex estimation was found to be ineffective.

Socioeconomic Status and Toothbrushing in Indigenous and Non-Indigenous Australian Children

INTRODUCTION

Dental caries in children is a multifactorial and complex condition. Toothbrushing helps maintain good oral hygiene and delivers fluoride. However, determinants of toothbrushing could vary based on Indigenous status.

OBJECTIVE

This study aimed to assess the association between socioeconomic status and adequate toothbrushing practice (brushing twice or more a day) in Indigenous and non-Indigenous Australian children.

METHODS

Data were acquired from the National Child Oral Health Survey (NCOHS) 2012 to 2014. NCOHS administered questionnaires to parents of a representative sample of 24,215 Australian children aged 5 to 14 y recruited using a complex sampling method. Data on the frequency of toothbrushing and socioeconomic status were collected through the questionnaires. Statistical analysis was conducted progressively from bivariate to multivariable regression modeling, stratified by Indigenous status.

RESULTS

Just over half of Indigenous children and over two-thirds of non-Indigenous children reported adequate toothbrushing. The prevalence of adequate brushing (twice or more a day) was 42% (95% confidence interval [CI], 1.10-1.84) higher among children with an overseas-born parent than those with Australian-born parents. Among non-Indigenous children, sex and age, parents' country of birth, number of children in the family, and other family socioeconomic indicators (education, income, private health insurance) were associated with adequate toothbrushing. The prevalence of adequate brushing was 1.09 (95% CI, 1.03-1.15) and 1.15 (95% CI, 1.10-1.21) times higher when their parent possessed vocational training and tertiary education, respectively, compared to those children whose parents had school-level education.

CONCLUSIONS

There were differences in patterns of socioeconomic disparities for toothbrushing practices between Indigenous and non-Indigenous Australian children.

KNOWLEDGE TRANSFER STATEMENT

To promote positive toothbrushing practices in children, dental clinicians and public health professionals must be aware of the determinants of toothbrushing practices. Socioeconomic disparities in toothbrushing frequency were more apparent in non-Indigenous children. These results will help develop population-specific interventions that tackle the determinants to help improve oral hygiene behavior in Indigenous and non-Indigenous children.

Evaluation of the Expression Levels of miR-21-5p and miR-429 Genes in Biopsy Samples from Patients with Oral Squamous Cell Carcinoma

Introduction: MicroRNAs (miRs) are a group of endogenous, non-coding, 18-24 nucleotide length single-strand RNAs that mediate gene expression at the post-transcriptional level through mRNA degradation or translational repression. They are involved in regulating diverse cellular biological processes such as cell cycle, differentiation, and apoptosis. The deregulation of miRs affects normal biological processes, leading to malignancies, including oral squamous cell carcinoma (OSCC). This study evaluates the expression level of miR-21-5p and miR-429 genes in biopsy samples from patients with OSCC and performs a comparison with controls. Materials and Methods: In this study, tissue samples were obtained from 40 individuals (20 OSCC patients and 20 healthy controls) to determine miR-21-5p and miR-429 expression using the ΔCT method and analyzed by the Mann–Whitney test. Results: The mean age of subjects in the control and patient groups was 47.15 and 53.8 years, respectively. According to the Mann–Whitney test, significant differences were observed in miR-21-5p (p < 0.0001) and miR-429 (p = 0.0191) expression levels between the two groups (p < 0.05). Conclusions: The expression of miR-21-5p, miR-429, and combined miRNAs in the OSCC group was significantly higher compared to the control group. As a result, changes in the expression of these biomarkers in cancerous tissues could potentially be considered as a marker for the early diagnosis of OSCC.

Testing the maturation and the radiographic visibility of the root pulp of mandibular third molars for predicting 21 years. A digital panoramic radiographic study in emerging adults of south Indian origin

Prediction of the attainment of legal age thresholds, especially in children and young adults, is a common task in medico-legal practice. In many countries, 21 years has medico-legal importance. In the present study, we assessed and compared the accuracy of the third molar maturity index (I3M) and the stages of radiographic visibility of the root pulp (RPV) in predicting the age threshold of 21 years. A sample of 910 digital panoramic radiographs (455 males and 455 females) of adolescents and young adults aged between 16 and 30 of south Indian origin were evaluated. The authors examined the performance of different I3M cut-off values and RPV stages. I3M cut-off value of 0.02 has resulted in better discrimination with an accuracy of 76.92% and 80.44%, specificity of 48.28% and 56.16% in males and females, a sensitivity of 100%, and post-test probability of 65.9% in both sexes. The accuracy and sensitivity of RPV stage 2 were 84.76% and 84.55%, 78.17%, and 78.97% in males and females, while the specificity and post-test probability were 100% in both sexes. In conclusion, the I3M method resulted in a more significant percentage of false positives and cannot be used to state the attainment of 21 years. However, the presence of RPV stage 2 could say that the subject had already attained the age of 21 years. Further studies are warranted to address the usefulness of these methods.

Associations between fear of COVID-19, dental anxiety, and psychological distress among Iranian adolescents

Objectives

The present study evaluated the association of fear of COVID-19 with dental anxiety, oral health-related quality of life (OHRQoL), and psychological distress (depression, anxiety and stress), as well as exploring the mediating role of dental anxiety in the association of fear of COVID-19 with OHRQoL and psychological distress.

Methods

A cross-sectional study was conducted among adolescents in high schools of Qazvin city (Iran) from March-June 2021, recruited through a two-stage cluster sampling method. All the adolescents completed a self-administered survey assessing (i) fear of COVID-19, (ii) depression, anxiety and stress, (iii) OHRQoL, and (iv) dental anxiety. Structural equation modelling was used to evaluate all the hypothesised associations, and the model fit was estimated.

Results

A total of 2429 adolescents participated in the study. The conceptual model fitted the data well. Fear of COVID-19 had a direct effect on dental anxiety (B = 0.316; bias-corrected bootstrapping 95% CI = 0.282, 0.349), depression (B = 0.302; bias-corrected bootstrapping 95% CI = 0.259, 0.347), anxiety (B = 0.289; bias-corrected bootstrapping 95% CI = 0.246, 0.334), stress (B = 0.282; bias-corrected bootstrapping 95% CI = 0.237, 0.328), and OHRQoL (B = −0.354; bias-corrected bootstrapping 95% CI = −0.530, −0.183). Also, dental anxiety mediated the association of fear of COVID-19 with depression, anxiety stress, and OHRQoL.

Conclusions

High levels of fear of COVID-19 were associated with high levels of dental anxiety and poorer OHRQoL. Moreover, fear of COVID-19 was positively associated with anxiety, depression and stress. Increased levels of dental anxiety were also associated with increased anxiety, stress, depression, and poorer OHRQoL.

Protocol of a cluster randomised controlled trial evaluating the effectiveness of an online parenting intervention for promoting oral health of 2-6 years old Australian children

INTRODUCTION

Dental decay is a major problem among Australian children. It can be prevented through good self-care and limiting sugar intake, but many parents/caregivers lack the skills and confidence to help their children adopt these practices. This trial will evaluate the efficacy of Healthy Habits Triple P - Oral health, a web-based online programme, in improving children's oral health-related behaviours (toothbrushing, snacking practices and dental visits) and related parenting practices, thereby preventing dental caries.

METHODS AND ANALYSIS

This is a cluster, parallel-group, single-blinded, randomised controlled trial of an online intervention for parents/caregivers of children aged 2-6 years. From the City of Gold Coast (Australia), 18 childcare centres will be randomly selected, with equal numbers randomised into intervention and control arms. Intervention arm parents/caregivers will receive access to a web-based parenting intervention while those in the control arm will be directed to oral health-related information published by Australian oral health agencies. After the completion of the study, the Healthy Habits Triple P - Oral health intervention will be offered to parents/caregivers in the control arm. The primary outcome of this trial is toothbrushing frequency, which will be assessed via Bluetooth supported smart toothbrushes and parent/caregiver report. Data on other outcomes: parenting practices and child behaviour during toothbrushing, consumption of sugar rich foods and parents' confidence in dealing with children's demands for sugar rich food, and dental visiting practices, will be collected through a self-administered questionnaire at baseline (before randomisation), and 6 weeks (primary endpoint), 6 months and 12 months after randomisation. Data on dental caries will be collected at baseline, 12 and 18 months post-randomisation.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from Human Research Ethics Committees of Griffith University (2020/700) and the University of Queensland (2020002839). Findings will be submitted for publication in leading international peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12621000566831.

Premolar maturity index (IPM) for indicating legal age 12 years in a sample of south Indian children - A digital pantomographic study

Legal age of 12 years has been set as the minimum age of criminal responsibility in many countries. This paper concerned a method for predicting the legal age 12 years based on the maturation of lower first and second premolars. The sample consisted of 900 digital pantomographs of south Indian children (450 males, 450 females) aged between 8 and 16 years. Among them, 580 DPTs were used as test sample and 320 DPTs as validation sample. New cut-offs at the age threshold 12 years were determined by using the measurement of open apices in first premolars (IPM1 < 0.10), second premolars (IPM2 < 0.14) and the combined method (IPM1 + IPM2 < 0.12). The sensitivity (Se), specificity (Sp) and posttest probability (PTP) were established. For IPM1 < 0.10, the Se, Sp and PTP were 92.4 %, 91.3 % and 91.1 % for males and 90.8 %, 87 % and 86.5 % for females. For IPM2 < 0.14, they were 92.6 %, 93.6 % and 93.4 % for males and 91.5 %, 83.1 % and 83.4 % for females. And, for the combined predictor (IPM1 + IPM2 < 0.12), these values were 92.6 %, 94.8 % and 94.6 % and 90.5 %, 84.9 % and 84.7 % in males and females respectively. The best score of positive predictive value and specificity was obtained for males with the combined predictor (IPM1 + IPM2 < 0.12) and with single predictor (IPM1 < 0.10) for females. To conclude, the combined predictor has resulted in better discrimination in males, while in females the single predictor (IMP1 < 0.10) did slightly better. Further studies are warranted to test the combination of dental and skeletal indicators for the prediction of 12 years in the studied population.

Child- and family-level factors associated with toothbrushing frequency in a sample of Australian children

BACKGROUND

Identifying the factors that are conducive to good toothbrushing practices is fundamental for planning oral health promotion interventions.

AIM

This study evaluated the relationships between child and family socio-demographic characteristics; children's behaviour during toothbrushing; family support for toothbrushing; parents' practices, attitudes and knowledge related to toothbrushing; general parenting practices; and children's behavioural problems, and children's toothbrushing frequency.

DESIGN

A cross-sectional survey was conducted between February and May 2020 with parents of children aged 2-8 years, recruited through childcare centres throughout Australia. Parents completed self-administered surveys on child and family characteristics.

RESULTS

A total of 606 parents completed the survey. Only half (52.5%) of the children of surveyed parents brushed their teeth twice or more/day. Children of university-educated parents [odds ratio (OR): 6.48; 95% confidence intervals (CIs): 1.21-34.71] and those concerned about their child's toothbrushing (OR: 1.44; 95% CI: 1.21-1.72) were more likely to brush twice or more/day. Where children were non-compliant during toothbrushing or parents reported using ineffective parenting strategies during toothbrushing, children were less likely to brush their teeth twice or more/day. Lack of concern of parent about toothbrushing was associated with brushing less than twice/day in children CONCLUSIONS: Measures of parenting and child behaviour that were specific to the toothbrushing context were associated with twice daily brushing while general measures of parenting and child behaviour were not correlated with twice daily brushing.

Poor implementation of tobacco control measures and lack of education influences the intention to quit tobacco: a structural equation modelling approach

BACKGROUND

Tobacco consumption remains a public health issue and is one of the major causes of death in India. This study presents a validated conceptual model to assess the interaction between education, perceived application of tobacco control measures, type of tobacco and their effects on the intention to quit tobacco. Additionally, the direct and mediating roles of tobacco use -frequency, -duration, and -dependency on the intention to quit is also investigated.

METHODS

An analytical cross-sectional study was carried out, and data from tobacco users of six randomly selected states in India was collected via face-to-face interviews. Structural equation modeling (SEM) was performed using R v 3.6.3 to test the model fit and to explore the association between tobacco control measures and the intention to quit tobacco.

RESULTS

From 1962 tobacco users, 43.7% wanted to quit tobacco immediately. Tambakoo (57.7%) was the most common type of tobacco used and 68.9% said that minors could buy tobacco. Findings from SEM showed that that one standard deviation (SD) increase in the perceived application of tobacco control measures is directly associated with a 0.181 SD increase in the intention to quit tobacco (B = 0.181, P < 0.001), and this effect was partially mediated by frequency of tobacco consumption (B = 0.06, P < 0.05). Also, a better education level was associated with a higher intention to quit tobacco (B = 0.14, P < 0.001).

CONCLUSIONS

To conclude, the application of tobacco control measures and a better education level may positively affect the intention to quit tobacco. The frequency of tobacco use and the number of influencers play an essential role in deciding to quit. In future, longitudinal studies are recommended to further substantiate the evidence.

Peri-Implant Surgical Treatment Downregulates the Expression of sTREM-1 and MMP-8 in Patients with Peri-Implantitis: A Prospective Study

sTREM-1 and its ligand PGLYRP1 play an essential role in the inflammatory process around teeth and implants. In this study, we aimed to evaluate the impact of peri-implant treatment on the salivary levels of the sTREM-1/PGLYRP-1/MMP-8 axis after 3 months. A total of 42 participants (with a mean age of 61 years old ± 7.3) were enrolled in this longitudinal study, 24 having peri-implant mucositis (MU) and 18 having peri-implantitis (PI). Clinical peri-implant parameters, such as probing pocket depth (PPD), % of plaque, and bleeding on probing (BOP), and the whole unstimulated saliva samples were evaluated at baseline and 3 months after treatment. The MU group received nonsurgical peri-implant treatment, while the PI group received open-flap procedures. The levels of sTREM-1, PGLYRP-1, MMP-8, and TIMP-1 were analyzed using enzyme-linked immunosorbent assays. BOP, plaque levels, and PPD significantly reduced after treatment in both groups. A significant decrease in the salivary levels of sTREM-1, MMP-8, and TIMP-1 in the PI group and PGLYRP1 and TIMP-1 in the MU group were observed. Salivary levels of sTREM-1 were significantly reduced in patients with PI but not with MU. Additionally, peri-implant treatment had a significantly higher impact on MMP-8 reduction in patients with PI than in those with MU.

Development and feasibility testing of a training programme for community pharmacists to deliver a culturally responsive medication review intervention

Background

Cultural differences between health professionals and Indigenous peoples contribute to health inequalities, and effective cross-cultural communication and person-centred healthcare are critical remedial elements. Community pharmacists can play a significant role by reducing medication-related problems through medication reviews, yet barriers to access include cultural and linguistic challenges. The Indigenous Medication Review Service (IMeRSe) aimed to address these barriers via a culturally responsive intervention. The aim of this paper is to present the cross-cultural training framework developed as a component of this intervention and the feasibility evaluation of the first stage of the training framework.

Methods

A training framework was developed, emphasising pharmacists’ skills and confidence in effective cross-cultural communication and relationship-building with Indigenous Australians (Please note that the use of the term ‘Indigenous’ in this manuscript includes all Aboriginal and Torres Strait Islander people and acknowledges their rich traditions and heterogenous cultures) across three stages: (1) online and workshop-based, covering Indigenous history and health, cross-cultural communication and a holistic, strengths-based approach to intervention delivery; (2) orientation to local Aboriginal Health Services, community and cultural protocols; and (3) ongoing mentoring. The feasibility evaluation of the first stage included the following: self-reported levels of cultural capability, cultural confidence and skills, motivators and barriers to working with Indigenous Australians, assessed pre- and post-training. Participants completed self-administered questionnaires including a 22-item validated Cultural Capability Measurement Tool. Paired t tests assessed change in mean scores of Likert scale data.

Results

Stage 1 development resulted in an 8.5-h standardised cross-cultural training programme tested with 39 pharmacists working across urban and rural/remote Australia. Thirty-six pharmacists completed the feasibility evaluation (75.7% female, all non-Indigenous, 75.7% never attended prior cross-cultural training). Participants reported overall acceptability with training; the majority perceived it added value to their practice. Improved cultural capability post-training was reflected in increased scores for 21/22 items, nine reaching statistical significance. There were significant improvements for all 26 confidence and skills statements, and selected motivational and barrier statements, particularly participants role in improving Indigenous health outcomes and cross-cultural communication.

Conclusions

This study provides preliminary evidence that the training programme was feasible to deliver and prepared pharmacists to deliver a culturally responsive medication review intervention. The online knowledge-based modules and face-to-face workshops provide a standardised framework for larger-scale implementation of the intervention training.

Trial registration

Australia and New Zealand Clinical Trials Registry ACTRN12618000188235.Prospectively registered 22 January 2018.

Evaluation of the effectiveness of a novel mouth rinse containing hyaluronic acid and hydrogen peroxide on gingivitis: A randomized pilot controlled trial

Objective

To evaluate and compare the effectiveness of a mouth rinse with hydrogen peroxide (H₂O₂) and hyaluronic acid (HA) versus a placebo mouth rinse on gingivitis.

Material and methods

This was a 21‐day, double blind, randomized, two‐arm parallel allocation placebo‐controlled trial of 50 study participants with a diagnosis of plaque‐induced gingivitis. Patients were randomly allocated to the test group or the placebo group and were assessed at three time points over the course of the study by the same operator, at baseline (T0), 7 days (T1), and 21 days follow‐up (T2). Primary outcomes of the trial were improvement in gingivitis and plaque accumulation.

Results

In both groups there was a decrease in gingival and plaque indices but the combination of the two actives (H₂O₂/HA) proved to be more effective against gingivitis (p = 0.001). Regarding plaque index, the differences between the test product and placebo were not statistically significant (p = 0.084). Besides, the new mouthwash was considered palatable, no adverse events were registered over the 21‐day period.

Conclusions

The H₂O₂ + HA product was more effective in reducing gingivitis when compared to a placebo while no differences were observed for plaque accumulation.

Knowledge of COVID-19 Infection Guidelines among the Dental Health Care Professionals of Jazan Region, Saudi Arabia

BACKGROUND

This study aimed to assess the knowledge about guidelines related to COVID-19 infection control procedures among dental health care professionals (DHCPs) in the Jazan region.

METHODS

A cross-sectional study involving DHCPs (dental students, interns, and dentists) of the Jazan region between January and March 2021. A questionnaire with 35 items was developed and circulated online among the DHCPs. The dimensionality of the questionnaire was assessed using exploratory factor analysis (EFA). The level of awareness (LOA) was compared across the genders, level of professional experience, and exposure to guidelines. Participants were considered to have high LOA when they responded to 26 or more items correctly.

RESULTS

A total of 363 DHCPs participated in the survey. The questionnaire was found to be valid and reliable. EFA revealed a distinct three-factor structure. Moreover, 61.2% of the respondents had high LOA related to COVID-19 infection prevention. Among those who had high LOA, dentists (65.5%) were relatively more than the students (62.5%) and interns (46.2%). Among the six guideline statements related explicitly to operative dentistry, more than 50% of the respondents were aware of 3 guideline statements, while less than 50% of the respondents were aware of the remaining statements.

CONCLUSIONS

Most DHCP had a high LOA for general COVID-19 infection prevention and control guidelines. Dentists, males, and those who read the guidelines had higher LOA than their counterparts.

Factors patients consider when accessing oral health care

The aim of this cross-sectional study was to understand patients' perceived importance of clinic- and clinician-related factors and contextual characteristics that shape the importance ratings for factors patients consider when accessing oral health care. This study was conducted at Griffith University Dental Clinic, Gold Coast, Australia. Patients answered a self-administered questionnaire on demographics and perceived need for attendance, which constituted the explanatory variables. In the second part of the questionnaire, patients were asked to rate the importance of 17 items related to the provision and quality of oral health services using a five-point scale. Exploratory factor analysis (EFA) was conducted to determine the dimensionality of the questionnaire. The questionnaire was completed by 298 patients. The importance of some of the clinician-related factors, such as 'concern for patients' and 'access to specialist care', were associated with sex, age and employment status. EFA revealed a two-factor structure, which consisted of items related to clinician characteristics and clinic environment characteristics. Female participants had higher importance scores for clinic environment characteristics (mean (±s.d.) 38.00 ± 4.86 vs 35.45 ± 6.30; P < 0.05) and clinician characteristics (32.39 ± 2.85 vs 31.33 ± 3.39; P < 0.05) than male participants. In conclusion, various clinician- and clinic-related aspects were considered important for the provision and quality of oral health services, with the importance of these factors associated with some contextual characteristics. Application of Andersen's behavioural model of health services use provided a framework that offers important insights into patient beliefs and perceptions towards oral health services and can serve as a baseline for future studies in dental clinics across Australia.

Global, regional, and national mortality among young people aged 10-24 years, 1950-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Documentation of patterns and long-term trends in mortality in young people, which reflect huge changes in demographic and social determinants of adolescent health, enables identification of global investment priorities for this age group. We aimed to analyse data on the number of deaths, years of life lost, and mortality rates by sex and age group in people aged 10-24 years in 204 countries and territories from 1950 to 2019 by use of estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019.

METHODS

We report trends in estimated total numbers of deaths and mortality rate per 100 000 population in young people aged 10-24 years by age group (10-14 years, 15-19 years, and 20-24 years) and sex in 204 countries and territories between 1950 and 2019 for all causes, and between 1980 and 2019 by cause of death. We analyse variation in outcomes by region, age group, and sex, and compare annual rate of change in mortality in young people aged 10-24 years with that in children aged 0-9 years from 1990 to 2019. We then analyse the association between mortality in people aged 10-24 years and socioeconomic development using the GBD Socio-demographic Index (SDI), a composite measure based on average national educational attainment in people older than 15 years, total fertility rate in people younger than 25 years, and income per capita. We assess the association between SDI and all-cause mortality in 2019, and analyse the ratio of observed to expected mortality by SDI using the most recent available data release (2017).

FINDINGS

In 2019 there were 1·49 million deaths (95% uncertainty interval 1·39-1·59) worldwide in people aged 10-24 years, of which 61% occurred in males. 32·7% of all adolescent deaths were due to transport injuries, unintentional injuries, or interpersonal violence and conflict; 32·1% were due to communicable, nutritional, or maternal causes; 27·0% were due to non-communicable diseases; and 8·2% were due to self-harm. Since 1950, deaths in this age group decreased by 30·0% in females and 15·3% in males, and sex-based differences in mortality rate have widened in most regions of the world. Geographical variation has also increased, particularly in people aged 10-14 years. Since 1980, communicable and maternal causes of death have decreased sharply as a proportion of total deaths in most GBD super-regions, but remain some of the most common causes in sub-Saharan Africa and south Asia, where more than half of all adolescent deaths occur. Annual percentage decrease in all-cause mortality rate since 1990 in adolescents aged 15-19 years was 1·3% in males and 1·6% in females, almost half that of males aged 1-4 years (2·4%), and around a third less than in females aged 1-4 years (2·5%). The proportion of global deaths in people aged 0-24 years that occurred in people aged 10-24 years more than doubled between 1950 and 2019, from 9·5% to 21·6%.

INTERPRETATION

Variation in adolescent mortality between countries and by sex is widening, driven by poor progress in reducing deaths in males and older adolescents. Improving global adolescent mortality will require action to address the specific vulnerabilities of this age group, which are being overlooked. Furthermore, indirect effects of the COVID-19 pandemic are likely to jeopardise efforts to improve health outcomes including mortality in young people aged 10-24 years. There is an urgent need to respond to the changing global burden of adolescent mortality, address inequities where they occur, and improve the availability and quality of primary mortality data in this age group.

FUNDING

Bill & Melinda Gates Foundation.

Psychometric Testing of the Modified Dental Anxiety Scale among Iranian Adolescents during COVID-19 Pandemic

(1) Background: The present study aimed to examine the psychometric properties of the Persian adaptation of the Modified Dental Anxiety Scale (MDAS) in Iranian adolescents. (2) Methods: Adolescents with a mean age of 15.10 (n = 3197; 47.1% males) were recruited from Qazvin city of Iran using a stratified cluster random sampling technique. All children completed the five-item Persian MDAS and information related to background characteristics. Psychometric testing was conducted using classical test theory (CTT) and Rasch models. For CTT, an item-total correlation of >0.4 was considered satisfactory while for Rasch analysis, infit and outfit mean squares (Mnsq) ranging from 0.5–1.5 were considered satisfactory. Confirmatory Factor Analysis (CFA) was conducted to confirm the unidimensional structure of MDAS using various fit indices. Differential item functioning (DIF) was evaluated based on gender and time since last dental visit. Moreover, latent class analysis (LCA) was used to classify the participants into different levels of dental fear based on their pattern of responses. Both item level reliability using Cronbachs alpha (α) and test-reliability using intraclass correlation coefficients were evaluated. (3) Results: Item-total correlations ranged from 0.69–0.78, infit MnSq ranged from 0.80 to 1.11 and the range of outfit MnSq was 0.84–1.10. The data confirmed a one-factor structure of MDAS with satisfactory fit indices. DIF analysis indicated that the scale was interpreted similarly across the genders and time since dental visit groups. LCA analysis identified three levels, low, moderate and high levels of dental anxiety. The groups with moderate and high levels of dental anxiety had more females (44.6% and 36.7%) than the group with low level of dental anxiety (18.8%; p < 0.001). α of the total scale was 0.89 and item test-retest reliability ranged from 0.72–0.86. (4) Conclusions: The Persian MDAS was unidimensional with satisfactory psychometric properties evaluated using both CTT and Rasch analysis among Iranian adolescents. The scale was stable across the genders and individuals with different dental visiting patterns. The Persian MDAS also demonstrated excellent reliability.

The influence of family socioeconomic status on toothbrushing practices in Australian children

OBJECTIVE

To assess the relationship between toothbrushing behavior and socio-demographic characteristics in Australian children.

METHODS

Data were collected through the 2012-2014 Australian National Child Oral Health Survey (NCOHS). NCOHS was a cross-sectional survey of representative school children aged 5-14 years of Australia with a total sample size of 24,664 children.

RESULTS

Two-thirds (69%) of Australian children brushed twice or more times a day and the mean age of starting toothbrushing with fluoridated toothpaste was 24 months. Males were less consistent with toothbrushing than females (OR = 0.85; 95% CI: 0.74-0.97) and the likelihood of brushing twice or more a day improved with the increase in age (OR = 1.05; 95% CI: 1.02-1.08). Children with university educated (OR = 1.80; 95% CI: 1.44-2.26), vocational trained parents'/guardians' (OR = 1.45, 95% CI 1.11-1.90), living in families with an income of >AU$120,000 (OR = 1.42; 95% CI: 1.08-1.89) and having an overseas born parent (OR = 1.30; 95% CI: 1.07-1.58) were more likely to brush their teeth twice or more a day than their comparative counterparts. Children in households with two children (OR = 1.33; 95% CI: 1.07-1.64) were more likely to brush twice or more than single-child households. Children with a health welfare card tended to delay the start of toothbrushing by 1.4 months in comparison to those without a welfare card. Children with one of the caregivers born overseas started brushing later than those with Australia born caregivers (B = 1.04; SE = 0.46). Children living in high income and educated families and households with two or more children tended to start toothbrushing at an earlier age.

CONCLUSIONS

Several family socio-demographic factors influenced toothbrushing habits in Australian children.

Immunological Traits of Patients with Coexistent Inflammatory Bowel Disease and Periodontal Disease: A Systematic Review

This systematic review assessed studies that evaluated the immunological traits of patients with both inflammatory bowel disease (IBD) and periodontal disease. An electronic search for literature was conducted on PubMed, Embase, Scopus, Cochrane and Web of Science. Studies that evaluated the immunological response in patients with IBD and periodontal disease were considered eligible for inclusion. A total of 6 cross-sectional studies of 275 patients were included. Immunological analyses were performed in gingival crevicular fluid, saliva, serum, intestinal and gingival biopsies. Four studies identified that the presence of IBD and periodontal disease was associated with higher levels of prostaglandin E2, aMMP8, IL-18 and S100A12, respectively, when compared to patients without the coexistence of both diseases. Furthermore, another study identified higher aMMP-8 levels with increasing severity of periodontitis in Crohn’s disease patients. The quality of overall evidence ranged from high to low due to the observational nature of contributing studies. The coexistence of IBD and periodontal disease seems to be associated with a more responsive inflammatory reaction compared with individuals having one or the other. More randomized controlled studies evaluating the coexistence of IBD and periodontitis are required to better explore the immunological interplay between them.

In vitro studies evaluating the efficacy of mouth rinses on Sars-Cov-2: A systematic review

This systematic review aims to evaluate the evidence on the efficacy of mouth rinses on SARS-CoV-2 from in vitro studies. Five electronic databases were searched up to February 2021; no language or time restrictions were used. Two independent reviewers conducted both selection and data extraction processes. The toxicological data reliability assessment tool was used to evaluate the risk of bias. Starting from 239 articles, retrieved by the electronic search, only eight studies were included in our systematic review. Povidone Iodine (PVP-I) was effective in killing SARS-CoV-2, demonstrated higher virucidal activity than other commonly used active ingredients. Conflicting results were found about the effectiveness of Chlorhexidine (CHX) while hydrogen peroxide (H₂O₂) proved less effective than PVP-I. Other active ingredients, such as quaternary ammonium compounds and Ethanol (particularly when combined with essential oils), have also shown promising results in reducing viral load, with results comparable to PVP-I.

Association of IL-10 and TNF-α Polymorphisms with Dental Peri-Implant Disease Risk: A Meta-Analysis, Meta-Regression, and Trial Sequential Analysis

Genetic susceptibility has been reported to be an important risk factor for peri-implant disease (PID). The aim of this meta-analysis was to assess the association between TNF-α and IL-10 polymorphisms and PID susceptibility. The Web of Science, Cochrane Library, Scopus, and PubMed/Medline databases were searched for studies published until 12 April 2021. RevMan 5.3, CMA 2.0, SPSS 22.0, and trial sequential analysis software were used. Twelve studies were included in our analysis. The pooled ORs for the association of TNF-α (−308 G > A), IL-10 (−1082 A > G), IL-10 (−819 C > T), and IL-10 (−592 A > C) polymorphisms were 1.12, 0.93, 1.35, and 0.77 for allelic; 1.42, 0.95, 3.41, and 0.34 for homozygous; 1.19, 1.88, 1.23, and 0.49 for heterozygous, 1.53, 1.12, 1.41, and 0.39 for recessive; and 1.16, 1.87, 2.65, and 0.75 for dominant models, respectively, with all the estimates being insignificant. The results showed an association between TNF-α (−308 G > A) polymorphism and the risk of PID in patients of Asian ethnicity (OR = 1.59; p = 0.03). The present meta-analysis illustrated that TNF-α (−308 G > A), IL-10 (−1082 A > G), IL-10 (−819 C > T), and IL-10 (−592 A > C) polymorphisms were not associated with the risk of PID, whereas TNF-α (−308 G > A) polymorphism was associated with an elevated risk of PID in Asian patients.

Impact of the Poor Oral Health Status of Children on Their Families: An Analytical Cross-Sectional Study

The impact of poor oral health may not just be limited to the children themselves but can impact their families. The current study aims to perform psychometric analyses of the Arabic version of the Family Impact Scale and investigate the association of its domains with the oral health status of children. This cross-sectional study was carried out in a sample of 500 parent-child dyads from high schools of Jazan city of the Kingdom of Saudi Arabia. The Arabic version of the Family Impact Scale was subjected to reliability and validity tests. The explanatory variables in the current study are: the oral health status, parents combined income, parents’ education, age and sex of the child. The descriptive analysis was reported using proportions, this was followed by the bivariate and multivariable analyses. About 24.2% of children were reported to have fair, poor, and very poor oral health. A lower frequency of family impact corresponded with better oral health (OH) status of children (p < 0.001). The likelihood of parent’s taking time off from work and having financial difficulties was nearly two-times greater if their children had poor oral health. Similarly, interruption in sleep and other normal activities of parents is four times and five times greater, respectively, if the child has poor oral health status. Thus, the poor oral health of school children in the Jazan region of Saudi Arabia is a matter of grave concern as it is observed to be associated with family impacts; particularly affecting the parent’s work, sleep, and other normal family activities.

Spatial, temporal, and demographic patterns in prevalence of smoking tobacco use and attributable disease burden in 204 countries and territories, 1990-2019: a systematic analysis from the Global Burden of Disease Study 2019

BACKGROUND

Ending the global tobacco epidemic is a defining challenge in global health. Timely and comprehensive estimates of the prevalence of smoking tobacco use and attributable disease burden are needed to guide tobacco control efforts nationally and globally.

METHODS

We estimated the prevalence of smoking tobacco use and attributable disease burden for 204 countries and territories, by age and sex, from 1990 to 2019 as part of the Global Burden of Diseases, Injuries, and Risk Factors Study. We modelled multiple smoking-related indicators from 3625 nationally representative surveys. We completed systematic reviews and did Bayesian meta-regressions for 36 causally linked health outcomes to estimate non-linear dose-response risk curves for current and former smokers. We used a direct estimation approach to estimate attributable burden, providing more comprehensive estimates of the health effects of smoking than previously available.

FINDINGS

Globally in 2019, 1·14 billion (95% uncertainty interval 1·13-1·16) individuals were current smokers, who consumed 7·41 trillion (7·11-7·74) cigarette-equivalents of tobacco in 2019. Although prevalence of smoking had decreased significantly since 1990 among both males (27·5% [26·5-28·5] reduction) and females (37·7% [35·4-39·9] reduction) aged 15 years and older, population growth has led to a significant increase in the total number of smokers from 0·99 billion (0·98-1·00) in 1990. Globally in 2019, smoking tobacco use accounted for 7·69 million (7·16-8·20) deaths and 200 million (185-214) disability-adjusted life-years, and was the leading risk factor for death among males (20·2% [19·3-21·1] of male deaths). 6·68 million [86·9%] of 7·69 million deaths attributable to smoking tobacco use were among current smokers.

INTERPRETATION

In the absence of intervention, the annual toll of 7·69 million deaths and 200 million disability-adjusted life-years attributable to smoking will increase over the coming decades. Substantial progress in reducing the prevalence of smoking tobacco use has been observed in countries from all regions and at all stages of development, but a large implementation gap remains for tobacco control. Countries have a clear and urgent opportunity to pass strong, evidence-based policies to accelerate reductions in the prevalence of smoking and reap massive health benefits for their citizens.

FUNDING

Bloomberg Philanthropies and the Bill & Melinda Gates Foundation.

Mini-Implant-Retained Overdentures for the Rehabilitation of Completely Edentulous Maxillae: A Systematic Review and Meta-Analysis

Purpose: Mini-dental implants (MDIs) have been used to support and retain overdentures, providing patients with a less invasive placement procedure. Although lucrative, the use of MDIs to retain a maxillary overdenture is still not an established treatment modality. This systematic review aims to answer the question: Do mini-implant-retained maxillary overdentures provide a satisfactory treatment outcome for complete edentulism? Methods: A systematic search for relevant articles was conducted to include articles published until April 2021 in the following electronic databases: CINAHL, Cochrane, EMBASE, PubMed, and Web of Science. All empirical studies evaluating the biological, survival, or patient-reported outcomes after placing mini-implant-retained overdentures in maxilla were considered for inclusion. The risk of bias was assessed by utilizing the Joanna Briggs Institute critical appraisal checklist. Study screening and data extraction were conducted by three reviewers independently. Results: The electronic search retrieved 1276 titles after omitting duplicates. Twenty articles were considered for full-text review, of which six studies were included in this systematic review. The included studies evaluated a total of 173 participants with a mean age of 66.3 years. The overall mini-implant survival rate was 77.1% (95% CI: 64.7–89.5%) with a mean follow-up time of 1.79 years (range: 6 months to 3 years). Implant survival differed significantly when comparing complete and partial palatal coverage overdentures. Those with complete palatal coverage exhibited less bone loss overall compared to partial coverage overdentures. Participants of all studies reported an increase in the quality of life and in satisfaction after rehabilitation treatment with MDIs. Conclusions: The survival rate of mini-implants retaining an overdenture in the maxilla was observed to be lower than the values reported for traditional implants in the literature. Improvements were observed in all aspects in terms of patient satisfaction, quality of life, oromyofunction, and articulation after the treatment.

The Antibacterial and Remineralizing Effects of Biomaterials Combined with DMAHDM Nanocomposite: A Systematic Review

Researchers have developed novel nanocomposites that incorporate additional biomaterials with dimethylaminohexadecyl methacrylate (DMAHDM) in order to reduce secondary caries. The aim of this review was to summarize the current literature and assess the synergistic antibacterial and remineralizing effects that may contribute to the prevention of secondary caries. An electronic search was undertaken in MEDLINE using PubMed, Embase, Scopus, Web of Science and Cochrane databases. The initial search identified 954 papers. After the removal of duplicates and screening the titles and abstracts, 15 articles were eligible for this review. The amalgamation of 2-methacryloyloxyethyl phosphorylcholine (MPC) and silver nanoparticles (AgNPs) with DMAHDM resulted in increased antibacterial potency. The addition of nanoparticles of amorphous calcium phosphate (NACP) and polyamidoamine dendrimers (PAMAM) resulted in improved remineralization potential. Further clinical studies need to be planned to explore the antibacterial and remineralizing properties of these novel composites for clinical success.

How Do Mothers Living in Socially Deprived Communities Perceive Oral Health of Young Children? A Qualitative Study

This qualitative study aims to explore and gain an in-depth understanding of the knowledge and perceptions of mothers living in Greater Western Sydney (GWS), one of Australia’s most socio-economically disadvantaged regions, regarding the factors that influence oral health of young children. Mother–child dyads (n = 45) were purposively selected from a population-based cohort study in GWS. Semi-structured in-depth interviews were audio-recorded, transcribed verbatim, and subsequently analyzed using thematic analysis. Five main themes emerged from the interviews: (1) beliefs about child oral health and first set of teeth; (2) awareness and attitudes towards oral health services; (3) identification of caries risk and protective factors; (4) broader cultural and social class influences on childhood oral health practices; and (5) the influence of parental self-confidence, self-efficacy, and perceived control. Overall, mothers reported having limited knowledge and awareness on the importance of baby teeth, child’s first dental visit, and seeking oral health care. Oral health and preventative practices in children were reported to be influenced by past dental experiences, culture and social class, and parental factors. The empirical findings of this study bring our attention to the critical factors that influence child oral health and the opportunities for co-creating child oral health promotion by targeting mothers.

A PRISMA-compliant meta-analysis on association between X-ray repair cross complementing (XRCC1, XRCC2, and XRCC3) polymorphisms and oral cancer susceptibility

BACKGROUND

Oral Cancer (OC) is one of the leading causes of death and the disease mainly occurs over 50 years of age. Herein, a meta-analysis aimed to assess the association between X-ray repair cross complementing (XRCC) polymorphisms and OC risk.

METHODS

Four databases were searched extensively until June 5, 2020. Subgroup analysis, meta-regression, and funnel plots, as well as the quality assessment were estimated.

RESULTS

Fifteen studies were entered to the analysis. With regards to allele, homozygote, heterozygote, recessive, and dominant models, the pooled ORs for XRCC1 rs1799782 polymorphism were 1.51 (P = 0.01), 1.45 (P = 0.11), 1.45 (P = 0.0003), 1.44 (P = 0.0002), and 1.29 (P = 0.26); for XRCC1 rs1799782 polymorphism were 1.65 (P = 0.11), 1.50 (P = 0.33), 1.06 (P = 0.83), 1.57 (P = 0.12), and 1.32 (P = 0.45); for XRCC1 rs25489 polymorphism were 0.01 (P = 0.19), 1.44 (P = 0.48), 1.21 (P = 0.72), 1.17 (P = 0.19), and 1.38 (P = 0.54); for XRCC2 rs2040639 polymorphism were 0.68 (P = 0.0002), 0.63 (P = 0.02), 0.95 (P = 0.92), 0.79 (P = 0.49), and 0.61 (P = 0.005); and for XRCC3 rs861539 polymorphism were 1.24 (P = 0.20), 1.28 (P = 0.48), 0.99 (P = 0.95), 1.15 (P = 0.46), and 1.52 (P = 0.15), respectively.

CONCLUSIONS

The T allele and CT genotype of XRCC1 rs1799782 polymorphism had an elevated risk, whereas the G allele and GG genotype of XRCC2 rs2040639 polymorphism had a protective role in OC.

Theoretical evidence explaining the relationship between socio-demographic and psychosocial barriers on access to oral health care among adults: A scoping review

OBJECTIVES

Current global models for oral health care are outdated. Out of pocket payments and exclusion from most national health systems has created a gap for access of services by socio-economically vulnerable adults. Our objective is to understand barriers to access and the causal associations between barriers to care.

DATA

All study designs with a theoretical/conceptual framework to explain access and barriers among adults were included.

SOURCES

6 electronic databases (PubMed, Medline (EBSCO), CINAHL, Embase, Web of Science) including grey literature searches (ProQuest) and expert consultation. The identified studies were then analysed using narrative synthesis and NVivo.

STUDY SELECTION/RESULTS

40 studies using a theoretical framework to explain access among adults were identified. Andersen's behavioural model was most used. Cost was the primary causal factor that perpetuated the effect of other barriers. Associations were found between age and education level, cost and need, cost and dental anxiety. Study design and analysis used to identify these associations had limitations in determining causality.

CONCLUSION

Oral health access research is based in theory, leading to the identification of socio-demographic and psychosocial barriers and their relationships. However, a lack of explanation of causal associations persists. This review recognises the importance of understanding the cause of barriers in addition to their nature. Appropriate study designs and analysis considering the impact of time varying factors on access is required. Empirical analysis needs to focus on the role of confounders and mediators to determine causality successfully. To achieve this a theory driven causal model has been proposed.

Health-related quality of life among oral and oropharyngeal cancer patients: An exploratory study

OBJECTIVES

To comprehensively explore the effect of several sociodemographic-, patient- and tumour-related factors on the health-related quality of life (HRQoL) of oral and oropharyngeal cancer patients.

METHODOLOGY

Patients diagnosed with oral and oropharyngeal cancers were included in the present cross-sectional study. Information pertaining to various sociodemographic-, patient- and tumour-related factors was recorded. HRQoL was assessed using standard 12-item Short Form Health Survey version 2 (SF12V2), and oral health-related quality of life (OHRQoL) was assessed by Oral Health Impact Profile-14 (OHIP).

RESULTS

A total of 108 patients participated in the present study. Results revealed that nodal metastasis, histological differentiation and pain were significant predictors of OHRQoL, while site, size, stage, histological differentiation and pain were significant predictors of HRQoL. Pain was the single most significant negative determinant of HRQoL that was associated with worst total OHIP (B = 2.01, β = 0.45, p < .0001), physical (B = -0.88, β = -0.21, p = .017) and mental (B = -1.00, β = -0.22, p = .016) component summary scores.

CONCLUSIONS

Number of sociodemographic-, patient- and tumour-related factors emerged as significant predictors of HRQoL and OHRQoL. Study results might help in formulating targeted treatment plan, optimising patient care and follow-up.

Measuring universal health coverage based on an index of effective coverage of health services in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Achieving universal health coverage (UHC) involves all people receiving the health services they need, of high quality, without experiencing financial hardship. Making progress towards UHC is a policy priority for both countries and global institutions, as highlighted by the agenda of the UN Sustainable Development Goals (SDGs) and WHO's Thirteenth General Programme of Work (GPW13). Measuring effective coverage at the health-system level is important for understanding whether health services are aligned with countries' health profiles and are of sufficient quality to produce health gains for populations of all ages.

METHODS

Based on the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we assessed UHC effective coverage for 204 countries and territories from 1990 to 2019. Drawing from a measurement framework developed through WHO's GPW13 consultation, we mapped 23 effective coverage indicators to a matrix representing health service types (eg, promotion, prevention, and treatment) and five population-age groups spanning from reproductive and newborn to older adults (≥65 years). Effective coverage indicators were based on intervention coverage or outcome-based measures such as mortality-to-incidence ratios to approximate access to quality care; outcome-based measures were transformed to values on a scale of 0-100 based on the 2·5th and 97·5th percentile of location-year values. We constructed the UHC effective coverage index by weighting each effective coverage indicator relative to its associated potential health gains, as measured by disability-adjusted life-years for each location-year and population-age group. For three tests of validity (content, known-groups, and convergent), UHC effective coverage index performance was generally better than that of other UHC service coverage indices from WHO (ie, the current metric for SDG indicator 3.8.1 on UHC service coverage), the World Bank, and GBD 2017. We quantified frontiers of UHC effective coverage performance on the basis of pooled health spending per capita, representing UHC effective coverage index levels achieved in 2019 relative to country-level government health spending, prepaid private expenditures, and development assistance for health. To assess current trajectories towards the GPW13 UHC billion target-1 billion more people benefiting from UHC by 2023-we estimated additional population equivalents with UHC effective coverage from 2018 to 2023.

FINDINGS

Globally, performance on the UHC effective coverage index improved from 45·8 (95% uncertainty interval 44·2-47·5) in 1990 to 60·3 (58·7-61·9) in 2019, yet country-level UHC effective coverage in 2019 still spanned from 95 or higher in Japan and Iceland to lower than 25 in Somalia and the Central African Republic. Since 2010, sub-Saharan Africa showed accelerated gains on the UHC effective coverage index (at an average increase of 2·6% [1·9-3·3] per year up to 2019); by contrast, most other GBD super-regions had slowed rates of progress in 2010-2019 relative to 1990-2010. Many countries showed lagging performance on effective coverage indicators for non-communicable diseases relative to those for communicable diseases and maternal and child health, despite non-communicable diseases accounting for a greater proportion of potential health gains in 2019, suggesting that many health systems are not keeping pace with the rising non-communicable disease burden and associated population health needs. In 2019, the UHC effective coverage index was associated with pooled health spending per capita (r=0·79), although countries across the development spectrum had much lower UHC effective coverage than is potentially achievable relative to their health spending. Under maximum efficiency of translating health spending into UHC effective coverage performance, countries would need to reach $1398 pooled health spending per capita (US$ adjusted for purchasing power parity) in order to achieve 80 on the UHC effective coverage index. From 2018 to 2023, an estimated 388·9 million (358·6-421·3) more population equivalents would have UHC effective coverage, falling well short of the GPW13 target of 1 billion more people benefiting from UHC during this time. Current projections point to an estimated 3·1 billion (3·0-3·2) population equivalents still lacking UHC effective coverage in 2023, with nearly a third (968·1 million [903·5-1040·3]) residing in south Asia.

INTERPRETATION

The present study demonstrates the utility of measuring effective coverage and its role in supporting improved health outcomes for all people-the ultimate goal of UHC and its achievement. Global ambitions to accelerate progress on UHC service coverage are increasingly unlikely unless concerted action on non-communicable diseases occurs and countries can better translate health spending into improved performance. Focusing on effective coverage and accounting for the world's evolving health needs lays the groundwork for better understanding how close-or how far-all populations are in benefiting from UHC.

FUNDING

Bill & Melinda Gates Foundation.

Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

In an era of shifting global agendas and expanded emphasis on non-communicable diseases and injuries along with communicable diseases, sound evidence on trends by cause at the national level is essential. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) provides a systematic scientific assessment of published, publicly available, and contributed data on incidence, prevalence, and mortality for a mutually exclusive and collectively exhaustive list of diseases and injuries.

METHODS

GBD estimates incidence, prevalence, mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) due to 369 diseases and injuries, for two sexes, and for 204 countries and territories. Input data were extracted from censuses, household surveys, civil registration and vital statistics, disease registries, health service use, air pollution monitors, satellite imaging, disease notifications, and other sources. Cause-specific death rates and cause fractions were calculated using the Cause of Death Ensemble model and spatiotemporal Gaussian process regression. Cause-specific deaths were adjusted to match the total all-cause deaths calculated as part of the GBD population, fertility, and mortality estimates. Deaths were multiplied by standard life expectancy at each age to calculate YLLs. A Bayesian meta-regression modelling tool, DisMod-MR 2.1, was used to ensure consistency between incidence, prevalence, remission, excess mortality, and cause-specific mortality for most causes. Prevalence estimates were multiplied by disability weights for mutually exclusive sequelae of diseases and injuries to calculate YLDs. We considered results in the context of the Socio-demographic Index (SDI), a composite indicator of income per capita, years of schooling, and fertility rate in females younger than 25 years. Uncertainty intervals (UIs) were generated for every metric using the 25th and 975th ordered 1000 draw values of the posterior distribution.

FINDINGS

Global health has steadily improved over the past 30 years as measured by age-standardised DALY rates. After taking into account population growth and ageing, the absolute number of DALYs has remained stable. Since 2010, the pace of decline in global age-standardised DALY rates has accelerated in age groups younger than 50 years compared with the 1990-2010 time period, with the greatest annualised rate of decline occurring in the 0-9-year age group. Six infectious diseases were among the top ten causes of DALYs in children younger than 10 years in 2019: lower respiratory infections (ranked second), diarrhoeal diseases (third), malaria (fifth), meningitis (sixth), whooping cough (ninth), and sexually transmitted infections (which, in this age group, is fully accounted for by congenital syphilis; ranked tenth). In adolescents aged 10-24 years, three injury causes were among the top causes of DALYs: road injuries (ranked first), self-harm (third), and interpersonal violence (fifth). Five of the causes that were in the top ten for ages 10-24 years were also in the top ten in the 25-49-year age group: road injuries (ranked first), HIV/AIDS (second), low back pain (fourth), headache disorders (fifth), and depressive disorders (sixth). In 2019, ischaemic heart disease and stroke were the top-ranked causes of DALYs in both the 50-74-year and 75-years-and-older age groups. Since 1990, there has been a marked shift towards a greater proportion of burden due to YLDs from non-communicable diseases and injuries. In 2019, there were 11 countries where non-communicable disease and injury YLDs constituted more than half of all disease burden. Decreases in age-standardised DALY rates have accelerated over the past decade in countries at the lower end of the SDI range, while improvements have started to stagnate or even reverse in countries with higher SDI.

INTERPRETATION

As disability becomes an increasingly large component of disease burden and a larger component of health expenditure, greater research and development investment is needed to identify new, more effective intervention strategies. With a rapidly ageing global population, the demands on health services to deal with disabling outcomes, which increase with age, will require policy makers to anticipate these changes. The mix of universal and more geographically specific influences on health reinforces the need for regular reporting on population health in detail and by underlying cause to help decision makers to identify success stories of disease control to emulate, as well as opportunities to improve.

FUNDING

Bill & Melinda Gates Foundation.

Global age-sex-specific fertility, mortality, healthy life expectancy (HALE), and population estimates in 204 countries and territories, 1950-2019: a comprehensive demographic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Accurate and up-to-date assessment of demographic metrics is crucial for understanding a wide range of social, economic, and public health issues that affect populations worldwide. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 produced updated and comprehensive demographic assessments of the key indicators of fertility, mortality, migration, and population for 204 countries and territories and selected subnational locations from 1950 to 2019.

METHODS

8078 country-years of vital registration and sample registration data, 938 surveys, 349 censuses, and 238 other sources were identified and used to estimate age-specific fertility. Spatiotemporal Gaussian process regression (ST-GPR) was used to generate age-specific fertility rates for 5-year age groups between ages 15 and 49 years. With extensions to age groups 10-14 and 50-54 years, the total fertility rate (TFR) was then aggregated using the estimated age-specific fertility between ages 10 and 54 years. 7417 sources were used for under-5 mortality estimation and 7355 for adult mortality. ST-GPR was used to synthesise data sources after correction for known biases. Adult mortality was measured as the probability of death between ages 15 and 60 years based on vital registration, sample registration, and sibling histories, and was also estimated using ST-GPR. HIV-free life tables were then estimated using estimates of under-5 and adult mortality rates using a relational model life table system created for GBD, which closely tracks observed age-specific mortality rates from complete vital registration when available. Independent estimates of HIV-specific mortality generated by an epidemiological analysis of HIV prevalence surveys and antenatal clinic serosurveillance and other sources were incorporated into the estimates in countries with large epidemics. Annual and single-year age estimates of net migration and population for each country and territory were generated using a Bayesian hierarchical cohort component model that analysed estimated age-specific fertility and mortality rates along with 1250 censuses and 747 population registry years. We classified location-years into seven categories on the basis of the natural rate of increase in population (calculated by subtracting the crude death rate from the crude birth rate) and the net migration rate. We computed healthy life expectancy (HALE) using years lived with disability (YLDs) per capita, life tables, and standard demographic methods. Uncertainty was propagated throughout the demographic estimation process, including fertility, mortality, and population, with 1000 draw-level estimates produced for each metric.

FINDINGS

The global TFR decreased from 2·72 (95% uncertainty interval [UI] 2·66-2·79) in 2000 to 2·31 (2·17-2·46) in 2019. Global annual livebirths increased from 134·5 million (131·5-137·8) in 2000 to a peak of 139·6 million (133·0-146·9) in 2016. Global livebirths then declined to 135·3 million (127·2-144·1) in 2019. Of the 204 countries and territories included in this study, in 2019, 102 had a TFR lower than 2·1, which is considered a good approximation of replacement-level fertility. All countries in sub-Saharan Africa had TFRs above replacement level in 2019 and accounted for 27·1% (95% UI 26·4-27·8) of global livebirths. Global life expectancy at birth increased from 67·2 years (95% UI 66·8-67·6) in 2000 to 73·5 years (72·8-74·3) in 2019. The total number of deaths increased from 50·7 million (49·5-51·9) in 2000 to 56·5 million (53·7-59·2) in 2019. Under-5 deaths declined from 9·6 million (9·1-10·3) in 2000 to 5·0 million (4·3-6·0) in 2019. Global population increased by 25·7%, from 6·2 billion (6·0-6·3) in 2000 to 7·7 billion (7·5-8·0) in 2019. In 2019, 34 countries had negative natural rates of increase; in 17 of these, the population declined because immigration was not sufficient to counteract the negative rate of decline. Globally, HALE increased from 58·6 years (56·1-60·8) in 2000 to 63·5 years (60·8-66·1) in 2019. HALE increased in 202 of 204 countries and territories between 2000 and 2019.

INTERPRETATION

Over the past 20 years, fertility rates have been dropping steadily and life expectancy has been increasing, with few exceptions. Much of this change follows historical patterns linking social and economic determinants, such as those captured by the GBD Socio-demographic Index, with demographic outcomes. More recently, several countries have experienced a combination of low fertility and stagnating improvement in mortality rates, pushing more populations into the late stages of the demographic transition. Tracking demographic change and the emergence of new patterns will be essential for global health monitoring.

FUNDING

Bill & Melinda Gates Foundation.

Psychometric Analyses of the Indian (Hindi) Version of the Child Perception Questionnaire (CPQ11-14)

The current research aims to evaluate the reliability and validity of the Hindi Child Perception Questionnaire (CPQ_11-14) in a child population of India. A randomly selected sample of children aged 11-14 years (n = 331) and their parents completed the Hindi translation of CPQ_11-14 and the Parental-Caregiver Perceptions Questionnaire (P-CPQ), respectively, in this cross-sectional study. Children also provided a self-rating of oral health and were examined for dental caries. Exploratory Factor Analysis (EFA) was conducted to assess the dimensionality of the Hindi-CPQ_11-14. Internal consistency and reliability on repeated administration were evaluated. Convergent and divergent validities were determined by estimating correlation coefficients between items and the hypothesised subscales. Concurrent validity was assessed using multiple linear regression analyses. The four factors extracted in EFA had a total variance of 38.5%, comprising 31 items. Cronbach's alpha for the internal consistency of the overall scale was 0.90; reliability on repeated administration was 0.92. All the Hindi CPQ_11-14 items had an item-hypothesised subscale correlation coefficient of ≥0.4, and these were greater than item-other hypothesised subscale correlations, demonstrating good convergent and divergent validities respectively. Hindi-CPQ_11-14 was associated with self-ratings of the oral health and overall P-CPQ scores demonstrating good concurrent validity. Hindi-CPQ_11-14 showed a factor structure different from the English CPQ_11-14 and exhibited good validity and reliability.

Effect of prosthetic rehabilitation on oral health-related quality of life of patients with head and neck cancer: a systematic review

Background

To review the evidence on the oral health-related quality of life (OHRQoL) of head and neck cancer survivors after they have been treated with prosthetic rehabilitation.

Methods

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) were utilized as the framework in designing, implementing and reporting the current review. Search of literature was done electronically using Medline, Embase, and Cochrane databases. Intervention component of the patient, intervention, comparison, outcome (PICO) for the current review was the prosthetic rehabilitation performed on the surgically treated head and neck cancer patients (participants); and outcome was the OHRQoL. Methodological index for non-randomized studies was the assessment tool utilized to report on the quality of the included studies.

Results

The initial search had identified 799 records and the final level of screening included eight articles. Six studies were experimental in design and two were cross-sectional. Cumulative sample of the head and neck cancer cases from the selected studies was 354, with 35.9 (14.9) and 72.4 (8.7) years as the highest and lowest mean age recorded from the included studies. More male cases (69.5%) were reported than female cases (30.5%) and squamous cell carcinoma was the most commonly diagnosed malignancy. Maxillary reconstruction and implant supported prosthesis were the choice of treatment for most of the cases. Different versions of oral health impact profile (OHIP) constructs were preferred by six studies. While, one study utilized University of Washington quality of life questionnaire and the other utilized European Organization for Research and Treatment of Cancer’s Quality of Life Questionnaire. Arguably, three studies had compared the OHRQoL scores of head and neck cancer patients with healthy counterparts through a follow-up period ranging from 1 to 2 years.

Conclusions

The included studies did not provide substantial evidence to demonstrate the improvement in OHRQoL of head and neck cancer patients after prosthetic rehabilitation. More prospective studies are needed with representative sample, robust methodology and a longer follow-up period. The current study provides a direction to the clinical decision-making process and the epidemiological research to enhance the patients and public health-related outcomes.

Clinical efficacy of a new cetylpyridinium chloride-hyaluronic acid-based mouthrinse compared to chlorhexidine and placebo mouthrinses-A 21-day randomized clinical trial

OBJECTIVE

To compare the effectiveness of a novel cetylpyridinium chloride (CPC)-hyaluronic acid (HA)-based mouthrinse with chlorhexidine (CHX) and placebo mouthrinses in preventing plaque and gingivitis. The secondary outcomes were calculus, extrinsic stains, oral malodour and occurrence of adverse events.

METHODS

A 21-day randomized, double-blind, three-arm parallel study with random allocation of young dental students to any of the three mouthrinse groups. Thorough prophylaxis was done at baseline followed by a baseline examination for oral malodour, extrinsic stains, calculus, gingivitis and plaque by a single examiner. All the subjects used the allocated mouthrinse twice daily for 21 days and were examined again at the end of the experimental period. They were also interviewed for adverse events. Change in the scores of clinical indices was calculated and compared between the groups.

RESULTS

A total of 75 subjects were included and completed the experiment. There was a significant difference for change in plaque index scores between the groups (P = .015); subjects in the placebo group experienced higher levels of plaque accumulation than the other groups. Teeth staining increased in the CHX (P < .001) and placebo groups (P = .002), but not in CPC-HA users (P = .573). No significant differences were found between the three experimental groups for change in the gingival index (P = .08), calculus scores (P = .494), oral malodour (P = .870) and reporting of adverse events (P = .249).

CONCLUSIONS

CPC-HA and CHX had similar effectiveness in preventing plaque accumulation, while no differences were observed between the mouthrinses for preventing gingivitis. Dental staining was caused by CHX and the placebo mouthrinses but not by CPC-HA mouthrinse.