Comparison of the Early Childhood Oral Health Impact Scale (ECOHIS-4D) and Child Health Utility Index (CHU-9D) in children with oral diseases

OBJECTIVE

Accurate assessment of child oral health is important for guiding economic evaluations and informing healthcare decision-making. Early Childhood Oral Health Impact Scale (ECOHIS-4D) is a preference-based instrument that measures the oral health-related quality of life of young children. The aim of this study was to compare the utility scores of ECOHIS-4D and Child Health Utility Index (CHU-9D), against an oral health indicator to evaluate which utility score corresponds better with the oral health indicator.

METHOD

The ECOHIS-4D and CHU-9D were applied to 314 parent/child dyads from preschools in a primary healthcare setting in Perth, Western Australia. Four parameters were used to assess which instrument corresponds better with the oral health indicator (decayed, missing and filled teeth score-dmft score): (i) discrimination, the ability to discriminate between different clinical severity groups, (ii) external responsiveness, how much the utility values relate to the changes in dmft scores, (iii) correlation, the association between the two instruments and the related dimensions and (iv) differences in the utility values across the two instruments.

RESULTS

Most participants (81%) were 2-6 years old, and nearly 50% had a dmft score <3. ECOHIS-4D demonstrated a superior ability to differentiate between dmft severity groups and respond to changes in dmft scores. A significant weak correlation was observed between dmft and ECOHIS-4D (-0.26, 95%, CI -0.36 to -0.15) compared to a non-significant very poor correlation between dmft and CHU-9D (0.01, 95% CI -0.12 to 0.10). The utility scores of the two instruments had relatively good agreement towards good health and weak agreement towards poor health.

CONCLUSIONS

ECOHIS-4D, the oral health-specific instrument, is more sensitive in assessing children's oral health-related quality of life than the generic CHU-9D. Thus, ECOHIS-4D is more appropriate for utility estimates in economic evaluations of oral health-related interventions and resource allocation decision-making.

Oral Health, Social and Emotional Well-Being, and Economic Costs: Protocol for the Second Australian National Child Oral Health Survey

BACKGROUND

Given the significant investment of governments and families into the provision of child dental care services in Australia, continued population oral health surveillance through national oral health surveys is imperative.

OBJECTIVE

The aims of this study are to conduct a second National Child Oral Health Survey (NCOHS-2) to (1) describe the prevalence, extent, and impact of oral diseases in contemporary Australian children; (2) evaluate changes in the prevalence and extent of oral diseases in the Australian child population and socioeconomic subgroups since the first National Child Oral Health Study (NCOHS-1) in 2012-2013; and (3) use economic modeling to evaluate the burden of child oral disease from the NCOHS-1 and NCOHS-2 and to estimate the cost-effectiveness of targeted programs for high-risk child groups.

METHODS

The NCOHS-2 will closely mimic the NCOHS-1 in being a cross-sectional survey of a representative sample of Australian children aged 5-14 years. The survey will comprise oral epidemiological examinations and questionnaires to elucidate associations between dental disease in a range of outcomes, including social and emotional well-being. The information will be analyzed within the context of dental service organization and delivery at national and jurisdictional levels. Information from the NCOHS-1 and NCOHS-2 will be used to simulate oral disease and its economic burden using both health system and household costs of childhood oral health disease.

RESULTS

Participant recruitment for the NCOHS-2 will commence in February 2024. The first results are expected to be submitted for publication 6 months after NCOHS-2 data collection has been completed. Thematic workshops with key partners and stakeholders will also occur at this time.

CONCLUSIONS

Regular surveillance of child oral health at an Australian level facilitates timely policy and planning of each state and territory's dental public health sector. This is imperative to enable the most equitable distribution of scarce public monies, especially for socially disadvantaged children who bear the greatest dental disease burden. The last NCOHS was conducted in 2012-2014, meaning that these data need to be updated to better inform effective dental health policy and planning. The NCOHS-2 will enable more up-to-date estimates of dental disease prevalence and severity among Australian children, with cost-effective analysis being useful to determine the economic burden of poor child dental health on social and emotional well-being and other health indicators.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/52233.

Developing an Australian utility value set for the Early Childhood Oral Health Impact Scale-4D (ECOHIS-4D) using a discrete choice experiment

PURPOSE

Preference-based quality of life measures (PBMs) are used to generate quality-adjusted life years (QALYs) in economic evaluations. A PBM consists of (1) a health state classification system and (2) a utility value set that allows the instrument responses to be converted to QALYs. A new, oral health-specific classification system, the Early Childhood Oral Health Impact Scale-4D (ECOHIS-4D) has recently been developed. The aim of this study was to generate an Australian utility value set for the ECOHIS-4D.

METHODS

A discrete choice experiment with duration (DCETTO) was used as the preference elicitation technique. An online survey was administered to a representative sample of Australian adults over 18 years. Respondents were given 14 choice tasks (10 tasks from the DCE design of 50 choice sets blocked into five blocks, 2 practice tasks, a repeated and a dominant task). Data were analyzed using the conditional logit model.

RESULTS

A total of 1201 respondents from the Australian general population completed the survey. Of them, 69% (n = 829) perceived their oral health status to be good, very good, or excellent. The estimated coefficients from the conditional logit models were in the expected directions and were statistically significant (p < 0.001). The utility values for health states defined by the ECOHIS-4D ranged from 0.0376 to 1.0000.

CONCLUSIONS

This newly developed utility value set will enable the calculation of utility values for economic evaluations of interventions related to oral diseases such as dental caries among young children. This will facilitate more effective resource allocation for oral health services.

Dental enamel defects and dental caries of primary teeth among Indigenous children in Western Australia

BACKGROUND

Teeth affected with enamel defects (EDs) are at an increased risk of dental caries. In spite of improving oral health status overall in Australia, Indigenous Australians still experience higher rates of dental caries than non-Indigenous Australians. This study reports on the prevalence of EDs and dental caries experience among Indigenous children in the Kimberley region of Western Australia.

METHODS

Health status of all the primary teeth (ICDAS II criteria) and the presence of EDs on index teeth (modified Dental Defects of Enamel index; DDE) of young Indigenous children who participated in a 2-arm intervention trial was recorded. Generalized estimating equations were used to estimate the association between EDs and dental caries and effect estimates were presented as odds ratios and associated 95% confidence intervals.

RESULTS

Person-level prevalence, from 237 children (mean age 3.6 years, standard deviation 1.7) assessed for EDs, was 58% and tooth-level prevalence was 24%. Teeth affected with demarcated or diffuse defects were associated with a twofold higher odds of having caries experience, odds ratio (OR) 2.5, 95% confidence interval (CI) 1.7-3.7 and OR 2.7, 95% CI 1.7-4.0 respectively.

CONCLUSIONS

The presence of EDs among young Indigenous children was associated with a higher odds of caries experience among affected teeth.

Motivational Interviewing and Childhood Caries: A Randomised Controlled Trial

BACKGROUND

This study tested the occurrence of early childhood caries (ECC) and changes in potential mediators of ECC after an early childhood oral health promotion intervention.

METHODS

Consenting parent/child dyads in Western Australia were randomised into test [motivational interviewing (MI) + anticipatory guidance (AG)] or control (lift the lip assessments by child health nurses). A questionnaire at baseline and follow-ups (at 18, 36 and 60 months) evaluated the parental factors and the children clinically examined. Data were analysed using parametric and non-parametric tests for two groups and paired comparisons. Multivariable analysis used negative binomial regression with robust standard errors for over-dispersed count data and effect estimates presented as incidence rate ratios.

RESULTS

Nine hundred and seventeen parent/child dyads were randomised (test n = 456; control n = 461). The parental attitude toward a child's oral hygiene needs improved among the test group at the first follow-up (n = 377; baseline 1.8, SD 2.2, follow-up 1.5, SD 1.9, p = 0.005). Living in a non-fluoridated area and parents holding a fatalistic belief increased the risk of caries (IRR = 4.2, 95% CI 1.8-10.2 and IRR = 3.5, 95% CI 1.7-7.3), respectively, but MI/AG did not reduce the incidence of dental caries.

CONCLUSION

The brief MI/AG oral health promotion intervention improved parental attitude but did not reduce ECC.

Atraumatic restorative treatments and oral health-related quality of life and dental anxiety in Australian Aboriginal children: A cluster-randomized trial

OBJECTIVES

The management of early childhood caries is challenging and the impacts of its treatment on child oral health-related quality of life (COHRQoL) and dental anxiety among Australian Aboriginal children is relatively unknown. The aim of the study was to compare the impact on COHRQoL and dental anxiety after approximately 12 months among Aboriginal children treated for early childhood caries (ECC) using the Atraumatic Restorative Treatment and the Hall Technique (ART/HT: test) or standard care (control).

METHODS

Consenting Aboriginal communities in the North-West of Western Australia were randomized into early (test) or delayed (control) intervention for the management of ECC. Children and parents/carers completed a questionnaire at baseline and at follow-up. The questionnaire sought information on COHRQoL using the proxy-reported Early Childhood Oral Health Impact Scale (ECOHIS) and the self-reported Caries Impacts and Experiences Questionnaire for Children (CARIES-QC). The test group was provided with the ART/HT care at baseline while the control group was advised to seek care through the usual care options available within the community. At follow-up, both groups were offered care using the ART/HT approach. Changes in the mean scores from baseline to follow-up within groups were evaluated using appropriate paired (t-test, Wilcoxon paired test), and between groups with unpaired tests (t-test). Multivariate regression analysis after multiple imputations of missing data used generalized estimating equation (GEE) controlling for clustering within communities.

RESULTS

Twenty-five communities and 338 children (mean age = 3.6 years, sd 1.7) participated in the study (test = 177). One child was excluded from the analysis because of a missing questionnaire and clinical data at baseline and follow-up. At baseline, test group children were older (test = 3.8 years, 95% CI 3.6-4.1;control = 3.3 years, 95% CI 3.1-3.6) and had higher caries experience (test dmft = 4.4, 95% CI 3.8-5.0;control dmft = 3.1, 95% CI 2.5-3.7), but there was no significant difference in COHRQoL or anxiety levels between the groups. At follow-up, parents in the delayed intervention reported worsening of COHRQoL (70% worsening of the family impact section of the ECOHIS and 37% worsening of the total ECOHIS scale), and there was an 8% reduction in child dental anxiety among the early treatment group.

CONCLUSIONS

The application of the ART/HT approaches was feasible, effective, and impacted positively on child oral health-related quality of life and child dental anxiety among Aboriginal children in remote communities. The model of care as tested in this study should be further developed for inclusion in main-stream service delivery programmes.

Parent perceptions of minimally invasive dental treatment of Australian Aboriginal pre-school children in rural and remote communities

INTRODUCTION

Aboriginal* children in rural and remote communities in Australia have a higher burden of dental decay and poorer access to dental services than their non-Aboriginal counterparts. In the Kimberley region of Western Australia (WA), Aboriginal children experience six times the rate of untreated dental decay of non-Aboriginal children. Access to dental care is challenged by the availability and appropriate delivery of services in remote locations. This study elicited the experiences and perceptions of parents and carers who participated in a project that tested the minimally invasive atraumatic restorative treatment and the Hall technique approaches (ART-HT) to manage early childhood dental caries among Australian Aboriginal preschool children.

METHODS

The core study design was a stepped-wedge, cluster-community-randomised controlled trial. Consenting communities in the Kimberley region of WA were randomised into early and delayed intervention groups. Children were clinically examined at study commencement; the early intervention group was offered dental treatment using the ART-HT approach, and the delayed group was advised to seek dental care from their usual service provider. At the 12-month follow-up, children in both groups were re-examined and offered care using the minimally invasive model of care, and parents and carers were invited to take part in focus group or one-to-one interviews. Semistructured interviews, guided by the yarning approach, were conducted with consenting parents and carers in community locations of convenience to participants. The same open-ended questions were asked of all participants, and the interviews were audio-recorded with permission and transcribed by an independent agency. Thematic analysis was undertaken, the transcripts were coded by NVivo software, and emergent themes were identified and developed.

RESULTS

One-to-one interviews were conducted with 29 parents and carers (10 from five test communities; 19 from eight control communities). Interview participants consisted of 3 males and 26 females. Following thematic analysis, three main themes (and subthemes) were identified: (1) access to care (barriers, service availability, impact on family due to lack of access); (2) experience of care (cultural safety, child-centred care, comprehensiveness of care); (3) community engagement (service information, engagement, oral health education). Structural and system factors as well as geography were identified as barriers by parents and carers in accessing timely and affordable dental care in culturally safe environments; parents and carers also identified the impacts from lack of access to care. They valued comprehensive care delivered within community, underpinned by child- and family-centred care. Of equal importance was the holistic approach adopted through the building of community engagement and trusting relationships.

CONCLUSION

A high level of satisfaction was reported by parents and carers with their experience of dental care for their children with the minimally invasive approach. Satisfaction was expressed around ease of accessing services delivered in a child- and family-centred manner, and that were well supported by appropriate engagement between service providers, communities and families. The findings from this study suggest a minimally invasive dental care model can be considered effective and culturally acceptable and should be considered in delivering oral health services for young children in rural and remote locations. * The term Aboriginal is inclusive of Aboriginal and Torres Strait Islander peoples.

Global Oral Health Policies and Guidelines: Using Silver Diamine Fluoride for Caries Control

Silver diamine fluoride (SDF) was developed in Japan in the 1960s. It is a clear solution containing silver and fluoride ions. Because of its anti-bacterial and remineralizing effect, silver diamine fluoride has been used in managing dental caries for decades worldwide. This paper aims to summarize and discuss the global policies, guidelines, and relevant information on utilizing SDF for caries management. SDF can be used for treating dental caries in most countries. However, it is not permitted to be used in mainland China. Several manufacturers, mainly in Australia, Brazil, India, Japan, and the United States, produce SDF at different concentrations that are commercially available around the world. The prices differ between contents and brands. Different government organizations and dental associations have developed guidelines for clinical use of SDF. Dental professionals can refer to the specific guidelines in their own countries or territories. Training for using SDF is part of undergraduate and/or postgraduate curriculums in almost all countries. However, real utilization of SDF of dentists, especially in the private sector, remains unclear in most places because little research has been conducted. There are at least two ongoing regional-wide large-scale oral health programs, using SDF as one of the components to manage dental caries in young children (one in Hong Kong and one in Mongolia). Because SDF treatment does not require caries removal, and it is simple, non-invasive, and inexpensive, SDF is a valuable strategy for caries management in young children, elderly people, and patients with special needs. In addition, to reduce the risk of bacteria or virus transmission in dental settings, using SDF as a non-aerosol producing procedure should be emphasized under the COVID-19 outbreak.

Cost-effectiveness analysis of atraumatic restorative treatment to manage early childhood caries: microsimulation modelling

BACKGROUND

This study assessed the cost-effectiveness of atraumatic restorative treatment and the Hall Technique approach (ART/HT) in managing dental caries in young children under the health provider perspective in order to explore a best-buy alternative to dental general anaesthesia (DGA).

METHODS

Sixty-five observations from a randomized controlled trial were used to construct 20 000 microsimulations representing individual-level clinical outcome and costs of the DGA and ART/HT. Outcome was percentage of successfully managed cases. Costs were reported in 2020 price. Three different scenarios with different assumptions of clinical success of the DGA and the ART/HT were analysed. Probabilistic sensitivity analysis was carried out.

RESULTS

The ART/HT successfully managed more cases at lower cost ($557) than the DGA when the system failure of the DGA was considered. Under per protocol analysis, participants in both arms were successfully managed, but the ART/HT costed $580 less than the DGA. Probabilistic sensitivity analysis confirmed the ART/HT was a dominant intervention.

CONCLUSIONS

The ART/HT approach was non-inferior in managing dental caries in young children but at lower costs than the DGA. The ART/HT could be a viable option in the provision of comprehensive dental care in locations with limited access to DGA and reduce hospital admission.

Minimally Invasive Dentistry: Parent/Carer Perspectives on Atraumatic Restorative Treatments and Dental General Anaesthesia to the Management of Early Childhood Caries

Introduction: Parents of children treated under dental general anaesthesia (DGA) have reported feelings of concern and anxiety. This study elicited the views of parents/carers (P/C) of children with early childhood caries (ECC) who participated in a randomised trial (core study) which tested the effectiveness of care under DGA or care using alternative minimally invasive Atraumatic Restorative Treatment and the Hall Technique approaches (ART/HT).

Methods: P/C of children treated using the ART/HT (test) approach or care under a DGA (control) were interviewed. Focus group semi-structured interviews with P/C were undertaken in community facilities. The transcripts were read and inductively coded into domains to identify emergent themes. The codes were entered into NVivo software to assist data management and were further refined into broad themes.

Results: Seven grouped interviews with 14 participants were conducted and one test participant provided a written response. Four groups with eight test participants; two groups with four control participants; and one combined group with one test and one control participant were interviewed. Five broad themes emerged after thematic analysis: (1) Impacts on the child and the family; (2) Child-/family-centred care; (3) Timeliness of care; (4) Affordable care; (5) Accessible care. Impacts were related to that of the effects of the disease, and of the care for the disease. Child-centred/family-centred care (CCC) was a source of appreciation by P/C of both groups when it was experienced. Frustration at the lack of timely care of their child's treatment needs, coupled with the perceived expensiveness of care and difficulties in physically getting to the location for a specialist consultation was expressed by P/Cs in the study.

Discussion: The use of the ART/HT enabled the establishment of a relationship between the clinical team and the child and P/C which was central to the delivery of CCC. P/Cs in the DGA arm of the study expressed dissatisfaction more often with the issues of timely care, cost of care and accessibility of care. P/C of both groups were equally satisfied with the treatment, where treatment had been received in a timely, child-centred manner.

Conclusion: The findings suggest that minimally invasive approaches which facilitated CCC are acceptable alternative options to the DGA and should be considered for the management of ECC.

Australian New Zealand Clinical Trials Registry: ACTRN12616001124426.

Developing an early childhood oral health impact-specific health-state classification system for a new preference-based instrument, the ECOHIS-4D

OBJECTIVES

Most of the paediatric quality-of-life instruments in oral health research are not preference-based measures, thus cannot be used in economic evaluations. The Early Childhood Oral Health Impact Scale (ECOHIS) is one such instrument which assesses oral health impact on children's quality of life among three- to five-year-olds. With increasing demands for more resource allocation in oral health care, there is a need for an outcome metric which can be used as the outcome in economic evaluations. The aim of this study was to develop a preference-based, health-state classification system from the existing ECOHIS instrument.

METHODS

The 13-item ECOHIS instrument was applied to the carers of 280 preschoolers who participated in a clinical trial in metropolitan Perth, Western Australia. Exploratory factor analysis was conducted to assess the dimensionality of the ECOHIS. Rasch analysis was used to eliminate and select items per determined dimensions and to reduce the number of response options for each item, because six levels were not amenable to valuation. The final classification system was determined through a combination of psychometric and expert advice.

RESULTS

Items loaded on to four dimensions with the factor analysis. Using Rasch analysis, three items were selected from the first dimension (child functional and psychological impact) and one item from the second dimension (child social interaction impact). None were selected from the third dimension (parental distress and family function impact) as it is not an appropriate proxy method of measuring the level of impact on a child. The final classification system has four dimensions with three levels in each, and so it has been named the ECOHIS-4D.

CONCLUSIONS

The ECOHIS-4D classification system is a new preference-based instrument derived from the existing ECOHIS instrument. Future valuation studies will develop a utility value set for the health states defined by this classification system, and this will guide economic evaluations related to oral health interventions.

Oral health of aboriginal people with kidney disease living in Central Australia

Background

Associations between kidney disease and periodontal disease are not well documented among Aboriginal people of Australia. The purpose of this investigation was to report and compare demographic, oral health, anthropometric and systemic health status of Aboriginal Australians with kidney disease and to compare against relevant Aboriginal Australians and Australian population estimates. This provides much needed evidence to inform dental health service provision policies for Aboriginal Australians with kidney disease.

Methods

Sample frequencies and means were assessed in adults represented in six datasets including: (1) 102 Aboriginal Australians with kidney disease residing in Central Australia who participated in a detailed oral health assessment; (2) 312 Aboriginal participants of the Northern Territory’s PerioCardio study; (3) weighted estimates from 4775 participants from Australia’s National Survey of Adult Oral Health (NSAOH); (4) Australian 2016 Census (all Australians); (5) National Health Survey 2017–2018 (all Australians) and; (6) Australian Health Survey: Biomedical Results for Chronic Diseases, 2011–2012 (all Australians). Oral health status was described by periodontal disease and experience of dental caries (tooth decay). Statistically significant differences were determined via non-overlapping 95% confidence intervals.

Results

Aboriginal Australians with kidney disease were significantly older, less likely to have a tertiary qualification or be employed compared with both PerioCardio study counterparts and NSAOH participants. Severe periodontitis was found in 54.3% of Aboriginal Australians with kidney disease, almost 20 times the 2.8% reported in NSAOH. A higher proportion of Aboriginal Australians with kidney disease had teeth with untreated caries and fewer dental restorations when compared to NSAOH participants. The extent of periodontal attachment loss and periodontal pocketing among Aboriginal Australians with kidney disease (51.0%, 21.4% respectively) was several magnitudes greater than PerioCardio study (22.0%, 12.3% respectively) and NSAOH (5.4%, 1.3% respectively) estimates.

Conclusions

Aboriginal Australians with kidney disease exhibited more indicators of poorer oral health than both the general Australian population and a general Aboriginal population from Australia’s Northern Territory. It is imperative that management of oral health among Aboriginal Australians with kidney disease be included as part of their ongoing medical care.

Lessons learned from a periodontal intervention to reduce progression of chronic kidney disease among Aboriginal Australians

Objective

Periodontal disease is associated with chronic kidney disease (CKD), with both conditions being highly prevalent among Australia’s Aboriginal population. This paper reflects on the lessons learned following implementation of a periodontal intervention in the Central Australian region of the Northern Territory among Aboriginal adults with CKD.

Results

Between Oct 2016 and May 2019, research staff recruited 102 eligible participants. This was far below the anticipated recruitment rate. The challenges faced, and lessons learned, were conceptualised into five specific domains. These included: (1) insufficient engagement with the Aboriginal community and Aboriginal community-controlled organisations; (2) an under-appreciation of the existing and competing patient commitments with respect to general health and wellbeing, and medical treatment to enable all study commitments; (3) most study staff employed from outside the region; (4) potential participants not having the required number of teeth; (5) invasive intervention that involved travel to, and time at, a dental clinic. A more feasible research model, which addresses the divergent needs of participants, communities and service partners is required. This type of approach, with sufficient time and resourcing to ensure ongoing engagement, partnership and collaboration in co-design throughout the conduct of research, challenges current models of competitive, national research funding.

Atraumatic Restorative Treatments in Australian Aboriginal Communities: A Cluster-randomized Trial

INTRODUCTION

The management of early childhood caries (ECC) is challenging.

OBJECTIVES

A model of care based on Atraumatic Restorative Treatment and the Hall Technique (ART-HT) to manage ECC was evaluated among remote Aboriginal communities in Australia.

METHODS

Aboriginal communities in the North-West of Western Australia were invited to participate and consenting communities were randomized into early or delayed intervention for the management of ECC. Children were examined at baseline and at the 11-mo follow-up. The early intervention group (test) was provided with the ART-based dental care at baseline while the delayed intervention group (control) was advised to seek care through the usual care options available within the community. At follow-up, both groups were examined by calibrated examiners, and were offered care using the ART-HT approach. Changes from baseline to follow-up in caries experience were tested using paired tests. Multivariate analysis after multiple imputation of missing data used generalised estimating equation (GEE) controlling for clustering within communities.

RESULTS

A total of 25 communities and 338 children (mean age = 3.6 y, SD 1.7) participated in the study (test = 177). At follow-up, 231 children were examined (68% retention, test = 125). At follow-up, children in the test group had more filled teeth (test filled teeth = 1.2, control filled teeth = 0.2, P < 0.001) and decreased levels of decayed teeth (mean test = 0.7 fewer teeth with decay, mean control = 1.0 more tooth with decay, P < 0.001). GEE analysis controlled for baseline caries experience, age, sex, and community water fluoride levels found increased rates of untreated decayed teeth (RR = 1.4, P = 0.02) and decreased rates of filled teeth (RR = 0.2, P < 0.001) at follow-up among the control group.

CONCLUSION

A model of care relying on the principles of minimally invasive atraumatic approaches enabled the delivery of effective dental services to young children (<6 y) in remote Aboriginal Australian communities resulting in increased levels of care and improved oral health.

KNOWLEDGE TRANSFER STATEMENT

This cluster-randomized trial tested a multi-component model of dental care to young children with ECC in remote Aboriginal communities in Australia. The intervention, based on the atraumatic approaches using minimally invasive techniques encompassing preventive care, Atraumatic Restorative Treatment and the Hall Technique (ART-HT), delivered more restorative care and reduced the incidence of caries. This model of care was more effective than available standard care and should be incorporated into mainstream service delivery programs.

Atraumatic restorative treatments improve child oral health-related quality of life: A noninferiority randomized controlled trial

OBJECTIVES

Management of dental caries under dental general anaesthesia (DGA) in young children improves their quality of life. A randomized controlled trial was undertaken to test the changes in oral health-related quality of life among children treated under a DGA or managed using the Atraumatic Restorative Treatment and Hall crown approaches (ARTs).

METHODS

Children scheduled for a DGA for the management of dental caries after assessment at the Oral Health Centre of Western Australia were invited to participate. Inclusion and exclusion criteria were applied. Child oral health-related quality of life (COHRQoL) was evaluated through the Early Childhood Oral Health Impact Scale (ECOHIS) and the child-specific Caries Impacts and Experiences Questionnaire for Children (CARIES-QC) at baseline and 12 months after consent. The changes in child oral health-related quality of life were analysed on an intention-to-treat basis. Paired t-test and Wilcoxon's matched-pairs rank test were used for within-group comparison and t-test, Mann-Whitney test, and test of proportions for between-group comparisons. Linear regression was used for multivariable analyses of the follow-up scores.

RESULTS

Sixty-five parents/carers agreed to participate and were randomized (Test = 32; Control = 33). Mean age = 4.7 years, SD 1.1; 51% male. At baseline, there were no statistically significant differences in age and sex between the groups; however, the ARTs group reported higher ECOHIS scores. At follow-up, both the ARTs and DGA groups had lower ECOHIS scores (20.7 vs 12.9 and 14.4 vs 13.3, respectively) and CARIES-QC scores (12.6 vs 7.1 and 9.9 vs 8.4, respectively). The within-group differences in the ARTs group were statistically significant while the differences in the DGA group were not, P < .01 and P > .05, respectively. In a linear regression of the follow-up scores, being in the DGA group increased the follow-up scores, but it was no longer statistically significant while baseline impact scores were significantly associated with greater follow-up scores for both the ECOHIS and the CARIES-QC, P < .01.

CONCLUSION

The child oral health-related quality life among children scheduled for dental general anaesthesia improved after receiving minimally invasive, atraumatic restorative treatments of dental caries.

Atraumatic restorative treatments reduce the need for dental general anaesthesia: a non-inferiority randomized, controlled trial

BACKGROUND

A dental general anaesthesia (DGA) is commonly undertaken for the management of dental caries in young children. A randomized-controlled trial was undertaken to test the feasibility of using the Atraumatic Restorative Treatment and Hall Technique approaches (ART/HT) to manage the dental treatment of children recommended for a DGA.

METHODS

Consenting children, recommended a DGA for caries management, at the Oral Health Centre of Western Australia were randomized. Test group children were treated using the ART/HT approach and the control group under a DGA. Children were examined after 12 months by two blinded, calibrated examiners. Analysis was on an intention to treat basis; between and within group comparisons were undertaken using appropriate paired and unpaired tests. Logistic regression was used to test restorative success, controlling for clustering of teeth.

RESULTS

Sixty-five children participated, (Test = 32; Control = 33). At study termination, 28 children (88%) in the ART/HT group and 20 children (61%) in the DGA group had been provided with care, P < 0.01. Crown restorations were protective of restorative failure in a multivariate logistic model (OR 0.05, P < 0.01).

CONCLUSION

Use of the ART/HT approach enabled timely dental treatment of young children recommended for a DGA, and should be among the treatment options considered.

Minimally Invasive Dentistry Based on Atraumatic Restorative Treatment to Manage Early Childhood Caries in Rural and Remote Aboriginal Communities: Protocol for a Randomized Controlled Trial

Background

The caries experience of Aboriginal children in Western Australia (WA) and elsewhere in Australia is more than twice that of non-Aboriginal children. Early childhood caries (caries among children <6 years) has a significant impact on the quality of life of children and their caregivers, and its management is demanding and commonly undertaken under general anesthesia. A randomized controlled trial using a minimally invasive dentistry approach based on Atraumatic Restorative Treatment (ART) in metropolitan Perth, WA, has demonstrated a significant reduction in the rate of referral to a dental specialist for dental care among children with early childhood caries, potentially reducing the need for treatment under general anesthesia. The tested approach was clinically successful and was without adverse effects on child dental anxiety. The model of ART-based primary care requires further testing and development if similar outcomes for Aboriginal children in remote and rural settings are to be achieved.

Objective

The study aims to develop, implement, and evaluate a remote primary care model to deliver effective primary dental services, encompassing treatment and preventive services, to Aboriginal preschool children (based on minimally invasive approaches including ART).

Methods

This is a two-arm parallel cluster randomized controlled study in which a test group will be provided with the intervention treatment at the start of the study and a control group will be provided with the intervention treatment 12 months after study commencement (delayed intervention). Participating communities, stratified by size of community (ie, number of children in the sample frame) and baseline caries experience, will be randomly assigned using a computer-generated block randomized list into immediate (test group) or delayed intervention (control group; provided with standard care). Informed consent will be obtained from all participants. Aboriginal research assistants will explain the study to the parents and assist the parents in completing the questionnaires. Participants in the randomized study will be examined at baseline and at 12 months follow-up by a calibrated examiner. Test group participants will subsequently be contacted and appropriate appointments coordinated for treatment. Control group participants will be provided with standard preventive care by the Aboriginal Health Workers and managed for treatment as per standard procedures.

Results

Community consultations have been undertaken and 26 communities have agreed to participate. Fieldwork is in progress to recruit study participants.

Conclusions

The significance of the study lies in its holistic approach to testing the model of care. Clinical evaluations as well as oral health‒related quality of life evaluations will be undertaken. Cost-effectiveness and cost-utility evaluations will assist in the development of policy options for oral health services for rural and remote communities. The elicitation of caregiver perspectives through focus group interviews will supplement the clinical, psychosocial, and cost-utility evaluations and provide a richer evaluation of the intervention.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12616001537448; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371735 (Archived by WebCite at http://www.webcitation.org/70UMxndFZ)

Registered Report Identifier

RR1-10.2196/10322

Service Use and Perceived Need among an Aboriginal Population in Western Australia

Limited information is available about dental service use, perceived need and perceived oral health status among Aboriginal populations in Western Australia. This study collected information from a convenience sample of people attending the opening ceremony of the 2014 National Aborigines and Islanders Day Observance Committee celebrations in Perth, Western Australia.

METHODS

People who visited the Dental Health Services display stall at the event completed a questionnaire on dental service use, perceived need and self-rated oral health domains.

RESULTS

Participants provided 145 usable questionnaires; 75% of the sample identified themselves as Aboriginal/Torres Strait Islander of whom 45% had a dental visit less than 12 months ago; 33% had a check-up visit and 25% rated their oral health as fair or poor.

CONCLUSIONS

More Aboriginal respondents reported lower frequency of service use and asymptomatic visiting compared with non-Aboriginal respondents.

Oral health of schoolchildren in Western Australia

BACKGROUND

The West Australian School Dental Service (SDS) provides free, statewide, primary dental care to schoolchildren aged 5-17 years. This study reports on an evaluation of the oral health of children examined during the 2014 calendar year.

METHODS

Children were sampled, based on their date of birth, and SDS clinicians collected the clinical information. Weighted mean values of caries experience were presented. Negative binomial regression modelling was undertaken to test for factors of significance in the rate of caries occurrence.

RESULTS

Data from children aged 5-15 years were used (girls = 4616, boys = 4900). Mean dmft (5-10-year-olds), 1.42 SE 0.03; mean DMFT (6-15-year-olds), 0.51 SE 0.01. Negative binomial regression model of permanent tooth caries found higher rates of caries in children who were from non-fluoridated areas (RR 2.1); Aboriginal (RR 2.4); had gingival inflammation (RR 1.5); lower ICSEA level (RR 1.4); and recalled at more than 24-month interval (RR 1.8).

CONCLUSIONS

The study highlighted poor dental health associated with living in non-fluoridated areas, Aboriginal identity, poor oral hygiene, lower socioeconomic level and having extended intervals between dental checkups. Timely assessments and preventive measures targeted at groups, including extending community water fluoridation, may assist in further improving the oral health of children in Western Australia.

Dental enamel defects, caries experience and oral health-related quality of life: a cohort study

BACKGROUND

The impact of enamel defects of the first permanent molars on caries experience and child oral health-related quality of life was evaluated in a cohort study.

METHODS

Children who participated in a study of enamel defects of the first permanent molars 8 years earlier were invited for a follow-up assessment. Consenting children completed the Child Perception Questionnaire and the faces Modified Child Dental Anxiety Scale, and were examined by two calibrated examiners. ANOVA, Kruskal-Wallis, negative binomial and logistic regression were used for data analyses.

RESULTS

One hundred and eleven children returned a completed questionnaire and 91 were clinically examined. Negative binomial regression found that oral health impacts were associated with gender (boys, risk ratio (RR) = 0.73, P = 0.03) and decayed, missing or filled permanent teeth (DMFT) (RR = 1.1, P = 0.04). The mean DMFT of children were sound (0.9, standard deviation (SD) = 1.4), diffuse defects (0.8, SD = 1.7), demarcated defects (1.5, SD = 1.4) and pit defects (1.3, SD = 2.3) (Kruskal-Wallis, P = 0.05). Logistic regression of first permanent molar caries found higher odds of caries experience with baseline primary tooth caries experience (odds ratio (OR) = 1.5, P = 0.01), the number of teeth affected by enamel defects (OR = 1.9, P = 0.05) and lower odds with the presence of diffuse enamel defects (OR = 0.1, P = 0.04).

CONCLUSIONS

The presence of diffuse enamel defects was associated with lower odds of caries experience.

Cost-effectiveness analysis of the atraumatic restorative treatment-based approach to managing early childhood caries

OBJECTIVE

Paediatric dental care under general anaesthesia among preschool children in Western Australia is increasing and costly. This study assessed cost-effectiveness of the atraumatic restorative treatment-based (ART-based) approach against the standard care (SC) approach to managing early childhood caries in a primary care setting based on a 1-year pragmatic randomized controlled trial.

METHODS

Cost-effectiveness analysis, from the service provider perspective, was conducted. Outcomes include number of referral to specialists and dental treatments. One-way and probabilistic sensitivity analyses were undertaken to test the robustness of the cost-effectiveness estimates.

RESULTS

Six children in the ART-based group and 62 children in the SC group (n = 127 each group) were referred for paediatric dental specialist care. Children in the ART-based group received more dental services than those allocated to the SC group (mean = 3.8, SD 2.0 and mean = 1.8, SD 1.8, respectively, Wilcoxon rank-sum test, P < 0.01). Total costs of the ART-based approach and the SC group were $137 860 and $178 217, respectively. Based on probabilistic sensitivity analysis, $654 was saved per referral to specialist avoided and $36 was saved per additional dental treatment. The probability that the ART-based approach is cost-saving was 63%. Specialist dental treatment fees had a big impact on the cost-effectiveness estimates.

CONCLUSION

The ART-based approach appears to be a worthwhile intervention because it resulted in fewer referred cases and enabled more treatments to be provided with cost-savings.

Restorative Outcomes of a Minimally Invasive Restorative Approach Based on Atraumatic Restorative Treatment to Manage Early Childhood Caries: A Randomised Controlled Trial

A pragmatic randomised controlled trial comparing a minimally invasive approach based on atraumatic restorative treatment (ART) procedures (test) was tested against the standard-care approach (control) to treat early childhood caries (ECC) in a primary-care setting in Perth, W.A., Australia. Parent/child dyads with ECC were allocated to the test or control group using stratified block randomisation. Children were examined at baseline and follow-up by two calibrated examiners blinded to group allocation status. Dental therapists trained in ART provided treatment to the test group and dentists treated the control group. Restoration quality was evaluated at follow-up using the ART criteria. Data were analysed on an intention-to-treat basis; test of proportions, Wilcoxon rank test and logistic regression, controlling for clustering of teeth, were used. Two hundred and fifty-four children were randomised (test = 127 and control = 127). There was no statistically significant difference in age, sex and baseline caries experience between the test and control groups. At follow-up (mean interval 11.4 months, SD 3.1), 220 children were examined (test = 115 and control = 105) and 597 teeth (test = 417 and control = 180) were evaluated for restoration quality, of which 16.8% (test) and 6.7% (control) were judged to have failed (required replacement; p < 0.01). Intention-to-treat, multiple logistic regression found multisurface restorations (OR = 10.4) had significantly higher odds of failure, while referral for specialist paediatric care had significantly lower odds of restoration failure (OR = 0.2). The ART-based approach enabled more children and teeth to be treated, and multisurface restoration and treatment in a primary-care setting had higher odds of restoration failure.

Periodontal disease and chronic kidney disease among Aboriginal adults; an RCT

BACKGROUND

This study will assess measures of vascular health and inflammation in Aboriginal Australian adults with chronic kidney disease (CKD), and determine if intensive periodontal intervention improves cardiovascular health, progression of renal disease and periodontal health over a 24-month follow-up.

METHODS

The study will be a randomised controlled trial. All participants will receive the periodontal intervention benefits, with the delayed intervention group receiving periodontal treatment 24 months following baseline. Inclusion criteria include being an Aboriginal Australian, having CKD (a. on dialysis; b. eGFR levels of < 60 mls/min/1.73 m(2) (CKD Stages 3 to 5); c. ACR ≥ 30 mg/mmol irrespective of eGFR (CKD Stages 1 and 2); d. diabetes plus albuminuria (ACR ≥ 3 mg/mmol) irrespective of eGFR), having moderate or severe periodontal disease, having at least 12 teeth, and living in Central Australia for the 2-year study duration. The intervention involves intensive removal of dental plaque biofilms by scaling, root-planing and removal of teeth that cannot be saved. The intervention will occur in three visits; baseline, 3-month and 6-month follow-up. The primary outcome will be changes in carotid intima-media thickness (cIMT). Secondary outcomes will include progression of CKD or death as a consequence of CKD/cardiovascular disease. Progression of CKD will be defined by time to the development of the first of: (1) new development of macroalbuminuria; (2) 30 % loss of baseline eGFR; (3) progression to end stage kidney disease defined by eGFR < 15 mLs/min/1.73 m(2); (4) progression to end stage kidney disease defined by commencement of renal replacement therapy. A sample size of 472 is necessary to detect a difference in cIMT of 0.026 mm (SD 0.09) at the significance criterion of 0.05 and a power of 0.80. Allowing for 20 % attrition, 592 participants are necessary at baseline, rounded to 600 for convenience.

DISCUSSION

This will be the first RCT evaluating the effect of periodontal therapy on progression of CKD and cardiovascular disease among Aboriginal patients with CKD. Demonstration of a significant attenuation of CKD progression and cardiovascular disease has the potential to inform clinicians of an important, new and widely available strategy for reducing CKD progression and cardiovascular disease for Australia's most disadvantaged population.

TRIAL REGISTRATION

This trial is registered with the Australian New Zealand Clinical Trial Registry ANZCTR12614001183673.

Child oral health-related quality of life (COHQoL), enamel defects of the first permanent molars and caries experience among children in Western Australia

Published reports suggest that children with enamel defects, especially where enamel is missing or breaking down, experience considerable discomfort and are generally more fearful of dental treatment. However, children's oral health-related quality of life in relation to enamel defects has not been reported. The aim of this study was to examine the association between oral health-related quality of life among children (COHQoL) with enamel defects of the first permanent molars and deciduous caries experience.

METHODS

Children attending pre-primary schools in metropolitan Perth, Western Australia, were recruited and classified for enamel defects using the modified Developmental Defects of Enamel index. Caries experience of deciduous molars and canines was also recorded. Parents completed a child oral health-related quality of life questionnaire. Data were analysed using Kruskal-Wallis, Spearman's rank correlation, chi-square, multiple linear regression and ordered logistic regression to test the factors for their influence on the COHQoL.

RESULTS

From the 550 children assessed (mean age 7.2 years) 522 COHQoL questionnaires were returned. Mean COHQoL score was 8.9 (sd 8.8). Bivariate tests showed no association of COHQoL with enamel defect status of the first permanent molars. COHQoL was associated with dmft (mean dmft 1.96, sd 2.62). Higher caries experience children had poorer reported oral health-related quality of life.

CONCLUSION

The presence of enamel defects in the first permanent molars did not affect the children's oral health-related quality of life.

Brief oral health promotion intervention among parents of young children to reduce early childhood dental decay

BACKGROUND

Severe untreated dental decay affects a child's growth, body weight, quality of life as well as cognitive development, and the effects extend beyond the child to the family, the community and the health care system. Early health behavioural factors, including dietary practices and eating patterns, can play a major role in the initiation and development of oral diseases, particularly dental caries. The parent/caregiver, usually the mother, has a critical role in the adoption of protective health care behaviours and parental feeding practices strongly influence children's eating behaviours. This study will test if an early oral health promotion intervention through the use of brief motivational interviewing (MI) and anticipatory guidance (AG) approaches can reduce the incidence of early childhood dental decay and obesity.

METHODS

The study will be a randomised controlled study with parents and their new-born child/ren who are seen at 6-12 weeks of age by a child/community health nurse. Consenting parents will complete a questionnaire on oral health knowledge, behaviours, self-efficacy, oral health fatalism, parenting stress, prenatal and peri-natal health and socio-demographic factors at study commencement and at 12 and 36 months. Each child-parent pair will be allocated to an intervention or a standard care group, using a computer-generated random blocks. The standard group will be managed through the standard early oral health screening program; "lift the lip". The intervention group will be provided with tailored oral health counselling by oral health consultants trained in MI and AG.Participating children will be examined at 24, and 36 months for the occurrence of dental decay and have their height and weight recorded. Dietary information obtained from a food frequency chart will be used to determine food and dietary patterns. Data analysis will use intention to treat and per protocol analysis and will use tests of independent proportions and means. Multivariate statistical tests will also be used to take account of socio-economic and demographic factors in addition to parental knowledge, behaviour, self-efficacy, and parent/child stress.

DISCUSSION

The study will test the effects of an oral health promotion intervention to affect oral health and general health and have the potential to demonstrate the "common risk factor" approach to health promotion.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: http://ACTRN12611000997954.

Risk factors in the occurrence of enamel defects of the first permanent molars among schoolchildren in Western Australia

BACKGROUND

The prevalence of enamel defects in the first permanent molars among children in Western Australia is higher than that reported for some European countries. The cause(s) of the defects, both white diffuse opacities and demarcated opacities, with or without hypoplasia, continue to be investigated. A recent review identified childhood illnesses and exposure to environmental toxins as putative causal factors for the occurrence of demarcated opacities (usually in association with hypoplasia). Diffuse opacities have been reported to be associated with exposure to the antibiotic amoxicillin, adjusted for otitis media and fluoride. The aim of this study was to examine the possible risk factors for enamel defects in the first permanent molars among children in Western Australia.

METHODS

Children attending pre-primary schools (1999-2000 year of birth) in metropolitan Perth, Western Australia, were invited to participate in the study. In 2005, before the child's first permanent molars had erupted, parents completed a questionnaire about the mother's health during pregnancy, and their child's health for the first 3 years. The first permanent molars were classified for type and extent of enamel defects using the modified Developmental Defects of Enamel (DDE) index. Caries experience and the presence of enamel defects on the deciduous molars and canines were also recorded using the WHO criteria. Bivariate, multinomial logistic and logistic regression analyses were used to test the factors for their influence on the occurrence of the enamel defects.

RESULTS

Five hundred and fifty children were examined for the occurrence of enamel defects on the first permanent molars. Multinomial logistic regression indicated that neonatal health conditions, prematurity (OR 2.75) and other health conditions (OR 2.40) were significant risk factors for the occurrence of diffuse enamel defects. Infection during the neonatal period was a strong risk factor for the occurrence of demarcated enamel defects (OR 6.88). Increased deciduous tooth caries experience increased the risk of demarcated enamel defects by 10% (OR 1.10) and living further from a heavy industrial area increased the risk of diffuse enamel defects nearly twofold (OR 1.93).

CONCLUSIONS

Neonatal health factors were found to be important risk factors for the occurrence of enamel defects in first permanent molars. The effects of residential location and the association between deciduous tooth caries experience and enamel defects require further investigations.

An unusual healing of a replanted permanent lateral incisor

BACKGROUND

Continued development and healing of an immature permanent tooth root was reported to have occurred. The continued viability of Hertwig's root sheath was thought to be necessary and responsible. Continued development of a tooth root separate from the body of the tooth was reported, but the initiation and development associated with a replanted tooth was not observed.

METHODS

A 9-year-old boy sustained an avulsion injury to his upper right lateral incisor. The tooth was replanted within 5-10 minutes of the incident and was splinted approximately 30 minutes after the injury, and then monitored for 2.25 years.

RESULTS

The periodontal tissues healed well. Root development was arrested with calcific deposit evident in the pulp canal. A radio-opaque structure, apical to the tooth root, was seen to develop on the radiograph 11 weeks after the initial trauma. The opaque mass continued to develop over the next two years of observation.

CONCLUSIONS

Immature permanent tooth roots show remarkable reparative powers. Clinicians need to be vigilant and close continued monitoring of traumatized immature teeth is recommended.

Enamel hypoplasia of the primary dentition in a 4-year-old with intestinal lymphangiectasia

Intestinal lymphangiectasia (IL) is a rare disorder, and its incidence and prevalence is unknown for either Australia or world-wide. It is characterized by diarrhoea, mild steatorrhoea, oedema, enteric loss of protein (protein-losing enteropathy) and abnormal dilated lymphatic channels in the small intestine. Whilst oedema and diarrhoea are the predominant clinical features, other observed features include hypoalbuminemia, hypogammaglobulinemia, trace metal deficiency, hypocalcemia and chylous pleural effusions. While medical presentation of the condition has been reported widely, few descriptions of oral findings have been published. A search of Medline found two reports of dental findings in the permanent dentition in patients with IL. To date, there have been no reports on dental findings in the primary dentition. The primary dentition of a 4-year-old boy with IL had teeth with enamel defects which reflected the timing of enamel development and the period in which the disease was active. The present report highlights the need for early involvement of the dental team in the dental management of children with IL.

Cost minimisation analysis of two occlusal caries preventive programmes

OBJECTIVE

Fissure sealants have been recommended for the prevention of pit and fissure caries since the 1970s. Few comparative studies have examined the cost-effectiveness of these procedures. This study reports on the cost minimisation analysis conducted as part of a field trial which compared the caries preventive effects of a programme comprising selective fissure sealing and application of topical fluorides on first permanent molars (control) with a programme of professional cleaning and oral health education (test).

DESIGN

The carious outcomes from the field trial were used to assign probability values to a hypothetical cohort of 100 children provided with the test or the control treatment. Incremental cost-effectiveness ratios were calculated using a 5% discount rate. Sensitivity analyses were conducted to test the sensitivity of the findings to the discount rate and labour costs.

RESULTS

An incremental cost-effectiveness ratio of a $40/child/year after two years for the test programme was found.

CONCLUSION

The findings suggest that the test programme comprising professional cleaning and oral health education should not be adopted on economic grounds. A longer period, of observation may be necessary before definitive conclusions regarding the cost-effectiveness of the preventive programmes can be made.

Oral hygiene in the control of occlusal caries

Occlusal pit and fissure caries accounts for a high proportion of the total caries burden among children. Studies from Denmark suggested that oral hygiene measures may be effective in the control of occlusal caries in permanent teeth. This study reports on the findings after 24 months of a controlled field trial comparing the caries-preventive effects of a professional tooth-cleaning and dental health education programme (test) with a standard preventive programme (control), comprising selective fissure sealing and application of topical fluorides. School Dental Service clinics of the Health Department of Western Australia, in Perth, were assigned to four test or four control clinics. Schoolchildren, mean age 6 years, with sound newly erupted first permanent molars were included in the study (207 test, 197 control). After 24 months, 179 test and 156 control children were examined by a calibrated examiner who was 'blind' to the test or control status of the child. Thirty-two test and 31 control children developed occlusal caries on the first permanent molars; the estimated risk ratio was 0.90 (95% CI 0.58-1.41). Children in both groups had an average DMFT score of 0.30. The 24-month results suggest that the two preventive programmes did not differ with respect to the control of occlusal caries in newly erupted molars.

Control of occlusal caries in the first permanent molars by oral hygiene

Caries of the pits and fissures of permanent teeth continues to be a problem for children, newly erupted permanent molars being particularly at risk. Oral hygiene measures have been shown to be able to reduce the incidence of caries. The aim of this study was to compare the caries-preventive effects on newly erupted first permanent molars of a professional tooth cleaning and oral health education program (test) with a standard preventive program (control), comprising selective fissure sealing and application of topical fluorides. School Dental Service clinics of the Health Department of Western Australia, in Perth, were assigned to four test or four control clinics. Schoolchildren, mean age 6.3 +/- 0.3 (s) years with sound, newly erupted first permanent molars were included in the study (207 test, 197 control). After 12 months, 186 test and 163 control children were examined by an examiner who was 'blind' to the test or control status of the children. Caries of the first permanent molars developed in 34 test and 35 control children; the estimated risk ratio was 0.86 (95% CI 0.56, 1.30). Children in the test group had an average DFT score of 0.26 +/- 0.62 compared with 0.29 +/- 0.64 DFT in the control group (t-test, P = 0.67). The 12-month results suggest that there was no statistically significant difference between the caries-preventive effects of a professional tooth cleaning and oral health education program and a program based on selective fissure sealing and application of topical fluorides.