Improving oral healthcare in Scotland with special reference to sustainability and caries prevention

Brett Duane Improving oral healthcare in Scotland with special reference to sustainability and caries prevention University of Turku, Faculty of Medicine, Institute of Dentistry, Community Dentistry, Finnish Doctoral Program in Oral Sciences (FINDOS-Turku), Turku, Finland Annales Universitatis Turkuensis, Sarja- Ser. D, Medica-Odontologica. Painosalama Oy, Turku, Finland, 2015. Dentistry must provide sustainable, evidence-based, and prevention-focused care. In Scotland oral health prevention is delivered through the Childsmile programme, with an increasing use of high concentration fluoride toothpaste (HCFT). Compared with other countries there is little knowledge of xylitol prevention. The UK government has set strict carbon emission limits with which all national health services (NHS) must comply. The purpose of these studies was firstly to describe the Scottish national oral health prevention programme Childsmile (CS), to determine if the additional maternal use of xylitol (CS+X) was more effective at affecting the early colonisation of mutans streptococci (MS) than this programme alone; secondly to analyse trends in the prescribing and management of HCFT by dentists; and thirdly to analyse data from a dental service in order to improve its sustainability. In all, 182 mother/child pairs were selected on the basis of high maternal MS levels. Motherswere randomly allocated to a CS or CS+X group, with both groups receiving Childsmile. Theintervention group consumed xylitol three times a day, from when the child was 3 months until 24 months. Children were examined at age two to assess MS levels. In order to understand patterns of HCFT prescribing, a retrospective secondary data analysis of routine prescribing data for the years 2006-2012 was performed. To understand the sustainability of dental services, carbon accounting combined a top-down approach and a process analysis approach, followed by the use of Pollard’s decision model (used in other healthcare areas) to analyse and support sustainable service reconfiguration. Of the CS children, 17% were colonised with MS, compared with 5% of the CS+X group. This difference was not statistically significant (P=0.1744). The cost of HCFT prescribing increased fourteen-fold over five years, with 4% of dentists prescribing 70% of the total product. Travel (45%), procurement (36%) and building energy (18%) all contributed to the 1800 tonnes of carbon emissions produced by the service, around 4% of total NHS emissions. Using the analytical model, clinic utilisation rates improved by 56% and patient travel halved significantly reducing carbon emissions. It can be concluded that the Childsmile programme was effective in reducing the risk for MS transmission. HCFT is increasing in Scotland and needs to be managed. Dentistry has similar carbon emissions proportionally as the overall NHS, and the use of an analytic tool can be useful in helping identify these emissions. Key words: Sustainability, carbon emissions, xylitol, mutans streptococci, fluoride toothpaste, caries prevention.Brett Duane Suuterveyden edistäminen kestävän kehityksen ja kariesprevention kannalta Turun yliopisto, Lääketieteellinen tiedekunta, Hammaslääketieteen laitos, Sosiaalihammaslää- ketiede. Suun terveystieteiden tohtoriohjelma (FINDOS-Turku), Turku, Suomi Annales Universitatis Turkuensis, Sarja- Ser. D, Medica-Odontologica. Painosalama Oy, Turku, Finland, 2015. Hammaslääketieteen pitää tuottaa kestävää sekä näyttöön ja ennaltaehkäisyyn perustuvaa hoitoa. Skotlannissa suuterveyden ennaltaehkäisyä hoidetaan Childsmile-ohjelmalla, jossa hyödynnetään yhä enemmän korkeapitoisia fluorihammastahnoja (HCFT). Verrattuna muihin maihin Skotlannissa tiedetään hyvin vähän ksylitolipreventiosta. Englannin hallitus on asettanut tiukat päästörajoitukset, joita kaikkien valtakunnallisten terveydenhuoltopalvelujen (NHS) on noudatettava. Tutkimuksen tarkoituksena oli 1) kuvailla Skotlannin suuterveyden ennaltaehkäisyohjelmaa Childsmilea (CS) ja selvittää vähentäisikö äitien käyttämä ksylitoli (CS+X) tehokkaammin lasten varhaista mutans streptokokki (MS) -kolonisaatiota verrattuna perusohjelmaan, 2) tutkia HCFT-tuotteiden reseptimääräyksiä ja käyttöä, 3) sekä suorittaa todennäköisyyslaskelmia hammaslääkärien vastaanotoilta saaduista tiedoista niiden kestävän kehityksen parantamiseksi. Satakahdeksankymmentäkaksi äiti-lapsi-paria valittiin tutkimukseen korkeiden MS-tasojen perusteella. Äidit satunnaistettiin CS- ja CS+X-ryhmiin, ja kumpikin ryhmä osallistui Childsmile-ohjelmaan. CS+X-ryhmä käytti ksylitolia kolme kertaa päivässä lapsen ollessa 3–24 kk. Lapset tutkittiin kahden vuoden iässä MS-tasojen määrittämiseksi. Korkeapitoisten fluorihammastahnojen reseptikäytäntöjen tutkimiseksi analysoitiin vuosina 2006–2012 vallinneita käytäntöjä. Hammaslääkärivastaanottojen kestävän kehityksen arvioimiseksi hiilikirjanpidossa käytettiin ylhäältä alaspäin- ja prosessianalyysi-lähestymistapojen yhdistelmää, ja sovellettiin lopuksi Pollardin mallia (käytössä muilla terveyspalvelun alueilla) kestävän palvelun uudelleenjärjestelyn analysoimiseksi ja tukemiseksi. Vain 17 % CS-ryhmän lapsista oli kolonisoitunut mutans streptokokeilla, ja vastaava luku CS+X-ryhmässä oli jopa 5 %. Ero ei kuitenkaan ollut tilastollisesti merkitsevä (P=0.1744). Viidessä vuodessa korkeapitoisten reseptihammastahnojen kustannukset 14-kertaistuivat, ja 4 % hammaslääkäreistä kirjoitti 70 % resepteistä. Matkat (45 %), hankinnat (36 %) ja rakennusten lämmityskustannukset (18 %) tuottivat vastaanotoille yhteensä 1800 tonnin hiilipäästöt, 4 % NHS:n kokonaispäästöistä. Käytettäessä analyysimallia vastaanottojen käyttöaste parani 56 %:lla ja potilaiden matkakustannukset puolittuivat, mikä vähensi hiilipäästöjä merkitsevästi. Päätelmänä voidaan sanoa, että Childsmile-ohjelma tehokkaasti vähensi MS-transmissiota. Korkeapitoisten fluorihammastahnojen määrääminen on lisääntynyt Skotlannissa, mikä vaatii sääntelyä. Hammaslääkärien hiilipäästöt ovat samaa luokkaa kuin NHS:llä yleensä ja analyysi- malli voi olla käyttökelpoinen päästöjen vähentämisessä. Avainsanat: Ksylitoli, mutans streptokokit, fluorihammastahna, kariespreventio, kestävä kehitys, hiilipäästöt.Siirretty Doriast

The environmental impact of community caries prevention - part 1: fluoride varnish application

BACKGROUND: Healthcare is a significant contributor to climate change and planetary health. Prevention of oral disease, such as caries, is an important part of any mechanism to improve sustainability. Caries prevention includes community schemes such as water fluoridation, toothbrushing, or fluoride varnish (FV) application. The aim of this study was to quantify the environmental impact of FV application. MATERIALS AND METHODS: A comparative life cycle assessment (LCA) was conducted to quantify the environmental impact of a five-year-old child receiving two FV applications in a one-year period in schools and in dental practice. RESULTS: FV application in dental practice during an existing appointment had the lowest environmental impact in all 16 categories, followed by FV application in schools. FV application at a separate dental practice appointment had the highest impact in all categories, with a majority of the impact resulting from the patient travel into dental practice. DISCUSSION: FV application while a child is already attending dental practice (for example, at routine recall) is the most sustainable way to deliver FV. School FV programmes are an alternative, equitable way to reach all children who may not access routine care in dental practice

The environmental impact of community caries prevention - part 2: toothbrushing programmes

Introduction Community-level caries prevention programmes includes supervised toothbrushing in schools and the provision of toothbrushes and toothpaste. The environmental impact of these interventions is an important factor to consider when commissioning these services.Materials and methods A comparative life cycle assessment (LCA) was conducted to quantify the environmental impact of a five-year-old child receiving one of two toothbrushing programmes over a one-year period; supervised toothbrushing in school, or the provision of toothbrushes and toothpaste.Results Supervised toothbrushing had a lower environmental impact than provision of toothbrushes and toothpaste in all 16 impact categories measured. The water use needed for children to brush their teeth was the greatest contributing factor to the provision of toothbrushes and toothpaste, accounting for an average of 48.65% of the impact results.Discussion All community-level caries prevention programmes have an associated environmental cost. LCA is one way to quantify the environmental impact of healthcare services and can be used along with cost and clinical effectives data to inform public healthcare policy. Organisations responsible for these programmes could use the results of this study to consider ways to reduce the environmental impact of their services

An environmental impact study of inter-dental cleaning aids

AIM: The aim of this study was to compare the environmental footprint of eight interdental cleaning aids. MATERIALS AND METHODS: A comparative LCA was conducted based on an individual person using interdental cleaning aids every day for 5 years. The primary outcome was a life cycle impact assessment. This comprised of 16 discrete measures of environmental sustainability (known as impact categories), for example greenhouse gas emissions (measured in kg CO2e), ozone layer depletion (measured in kg CFCe), and water use (measured in m3 ). Secondary outcomes included normalised data, disability adjusted life years, and contribution analysis. RESULTS: Interdental cleaning using floss picks had the largest environmental footprint in 13 out of 16 impact categories. Depending on the environmental impact category measured, the smallest environmental footprint came from daily interdental cleaning with either bamboo interdental brushes (5 impact categories, including carbon footprint), replaceable-head interdental brushes (4 impact categories), regular floss (3 impact categories), sponge floss (3 impact categories) and bamboo floss (1 impact category). CONCLUSION: Daily cleaning with interdental cleaning aids has an environmental footprint that varies depending on the product used. Clinicians should consider environmental impact alongside clinical need and cost when recommending interdental cleaning aids to patients

Hand hygiene with hand sanitizer versus handwashing: what are the planetary health consequences?

In order to reduce the transmission of pathogens, and COVID-19, WHO and NHS England recommend hand washing (HW) and/or the use of hand sanitizer (HS). The planetary health consequences of these different methods of hand hygiene have not been quantified. A comparative life cycle assessment (LCA) was carried out to compare the environmental impact of the UK population practising increased levels of hand hygiene during the COVID-19 pandemic for 1 year. Washing hands with soap and water was compared to using hand sanitizer (both ethanol and isopropanol based sanitizers were studied). The isopropanol-based HS had the lowest environmental impact in 14 out of the 16 impact categories used in this study. For climate change, hand hygiene using isopropanol HS produced the equivalent of 1060 million kg CO2, compared to 1460 million for ethanol HS, 2300 million for bar soap HW, and 4240 million for liquid soap HW. For both the ethanol and isopropanol HS, the active ingredient was the greatest overall contributing factor to the environmental impact (83.24% and 68.68% respectively). For HW with liquid soap and bar soap, there were additional contributing factors other than the soap itself: for example tap water use (28.12% and 48.68% respectively) and the laundering of a hand towel to dry the hands (10.17% and 17.92% respectively). All forms of hand hygiene have an environmental cost, and this needs to be weighed up against the health benefits of preventing disease transmission. When comparing hand sanitizers to handwashing with soap and water, this study found that using isopropanol based hand sanitizer is better for planetary health. However, no method of hand hygiene was ideal; isopropanol had a greater fossil fuel resource use than ethanol based hand sanitizer. More research is needed to find hand hygiene sources which do not diminish planetary health, and environmental impact is a consideration for public health campaigns around hand hygiene

Evaluation of Infrasound and Strobe Lights to Elicit Avoidance Behavior in Juvenile Salmon and Char.

Experimental tests were conducted using hatchery reared and wild juvenile chinook salmon Oncorhynchus tshawytscha, eastern brook trout Salvelinus fontinalis, and rainbow trout O. mykiss to determine specific behavior responses to infrasound (<20 Hz) and flashing strobe lights. Caged fish were acclimated in a static test tank and their behavior was recorded using low light cameras. Species specific behavior was characterized by measuring movements of the fish within the cage as well as observing startle and habituation responses. Wild chinook salmon (40-45 mm) and hatchery reared chinook salmon (45-50mm) exhibited avoidance responses when initially exposed to a 10 Hz volume displacement source. Rainbow and eastern brook trout (25-100 mm) did not respond with avoidance or other behaviors to infrasound. Habituation to the infrasound source was evident for chinook salmon during repeated exposures. Wild and hatchery chinook displayed a higher proportion of movement during the initial exposures to infrasound when the acclimation period in the test tank was 2-3 h as compared to a 12-15 h acclimation period. A flashing strobe light produced higher and more consistent movement rates in wild chinook (60% of the tests); hatchery reared chinook salmon (50%) and rainbow trout (80%). No measurable movement or other responses was observed for eastern brook trout. Little if any habituation was observed during repeated exposures to strobe lights. Results from this study indicate that consistent repeatable responses can be elicited from some fish using high intensity strobe lights under a controlled laboratory testing. The specific behaviors observed in these experiments might be used to predict how fish might react to low frequency sound and strobe lights in a screening facility. Because sub-yearling salmonids and resident species are susceptible from becoming entrained at water diversion structures we conducted tests in conjunction with our evaluation of juvenile fish screening facilities. This is the reason our tests focused on fry life stages

PA-GOSUB: a searchable database of model organism protein sequences with their predicted Gene Ontology molecular function and subcellular localization

PA-GOSUB (Proteome Analyst: Gene Ontology Molecular Function and Subcellular Localization) is a publicly available, web-based, searchable and downloadable database that contains the sequences, predicted GO molecular functions and predicted subcellular localizations of more than 107 000 proteins from 10 model organisms (and growing), covering the major kingdoms and phyla for which annotated proteomes exist (http://www.cs.ualberta.ca/~bioinfo/PA/GOSUB). The PA-GOSUB database effectively expands the coverage of subcellular localization and GO function annotations by a significant factor (already over five for subcellular localization, compared with Swiss-Prot v42.7), and more model organisms are being added to PA-GOSUB as their sequenced proteomes become available. PA-GOSUB can be used in three main ways. First, a researcher can browse the pre-computed PA-GOSUB annotations on a per-organism and per-protein basis using annotation-based and text-based filters. Second, a user can perform BLAST searches against the PA-GOSUB database and use the annotations from the homologs as simple predictors for the new sequences. Third, the whole of PA-GOSUB can be downloaded in either FASTA or comma-separated values (CSV) formats

Unprecedented generation of 3D heterostructures by mechanochemical disassembly and re-ordering of incommensurate metal chalcogenides

Three-dimensional heterostructures are usually created either by assembling two-dimensional building blocks into hierarchical architectures or using stepwise chemical processes that sequentially deposit individual monolayers. Both approaches suffer from a number of issues, including lack of suitable precursors, limited reproducibility, and poor scalability of the preparation protocols. Therefore, development of alternative methods that enable preparation of heterostructured materials is desired. We create heterostructures with incommensurate arrangements of well-defined building blocks using a synthetic approach that comprises mechanical disassembly and simultaneous reordering of layered transition-metal dichalcogenides, MX2, and non-layered monochalcogenides, REX, where M = Ta, Nb, RE = Sm, La, and X = S, Se. We show that the discovered solid-state processes are rooted in stochastic mechanochemical transformations directed by electronic interaction between chemically and structurally dissimilar solids toward atomic-scale ordering, and offer an alternative to conventional heterostructuring. Details of composition–structure–properties relationships in the studied materials are also highlighted