New non-invasive treatments for the control and treatment of early childhood caries
Oral health is essential to general health and significantly influences the development of children. Dental caries has a high economic and social impact due both to the costs associated with its treatment as well as the societal cost of days lost in school by children, in the work by their parents and the sequels that remain throughout life. Every year the world’s economies lose more than 442 billion USD because of oral diseases. Preschool children with caries have higher hospitalisation costs, poorer school attendance, physical development, and their parents lose more work days.
Two out of three young people in Latvia currently have active caries lesions, which can no longer be prevented. There are generations of Latvians whose only experience of dentists has been the extraction or restoration of their teeth. This traditional operative treatment of carious lesions often fail. This is especially true when tooth restoration is performed at an early age, as usually results in premature tooth extraction.
Dentistry is moving from a surgical to a minimally invasive approach, as traditional treatments have shown to be ineffective, specially against early childhood caries (ECC). Less invasive caries treatment strategies have been proposed that would have the advantage of lowering the costs of care as well as decreasing the number of tooth extractions. These include fluoride varnishes and silver diamine fluoride (SDF) applications. Fluoride applications have been shown to be effective in decreasing the incidence of early childhood caries while SDF has been shown to be effective in arresting the progression of cavitated lesions. However, a usual adverse effect of SDF is that it stains the teeth black. New formulations have appeared that replace silver with copper (Tiefenfluorid), to avoid this. At this moment, the effectiveness of Tiefenfluorid to arrest carious lesions in permanent teeth is proven, but there are no studies in deciduous dentition, or clinical studies comparing the effectiveness of all those non-invasive treatments.
We aim to improve the oral health of pre-schoolers through a cost-effective, non-invasive and painless approach in order to increase the probability that Latvian children develop in a healthy manner and can realize their full potential. Based on acquired results new clinical guidelines with evidence-based treatment protocols will be introduced for the treatment of ECC and subsequent new pharmaceutical products could be developed.
Activities in the project
- Project result dissemination
In order to inform the public about the current issues of the project, information about the results of the research has been disseminated in various ways.
In the journal Zobārstniecības raksti, a popular scientific article titled “Noninvasive and minimally invasive caries treatment methods and their role in COVID-19 pandemic circumstances” ("Neinvazīvas un minimāli invazīvas kariesa ārstēšanas metodes un to loma COVID-19 pandēmijas apstākļos") was published in the printed version of the journal. https://lza-zobi.lv/lv/par-asociaciju/zurnals-zobarstniecibas-raksti/1-nr-2021
An article (in Latvian) about the treatment methods used in the clinical trial was published in Delfi.lv https://www.delfi.lv/campus/raksti/vai-speciala-laka-aizstas-piena-zobu-labosanu?id=52743333
Participation in the TV programme Pārtikas revidents, talking about caries problem in Latvia, reasons and solutions. https://replay.lsm.lv/lv/ieraksts/ltv/207904/partikas-revidents
Participation in the virtual event of the European Scientists' Night 2021 with a poster presentation. https://drive.google.com/file/d/1hdSkCrXfbs-32n0vk_c48Cc3PIWEv56h/view?usp=sharing
In relation to the topic of the study and the need for measures to reduce the spread of COVID infection in the dental sector, clinical guidelines have been prepared and submitted to the Latvian Dental Association. See the guidelines
Interview with Ilze Maldupa in the cycle 'Return to RSU'. The postdoctoral project has been one of the motivators for continuing a researcher's career in Latvia.
- Achievements in the first half of the year
Due to the international situation created by COVID-19, the planned mobility activities to the University of Michigan in the USA and to the University of Dundee in the UK were cancelled, however, these visits were replaced by online webinars, where we improved the research protocol together with prof. Carlos Gonzalez-Cabezas and Margherita Fontana from the University of Michigan and with Nicola Innes from the University of Dundee and Cardiff University in the UK.
All the necessary research instruments for the clinical trial during the project have been prepared - an informative letter with an informed consent form, visual analogue scale (VAS) to assess patient satisfaction after treatment, form to register any emergency treatment performed in the time of the study, examination form to be used at the beginning of the study – includes questions about risk factors and clinical examination form; examination form to be used at the follow-up visit – includes Likert scale questions about parental acceptance of the performed treatment, questions about risk factors, VAS to evaluate patient satisfaction with the treatment performed and clinical examination forms.
Guidelines have been developed for all those involved in the study - reception staff, dentists and assistants from two different working groups. Several instruction sessions have been held - in clinical photography, reception staff instructive session, guidelines for dentists and assistants.
Information about the project has been promoted in various ways. Public activity event was organized - interview for the radio podcast "Known in the Unknown". https://replay.lsm.lv/lv/ieraksts/lr/128224/mutes-dobuma-ve…
A popular scientific article has been written to update the topic of caries and to inform the public, including medical staff, published in Doctus journal, August 2020. https://www.doctus.lv/2020/8/augusta-numura-saturs-8
Participation in seminars for residents on the aetiology of caries, non-invasive and minimally invasive caries treatment methods, thus promoting understanding of these new methods among professionals.
The knowledge of Latvian dentists about these methods and the desire for professional development courses for non-invasive and minimally invasive methods of caries treatment are identified.
A website and social networking pages have been created with the public aim of promoting Latvian children's dental health, placing information on research activities that the public should be aware of, as well as other research united by the common goal of improving children's oral health.
- The clinical trial phase has been initiated
By December 1, 2020, 305 patients were registered in the study; currently 140 patients were included (33% of those required in the study). The children included in the study have received a varnish application according to the protocols of the respective treatment group.
During the consultations, we are trying to find reasons for damaged teeth together with parents. We talk about sugar's role in caries development and about the most important dental hygiene habits.
The public interest about the study is huge; after opening and announcing the registration on social networks, 200 parents registered within three days. The recruitment of patients will continue until we reach 420 children (at least until March-May 2021, depending on the epidemiological situation of COVID-19, the health status of children and staff).
During the project was developed a brief overview of current global guidelines for Covid-19 and recommendations for caries treatment. Recommendations has been given to Andis Paeglītis, Chief Dental Officer of the Latvian Centre for Disease Prevention and Control, to promote the studied methods, especially in conditions of increased risk of droplet infection. The recommendations about non-invasive caries treatment methods which do not generate aerosols are included in the official recommendations’ bulletin (based on the recommendations of several world experts and associations).
- Several project publicity activities have taken place
In order to inform the public about the progress of the project, a number of public information and education activities have taken place. Interview titled “How to change dental treatment for children?” published in the “Science Bulletin” (in Latvian): https://www.lza.lv/publikacijas/zinatnes-vestnesis/download… and in the RSU webpage (in Latvian): https://www.rsu.lv/aktualitates/ka-mainit-zobu-arstesanas-m…
A popular scientific article has been written to update the topic in the community of medical professionals. It has been published in the December issue of the journal “Doctus” (in Latvian).
14.11.2020, online lecture at the monthly conference of the Latvian Dental Hygienists’ Association. Lecture title “Caries Control in Children”. Latvian dental hygienists were informed about the new caries treatment methods, which may also be within the competence of dental hygienists. We also tested the knowledge about sealant applications in an interactive game.
21.11.2020, online lecture at the conference of the Scientific Society of Dental Students in Chile (SOCEO UACH) “Experiencia en investigación y publicaciones desde el pregrado hasta el postdoctorado” (in Spanish). I talked about the topic of post-doctoral research and gave advice to Chilean students on how to begin a research in a pre-graduate level (for dentistry, physiotherapy and medical students from three Chilean universities).
26.11.2020, online meeting with 11th and 12th grade students of Jelgava State Gymnasium. We talked about dentistry, research; I introduced the students to the non-invasive methods of caries treatment, provided recommendations for beginning a research career, how to plan a research and how to prepare for medical studies.
- Research activities
Extending the line of research, a research protocol for a case-control study "Risk Factors of Early Childhood Caries" has been written, RSU Ethics Committee approval No 22-2/148/2021 has been obtained. Data collection has started, questionnaires have been completed in 425 case group patients and 28 caries-free children (control group).
Clinical trial protocol has been registred in BMC ISRCTN register No ISRCTN17005348 https://doi.org/10.1186/ISRCTN17005348
One part of the study, titled “Latvian Dentist Treatment Decisions During COVID19 Pandemic” has been finished, the questionnaire, the data and codebook are published in data repository dataverse.rsu with doi:10.48510/FK2/PZL9DW: https://dataverse.rsu.lv/dataset.xhtml?persistentId=doi:10…
In relation to the topic of the study and the need for measures to reduce the spread of COVID infection in the dental sector, clinical guidelines have been prepared and submitted to the Latvian Dental Association. The guidelines are available here: https://www.bernuzobi.lv/profesion%C4%81%C4%BCiem
- Dissemination of scientific results
The manuscript “COVID-19 as an opportunity for minimally-invasive dentistry: a national cross-sectional survey” has been sent to the journal “Caries research” to promote the scientific results.
Presentation of the poster took place in 2 conferences IAPD (International Association of Pediatric Dentistry) 28th virtual congress (https://iapdvirtual.org/) and ORCA (European Organization of Caries Research) 68th congress (https://orca2021.com/)
The poster “Parental Acceptance of Silver Diamine Fluoride Staining in Latvia” was presented at the IAPD conference (available at https://drive.google.com/file/d/1C5kn2szaklgKDYQJ_sltosU3VD…), while at the ORCA conference the poster “Effect of COVID-19 on the frequency of paediatric dental treatment in general anesthesia in Latvia”(available here: https://drive.google.com/file/d/1VupBEanLpG9xRe0WWuAkZpaYUz…)
Lecture "Actual recommendations for managing dental caries in dental hygienist practice reducing aerosol generation" was provided at the international conference "Baltic conference of dental hygienists" on 11 September. https://baltichygienistconference.mozello.lv/
- Virtual mobility at Cardiff University, UK
From September to December 2021, weekly webinars were held with prof. Nicola Innes, during which I actualized the data management plan. Based on Prof Innes' previous experience in several clinical trials, we selected the most accurate data analysis methods to assess outcomes at patient and tooth level. By analyzing literature we also identified opportunities for further research. Through the analysis of clinical cases, I continue to learn and improve the use of non-invasive and minimally invasive techniques in the treatment of carious lesions.
As a result of the collaboration, a project application Institutionalisation of an Evidence-Based Paediatric Caries Management Strategies in Latvian Clinical Practice - an Evidence Transfer Study was submitted on 1 November 2021 for consideration for funding from The Borrow Foundation.
Updated on December 30, 2021
- Virtual mobility at the University of Michigan, USA
From September to December 2021, several activities were conducted in cooperation with the University of Michigan, with Prof. Carlos Gonzalez and Prof. Margherita Fontana. The collaboration took place through webinars, analysis of current literature, analysis of clinical research cases, participation in a postgraduate course in Cariology, meetings with postgraduate students from different countries and an expert from Chile, Prof. Rodrigo Giacaman (University of Talca, Chile).
Through the mobility, the following objectives were achieved:
- Deciding on the carious lesion assessment system to be used in the study.
- Creation of data input forms (study instruments).
- Exchange of experience on clinical studies of similar design.
- Exchange of experience on the drugs (SDF and other fluoride varnishes) to be used in the clinical study.
- Exchange of experience in the organisation of postgraduate education.
- Discussion of scientific methodology - questionnaires for studies.
- Discussion of scientific methodology - for clinical studies.
- Expand international contacts.
Updated on December 30, 2021
- Mobility at the University of Southern Chile, Chile
The aim of the mobility was to expand international contacts within the project New non-invasive treatments for the control and treatment of early childhood caries in the context of data management. I will be able to apply the acquired knowledge in data management in the analysis, organisation and visualisation of data for the next project phase using the R software.
I participated in several meetings both within my specialty and at the annual faculty summary meeting, gaining practical experience in communication and problem solving among colleagues.
I also participated in the evaluation of the research thesis of undergraduate students. I observed high quality of research papers, good knowledge of students in scientific methodology. The University of Southern Chile has 5 different courses related to scientific methodology, each lasting one semester. After such preparation, students are fluent in discussing the different types of research, they are well aware of research protocol, obtaining Ethics Committee approval, validation of research instruments, different data processing methods and data visualisation. Often, students' work is published in journals of the SCIELO or SCOPUS database.
Updated on February 7, 2022
- Visit to the University of Valparaiso, Chile
I had the opportunity to participate in a paediatric specialty dental clinic (Valparaiso University), both observing and practicing the methods I used in my clinical research. I observed different behavioural management techniques in paediatric dentistry that improve patient cooperation, reduce anxiety and promote long-lasting collaboration between patient and specialist. Together with experienced experts - prof. Juan Eduardo Onetto and prof. Marie Therese Flores, we analysed the clinical cases of the study.
I visited the basic sciences laboratory located in the Faculty of Dentistry of the University of Valparaiso, whose work also involves undergraduate and postgraduate students.
The Valparaiso University colleagues were interested in further collaboration and an interview about our visit is published on the university's website: https://www.uv.cl/pdn/?id=12940.
Updated on February 8, 2022
- Dissemination activities of project results
14.05.2022. – lecture at the meeting of the Latvian Dental Association Minimally invasive dentistry – sustainable caries treatment techniques for children and adults.
16.05.2022. – at the meeting of the Department of Conservative Dentistry and Oral Health of Riga Stradiņš University presented the first preliminary results of the clinical trial.
19.05.2022. – lecture Noninvasive and minimal invasive caries management for dental hygiene students from Latvia, Finlandia and Belgium as part of the Erasmus+ Intensive Course.
11.06.2022. – all day course for dentists and dental hygienists Noninvasive and minimally invasive caries treatment methods in dental hygienists’ practice.
- The clinical research phase has been completed
The clinical study was performed in children in several groups to evaluate the efficacy and possible side effects of non-invasive methods such as the application of silver diamine fluoride (SDF).
A total of 431 patients were included in the study and 354 patients were re-examined after a 12-month follow-up period, representing 82% of the total number of patients. The result is considered a high achievement, as re-examinations were planned for as many as 70. The main reasons for dropouts were changes of domicile as a result of the COVID19 pandemic or dental treatment with traditional methods during the follow-up period. Processing and analysis of all obtained data has started. Reports for scientific conferences and scientific articles are being prepared and will be prepared by the end of the project.
- Participation in EAPD Congress
16.06.2022. – together with third-year paediatric dentistry resident Dr. Jeļena Grišakova, we presented the results of the study Early childhood caries risk indicators in Latvia: a case-control study at the 16th Congress of the European Academy of Paediatric Dentistry. The main findings were that if parents brush their children's teeth every night with toothpaste containing at least 1000 ppm fluoride, the risk of caries is reduced by about ten times, even with frequent consumption of sweets. And interestingly, in families where children already have a caries history, there is a tendency to reduce eating sweets and drinking sugary drinks.