Saudi Cultural Missions Theses & Dissertations
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Item Restricted Investigating opportunities to provide behaviour change conversations to promote child oral health in non-dental settings(University of Manchester, 2024) Alshammari, Dalil; Peters, Sarah; Goldthorpe, Joanna; Coupe, NiaBackground: In 2022, almost a quarter of 5-year-old children in England had at least three untreated teeth with deep tooth decay. This is partly due to limited access to dentists, suggesting a need for additional ways to support children's oral health. Therefore, this PhD project sought to investigate opportunities to provide behaviour change conversations (BCC) to reduce children's oral health problems in early years settings (EYS). Method: The thesis aim was addressed through three stages using a mixed-method approach. In the first stage, a secondary analysis was conducted of electronic records of children referred to general dental anaesthesia in northwest England for tooth extraction. In the second phase,14 parents and 11 EYS staff were interviewed to explore their views regarding delivering and receiving messages to promote children's oral health. Sampling of participants sought to include those from varied backgrounds and 8 (57%) of parent interviews were conducted in Arabic. A systematic approach was developed to ensure accurate translation of non-English data, which preserved cultural and linguistic nuances during analysis. In the final stage, the behaviour change wheel approach was used to design an intervention to address the barriers and challenges identified in the previous stages. Results: Stage one revealed that despite an increased need, there were 90% fewer referrals to general anaesthesia during lockdown than in the corresponding period in the previous year. These findings indicate the need to explore the potential for non-clinical settings to address children’s oral healthcare. Stage two revealed that parents have limited awareness of oral health activities in EYS. They acknowledged that EYS staff could influence children's oral health behaviours, but identified several limitations, such as staff credibility. EYS staff recognised the need to address child oral health yet viewed the inclusion of oral health activities as overwhelming and reported how they avoid difficult conversations about oral health with parents. In response to the challenges of translating non-English data, a framework consisting of six stages was developed to ensure accurate translation and to guide researchers through the translation process. In stage three, the ToothTalk toolkit intervention was developed to facilitate communication between EYS staff and parents regarding children's oral health. This comprised a booklet for staff with information and behaviour change techniques to support their conversations, and an accompanying parents’ interactive workbook. Conclusion: The thesis provides timely and important evidence to support the existing rollout and proposals for expanding oral health practice at EYS in England, which may have potential also for other geographical localities. It found that oral health is considered a delicate conversation where staff need training to develop the necessary communication skills and confidence to initiate and hold tooth-kind conversations. Parents need support to trust and engage more in these conversations. The ToothTalk intervention was developed to address the identified barriers, which aim to increase the frequency and quality of oral health-related discussions initiated by EYS staff with parents. Further research is necessary to evaluate its effectiveness and acceptability in the EYS context. As well as its potential to be tailored to other contexts both within the four nations of the UK, and beyond.17 0Item Restricted UNRAVELING THE LINK BETWEEN ANTI-INFLAMMATORY DIET, ZINC, AND CADMIUM TOXICITY IN INFLAMMATION REGULATION AMONG CHILDREN AND ADOLESCENTS(Florida International University, 2024-10-29) Mobarki, Huda; Liuzzi, JuanZinc (Zn) possesses antioxidant and anti-inflammatory properties essential for regulating the body’s inflammatory response. However, the interplay between diet, heavy metal toxicity, and Zn status in influencing inflammation in children remains poorly understood. This study examined the associations among diet, Zn levels, cadmium (Cd) toxicity, and inflammation, using high-sensitivity C-reactive protein (hsCRP) and white blood cell count (WBCs) as biomarkers. Data from the 2015-2016 National Health and Nutrition Examination Survey (NHANES), comprising 3,507 U.S. children aged 2–19 years, were analyzed. Linear regression models assessed the relationships between serum Zn, the Anti-inflammatory Diet Score (ADS), Cd levels, and inflammatory markers. Of the participants, 49.4% were male and 50.6% female. Serum Zn was inversely associated with inflammation (β = -0.236, p = 0.008 for WBCs; β = -0.223, p = 0.035 for hsCRP) after adjusting for covariates. Although ADS showed an inverse relationship with inflammation, the associations were not statistically significant. Blood Cd levels were positively associated with WBCs (β = 0.436, p = 0.008), but not hsCRP. Interestingly, adjusting for Zn reversed the association between Cd and inflammation, though the results were not significant, suggesting Zn may counteract Cd’s pro-inflammatory effects. Complementary studies in C. elegans were conducted to further explore these findings. Survival assays showed that Cd exposure significantly reduced worm survival, whereas co-incubation with equal concentrations of Zn (100 µM) mitigated this toxic effect, as demonstrated by two-way ANOVA and Tukey tests. Overall, this study highlights that serum Zn is a more reliable marker of inflammation than dietary Zn intake in children. Zn appears to partially neutralize Cd's toxic effects, with findings supported by both epidemiological data and experimental models. Maintaining adequate Zn levels may reduce inflammation and counteract Cd toxicity. These results underscore the importance of dietary strategies to enhance Zn status, potentially mitigating the adverse health effects of environmental Cd exposure in children.17 0Item Restricted The Psychosocial Impact on Families of Paediatric LT-MCS Patients During In- Hospital Bridge to Transplant: A Modified Systematic Review(University of Nottingham, 2024-09) Alawami, Sakinah; Hemingway, PippaIntroduction: End-stage heart failure children waiting for heart transplants have better survival rates with long-term mechanical circulatory support (LT-MCS). However, the shortage of donor hearts prolongs the transplant bridging period, extending hospitalisation, disrupting family life, and adding uncertainty. While a previous mixed-method systematic review has explored the home experience of these families, understanding their in-hospital experiences remains limited. Therefore, this review aims to examine the psychosocial impact on these families during their LT-MCS children’s in-hospital bridged to transplant, illuminating their challenges and resilience. Methods: This review employed the SPIDER framework searching for PubMed, CINAHL, ASSIA, Embase, and ProQuest (dissertations and theses) for English-published and non-published qualitative studies according to the pre-defined inclusion criteria. Findings: Six qualitative studies matched the pre-defined inclusion criteria. The review synthesised four themes using Braun and Clarke reflexive thematic analysis: (1) Commencing the families' journey with LT-MCS discussing the diagnosis and LT-MCS implantation’s impact. (2) Navigating the LT-MCS paediatric patients’ families through Bridging: addressing LT-MCS children-mother role changes, caregiver's daily life, complications, and grief. (3) Crossroads of blessings and challenges: LT-MCS children's families await a new heart, highlighting donor heart uncertainty. (4) The power stations of LT-MCS children’s families focus on supporting systems. After synthesising themes, findings were examined through Dr. Mishel’s Uncertainty in Illness Theory, Theor yielding recommendations aligned with Advanced Nursing Practice's pillars. Conclusion: This systematic review highlights the profound psychosocial impact and uncertain experience on LT-MCS children’s families during diagnosis, hospitalisation, complications, grieving, and the waiting period for a new heart. It calls for urgent tailored educational and supportive interventions by clinicians for sudden and previously diagnosed heart failure children's families, robust policy initiatives, and innovative research. Additionally, it points out the role and potential needs of healthcare providers in helping families mitigate the stresses associated with the in-hospital bridging period.21 0Item Restricted UNRAVELING THE LINK BETWEEN ANTI-INFLAMMATORY DIET, ZINC, AND CADMIUM TOXICITY IN INFLAMMATION REGULATION AMONG CHILDREN AND ADOLESCENTS(Florida International University, 2024) Mobarki, Huda; Liuzzi, JuanZinc (Zn) is known for its antioxidant and anti-inflammatory properties and is important in regulating the body’s inflammatory response. However, there is limited evidence on how factors such as diet and heavy metal toxicity contribute to inflammation in children, and whether these effects are influenced by Zn status. This study aimed to investigate the links between diet, Zn, and cadmium (Cd) toxicity with inflammation, using high-sensitivity C-reactive protein (hsCRP) and white blood cell count (WBCs) as biomarkers. Using data from the 2015-2016 National Health and Nutrition Examination Survey (NHANES), which included 3,507 children in the U.S. aged 2-19 years, we explored the associations between the main exposure variables (Zn, Anti-inflammatory Diet Score (ADS), and Cd) and inflammatory biomarkers. Statistical analysis was conducted using a linear regression model. Of the participants, 49.4% were male and 50.6% female. We observed an inverse relationship between serum Zn and inflammation (β = -.236, p = .008 for WBCs, and β = -.223, p = .035 for hsCRP) after adjusting covariates. Although ADS was inversely associated with inflammation, the relationship was not significant (β = -.006, p = .186 for WBCs, and β = -.003, p = .210 for hsCRP). Significant associations were found between blood Cd and WBCs (β = .436, p = .008), but not for hsCRP. After adjusting for Zn, the relationship between Cd and inflammation became inversely associated (β = -.083 for WBCs, β = -.099 for hsCRP), although these results were not significant, suggesting that Zn may mitigate Cd’s inflammatory effects. To further support the epidemiological findings, we conducted studies using young C. elegans. The experiment consisted of two studies analyzing the effects of Zn and Cd on the survival of the worms using two-way ANOVA and Tukey tests. The results showed that Cd treatment significantly decreased the survival of worms; however, co-incubation with Zn attenuated this effect when the concentration of Cd and Zn were equal (100 µM). In conclusion, the epidemiological data indicate that serum Zn is a more reliable indicator of inflammation in children than Zn intake. The study also suggests zinc status neutralizes Cd's pro-inflammatory effects on inflammatory biomarkers. Additionally, C. elegans model demonstrated that Zn supplementation mitigated Cd-induced toxicity. These findings highlight the importance of maintaining adequate Zn status to mitigate the harmful effects of Cd exposure in children. Therefore, dietary interventions that improve Zn status could potentially reduce inflammation and counteract the adverse impact of Cd exposure on a population level.15 0Item Restricted THE ASSOCIATION BETWEEN HOUSING CHARACTERISTICS AND DENTAL CARIES AMONG CHILDREN IN THE USA(King's College London, 2024-08) Alsaeed, Lina; Sabbah, Waelassociation between housing characteristics and dental caries among children. Objectives: To examine the association between housing characteristics and caries experience among 2-6 years American children. Methods: Data from the National Health and Nutrition Examination Survey 2017-18 was used. Children aged 2-6 were included. The association between housing characteristics and the sum of decayed and filled primary teeth was assessed adjusting for family income, ethnicity, age, gender, and dental visits. Results: A total of 861 child were included in the analysis. The mean number of decayed and filled primary teeth was 1.28. Compared to those who lived in owned home, Children living in rented homes or homes with other arrangement had higher rate ratios for decayed and filled teeth with rate ratios 1.98 (95% Confidence Interval “CI” 1.25, 3.12) and 2.60 (95%CI:1.14, 5.93), respectively. Higher family income was also associated with lower rates of decayed/filled teeth. Conclusion: The analysis highlighted the importance of housing characteristics as a social determinant of children caries.16 0Item Restricted THE ASSOCIATION BETWEEN HOUSING CHARACTERISTICS AND DENTAL CARIES AMONG CHILDREN IN THE USA(King's College London, 2024) Alsaeed, Lina; Sabbah, WaelBackground: Despite the strong evidence on the role of the social determinants in dental caries, there is limited research on association between housing characteristics and dental caries among children. Objectives: To examine the association between housing characteristics and caries experience among 2-6 years American children. Methods: Data from the National Health and Nutrition Examination Survey 2017-18 was used. Children aged 2-6 were included. The association between housing characteristics and the sum of decayed and filled primary teeth was assessed adjusting for family income, ethnicity, age, gender, and dental visits. Results: A total of 861 child were included in the analysis. The mean number of decayed and filled primary teeth was 1.28. Compared to those who lived in owned home, Children living in rented homes or homes with other arrangement had higher rate ratios for decayed and filled teeth with rate ratios 1.98 (95% Confidence Interval “CI” 1.25, 3.12) and 2.60 (95%CI:1.14, 5.93), respectively. Higher family income was also associated with lower rates of decayed/filled teeth. Conclusion: The analysis highlighted the importance of housing characteristics as a social determinant of children caries.31 0Item Restricted A pragmatic cluster randomised controlled trial (cRCT) of an educational intervention to promote asthma prescription uptake in General Practitioner Practices(University of Sheffield, 2024-04-23) Alyami, Rami; Julious, Steven A.; Simpson, Rebecca M.; Oliver, PhillipBackground: Asthma exacerbation rates in school-age children peak following the return to school after the summer break. Studies have shown a decline in prescriptions collection during August, which is followed by an increase in unscheduled visits to healthcare providers. A previous study (the PLEASANT trial) found that sending reminder letters to parents of children with asthma during the summer vacation led to a 30% increase in August prescriptions being prescribed and reduced unscheduled care visits after the return to schools in the period September to December. The intervention also resulted in an estimated cost saving of £36.07 per patient per year. Objective: To determine if informing general practitioner (GP) practices about the PLEASANT trial intervention results leads to its implementation. Design: A pragmatic cluster randomised trial which utilised the Clinical Practice Research Datalink (CPRD) to send the intervention and collect data. Participants: A total of 1,326 GP practices in England, including 90,583 individuals, with 664 practices (44,708 individuals) in the intervention group and 662 practices (45,875 individuals) in the control group. Intervention: In June 2021, the intervention practices received a letter from CPRD about the PLEASANT study findings and recommendations. The letter was sent to the asthma lead and/or practice manager via postal mail and email. Control Arm: Usual care. Randomisation: GP practices were stratified by practice size (decile) and randomly allocated to either the intervention or control group. Main Outcome: The proportion of children with asthma who had a prescription for an asthma preventer medication in August and September 2021. Results: The intervention did not significantly affect the proportion of children with asthma who had a prescription in August and September 2021 compared to the control arm. In the intervention group, 15,716 out of 44,465 children (35.3%) had a prescription issued, compared to 16,001 out of 45,559 children (35.1%) in the control group (OR 1.01; 95% CI: 0.97 to 1.04). There was also no intervention effect on the number of prescriptions uptake in the same period (IRR 1.01; 95% CI: 0.98 to 1.03). Furthermore, the letter did not reduce the number of unscheduled medical contacts after returning to school from September to December 2021 (IRR 0.99; 95% CI: 0.96 to 1.02) and all medical contacts remained unchanged (IRR 1.00; 95% CI: 0.97 to 1.02). Conclusion: The study findings suggest that passive intervention of providing a letter to GPs did not achieve the intended outcomes. To bridge the gap between evidence and practice, alternative, more proactive strategies could be explored to address the identified issues.10 0Item Restricted Improving the Prognosis of Compromised First Permanent Molars in Children(2023-07-01) AlKhalaf, Reem; Banerjee, Avijit; Hosey, Marie ThérèseFirst permanent molars (FPMs) are widely regarded as being the most susceptible to developing dental caries. Due to the timing of hard tissue formation, these teeth are also more prone to idiopathic hypomineralisation enamel defects, known as molar-incisor hypomineralisation (MIH). Molar-incisor hypomineralisation affects one out of six children globally and in the United Kingdom (UK), its prevalence is around 16%. The most important treatment decision regarding compromised FPMs (cFPMs) is whether to retain or extract them. Unfortunately, this conversation typically occurs very early in a child's life due to the importance of considering the ‘ideal’ timing should extraction be favoured. According to the National Clinical Guidelines, elective extraction of FPMs with ‘a questionable long-term prognosis’ should be considered. This technique is based on a pragmatic orthodontic approach towards extracting FPMs that are considered to be of poor prognosis at the optimal time to permit spontaneous space closure during the dentition development. However, this often means a costly and upsetting hospital general anaesthesia (GA) admission. Thus, the aim of this project was to improve the prognostic evaluation of cFPMs in children through the understanding of the current protocol of management of children with cFPMs referred to specialist centres and defining the diagnostic thresholds of management of cFPMs and its compatibility with the contemporary operative evidence-based science and materials. To ultimately change the current orthodontic guidelines used in the UK and followed by other countries and reduce the number of hospital admissions of GA in children. To achieve this aim, a question was raised about the current management of children with cFPMs and the diagnostic threshold of extraction decision. Only a few national and international survey-based research papers have investigated management of children with cFPMs. Thus, to answer these questions, an evaluation of the protocol of management of children with cFPMs referred to specialist paediatric dental department at a London hospital NHS trust (Guy’s and St Thomas’ Hospital NHS Trust (GSTT)) was conducted. A framework/ database was established, and a retrospective evaluation was performed, based on the clinical case-records of medically fit children referred for management of cFPMs at GSTT. The presence of hypomineralisation and/or post-eruptive breakdown (PEB) and the proposed care plans were recorded while radiographic signs of severity were scored using the ICDAS index after researcher calibration. At Guy's and St Thomas' NHS Foundation Trust (GSTT), 249 records were included in a four-month period. Nearly 81% of the patients were planned for extraction of at least one cFPM, while 19.3% were managed without extractions. More than half of the extraction cases (n=105) had radiographic radiolucencies that did not exceed the middle third of dentine in the worst-affected FPM. General anaesthesia was used in 97.5% of the cases and 40.8% had never received previous treatment in any of their affected FPMs. Children who were referred with cFPMs at GSTT tended to undergo hospitalisation for extraction under GA. The management at GSTT poses further research questions about the current care protocol for patients with cFPMs referred to other specialist care centres in the UK. Two additional UK hospital specialist centres (Newcastle University Dental Hospital (NUDH) and Liverpool University Dental Hospital (LUDH)) were also included in the retrospective evaluation using the validated methodology developed in the first study. From 233 and 116 case notes screened in NUDH and LUDH, 200 and 80 met the selection criteria, respectively. Thirty-nine percent at NUDH and 56% at LUDH were planned to have extraction of at least one FPM. Nearly 58% in NUDH and 40% of patients in LUDH had a maximum radiographic radiolucency severity that did not exceed the middle third of dentine in the worst-affected cFPM. GA was the most used method of pain control within the three national centres (75.6%, 60% and 97.5% in NUDH, LUDH and GSTT, respectively) and a substantial number of the extraction cases (82.1%, 80% and 40%, respectively) received no previous treatment in any of their cFPMs. Collectively, these analyses have shown a national trend in the management of children with cFPMs within the three sampled centres in the UK. The children who were referred to the UK centres due to cFPM(s) tended to undergo hospitalisation for extraction. The clinical rationality of the local (UK) approach was questioned. Further questions were raised about the current care protocol for children with cFPMs referred to specialist centres globally, and the current diagnostic thresholds of management of cFPMs in children internationally. Thus, a multi-centre retrospective evaluation employed the same methodology to access how specialist paediatric dental departments at seven international centres in five different countries managed children referred with cFPMs and to compare with the three national (UK) centres. The following international centres and number of records have been included: King Saud University Medical City / KSU (269), King Abdulaziz Medical City / KAMC (160), University of Jordan Hospital / UJ (154), Warszawski Uniwersytet Medyczny / WUM (104), Miły Uśmiech Stomatologia / MUS (49), Academic Centre for Dentistry Amsterdam / ACTA (99) and University of Pittsburgh / UPITT (117) over a consecutive period in 2019. In contrast to UK centres, extraction cases were minority in each international centre, being 1% or less in KSU, WUM and MUS and reaching 8-10% in KAMC, ACTA and UPITT. The highest percentage of extraction cases internationally was recorded in UJ (25.3%) where it was still lower than all other UK centres. The majority of the extraction cases in the international centres had a minimum radiolucency reaching the inner third of dentine or documented as restored in the worst-affected element (99.9% at KSU; 100% at KAMC and 89.7% at UJ; 100% at WUM; 70% at ACTA; 100% at UPITT). Although GA was also present as a method of pain control in the international centres, whenever extraction was planned, alternative modalities such as inhalation sedation or local anaesthesia alone were present and predominant in a few of the sampled international centres (69.2% in KAMC, 70% in ACTA). In chapter five, the feasibility of a biochemical threshold to differentiate between the clinical severities of MIH-affected enamel using non-invasive Raman spectroscopic analysis was investigated. Stereomicroscopic images of extracted human FPMs, showing demarcated opacities in enamel, were scored by four independent examiners, to assess their severity. Using high-resolution Raman microscopy, the ratio of the characteristic vibration mode of the normalised amide I, carbonate and phosphate bands were calculated from 621 points scanned on a line scan across the different severities of the opacities. The logistic regression analysis indicated that the cut-off values (carbonate / phosphate) and (amide 1/ phosphate) between the white-creamy (WC) and yellow-brown (YB) lesions were 0.13 and 0.12 peak ratio respectively, which meant that >0.13 in carbonate / phosphate or >0.12 for amide 1/ phosphate represented YB tissue and <0.13 or <0.12 respectively represented WC tissue with 90% sensitivity and 92.6% specificity (p <0.0001) for carbonate / phosphate cut-off value and 95% sensitivity and 94.7% specificity (p <0.0001) for amide 1 / phosphate cut-off value. The logistic regression analysis indicated that the cut-off value of peak ratio between WC and sound tissue was 0.01 with 98.9% sensitivity and 10.5% specificity (p =0.001), whereas it was equal to 0.23 for amide 1 / phosphate cut-off value between WC and sound tissue with 98.9% sensitivity and 5.3% specificity. The defined Raman diagnostic thresholds were validated against the clinical severity. For the diagnostic threshold between WC versus YB lesions, examiners’ visual characterisation and the validated Raman carbonate / phosphate and amide 1/ phosphate cut-off threshold showed a substantial agreement ( Kappa=0.63 and 0.69 respectively). Thus, Raman spectroscopy could be used objectively in in-vitro studies discriminating the clinical severity of MIH demarcated opacities. In chapter six, a clinical-based minimally invasive (MI) treatment protocol to manage different severities of cFPMs in children is proposed. This protocol is applied into a proposition for a future clinical observational cohort study. The developed research methodology considered not affecting the ideal time of extraction if still needed. The feasibility of applying this observational clinical study to test the efficiency of MI as an alternative for the current management of extracting affected FPMs under GA was assessed. The clinical treatment protocol and the methodology were reviewed by four GSTT-NHS specialists, a research team, including restorative and paediatric academics and consultants in the field and two independent reviewers. The feasibility study showed a potential recruitment of (5.4 / week) at GSTT, thus a total of about 130 patients is expected in six months, considering that 70% of the patients will agree to join the study that informed the feasibility of 91 patients in six months.12 0