Related Articles

The goal of this workshop is to develop a consensus within the biomaterials/bioengineering community for a research agenda focused on creating technologies that will address the current dental caries pandemic. The workshop will bring together expertise from academia, industry, and the NIH institutes in the areas of oral biofilm microbiology and innovative biomaterials. The rationale for the workshop is that science and technology have not produced sufficient practical tools for public health practitioners and the private delivery system to address the pandemic in dental caries that exists for children and adults from families with low incomes and for numerous ethnic minority and racial groups. Moreover, it is unclear whether the barriers are remediable bioengineering and technical problems or fundamental science questions. Nevertheless, the obligation to address the gap between scientific research and practical application is especially relevant today. The U.S. and state governments bear the majority of the cost of trying to control this pandemic through Medicaid, the Public Health Service, Indian Health Service and other similar programs. These costs continue to escalate as continued applications of existing technology are unlikely to markedly reduce disparities. The mainstays of caries prevention, topical and systemic fluorides and pit and fissure sealants, are technologies developed in the 1950s and 1960s.

Despite impressive worldwide improvements in oral health, inequalities in oral health status among and within countries remain a daunting public health challenge. Oral health inequalities arise from a complex web of health determinants, including social, behavioral, economic, genetic, environmental, and health system factors. Eliminating these inequalities cannot be accomplished in isolation of oral health from overall health, or without recognizing that oral health is influenced at multiple individual, family, community, and health systems levels. For several reasons, this is an opportune time for global efforts targeted at reducing oral health inequalities. Global health is increasingly viewed not just as a humanitarian obligation, but also as a vehicle for health diplomacy and part of the broader mission to reduce poverty, build stronger economies, and strengthen global security. Despite the global economic recession, there are trends that portend well for support of global health efforts: increased globalization of research and development, growing investment from private philanthropy, an absolute growth of spending in research and innovation, and an enhanced interest in global health among young people. More systematic and far-reaching efforts will be required to address oral health inequalities through the engagement of oral health funders and sponsors of research, with partners from multiple public and private sectors. The oral health community must be “at the table” with other health disciplines and create opportunities for eliminating inequalities through collaborations that can harness both the intellectual and financial resources of multiple sectors and institutions.

Background

There is growing evidence of the impact of overweight and obesity on short- and long-term functioning, health and well-being. Internationally, childhood obesity rates continue to rise in some countries (for example, Mexico, India, China and Canada), although there is emerging evidence of a slowing of this increase or a plateauing in some age groups. In most European countries, the United States and Australia, however, socioeconomic inequalities in relation to obesity and risk factors for obesity are widening. Addressing inequalities in obesity, therefore, has a very high profile on the public health and health services agendas. However, there is a lack of accessible policy-ready evidence on what works in terms of interventions to reduce inequalities in obesity.

Methods and design

This article describes the protocol for a National Health Service Trust (NHS) National Institute for Health Research-funded systematic review of public health interventions at the individual, community and societal levels which might reduce socioeconomic inequalities in relation to obesity amongst children ages 0 to 18 years. The studies will be selected only if (1) they included a primary outcome that is a proxy for body fatness and (2) examined differential effects with regard to socioeconomic status (education, income, occupation, social class, deprivation and poverty) or the intervention was targeted specifically at disadvantaged groups (for example, children of the unemployed, lone parents, low income and so on) or at people who live in deprived areas. A rigorous and inclusive international literature search will be conducted for randomised and nonrandomised controlled trials, prospective and retrospective cohort studies (with and/or without control groups) and prospective repeat cross-sectional studies (with and/or without control groups). The following electronic databases will be searched: MEDLINE, Embase, CINAHL, PsycINFO, Social Science Citation Index, ASSIA, IBSS, Sociological Abstracts and the NHS Economic Evaluation Database. Database searches will be supplemented with website and grey literature searches. No studies will be excluded on the basis of language, country of origin or publication date. Study inclusion, data extraction and quality appraisal will be conducted by two reviewers. Meta-analysis and narrative synthesis will be conducted. The main analysis will examine the effects of (1) individual, (2) community and (3) societal level public health interventions on socioeconomic inequalities in childhood obesity. Interventions will be characterised by their level of action and their approach to tackling inequalities. Contextual information on how such public health interventions are organised, implemented and delivered will also be examined.

Discussion

In this review, we consider public health strategies which reduce and prevent inequalities in the prevalence of childhood obesity, highlight any gaps in the evidence base and seek to establish how such public health interventions are organised, implemented and delivered.

PROSPERO registration number: CRD42011001740

This article charts the historical development of the discipline of global mental health, whose goal is to improve access to mental health care and reduce inequalities in mental health outcomes between and within nations. The article begins with an overview of the contribution of four scientific foundations toward the discipline's core agenda: to scale up services for people with mental disorders and to promote their human rights. Next, the article highlights four recent, key events that are indicative of the actions shaping the discipline: the Mental Health Gap Action Programme to synthesize evidence on what treatments are effective for a range of mental disorders; the evidence on task shifting to nonspecialist health workers to deliver these treatments; the Movement for Global Mental Health's efforts to build a common platform for professionals and civil society to advocate for their shared goal; and the Grand Challenges in Global Mental Health, which has identified the research priorities that, within the next decade, can lead to substantial improvements in the lives of people living with mental disorders. The article ends by examining the major challenges for the field, and the opportunities for addressing them in the future. (harv rev psychiatry 2012;20:6–12.)

The National Institute of Dental Research (NIDR) was created by President Harry S Truman on June 24, 1948, as the third of the National Institutes of Health. NIDR's legislation contained the mandate to conduct research and research training to improve oral health. An impetus for federally funded dental research was the finding in World War II that the major cause of rejection for military service was missing teeth. Because of the population's widespread tooth decay problems, early NIDR research focused on eliminating dental caries. NIDR scientists confirmed the safety and effectiveness of the use of fluoride in tooth decay prevention, leading to one of the nation's most successful public health efforts, community water fluoridation. During the past 40 years, NIDR scientists have provided research advances and fostered technologies which changed the philosophy and practice of dentistry and brought dental sciences into the mainstream of biomedical research. Dental researchers contribute to studies of such diseases and problems as AIDS, cancer, arthritis, cystic fibrosis, diabetes, herpes, craniofacial anomalies, pain, and bone and joint disorders. NIDR's 40th anniversary in 1988 recognizes its continuing commitment to oral disease prevention and health research, and to achieving the goal of people maintaining their natural dentition for a lifetime.

Images

The SMILE project represented a partnership among the University of Texas Health Science Center at San Antonio Libraries, the Gateway Clinic in Laredo, and the San Antonio Metropolitan Health District. The project focused on improving dental practitioners' access to reliable information resources and integrating the best evidence into public health dental practice. Through its training program, SMILE cultivated a set of “power information users” among the dentists, dental hygienists, and community health workers (promotores) who provide public health preventive care and oral health education. The dental public health practitioners gained information literacy skills and increased their knowledge about reliable sites such as blogs, PubMed®, and MedlinePlus®. This project fostered opportunities for expanded partnerships with public health personnel.

The Malaria Eradication Research Agenda (malERA) Consultative Group on Modeling outline a research and development agenda to ensure that appropriate models are in place to guide malaria elimination.

Malaria modeling can inform policy and guide research for malaria elimination and eradication from local implementation to global policy. A research and development agenda for malaria modeling is proposed, to support operations and to enhance the broader eradication research agenda. Models are envisioned as an integral part of research, planning, and evaluation, and modelers should ideally be integrated into multidisciplinary teams to update the models iteratively, communicate their appropriate use, and serve the needs of other research scientists, public health specialists, and government officials. A competitive and collaborative framework will result in policy recommendations from multiple, independently derived models and model systems that share harmonized databases. As planned, modeling results will be produced in five priority areas: (1) strategic planning to determine where and when resources should be optimally allocated to achieve eradication; (2) management plans to minimize the evolution of drug and pesticide resistance; (3) impact assessments of new and needed tools to interrupt transmission; (4) technical feasibility assessments to determine appropriate combinations of tools, an associated set of target intervention coverage levels, and the expected timelines for achieving a set of goals in different socio-ecological settings and different health systems; and (5) operational feasibility assessments to weigh the economic costs, capital investments, and human resource capacities required.

It is important that we monitor socio-economic inequality in health. Inequality in child oral health has been expected to widen because of widening socio-economic inequality. This study aimed to evaluate trends in income-related inequality in caries experience of Australian children. Cross-sectional studies in 1992/93 and 2002/03 collected data on deciduous caries experience of 5- to 10-year-olds and permanent caries experience of 6- to 12-year-olds. Household composition and income was used to calculate quartiles of equivalized income. Slope Index of Inequality (SII), Concentration Index (CI), and regression-based rate ratios were used to quantify income-related inequality and to evaluate trends. Income-related inequality in caries experience was evident regardless of time and dentition. The three indicators of inequality indicate a significant increase in income-related inequality in child deciduous caries experience during the decade. The income inequality in permanent caries experience did not change significantly. Income inequalities increased in deciduous teeth, but not in permanent teeth, among Australian children.

Background

In the past 15 years, knowledge translation in healthcare has emerged as a multifaceted and complex agenda. Theoretical and polemical discussions, the development of a science to study and measure the effects of translating research evidence into healthcare, and the role of key stakeholders including academe, healthcare decision-makers, the public, and government funding bodies have brought scholarly, organizational, social, and political dimensions to the agenda.

Objective

This paper discusses the current knowledge translation agenda in Canadian healthcare and how elements in this agenda shape the discovery and translation of health knowledge.

Discussion

The current knowledge translation agenda in Canadian healthcare involves the influence of values, priorities, and people; stakes which greatly shape the discovery of research knowledge and how it is or is not instituted in healthcare delivery. As this agenda continues to take shape and direction, ensuring that it is accountable for its influences is essential and should be at the forefront of concern to the Canadian public and healthcare community. This transparency will allow for scrutiny, debate, and improvements in health knowledge discovery and health services delivery.

Oral diseases are major health problems with dental caries and periodontal diseases among the most important preventable global infectious diseases. Oral health influences the general quality of life and poor oral health is linked to chronic conditions and systemic diseases. The association between oral diseases and the oral microbiota is well established. Of the more than 750 species of bacteria that inhabit the oral cavity, a number are implicated in oral diseases. The development of dental caries involves acidogenic and aciduric Gram-positive bacteria (mutans streptococci, lactobacilli and actinomycetes). Periodontal diseases have been linked to anaerobic Gram-negative bacteria (Porphyromonas gingivalis, Actinobacillus, Prevotella and Fusobacterium). Given the incidence of oral disease, increased resistance by bacteria to antibiotics, adverse affects of some antibacterial agents currently used in dentistry and financial considerations in developing countries, there is a need for alternative prevention and treatment options that are safe, effective and economical. While several agents are commercially available, these chemicals can alter oral microbiota and have undesirable side-effects such as vomiting, diarrhea and tooth staining. Hence, the search for alternative products continues and natural phytochemicals isolated from plants used as traditional medicines are considered as good alternatives. In this review, plant extracts or phytochemicals that inhibit the growth of oral pathogens, reduce the development of biofilms and dental plaque, influence the adhesion of bacteria to surfaces and reduce the symptoms of oral diseases will be discussed further. Clinical studies that have investigated the safety and efficacy of such plant-derived medicines will also be described.

Despite its relatively recent emergence over the past few decades, oral health-related quality of life (OHRQoL) has important implications for the clinical practice of dentistry and dental research. OHRQoL is a multidimensional construct that includes a subjective evaluation of the individual’s oral health, functional well-being, emotional well-being, expectations and satisfaction with care, and sense of self. It has wide-reaching applications in survey and clinical research. OHRQoL is an integral part of general health and well-being. In fact, it is recognized by the World Health Organization (WHO) as an important segment of the Global Oral Health Program (2003). This paper identifies the what, why, and how of OHRQoL and presents an oral health theoretical model. The relevance of OHRQoL for dental practitioners and patients in community-based dental practices is presented. Implications for health policy and related oral health disparities are also discussed. A supplemental Appendix contains a Medline and ProQuest literature search regarding OHRQoL research from 1990-2010 by discipline and research design (e.g., descriptive, longitudinal, clinical trial, etc.). The search identified 300 articles with a notable surge in OHRQoL research in pediatrics and orthodontics in recent years.

Background

Inadequate public action in vulnerable communities is a major constraint for the health of poor and marginalized groups in low and middle-income countries (LMICs). The south Indian state of Kerala, known for relatively equitable provision of public resources, is no exception to the marginalization of vulnerable communities. In Kerala, women’s lives are constrained by gender-based inequalities and certain indigenous groups are marginalized such that their health and welfare lag behind other social groups.

The research

The goal of this socially-engaged, action-research initiative was to reduce social inequalities in access to health care in a rural community. Specific objectives were: 1) design and implement a community-based health insurance scheme to reduce financial barriers to health care, 2) strengthen local governance in monitoring and evidence-based decision-making, and 3) develop an evidence base for appropriate health interventions.

Results and outcomes

Health and social inequities have been masked by Kerala’s overall progress. Key findings illustrated large inequalities between different social groups. Particularly disadvantaged are lower-caste women and Paniyas (a marginalized indigenous group), for whom inequalities exist across education, employment status, landholdings, and health. The most vulnerable populations are the least likely to receive state support, which has broader implications for the entire country. A community based health solidarity scheme (SNEHA), under the leadership of local women, was developed and implemented yielding some benefits to health equity in the community—although inclusion of the Paniyas has been a challenge.

The partnership

The Canadian-Indian action research team has worked collaboratively for over a decade. An initial focus on surveys and data analysis has transformed into a focus on socially engaged, participatory action research.

Challenges and successes

Adapting to unanticipated external forces, maintaining a strong team in the rural village, retaining human resources capable of analyzing the data, and encouraging Paniya participation in the health insurance scheme were challenges. Successes were at least partially enabled by the length of the funding (this was a two-phase project over an eight year period).

In recent years, health inequalities have become an important public health concern and the subject of both research and policy attention in Korea. Government reports, as well as many epidemiological studies, have provided evidence that a wide range of health outcomes and health-related behaviors are socioeconomically patterned, and that the magnitude of health inequalities is even increasing. However, except for the revised Health Plan 2010 targets for health equity, few government policies have explicitly addressed health inequalities. Although a number of economic and social policies may have had an impact on health inequalities, such impact has scarcely been evaluated. In this review, we describe the current status of research and policy on health inequalities in Korea. We also suggest future challenges of approaches and policies to reduce health inequalities and highlight the active and intensive engagement of many policy sectors and good evidence for interventions that will make meaningful reduction of health inequalities possible.

There is a serious shortage of senior African social scientists to lead health-related research in Africa. This is despite the existence of many African social science graduates, and decades of Northern funded research programmes intended to develop local capacity. To investigate the barriers to developing health social science research capacity in East Africa, 29 in-depth interviews, informal conversations and a group discussion were conducted with professionals in this field.

Respondents’ explanations for inadequate social science research capacity primarily related to under-development and global economic inequalities. However, a recurrent theme was the predominance of individually contracted research consultancies. These seem to divert university staff from academic research, supporting colleagues and training the next generation of researchers, stunt the institutional capacity of university departments, restrict the sharing of research findings and perpetuate donors’ control of the research agenda.

Although primarily due to macro-economic factors, limited research capacity in sub-Saharan Africa might be ameliorated by modifying the process by which much research is conducted. This exploratory study suggests that institutional research capacity might be strengthened if consultancy research were commissioned through institutions, rather than individuals, with the payment of substantial overheads.

This report describes the research productivity of the members of the International Association for Dental Research (IADR) Behavioral Sciences and Health Services Research Group and examines personal and professional factors related to greater productivity. The findings from previous studies suggested there might be gender discrimination in opportunities for women faculty. Members on the active membership list for this IADR group were surveyed by email. Most were dentists, and three-quarters had external funding for their research. The primary outcome measure was the number of self-reported published articles in PubMed in the preceding twenty-four months. The mean number of these publications was 4.9 (SD=5.1). Gender and time in research were the best predictors of research productivity of this population. There was no difference in time for research between the men and women in this study. Controlling for gender, the best single predictor of research productivity remained percent time spent in research. Overall, the members of the IADR group spent almost three times as much time in research and were more than twice as productive as faculty members as a whole as described in earlier studies. In view of the current emphasis in many countries on addressing the social and behavioral determinants of oral health disparities, the productivity of this area of dental research is very important. Trends toward clinically oriented, non-research-intensive dental schools in the United States and reductions in time and funding available to conduct research should be of concern.

In this nation, the unequal burden of disease among People of Color has been well documented. One starting point to eliminating health disparities is recognizing the existence of inequities in health care delivery and identifying the complexities of how institutional racism may operate within the health care system. In this paper, we explore the integration of community-based participatory research (CBPR) principles with an Undoing Racism process to conceptualize, design, apply for, and secure National Institutes of Health (NIH) funding to investigate the complexities of racial equity in the system of breast cancer care. Additionally, we describe the sequence of activities and “necessary conflicts” managed by our Health Disparities Collaborative to design and submit an application for NIH funding. This process of integrating CBPR principles with anti-racist community organizing presented unique challenges that were negotiated only by creating a strong foundation of trusting relationships that viewed conflict as being necessary. The process of developing a successful NIH grant proposal illustrated a variety of important lessons associated with the concepts of cultural humility and cultural safety. For successfully conducting CBPR, major challenges have included: assembling and mobilizing a partnership; the difficulty of establishing a shared vision and purpose for the group; the problem of maintaining trust; and the willingness to address differences in institutional cultures. Expectation, acceptance and negotiation of conflict were essential in the process of developing, preparing and submitting our NIH application. Central to negotiating these and other challenges has been the utilization of a CBPR approach.

Background

Health policy and systems research (HPSR) is an international public good with potential to orient investments and performance at national level. Identifying research trends and priorities at international level is therefore important. This paper offers a conceptual framework and defines the HPSR portfolio as a set of research projects under implementation. The research portfolio is influenced by factors external to the research system as well as internal to it. These last include the capacity of research institutions, the momentum of research programs, funding opportunities and the influence of stakeholder priorities and public opinion. These dimensions can vary in their degree of coordination, leading to a complementary or a fragmented research portfolio.

Objective

The main objective is to identify the themes currently being pursued in the research portfolio and agendas within developing countries and to quantify their frequency in an effort to identify current research topics and their underlying influences.

Methods

HPSR topics being pursued by developing country producer institutions and their perceived priorities were identified through a survey between 2000 and 2002. The response to a call for letters of intent issued by the Alliance in 2000 for a broad range of topics was also analyzed. The institutions that were the universe of this study consisted of the 176 institutional partners of the Alliance for Health Policy and Systems Research producing research in low and middle income countries outside Europe. HPSR topics as well as the beneficiaries or issues and the health problems addressed were content analyzed. Topics were classified into 19 categories and their frequency analyzed across groups of countries with similar per capita income. Agendas were identified by analyzing the source of funding and of project initiation for projects under implementation.

Results

The highest ranking topic at the aggregate level is "Sector analysis", followed by "Disease burden" and "Management and organization". Categories at the bottom of this ranking are "Equity", "Policy process", "Economic policy and health" and "Information systems". "Disease burden" is more often funded than other topics for which there is more demand or perceived priority. Analysis suggests few although important differences across priorities, demand for funding and actual project funding. The donors' agenda coincides most with the ranking of research topics overall.

Ranking across country income groups shows important differences. Topics that gain prominence in low income countries are "Disease burden" and "Accessibility". In lower middle income countries "Insurance" gains prominence. In upper middle income countries "Decentralization/local health systems", "Equity" and "Policy process" are more prominent. "Program evaluation" is the most consistently ranked topic across income regions, showing a neutral influence by donors, governments or researchers.

Conclusions

The framework proposed offers a basis to identify and contrast research needs, projects and products at the international level and to identify the actor agendas and their influence. Research gaps are suggested when comparing topic ranking against the challenges to health system strengthening and scaling up of disease control programs. Differences across per capita income groups suggests the need for differentiated priority setting mechanisms guiding international support. Data suggests that stakeholders have different agendas, and that donors predominate in determining the research portfolio. High-level consensus building at the national and international levels is necessary to ensure that the diverse agendas play a complementary role in support of health system objectives.

The Ministerial Summit for Health Research to be held in Mexico in November 2004 should be an opportunity to analyze further data and to commit funding for priorities identified through sharing and discussion of agendas.

Background

In response to policy recommendations, nine National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Health Research and Care (CLAHRCs) were established in England in 2008, aiming to create closer working between the health service and higher education and narrow the gap between research and its implementation in practice. The Greater Manchester (GM) CLAHRC is a partnership between the University of Manchester and twenty National Health Service (NHS) trusts, with a five-year mission to improve healthcare and reduce health inequalities for people with cardiovascular conditions. This paper outlines the GM CLAHRC approach to designing and evaluating a large-scale, evidence- and theory-informed, context-sensitive implementation programme.

Discussion

The paper makes a case for embedding evaluation within the design of the implementation strategy. Empirical, theoretical, and experiential evidence relating to implementation science and methods has been synthesised to formulate eight core principles of the GM CLAHRC implementation strategy, recognising the multi-faceted nature of evidence, the complexity of the implementation process, and the corresponding need to apply approaches that are situationally relevant, responsive, flexible, and collaborative. In turn, these core principles inform the selection of four interrelated building blocks upon which the GM CLAHRC approach to implementation is founded. These determine the organizational processes, structures, and roles utilised by specific GM CLAHRC implementation projects, as well as the approach to researching implementation, and comprise: the Promoting Action on Research Implementation in Health Services (PARIHS) framework; a modified version of the Model for Improvement; multiprofessional teams with designated roles to lead, facilitate, and support the implementation process; and embedded evaluation and learning.

Summary

Designing and evaluating a large-scale implementation strategy that can cope with and respond to the local complexities of implementing research evidence into practice is itself complex and challenging. We present an argument for adopting an integrative, co-production approach to planning and evaluating the implementation of research into practice, drawing on an eclectic range of evidence sources.

Background

The paradigm of translational medicine that underpins frameworks such as the Cooksey report on the funding of health research does not adequately reflect the complex reality of the public health environment. We therefore outline a translational framework for public health research.

Discussion

Our framework redefines the objective of translation from that of institutionalising effective interventions to that of improving population health by influencing both individual and collective determinants of health. It incorporates epidemiological perspectives with those of the social sciences, recognising that many types of research may contribute to the shaping of policy, practice and future research. It also identifies a pivotal role for evidence synthesis and the importance of non-linear and intersectoral interfaces with the public realm.

Summary

We propose a research agenda to advance the field and argue that resources for 'applied' or 'translational' public health research should be deployed across the framework, not reserved for 'dissemination' or 'implementation'.

HIV exceptionalism (and disease-specific programs generally) garner both unbalanced funding and the most talented personnel, distorting local health priorities. In support of HIV exceptionalism, the successful mobilization of significant global health sector resources was not possible prior to HIV. Both sides of the debate have merits; rather than perpetuating polarization, we suggest that sustained improvements in global health require creating a prevention infrastructure to meet multiple health challenges experienced by local communities. We propose four fundamental shifts in HIV and disease prevention: (1) horizontally integrating prevention at one site locally, with priorities tailored to local health challenges and managed by local community leaders; (2) using a family wellness metaphor for services, not disease prevention; (3) implementing evidence-based prevention programs (EBPP) based on common principles, factors, and processes, rather than replication of specific programs; and (4) utilizing the expertise of private enterprise to re-design EBPP into highly attractive, engaging, and accessible experiences.

Background

Public health services implement individual, community and population level interventions to change health behaviours, improve healthy life expectancy and reduce health inequalities. Understanding and changing health behaviour is complex. Integrating behaviour change theory and evidence into interventions has the potential to improve services.

Methods

Health Psychologists apply evidence and theories aimed at understanding and changing health behaviour. A Scottish programme is piloting the training of Health Psychologists within NHS contexts to address prominent public health challenges.

Results

This article outlines the details of this novel programme. Two projects are examined to illustrate the potential of partnership working between public health and health psychology.

Conclusion

In order to develop and improve behaviour change interventions and services, public health planners may want to consider developing and using the knowledge and skills of Health Psychologists. Supporting such training within public health contexts is a promising avenue to build critical NHS internal mass to tackle the major public health challenges ahead.

Orthodontic treatment represents an important fraction in dental interventions. According to other medical methods the question for scientific evidence for the effectiveness of these treatments arises.

The question of the effectiveness is connected with the question what is understood as an effect. In principle, the effect of the intervention is understood on the basis of the occlusion or dental health, what disregards further functions of oral health. The generalization to oral health is therefore a necessary consideration in science now.

If one appreciates this further development, then there is no one single randomised study available which examines the long-term effect of the orthodontic intervention or for the effects on the oral health.

The question, whether the application of a fixed appliance in an orthodontic treatment causes a long-term improvement in oral health, cannot be answered at the present time. The scientific status is the definition of oral health at present. Also the question, whether in the long run the dental health can be improved by fixed appliances cannot be answered with a quality usually achieved by evidence-based medicine.

Whether correction of a dental malposition is an effective prerequisite for the preservation of the natural teeth, cannot be answered. There is no generalizing study with sufficient scientific background for Europe or Germany to this topic.

The risk for caries cannot be quantified. Caries is identified as a central topic in general but due to numerous factors influencing the risk it is not quantified.

The question of the indications is completely open from the scientific literature. For the question of the therapy need or therapy priority some indexes were developed, which lead to a quantification. These indices however are fundamentally criticised by recent research in their meaning and the empirical relevance.

There is an impression that there exists a big gap between the practical application and the scientific investigation of this effectiveness of fixed appliances or orthodontic treatment in general. There is much research in the area of diagnostics or further development of appliances or techniques done, however extremely few in the area of need for intervention, analysis of the sustainability; influence factors on the success, like caries or quantification of side effects e. g. root resorption.

This research to evaluate the indications is completely lacking, also the required evaluation parameters (e. g. means long-term dental maintenance).

This gap is in this respect dubious since a link of determining the demand (inducing demand) and supply in Central European health systems is economically given. This enables to create a possibility for a so-called supply induced demand.

To get rid of discussions that the professional work of orthodontics can be near to induced demand or unnecessary indications, research of this topic is quite essential. This requires much stronger information for indications. This can improve confidence for patients and insurance companies. Existing indices like the Index of Treatment Need (IOTN) seem to be of academic interest without practice importance for daily work.

The question which indications can be regarded as scientifically proven for the intervention must be given big attention immediately. The individual and subjective assessment of the orthodontist (whose experience is not doubted) has to be considered as not sufficient. The scientific background is absolutely necessary due to ethic reasons for the patient, economic reasons for the social insurance system or financiers and also for the orthodontists to evaluative and legitimates the treatment.

Well coordinated research with the goal of collecting specific data is urgently required for individual therapeutic processes with appropriate design. The study quality is also an essential topic. It is unacceptable at the beginning of the 21st century with the background of the evidence based medicine, that studies are published with enormous methodological errors. Orthodontics deserves a well discussed scientific position to prove the enormous individual success and to demonstrate the effectiveness of the developed treatments.

The effect of emergency department (ED) crowding on equitable care is the least studied of the domains of quality as defined by the Institute of Medicine (IOM). Inequities in access and treatment throughout the health care system are well documented in all fields of medicine. While there is little evidence demonstrating that inequity is worsened by crowding, theory and evidence from social science disciplines, as well as known barriers to care for vulnerable populations, would suggest that crowding will worsen inequities.

To design successful interventions, however, it is important to first understand how crowding can result in disparities and base interventions on these mechanisms. A research agenda is proposed to understand mechanisms that may threaten equity during periods of crowding and design and test potential interventions that may ensure the equitable aspect of quality of care.

A new emphasis on caries measurement and management is required for the dental community. The dental professionals need new approaches in caries detection, its assessment, and management. The future of research, practice, and education in Cariology requires the development of an integrated definition of dental caries, and uniform systems for measuring the caries process. Keeping this in view, the International Caries Detection and Assessment System (ICDAS) has presented a new paradigm for the measurement of dental caries, which was developed from the systematic reviews of literature on the clinical caries detection system and other sources. The ICDAS can serve as a basis and benchmark for clinical and epidemiological research and inform dental undergraduate and postgraduate teaching in Cariology. The ICDAS system was developed to bring forward the current understanding of the process of initiation and progression of dental caries to the fields of epidemiological and clinical research.

The mouth is an obvious portal of entry to the body, and oral health reflects and influences general health and well being. Maternal oral health has significant implications for birth outcomes and infant oral health. Maternal periodontal disease, that is, a chronic infection of the gingiva and supporting tooth structures, has been associated with preterm birth, development of preeclampsia, and delivery of a small-for-gestational age infant. Maternal oral flora is transmitted to the newborn infant, and increased cariogenic flora in the mother predisposes the infant to the development of caries. It is intriguing to consider preconception, pregnancy, or intrapartum treatment of oral health conditions as a mechanism to improve women's oral and general health, pregnancy outcomes, and their children's dental health. However, given the relationship between oral health and general health, oral health care should be a goal in its own right for all individuals. Regardless of the potential for improved oral health to improve pregnancy outcomes, public policies that support comprehensive dental services for vulnerable women of childbearing age should be expanded so that their own oral and general health is safeguarded and their children's risk of caries is reduced. Oral health promotion should include education of women and their health care providers ways to prevent oral disease from occurring, and referral for dental services when disease is present.