Determining the optimal model for role-substitution in NHS dental services in the United Kingdom

Background

Role-substitution describes a model of dental care where Dental Care Professionals (DCPs) provide some of the clinical activity previously undertaken by General Dental Practitioners. This has the potential to increase technical efficiency, the capacity to care and reduce costs. Technical efficiency is defined as the production of the maximum amount of output from a given amount of input so that the service operates at the production frontier i.e. optimal level of productivity. Academic research into technical efficiency is becoming increasingly utilised in health care, although no studies have investigated the efficiency of NHS dentistry or role-substitution in high-street dental practices. The aim of this study is to examine the barriers and enablers that exist for role-substitution in general dental practices in the NHS and to determine the most technically efficient model for role-substitution.

Methods/design

A screening questionnaire will be sent to DCPs to determine the type and location of role-substitutive models employed in NHS dental practices in the United Kingdom (UK). Semi-structured interviews will then be conducted with practice owners, DCPs and patients at selected sites identified by the questionnaire. Detail will be recorded about the organisational structure of the dental team, the number of NHS hours worked and the clinical activity undertaken. The interviews will continue until saturation and will record the views and attitudes of the members of the dental team. Final numbers of interviews will be determined by saturation.

The second work-stream will examine the technical efficiency of the selected practices using Data Envelopment Analysis and Stochastic Frontier Modeling. The former is a non-parametric technique and is considered to be a highly flexible approach for applied health applications. The latter is parametric and is based on frontier regression models that estimate a conventional cost function.

Discussion

Maximising health for a given level and mix of resources is an ethical imperative for health service planners. This study will determine the technical efficiency of role-substitution and so address one of the key recommendations of the Independent Review of NHS dentistry in England.

Strategies for maximizing consent rates for child dental health surveys: a randomised controlled trial

Background

Poor response rates can jeopardise the validity of the findings of epidemiological surveys. The aim of this study was to undertake a randomised controlled trial to determine the effectiveness of different strategies for maximizing parental consent rates for dental health surveys of young children.

Methods

The trial took place within the 2007/2008 NHS Epidemiological Dental Health Survey of 5-year-old children in the North West of England. Schools were randomised to one of five interventions: multiple letters to parents; promoting the research by providing additional information to parents and children; a financial incentive to the school; a financial incentive to the school administrator plus direct mailing to parents; and a control intervention comprising of usual practice, that is a single letter home to parents via the children.

Results

A total of 335 schools (11,088 children) were recruited. The mean percentage consent rates ranged from 47% (financial incentive to school administrator plus direct mailing) to 63% (multiple letters). Pair-wise comparisons indicated that the multiple letter group had a statistically significantly greater consent rate than the financial incentive to the school administrator plus direct mailing group and promoting the research by providing additional information group, but was not statistically significantly different from the financial incentive to the school group and the control group.

Conclusions

There was little evidence to show that any of the five interventions made a significant difference to consent rates when compared to the control group. Financial incentives to schools were less effective than multiple reminder letters to parents. Trials should be built into surveys to test different interventions, in different contexts to expand the evidence base for improving consent rates in health surveillance programmes.

The views of examiners on the use of intra-oral photographs to detect dental caries in epidemiological studies

AIM

The aim of the study was to obtain the views of examiners on their experience of using intra-oral photographs as a means of detecting caries in epidemiological studies compared to an established visual examination method.

METHOD

A focus group discussion was conducted with five examiners experienced in an established visual examination method after they had performed visual dental examinations of a sample of children as well as assessed intra-oral photographs of the same children.

RESULTS

The time taken by examiners to assess intraoral photographs becomes extended when compared to performing a visual examination. The ability to assess intra-oral photographs on a screen at a convenient time and place was considered advantageous. The examiners found it easier to make caries detection decisions on intra-oral photographs of primary teeth than permanent teeth. Adequate removal of debris and moisture control prior to obtaining the photographs were considered important.

CONCLUSION

The views of examiners in this study suggest that to improve the utility of photographic method, further research is needed to determine adequate drying methods for use in the field. Consideration should be given to a time-limited, standardised presentation of the photographs including the size and resolution. Specific training on caries detection from photographs is also required.

Comparison of caries detection methods using varying numbers of intra-oral digital photographs with visual examination for epidemiology in children

Background

This was a method comparison study. The aim of study was to compare caries information obtained from a full mouth visual examination using the method developed by the British Association for the Study of Community Dentistry (BASCD) for epidemiological surveys with caries data obtained from eight, six and four intra-oral digital photographs of index teeth in two groups of children aged 5 years and 10/11 years.

Methods

Five trained and calibrated examiners visually examined the whole mouth of 240 5-year-olds and 250 10-/11-year-olds using the BASCD method. The children also had intra-oral digital photographs taken of index teeth. The same 5 examiners assessed the intra-oral digital photographs (in groups of 8, 6 and 4 intra-oral photographs) for caries using the BASCD criteria; dmft/DMFT were used to compute Weighted Kappa Statistic as a measure of intra-examiner reliability and intra-class correlation coefficients as a measure of inter-examiner reliability for each method. A method comparison analysis was performed to determine the 95% limits of agreement for all five examiners, comparing the visual examination method with the photographic assessment method using 8, 6 and 4 intra-oral photographs.

Results

The intra-rater reliability for the visual examinations ranged from 0.81 to 0.94 in the 5-year-olds and 0.90 to 0.97 in the 10-/11-year-olds. Those for the photographic assessments in the 5-year-olds were for 8 intra-oral photographs, 0.86 to 0.94, for 6 intra-oral photographs, 0.85 to 0.98 and for 4 intra-oral photographs, 0.80 to 0.96; for the 10-/11-year-olds were for 8 intra-oral photographs 0.84 to 1.00, for 6 intra-oral photographs 0.82 to 1.00 and for 4 intra-oral photographs 0.72 to 0.98. The 95% limits of agreement were −1.997 to 1.967, -2.375 to 2.735 and −2.250 to 2.921 respectively for the 5-year-olds and −2.614 to 2.027, -2.179 to 3.887 and −2.594 to 2.163 respectively for the 10-/11-year-olds.

Conclusions

The photographic assessment method, particularly assessment of 8 intra-oral digital photographs is comparable to the visual examination method in the primary dentition. With the additional benefits of archiving, remote scoring, allowing multiple scorers to score images and enabling longitudinal analysis, the photographic assessment method may be used as an alternative caries detection method in the primary dentition in situations where the visual examination method may not be applicable such as when examiner blinding is required and in practice based randomised controlled trials (RCTs).

Letter from America: UK and US state-funded dental provision

OBJECTIVES

Current UK and US economic conditions have re-focussed attention on the need to deliver dental care with limited finance and resources. This raises hard questions determining which services will be offered and what they should achieve to satisfy public demands and needs. We consider impending dental health reforms in the US and UK within the context of contemporary experiences to identify issues and delivery goals for the two nations.

BACKGROUND

The paper provides a brief history and background of the development of social dental care models in the UK and US, highlighting some differences in state-funded delivery of dental care. SHIFTING DEMAND: From the 1950s, demand for dental treatment has increased and acquired a more complex composition growing from predominantly surgical and restorative treatment to encompass preventive care and cosmetic services. PRIORITISING CARE ACCORDING TO NEED: Despite improvements in general health and technology, inequalities in access and utilisation of dental care are still experienced, primarily by groups with low socio-economic status. DELIVERY: BALANCING RESOURCES, DEMAND AND NEED: In developing and delivering reform agendas, much can be learned from previous policy interventions. Pressures of cost, coverage, and capacity, besides demand versus need must be carefully considered and balanced to deliver quality service and value for users and taxpayers.

CONCLUSIONS

Ethical and moral consideration should be given to making services needs-driven to address high treatment requirements rather than the high care demands of the worried well. This challenge brings the additional political pressure of convincing many of the voters (and subsequent complainers) that their demands may be less important than the needs of others.

Children's views on the experience of a visual examination and intra-oral photographs to detect dental caries in epidemiological studies

AIM

To elicit children's views on the established visual examination method used for the epidemiological surveillance of dental caries and an experimental intra-oral photographic examination method.

METHOD

Focus group interviews were conducted with 5-year-olds (with the aid of a puppet) and 10/11-year-olds (without puppet) after experiencing both methods. Ten focus groups were conducted in each cohort.

RESULTS

The children's views on the methods related to the acceptability of their experience. The key factors affecting acceptability and preferences related to the combined effects of contextual factors prior to the examination and experiences during the examination. These included communication and children's expectations. These factors influenced the examination experience along with their feelings about the environment and the tactile sensation from instruments in the mouth. Most children preferred the experimental photographic method as a means of caries detection over the traditional visual examination. They also wanted feedback on their oral health and more communication on what was happening during the examination. CONCLUSION Appropriate communication, attention to the examination environment and handling of instruments can enhance the dental examination experience for children in the school setting. The children's preferences indicated that generally, the intra-oral camera was well received as a means of caries detection for epidemiological studies within the school setting. These results may have implications for seeking ethical approval and conducting epidemiological studies on children in the future.

Systemic interventions for recurrent aphthous stomatitis (mouth ulcers)

BACKGROUND

Recurrent aphthous stomatitis (RAS) is the most frequent form of oral ulceration, characterised by recurrent oral mucosal ulceration in an otherwise healthy individual. At its worst RAS can cause significant difficulties in eating and drinking. Treatment is primarily aimed at pain relief and the promotion of healing to reduce the duration of the disease or reduce the rate of recurrence. A variety of topical and systemic therapies have been utilised.

OBJECTIVES

To determine the clinical effect of systemic interventions in the reduction of pain associated with RAS, a reduction in episode duration or frequency.

SEARCH METHODS

We undertook electronic searches of: Cochrane Oral Health Group and PaPaS Trials Registers (to 6 June 2012); CENTRAL via The Cochrane Library (to Issue 4, 2012); MEDLINE via OVID (1950 to 6 June 2012); EMBASE via OVID (1980 to 6 June 2012); CINAHL via EBSCO (1980 to 6 June 2012); and AMED via PubMed (1950 to 6 June 2012). We searched reference lists from relevant articles and contacted the authors of eligible trials to identify further trials and obtain additional information.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in which the primary outcome measures assess a reduction of pain associated with RAS, a reduction in episode duration or a reduction in episode frequency. Trials were not restricted by outcome alone. We also included RCTs of a cross-over design.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data in duplicate. We contacted trial authors for details of randomisation, blindness and withdrawals. We carried out risk of bias assessment on six domains. We followed The Cochrane Collaboration statistical guidelines and risk ratio (RR) values were to be calculated using fixed-effect models (if two or three trials in each meta-analysis) or random-effects models (if four or more trials in each meta-analysis).

MAIN RESULTS

A total of 25 trials were included, 22 of which were placebo controlled and eight made head-to-head comparisons (five trials had more than two treatment arms). Twenty-one different interventions were assessed. The interventions were grouped into two categories: immunomodulatory/anti-inflammatory and uncertain. Only one study was assessed as being at low risk of bias. There was insufficient evidence to support or refute the use of any intervention.

AUTHORS' CONCLUSIONS

No single treatment was found to be effective and therefore the results remain inconclusive in regard to the best systemic intervention for RAS. This is likely to reflect the poor methodological rigour of trials, and lack of studies for certain drugs, rather than the true effect of the intervention. It is also recognised that in clinical practice, individual drugs appear to work for individual patients and so the interventions are likely to be complex in nature. In addition, it is acknowledged that systemic interventions are often reserved for those patients who have been unresponsive to topical treatments, and therefore may represent a select group of patients.

Comparison of photographic and visual assessment of occlusal caries with histology as the reference standard

Background

The purpose of this study was to compare diagnostic performance for the detection of caries using photographs with an established visual examination method and histological sections as the reference standard.

Methods

50 extracted permanent teeth were assessed for the presence of occlusal caries by 9 examiners using two methods; traditional visual examination developed by BASCD and photographs produced by an intra-oral camera. For both methods, diagnoses were made at “caries into dentine” level. The teeth were histologically sectioned and the diagnostic decisions using visual and photographic assessment were compared to the histological reference standard. Inter- and intra- examiner reliability for the methods was assessed and weighted kappa values were calculated.

Results

The visual examination method had a median sensitivity value of 65.6% and a median specificity value of 82.4%. The photographic assessments method had a median sensitivity of 81.3% and a median specificity of 82.4%.

Conclusions

The photographic assessments method had a higher sensitivity for caries detection than the visual examination. The two methods had comparable specificities and good intra- and inter- examiner reliability.

Predictors of pain associated with routine procedures performed in general dental practice

OBJECTIVES

The objective of the study was to investigate factors that influence pain intensities associated with routine dental procedures.

METHOD

Four hundred and fifty-one dental patients self-reported pain experienced during the procedure immediately after undergoing a variety of common dental interventions and 1 day after the completion of the procedure. Pain character was measured using the McGill short-form pain questionnaire and intensity using a numerical rating (NRS) scale. Information was collected on a number of factors that could influence pain: dental anxiety was measured using the Corah Dental Anxiety Scale to categorize patients into four domains (fearless, some unease, nervous and very anxious). Dentists provided information regarding the type(s) of procedure and use of local anaesthetic (LA).

RESULTS

Seventy-five percent of patients (339/451) reported no pain during their procedure when the data were collected immediately postoperatively (NRS score = 0). Univariate analyses showed that dental anxiety, LA use and type of procedure (extractions) were significant (P < 0.05) predictors of reported intra-operative pain. However, when these factors were combined in a multivariate model, the strongest predictor of pain was dental anxiety [odds ratio (OR) = 4.98 (95% CI 1.42-17.44)] and LA use [OR = 2.79 (95% CI 1.39-5.61)]. Although the strongest predictor of postoperative pain on the next day was pain reported during the procedure [OR = 5.85 (95% CI 2.71-12.64)], LA remained a significant predictor of pain the day after the procedure [OR = 3.16 (95% CI 1.02-9.81)].

CONCLUSIONS

Dentists need to assess their patients both preoperatively for dental anxiety and intra-operatively for signs of suboptimal local anaesthesia so as to effectively align patient management and clinical techniques to control dental anxiety and produce adequate anaesthesia.

Conundrums in health care reform: current experiences across the North Atlantic

OBJECTIVE

To assist stakeholders (policy makers, dentists and patients) implementing the Patient Protection and Affordable Care Act of 2010 in the United States by providing information on conundrums arising from previous policies of the UK Labour government and emergent policies of the recently elected Coalition Government.

METHODS

The authors provide a background to the development of National Health Service dental services contrasted with US provision. Considerations are given from the different perspectives of stakeholders involved (policy makers, dentists, and patients).

CONCLUSIONS

Policy makers must work under pressure for services to remain within boundaries of finite economic resources and what people are willing to pay for. The importance is stressed that they respond to public demands and workforce capability by clearly determining what the priorities should be, what services will be delivered, and defining responsibilities.

Clinical outcomes of single-visit oral prophylaxis: a practice-based randomised controlled trial

BACKGROUND

Practice-based general dental practitioners routinely provide "scale and polish" or "oral prophylaxis" to patients attending their practices. Despite its routine provision, there is no evidence to support the clinical effectiveness of single-visit scale and polish, nor the frequency at which it should be provided. A recent systematic review recommended that future trials investigating scale and polish should involve dental practice patients.

METHODS

A practice-based parallel randomised controlled trial with 24-month follow-up was conducted. Healthy adults (Basic Periodontal Examination [BPE] codes <3) were randomly assigned to 3 groups (6-month, 12-month, or 24-month interval between scale and polish). The primary outcome was gingival bleeding with the hypothesis that 6-monthly scale and polish would result in lower prevalence than 12-month or 24-month frequency. Follow-up measurements were recorded by examiners blinded to the allocation. 125, 122 and 122 participants were randomised to the 6-month, 12-month and 24-month groups respectively. Complete data set analyses were conducted for 307 participants: 107, 100, and 100 in the 6-month, 12-month and 24-month groups respectively. Chi-square test and ANOVA were used to compare treatment groups at follow-up. Logistic regression and ANCOVA were used to estimate the relationship between outcome and treatment group, adjusted for baseline values. Multiple imputation analyses were also carried out for participants with incomplete data sets.

RESULTS

Prevalence of gingival bleeding at follow-up was 78.5% (6-month), 78% (12-month) and 82% (24-month) (p = 0.746). There were no statistically significant differences between groups with respect to follow-up prevalence of plaque and calculus. Statistically significant differences detected in the amount (millimetres) of calculus were too small to be clinically significant. Seventeen (4.6%) participants were withdrawn from the trial to receive additional treatment.

CONCLUSIONS

This trial could not identify any differences in outcomes for single-visit scale and polish provided at 6, 12 and 24 month frequencies for healthy patients (with no significant periodontal disease). However, this is the first trial of scale and polish which has been conducted in a general practice setting and the results are not conclusive. Larger trials with more comprehensive measurement and long-term follow up need to be undertaken to provide a firm evidence base for this intervention. This trial informs the design of future practice-based trials on this subject.

Protocol for Northern Ireland Caries Prevention in Practice Trial (NIC-PIP) trial: a randomised controlled trial to measure the effects and costs of a dental caries prevention regime for young children attending primary care dental services

BACKGROUND

Dental caries is a persistent public health problem with little change in the prevalence in young children over the last 20 years. Once a child contracts the disease it has a significant impact on their quality of life. There is good evidence from Cochrane reviews including trials that fluoride varnish and regular use of fluoride toothpaste can prevent caries. The Northern Ireland Caries Prevention in Practice Trial (NIC-PIP) trial will compare the costs and effects of a caries preventive package (fluoride varnish, toothpaste, toothbrush and standardised dental health education) with dental health education alone in young children.

METHODS/DESIGN

A randomised controlled trial on children initially aged 2 and 3 years old who are regular attenders at the primary dental care services in Northern Ireland. Children will be recruited and randomised in dental practices. Children will be randomised to the prevention package of both fluoride varnish (twice per year for three years), fluoride toothpaste (1,450 ppm F) (supplied twice per year), a toothbrush (supplied twice a year) or not; both test and control groups receive standardised dental health education delivered by the dentist twice per year. Randomisation will be conducted by the Belfast Trust Clinical Research Support Centre ([CRSC] a Clinical Trials Unit). 1200 participants will be recruited from approximately 40 dental practices. Children will be examined for caries by independent dental examiners at baseline and will be excluded if they have caries. The independent dental examiners will examine the children again at 3 years blinded to study group.The primary end-point is whether the child develops caries (cavitation into dentine) or not over the three years. One secondary outcome is the number of carious surfaces in the primary dentition in children who experience caries. Other secondary outcomes are episodes of pain, extraction of primary teeth, other adverse events and costs which will be obtained from parental questionnaires.

DISCUSSION

This is a pragmatic trial conducted in general dental practice. It tests a composite caries prevention intervention, which represents an evidence based approach advocated by current guidance from the English Department of Health which is feasible to deliver to all low risk (caries free) children in general dental practice. The trial will provide valuable information to policy makers and clinicians on the costs and effects of caries prevention delivered to young children in general dental practice.

TRIAL REGISTRATION

EudraCT No: 2009 - 010725 - 39 ISRCTN: ISRCTN36180119 Ethics Reference No: 09/H1008/93:

QIPP: cutting budgets or working smarter?

The Department of Health's response to the national budget deficit is to ensure that the provision of NHS services is guided by four fundamental 'QIPP' principles: Quality, Innovation, Prevention, and Productivity. This agenda will govern all aspects of the National Health Service's (NHS') health care provision for the foreseeable future. NHS dental services will, like all other NHS services, need to make a contribution to the QIPP agenda. The purpose of this paper is to outline the implications for NHS dentistry.

A cluster-randomized controlled trial: fluoride varnish in school children

We conducted a school-based parallel cluster randomized controlled trial with 36-month follow-up of children aged 7 to 8 years. Primary schools were randomly assigned to 2 groups: 3 applications of fluoride varnish (22,600 ppm) each year or no intervention. The primary outcome was DFS increment in the first permanent molars, with the hypothesis that 9 applications of varnish over 3 years would result in a lower increment in the test group. Follow-up measurements were recorded by examiners blind to the allocation. Ninety-five schools were randomized to the test and 95 to the reference groups; 1473 (test) and 1494 (reference) children participated in the trial. An intention-to-treat analysis was carried out with random effects models. The DFS increment was 0.65 (SD 2.15) in the test and 0.67 (SD 2.10) in the reference groups, respectively. There was no statistically significant difference between the groups. We were unable to demonstrate an effect for fluoride varnish when it was used as a public health intervention to prevent caries in the first permanent molar teeth (Inter-national Standard Randomized Controlled Trial Registration: ISRCTN: #72589426).

A qualitative investigation of the views of primary care dentists on participating in prospective studies in the North-West of England

BACKGROUND

There is a poor understanding of to how to recruit and involve primary care dentists in clinical trials.

AIM

To use a qualitative paradigm to explore the views of primary care dentists towards participating in clinical trials and develop an understanding of the factors that facilitate and prevent their involvement. DESIGN, SETTING, SUBJECTS AND METHODS: An iterative approach was undertaken using a focus group (n = 6) followed by phased semi-structured interviews (n = 18). Data were analysed using thematic analysis and constant comparative analysis.

FINDINGS

The semi-structured interviews generated nine codes which were organised into three themes: technical issues for trials in primary dental care, practical issues for research in primary dental care and primary care dentists as research consumers. Overall, primary care dentists had a poor understanding of research methodology and clinical research. Barriers to participation included loss of clinical freedom and control, practice disruption, patient welfare, staff workload, financial loss and time.

CONCLUSIONS

Barriers to primary dental care research need to be overcome through appropriate protocols, funding, training and support. Joint working of primary dental care teams and academic researchers is essential, along with a constructive and open dialogue, if clinical trials are to be successfully undertaken in a practice environment.

Estimating the potential impact on dental caries in children of fluoridating a UK city

OBJECTIVE

To estimate the potential reduction in dental caries among 5-6-year-old children in a city in the South West of England after six years of water fluoridation.

METHOD

Thirteen out of 35 inner city wards and seven out of 43 outer city wards (sharing the same water supply) having the highest mean dmft of 5-6-year-olds (recorded in a census survey in 2005/6) and/or highest indexes of multiple deprivation (IMD) were the principal focal point. Population demographic data and 5-6-year-old caries prevalence and experience were examined. Mean IMD scores and aggregated, weighted mean values for dmft and caries prevalence were referred to previously published regression analyses of caries levels plotted against IMD for 34 fluoridated (F) and 233 non-fluoridated (NF) health districts in England in order to estimate potential caries reductions.

RESULTS

Mean dmft of 5-6-year-olds in the 20 wards with the highest caries levels and/or social deprivation was 2.10 (95% CI 1.87, 2.33) and caries prevalence 49% (95% CI 47%, 52%). In three wards, mean dmft exceeded 2.60. Population of the selected wards was approximately 210,800 with a mean IMD score of 33.70 As a conservative estimate, after six years of fluoridation a caries reduction of > 40% could be expected in 5-6-year-olds for the conurbation overall and for the 20 high caries/high IMD wards, with a gain of 12 percentage points in the absolute proportion caries-free. The overall population of the 78 wards served by the three relevant water treatment works identified was approximately 700,000.

CONCLUSIONS

On the basis of current caries levels and population demographics, it appears that a comprehensive fluoridation scheme covering the inner and outer city districts would substantially improve the dental health of the city's children.