Primary and secondary dental care: how ideal is the interface?

Association between socioeconomic contextual factor, dental care service availability, and prevalence of periodontitis in Brazil: a multilevel analysis

This study aimed to examine the effect of dental care services on periodontitis cases in Brazilian municipalities. The sample comprised 3,426 individuals aged 35-44 years. Moderate to severe periodontitis with clinical attachment loss and probing depth was the dependent variable, both > 3mm. Its exploratory variables were grouped into four categories: (1) individual characteristics; (2) contextual development indicators; (3) health service and structural factors; and (4) dental care use. Data were collected using the SBBrasil 2010 Project, the Brazilian Institute of Geography and Statistics, the Brazilian Information System of Primary and Secondary Care, and the Program to Improve Access and Quality of Dental Specialization Centers (PMAQ-CEO). Multilevel logistic regression was used to assess associations of periodontitis with individual and context variables. Municipalities with > 1 CEO or > 1 of any centers were associated with periodontitis, with OR = 0.97 (95%CI: 0.55-1.71) and OR = 0.41 (95%CI: 0.17-0.97), respectively. Prevalence of periodontitis was more likely in older people, lower education levels, and individuals that sought dental visits for pain/extraction and periodontal treatment. Other dental care services availability were not associated with the prevalence of periodontitis.

Effectiveness of and Patient’s Satisfaction with Dental Emergency Unit in Pitié Salpêtrière Hospital (Paris), Focusing on Pain and Anxiety

Background

The Dental Emergency Unit (DEU) of the Pitié Salpêtrière Hospital receives mainly painful emergencies. This study aimed at evaluating the suppression of pain and anxiety as well as the patient's satisfaction after a visit to the DEU. Patients and Methods. A prospective study was carried out in 2019 (NCT03819036) in adult patients. Data was collected on D0 on site and then on D1, D3, and D7 by phone, during daytime. The main objective and secondary objectives were, respectively, to assess the intensity of pain on D1; the intensity of pain on D3 and D7; the evolution of anxiety on D1, D3, and D7; and the patients' satisfaction. They were evaluated with a 0–10 numeric scale (NS) on D1, D3 and D7; mean scores were compared with nonparametric statistics (ANOVA, Dunn's test).

Results

814 patients were contacted and 581 patients included; 87 were lost to follow-up. 376 patients completed all the questionnaires. In the final sample (59% men, 40 ± 16 y.o.), 86% had health insurance. The mean pain scores were as follows: D0: 6.36 ± 0.12; D1: 3.49 ± 0.13; D3: 2.23 ± 0.13; D7: 1.07 ± 0.11—indicating a significant decrease of 45%, 65%, and 93% on D1, D3, and D7, respectively, compared to D0 (p < 0.0001) between D0 and D1, D3, D7. The mean NS anxiety scores were as follows: D0: 3.32 ± 0.15; D1: 3.69 ± 0.16; D3: 2.75 ± 0.16; D7: 1.98 ± 0.15. The decrease was significant between D0 and D7 (p < 0.0001). The perception of general heath improved between D1 and D7. The overall score of satisfaction was 8.64 ± 0.06.

Conclusion

DEU enabled a significant reduction in pain and anxiety with high overall satisfaction.

Referrals to Urgent Dental Centres During the COVID-19 Pandemic: A Multi-Site Analysis Research Project

INTRODUCTION

The COVID-19 pandemic enforced the cessation of routine dentistry and the creation of local urgent dental care systems in the UK. General dental practices are obligated by NHS guidance to remain open and provide remote consultation and referral where appropriate to patients having pain or problems.

AIMS

To compare two urgent dental centres with different triage and referral systems with regard to quality and appropriateness of referrals, and patient management outcomes.

METHODS

110 consecutive referrals received by a primary care urgent dental centre and a secondary care urgent dental centre were assessed. It was considered whether the patients referred had access to remote primary care dental services, fulfilled the criteria required to be deemed a dental emergency as mandated by NHS guidance, and what the outcomes of referrals were.

RESULTS

At the primary care centre, 100% of patients were referred by general dental practitioners and had access to remote primary care dental services. 95.5% of referrals were deemed appropriate and were seen for treatment. At the secondary care site, 94.5% of referrals were direct from the patient by contacting NHS 111. 40% had received triaging to include 'advice, analgesia and antimicrobial' from a general dental practitioner, and 25.5% were deemed appropriate and resulted in treatment.

CONCLUSION

Urgent dental centres face many issues, and it would seem that easy access to primary care services, collaboration between primary care clinicians and urgent dental centres, and training of triaging staff are important in operating a successful system.

Dental emergency: Scoping review

Part of the oral health care in the care network encompasses users in emergency cases. This study proposed mapping the determinants of the use of dental care services within the health care network to address dental emergencies within the Brazilian Unified Health System (UHS) and to verify the main gaps in the research in this area. This is a scoping review that took place in 2018 using Andersen's behavioral model as a reference. A total of 16 studies, out of 3786 original articles identified, were included and reviewed. Two reviewers independently conducted the selection process and the decision was consensually made. The mapping of the determinants revealed a greater number of enabling factors and a larger gap in the results. Greater use of the emergency service was registered by people in pain, women, adults, those from an urban area, people with a lower income, and those with less education. In future studies, primary surveys are recommended, which include all ages, and analyze different groups of needs and users that take into account the country's northern region and the different subjects pointed out by this review.

Evaluation of secondary care in endodontics at a Dental Specialties Center (DSC)

This study aimed to evaluate secondary endodontic care at a Dental Specialties Center (DSC) in Belo Horizonte, MG. Data collection used two forms: (1) on endodontic treatment, completed by the endodontists (2) on the restorative treatment, with data from the medical records. The SPSS 22.0 program was used to analyze the results using frequency and percentiles. In total, 452 endodontic procedures were completed in adult patients. The patients had a median of 39 years of age, most were female (69.7%) and had a primary care referral order (96.2%). Most endodontic treatments were performed in upper premolars (23.7%) followed by lower molars (22.3%), using a mixed technique (74.1%) and in a single session (64.2%). The referral for restorative treatment was for the DSC in 81.2% of cases and finished in 24.1% (n = 109). The counter-referral following restorative treatment occurred in 58.7% of the completed cases. It is necessary to jointly plan the dental treatment between primary and secondary care and, within the latter, among the specialties, in addition to an adequate referral and counter-referral process aimed at ensuring comprehensive care and efficient and effective service.

An evaluation of a referral management and triage system for oral surgery referrals from primary care dentists: a mixed-methods study

Background

Oral surgery referrals from dentists are rising and putting increased pressure on finite hospital resources. It has been suggested that primary care specialist services can provide care for selected patients at reduced costs and similar levels of quality and patient satisfaction.

Research questions

Can an electronic referral system with consultant- or peer-led triage effectively divert patients requiring oral surgery into primary care specialist settings safely, and at a reduced cost, without destabilising existing services?

Design

A mixed-methods, interrupted time study (ITS) with adjunct diagnostic test accuracy assessment and health economic evaluation.

Setting

The ITS was conducted in a geographically defined health economy with appropriate hospital services and no pre-existing referral management or primary care oral surgery service. Hospital services included a district general, a foundation trust and a dental hospital.

Participants

Patients, carers, general and specialist dentists, consultants (both surgical and Dental Public Health), hospital managers, commissioners and dental educators contributed to the qualitative component of the work. Referrals from primary care dental practices for oral surgery procedures over a 3-year period were utilised for the quantitative and health economic evaluation.

Interventions

A consultant- then practitioner-led triage system for oral surgery referrals embedded within an electronic referral system for oral surgery with an adjunct primary care service.

Main outcome measures

Diagnostic test accuracy metrics for sensitivity and specificity were calculated. Total referrals, numbers of referrals sent to primary care and the cost per referral are reported for the main intervention. Qualitative findings in relation to patient experience and whole-system impact are described.

Results

In the diagnostic test accuracy study, remote triage was found to be highly specific (mean 88.4, confidence intervals 82.6 and 92.8) but with lower values for sensitivity. The implementation of the referral system and primary care service was uneventful. During consultant triage in the active phases of the study, 45% of referrals were diverted to primary care, and when general practitioner triage was used this dropped to 43%. Only 4% of referrals were sent from specialist primary care to hospital, suggesting highly efficient triage of referrals. A significant per-referral saving of £108.23 [standard error (SE) £11.59] was seen with consultant triage, and £84.13 (SE £11.56) with practitioner triage. Cost savings varied according the differing methods of applying the national tariff. Patients reported similar levels of satisfaction for both settings, and speed of treatment was their over-riding concern.

Conclusions

Implementation of electronic referral management in primary care can lead, when combined with triage, to diversions of appropriate cases to primary care. Cost savings can be realised but are dependent on tariff application by hospitals, with a risk of overestimating where hospitals are using day case tariffs extensively.

Study limitations

The geographical footprint of the study was relatively small and, hence, the impact on services was minimal and could not be fully assessed across all three hospitals.

Future work

The findings suggest that the intervention should be tested in other localities and disciplines, especially those, such as dermatology, that present the opportunity to use imaging to triage.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Interface entre a Atenção Primária e a Secundária em odontologia no Sistema Único de Saúde: uma revisão sistemática integrativa

Resumo A atenção secundária em odontologia no Brasil apresenta recursos escassos e em grande parte subutilizados. O desafio consiste em realizar a interface entre a atenção primária à saúde (APS) e a atenção secundária de forma a consolidar o acesso da população à atenção odontológica especializada no Sistema Único de Saúde (SUS). O objetivo deste artigo é analisar publicações nacionais em língua portuguesa e inglesa sobre a interface entre a atenção secundária e a APS em odontologia na perspectiva da integralidade do cuidado no âmbito do SUS. Revisão integrativa considerando as publicações dos seguintes bancos de dados: SciELO (Scientific Eletronic Library Online), Lilacs (Literatura Latino-Americana e do Caribe), Web of Science, Scopus, PubMed (Literatura Internacional em Ciências da Saúde) e Google Acadêmico. Foram encontrados 966 artigos, dos quais 12 foram utilizados na integra. A cobertura das equipes de saúde bucal (ESB) nas estratégias de saúde da família (ESF), a implantação da APS de forma estruturada, o acesso a atenção secundária, o contrarreferenciamento para APS, os indicadores de desenvolvimento e as condições socioeconômicas e desigualdades na distribuição dos CEO’s são fatores que influenciam a integralidade do cuidado em saúde bucal no SUS.

Orthodontic referrals: why do GDPs get it wrong?

Aim &objectives A clinical audit was carried out to assess suitability of orthodontic referrals at Kings College Hospital Orthodontic Department with the objective to investigate the reasons and seek solutions to inappropriate orthodontic referrals.Design and setting Prospective audits of consecutive new patient referrals to the King's College Hospital Orthodontic department diagnostic teaching clinics.Methodology Two hundred and twenty-eight patients referred to the orthodontic diagnostic teaching clinics over a 5-month period were assessed. Data were collected using a questionnaire, completed by the undergraduate dental student and checked by the supervising clinical teacher. A second audit cycle was carried using the same methods after implementation of an action plan devised for referral guidelines and pathway to be sent back to the referring practitioner.Results At the initial audit cycle, 37.2% of patients met the standards, dropping to 33.3% at second audit cycle demonstrating high levels of inappropriate referrals. Our results showed: poor use of IOTN, patients presenting with IOTN scores too low for treatment, poor oral hygiene and caries; patients presenting too early for treatment, adult patients; and incorrect referral pathway implementation. Targeted education of referring practitioners via referral guidelines were found ineffective. We suggest that other methods to improve the quality of referrals are required, such as proformas and improving education among the profession.

The Interface between Primary Care and Emergency Dental Services (SOU) in the SUS: the interface between levels of care in oral health

Considering that emergency dental services include the referral network and the counter-referral network, interacting at the intersection between primary, secondary and tertiary healthcare, this study aims to describe the interface between primary healthcare (APS - Atenção Primária a Saúde), particularly of the Family Health Strategy, and secondary care in oral health, using the Emergency Dental Services (SOU), in the municipality of Recife. It is a qualitative, exploratory and descriptive case study. The data was collected through semi-structured interviews. Classical ALCESTE analysis was used based on the Descending Hierarchical Classification Dendrogram, making it possible to understand the expressions and each one of the words spoken by the dental health professionals, analyzing them using their social places and contexts as a starting point. What we found was only a fragile degree of integration, and little capacity for solution, between the levels of care - a partially disconnected network. Undoubtedly the problems with the interface between primary care and the emergency services in oral health are multiple and complex. The individual solutions have low efficacy, and are complex in their operation.

Perceptions of Private Dental Practitioners of Specialist Prosthodontic Dental Services in Gujarat: A Survey

To identify the perceptions towards and utilization of specialist Prosthodontic services among Private Dental Practitioners (PDPs) of Gujarat state. To study the influence of presence or absence of a Prosthodontic post graduate course during the PDP's dental education and years of experience in practice on the decisions to treat Prosthodontic cases themselves or to utilise Prosthodontic speciality services. A postal questionnaire examined by a panel of Prosthodontists, piloted on 15 PDPs, was sent to 150 randomly selected private dental practitioners of Gujarat state. The collected data were subjected to descriptive and Chi-square statistical analysis. Though 78.64 % dentists considered the treatment provided by the Prosthodontist to be effective, only 34.95 % of them availed their services. 33 % PDPs without a Prosthodontic post graduate course in their institute were significantly more likely to refer patients to a Prosthodontist. Years of experience had no influence on utilization of Prosthodontic speciality service. 18.44 % PDPs had a Prosthodontic speciality clinic in their region, 65.04 % did not have, whereas 11.65 % were not aware of such clinic. PDPs have high regards for the Prosthodontic speciality but their reported demand was less as compared to other specialities indicating a need for the Prosthodonitst to put in efforts to make the PDPs aware of their services.

Who did not appear? First dental visit absences in secondary care in a major Brazilian city: a cross-sectional study

The study sought to identify possible factors associated with non-attendance at first dental appointments scheduled in 2011 of users living in Belo Horizonte, Minas Gerais, who were referred from primary care to different dental specialties in secondary care within the public health services of the city. A cross-sectional study was conducted based on research in secondary data bases of the public health regulatory system. The dependent variable was "no shows" for scheduled appointments, and the independent variables were age, time on the waiting list, gender, health district, and the specialty to which the individual was referred. Among the 6,428 first dental visits scheduled for 2011 in the specialties selected for analysis, 32.9 % were not performed due to the absence of the user. Bivariate analysis revealed a statistically significant association between non-attendance of the user and the five independent variables. Young adults, male, and resident in given districts who were referred to the specialties of surgery and endodontics and who waited longer on the waiting list exhibited a higher frequency of no-shows.

Análise da atenção secundária em saúde bucal no estado de Minas Gerais, Brasil

Este estudo descreveu e analisou os procedimentos especializados ambulatoriais nas áreas de periodontia, endodontia e cirurgia bucal em Minas Gerais, 2010. Utilizou-se dados secundários dos procedimentos realizados nos estabelecimentos de saúde e registrados no Sistema de Informação do Sistema Único de Saúde. A análise descritiva e bivariada foi realizada, considerando p < 0,05. Foram executados 707.559 procedimentos em 2.547 unidades de saúde distribuídas em 693 (81%) municípios. Destes procedimentos, 55% são da área de cirurgia, 28% da periodontia e 17% são da endodontia. As unidades são predominante públicas, sob administração municipal, 52,5% possuem alguma equipe de saúde bucal (ESB), 96,9% não tem habilitação como Centros de Especialidades Odontológicas (CEO). Os CEO são mais eficientes que as demais unidades (p < 0,001), mas há importante percentual que não cumpre as metas do Ministério da Saúde. Os municípios com CEO possuem maior população, mais ESB, menor cobertura potencial por estas e melhores IDH. Um significativo número de procedimentos especializados é realizado, especialmente em estabelecimentos de atenção básica. CEO são mais eficientes do que os não CEO, considerandose a média de procedimentos realizados. As metas de produção mínima são cumpridas por uma minoria de CEO.

[Evaluation of the accessibility to the Specialized Dental Care Center within the scope of the macro region of Sobral, in the state of Ceará, Brazil]

The Specialized Dental Care Center for the region of Sobral in the state of Ceará (CEO-R) has characteristics that render it unique, as it has regional coverage and is managed by a Local Health Consortium (which comprises 24 cities). It also works in conjunction with the School of Dentistry of the Federal University of Ceará - Sobral Campus, combining care and academic study in the same location. The scope of this article was to evaluate the accessibility to specialized care in this region with the implementation of this CEO-R. A descriptive-exploratory study with a quantitative approach was conducted by means of the collection and analysis of secondary data regarding the availability and usage of this service in addition to the application of semi-structured interviews with Oral Health Coordinators of the 24 municipalities in the consortium. The results showed that the CEO-R is equipped to meet the demand. However, geographic, financial and organizational barriers were detected, which explains the low rates of appointments scheduled and use of the services and the high rate of missed appointments, causing a significant financial impact on the cities included in the consortium.

A survey of the perception of comprehensiveness among dentists in a large Brazilian city

Objectives: To quantitatively identify the perception of dentists regarding comprehensiveness and its domains of “patient welcoming”, “bonding” and “quality of care” in primary dental care settings of a large Brazilian city. Methods: A questionnaire was administered to all dentists comprising the primary health care service to Belo Horizonte with tenured jobs and 40 work hours per week, totalling a population of 207 professionals. The response rate was 90.34%. A pilot test was conducted with 44 dentists working in primary care for at least two years and who did not participate in the main study. Descriptive statistical analysis involved calculating proportions. No confidence intervals were calculated because this was a census study. Results: In most items (79.0%), professionals’ perceptions about the comprehensiveness were overwhelmingly positive. When we stratified the analysis by domain and checked those items about which dentists had a less favourable perception, 22.7% were in the patient welcoming domain, 25.0% were in the bonding domain and 12.5% were in quality of care. Conclusions: Comprehensiveness, as an approach in health care practice, needs to be enhanced, and there is evidence that these dentists are aware of its importance.

Análise da produção ambulatorial em municípios com e sem centros de especialidades odontológicas no Brasil em 2010

O objetivo foi descrever a produção de serviços especializados em municípios brasileiros com e sem Centros de Especialidades Odontológicas (CEO) e estudar fatores associados. Para a coleta de dados, foram consultados: o Departamento de Informática do SUS, dados do Atlas de Desenvolvimento Humano do Brasil e do Instituto Brasileiro de Geografia e Estatística. Utilizou-se regressão binominal negativa inflada de zeros para modelar taxas de procedimentos de endodontia, atenção básica, periodontia e cirurgia. Após controle por fatores sociodemográficos, os municípios com CEO apresentaram taxas maiores do que os sem, exceto para taxas de atenção básica. No modelo final, com variáveis de estrutura dos serviços, os municípios com CEO do tipo III tiveram uma taxa de procedimentos de endodontia 2,08 (IC95%: 1,26; 3,44) vezes maior que sem CEO. Das variáveis de estrutura, mais gastos em saúde e maiores taxas de dentistas no SUS estavam consistentemente associados a maiores taxas de quaisquer procedimentos. Os CEO parecem ter um efeito positivo na produção municipal de procedimentos especializados, particularmente para a taxa de procedimentos de endodontia, e esse efeito não é explicado por variáveis de estrutura.

Organização da demanda de um Centro de Especialidades Odontológicas

INTRODUÇÃO: A Atenção Secundária em saúde bucal no Brasil ainda é um assunto pouco pesquisado. OBJETIVO: Analisar a resolubilidade dos serviços odontológicos do Sistema Único de Saúde, com base na referência para a atenção secundária e a contrarreferência à atenção primária. METODOLOGIA: Trata-se de um estudo descritivo, quantitativo, que utilizou dados secundários coletados dos prontuários dos pacientes atendidos no Centro de Especialidades Odontológicas de um município do Estado de São Paulo. RESULTADO: Do total de 1030 prontuários analisados, verificaram-se 1236 procedimentos referenciados para atenção especializada. Destes, 86,4% deram entrada na Unidade Básica de Saúde por livre demanda e 50,4% (n=623), para especialidade de Endodontia. Houve evasão de 2,2% (n=28) já na primeira consulta especializada. Nos pacientes que deram início ao tratamento especializado, foram realizados 1.208 procedimentos no Centro de Especialidades Odontológicas, tendo sido 62,6% (n=757) concluídos e contrarreferenciados para a Atenção Primária, que finalizou 61,1% (n=463) dos procedimentos. Para a conclusão do tratamento, considerando o tempo no Centro de Especialidades Odontológicas e na Atenção Básica, houve variação de acordo com a especialidade: Periodontia, 62 dias (dp= ±68), e Endodontia, 71 dias (dp= ±51,8), sendo necessárias três consultas em média, independentemente da especialidade. CONCLUSÃO: O Centro de Especialidades Odontológicas referencia, contrarreferencia e atende à maioria da demanda, independentemente da especialidade. Porém, ainda há muita evasão durante o tratamento odontológico, servindo de alerta para os gestores desenvolverem métodos de controle dos pacientes atendidos, com vistas à diminuição de gastos e ao aumento da resolutividade dos serviços, com a conclusão dos tratamentos iniciados.

Qualidade técnica e satisfação relacionadas às próteses totais

A perda dentária é muito prevalente no Brasil, sobretudo entre idosos, onde mais de 3 milhões precisam de prótese total bimaxilar. Para mudar este quadro, o governo Federal instituiu os Centros de Especialidades Odontológicas (CEO). Assim, este estudo avaliou uma das atribuições desses Centros, a provisão de próteses totais convencionais (PTC) sob a ótica da qualidade e satisfação relacionadas a este produto. Para tanto, fez-se um estudo seccional com 149 indivíduos reabilitados em CEO do Rio Grande do Norte com tais próteses entre 2007 a 2009. Os dados foram obtidos por questionário e exame clínico da PTC quanto a sua retenção, estabilidade, estética e fixação. Das 233 PTC avaliadas; 52,7% das superiores e 9,5% das inferiores foram tecnicamente satisfatórias. Contudo, 69,1% (n = 103) dos entrevistados relataram satisfação com suas próteses. Quanto a associação entre qualidade técnica e satisfação, o teste Qui-quadrado indicou que PTC superiores tecnicamente adequadas (p = 0,041), sobretudo quanto a retenção (p = 0,002) e estabilidade (p = 0,000), estavam associados à satisfação positiva do usuário. Assim, as próteses satisfizeram à população assistida, apesar dos déficits técnicos. No entanto, essa satisfação pode advir da reabilitação em si e não de sua funcionalidade.

[Characteristics of the access and utilization of public dental services in medium-sized cities]

This cross-sectional study sought to describe the main characteristics of access and utilization of primary and specialized public dental services in two medium-sized cities in Bahia with 100% coverage of the Family Health Program. A survey of 952 households and 2.539 individuals aged over 15 years was conducted. The main variables analyzed were: perceived oral health needs, demand for the service, barriers of organizational access and the type of service and procedure utilized. The use of specialized public dental services was of 11.7% and primary care was 26%. In the city where there was greater use of public dental services, there was less use of private services. The main barrier to access remained in primary care (from 5.0% to 15.2%). There was little interface between secondary care a primary care, as only 16.6% of users returned to this level of care. In conclusion, the main barrier to access in cities with specific organizational and geographic realities appears to be in primary dental care. Individual preventive actions were little reported. It is recommended that barriers to access in primary care be eliminated, and also that a protocol (clinical guides) be established to foster the continuity and longitudinality of primary dental care.

Avaliação da atenção secundária em saúde bucal: uma investigação nos centros de especialidades do Brasil

Este trabalho discorre a respeito da avaliação da atenção secundária no âmbito da vigilância em saúde. Estudo descritivo, de caráter avaliativo normativo. Para análise de desempenho, foram utilizados dados secundários, com base na série histórica da produção de procedimentos odontológicos realizados nos CEO implantados no país e registrados pelo SIA/SUS no ano de 2007, e dados primários, pela visita in loco de 10% dos serviços implantados, com uso de questionários dirigidos à equipe profissional do CEO. Dentre os CEO analisados, observou-se que na maioria das regiões houve dificuldade no cumprimento das metas relativas à quantidade de procedimentos a serem informados no SIA/SUS. Sendo a Região Norte com menor percentual de serviços implantados. O indicador Cumprimento da Atenção Secundária em Saúde Bucal foi de 64,4%. Os CEO tipo III tiveram melhores resultados para o desempenho e cumprimento das metas. Foi evidenciada a necessidade de revisão no marco legal para a implantação dos CEO pela readequação dos critérios e normas, como também definições de novos padrões e cumprimento de metas para avaliação e monitoramento desses serviços.

Avaliação da oferta e utilização de especialidades odontológicas em serviços públicos de atenção secundária na Bahia, Brasil

O estudo visou avaliar a taxa de utilização dos serviços odontológicos especializados de quatro CEOs da Bahia, Brasil, identificando fatores relacionados. Trata-se de uma pesquisa avaliativa onde a etapa quantitativa foi conduzida através de um estudo transversal utilizando dados secundários do Sistema de Informações Ambulatoriais do Sistema Único de Saúde (SIA-SUS) e a qualitativa foi a partir de vinte entrevistas semi-estruturadas junto aos coordenadores e executores, além de observação in loco do serviço. O estudo revelou bons resultados na oferta desse serviço na percepção dos profissionais, mas há uma baixa taxa de utilização. A baixa taxa de utilização revela barreiras de acesso do próprio serviço de saúde, como a ausência de padrões e metas de desempenho por especialidade, a falta dos pacientes, que não são substituídos, além das diferentes tecnologias utilizadas por cada especialista. Sugerem-se estudos que analisem diferentes formas de organização do serviço que tenham possibilitado maior utilização da oferta disponível, como diferenças de remuneração, articulação com atenção primária e adequação da oferta às necessidades de saúde populacionais.

Brazilian Oral Health Policy: factors associated with comprehensiveness in health care

OBJECTIVE

To analyze the factors associated with comprehensiveness in oral health care in Centers of Dental Specialists, according to the guiding principles of the Brazilian Oral Health Policy.

METHODS

An exploratory cross-sectional study, based on an interview with 611 users of four specialized dental care centers, was performed in the state of Bahia, Northeastern Brazil, in 2008. The dependent variable was described as "comprehensiveness in oral health care", corresponding to having a primary dental care performed before specialized treatment or concomitantly with it. The main covariables referred to the level of coverage of the family health strategy in the city, users' sociodemographic characteristics, and organizational and geographic accessibility to the service, in addition to the type of specialized care required.

RESULTS

Residents of the cities where the Family Healthcare Program had a coverage >50% were more likely to conclude their dental treatment (PR=2.03, 95% CI: 1.33;3.09), compared to those who lived in places with lower coverage. Individuals who sought endodontic treatment were more likely to receive comprehensive oral health care than users who were seeking other types of specialized care (PR=2.31, 95% CI: 1.67;3.19). Users with better geographic accessibility to specialized services (PR=1.22, 95% CI: 1.03;1.41), with a reference guide from primary care (PR=2.95, 95% CI: 1.82;4.78) and coming from primary health care services (PR=3.13, 95% CI: 1.70;5.77) were more likely to achieve comprehensiveness in oral health care than other users.

CONCLUSIONS

Users with better geographic accessibility, lower age and need of endodontic services were more likely to receive comprehensive health care. Implementation of Centers of Dental Specialists in cities where primary healthcare is not adequately structured is not recommended, because secondary health care would meet the free demand and perform basic procedures, thus not fulfilling the expected principle of comprehensiveness.

Construção da atenção secundária em saúde bucal: um estudo sobre os Centros de Especialidades Odontológicas em Pernambuco, Brasil

Objetivando avaliar os Centros de Especialidades Odontológicas de Pernambuco, Brazil, realizou-se estudo exploratório, utilizando dados secundários da produção ambulatorial 2006, critérios e normas instituídos para implantação destes serviços. Descreveu-se o cumprimento global das metas dos Centros de Especialidades Odontológicas, variáveis de caracterização dos serviços e dos municípios. Foram utilizadas análises do tipo descritiva e do tipo correlacional não paramétrica (coeficiente de Spearman), considerando-se o nível de significância de 5%. Dos 22 Centros de Especialidades Odontológicas, 40,9% obtiveram um desempenho bom, destacando que 81,8% cumpriram a meta para o subgrupo atenção básica em contraste com 13,6% que cumpriram a meta do subgrupo cirurgia oral menor. Dentre as variáveis independentes analisadas, apenas o porte populacional e o índice de desenvolvimento humano do município foram correlacionados ao desempenho dos Centros de Especialidades Odontológicas, quanto menor a cidade (r = 0,678; p < 0,001) e menor desenvolvimento humano (r = 0,599; p < 0,001), piores desempenhos foram observados. O estudo sugeriu que a normatizaçao para implantação e funcionamento dos Centros de Especialidades Odontológicas deva ser monitorada e avaliada para garantir uma melhor qualidade dos serviços para população.

Unravelling Referral Paths Relating to the Dental Care of Children: A Study in Liverpool

Objective

To describe primary care referral networks relating to children's dental care and the main influences on referral decisions taken by dentists working in a primary care setting.

Design

A postal questionnaire to all 130 general dental practitioners (GDPs) in contract with Primary Care Trusts (PCTs), and 24 Community Dental Service (CDS) dentists in Liverpool.

Outcome measures

Characteristics of patient groups and factors influencing the choice of referral pathway of children referred from primary dental care.

Results

There were good responses rates (110 [85%] GDPs and 22 [92%] CDS dentists). The two main reasons why GDPs referred children to hospitals were (a) for treatment under general anaesthetic (GA) or relative analgesia (RA) and (b) for restorative care of dentally anxious children. GDPs also referred anxious children requiring simple restorative care and/or RA to the CDS. Only eight GDPs (7%) cited a lack of experience as a reason for referral of dentally anxious children for simple restorative care, compared to 53 (48%) who cited a lack of RA facilities, and 25 (23%) who cited financial considerations.

Conclusions

GDPs refer children to both hospital services and the CDS, and identify a lack of RA facilities and economic pressures as key reasons for referral.

Bleeding after dental extractions in patients taking warfarin

OBJECTIVE

To assess the incidence of bleeding after dental extractions in subjects taking warfarin continuously before and after extractions whose International Normalised Ratio (INR) was below 4.0 at the time of extraction.

METHODS

This was a case series study of 150 patients without controls who required extraction of at least one tooth under local anaesthetic. All sockets were subsequently packed with absorbable oxycellulose and sutured.

RESULTS

A total of 58 women and 92 men were included (mean age 66 years); their ages were similar. The mean INR (S.D.) was 2.5 (0.56), although most patients had an INR less than 2.5 (n=101). Ten patients (7%) bled after extraction, enough to require a return to hospital. Five patients of 101 with an INR</=2.5, and 5 with an INR>2.5 out of 49 bled after extraction (p=0.29). Bleeding after extraction was not associated with operative antibiotics. All patients who bled were managed conservatively and none was admitted to hospital.

CONCLUSION

Patients taking warfarin whose INR is up to 4.0 and who have dental extractions in hospital do not have clinically significant bleeds post-operatively.

Special Care Dentistry: a professional challenge

As a profession we have a responsibility to ensure that the oral health needs of individuals and groups who have a physical, sensory, intellectual, medical, emotional or social impairment or disability are met. In the UK, over 200,000 adults have profound learning disabilities and/or complex medical conditions. Adults with a disability often have poorer oral health, poorer health outcomes and poorer access to services than the rest of the population. This paper examines the need for Special Care Dentistry based on a review of published literature, surveys and health policy, and suggests how services might be delivered in the future. Existing models of good practice reveal that established clinicians working in this field have a patient base of between 850 and 1,500 patients per year and work across primary care and hospital settings, liaising with colleagues in health, social services and the voluntary sector to ensure integrated health care planning. On this basis, a conservative estimate of 133 specialists is suggested for the future, working in networks with Dentists with Special Interests (DwSIs) and primary dental care practitioners. A skilled workforce that can address the wider needs of people requiring Special Care Dentistry should be formally recognised and developed within the UK to ensure that the needs of the most vulnerable sections of the community are addressed in future.

'Management is a black art' – professional ideologies with respect to temporomandibular disorders

OBJECTIVE

To gain a deeper understanding of the range of influences on the full range of dental professionals who provide treatment for temporomandibular disorders (TMD).

DESIGN

Qualitative semi-structured interviews.

SETTING

Primary and secondary care in the North and South of the United Kingdom.

SAMPLE AND METHOD

A criterion-based purposive sample was taken of dental practitioners, comprising primary and secondary care practitioners. In-depth interviews were conducted and data collection and analysis occurred concurrently until data saturation was achieved. DATA AND DISCUSSION: There was a reported lack of adequate remuneration for provision of treatment for TMD within primary care. This alongside the primary care practitioners' reported uncertainty in diagnosis of TMD appeared to lead to a propensity for referral to secondary care. Practitioners recognised a poor and scanty evidence base on which to base their care, and this allowed for idiosyncratic practice. Often the outcome measure for treatment was a subjective questioning of the patient focussing mainly on relief of pain.

CONCLUSION

There is a need for better quality evidence on which to base TMD treatment, more continuing professional development and improvement in contracting arrangements to enable primary practitioners to feel confident in managing TMD.

Attitudes regarding specialist referrals in periodontics

OBJECTIVE

To examine the attitudes of dental practitioners towards specialist periodontal referral in the North East of England.

SUBJECTS AND METHODS

Semi-structured interviews were conducted with a purposive sample of 10 practitioners. Interviews continued until data saturation occurred. The data were organised using a framework and analysed by two researchers working independently.

RESULTS

Perceptions of periodontal disease and treatment appear to be heavily influenced by the NHS remuneration system. Treatment in general practice was limited to simple scaling and there was an apparent reluctance to treat advanced periodontitis. Such cases were commonly referred to specialists, confirming the demand for a referral service in periodontics. The perceived potential for medico-legal consequences was a strong driver of referrals. Distance to the referral centre and the perceived costs of treatment were significant barriers to referral. Dentists valued the specialist's personal reputation and clinical skills more highly than academic status. Deficiencies in communication between primary and secondary care were highlighted.

CONCLUSIONS

Increased resources are required to manage periodontal diseases within the NHS. There is a need for a periodontal referral service in the North East of England to improve accessibility to specialist care. This would appear to be most appropriately delivered by increased numbers of specialist practitioners.

Conscious sedation training received by specialist registrars in restorative dentistry in the UK: a survey

OBJECTIVE

To investigate conscious sedation training received by Specialist Registrars in Restorative Dentistry (SpRs) during their training programme.

DESIGN

Postal questionnaire survey in the UK. Setting SpRs and recently certificated Consultants in Restorative Dentistry (CRDs).

METHOD

A questionnaire was sent to 81 current SpRs in Restorative Dentistry and CRDs who had been awarded a Certificate of Completion of Specialist Training within the previous three years. One follow-up letter was sent to non-responders.

RESULTS

The completed questionnaire was returned by 67 (83%) SpRs and CRDs. Analysis revealed that 44 (69%) respondents had received conscious sedation training during their specialist training programme and that 50 (78%) respondents carried out restorative dental treatment under sedation during their programme. Thirteen (20%) respondents had not received conscious sedation training in their programmes but eight (13%) SpRs indicated that sedation training was planned. Training experiences differed throughout the UK: 29 (66%) respondents gained experience in inhalational and single agent intravenous sedation techniques under the supervision of an experienced colleague. Fourteen (32%) respondents who performed sedation had not been on a resuscitation course in the previous year. These included nine (21%) current SpRs. Sixteen (53%) current SpRs intended to offer restorative dental treatment under sedation after specialist training. Fifty-nine (92%) respondents thought that all SpRs in Restorative Dentistry should receive sedation training and 42 (71%) thought that a structured core course would be the most appropriate format.

CONCLUSIONS

Although the majority of SpRs and recently certificated CRDs considered that all SpRs should receive training in conscious sedation via a core course during the restorative dentistry training programme, a small number had not received or planned to undertake such training. Conscious sedation training experiences differed throughout the UK and SpRs treated a wide range of deserving patient categories under sedation. It is encouraging that many SpRs hope to continue employing sedation techniques after their restorative dentistry training has finished. The results of this survey should inform all those involved with restorative dentistry training programmes.

Conscious sedation services provided in secondary care for restorative dentistry in the UK: a survey

OBJECTIVES

To assess the views of consultants in restorative dentistry on sedation services in secondary care for restorative dentistry and their involvement in the provision of this.

DESIGN

Postal questionnaire survey in the UK.

SETTING

Consultants in restorative dentistry.

RESULTS

There was an 80% response rate from 179 consultants. Among consultants in restorative dentistry there was a perceived need for sedation services in restorative dentistry within NHS hospitals other than for teaching purposes. Anxiety and level of trauma of dental treatment affected whether consultants felt it appropriate for patients to have such treatment under sedation. One third (48) of consultants treated patients under conscious sedation, a significant number of these held NHS posts and had graduated more recently. Of those (41) who provided treatment under conscious sedation in an NHS setting, most (38, 93%) provided treatment under intravenous sedation of whom only eight (21%) acted as operator/sedationist. Nearly all consultants (135, 94%) felt that specialist registrars in restorative dentistry should undergo some form of training in sedation.

CONCLUSIONS

Although consultants in restorative dentistry recognise the need for training in and the provision of sedation in secondary care for restorative dentistry, only one third of respondents currently provide this service.

Facilitators and barriers to improving the quality of referrals for potential oral cancer

The quality and content of referral letters are important for prioritisation of patients who may have oral cancer. Referrals letters to the Oral Medicine Clinic at Birmingham Dental Hospital were analysed and practitioners interviewed. Whilst acceptable for general purposes, most letters did not contain sufficient information to allow effective prioritisation. Interviews disclosed a misunderstanding amongst practitioners about the way in which referrals were handled. A number of barriers to increasing the information included in letters were identified. Referral guidelines and a standardised proforma might help improve the ability of the service to operate a fast-track system.