Patient-centred care: barriers and opportunities in the dental surgery

Multidisciplinary full-mouth rehabilitation using minimally invasive dental implant therapy: a report on three different clinical scenarios

Conventional operative dental procedures are being revisited with an approach that seeks to preserve the original tissue as much as possible. Implant dentistry has also seen the advent of various techniques which make minimal alteration to natural tissue. The flapless technique involves implant placement either through a freshly extracted socket or through a tansmucosal punch hole, without elevating mucoperiosteal flap. This paper presents a report on three cases of patient centric, conventional dental implant-based full-mouth rehabilitation, which was successfully carried out using the flapless technique, under varied clinical situations. Each case showed a favourable outcome in terms of restoration of the form and function of the patient's dentition.

Barriers and facilitators to using an objective risk communication tool during primary care dental consultations: A Theoretical Domains Framework (TDF) informed qualitative study

OBJECTIVES

Objective risk communication tools can supplement clinical judgement and support the understanding of potential health risks. This study used the Theoretical Domains Framework (TDF) to identify barriers and facilitators to implementing a risk communication aid within primary care dental consultations.

METHODS

Dentists (N = 13), recruited via a dental practice database and through professional contacts were interviewed using a TDF-informed semi-structured interview schedule. Data were analysed inductively and deductively coding the themes using the TDF.

RESULTS

Eight theoretical domains (environmental context and resources; beliefs about consequences; goals; memory, attention, and decision processes; optimism; reinforcement; social influences and behavioural regulation) and thirteen sub-themes were identified. Insufficient resources and patient factors were commonly encountered barriers and led to increasing pressure to prioritise other tasks. Whilst dentists had a favourable view towards a risk communication aid and acknowledged its benefits, some were sceptical about its ability to facilitate behaviour change. Self-monitoring strategies and colleague support facilitated tool usage.

CONCLUSIONS

This study identified six barriers and seven facilitators to implementing a risk communication tool within primary care dental settings. Dentists appreciated the value of using a risk communication tool during dental consultations, although some required further support to integrate the tool into practice.

CLINICAL SIGNIFICANCE

Our findings provide a sound theoretical base for interventions aimed at facilitating patient behaviour change through the use of risk communication in dentistry. Further research should apply behavioural science to support the implementation of the tool in clinical practice.

Moving towards social dentistry: How do dentists perceive the Montreal-Toulouse model?

OBJECTIVES

This study aimed to understand the perspectives of dentists towards the Montreal-Toulouse model, an innovative approach that encompasses person-centredness and social dentistry. This model invites dentists to take three types of actions (understanding, decision-making, intervening) on three overlapping levels (individual, community, societal). This study aimed to understand (a) How dentists perceived the Montreal-Toulouse model as a framework for the practice of dentistry and (b) What parts of this model they were ready to adopt in their own practice.

METHODS

A qualitative descriptive study was conducted based on semi-structured interviews with a sample of dentists in the Province of Quebec, Canada. A combination of maximum variation and snowball sampling strategies was employed and 14 information-rich participants were recruited. The interviews were conducted and audio-recorded through Zoom and lasted approximately 1 h and a half. The interviews were transcribed verbatim and thematically analysed through a combination of inductive and deductive coding.

RESULTS

The participants explained they valued person-centred care and tried to put the individual level of the Montreal-Toulouse model into practice. However, they expressed little interest in the social dentistry aspects of the model. They acknowledged not knowing how to organize and conduct upstream interventions and were not comfortable with social and political activism. According to them, advocating for better health-related policies, while a noble act, 'was not their job'. They also highlighted the structural challenges that dentists face in fostering biopsychosocial approaches such as the Montreal-Toulouse model.

CONCLUSIONS

To promote the Montreal-Toulouse model and empower dentists to address social determinants of health, an educational and organizational 'paradigm shift' towards social accountability might be necessary. Such a shift requires curricular modifications and reconsidering traditional teaching approaches in dental schools. Moreover, dentistry's professional organization could facilitate dentists' upstream actions through proper resource allocation and openness to collaboration with them.

Developing a person-centred approach in dentistry beyond NHS recall intervals: a commentary

Person-centred care (PCC) is acknowledged as a fundamental dimension of quality within health care and provides significant benefits for patients and clinicians. Models of PCC have primarily been developed from the medical literature, with limited consideration of their application within dentistry. The Personalised Care Institute was established to deliver education and training on PCC and is working with the Office of the Chief Dental Officer for England to develop resources on shared decision-making (SDM) to promote tailored recall intervals.This paper seeks to promote the value of PCC and SDM in delivering high-quality care but cautions against the use of generic models or training in view of the potential differences which may exist within dentistry, particularly general dental practice. The authors highlight the need to develop materials and training which are appropriate, contextualised and relevant to dentistry. The capacity and desire to deliver PCC is strongly influenced by the healthcare system which is in operation. The current units of dental activity (UDA) system operating in England would appear to act as a barrier to the delivery of PCC. Unless significant and rapid changes are introduced to the NHS Contract, UDA targets will continue to take precedence over PCC, SDM and tailored recall intervals.

Factors affecting oral health care for asylum seekers and refugees in England: a qualitative study of key stakeholders' perspectives and experiences

Aims To investigate factors influencing oral health behaviours and access to dental services for asylum seekers and refugees (ASRs).Methods A qualitative research study using purposeful sampling was undertaken in South West England. Online semi-structured interviews with stakeholders working with or supporting ASRs were analysed through reflexive thematic analysis.Results Twelve participants providing support to ASRs in various capacities participated. Two interviewees had lived experience of forced displacement and the UK asylum process. Key themes into what hinders ASRs' oral health care were: prioritising safety and survival; variations in cultural norms and practice; lack of knowledge about dental care; financial hardship and affordability of care; a gulf of understanding of what dental care would be like and experiences of it; and structures of dental services that leave vulnerable groups behind. Opportunities for improving oral health care were: accessible oral health education; partnership working and creating supportive environments; translation; providing culturally sensitive and person-centred care; and incorporating ASRs' views into service design.Conclusions Several factors affect to what extent ASRs can and are willing to engage with oral health care. Co-developing accessible and relevant prevention programmes and ensuring equitable access to dental services for ASRs is important. Future research should explore ASRs' views and experiences of dental care and explore informed suggestions on how to optimise oral health promotion and provision of care.

General dental practitioners' perceptions of shared decision making: a qualitative study

Introduction As patient-centred care becomes more of the focus in healthcare, informed consent is receiving more attention in dental practice as the pinnacle principle in patient care. Shared decision making or person-centred care appears to be taking a back foot in dentistry.Aim This study aims to gain insight into the current views and perceptions of shared decision making by general dental practitioners and how it can be utilised in daily practice.Method Empirical qualitative data were collected using semi-structured interviews of nine dentists working in general practice, with an average of 30 minutes for each interview. The data were analysed using thematic analysis.Results Overall, there was a misunderstanding of what constitutes shared decision making among dental practitioners, with communication focused more on information provision rather than collaborative discussion. There were barriers which prevented full discussions with patients from occurring, some of which directly conflicted with the focus of shared decision making.Conclusion There is a need to provide more clarity of what shared decision making is and how it can facilitate person-centred care in dental practice. Dental practitioners felt that standards and guidelines were not clear; therefore, they were confused as to what was expected of them with regards to communication. More support, in the form of standardised decision-making aids, is needed to assist dental practitioners to streamline the delivery of shared decision making in primary care.

COVID-19 presents an opportunity for dental teams to become ready for person-centred care

Two publications that recently appeared in the British Dental Journal mooted the position that dentistry may not be ready for person-centred care. This commentary takes up this discussion and agrees that while person-centred care is essential to dentistry, it is not without its challenges. Drawing on the multidisciplinary expertise of its authors (two sociologists, one psychologist and a dentist), the nature of these challenges is interrogated further. It also identifies opportunities for change on this position from within the literature, as well as by clinical practice. We present evidence to suggest that the current pandemic has shown that dental teams are capable of rising to a challenge and adapting to change. In this light, we propose that the pandemic presents dental teams with an opportunity to be even more person-centred.

Shared Decision Making in Endodontics

Engaging patients in shared decision making (SDM) is a professional requirement since the Montgomery ruling in 2015. Endodontic treatments present a specific challenge to achieving SDM, both for the clinician and the patient. The treatments are often perceived as more challenging to complete by the clinician, and the assessment of risk and likely outcome requires a deep understanding of the (limited) evidence base. For the patient, decisions can be required at a time of acute symptoms and prolonged treatments. There are health literacy demands in comparison to some less complex dental treatments. Treatment decisions may be based more on inherent biases and prior experiences than objective probabilities. This article discusses options and supports effective shared decision making in endodontic treatment.

Professional consensus on orthodontic risks: What orthodontists should tell their patients

INTRODUCTION

Effective communication of risk is a requisite for valid consent, shared decision-making, and the provision of person-centered care. No agreed standard for the content of discussions with patients about the risks of orthodontic treatment exists. This study aimed to produce a professional consensus recommendation about the risks that should be discussed with patients as part of consent for orthodontic treatment.

METHODS

A serial cross-sectional survey design using a modified electronic Delphi technique was used. Two survey rounds were conducted nationally in the United Kingdom using a custom-made online system. The risks used as the prespecified items scored in the Delphi exercise were identified through a structured literature review. Orthodontists scored treatment risks on a 1-9 scale (1 = not important, 9 = critical to discuss with patients). The consensus that a risk should be discussed as part of consent was predefined as ≥70% orthodontists scoring risk as 7-9 and <15% scoring 1-3.

RESULTS

The electronic Delphi was completed by 237 orthodontists who reached a professional consensus that 10 risks should be discussed as part of consent for orthodontic treatment; demineralization, relapse, resorption, pain, gingivitis, ulceration, appliances breaking, failed tooth movements, treatment duration, and consequences of no treatment.

CONCLUSIONS

A professional orthodontic consensus has been reached that 10 key risks should be discussed with patients as part of consent for orthodontic treatment. The information in this evidence base should be tailored to patients' individual needs and delivered as part of a continuing risk communication process.

Developing Person-Centred Dental Care: The Perspectives of People Living in Poverty

Dentistry has seen a slow trend toward person-centred care (PCC), with most approaches developed by scholars who have tried to progress away from disease-centred care. Unfortunately, the perspectives and experiences of underprivileged people have not been considered in the development of these approaches. Our objective was thus to understand underprivileged people's experiences and expectations about dental care and contribute to the development of person-centred dentistry. We conducted a qualitative descriptive study with a sample of 13 people living in poverty. We used a maximum variation sampling strategy and selected them among the users of a free dental clinic in Montreal, Canada. We conducted semi-structured interviews that we audio recorded, transcribed verbatim, and thematically analysed. Our main finding is that participants wanted to feel human and respected by dentists. More specifically, they wanted to be more involved in the dental care process through quality time and empathetic conversations with the dentist. They also wished for an exchange of information free of technical terms and built on mutual trust. In conclusion, person-centred dental care models should emphasize empathy, trust, and quality care beyond technical skills. Clinicians should provide comprehensive information in dental encounters and treat their patients as whole persons.

Dentists' perceptions of a practical model of patient-centred care: providing information and choice in a dental consultation

Adopting a patient-centred approach when engaging with patients has been linked to positive outcomes in medicine. However, in the field of dentistry, patient-centred care (PCC) has been understudied. The aim of this study was to explore dentists' opinions about the usefulness of a theoretical model of PCC and its applicability to a dental setting. Twenty semi-structured interviews were conducted with dentists working at a major university hospital in south London. The interviews were audiotaped and analysed using thematic analysis. The analysis showed that dentists found the PCC model to be useful for practical application but mostly for 'other' dentists. They viewed the lowest and highest levels of PCC that the model advocates as 'out-dated' and 'ideal', respectively. Dentists felt that giving patients full choice and control over their treatment was not applicable to everyday clinical practice. They expressed that a tool developed on the basis of this hierarchy of PCC could be useful for self-assessment purposes, although with some reservations. In conclusion, dentists seemed to embrace the practice of PCC and felt that their provision of PCC was at an acceptable standard. They believed that a moderate level of information and choice was most suitable for patients.

Relatives' strategies in subacute brain injury rehabilitation: The warrior, the observer and the hesitant

BACKGROUND

Relative involvement is crucial in rehabilitation when patients are incapable of being involved due to cognitive and functional dysfunction. However, studies have shown that this is complex because of differing understandings of the meaning of involvement as well as diverse needs to be involved.

AIMS AND OBJECTIVES

To explore the experience of the rehabilitation process from the perspectives of relatives of patients with a traumatic brain injury. The aim of the study was, through a theoretical-empirical analysis, to identify relatives' strategies and practices in the rehabilitation process as evidenced in meetings with providers.

DESIGN

A longitudinal study with a qualitative approach, drawing on the theory of Pierre Bourdieu.

METHODS

Data were generated using participant observation and semi-structured interviews. Participants were eleven relatives of patients with a severe traumatic brain injury, followed through in-patient rehabilitation varying from 9-12 weeks. Analysis was undertaken using both an inductive and deductive approach.

FINDINGS

Drawing on Bourdieu's concept of strategy, three relative positions were identified, the warrior, the observer and the hesitant. These positions illustrate how different relative positions and their related dispositions influence the strategies used by relatives of patients with a severe traumatic brain injury evidenced in how they act, participate and relate to both the patient and the providers during the course of rehabilitation.

CONCLUSIONS

Acknowledging the relatives' positions during the rehabilitation process enables better understanding and support of the relatives in the rehabilitation process to meet their (and thus the patients') diverse needs.

RELEVANCE TO CLINICAL PRACTICE

The findings have practical implications in informing how clinicians meet, interact, communicate and involve relatives of adult patients' with traumatic brain injury in decision-making during rehabilitation.

Adolescent perceptions of orthodontic treatment risks and risk information: A qualitative study

INTRODUCTION

For effective risk communication, clinicians must understand patients' values and beliefs in relation to the risks of treatment. This qualitative study aimed to explore adolescent perceptions of orthodontic treatment risks and risk information.

METHODS

Five focus groups were carried out with 32 school/college pupils aged 12-18 in Wales, UK. Participants were purposively selected and had all experienced orthodontic treatment. A thematic approach was used for analysis and data collection was completed at the point of data saturation.

RESULTS

Four themes emerged from the data; (a) day-to-day risks of orthodontic treatment, (b) important orthodontic risk information, (c) engaging with orthodontic risk information and (d) managing the risks of orthodontic treatment. Day-to-day risks of orthodontic treatment that were affecting participants "here and now" were of most concern. Information about preventing the risks of treatment was deemed to be important. Participants did not actively seek risk information but engaged passively with information from convenient sources. Perceptions of risk susceptibility influenced participants' management of the risks of orthodontic treatment.

CONCLUSIONS

This study demonstrates that adolescent patients can understand information about the nature and severity of orthodontic treatment risks. However, adolescent patients can have false perceptions if the risks are unfamiliar, perceived only to have a future impact or if seen as easy to control. Adolescent patients must be provided with timely and easily accessible risk information and with practical solutions to prevent the risks of treatment.

CLINICAL SIGNIFICANCE

The views and experiences gathered in this study can assist clinicians to better understand their young patients' beliefs about treatment risks, facilitate effective risk communication and contribute to improved patient-centred care.

A study to explore specific stressors and coping strategies in primary dental care practice

Background and aims It is widely acknowledged that dentists experience occupational stress. This qualitative study aimed to explore previously identified specific stressors in more detail in order to inform the development of a future stress management programme.Method Two focus groups of dentists (N: 7 &6) were conducted to explore, in more detail, nine specific stressors and concepts; being out of one's comfort zone, zoning out from the patient, celebrating the positive aspects of work, thinking aloud, the effect of hurting patients, the impact of perfectionism, responsibility for patient's self-care, the emotional impact of difficult situations as a foundation dentist. Participants were also asked for their views on the structure and contents of the proposed stress management package. Verbatim transcripts were subjected to thematic analysis.Results and discussion Dentists described the impact of these stressors and their current coping methods; thematic analysis revealed nine themes which covered the above concepts and a further overall theme of need for control. The findings are elaborated in connection to their relevant stress, coping and emotion psychological theory. Their implications for personal well-being and clinical outcomes are discussed.Conclusion Dentists' stressful and coping experiences are complex and it is essential that any stress management programme reflects this and that the skills are easily accessible and sustainable within the context of a busy dental practice.

Risk communication in the dental practice

The communication of risk in dental settings is a routine task that most clinicians are familiar with in their clinical encounters. However, work from medical settings has suggested that using this process in order to support health behaviour change in people may well be undermined by difficulties in understanding risk information, in presenting the information in a way that is clearly understood by the recipient and in the effects that such information may have for supporting further health behaviours by patients. This paper synthesises literature in the area that addresses these issues and explores approaches dental care professionals might consider when communicating risks in the dental surgery.

Risk communication for the dental team

Risk communication within dentistry involves giving patients information about potential risks they may encounter as a result of a dental disease, a clinical procedure or a particular behaviour. It is a personalised communication and allows patients the opportunity to make an informed choice about the provision of clinical care or the choice of a particular behaviour. Risk communication should form part of every patient interaction and is a task with which most dental professionals are familiar. Although risk communication is routine practice for dental professionals, evidence from other healthcare settings suggests that clinicians find the process challenging and may not possess the necessary skills and training to be effective. This paper aims to summarise the research findings for risk communication within healthcare and to explain the principles of effective risk communication. By developing a clearer understanding of the complexities of communication and presenting risks to patients, we may reduce misunderstandings and enable more informed decision-making.

Advancing Health Promotion in Dentistry: Articulating an Integrative Approach to Coaching Oral Health Behavior Change in the Dental Setting

Oral health is managed based on objective measures such as the presence and severity of dental caries and periodontal disease. In recent years, oral health researchers and practitioners have shown increasing interest in a widened array of physical, psychological, and social factors found to influence patients' oral health. In this article, we introduce a behavior change coaching approach that can be used to enhance psychosocial diagnosis and client-centered delivery of health-promoting interventions. Briefly, this health coaching approach is based on an interactive assessment (both physical and psychological), a non-judgmental exploration of patients' knowledge, attitudes, and beliefs, a mapping of patient behaviors that may contribute to disease progression, gauging patient motivation, and tailoring health communication to encourage health-promoting behavior change. Developed in a clinical setting, this coaching model is supported by interdisciplinary theory, research, and practice on health behavior change. We suggest that, with supervision, this coaching process may be learned.