The efficacy of screening for common dental diseases by hygiene-therapists: a diagnostic test accuracy study

National and Subnational Trend of Dental Caries of Permanent Teeth in Iran, 1990-2017

OBJECTIVE

There are currently no integrated data on the trend of dental caries amongst distinct age groups in Iran. We aimed to assess the national and subnational trend of dental caries of permanent teeth in Iran from 1990 to 2017.

METHODS

A literature search about dental caries and the decayed-missing-filled teeth index (DMFT) was performed in PubMed, Web of Science, Scopus, and 3 national databases (in Persian). All eligible national oral health surveys in these 28 years were included. We categorised and aggregated the DMFT values and their components based on age (5-year-based groups from 5 to 9 to 60+ years), sex, year, and province. The data for missing spots were estimated using the spatiotemporal Bayesian hierarchical model. We used the bootstrap method in multilevel models to predict the uncertainty interval (UI) of the modelled results.

RESULTS

Nationally, the all-ages mean DMFT increased by nearly 58.0% (6.8 [95% UI, 4.1-10.5] in 1990 to 10.8 [95% UI, 7.5-14.5] in 2017). Decayed teeth (DT) and missing teeth (MT) rose by 84.5% and 31.6% during this period, respectively. Filled teeth (FT) showed almost a 2.6-fold increase in the same period from 0.6 (95% UI, 0.01-1.6) in 1990 to 1.7 (95% UI, 0.6-2.8) in 2017. The proportion of DT and FT continuously increased in both sexes. In 2017, the highest DT, MT, and FT were estimated in the 25-29 (4.9 [95% UI, 2.5-7.2]), 60+ (21.5 [95% UI, 17.5-25.4]), and 35-39 (2.6 [95% UI, 1.3-4.0]) year age groups.

CONCLUSIONS

Caries of permanent dentition levies a growing burden on the Iranian population. Considering the continuous increase in caries during the 1990-2017 period, Iranian policymakers should pay heed to these findings and react more proactively to mitigate this perpetuating issue. Implementing nationwide interventions such as sugar consumption management should be encouraged to achieve sustainable outcomes in this regards.

uSing rolE-substitutioN In care homes to improve ORal health (SENIOR): a study protocol

Background

Dental service provision in the care home sector is poor, with little emphasis on prevention. Emerging evidence suggests that the use of Dental Care Professionals (dental therapists and dental nurses) as an alternative to dentists has the potential to improve preventive advice, the provision of care and access to services within care homes. However, robust empirical evidence from definitive trials on how to successfully implement and sustain these interventions within care homes is currently lacking. The aim of the study is to determine whether Dental Care Professionals could reduce plaque levels of dentate older adults (65 + years) residing in care homes.

Methods

This protocol describes a two-arm cluster-randomised controlled trial that will be undertaken in care homes across Wales, Northern Ireland and England. In the intervention arm, the dental therapists will visit the care homes every 6 months to assess and then treat eligible residents, where necessary. All treatment will be conducted within their Scope of Practice. Dental nurses will visit the care homes every month for the first 3 months and then three-monthly afterwards to promulgate advice to improve the day-to-day prevention offered to residents by carers. The control arm will be ‘treatment as usual’.

Eligible care homes (n = 40) will be randomised based on a 1:1 ratio (20 intervention and 20 control), with an average of seven residents recruited in each home resulting in an estimated sample of 280. Assessments will be undertaken at baseline, 6 months and 12 months and will include a dental examination and quality of life questionnaires. Care home staff will collect weekly information on the residents’ oral health (e.g. episodes of pain and unscheduled care). The primary outcome will be a binary classification of the mean reduction in Silness-Löe Plaque Index at 6 months. A parallel process evaluation will be undertaken to explore the intervention’s acceptability and how it could be embedded in standard practice (described in a separate paper), whilst a cost-effectiveness analysis will examine the potential long-term costs and benefits of the intervention.

Discussion

This trial will provide evidence on how to successfully implement and sustain a Dental Care Professional-led intervention within care homes to promote access and prevention.

Trial registration

ISRCTN16332897. Registered on 3 December 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06487-3.

How do dentists perceive portable dentistry? A qualitative study conducted in Quebec

INTRODUCTION

People with impaired mobility face difficulty accessing dental care. One solution is portable dentistry, which includes delivering dental care in homes or residential institutions. Dentists, however, appear reluctant to offer such services. Our objective was to understand how dentists perceived portable dentistry and potential challenges to its implementation.

METHODS

We conducted a qualitative descriptive study based on semi-structured interviews with a sample of dentists in Quebec, Canada. We employed a combination of maximum variation and snowball sampling strategies to recruit 14 participants. The interviews were conducted and audio-recorded through Zoom and lasted approximately 40 minutes. After transcribing them, we performed a thematic analysis with a combination of inductive and deductive coding.

RESULTS

Despite perceiving portable dentistry as a valuable practice model, participants showed little interest in adopting this approach, arguing it was not every dentist's "job" to provide portable services. They believed portable dentistry must be financially burdensome and difficult to integrate into their daily work due to lack of time and portable equipment. Accordingly, participants considered it was the duty of governments, professional organisations overseeing dentistry education and practice, and dental schools to develop portable dentistry programs and hire dentists to deliver such services.

CONCLUSIONS

To promote portable dentistry, it may be necessary to improve the knowledge and competencies of dentists, but also to challenge their professional identity as well as the current model of dental clinics as the standard of care delivery. To achieve this, we need strong leadership from dental schools, professional organisations and government.

Dental therapists compared with general dental practitioners for undertaking check-ups in low-risk patients: pilot RCT with realist evaluation

Background

Many dental ‘check-ups’ in the NHS result in no further treatment. The patient is examined by a dentist and returned to the recall list for a further check-up, commonly in 6 or 12 months’ time. As the oral health of regular dental attenders continues to improve, it is likely that an increasing number of these patients will be low risk and will require only a simple check-up in the future, with no further treatment. This care could be delivered by dental therapists. In 2013, the body responsible for regulating the dental profession, the General Dental Council, ruled that dental therapists could see patients directly and undertake check-ups and routine dental treatments (e.g. fillings). Using dental therapists to undertake check-ups on low-risk patients could help free resources to meet the future challenges for NHS dentistry.

Objectives

The objectives were to determine the most appropriate design for a definitive study, the most appropriate primary outcome measure and recruitment and retention rates, and the non-inferiority margin. We also undertook a realist-informed process evaluation and rehearsed the health economic data collection tool and analysis.

Design

A pilot randomised controlled trial over a 15-month period, with a realist-informed process evaluation. In parallel, we rehearsed the health economic evaluation and explored patients’ preferences to inform a preference elicitation exercise for a definitive study.

Setting

The setting was NHS dental practices in North West England.

Participants

A total of 217 low-risk patients in eight high-street dental practices participated.

Interventions

The current practice of using dentists to provide NHS dental check-ups (treatment as usual; the control arm) was compared with using dental therapists to provide NHS dental check-ups (the intervention arm).

Main outcome measure

The main outcome measure was difference in the proportion of sites with bleeding on probing among low-risk patients. We also recorded the number of ‘cross-over’ referrals between dentists and dental therapists.

Results

No differences were found in the health status of patients over the 15 months of the pilot trial, suggesting that non-inferiority is the most appropriate design. However, bleeding on probing suffered from ‘floor effects’ among low-risk patients, and recruitment rates were moderately low (39.7%), which suggests that an experimental design might not be the most appropriate. The theory areas that emerged from the realist-informed process evaluation were contractual, regulatory, institutional logistics, patients’ experience and logistics. The economic evaluation was rehearsed and estimates of cost-effectiveness made; potential attributes and levels that can form the basis of preference elicitation work in a definitive study were determined.

Limitations

The pilot was conducted over a 15-month period only, and bleeding on probing appeared to have floor effects. The number of participating dental practices was a limitation and the recruitment rate was moderate.

Conclusions

Non-inferiority, floor effects and moderate recruitment rates suggest that a randomised controlled trial might not be the best evaluative design for a definitive study in this population. The process evaluation identified multiple barriers to the use of dental therapists in ‘high-street’ practices and added real value.

Future work

Quasi-experimental designs may offer more promise for a definitive study alongside further realist evaluation.

Trial registration

Current Controlled Trials ISRCTN70032696.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 3. See the NIHR Journals Library website for further project information.

Cost of providing a mobile dental service for dependent older people

BACKGROUND AND OBJECTIVE

Dental care provision in long-term care facilities (LTCFs) is often a problem despite the high demand. LTCF residents would greatly benefit from a concept that provides an onsite dental care. A rational evaluation of the costs to render this service as well as the cost benefits is worth investigating. This study aimed to calculate the costs involved in providing a mobile dental clinic (MDC) service for LTCF residents in Zurich, Switzerland.

MATERIALS AND METHODS

Cost models for setting up, executing and maintaining an MDC unit were generated. The costs included personnel, equipment/material, maintenance and running costs. The treatment costs were calculated for the treatment in MDC, university-setting dental clinic (UC) and private practice (PP). Hypothetical cost estimates were generated for the return of the invested capital. Costs incurred for the institutions for accommodating the MDC visit were also calculated.

RESULTS

The set-up capital required to start a MDC in Switzerland (for 2020) was approximately around CHF 505'007.90 (Euros 466'576.80) and was around CHF 452'666.48 (Euros 418'218.56) when a dental care professional (DCP) substituted the dentist. The estimated cost savings for an LTCF resident in the MDC were CHF 205.60 (Euros 189.95) when compared to a UC and approximately CHF 226.34 (Euros 209.12) when compared to a PP. With the dentist, the return of the invested capital can be expected by 3 years while it would take around 6 years with the DCP, assuming that the maximum number of patients possible-to-treat are treated every year. The daily running costs for the LTCF for accommodating the MDC visit were approximately CHF 299.04 (Euros 276.28).

CONCLUSIONS

Delivery of oral health services for LTCF residents through the use of a MDC service seems to be an effective model for dependent elders with limited access to care. However, the costs of maintaining this service are high with similarly large start-up costs. Future development of this model by utilising dental care professionals may produce cost savings but with a more limited range of services offered.

Dental therapists in general dental practice. A literature review and case-study analysis to determine what works, why, how and in what circumstances

INTRODUCTION

In the United Kingdom, policy and guidance changes regarding the role of dental therapists (DTs) were implemented in recent years with a view to changing dental care to a more preventive-focussed, teamwork approach. However, success in the adoption of this model of working has been varied.

AIMS

Adopting a realist approach, our aim was, to examine the use of DTs in general dental practices in Wales, exploring what works, why, how and in what circumstances.

MATERIALS AND METHODS

The research comprised two stages. (a) A structured literature search, dual-coding papers for high-level factors describing the conditions or context(s) under which the mechanisms operated to produce outcomes. From this, we derived theories about how skill-mix operates in the general dental service. (b) Six case studies of general dental practices (three with a dental therapist/three without a dental therapist) employing a range of skill-mix models incorporating semi-structured interviews with all team members. We used the case studies/interviews to explore and refine the theories derived from the literature.

RESULTS

Eighty-four papers were coded. From this coding, we identified seven theories which reflected factors influencing general dental practices within three broad contexts: the dental practice as a business, as a healthcare provider and as a workplace. We tested these theories in interviews with 38 dental team members across the six care studies. As a result, we amended five of the theories.

CONCLUSION

Our analysis provides theory about outcomes that DTs may facilitate and the mechanisms that may assist the work of DTs within different contexts of general dental practice.

Teledentistry as a novel pathway to improve dental health in school children: a research protocol for a randomised controlled trial

BACKGROUND

Despite great improvement in child oral health, some children subgroups still suffer from higher levels of dental caries. Geographic and socioeconomic barriers and the lack of access to dental care services are among common reasons for poor oral health in children. Historically in Australia, oral health therapists or dental therapists have been responsible for providing dental care for school children through the School Dental Services (SDS). The current SDS has been unable to provide sustainable dental care to all school children due to a reduction in workforce participation and limited resources. We propose a paradigm shift in the current service through the introduction of user-friendly technology to provide a foundation for sustainable dental care for school children.

METHODS/DESIGN

We describe an ongoing parallel, two-armed, non-inferiority randomised controlled trial that compares routine and teledental pathway of dental care in children aged 4-15 years (n = 250). Participating schools in Western Australia will be randomly assigned to the control or teledental group, approximately three schools in each group with a maximum of 45 children in each school. All participants will first receive a standard dental examination to identify those who require urgent referrals and then their teeth will be photographed using a smartphone camera. At the baseline, children in the control group will receive screening results and advice on the pathway of dental care based on the visual dental screening while children in the teledental group will receive screening results based on the assessment of dental images. At 9 months follow-up, all participants will undergo a final visual dental screening. The primary outcomes include decay experience and proportion of children become caries active. The secondary outcomes include the diagnostic performance of photographic dental assessment and costs comparison of two pathways of dental care.

DISCUSSION

The current project seeks to take advantage of mobile technology to acquire dental images from a child's mouth at school settings and forwarding images electronically to an offsite dental practitioner to assess and prepare dental recommendations remotely. Such an approach will help to prioritise high-risk children and provide them with a quick treatment pathway and avoid unnecessary referrals or travel.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12619001233112. Registered 06 September 2019.

Improving Oral-Systemic Healthcare through the Interoperability of Electronic Medical and Dental Records: An Exploratory Study

OBJECTIVES

Electronic health records (EHRs) are rarely shared among medical and dental providers. The purpose of this study was to assess current information sharing and the value of improved electronic information sharing among physicians and dentists in Germany and the United States.

MATERIALS AND METHODS

A survey was validated and distributed electronically to physicians and dentists at four academic medical centers. Respondents were asked anonymously about EHR use and the medical and dental information most valuable to their practice.

RESULTS

There were 118 responses, a response rate of 23.2%. The majority (63.9%) of respondents were dentists and the remainder were physicians. Most respondents (66.3%) rated the importance of sharing information an 8 or above on a 1-to-10 Likert scale. Dentists rated the importance of sharing clinical information significantly higher than physicians (p = 0.0033). Most (68.5%) providers could recall an instance when access to medical or dental information would have improved patient care. Dentists were significantly more likely to report this than physicians (p = 0.008).

CONCLUSION

Physicians would value a standardized measure of "oral health" in their EHR. Dentists were less likely to find specific medical diagnostic test results of value. Both dentists and physicians agreed that oral-systemic health was important; interoperable EHRs could facilitate information transfer between providers and enhance research on oral-systemic health connections. Both dentists and physicians believed that an interoperable EHR would be useful to practice, but desired information was different between these groups. Refinement of the information needed for shared practice is required.

Accuracy of partial protocol to assess prevalence and factors associated with dental caries in schoolchildren between 8-12 years of age

Abstract: The aim of this study was to test accuracy and reliability of a partial protocol (PP) of oral examination involving the permanent first molars. This cross-sectional study was carried out in two stages. First, a cross-sectional study was performed in a representative sample of 1,211 children using DMFT-index in a full-mouth protocol (FM). A PP was simulated from FM data using only data from the permanent first molars. A second part was performed with 202 children examined by a gold standard examiner (FM) and three dentists using the PP to assess its reliability. Accuracy of PP was assessed by sensitivity/specificity/predictive positive and negative values. Inter-examiner reliability in comparison with gold standard examiner was assessed using weighted kappa. The prevalence of dental caries observed using DMFT index was 32.4% and was 30.2% for PP . The PP presented high sensitivity (93.1%; 95%CI: 91.5-94.5), showing similar magnitude of association’s measures for all associated factors investigated. When compared with the gold standard FM examination, all examiners obtained high parameters of sensitivity and specificity (around 90%). Predictive negative values were higher than predictive positive values for the examiners. This study showed that this partial protocol involving the permanent first molars is accurate and reliable as a screening tool to assess dental caries prevalence and associated factors in schoolchildren.

Validity and reliability of remote dental screening by different oral health professionals using a store-and-forward telehealth model

Objective This study was conducted to evaluate the validity and reliability of intraoral photographic assessments by different members of a dental team as a means for dental screening in children.Methods The intraoral photographic records of 126 children (2 to 18 years old) were obtained from routine clinical records taken before dental treatment. Intraoral photographs were obtained using a DSLR camera and then uploaded to a cloud-based server using store-and-forward telehealth technology. Images were reviewed by an expert panel to formulate a benchmark screening baseline, to which the screeners' data were compared. The photographic assessments conducted by a mid-level dental practitioner (MLDP) and dentist, were compared to the benchmark expert panel assessment.Results The screeners' assessments by means of intraoral photography, when compared to the expert panel assessment had a sensitivity value of 82-89% and specificity value of 97%. The inter-examiner agreement between the expert panel assessment and photographic method (assessed by a dentist and MLDP), was almost perfect, with a kappa score ranging from 0.82 to 0.88. The mean DFT/dft score for the children as determined by the expert panel's review and photographic assessment ranging from 5.41 to 5.79, with mean scores between the two assessment methods not significantly different (P = 0.746).Conclusion Our results suggested that oral health professionals (other than dentists) have the potential to screen for caries from intraoral photographs with the same diagnostic accuracy and reliability as dentists. This strategy has implications for supporting the use of MLDPs such as dental therapists or hygienists to screen for oral disease using telehealth.

Feasibility study: assessing the efficacy and social acceptability of using dental hygienist-therapists as front-line clinicians

Background The oral health of the adult population has been improving in the United Kingdom decade upon decade. Over half of dental service activity in the National Health Service (NHS) is limited to a check-up without any further treatment. This raises a question as to whether check-ups could be provided by dental hygienist-therapists, rather than general dental practitioners. The aim of this study was to assess the feasibility of a definitive trial to evaluate the costs and effects of using dental hygienist-therapists to undertake the check-up.Methods/design Adult NHS patients were randomised into three arms in two dental practices: patients who only saw dental hygienist-therapists for a check-up, those that saw the general dental practitioner and dental hygienist-therapist alternatively and a control, where patients only saw the general dental practitioner for their check-up. The study ran for 15 months. The primary outcome measures of the study were patient recruitment, retention and fidelity. A parallel and embedded qualitative study was undertaken which recorded the views of participating patients to determine the social acceptability of the intervention.Results Sixty patients participated in the study. The initial recruitment rate for the study was 33.7%. This figure increased to over 82.1% when telephone calls or face-to-face recruitment was utilised. The retention rates were 60% for both the dental hygienist-therapist only group and the alternate general dental practitioner and dental hygienist-therapist group, compared to 70% for the general dental practitioner only group. Fifteen patients were interviewed in the qualitative study and supported a team approach to the provision of check-ups in the NHS. Conclusion This study demonstrates the feasibility of a definitive trial to evaluate the costs and effects of using dental-hygienist-therapists to undertake the check-up.

Cost savings from a teledentistry model for school dental screening: an Australian health system perspective

Objective The aim of the present study was to compare the costs of teledentistry and traditional dental screening approaches in Australian school children. Methods A cost-minimisation analysis was performed from the perspective of the oral health system, comparing the cost of dental screening in school children using a traditional visual examination approach with the cost of mid-level dental practitioners (MLDPs), such as dental therapists, screening the same cohort of children remotely using teledentistry. A model was developed to simulate the costs (over a 12-month period) of the two models of dental screening for all school children (2.7 million children) aged 5–14 years across all Australian states and territories. The fixed costs and the variable costs, including staff salary, travel and accommodation costs, and cost of supply were calculated. All costs are given in Australian dollars. Results The total estimated cost of the teledentistry model was $50 million. The fixed cost of teledentistry was $1 million and that of staff salaries (tele-assistants, charters and their supervisors, as well as information technology support was estimated to be $49 million. The estimated staff salary saved with the teledentistry model was $56 million, and the estimated travel allowance and supply expenses avoided were $16 million and $14 million respectively; an annual reduction of $85 million in total. Conclusions The present study shows that the teledentistry model of dental screening can minimise costs. The estimated savings were due primarily to the low salaries of dental therapists and the avoidance of travel and accommodation costs. Such savings could be redistributed to improve infrastructure and oral health services in rural or other underserved areas. What is known about the topic? Caries is a preventable disease, which, if it remains untreated, can cause significant morbidity requiring costly treatment. Regular dental screening and oral health education have the great potential to improve oral health and save significant resources. The use of role substitution, such as using MLDPs to provide oral care has been well acknowledged worldwide because of their ability to provide safe and effective care. The teledentistry approach for dental screening offers a comparable diagnostic performance to the traditional visual approach. What does this paper add? The results of the present study suggest that teledentistry is a practical and economically viable approach for mass dental screening not only for isolated communities, but also for underserved urban communities. The costs of the teledentistry model were substantially lower than the costs associated with a conventional, face-to-face approach to dental screening in both remote and urban areas. The primary driver of net savings is the low salary of MLDPs and avoidance of travel and overnight accommodation by MLDPs. What are the implications for practitioners? The use of lower-cost MLDPs and a teledentistry model for dental screening has the potential to save significant economic and human resources that can be redirected to improve infrastructure and oral care services in underserved regions. In the absence of evidence of the economic usefulness of teledentistry, studies such as the present one can increase the acceptance of this technology among dental care providers and guide future decisions on whether or not to implement teledentistry services.

A Markov model assessing the impact on primary care practice revenues and patient's health when using mid-level providers, lesson learned from the United Kingdom

OBJECTIVE

To evaluate the cost-effectiveness of using mid-level providers for dental "check-up" examinations and the treatment of caries in different NHS settings in the United Kingdom. Mid-level providers are a broad category that describes non-dentist members of dental teams. This study focused on the potential use of Dental Hygiene Therapists undertaking dental "check-up" examinations and simple restorative treatment, instead of dentists.

METHODS

A Markov model was used to construct the natural history of caries development in adults that visit a dental practice every six months over a five-year period. Three cost perspectives are taken: those borne to dental healthcare providers in England and Wales, Northern Ireland and Scotland. These represent three separate forms of retrospective payment system that are currently in use in the United Kingdom. The cost outcome was the average amount of retained practice earnings required to provide healthcare per patient visit. The health outcome was the average length of time in a cavity-free state and the cost-effectiveness outcome was incremental cost for six months in a cavity-free state.

RESULTS

No statistical difference was found between dentists and mid-level providers in the length of time in a cavity-free state but the use of the latter saved money in all three NHS health system jurisdictions. This ranged from £7.85 (England and Wales) to £9.16 (Northern Ireland) per patient visit ($10.20 to $11.90, respectively) meaning the incremental cost for six month in a cavity-free state ranged from £261.67 ($339.93) in England and Wales to £305.33 ($369.68) in Northern Ireland. Further, changes in baseline assumptions and parameter values did not change mid-level providers being the dominant service intervention.

CONCLUSION

In a time of limited funds for dental services, these results suggest that resources in public funded systems could be saved using mid-level providers in dental practices, without any health risk to patients or capital investment.

Determining the optimal model for role substitution in NHS dental services in the UK: a mixed-methods study

Background

Maximising health gain for a given level and mix of resources is an ethical imperative for health-service planners. Approximately half of all patients who attend a regular NHS dental check-up do not require any further treatment, whereas many in the population do not regularly attend. Thus, the most expensive resource (the dentist) is seeing healthy patients at a time when many of those with disease do not access care. Role substitution in NHS dentistry, where other members of the dental team undertake the clinical tasks previously provided by dentists, has the potential to increase efficiency and the capacity to care and lower costs. However, no studies have empirically investigated the efficiency of NHS dental provision that makes use of role substitution.

Research questions

This programme of research sought to address three research questions: (1) what is the efficiency of NHS dental teams that make use of role substitution?; (2) what are the barriers to, and facilitators of, role substitution in NHS dental practices?; and (3) how do incentives in the remuneration systems influence the organisation of these inputs and production of outputs in the NHS?

Design

Data envelopment analysis was used to develop a productive efficiency frontier for participating NHS practices, which were then compared on a relative basis, after controlling for patient and practice characteristics. External validity was tested using stochastic frontier modelling, while semistructured interviews explored the views of participating dental teams and their patients to role substitution.

Setting

NHS ‘high-street’ general dental practices.

Participants

121 practices across the north of England.

Interventions

No active interventions were undertaken.

Main outcome measures

Relative efficiency of participating NHS practices, alongside a detailed narrative of their views about role substitution dentistry. Social acceptability for patients.

Results

The utilisation of non-dentist roles in NHS practices was relatively low, the most common role type being the dental hygienist. Increasing the number of non-dentist team members reduced efficiency. However, it was not possible to determine the relative efficiency of individual team members, as the NHS contracts only with dentists. Financial incentives in the NHS dental contract and the views of practice principals (i.e. senior staff members) were equally important. Bespoke payment and referral systems were required to make role substitution economically viable. Many non-dentist team members were not being used to their full scope of practice and constraints on their ability to prescribe reduced efficiency further. Many non-dentist team members experienced a precarious existence, commonly being employed at multiple practices. Patients had a low level of awareness of the different non-dentist roles in a dental team. Many exhibited an inherent trust in the professional ‘system’, but prior experience of role substitution was important for social acceptability.

Conclusions

Better alignment between the financial incentives within the NHS dental contract and the use of role substitution is required, although professional acceptability remains critical.

Study limitations

Output data collected did not reflect the quality of care provided by the dental team and the input data were self-reported.

Future work

Further work is required to improve the evidence base for the use of role substitution in NHS dentistry, exploring the effects and costs of provision.

Funding

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

Alternative scenarios: harnessing mid-level providers and evidence-based practice in primary dental care in England through operational research

BACKGROUND

In primary care dentistry, strategies to reconfigure the traditional boundaries of various dental professional groups by task sharing and role substitution have been encouraged in order to meet changing oral health needs.

AIM

The aim of this research was to investigate the potential for skill mix use in primary dental care in England based on the undergraduate training experience in a primary care team training centre for dentists and mid-level dental providers.

METHODS

An operational research model and four alternative scenarios to test the potential for skill mix use in primary care in England were developed, informed by the model of care at a primary dental care training centre in the south of England, professional policy including scope of practice and contemporary evidence-based preventative practice. The model was developed in Excel and drew on published national timings and salary costs. The scenarios included the following: "No Skill Mix", "Minimal Direct Access", "More Prevention" and "Maximum Delegation". The scenario outputs comprised clinical time, workforce numbers and salary costs required for state-funded primary dental care in England.

RESULTS

The operational research model suggested that 73% of clinical time in England's state-funded primary dental care in 2011/12 was spent on tasks that may be delegated to dental care professionals (DCPs), and 45- to 54-year-old patients received the most clinical time overall. Using estimated National Health Service (NHS) clinical working patterns, the model suggested alternative NHS workforce numbers and salary costs to meet the dental demand based on each developed scenario. For scenario 1:"No Skill Mix", the dentist-only scenario, 81% of the dentists currently registered in England would be required to participate. In scenario 2: "Minimal Direct Access", where 70% of examinations were delegated and the primary care training centre delegation patterns for other treatments were practised, 40% of registered dentists and eight times the number of dental therapists currently registered would be required; this would save 38% of current salary costs cf. "No Skill Mix". Scenario 3: "More Prevention", that is, the current model with no direct access and increasing fluoride varnish from 13.1% to 50% and maintaining the same model of delegation as scenario 2 for other care, would require 57% of registered dentists and 4.7 times the number of dental therapists. It would achieve a 1% salary cost saving cf. "No Skill Mix". Scenario 4 "Maximum Delegation" where all care within dental therapists' jurisdiction is delegated at 100%, together with 50% of restorations and radiographs, suggested that only 30% of registered dentists would be required and 10 times the number of dental therapists registered; this scenario would achieve a 52% salary cost saving cf. "No Skill Mix".

CONCLUSION

Alternative scenarios based on wider expressed treatment need in national primary dental care in England, changing regulations on the scope of practice and increased evidence-based preventive practice suggest that the majority of care in primary dental practice may be delegated to dental therapists, and there is potential time and salary cost saving if the majority of diagnostic tasks and prevention are delegated. However, this would require an increase in trained DCPs, including role enhancement, as part of rebalancing the dental workforce.

Direct access in the UK: what do dentists really think?

OBJECTIVE

To investigate dentists' views on the likely impact of direct access (DA), the clinical competence of hygienists and therapists to work autonomously and possible predictors of such views.

DESIGN

Random survey of registered dentists.

SETTING

UK, 2014.

SUBJECTS AND METHODS

A random sample of UK-based dentists registered with the General Dental Council (GDC). A unique-access online questionnaire was developed, with a paper alternative. Email and postal reminders were sent.

MAIN OUTCOME MEASURES

Measures of positive/negative views regarding the impact of DA and clinical competence of hygienists and therapists to work without a dentist's prescription.

RESULTS

One hundred and fifty-nine responded (response rate: 27%), 78 (49.1%) of whom were female. No significant sources of response bias were identified. While 122 (77%) had not undergone joint training with dental hygienists or therapists at the undergraduate level, 98 (62.4%) currently worked with a hygienist and 33 (21.0%) with a therapist. Eighty-three (53.2%) disagreed with the GDC decision regarding DA for hygienists, and 94 (59.1%) felt the same regarding therapists. Concern was greatest in respect to diagnosis, treatment planning and restorations. Comments were predominantly negative and reflected concerns over patient safety, what was seen as hygienists' and therapists' inadequate training or expertise, the undermining of the dentist's role, service delivery, the reform being poorly planned, implemented or being a cost-cutting exercise. Experience of teamwork was not predictive of positive/negative views.

CONCLUSIONS

Response was low, thus posing a potential threat to the study's representativeness. Many dentists had concerns and reservations about DA which were unrelated to teamwork experience. The dissemination of information on curricula and scope of practice may help allay such concerns, as may a greater emphasis on joint training at both the undergraduate level and within continuing professional development programmes.