Toward More Patient-Centered and Prevention-Oriented Oral Health Care: The ADVOCATE Project

A scoping review of dental practitioners' perspectives on perceived barriers and facilitators to preventive oral health care in general dental practice

BACKGROUND

Oral health has an important role in the general health and well-being of individuals. Dental teams are ideally placed to support patients in preventing ill-health. Understanding the barriers and facilitators to the adoption, promotion and facilitation of preventive advice and treatment is key to improving oral health services. The Theoretical Domains Framework (TDF) is a useful psychological framework to help identify individual, interpersonal and environmental issues which could be impacting clinicians' ability to provide preventive advice and care. The aim of this review was to identify the perceived barriers and facilitators to preventive oral health care from the perspectives of the oral healthcare team within the general dental practice.

METHODS

A search strategy was developed, piloted, and run in: Medline via Ovid, PsycInfo, Web of Science, SCOPUS, EMBASE, Conference Proceedings Citation Index- Science, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews and followed PRISMA guidelines. Identified records were screened independently by two researchers. Data were coded using the Theoretical Domains Framework (TDF) and analysed using narrative data synthesis.

RESULTS

5610 papers were identified, and 19 included in this review. Thirteen papers focussed on dentists. Of the 106 items mapped onto the TDF, 48 were facilitators. The domains most frequently represented were, environmental context and resources, beliefs about consequences, social professional role and identity, skills, beliefs about capabilities and knowledge. Six studies focussed on dental hygienists. There were 47 items mapped onto the TDF, 18 were facilitators. The domains most frequently represented were environmental context and resources, social influences, beliefs about consequences and knowledge.

CONCLUSIONS

The review identified that the delivery of preventive activities did not focus solely on the patient and dental professional interaction as many previous studies have highlighted. The review found that multiple factors influence whether prevention is delivered to patients. The largest barrier and facilitator for the dental professionals identified in this review was the environmental context and resources. Further research is needed to evaluate the effectiveness of interventions that aim to promote preventive oral health care in primary care settings to understand whether they address the barriers identified in this review.

Barriers to prevention in oral health care for english NHS dental patients: a qualitative study of views from key stakeholders

BACKGROUND

Despite significant progress in the control of oral diseases since the discovery of fluoride in the 1940s, dental caries and periodontal diseases continue to affect a significant proportion of the population, particularly socially disadvantaged and lower socioeconomic groups. The National Health Service in England provides preventive advice and treatments as part of an oral health assessment, and evidence-based guidance recommends the use of fissure sealants and topical fluorides in addition to dietary and oral hygiene advice. Although oral health promotion and education have become expected parts of dental care, the need for restorative treatments remains relatively high. We aimed to explore how barriers to preventive advice and treatment for NHS patients may be hindering the provision of prevention in oral health to patients from the perspectives of multiple key stakeholders.

METHODS

Semi-structured interviews and focus groups were undertaken between March 2016-February 2017 with four groups of stakeholders: dentists, insurers, policy makers and patient participants. The interviews were analysed using deductive, reflexive thematic analysis.

RESULTS

Thirty-two stakeholders participated: 6 dentists, 5 insurers, 10 policy makers, and 11 patient participants. Four themes were developed: Perspectives on the clarity of oral health messaging and patient's knowledge, The variability of prioritising prevention, Influences of the dentist-patient relationship on effective communication and Motivation to enact positive oral health behaviours.

CONCLUSIONS

The findings from this research indicate that patients' knowledge of and priority placed on prevention is variable. Participants believed that more targeted education could be valuable in enhancing these. A patient's relationship with their dentist could also influence their level of knowledge through the information shared with them, their receptivity to the preventive messages and the value they place on it. However, even with knowledge, prioritising prevention and a good patient-dentist relationship, without motivation to engage in preventive behaviour the impact of these is reduced. Our findings are discussed in relation to the COM-B model of behaviour change.

Outcomes of periodontal therapy: Strengthening the relevance of research to patients. A co-created review

Periodontitis is a long-term condition affecting up to half of the population globally and causing significant impacts on life quality. Successful management depends on taking life-long ownership of the condition by those affected. There is a wealth of research to inform on management options. However, most of the research has been designed by professional experts with outcomes to gauge benefits and harms based on parameters that inform on the disease process but which might not be informative to support decision-making in people with lived experience (PWLE) of periodontal ill-health (including both patients and carers). The importance of relevant outcomes is highlighted in the concept of the "expert patient" which aims to strengthen the capacity of PWLE to make health-care choices that are important for them, elements of which are likely to be already familiar to many clinicians delivering periodontal health care. Therefore, the voice and collaboration of PWLE in research are recognised as crucial to developing high quality, relevant evidence especially for long-term conditions. In this paper, we review what is known about the relevance of treatment outcomes to PWLE. We also examine the degree to which PWLE have been involved in identifying outcomes that are important to them as well as the diversity and therefore representativeness of PWLE recruited for studies. We consider why having more relevant outcomes could enhance the expertise of PWLE in managing their periodontitis. We then conclude with key learnings from our review which we hope will encourage more rapid development of these initiatives in periodontology for the benefit of global health and wellbeing.

Cost-effectiveness of AI for Caries Detection: Randomized Trial

OBJECTIVES

We assessed the cost-effectiveness of AI-supported detection of proximal caries in a randomized controlled clustered cross-over superiority trial.

METHODS

Twenty-three dentists were sampled to assess 20 bitewings; 10 were randomly evaluated supported by an AI-based software (dentalXrai Pro 1.0.4, dentalXrai Ltd, Berlin, Germany) and the other 10 without AI support. The reference test had been established by four independent experts and an additional review. We evaluated the proportion of true and false positive and negative detections and the treatment decisions assigned to each detection (non-invasive, micro-invasive, invasive). Cost-effectiveness was assessed using a mixed public-private-payer perspective in German healthcare. Using the accuracy and treatment decision data from the trial, a Markov simulation model was populated and posterior permanent teeth in initially 31-years old individuals followed over their lifetime. The model allowed extrapolation from the initial detection and therapy to treatment success, re-treatments and, eventually, tooth loss and replacement, capturing long-term effectiveness (tooth retention) and costs (cumulative in Euro). Costs were estimated using the German public and private fee catalogues. Monte-Carlo microsimulations were used and incremental cost-effectiveness at different willingness-to-pay ceiling thresholds assessed.

RESULTS

In the trial, AI-supported detection was significantly more sensitive than detection without AI. However, in the AI group, lesions were more often treated invasively. As a result, AI and no AI showed identical effectiveness (tooth retention for a mean (2.5-97.5%) 49 (48-51)) and nearly identical costs (AI: 330 (250-409) Euro, no AI: 330 (248-410) Euro). 41% simulations found AI and 43% no AI to be more cost-effective. The resulting cost-effectiveness remained uncertain regardless of a payer's willingness-to-pay.

CONCLUSIONS

Higher accuracy of AI did not lead to higher cost-effectiveness, as more invasive treatment approaches generated costs and diminished possible effectiveness advantages.

CLINICAL SIGNIFICANCE

The cost-effectiveness of AI could be improved by supporting not only caries detection, but also subsequent management.

[Dental and oral health services research in Germany]

In den letzten 8 Jahren wurde in Deutschland nicht nur „mehr Versorgungsforschung in der Zahnmedizin“ gefordert, sondern auch geleistet. Insgesamt finden sich an 12 Medizinischen Fakultäten themenbezogene Aktivitäten der Zahn‑, Mund- und Kieferheilkunde in der Versorgungsforschung; deutschlandweit werden 9 Großprojekte verortet, die vom Bundesministerium für Bildung und Forschung oder vom Innovationsfonds gefördert werden. Gleichwohl ist der Bedarf an Versorgungsforschung größer als die jetzige Leistungsfähigkeit der universitären und außeruniversitären Zahnmedizin: Um eine nachhaltige, bedarfsgerechte und zukunftssichere zahnärztliche Versorgung aller Menschen in Deutschland gewährleisten zu können, bedarf es strukturierter, methodisch versierter und in die Versorgung hinein vernetzter Verbünde, die das wissenschaftliche Fundament für erwartete Versorgungsumbrüche legen können.

Der vorliegende Beitrag soll den Stand der Versorgungsforschung in der Zahn‑, Mund- und Kieferheilkunde in Deutschland beschreiben. Die wesentlichen Herausforderungen werden adressiert: Methodenkompetenz, Zugang zu Daten und deren Nutzung sowie die langfristige Perspektive dieses Forschungsbereichs. Derzeitige Forschungsaktivitäten und Infrastruktur inklusive Förder- und Fortbildungsinstrumente werden dargestellt.

Die Erkenntnisse aus der zahnärztlichen Versorgungsforschung in Deutschland können auch für andere Länder richtungsweisend sein; umgekehrt kann Versorgungsforschung Ansätze aus anderen Ländern sinnvoll in das deutsche Gesundheitssystem übertragen. Versorgungsforschende sollten sich professionalisieren und vernetzen. Nachhaltige Strukturen (Professuren, Mittelbau) und Rahmenbedingungen (Datennutzung, Förderung) sollten geschaffen und Forschungsergebnisse zeitnah verwertet werden.

Whose Responsibility Is It Anyway? Exploring Barriers to Prevention of Oral Diseases across Europe

INTRODUCTION

Dental caries, gum disease, and tooth loss are all preventable conditions. However, many dental care systems remain treatment oriented rather than prevention oriented. This promotes the treatment of oral diseases over preventive treatments and advice. Exploring barriers to prevention and understanding the requirements of a paradigm shift are the first steps toward delivering quality prevention-focused health care.

OBJECTIVES

To qualitatively explore perceived barriers and facilitators to oral disease prevention from a multistakeholder perspective across 6 European countries.

METHODS

A total of 58 interviews and 13 focus groups were undertaken involving 149 participants from the United Kingdom, Denmark, Germany, the Netherlands, Ireland, and Hungary. Interviews and focus groups were conducted in each country in its native language between March 2016 and September 2017. Participants were patients (n = 50), dental team members (n = 39), dental policy makers(n = 33), and dental insurers (n = 27). The audio was transcribed, translated, and analyzed via deductive thematic analysis.

RESULTS

Five broad themes emerged that were both barriers and facilitators: dental regulation, who provides prevention, knowledge and motivation, trust, and person-level factors. Each theme was touched on in all countries; however, cross-country differences were evident surrounding the magnitude of each theme.

CONCLUSION

Despite the different strengths and weaknesses among the systems, those who deliver, organize, and utilize each system experience similar barriers to prevention. The findings suggest that across all 6 countries, prevention in oral health care is hindered by a complex interplay of factors, with no particular dental health system offering overall greater user satisfaction. Underlying the themes were sentiments of blame, whereby each group appeared to shift responsibility for prevention to other groups. To bring about change, greater teamwork is needed in the commissioning of prevention to engender its increased value by all stakeholders within the dental system.

KNOWLEDGE TRANSFER STATEMENT

The results from this study provide an initial first step for those interested in exploring and working toward the paradigm shift to preventive focused dentistry. We also hope that these findings will encourage more research exploring the complex relationship among dental stakeholders, with a view to overcoming the barriers. In particular, these findings may be of use to dental public health researchers, dentists, and policy makers concerned with the prevention of oral diseases.

Improving Oral Health care Using Academic Detailing-Reproducibility and Scalability of the Added Value for Oral Care Field Studies Approach

OBJECTIVES

A proof-of-concept study has shown that the Added Value for Oral Care (ADVOCATE) Field Studies approach (academic detailing with feedback data) is considered a feasible, useful, and acceptable way to motivate general dental practitioners (GDPs) to reflect on and, if required, change their oral health-care delivery. The aims of this proof-of-principle study were to test whether such results were reproducible and to reach consensus among stakeholders on recommendations for wider implementation.

METHODS

Eleven groups of GDPs were recruited in 6 countries (Denmark, England Germany, Hungary, Ireland, and The Netherlands). Each group had 3 academic detailing meetings, being stimulated by feedback data. Focus group interviews were held to evaluate the reproducibility of the Field Studies approach. A World Café session explored suggestions for the wider implementation of the approach.

RESULTS

Replicable results on feasibility, acceptability, and usefulness of the Field Studies approach were seen; 7 out of 9 themes identified in the proof-of-concept study were validated. Directed content analyses identified that adjustments to procedures to collect and present feedback data were desirable. Overall, the approach can stimulate GDPs to reflect on and change aspects of their oral health-care delivery.

CONCLUSIONS

The Field Studies approach, after some adjustments to data collection procedures, is ready for further testing in larger studies.

Usage and Scientific Properties of the ADVOCATE Oral Health Care Measures

BACKGROUND

Feedback information about the quality of oral health care is important for reflective learning by oral health care professionals and the wider health system. To this end, a list of 48 topics describing oral health and oral health care was recently agreed as part of the EU H2020 ADVOCATE project.

OBJECTIVE

This article reports on the formulation of measures based on the ADVOCATE topics and provides information on usage, reporting, validity, and reliability of the measures.

METHODS

The AIRE instrument was used to guide the methodological approach adopted. The appropriateness of the measures was tested among 39 general dental practitioners (GDPs) in Denmark, Germany, and the Netherlands. Data were collected from a convenience sample of patients via a questionnaire deployed in an online application in their practice. Feasibility, acceptability, and usefulness of the measures were evaluated through focus group interviews with GDPs. Face validity and test-retest reliability of the measures were assessed.

RESULTS

For 46 of the 48 topics, a measure could be defined by constructing a definition and a numerator and denominator. Data collection for all 46 measures was feasible and acceptable for patients using the online questionnaire. The practicalities of using claims data for the purpose of giving feedback to individual and groups of GDPs proved to be challenging in terms of timely access of such data, the granularity of the data, and matching the content of the data with the consented items on quality of oral health care. Face validity was considered appropriate, as the patients found the questionnaire easy to understand. Test-retest reliability was found to be acceptable for 36 of 46 measures.

CONCLUSION

The broad range of the ADVOCATE oral health care measures could make a useful contribution to a more transparent, evidence-based, and patient-centered oral health care system.

KNOWLEDGE TRANSFER STATEMENT

This study shows the usage, reliability, and validity of 46 oral health care measures. The measures, which include patient experience and health behaviors, were found to be useful to stimulate discussions about clinical practice. The measures can provide essential information for quality improvement strategies and useful and relevant feedback information for GDPs.

Value-Based Oral Health Care: Moving Forward With Dental Patient-Reported Outcomes

Value-based oral health care is about improving people's oral health outcomes divided by the costs involved. This article addresses five questions (the "5 W's") pertaining to the measurement of oral health outcomes: why oral health outcomes should be measured, what should be measured, by whom, when, and where. Therefore, dental patient-reported outcome measures offer great potential for driving improvements in oral health care. For illustration, a tentative set of seven key relevant items is presented, which comprises the four dimensions of oral health-related quality of life and the three dental conditions with the highest burden of disease. Through promoting the ample use of oral health outcome measures, it is hoped that this article can contribute to expedite value-based oral health care.

Improving oral healthcare using academic detailing - design of the ADVOCATE Field Studies

Background: Academic detailing (AD) is a defined form of educational outreach that can be deployed to intrinsically motivate practitioners towards improving quality of care. This paper describes the design of the ADVOCATE Field Studies. This proof of concept study aims to evaluate the feasibility, acceptability and usefulness of AD, reinforced with feedback information to promote prevention-oriented, patient-centred and evidence-based oral healthcare delivery by general dental practitioners (GDPs). Methods: Six groups of GDPs will be recruited; two groups of six to eight GDPs in each of three countries - the Netherlands, Germany and Denmark. GDPs will meet for four Academic Detailing Group (ADG) meetings for open discussions using comparative feedback data to stimulate debate about their dental practice performance and care delivery. Group meetings will be moderated using the AD methodology. Qualitative data will be collected through focus group interviews, an online discussion forum, field notes and debriefs of ADG meetings and analysed by conventional content analysis using MaxQDA software. Discussion: The results of the study will provide novel information on the feasibility, perceived acceptability and usefulness of AD and feedback data for GDPs to improve oral healthcare delivery.

Barriers and facilitators for prevention in Danish dental care

Objective: To explore barriers and facilitators to oral disease prevention in Danish dental care from a multi-stakeholder perspective. Methods: Eleven semi-structured focus groups and interviews about Danish oral healthcare were conducted with 27 stakeholders (general public, dental teams, dental policy makers) in Copenhagen. Transcripts were analyzed using deductive thematic analysis independently by KR and HL, supervised by JC and KVC. Results: Seven broad themes were identified, including both barriers and facilitators: Knowledge and attitudes, Education and training, Regulation, Incentivization, Multidisciplinary approach, Access to care and the Dental professional-patient relationship. Whilst all themes were relevant to each group of stakeholders, the salient driver within each theme was different for each group. Conclusions: Stakeholder perspectives on the Danish Oral health care system suggest the following are important features for a preventively focused system: (a) Involving all stakeholders in oral healthcare planning. (b) Securing sufficient and ongoing briefing regarding disease prevention for all stakeholders. (c) Regulatory support and creation of incentives to promote and facilitate implementation of disease prevention. (d) Appropriate prevention for disadvantaged groups within society which may be possible to a higher degree by means of multidisciplinary collaboration. (e) Personal relations between the patient and the professional based on mutual trust.

Needs-based planning for the oral health workforce - development and application of a simulation model

BACKGROUND

The World Health Organization's global strategy on human resources for health includes an objective to align investment in human resources for health with the current and future needs of the population. Although oral health is a key indicator of overall health and wellbeing, and oral diseases are the most common noncommunicable diseases affecting half the world's population, oral health workforce planning efforts have been limited to simplistic target dentist-population or constant services-population ratios which do not account for levels of and changes in population need. Against this backdrop, our aim was to develop and operationalise an oral health needs-based workforce planning simulation tool.

METHODS

Using a conceptual framework put forward in the literature, we aimed to build the model in Microsoft Excel and apply it in a hypothetical context to demonstrate its operability. The model incorporates a provider supply component and a provider requirement component, enabling a comparison of the current and future supply of and requirement for oral health workers. Publicly available data, including the Special Eurobarometer 330 Oral Health Survey, were used to populate the model. Assumptions were made where data were not publicly available and key assumptions were tested in scenario analyses.

RESULTS

We have systematically developed a needs-based workforce planning model for the oral health workforce and applied the model in a hypothetical context over a 30-year time span. In the 2017 baseline scenario, the model produced a full-time equivalent (FTE) provider requirement figure of 899 dentists compared with an FTE provider supply figure of 1985. In the scenario analyses, the FTE provider requirement figure ranged from 1123 to 1629 illustrating the extent of the impact of changing parameter values.

CONCLUSIONS

In response to policy makers' recognition of the pressing need to better plan human resources for health and the scarcity of work in this area for dentistry, we have demonstrated the feasibility of producing a workable, practical and useful needs-based workforce planning simulation tool for the oral health workforce. In doing so, we have highlighted the challenges faced in accessing timely and relevant data needed to populate such models and ensure the reliability of model outputs.

A Consensus-Based Set of Measures for Oral Health Care

Increasingly more responsive and accountable health care systems are demanded, which is characterized by transparency and explicit demonstration of competence by health care providers and the systems in which they work. This study aimed to establish measures of oral health for transparent and explicit reporting of routine data to facilitate more patient-centered and prevention-oriented oral health care. To accomplish this, an intermediate objective was to develop a comprehensive list of topics that a range of stakeholders would perceive as valid, important, and relevant for describing oral health and oral health care. A 4-stage approach was used to develop the list of topics: 1) scoping of literature and its appraisal, 2) a meeting of experts, 3) a 2-stage Delphi process (online), and 4) a World Café discussion. The aim was to create consensus through structured conversations via a range of stakeholders (general dental practitioners, patients, insurers, and policy makers) from the Netherlands, Germany, the United Kingdom, Ireland, Hungary, and Denmark. The study was part of the ADVOCATE project, and it resulted in a list of 48 topics grouped into 6 clusters: 1) access to dental care, 2) symptoms and diagnosis, 3) health behaviors, 4) oral treatments, 5) oral prevention, and 6) patient perception. All topics can be measured, as they all have a data source with defined numerators and denominators. This study is the first to establish a comprehensive and multiple-stakeholder consented topic list designed for guiding the implementation of transparent and explicit measurement of routine data of oral health and oral health care. Successful measurement within oral health care systems is essential to facilitate learning from variation in practice and outcomes within and among systems, and it potentiates improvement toward more patient-centered and prevention-oriented oral health care.

GPs' and dentists' experiences and expectations of interprofessional collaboration: findings from a qualitative study in Germany

BACKGROUND

Against the background of well-described associations between oral and general health, collaboration between dentists and general practitioners (GP) is crucial to provide therapeutic and preventive patient care. However, in the German health system, GPs and dentists are organizationally separated, implying that interprofessional collaboration can only occur informally and on a voluntary basis. Given the scarce evidence of interprofessional collaboration between dentists and GPs, an explorative study was conducted. This paper outlines the findings of this study with regard to GPs' and dentists' experiences and expectations of interprofessional collaboration.

METHODS

Semi-structured interviews were conducted with GPs (n = 15) and dentists (n = 13) from three structurally different regions in Baden-Wurttemberg, Germany. The interview guide included questions on occasions, expectations and experiences of interprofessional collaboration. The interviews were transcribed verbatim and analysed using qualitative content analysis according to Mayring.

RESULTS

Both GPs and dentists reported perceived knowledge deficits of the other profession with regard to medication, particularly anticoagulants and bisphosphonates, as well as systemic and general respectively dental diseases. Expectations regarding the scope of collaboration diverge: whereas dentists were interested in extending collaboration, most GPs saw no need for collaboration.

CONCLUSIONS

The perceived medical knowledge deficits of the other profession as well as divergent expectations concerning the scope of collaboration hinder profound and regular interprofessional collaboration between GPs and dentists. These perceived knowledge deficits may be rooted in the separate education of dentists and GPs in Germany. Fostering interprofessional education is a promising way to improve cooperation between GPs and dentists in the long term.