Does the Self-Reported Behavioural Automaticity Index provide a valid measure of toothbrushing behaviour in adults?

BACKGROUND

Studies to promote regular toothbrushing usually rely on self-reports of toothbrushing frequency (SRF). However, toothbrushing frequency measures may be open to responder bias since twice-daily toothbrushing is a commonly accepted social norm. The validity of SRF measures is unclear, meaning that their use as outcomes in interventional work may be flawed. The study's aim was to compare two different self-reported toothbrushing measures: SRF and the Self-Reported Behavioural Automaticity Index (SRBAI); with measurement of observed toothbrushing frequency tracked over 6 weeks. A secondary aim was to explore the interaction effect of various moderators (age, ethnicity, socioeconomic status (SES), sex, self-efficacy, participant personality and routine preference) upon the correlation between SRBAI and observed toothbrushing frequency.

METHODS

One hundred and sixty-four adults were recruited via a number of different community groups and workplaces outside the dental setting. After consent, participants completed a questionnaire which collected demographic and participant characteristics measures (age, ethnicity, SES, sex, self-efficacy, participant personality and routine preference) and self-reported toothbrushing habits. Participants then attached a 'Brushlink' device to their toothbrush for 6 weeks to track their observed toothbrushing frequency.

RESULTS

Using the Pearson correlation coefficient, a moderately strong positive linear association (r = 0.65) between SRBAI and observed toothbrushing frequency was found. By comparison, the correlation between SRF and observed toothbrushing frequency was weak (r = 0.39). There was a weak positive association between self-reported behaviour frequency and SRBAI score (r = 0.35). Using multivariable linear regression, no statistically significant interactional effect was demonstrated for any moderator variable upon the correlation coefficient of SRBAI and observed toothbrushing frequency.

CONCLUSIONS

The SRBAI provided a stronger association with observed toothbrushing frequency than the SRF measure. A moderately strong relationship between SRBAI and observed toothbrushing frequency was found, compared to a weak positive relationship between self-reported behaviour frequency and SRBAI score. This suggests that the SRBAI score could be a suitable proxy to measure observed toothbrushing behaviour and preferable to SRF in interventional work.

Screening of atrial fibrillation in dental practices: a qualitative feasibility study

OBJECTIVES

To increase the detection of unknown atrial fibrillation (AF), general practitioners have started screening their patients using small hand-held devices. It is thought that dental settings could be utilized for screening as they have regular access to patients. The aim of this study was to explore the perceptions of dental staff of screening for AF using a hand-held electronic device in primary dental care.

METHODS

The research took place in one large mixed NHS and private general dental practice. Views from staff including dentists, dental therapists, dental nurses, and managers were elicited via semi-structured interviews conducted face-to-face, audio recorded, and transcribed verbatim. Interviews continued until there were no new themes or patterns emerging from the data, and thematic saturation had been achieved.

RESULTS

Eleven participants were interviewed. The main themes generated were methodology for screening, acceptability for screening within the practice, attitudes to screening, and implementation of screening. Overall, participants were positive about implementing AF screening in a dental practice but expressed concerns about time and remuneration. Staff also gave encouraging feedback regarding the simplicity of the portable screening device.

CONCLUSIONS

Participants felt that AF screening in primary care dental practices was a good concept but may be challenging to implement in NHS Dentistry, especially due to the pandemic.

Acute Dental Periapical Abscess and New-Onset Atrial Fibrillation: A Nationwide, Population-Based Cohort Study

There are limited data on the relationship of acute dental infections with hospitalisation and new-onset atrial fibrillation (AF). This study aimed to assess the relationship between acute periapical abscess and incident AF. This was a retrospective cohort study from a French national database of patients hospitalized in 2013 (3.4 million patients) with at least five years of follow up. In total, 3,056,291 adults (55.1% female) required hospital admission in French hospitals in 2013 while not having a history of AF. Of 4693 patients classified as having dental periapical abscess, 435 (9.27%) developed AF, compared to 326,241 (10.69%) without dental periapical abscess that developed AF over a mean follow-up of 4.8 ± 1.7 years. Multivariable analysis indicated that dental periapical abscess acted as an independent predictor for new onset AF (p < 0.01). The CHA₂DS₂VASc score in patients with acute dental periapical abscess had moderate predictive value for development of AF, with Area Under the Curve (AUC) 0.73 (95% CI, 0.71–0.76). An increased risk of new onset AF was identified for individuals hospitalized with dental periapical abscess. Careful follow up of patients with severe, acute dental periapical infections is needed for incident AF, as well as investigations of possible mechanisms linking these conditions.

Atrial fibrillation and cardiac arrhythmia associated with acute dental infection: A systematic literature review and case report

OBJECTIVES

This paper outlines how oral diseases such as periodontitis and periapical periodontitis may be linked to cardiovascular disease, atrial fibrillation and cardiac arrhythmia. We undertake a systematic review of the literature focused on acute dental infection and types of cardiac arrhythmia and also describe an illustrative case where an acute dental infection diagnosed as periapical periodontitis was associated with the occurrence of atrial fibrillation.

METHODS

An electronic search was undertaken using MEDLINE and SCOPUS from 01 Jan 1970 to 30 June 2020. We also undertook manual searches using forward and backward citation chasing. Inclusion criteria were any primary research studies investigating any acute dental infection, with outcomes of cardiac arrhythmia or atrial fibrillation.

RESULTS

Over the last fifty years, only two low-quality studies have been investigated in this area. Our illustrative case involved a 58 year-old who was diagnosed with an acute dental infection from an upper canine tooth who then developed atrial fibrillation.

CONCLUSIONS

Based on the biological plausibility of a link between acute dental infection and types of cardiac arrhythmia such as atrial fibrillation, together with the case report presented, it is evident that further study in this area is needed. If there are possible cardiovascular consequences for patients suffering from acute dental infection, then this will have implications for healthcare staff since they can integrate professional advice relating to oral health with cardiovascular disease and atrial fibrillation. Screening programmes situated in dental settings can facilitate early intervention and prevention producing benefits for patients and savings to the health system.

Is toothbrushing behaviour habitual? Cues, context, motivators and patient narratives

OBJECTIVES

Toothbrushing is generally considered as a key self-care behaviour necessary for maintaining good oral health. Although twice-daily brushing is widely recommended as beneficial since this provides both biofilm removal and a regular application of fluoride, some people such as those with low socio-economic (SES) backgrounds often brush less regularly. Habit theory identifies that behaviours become habitual when they are undertaken repeatedly in response to a particular cue within a stable context. Once behaviour becomes automatic, long-term maintenance is more likely even if motivation wanes. Establishing toothbrushing as a habitual behaviour is therefore an intervention strategy which may help reduce health inequalities. Therefore, the objective was to more fully understand the nature of toothbrushing behaviour in adults and what prompts its instigation and execution in the morning and evening, in order to inform the design of interventions in this area.

METHODS

Twenty-nine semi-structured interviews were undertaken in an urgent dental care centre in a deprived area of North West England. Thematic analysis using a framework method was used to code the data into theoretically derived categories.

RESULTS

Morning toothbrushing was found to be strongly integrated into cleansing routines and was identified as a behaviour predominantly initiated in response to visual cues. Some toothbrushing behaviour was prompted by internal cues, expressed as strong feelings or urges. These were more related to night-time toothbrushing habits. Common morning motivators were aesthetics and social acceptability. Evening motivators were relatively idiosyncratic. Cleaning of the mouth following a hard, manual working day emerged as a strong driver for low SES males.

CONCLUSION

Understanding the nature of habitual morning and evening toothbrushing is important for the design of effective behavioural interventions, especially those aiming to achieve sustainable improvement in the frequency of night-time toothbrushing.

What are the underlying reasons behind socioeconomic differences in doctor-patient communication in head and neck oncology review clinics?

OBJECTIVE

To explore socioeconomic status (SES) differences in patterns of doctor-patient communication within head and neck cancer clinics and why such differences exist.

METHODS

Thirty-six head and neck cancer review appointments with five Physicians were observed and audio-taped, along with follow-up interviews involving 32 patients. Data were analysed using Thematic Analysis, and compared by patient SES (education, occupation and Indices of Multiple Deprivation).

RESULTS

Three main themes were identified: (a) Physicians used more humour and small talk in their consultations with high SES patients; (b) Low SES patients were more passive in their participation, engaged in less agenda setting and information-seeking, and framed their clinical experience differently; (c) Low SES patients had different preferences for involvement, defining involvement differently to high SES patients and were seen to take a more stoical approach.

CONCLUSION

Low SES patients take a more passive role in medical consultations, engage in less relational talk and are less likely to raise concerns, but were satisfied with this. Physicians may adapt their communication behaviour in response to low SES patients' expectations and preferences.

PRACTICE IMPLICATIONS

A question prompt list may help low SES patients to raise concerns during their consultations. This may reduce inequalities in communication and health.

Disentangling a web of causation: An ethnographic study of interlinked patient barriers to planned dental visiting, and strategies to overcome them

OBJECTIVE

To explore barriers to planned dental visiting, investigating how barriers interlink, how they accumulate and change, and how individuals envisage overcoming their combination of barriers through personal strategies.

METHODS

An ethnographic study was conducted of adult urgent dental care attenders who did not have a dentist, including 155 hours of nonparticipant observations, 97 interviews and 19 follow-up interviews in six urgent dental care settings. Data were analysed using constant comparison, first identifying barriers and personal strategies to overcome them, and subsequently analysing interlinks between barriers and personal strategies.

RESULTS

Accounts of barriers to planned dental visiting encompassed multiple barriers, which related to socioeconomic circumstances as well as experiences of oral health care. Barriers were multi-layered and more difficult to overcome when occurring together. Personal strategies to overcome diverse barriers often hinged on increasing importance of oral health to individuals, yet this was not always sufficient. The combination of barriers participants experience was dynamic, changing due to personal, family, or employment circumstances, and with increasing severity of barriers over time. Over time, this could lead to higher cost, and additional barriers, particularly embarrassment.

CONCLUSION

Barriers to planned dental visiting are complex, multi-layered and change over time, constituting a 'web of causation'. This adds a novel perspective to the literature on barriers to dental visiting, and requires that researchers, dental practitioners and policy makers remain open to barriers' interlinked effects, changes in primacy among individual patients' barriers, and their accumulation over time to better support uptake of planned dental visiting.

Socio-economic differences in patient participation behaviours in doctor-patient interactions-A systematic mapping review of the literature

Background

The degree to which patients participate in their care can have a positive impact on health outcomes. This review aimed to map the current literature on patient participation behaviours in interactions with physicians and the extent to which differences in these behaviours can be explained by socio‐economic status (SES).

Search strategy

Four electronic databases were searched from 1980 onwards using key words related to socio‐economic status and patient participation behaviours.

Study selection

Titles, abstracts and full texts were screened by two reviewers, with the second reviewer screening 20% of all entries.

Data extraction

Data on year of publication, country, patient population, setting, patient participation behaviour studied, and SES measure used were extracted.

Main results

Forty‐nine studies were included in the review. Most studies were conducted in the United States, and the most commonly studied patient participation behaviour was involvement in decision making. Most studies measured SES using education as an indicator, with very few studies using occupation as a measure. Many studies did not report on participants’ medical condition or study setting. Patient participation in their health‐care appointment increased with increasing SES in 24 studies, although in 27 studies no significant association was found.

Discussion and conclusions

Current literature was found to be mainly US‐centric. Many studies did not specify participants’ medical condition or in what setting the study was undertaken. More studies are needed on less commonly studied patient participation behaviours. It would be helpful for further studies to also include a wider range of SES indicators.

Interventions to reduce socio-economic inequalities in dental service utilisation - a systematic review

OBJECTIVE

A gradient exists where people with lower socio-economic status (SES) use dental services less regularly than others. Evidence suggests these SES differences may contribute to inequalities in oral health. A variety of approaches have been tried to increase regular dental service use, although it is possible that some are ineffective or may even widen SES inequalities. We aimed to undertake a systematic review of interventions to reduce SES differences in dental visiting.

BASIC RESEARCH DESIGN

Interventions limited to those influencing dental service use by adults. Any type of experimental design, investigating interventions aiming to reduce SES inequalities in dental service use, was included. Primary outcome was a measure of dental utilisation.

RESULTS

Electronic search of 8 databases, with citation snowballing, identified 14,396 titles and abstracts. Paper eligibility screening identified 63 full papers, of which 6 met the inclusion criteria. All included studies were conducted in the United States. Of these, three were targeted to parents, and two towards pregnant women. Two studies incorporated mailing postcards as (at least) one component of the intervention, although results were mixed. Another three studies included scheduling dental appointments as part of a multi-component approach, again with mixed results. The remaining study, involving community health advisors undertaking activities aimed at raising community awareness, found no significant intervention effect.

CONCLUSIONS

Evidence in this area is limited and results are mixed. More work is needed to investigate the effectiveness of interventions to reduce SES inequalities, especially in different healthcare systems and involving a wider participant range.

A systematic review of interventions using cue-automaticity to improve the uptake of preventive healthcare in adults: applications to dental visiting

OBJECTIVE

Since behaviour is underpinned by both cognitive and automatic processes, psychological interventions aiming to instigate or modify habitual behaviour (cue-automaticity interventions) offer an alternative to the more commonly used (mainly educational) strategies to increase preventive healthcare use. Theory suggests that low socio-economic (SES) groups are especially likely to benefit. Cue-automaticity describes how repetition of behaviour, initiated by a particular 'cue', in a constant context, leads to the automatic instigation and/or execution of behaviour. Our primary objective was to assess the effectiveness of cue-automaticity interventions to improve the uptake of adult preventive healthcare, and to consider how this might be applied to the design of interventions to promote preventive dental visiting.

BASIC RESEARCH DESIGN

An electronic search, with citation snowballing, of cue-automaticity interventions to influence adult preventive healthcare use was undertaken.

RESULTS

Searching identified 11,888 titles and abstracts. Paper screening left 26 papers, of which 6 RCTs met the inclusion criteria. All 6 incorporated an Implementation Intention (I-I) component. Four studies involved cancer screening and 2 involved vaccination programmes. Five studies showed a significantly positive increase in preventive healthcare use, while one did not.

CONCLUSIONS

Whilst few studies using cue-automaticity to underpin the promotion of preventive care use have been undertaken, studies that do exist have promising results. As cue-automaticity interventions may be of particular benefit to low SES groups, research is needed to investigate whether cue-automaticity interventions can translate into reducing inequalities in attendance for dental check-ups.

The use of diet diaries in general dental practice in England

Objectives

Diet diaries are recommended as a tool to support behaviour change in dental patients at high risk of dental diseases. However, little is known about their use in dental practice. This study aimed to investigate whether and how general dental practitioners (GDPs) use diet diaries and identify factors which influence their use.

Methods

A postal questionnaire was sent to a stratified random sample of general dental practitioners. The questionnaire asked about demographic and professional characteristics of the GDPs and their practices regarding diet advice, collection of dietary information, diet diaries usage (e.g. frequency, considerations and barriers), and interpretation of diet diaries. Descriptive, bivariate and multivariate analyses were conducted.

Results

From 972 eligible GDP participants, 250 (26%) responses were received. Whilst almost all of these GDPs reported giving diet advice to patients routinely, and 40% reported also referring to dental care professionals in the practice to deliver dietary advice, only 28% (70) reported that they are involved in using diet diaries. GDPs appeared to target patients for dietary advice: GDPs reported they personally gave diet advice to an estimated 63% of their patients, and referred patients to DCPs for diet advice for 11% of their (GDPs') patients. GDPs used diet diaries more often for child than adult patients. Diet diaries usage was lower among younger dentists and in practices with higher percentages of NHS patients (p⟨0.05). Perceived insufficient remuneration for time involved in using diet diaries was the main reason given for their lack of use.

Conclusion

Although recommended as best practice, most English GDPs do not frequently use diet diaries to collect diet information in dental practice, mainly due to perceived financial and time constraints. Development of a more efficient tool to assess the dietary habits of dental patients is needed.

The development and psychometric properties of the Arabic version of the child oral health impact profile-short form (COHIP- SF 19)

Background

This study aims to cross-culturally adapt the original English-language COHIP-SF 19 to Arabic culture and to test its psychometric properties in a community sample.

Methods

The Arabic COHIP-SF 19 was developed and its psychometric properties were examined in a population-based sample of 876 schoolchildren who were aged 12 years of age, in Benghazi, Libya. The Arabic COHIP-SF 19 was tested for its internal consistency, reproducibility, construct validity, factorial validity and floor as well as ceiling effects. A Mann-Whitney U test was used to compare the mean scores of COHIP-SF 19 by participants’ caries status and self-reported oral health rating, satisfaction and treatment need.

Results

The Arabic COHIP-SF 19 was successfully and smoothly developed. It showed an acceptable level of equivalence to the original version. Overall, the internal consistency and reproducibility were acceptable to excellent, with a Cronbach’s alpha of 0.84 and an intra-class correlation coefficient (ICC) of 0.76. All hypotheses predefined to test construct validity were confirmed. That is, children who had active dental caries, and who rated their oral health as poor, were not satisfied with their oral health or indicated the need of treatment had lower COHIP-SF 19 scores (P < 0.05). Floor or ceiling effects were not observed. The exploratory Factorial analysis suggested a 4-component solution and deletion of one item.

Conclusion

The Arabic COHIP-SF 19 was successfully developed. The measure demonstrated satisfactory reliability and validity to estimate OHRQoL in a representative sample of 12-year-old schoolchildren.

Preventive dental visiting: a critical interpretive synthesis of theory explaining how inequalities arise

BACKGROUND

In many countries, those with lower socioeconomic status are disproportionately affected by poor oral health. This can be attributed, at least in part, to differences in preventive dental visiting. While several theories have been applied to the area, they generally fail to capture the recursive nature of dental visiting behaviour, and fall short of informing the design of complex interventions to tackle inequalities.

OBJECTIVE

To undertake a systematic review and synthesis of theory in order to provide an overview of the pathways which bring about socioeconomic inequalities in early dental visiting, and identify possible intervention points.

METHODS

Electronic searching identified 8947 titles and abstracts. Paper screening and citation snowballing left 77 included papers. Drawing on the tenets of Critical Interpretive Synthesis, data extraction involved capturing concepts and relationships and translating these sometimes into synthetic constructs.

RESULTS

We theorize that at the individual (micro-level), dental visiting behaviour is influenced by: the 'Importance of obtaining care', 'Emotional response' and 'Perceived control', which feed into a balancing of 'Competing Demands' against 'Internal resources' (coping, self-identity), although attendance is tempered by the effective 'Affordability and Availability of services'. Positive Care experiences are theorized to lower the demands and increase internal resources associated with dental visiting. We also outline meso-level factors 'Social norms and sanctions', 'Obligations, expectations and trust', 'Information channels', 'Social structures' and theorize how these can exert an overwhelming influence in deprived areas.

CONCLUSIONS

Socioeconomic inequalities in early dental visiting emerge from several stages in the care-seeking process. Dental visiting behaviour should be viewed not just as a one-off event, but extending over time and social space. Since there is recursivity in peoples' most recent dental experience any future visits we identify that interventions which make care a positive experience for low socioeconomic patients may be particularly beneficial in reducing inequalities.

The information filter: how dentists use diet diary information to give patients clear and simple advice

OBJECTIVES

Diet diaries are recommended for dentists to monitor children's sugar consumption. Diaries provide multifaceted dietary information, but patients respond better to simpler advice. We explore how dentists integrate information from diet diaries to deliver useable advice to patients.

METHODS

As part of a questionnaire study of general dental practitioners (GDPs) in Northwest England, we asked dentists to specify the advice they would give a hypothetical patient based upon a diet diary case vignette. A sequential mixed method approach was used for data analysis: an initial inductive content analysis (ICA) to develop coding system to capture the complexity of dietary assessment and delivered advice. Using these codes, a quantitative analysis was conducted to examine correspondences between identified dietary problems and advice given. From these correspondences, we inferred how dentists reduced problems to give simple advice.

RESULTS

A total of 229 dentists' responses were analysed. ICA on 40 questionnaires identified two distinctive approaches of developing diet advice: a summative (summary of issues into an all-encompassing message) and a selective approach (selection of a main message approach). In the quantitative analysis of all responses, raw frequencies indicated that dentists saw more problems than they advised on and provided highly specific advice on a restricted number of problems (e.g. not eating sugars before bedtime 50.7% or harmful items 42.4%, rather than simply reducing the amount of sugar 9.2%). Binary logistic regression models indicate that dentists provided specific advice that was tailored to the key problems that they identified.

CONCLUSION

Dentists provided specific recommendations to address what they felt were key problems, whilst not intervening to address other problems that they may have felt less pressing.

Is social inequality related to different patient concerns in routine oral cancer follow-up clinics?

Oral cancer has a higher incidence in the lower social strata, and these patients are less likely to engage in supportive interventions and report a poorer quality of life (QoL). The aim of this paper is to compare the Patient Concerns Inventory (PCI) responses across social groups attending routine oral cancer follow-up clinics with particular focus on the deprivation lower quartile. The PCI package is completed by patients as part of their routine review consultation with SNR. Patients were those diagnosed between 2008 and 2012. Deprivation was stratified using the IMD 2010 from postcode. Of the 106 eligible patients, 85 % used the PCI. Just over half (54 %) were living in the most deprived quartile, with two-thirds (68 %) of males in the most deprived quartile, compared with 35 % of females (p = 0.004). In regard to number and type of PCI items selected by patients at their first PCI clinic, there were no notable differences in respect of IMD classification. The two commonest concerns were fear of recurrence (43 %) and sore mouth (43 %). The most deprived quartile reported significant problems in regard to mood (p = 0.004) and recreation (p = 0.02), and a non-significant trend (36 vs 18 %, p = 0.09) in stating their overall QoL as being less than good. It is possible to identify the concerns of patients from lower socioeconomic strata as part of routine follow-up clinics. This allows for targeted multi-professional intervention and supports to improve the outcome in this hard to reach group.

Do 'poor areas' get the services they deserve? The role of dental services in structural inequalities in oral health

All over the world, we see that communities with the greatest dental need receive the poorest care--a truism first summarised by the Inverse Care Law in 1971. Despite efforts to attract dentists to under-served areas with incentives such as 'deprivation payments', the playing field is still uphill because of the fundamental inequalities which exist in society itself Deep-seated cultural values which are accepting of a power difference between the 'haves' and 'have nots', and that emphasise individualism over collectivism, are hard to shift. The marketization of health care contributes, by reinforcing these values through the commodification of care, which stresses efficiency and the transactional aspects of service provision. In response, practitioners working in deprived areas develop 'scripts' of routines that deliver 'satisfactory care', which are in accord with the wishes of patients who place little value on oral health but which also maintain the viability of the practice as a business. A compliance framework contrasting types of organisational (dental practice) power (coercive, utilitarian, normative) with types of patient orientation (alienative, calculative, moral) identifies where certain combinations 'work' (e.g. normative power--moral orientation), but where others struggle. Thus institutional structures combine with patients' and the wider community's demands, to generate a model of dental care which leaves little scope for ongoing, preventive dental treatment. This means that in poor areas, all too often, not only is less care available, it is of lower quality too--just where it is needed most.

Operationalisation of the construct of access to dental care: a position paper and proposed conceptual definitions

BACKGROUND

'Access' is a term readily used in a political and policy context, but one which has not leant itself to measurement of progress towards policy goals or comparisons between health systems. Like 'quality', 'access' is a multi-dimensional construct, but currently often remains a vague and abstract concept which is difficult to translate into something specific, concrete and therefore measureable.

METHODS

The paper describes previous work and identifies a need for a greater consensus and conceptual clarity in the selection of metrics for dental access.

RESULTS

The construct of dental access is described as involving the concepts of 1: opportunity for access; 2, realised access (utilisation); 3, equity and 4, outcomes. Proposed conceptual definitions are given and a case made for measuring 'initial utilisation' separately from 'continued utilisation', reflecting modern approaches which distinguish 'entry access' (gaining entry to the dental care system), from the process of gaining access to higher levels of care. Using a distinction between 'entry access' and 'effective access' allows a choice of whether to restrict measurement to mainly supply side considerations, or alternatively to extend the measurement to include whether there is equity in the proportion of patients who are able obtain effective needed interventions.

CONCLUSIONS

A development of conceptual definitions of dental access could facilitate measurement of progress towards policy goals and operationalisation of the construct.

Dental practitioner concepts of efficiency related to the use of dental therapists

OBJECTIVES

Efficiency is concerned with producing maximum output with the minimum input, although what constitutes inputs and outputs within an organization is not always clear. Labour substitution is one method of achieving efficiency gains, although cost savings are found to be context dependent and may not be achieved in some situations. Because dental therapists (DTs) in England are permitted to work in dental practices, we set out to investigate how efficiency with respect to the use of DTs is conceptualized by practitioners to deepen our understanding of the potential for substitution to realize efficiency gains in dental practice.

METHODS

Nine dental practices were selected using a purposive sampling methodology to give a range of practice size and DT employment arrangements. Semi-structured interviews were held with 26 dentists. Transcripts were coded and analysed thematically.

RESULTS

Efficiency was perceived as optimum use of surgery time to generate intermediate outputs of (i) managing patient flow to give patient satisfaction and business cash flow and (ii) volume of work (procedures and numbers of patients). DT efficiency gains were evaluated according to whether lower labour costs were offset by a slower working pace and higher rate of failed appointments. Patient need and demand, and whether the practice had health improvement goals, influenced whether DTs were deemed to improve efficiency.

CONCLUSIONS

Findings are in accord with skill mix reviews in wider health care that substitution may be effective in improving efficiency but this may be limited to particular situations where conditions are conducive. More studies are needed to explore these issues further in other dental practice contexts and with other groups of dental auxiliary.

Translation of remuneration arrangements into incentives to delegate to English dental therapists

OBJECTIVES

To investigate how changes to the dental remuneration system have translated into disincentives to delegate to dental therapists in dental practices.

METHOD

A purposive sample of nine practices was identified incorporating a mix of small, medium and large practices, both with and without dental therapists (DTs). Semi-structured interviews were carried out with 48 principal dentists, associate dentists, DTs, practice managers and dental hygienists. Interview transcripts were analysed using a general inductive approach to identify themes and sub-themes.

RESULTS

Four themes were identified: practice finances, productivity, lack of management information relating to the use of DTs, and fairness. DTs were often seen as a 'cost' to the team, rather than part of the team as a whole, within a system where contributions were evaluated according to a cost-volume-profit business model. Thus DTs were expected to be 'self-financing'. The fairness of deducting the salary costs of the DT from associate dentists' income was an issue.

CONCLUSIONS

The study reveals that the financial risk sharing model which predominates in dental practice significantly influences how the remuneration system translates into establishing delegation incentives. New organisational forms or a shift in practitioner worldviews of team-working are needed in order for DTs to be fully integrated into dental practice teams.

The use of conversation mapping to frame key perceptual issues facing the general dental practice system in England

OBJECTIVE

To demonstrate the use of a novel qualitative methodology namely conversation mapping, which can be used to capture differences in stakeholder perspectives and give a root definition of the problem in a complex policy area. The methodology is used in the context of the changes introduced in the English general dental practice system in April 2006, to investigate the key issues facing the system, as perceived by general dental practitioners (GDPs).

BASIC RESEARCH DESIGN

From a broad trigger statement, three transformational statements were produced. Each participant recorded their contribution on a hard diagrammatic form as a 'map', with others responding with their own written comment, thus generating three conversation maps. Thematic analysis resulted in the generation of a preliminary model summarising key perceptual issues.

RESULTS

The five emergent themes identified were: financing, dentists' wants/needs, the role of the public and patients, system goals and policy level decision making. Financing was identified as the core category to which all other categories were related.

CONCLUSIONS

Conversation mapping, a methodology arising from a systems approach, can be used to develop a 'rich picture' of an oral health care system in order to define the core problem within this policy area. Findings suggest that GDPs identify the financing of the system as a fundamental source of problems within the general dental practice system. This appears to be at variance with the perception of policy makers, who report a more limited view, identifying the system of remuneration as the 'heart of the problem'.

Measurement of attitudes of U.K. dental practitioners to core job constructs

OBJECTIVES

To develop a measure to identify dental practitioner attitudes towards core job dimensions relating to job satisfaction and motivation and to test this against practice characteristics and provider attributes of U.K. practitioners.

RESEARCH DESIGN

an 83-item questionnaire was developed from open-ended interviews with practitioners and use of items in previously used dentist job satisfaction questionnaires. This was subsequently sent to 684 practitioners. Item analysis reduced the item pool to 40 items and factor analysis (PCA) was undertaken.

RESULTS

440 (64%) dentists responded. Factor analysis resulted in six factors being identified as distinguishable job dimensions, overall Cronbach's alpha = 0.88. The factors were: 'restriction in being able to provide quality care (F1)', 'respect from being a dentist (F2)', 'control of work (F3)', 'running a practice (F4)', 'clinical skills (F5)', and 'caring for patients (F6)'. All six factors were correlated with a global job satisfaction score, although F1 was most strongly related (r = 0.60). Regression model analysis revealed that 'whether the dentist worked within the National Health Service or wholly or partly in the private sector' (p < 0.001), 'time since qualification' (p = 0.009), and the position of the dentist within the practice (whether a practice owner or associate dentist), (p = 0.047) were predictive of this factor.

CONCLUSIONS

Six core job constructs of U.K. practitioners have been identified, together with several practice characteristics and practitioner attributes which predict these factors. The study demonstrates the importance of refining measures of dentists' job satisfaction to take account of the culture and the system in which the practitioner works.

The promotion of oral health within the Healthy School context in England: a qualitative research study

Background

Healthy Schools programmes may assist schools in improving the oral health of children through advocating a common risk factor approach to health promotion and by more explicit consideration of oral health. The objectives of this study were to gain a broad contextual understanding of issues around the delivery of oral health promotion as part of Healthy Schools programmes and to investigate the barriers and drivers to the incorporation of oral health promoting activities in schools taking this holistic approach to health promotion.

Methods

Semi-structured telephone interviews were carried out with coordinators of Healthy Schools programmes in the Northwest of England. Interview transcripts were coded using a framework derived from themes in the interview schedule.

Results

All 22 Healthy Schools coordinators participated and all reported some engagement of their Healthy Schools scheme with oral health promotion. The degree of this engagement depended on factors such as historical patterns of working, partnerships, resources and priorities. Primary schools were reported to have engaged more fully with both Healthy Schools programmes and aspects of oral health promotion than secondary schools. Participants identified healthy eating interventions as the most appropriate means to promote oral health in schools. Partners with expertise in oral health were key in supporting Healthy Schools programmes to promote oral health.

Conclusion

Healthy Schools programmes are supporting the promotion of oral health although the extent to which this is happening is variable. Structures should be put in place to ensure that the engagement of Healthy Schools with oral health is fully supported.

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

Objective

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

Design

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

Outcome measures

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

Results

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

Conclusions

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

An investigation of the relationship between untreated decayed teeth and dental sepsis in 5-year-old children

OBJECTIVES

To investigate the prevalence of dental sepsis in 5-year-old children in Scotland and the relationship between sepsis, treated and untreated decayed teeth, oral cleanliness (visible plaque on anterior teeth) and socio-economic deprivation.

SUBJECTS AND METHODS

Six thousand, nine hundred and ninety-four children of mean age 5.3 years were examined as part of a survey conducted under the Scottish Health Board's Dental Epidemiological Programme. The presence of dental sepsis was recorded, in addition to caries status, and presence of plaque. Postal code information was used to obtain a measure of material deprivation. Relationships between sepsis and its possible contributory factors were explored using stepwise logistic regression.

MAIN RESULTS

In the whole sample, 4.8% of children examined had dental sepsis, ranging from 2% in the most affluent areas to 11% in the most deprived. Children with sepsis had much higher caries experience (mean dmft 6.30) than those without sepsis (mean dmft 2.36). However, when these factors and the presence of plaque were entered into a logistic regression model to predict presence or absence of dental sepsis, the most important factor was not deprivation, but untreated decay.

CONCLUSIONS

The proportion of children with sepsis increases markedly with caries experience. This disadvantage can be mitigated if more of the caries experience is treated. These findings would not support a policy of non-intervention for deciduous caries if oral sepsis is to be minimised.

Recording and understanding social histories by dental undergraduates in a community-based clinical programme

Although social inequalities are known to account for large differences in dental health, attitudes to dental attendance and the type of treatment received by the patient, the taking of a patient's social history receives little emphasis in dental undergraduate teaching. Social history is defined as recording the social and family circumstances of the patient. An exercise undertaken by undergraduate dental students on clinical placements in the Community Dental Service (CDS) is described. Students write a profile of the community in which the clinic is situated, write case histories for two of their patients and then highlight issues illustrated by the case histories with reference to information on the wider community and published literature on inequalities in health and barriers to care. Students completing the exercise in April 2000 and their tutors were given additional information, including a checklist to help in the completion of the social histories of the two patients. A comparison with the reports submitted in the previous year showed that this significantly improved the recording and understanding of social history. This exercise provides a means whereby dental public health issues can be taught to undergraduates whilst maintaining relevance to the clinical setting.

General dental practitioner advice regarding the use of fluoride toothpaste in two areas with a school-based milk fluoridation programme and one without such a programme

OBJECTIVE

To describe the knowledge and practice of general denta practitioners (GDPs) working in Liverpool (where there is no milk fluoridation programme) and St Helens and Knowsley, and the Wirral (where children have fluoridated milk in schools and pre-schools) relating to the advice given for child patients regarding the use of fluoridated toothpaste.

DESIGN

Data were collected via a postal questionnaire sent to all 329 GDPs working within the three areas. GDPs working in more than one of the areas and those working in specialist orthodontic or oral surgery practices were excluded.

RESULTS

Two hundred and thirty-four (71%) questionnaires were completed and returned. Only 3% of dentists said that no-one in their practice gave advice on the concentration of fluoride toothpaste to be used. For caries free children under 7 years of age only 64% of GDPs gave advice concerning the concentration of toothpaste which coincided with the available clinical guidelines. Twenty eight per cent of GDPs also contradicted the guidelines by advising children under 7 with high caries to use a low fluoride toothpaste. Although 59% of GDPs in the fluoridated milk areas asked the child whether they had fluoridated milk at school, they did not appear to alter the advice given regarding the use of fluoridated toothpaste.

CONCLUSION

The study showed that a significant number of GDPs did not adhere to clinical guidelines relating to the use of fluoride toothpaste when giving advice to their child patients. For evidence-based dentistry to become a reality in this area, ways must be found to disseminate the available guidelines more fully and increase their acceptance and use by practitioners.

Clinical record keeping by general dental practitioners piloting the Denplan 'Excel' accreditation programme

BACKGROUND

Denplan is a private capitation-based system of providing primary dental care in the UK. An additional programme called Denplan Excel has been developed which requires General Dental Practitioners to instigate various quality processes within their practices in order to become accredited. Clinical record keeping is one area where standards are monitored. This study reports changes in record keeping at patient recall appointments following the implementation of the Denplan Excel programme.

METHOD

Fifty dentists participating in the Denplan Excel pilot programme from different areas of the UK were sampled by means of cluster sampling. Twenty records for each dentist were sampled and items recorded for patients recalled both pre- and post-pilot were compared.

RESULTS

The majority of dentists recorded presenting complaint, diagnosis and treatment plan both pre- and post-pilot. However, post-pilot there were a number of improvements in record keeping. Caries recorded on a grid increased from 7% of records to 46%, basic periodontal examination increased from 48% to 85% of records and the updating of medical history increased from 51% to 65% of records. These findings were all significant at the p<0.01 level.

CONCLUSION

Changes can be achieved by voluntary participation in a system of structured record keeping.

The development and use of a triage protocol for patients with dental problems contacting an out-of-hours general medical practitioner cooperative

PURPOSE OF THE STUDY

The number of patients contacting general medical practitioner (GMP) out-of-hours services with dental problems is perceived to be a significant problem by the medical profession. This study was undertaken to design and pilot a triage protocol that could be used by non-dental staff to refer callers with dental complaints for appropriate treatment.

BASIC PROCEDURES

A triage protocol was designed to address the patient conditions considered to be relevant to emergency dental care. The triage protocol was piloted for three months at a GMP cooperative in North Wales, which provided an out-of-hours service for 61 GMPs. Baseline data were collected for three months prior to the introduction of the triage protocol.

MAIN FINDINGS

The study showed that the number of dental callers contacting the out-of-hours service was not as great as GMPs imagined, and was similar to other studies. The introduction of the triage protocol resulted in a rise in the number of callers asked to call the general dental practitioner (GDP) support line. The number of unregistered patients given the name of a dentist also increased. The need to make a second telephone call seemed not to affect patient satisfaction since when patients were later questioned on their experience, those who had used the service since the introduction of the triage protocol were more likely to be satisfied with the service.

PRINCIPAL CONCLUSIONS

This study provides some evidence that a triage protocol can be used successfully by non-dental staff to sift requests for out-of-hours emergency dental care.

The role of team dentistry in improving access to dental care in the UK

The role of professionals complementary to dentistry (PCDs) in improving access to NHS primary dental care is discussed. The pattern of under-supply of dentists in poor socio-economic areas is highlighted and identified, in drawing a parallel to the workings of primary medical teams, as a possible area where PCDs could be used.

The stereochemistry of desaturations of long-chain fatty acids in Chlorella vulgaris

1. A study was made of the stereospecificity of hydrogen removal in the sequential desaturations performed by intact cells of Chlorella vulgaris in the biosynthesis of oleic acid, linoleic acid and alpha-linolenic acid. 2. By use of erythro- and threo-9,10-(2)H(2)-, -12,13-(2)H(2)- and -15,16-(2)H(2)-labelled precursors, it was demonstrated that the pair of hydrogen atoms removed from each of these positions had the cis relative configuration. 3. That the hydrogen atoms removed in oleic acid and linoleic acid formation were of the d absolute configuration was proved by use of d- and l-9-(3)H-and -12-(3)H-labelled precursors. 4. The presence of a substantial kinetic isotope effect of deuterium at both positions of the putative double bond was indicated, suggesting that the mechanism of desaturation involves simultaneous concerted removal of the pair of hydrogen atoms.