The impact of a guided paced breathing audiovisual intervention on anxiety symptoms in Palestinian children: a pilot randomized controlled trial

BACKGROUND

Children in Palestine may be at high risk for anxiety symptoms. However, access to mental health services is limited. Therefore, the objective of this study was to conduct a pilot randomized controlled trial to examine whether a guided audiovisual paced breathing intervention was feasible, acceptable, and improved anxiety symptoms in Palestinian children.

METHODS

Students (6-10 years old) in an after-school program in Palestine were randomly assigned to the intervention or control condition. All participants completed a pre- and post-intervention measure of anxiety using the Revised Children's Manifest Anxiety Scale. Participants in the intervention completed 24 sessions over 8 weeks and rated breathing ease as well as pre- and post-session relaxation on a 5-point Likert scale. To examine condition differences in post-intervention anxiety, four analyses of covariance were conducted, adjusting for age, sex, and pre-intervention anxiety.

RESULTS

A total of 144 participants (65.3% girls; Mage  = 7.5 ± 1.2; 50% per condition) enrolled in the study. There were no differences in demographics or baseline anxiety between the two conditions (ps > .05). Participants reported that it was easy to breathe during the sessions (Ms = 4.1-4.7, SDs = 0.5-1.1). For all but the first session, participants reported being more relaxed after the breathing session than before (ps < .003). Post-intervention, participants in the intervention reported fewer anxiety symptoms compared to participants in the control condition (ps < .01).

CONCLUSION

A guided paced breathing audiovisual intervention was feasible and had a significant positive impact on anxiety symptoms in Palestinian children compared to a control condition. Future research should examine whether the audiovisual guided breathing intervention significantly improves long-term outcomes.

Improving the Health of the Homeless and How to Achieve It within the New NHS Architecture

The publication of the National Health Service (NHS) Long Term Plan sees the creation of Primary Care Networks as the most appropriate solution to help improve overall health and address health inequalities. A key segment of society that suffers from poor health is the homeless. While the potential for the group to benefit from the NHS reform policy programme in England exists, it requires stronger collaborative working between the health and social care sectors Not least the new arrangements provide opportunities to tackle existing disease as well as the determinants of future ill health. However, if the policy vision is to be achieved, relations between the two sectors must occur and cross sector boundaries be broken down.

The standard of newly qualified dental graduates - foundation trainer perceptions

Background There have been anecdotal concerns that the skill mix of recently qualified graduates is very different to those qualifying several years ago, in particular that the clinical skills on qualification are less. If true, such changes may have ramifications for providers of undergraduate training, postgraduate training, particularly at foundation training level, and ultimately the public.Aim The aim of this study was to assess changes in perceived standards of newly qualified graduates as reported by foundation trainers.Method A cross-sectional survey was conducted using a self-completed internet-based survey tool sent to all foundation trainers (FTs) in England, Northern Ireland and Wales.Results A total of 312 responses were obtained covering all postgraduate deaneries. There was mixed opinion regarding standards of new graduates, with 51% reporting that the overall standard of those entering foundation training was 'unsatisfactory'. Standards in key clinical areas were considered unsatisfactory by large proportions of respondents. Eighty-five percent considered standards to be unsatisfactory in 'crown and bridge', 75% in 'extraction of teeth', 74% in endodontics, 67% in removable prosthodontics, and 62% in treatment planning. Experienced trainers identified a decline in standards in particular clinical areas.Conclusions A large proportion of foundation trainers consider the current standard of new graduates to be unsatisfactory for entering foundation training. There are a number of key clinical areas of concern and a perception of declining standards.

Dementia-Friendly Dentistry: Why Dementia Guidelines?

FGDP(UK) recently launched its dementia-friendly dentistry: good practice guidelines publication, which members will have received free-of-charge. Vice Dean and editor of the guidelines, Paul Batchelor, explains why the publication is necessary and why all practitioners should make the effort to incorporate these recommendations into their practice.

Bonfire of the verities

The emphasis on ensuring improved governance within the UK dental care system continues to rely on the identification of poorly performing individuals. Such an approach, while addressing certain political expediencies, fails to take into account both the wider system issues and the extensive literature on how to influence performance in a positive way. If sustainable improvements in the qualities of care are to occur, an acknowledgement of the system's shortcomings by the main parties must be made and where individual performance has fallen below that regarded as acceptable, the contribution of the delivery system in general needs to be noted. In addition, changes to the clinical negligence arrangements away from an adversarial approach to one that uses an open non-punitive process is necessary. As in health, the environment that individuals find themselves in is a major determinant of good outcomes.

The changing epidemiology of oral diseases in the elderly, their growing importance for care and how they can be managed

This article provides an overview of the changing epidemiology of oral diseases and the impacts for the population. Considerable improvements have occurred in oral health, and many more people are retaining teeth for longer. However, the conditions of teeth and mouth are varied, and all older people are at risk of future oral disease. With the increased prevalence of other more general health conditions, the risks of poor oral health are increasing. Poor oral health gives rise to considerable problems that impact both on an individual's well-being and qualities of life as well as increasing the risks of general health issues. To ensure that the risks of such adverse impacts are minimised, a more collaborative approach involving all care workers is required, addressing the determinants of health and ensuring that better care management arrangements for older people are developed.

What do we mean by population health?

The term 'population health' is part of the natural evolution of the science of epidemiology. With the recognition of the importance of a life-course approach to help understand health along with the recognition of the importance of the wider determinants of health, epidemiology requires new techniques and thinking. 'Population health' recognizes that to improve oral health, then the determinants have to be tackled. These include both those that may be described as belonging to the environment and those influenced by the care system. The key issue for policy development is the need to recognize that with globalization and the extended time frame to undertake research, partnerships will be a key necessity to help ensure success in addressing inequalities and overall levels of health.

Improving governance to improve oral health: addressing care delivery systems

The evolving role of the state in the provision of health care has seen the adoption of new management philosophies to ensure that goals set for the system are reached. In particular, the term New Public Management (NPM) has tended to dominate reforms to help address perceived shortcomings in public sector services. NPM is based on the use of freemarket type arrangements as a mechanism to solve problems, the control of which provides new challenges. One particular challenge that has arisen from the combination of NPM with the large number of agencies involved in care provision is that of addressing the issues arising from the improved understanding of the determinants of health. This has led to the evolution of differing care arrangements across differing sectors at all levels. If resources are to be used as intended, the control of delivery systems to oversee their use must exist. The overarching term for such activity is â governance. This paper provides an overview of the issues that arise for addressing governance of oral health care and the subsequent challenges that face those responsible for ensuring compliance.

The Great Debate

It is usual to hold debates with a live audience. However, they can be held via the written word. Indeed, Letters to the Editor and responses are in many ways a debate. Specialist lists were introduced by the General Dental Council in 1997 and have been discussed ever since. This discussion will doubtless continue for many years. Two longstanding Faculty members have strong views on the topic. They were therefore invited to conduct a written debate to mark the occasion of the 20th anniversary of the Faculty.

Negotiation: a necessary art for dental practice

This brief paper explains why the art of negotiation has become far more important for general dental practitioners. It explains that negotiations take place with patients, with practice staff, and with funding agencies such as Primary Care Trusts. It sets out the principles for successful negotiation and gives two examples of how they can be applied. It concludes that negotiation is a skill that can be learned and that it will be a key skill as the profession faces future challenges.

Patterns of dental service use among homeless people using a targeted service

OBJECTIVE

The objective of this study was to describe the patterns of dental service use among homeless people using a targeted dental service from 1992 to 2001.

METHOD

A case-note review of a selection of patients (n = 204) was undertaken using a pre-designed data abstraction form.

RESULTS

For those presenting at their first contact, 40 percent (n = 68) expressed need in relation to oral pain and disease/tissue damage, and 28 percent (n = 33) in relation to dental checking and oral prophylaxis. Most homeless people had normative need for dental treatment (93 percent: n = 153). The dental service was delivered using a mix of outreach and fixed site clinics, with 75 percent (n = 153) of all first contacts made at outreach clinics. The targeted service was moderately successful at getting people to attend the fixed site service for continuing care, with 51 percent (n = 87) attending for subsequent visits. Location of first contact with the targeted dental service did not predict subsequent attendance. Those who did attend for further care tended to have normative needs for periodontal disease and dental decay and have their presenting complaint met. Only 23 percent (n = 46) of people completed a treatment plan, over a mean of 8.2 (standard deviation +/- 9.4) visits. No factors appeared to predict completion of treatment.

CONCLUSIONS

While the small sample limits the findings in this study, it is hypothesized that the presence of the dental service promoted uptake of dental care. Flexible attendance tended to result in multiple visits and delayed outcomes, which themselves could have acted as barriers to care.

Oral health care needs and oral health-related quality of life (OHIP-14) in homeless people

OBJECTIVES

The aim of this study was (i) to determine the oral health status and oral health care needs of this population, (ii) to assess oral health-related quality of life using OHIP-14 and (iii) to explore whether there is a relationship between oral health status and oral health-related quality of life.

METHODS

A convenience sample was drawn from eight facilities catering for homeless people in south east London. Participants were invited to attend an outreach dental clinic and receive a clinical oral health and treatment needs assessment. The impact of oral disease was assessed using OHIP-14.

RESULTS

There were 102 people from a range of vulnerable housing situations invited to participate in the study. The mean age was 39.5 (SD +/- 12.3) and 92% (n = 92) were men. The mean DMFT of dentate participants (n = 94) was 15.5 (SD +/- 7.6), mean DT was 4.2 (SD +/- 5.2), mean MT was 6.8 (SD +/- 6.0) and mean FT was 4.6 (SD +/- 4.8). Normative needs were extensive with 76% having a restorative need, 80% having a need for oral hygiene measures and periodontal treatment and 38% having a prosthetic treatment need. Ninety one per cent of homeless people experienced at least one impact and the mean number of impacts (n = 90) was 5.9 (SD +/- 4.8).The most commonly experienced oral health-related quality of life impacts were in the dimension of pain, with aching in the mouth having a prevalence of 65% and discomfort while eating foods having a prevalence of 62%. Forty-four per cent felt handicapped by their oral condition. The experience of oral impact had only a slight relationship with clinical status and there were no differences in clinical status or oral impact by vulnerability of housing situation.

CONCLUSIONS

Oral health care needs were extensive and greater than that of the general population in the UK, although disease levels were similar. While homeless people experienced many more oral impacts (as measured with OHIP-14) compared with adults of the same age in the general population in the UK, there was only a slight relationship with clinical status and oral health-related quality of life.

Addressing underperformance in the United Kingdom NHS dental system and its possible implications for other care systems

OBJECTIVE

To outline the rationale for, background to and role of the National Clinical Assessment Service (NCAS) in helping improve the quality of care provided through the NHS dental care system and identify possible lessons for international dental care delivery systems.

DESCRIPTION

Due to shortcomings in the provision of healthcare and changes in societal attitudes towards healthcare professionals new arrangements for ensuring the quality of care are evolving. The performance of individual practitioners is increasingly being challenged as new regulatory mechanisms for the delivery of care evolve. Historically, regulatory bodies have had few options to handle poor performance and this will need to change: one such approach is the development of an agency to help identify the rationale for poor performance and, most importantly, develop solutions to address them.

SUMMARY

The creation of NCAS has provided a mechanism through which shortcomings in dental practitioners' performance can be addressed in a systematic and more appropriate manner than has previously existed. The approach used has applicability for helping improve the quality of care within all oral health care systems.

NHS dental care and the issues of public service ethos, governance, accountability and probity

A decision by any government to intervene in dental care requires that accountability arrangements exist and that the public has faith in them. Such arrangements require a range of governance mechanisms that in turn create routes of accountability. If accountability is to have meaning an appropriate probity system is necessary. Existing probity arrangements in the NHS dental care system are far from ideal: the checks on claims are far less vigorous than under the previous contractual agreement. While the Dental Reference Service continues to refine its probity activities there are few, if any, assessments of the quality of diagnosis and treatment planning let alone the quality of the treatment provided, along with financial shortfalls. The nature of the contract introduced in April 2006 means that, even with compliance, its use as a quality assurance mechanism is substantially weaker. To address these shortfalls requires improvements in the governance arrangements a key element of which is clarity in accountability. Accountability provides an understanding of how a delivery system works, the pressures and incentives facing its actors and allows for better reform design and implementation. If a public dental service is to have excellent outcomes, be fair and equitable and offer value for money the present failings must be addressed. As has been identified in other public services: "...certain assumptions appear to be based on a belief that these standards were general throughout the public sector and would be maintained or adapted during periods of change. Little attention was given to what compromises the standards, how they are perceived and implemented across the public sector and who monitors or polices them, particularly in times of change." (Doig, 1995). The development of improved probity arrangements and a suitable contract through which the service delivered is specified would be a starting point. Perhaps then both the public and the profession can begin to strengthen their faith in a delivery system and improve their trust in the political system. This in turn will help give rise to a modern and dependable care system, something the present government has been attempting and failing to achieve for over 10 years.

Developing consumer involvement in primary dental care. Report of a half-day seminar held at the Royal College of Surgeons of England on 15th September 2008

The seminar on developing consumer involvement in primary dental care, held during the morning of 15th September 2008, was a collaboration between the Lay Advisory Group and Research Committee of the Faculty of General Dental Practice (UK) (FGDP[UK]). As Professor Mike Mulcahy (immediate past Dean of the Faculty) remarked during his address of welcome, it marked a new and exciting development in the Faculty's role in setting and maintaining professional standards for the benefit of patients. It brought together nearly 50 representatives of national bodies, such as the National Audit Office, consumer groups, the Faculty's Lay Advisory Group and Research Committee, the media and others. Many of the national bodies represented at the seminar had published reports on primary dental care during the last five years.

Developing, enabling and facilitating practice-based research in primary dental care. Report of a one-day seminar, held at the Royal College of Surgeons of England on Friday, 1st February 2008

As part of the Faculty of General Dental Practice (UK)'s strategy to develop a research base for primary dental care, a one-day seminar was held at The Royal College of Surgeons of England on Friday, 1st February 2008. The aims for the day were to bring together the Divisional Research Contacts (DRCs), Faculty members with an interest in research, and regional and national leaders in primary care research; to update DRCs and Faculty members on developments and opportunities in primary care research; and to raise awareness of the Faculty's work among the leaders of primary care research. Of the 33 who attended the seminar, 12 were DRCs.

An initial analysis of the research competency level of the Faculty of General Dental Practice (UK)'s Divisional Research Contacts. An in-house survey

PURPOSE

The purpose of this survey was to identify the current level of competence of the Faculty of General Dental Practice (UK)'s [FGDP(UK)'s] Divisional Research Contacts (DRCs).

METHODOLOGY

The FGDP(UK)'s DRCs were each sent a copy the Faculty's Research Competencies Framework (RCF). A mutually convenient time for a telephone interview was then agreed between the DRCs and one of the Faculty's two National Research Facilitators. During the interview, a structured questionnaire was used and the DRCs' qualifications and research experience were recorded along with their perceived knowledge and skill levels for each of the 21 competencies in the RCF, using a five-point Likert scale.

RESULTS

Eighteen of the 20 DRCs were interviewed, of whom 12 either possessed or were studying for higher research or partresearch degrees (PhD or MSc). All had some previous research experience. For 11 of the 15 competencies in the four domains of practical skills, problem-solving, attitudes and dissemination, DRCs rated their knowledge and skills levels as average or higher. For two of these 11 competencies (communication skills and understanding the need for research to support clinical practice), all 18 DRCs rated their levels of knowledge and skills as good or excellent. In the domain of roles and functions, DRCs rated their levels of knowledge and skills at a lower level. Seven rated their competence in designing and implementing a series of studies that address a significant issue and in writing research funding applications to major bodies as poor or very poor.

CONCLUSIONS

The present survey has provided the basis for a future, in-depth training needs analysis along with an insight into the research competency level of 18 of the Faculty's 20 DRCs.

Options for types of dental health personnel to train for ghana

SUMMARY OBJECTIVES

To explore the degree of agreement on issues surrounding the proposals for dental health personnel requirements among key oral health personalities who are central to determining policy on oral health personnel requirements for Ghana and to make recommendations to assist in the future development of dental health personnel requirements.

DESIGN

A review of the literature, published documents and in-depth semi-structured interviews.

SETTING

Dental health service in Ghana

PARTICIPANTS

Key oral health personalities who are central to determining policy on oral health personnel requirements for Ghana

RESULTS

There was a lack of consensus regarding key aspects of planning personnel requirements including the numbers and the kinds of professionals complementary to dentistry (PCDs) to develop, who should be responsible for their training, and which people to admit as trainees of PCDs.

CONCLUSION

Greater discussion between the various agencies involved should take place to help ensure consensus on the overall policy objectives.

A longitudinal study into changing ethical attitudes of newly-qualified dentists in South-East England

OBJECTIVE

To report the ethical stances taken by newly-qualified dental graduates working in the south-east of England and how these changed over their first two years in practice.

METHODS

A longitudinal self-completed questionnaire-based study using scenarios and closed questions was completed by an initial group of 135 vocational dental practitioners at the very beginning of their vocational training year, at the end of the year, and, finally, at the end of the subsequent year. Their answers were then analysed to see whether or not their views had changed during this period.

RESULTS

At the commencement of the study in 2003, 133 (99%) newly-qualified dental graduates completed the questionnaire and answered the closed questions. The following year, 129 (96%) completed these documents and in 2005, at the end of the study, this figure was 97 (72%). There was considerable variation in the attitudes taken by the responding dentists. Reported attitudes changed over the study period in seven of the nine scenarios. Responses to the scenarios used could be grouped into three categories: those in which there was no change; those in which the change happened following completion of vocational training; and those in which there was a continual change. Answers to the four closed questions indicated a growing negativity to practice within the National Health Service over the study period.

CONCLUSIONS

Dental educators need to be aware of the findings from this study. The importance of the ethical attitudes held and the reasons underpinning them should be explored if problems with delivery of care are to be avoided in the future.

A reassessment of recall frequency intervals for screening in low caries incidence populations

OBJECTIVES

To reassess the recall frequency interval for dental examinations for children, based on annual caries increments.

METHODS

Cross sectional data collected on school children in eight rural and urban schools through the national Incremental Dental Care Programme (IDCP) for one district in Malaysia were analysed to assess their annual caries increment and trend lines. The Restorative Index was calculated to assess the success of the IDCP in rendering children dentally fit.

RESULTS

The annual caries increments were low; the current caries levels were between 0.65 and 1.50 for 12 year-old children in Kota Tinggi District. Most of the caries experience was on pits and fissures. From 7 to 12 years old, the overall annual caries increment for the total study population was 0.19. The mean annual caries increment increased slightly between the ages of 12 to 14 years and 14 to 16 years and was 0.24 and 0.25 respectively. Two distinct caries incremental trend lines were observed for children aged 7 to 16 years. One group reached a mean DMFT of about 0.75 while the other group a mean DMFT of about 1.4 at 12 years. The trend lines continued over the next 4 years until the children were 16 years old. The Restorative Index was higher in urban schools that also had low DMFT levels.

CONCLUSIONS

Based on the low annual caries increments of between 0.65 and 1.50, yearly dental examination intervals can safely be extended to 2-yearly intervals or even longer. Such a change of screening recall intervals would help improve resource allocation. Resources saved by extending recall intervals can be redirected to the small proportion of children with higher disease levels. This will help render more school children dentally fit and reduce inequalities in oral health.

Informing Research in Primary Dental Care: Setting Priorities

This paper suggests that priorities for research in primary dental care should follow the examples set in other areas of primary healthcare. It reviews the history of research in primary dental care, since 1990, and goes on to explain how the Delphi exercise, initiated by the Faculty of General Dental Practice (UK), has identified five priority areas for research in primary dental care. These areas are:

1. Research into the application of evidence-based dentistry into practice.

2. The effects of different systems of remuneration on treatment patterns in practice.

3. The oral health assessment on determining recall intervals and its effect on oral health.

4. Factors that influence and affect dentists’ treatment modalities.

5. The evaluation of the cost benefits of whole team training.

Future Opportunities for Research in Primary Dental Care: Developing Research to Support the Commissioning of Care

On 23rd November 2005, there was a first for the Faculty of General Dental Practice (UK) [FGDP(UK)] when it hosted an open, national research study day, funded by the Department of Health. The study day followed on from a national Research and Development in Primary Dental Care meeting, ‘Reflection and Moving Forward’, held in Manchester in March 2004.1

The historical and political background to the proposals for local commissioning of primary dental care by primary care trusts

This paper provides a background to the changes that are about to occur in the system for primary oral healthcare delivery in the NHS. This is part of a far wider reform programme involving all public sector services. The challenges that the Government faces are not unique: all countries are striving to alter their care systems to address the changing expectations of the electorate while attempting to control both the costs and inequalities. What is unique to the United Kingdom is the historical legacy of the NHS and its political importance, which should not be underestimated. An overview of the agenda for change in all parts of the health sector is presented. This is followed by a more detailed analysis of the proposals for future delivery of primary oral care in the NHS and the subsequent issues arising. A consistent theme running throughout the Government's agenda is devolution. Indeed, the detailed programme discussed in this paper applies only to England and Wales. The fact that Scotland has different plans highlights the importance of the political and cultural setting to any reform programme.

The limitations of a 'high-risk' approach for the prevention of dental caries

The decline in the prevalence of caries has lead several authors to advocate the adoption of a 'high-risk' approach for caries preventive strategies. This paper analyses such an approach. It argues that the distribution of caries within a population follows certain laws: first, the mean caries score is a function of the prevalence; second, the variance is a function of the mean; and third, for a particular mean score, the distribution within the population is predetermined. Using data from the National Preventive Dentistry Demonstration Programme (NPDDP) in the US and the British Association for the Study of Community Dentistry (BASCD) epidemiological programmes in the UK the functions determining the distribution of caries within the population are examined. The findings indicate the changes in caries experience observed occurred throughout populations and are not confined to subgroups. Strategies limited to individuals 'at risk' would fail to deal with the majority of new lesions. The main emphasis should be centred on a population approach.

Does perceived risk of oral problems influence the use of dental services in university entrants?

OBJECTIVE

To assess if the self-perceived risk of oral problems is related to reported dental service usage in university entrants.

DESIGN

Self-completed questionnaire.

SAMPLE

1,180 university entrants with an average age of 19.1 years. Fifty-six per cent of the sample were female, 44% males; 16% were medical undergraduates, 27% arts students, and 52% science undergraduates.

RESULTS

Females rated their own dental health more positively than males. Overall, the perceived risk of future problems was low. Seventy-five per cent of graduates reported attending dentists on a regular basis. Females were more likely to attend dentists regularly. Those who reported attending on a regular basis rated their dental health higher than those reporting other dental attendance patterns. There was no significant difference between those who reported a regular attendance service pattern and their perceived likelihood of requiring a filling or getting gum disease within the next five years.

CONCLUSION

Differences in reported dental services usage were related to the perceived benefits of dental check-ups but not to the risk of future problems.

Issues concerning the development of a competency-based assessment system for dentistry

The issue of standards of competence and assessment is central to professions. For the dental profession there have been suggestions that a change from overall competence to specific fields of competence would be a more suitable mechanism to assess whether an individual was competent. This paper examines the implications of such proposed changes and highlights several key issues, answers to which need to be provided prior to adopting new proposals. Failure to do so may well provide additional problems without addressing shortcomings in the present system.

Health through oral health; guidelines for planning and monitoring for oral health care: a critical comment on the WHO model

Recently a joint working group of WHO/FDI published guidelines for planning and monitoring oral health care. In the report a model for calculations of future need for dental manpower was introduced as an effective planning tool. An analysis of whether the WHO model is appropriate to calculate the future need for manpower planning was carried out. It appears that the model has serious methodological shortcomings. The model expects the user to know the future oral care needs concerning preventive, special group, surgical, orthodontic, and periodontal care. In calculating future needs for restorative and prosthetic care, the model restricts itself to looking back in time and roughly calculating what has happened in the past, assuming this will happen again.