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The Department of Health's response to the national budget deficit is to ensure that the provision of NHS services is guided by four fundamental 'QIPP' principles: Quality, Innovation, Prevention, and Productivity. This agenda will govern all aspects of the National Health Service's (NHS') health care provision for the foreseeable future. NHS dental services will, like all other NHS services, need to make a contribution to the QIPP agenda. The purpose of this paper is to outline the implications for NHS dentistry.

Aim To explore the knowledge of chronic orofacial pain within general dental practitioners (GDPs) and dental specialists. Methods Following a recent national survey of GDPs and specialists on the diagnosis of facial pain, all those who responded were asked to answer four multiple-choice questions on chronic orofacial pain as part of a continuing professional development exercise. The questions were formulated using a review of the literature and consultation with a facial pain expert and were administered by post. Results Of the 380 subjects who completed the original survey, 212 (56%) returned completed multiple-choice questionnaires. Specialists correctly answered significantly more questions than GDPs ( PConclusions The results suggest that specialists and GDPs may have sufficient knowledge to make an appropriate diagnosis of COFP, but they also highlight the knowledge gaps and perhaps the need for more extensive inclusion of COFP in the dental undergraduate curriculum.

Hopper L, Morris L, Tickle M. How primary care dentists perceive and are influenced by research. Community Dent Oral Epidemiol 2011; 39: 97-104. � 2010 John Wiley & Sons A/S Abstract?-? Introduction:? Little is understood as to how primary care dentists alter their clinical practice. Aim:? To develop an understanding of how primary care dentists view and use research to inform their clinical practice. Methods:? An iterative approach was followed using two methods of data collection. A focus group was undertaken with dentists and researchers who had been involved in primary care dental research. Subsequently phased, qualitative interviews were undertaken with primary care dentists with a range of research experiences. Focus group and interviews were audio-recorded and transcribed verbatim. Six people participated in the focus group. Eighteen dentists participated in the interviews. Interviews were undertaken in four phases until saturation was achieved. Data were analysed using constant comparison. Findings:? Evidence-based dentistry was considered the ideal. However, the research base for primary care dentistry was thought to lag behind clinical services, to focus on incorrect endpoints, to disregard the patients' voice and failed to consider the impact of conducting research on dental practices. Dentists modified their clinical practice based upon research, colleagues' opinions, courses and ad hoc personal evaluation. Uptake of research was affected by the ethos of the practice, which determined whether the dentists were early or late adopters of research and financial viability of new interventions. Conclusion:? Dentists wanted concise, timely evidence-based guidance to aid their management of patients. Further research needs to be undertaken to understand how to develop an evidence-based culture in primary dental care.

This article aims to give dental practitioners the background to the new NHS quality agenda. The clinical context of Lord Darzi's NHS review is examined alongside other policy documentation and Professor Jimmy Steele's independent review of NHS dental services. The potential impact of the new quality requirements on general dental practitioners is considered. Finally, opportunities for development are suggested so that practitioners can engage with the quality agenda and can demonstrate quality measures and improvements.All general dental practitioners in both the NHS and private sectors have an obligation to continue to deliver high quality dental services. Dentists practising in England will need to ensure that they comply with new quality requirements by 2011.

Aim To record English general dental practitioners' views on the new contract. Sample One thousand and forty nine general dental practitioners working under the PDS or GDS contract. Locations Randomly selected general dental practitioners working within the NHS in England. Methods Postal questionnaire, made up of two components: closed questions and a free answer section. Three waves of mailings were undertaken. Results Poor response rate of 28.5 per cent. Dentists felt marginalized by the government and disillusioned with the new contract. The free answer section was characterized by angry responses and worry about the impact of the changes on patient care and income. Discussion The fact that the Dental Practice Board circulated the questionnaire made many of the respondents suspicious of the overall aim of the research. This factor may have contributed to the low response rate. Conclusion More care should have been taken when piloting the questionnaire as the researchers under estimated the difficulties of collecting information in a time of change.

Objectives: To describe the occurrence of dental pain and extractions in young children in relation to the caries and restoration history of their primary molar teeth. Methods: A prospective cohort study of 739 children aged 2.8 to 6.2 years attending 50 dental practices in the North West of England followed for 3 years. Incidence rates for pain and extraction in primary molar teeth were calculated for children with and without dental caries. Tooth years at risk of extraction or pain were calculated for each primary molar according to whether they were caries-free, carious and unrestored, or restored. Results: A total of 119 (16.1 percent) children had caries at recruitment and 157 developed caries during follow-up. Each year approximately one in five children with caries, but only one in 100, who was caries-free, presented with dental pain. In the whole population, each year, approximately one in 40 children had a primary molar tooth extracted but in children with caries it was one in 10. In the total cohort, incidence of pain was higher in unrestored carious teeth than restored, but incidence of extraction was higher in restored than in unrestored teeth. Conclusion: The majority of children attending general dental practice remained caries-free and did not experience pain or extraction over 3 years. Children with caries had a substantial risk of developing pain or having an extraction. The study was unable to demonstrate that restoring carious primary molar teeth prevents pain and extraction.

Objectives: This study compares methods for detecting and correcting the bias associated with nonresponse to postal questionnaires. Methods: Questionnaires were sent out in three sequential stages to parents of all 5-year-old children examined in a clinical survey. Each stage progressively targeted nonresponders. Data on dmft and area measures of socioeconomic status were available for all children. Estimates for whole population dmft were produced by different methodologies comparing the relationship between dmft and stage of response and three area measures of socioeconomic status.Results: A total of 1,776 children were examined and 1,437 questionnaires were obtained, a response rate of 80.9 percent. The mean dmft of the total population (1.49) was 17.3 percent more than responders (1.27). The dmft of the nonresponders was 2.41, 89.7 percent more than responders. There were significant linear trends in dmft and socioeconomic status across the mailing stages. The methodology using mailing stage regressed against dmft produced the most accurate adjusted dmft value (1.42). The methods using area measures of socioeconomic status produced nearly identical adjusted dmft values ranging from 1.31 to 1.32.Conclusions: Even with an “acceptable” response rate, nonresponse bias can still be present. Researchers should report the outcomes of analyses to detect nonresponse bias when publishing questionnaire studies.

To determine whether caries experience in late childhood (aged 7-9 years) was predictive of adolescent obesity (ages 12-16 years) to inform the use of a common risk factor approach (CRFA) for prevention.A cohort study was conducted in an area of North West England. Clinical assessment of caries took place using the same methodology at ages 7-9 years and 12-16 years. Body mass index (BMI) category was calculated from height and weight measurements using age and gender specific cut-offs at 12-16 years only. The association between dependent variable (BMI category dichotomized as underweight/normal and overweight/obese) and explanatory variables (baseline and follow-up dental caries and sociodemographic status) adjusted for age, was assessed.At baseline, 5,470 (96.8 percent) participants took part and information was available for 2,958 (54.1 percent) participants at follow-up. Univariate analysis indicated that BMI category in adolescence was not shown to be significantly associated with: the presence or absence of caries in late childhood (P = 0.61); in adolescence (P = 0.06); gender (P = 0.91); or deprivation (P = 0.35). Multivariate logistic regression indicated that BMI category in adolescence was not predicted by caries in late childhood or adolescence, after adjusting for sociodemographic variables.Caries and obesity were highly prevalent in this population. Caries in childhood was not shown to be associated with obesity in adolescence and there was no cross-sectional association between the two diseases in adolescence. A CRFA is not precluded, however, the results suggest that additional interventions, specific for each disease, are required to prevent obesity and caries.

Objectives To obtain insight into the views of relevant 'stakeholders' (parents, teachers and school nurses) in dental screening in schools. Methods Eight schools in Chester and Ellesmere Port in the UK formed the setting of this study. A teacher from each school participated in one-to-one interviews, and focus groups for parents were carried out in each school. A focus group for school nurses working in the locality was also held. The same trained researcher undertook the interviews and focus groups; all interviews and focus groups were tape recorded, transcribed verbatim and thematically analysed independently by two trained individuals. Results Teachers, school nurses and parents all perceived the process of negative consent and the current dental examination as acceptable. The follow up procedure for identification of screened positive children was seen as inadequate. There was a strong feeling within each group that parents were ultimately responsible for their children's oral health and that state institutions had a limited role in ensuring children attended and received dental treatment. Conclusions All of the groups considered it was primarily the responsibility of parents to take screened positive children to see a dentist. The NHS has limited influence on this process. This fact represents a significant challenge to improving the effectiveness of school dental screening.

We undertook a case control study that compared 220 patients diagnosed with disc displacement with reduction at the Dental Hospital of Manchester with 1100 controls drawn from participants in the 1998 Adult Dental Health Survey. We found that patients were not significantly more likely to have had extraction of third molars than controls; odds ratio: 1.28, 95% CI: 0.96-1.71. Also only 21 patients (9.5%) reported having had extraction of third molars in the 5 years before their diagnosis. We conclude that for most patients extraction of third molars is unlikely to have caused disc displacement with reduction.

Currently more than 16,000 children in Manchester receive plain milk or milk with added fluoride (dental milk) at school. The health benefits of drinking plain or dental milk can be maximised by ensuring high levels of uptake by maintaining good quality in the supply process. In response to Clinical Governance requirements to measure and improve quality and in response to adverse comments from consumers of school milk in Manchester, a simple audit of milk quality was carried out in June 2003 and repeated in 2004. The aim was to investigate quality issues and take action to make improvements where possible, to maximise the number of children drinking milk in school. Four audit standards were set relating to the accuracy of deliveries, milk freshness, quality of packaging, and milk temperature. The audit tools were a questionnaire designed to be completed by school pupils and an electronic milk thermometer. Fourteen schools took part in the initial audit, each completing a questionnaire on five dif...

Objectives To examine the relationship between dental anxiety, dental attendance and past treatment history in 5-year-old children after taking into account confounding influences. Methods A cross sectional study of all 5-year-old children living in Ellesmere Port and Chester. All children were clinically examined and dmft and its components were recorded. A postal questionnaire was sent to parents of participating children to identify whether children attended the dentist on a regular asymptomatic basis or only when experiencing problems. Additionally parents were asked to judge whether they and their child were anxious about dental treatment. The socio-economic status of the family was measured using the Townsend Material Deprivation Index of the electoral ward in which they resided. The bivariate relationships between anxiety and reported attendance, caries experience, past extraction and restoration history were assessed using chi-square and t-tests. Multiple logistic regression analyses were used to identify predictors for dental anxiety. Results A total of 1,745 children received both a clinical examination and a questionnaire and 1,437 parents responded, a response rate of 82.3%. One in ten parents (10.8%) judged their child to be dentally anxious. Anxious children had significantly (p

Objectives To identify the relationship between the preventive and restorative care provided to children who frequently attend the General Dental Service in the UK after taking into account socio-economic status, gender and dental caries experience. Setting General dental practices in the North West of England. Subjects and materials The study design involved a retrospective investigation of case notes of 677 children who regularly attended 50 general dental practitioners. The complete history of the dental care received by each child during the primary dentition period was recorded. Analyses took place at the patient level. Information was recorded on the total number of carious teeth and restorative and preventive care provided to the children. Preventive care was categorised as dietary advice, oral hygiene instruction, prescription of fluoride tablets and application of fluoride varnish. Socio-economic status was measured using the Townsend score of the electoral ward of residence of each subject. Logistic regression models, taking into account the clustering of the subjects within dental practices were fitted to identify whether or not socio-economic status was significantly associated with provision of each category of preventive care, after controlling for gender, the total number of teeth affected by caries and the proportion of carious teeth which were restored. Results Children from poorer backgrounds were significantly more likely to receive oral hygiene instruction than their more affluent peers. Socio-economic status did not influence dentists' decisions to prescribe fluoride tablets, but children from affluent backgrounds were significantly more likely to have fluoride varnish applied to their teeth than children from deprived backgrounds after controlling for other factors. The more teeth affected by decay significantly increased the odds of giving dietary advice, prescription of fluoride tablets and application of fluoride varnish, but had no effect on whether or not oral hygiene instruction was given. As the percentage of decayed but filled teeth decreased the odds of giving dietary advice or applying fluoride varnish increased significantly. Conclusion It would appear that dentists are providing appropriate preventive care according to the aetiological causes of dental disease. They also look to be providing preventive care in compensation for decisions not to restore carious primary teeth. However the preventive care provided seems to be reactive to disease patterns, and in this high risk group of patients does not seem to be particularly effective.

Objectives: To identify the relationship between the socioeconomic status of frequently attending children and the dental care of their primary dentition provided by dentists working in the General Dental Service (GDS) of the UK National Health Service (NHS). Methods: The study design involved a retrospective investigation of the case notes of 658 children who were regularly attending patients of 50 General Dental Practitioners (GDPs) working in the North West of England. The socioeconomic status of each subject was measured using the Townsend score of their electoral ward of residence. Logistic regression models, taking into account the clustering of the subjects within dental practices, were fitted to identify whether or not socioeconomic status was significantly associated with the proportion of carious teeth that were restored, all dental extractions, dental extractions for pain or sepsis alone and courses of antibiotics prescribed after controlling other variables. Results: A significant association between socioeconomic status and caries experience could not be found. There was also no association between socioeconomic status and the proportion of carious teeth filled or courses of antibiotics prescribed. Disadvantaged children were significantly more likely to have teeth extracted than their more affluent peers, but there was no association between deprivation and extractions for pain or sepsis alone. Conclusions: Children from deprived backgrounds who regularly attended this group of UK dentists were more likely to have extractions than their more affluent peers, irrespective of their caries experience.

Objectives: The objective was to examine the relationship between dental pain (and its sequaelae), and the extent of restorative care provided for primary molars, amongst children who regularly attend a general dental practitioner. Methods: A retrospective review of the clinical case notes of 677 children with caries who attended 50 general dental practitioners on a regular basis. Analyses were performed at the subject level. Logistic regression models were fitted for the dependent variables whether or not pain, a dental extraction for pain or sepsis and a course of antibiotics was recorded, after taking into account the proportion of carious teeth that were restored, the total number of carious teeth, the age caries was first recorded, gender and the clustering of the subjects within dental practices. Results: Almost half of the children in the study (48%) were recorded as having at least one episode of pain. Total decay experience in the primary molars was a significant predictor of pain, extraction due to pain or sepsis and prescription of antibiotics. There was no significant association between the proportion of carious teeth restored and each of the three dependent variables. Conclusions: For those children who regularly attend their general dental practitioner and who have decay in their primary molars, dental pain is a common finding. Total decay experience in primary molars is the principal predictor of pain, extraction due to pain and the need for antibiotics, whilst the level of restorative care in the primary dentition is less important. In order to reduce the incidence of dental pain in young children, effective methods of preventing caries at the individual and public health levels need to be expanded.

Introduction Most dental treatment for children in the United Kingdom (UK) is provided by general dental practitioners (GDPs) working in the National Health Service (NHS). A working party of the British Society of Paediatric Dentistry, in a special publication from the Dental Practice Board, has suggested that failure to provide restorative care for the deciduous dentition is unacceptable, yet GDPs are filling fewer teeth in young children. The study aimed to evaluate the health outcomes obtained from restoring carious deciduous molar teeth. Method The dental records of 677 children cared for by 50 GDPs in the north west of England were analysed. Results The results showed that 18.8% of deciduous molars with unrestored caries and 17.0% with a history of restorative care went on to be extracted because of pain or sepsis. Conclusion The results suggest that the risk of carious deciduous molars being extracted is similar whether these teeth receive restorative care or not.

BACKGROUND: Poor or inequitable access to oral health care is commonly reported in high-, middle- and low-income countries. Although the severity of these problems varies, a lack of supply of dentists and their uneven distribution are important factors. Delegating care to dental auxiliaries could ease this problem, extend services to where they are unavailable and liberate time for dentists to do more complex work. Before such an approach can be advocated, it is important to know the relative effectiveness of dental auxiliaries and dentists. OBJECTIVES: To assess the effectiveness, costs and cost effectiveness of dental auxiliaries in providing care traditionally provided by dentists. SEARCH METHODS: We searched the following electronic databases from their inception dates up to November 2013: the Cochrane Effective Practice and Organisation of Care (EPOC) Group's Specialised Register; Cochrane Oral Health Group's Specialised Register; the Cochrane Central Register of Controlled Trials (Issue 11, 2013); MEDLINE; EMBASE; CINAHL; Cochrane Database of Systematic Reviews; Database of Abstracts of Reviews of Effectiveness; five other databases and two trial registries. We also undertook a grey literature search and searched the reference list of included studies and contacted authors of relevant papers. SELECTION CRITERIA: We included randomised controlled trials (RCTs), non-randomised controlled clinical trials (NRCTs), interrupted time series (ITSs) and controlled before and after studies (CBAs) evaluating the effectiveness of dental auxiliaries compared with dentists in undertaking clinical tasks traditionally performed by a dentist. DATA COLLECTION AND ANALYSIS: Three review authors independently applied eligibility criteria, extracted data and assessed the risk of bias of each included study and two review authors assessed the quality of the evidence from the included studies, according to The Cochrane Collaboration's procedures. Since meta-analysis was not possible, we gave a narrative description of the results. MAIN RESULTS: We identified five studies (one cluster RCT, three RCTs and one NRCT), evaluating the effectiveness of dental auxiliaries compared with dentists in providing dental care traditionally provided by dentists, eligible for inclusion in this review. The included studies, which involved 13 dental auxiliaries, six dentists, and more than 1156 participants, evaluated two clinical tasks/techniques: placement of preventive resin fissure sealants and the atraumatic restorative technique (ART). Two studies were conducted in the US, and one each in Canada, Gambia and Singapore.Of the four studies evaluating effectiveness in placing preventive resin fissure sealants, three found no evidence of a difference in retention rates of those placed by dental auxiliaries and dentists over a range of follow-up periods (six to 24 months). One study found that fissure sealants placed by a dental auxiliary had lower retention rates than one placed by a dentist after 48 months (9.0% with auxiliary versus 29.1% with dentist). The same study reported that the net reduction after 48 months in the number teeth exhibiting caries (dental decay) was lower for teeth treated by the dental auxiliary than the dentist (3 with auxiliary versus 60 with dentist, P value < 0.001).One study showed no evidence of a difference in dental decay after treatment with fissure sealants between groups. The one study comparing the effectiveness of dental auxiliaries and dentists in performing ART reported no difference in survival rates of the restorations (fillings) after 12 months.All studies were at high risk of bias and the overall quality of the evidence was very low, as assessed using the GRADE approach. In addition, four of the included studies were more than 20 years old; the materials used and the techniques assessed were out of date. We found no eligible studies comparing the effectiveness of dental auxiliaries and dentists in the diagnosis of oral diseases and conditions, in delivering oral health education and other aspects of health promotion, or studies assessing participants' perspectives including the acceptability of care received. None of the included studies reported adverse effects. In addition, we found no studies comparing the costs and cost-effectiveness of dental auxiliaries and dentists, their impact on access and equity of access to care that met the pre-specified inclusion criteria. AUTHORS' CONCLUSIONS: We only identified five studies for inclusion in this review, all of which were at high risk of bias and four were published more than 20 years ago, highlighting the paucity of high-quality evaluations of the relative effectiveness, cost-effectiveness and safety of dental auxiliaries compared with dentists in performing clinical tasks. No firm conclusions could be drawn from the present review about the relative effectiveness of dental auxiliaries and dentists.

Objective To identify the relative influence of home and school environments on children's caries experience in both the primary and secondary dentitions. Setting The north west of England. Method Data were used from surveys of 5- and 12-year-old children in the north west of England. Super Profiles was used to categorise children into four groups based on the areas in which their home address and school were located. Differences in dental caries experience were examined using t-tests with Bonferroni modification to the p-value. Results Five-year-old children living in deprived areas and attending schools in deprived areas, and those living in a deprived area but attending a school in an affluent area had significantly (p Conclusions The results suggest that the main influence on dental disease experience in both 5- and 12-year-olds is the home environment. The results have implications for the planning of health promotion interventions.

Objective To measure the relationship between tooth decay, contact with dental services and deprivation at electoral ward level. Setting The study was carried out in 1998 in Ellesmere Port in the North West of England. Subjects and Materials All children younger than six years resident in Ellesmere Port registered with GDS services and those using CDS services were matched against the HA population register to identify unregistered children. Rates for children aged 3-5 years 'in contact' with primary dental care services, whether CDS or GDS, were calculated at ward level. One calibrated examiner examined all 5-year-old children in Ellesmere Port and dmft scores were calculated at ward level. Ward deprivation was measured using the Jarman score. Bivariate linear regressions at ward level were performed in turn between: dmft and Jarman score; rates for 3-5-year-olds in contact with dental services and Jarman score; and dmft and rates for 3-5-year-olds in contact with dental services. Results A significant linear relationship was observed between dmft and Jarman score (P=0.02, R2 = 0.43). Significant inverse relationships were found between rates for 3-5-year-olds in contact with dental services and Jarman score (P=0.001, R2 = 0.67), and also between dmft and rates for 3-5-year-olds in contact with dental services (P=0.002, R2 = 0.65). Conclusions A strong inverse relationship was found between dental caries and contact with primary dental care services at electoral ward level. This relationship needs to be explored over a wider geographical area to establish if it is consistent and independent of deprivation.

The objectives of this study were to compare the socioeconomic make-up and the dental caries and dental treatment patterns of a general dental practice (GDP) population of five-year-old children with those of the total resident population of five-year-old children in a specific locality, and, secondly, to examine the process of gathering information on oral healthcare needs in primary dental care. The study was set in Halton, North Cheshire. Data were collected retrospectively from the patient records of four GDP ‘sentinel’ practices using a common data abstraction form. The socioeconomic profiles of the GDP population and the 1995/6 NHS child dental health survey population were compared using the Super Profiles geodemographic classification by plotting frequency distributions. The dmft of each population was compared by calculating 95% confidence intervals. The GDP population showed a slight over-representation in the more affluent groupings of the Super Profiles Lifestyle categories and a more dramatic under-representation in two of the more deprived groupings. The confidence intervals for dt and dmft of the GDP data did not include the mean figures produced by the NHS survey, indicating a significant difference at the P

Objectives This study aimed to examine the relationship between socio-economic status and both normatively assessed and self perceived need for orthodontic treatment. Methods More than six thousand 14-year-old children were assessed for orthodontic treatment by trained and calibrated examiners. The Index of Orthodontic Treatment Need was the measuring instrument along with a questionnaire which asked: "Do you think your teeth need straightening?" Results Normative need for orthodontic treatment (IOTN >3) was more common amongst deprived children than among their affluent counterparts. The same was found for perceived need. However, the children who wanted treatment were not necessarily those who needed it and vice versa. Conclusions Socio-economic status affects normatively measured orthodontic treatment need through, as yet, undefined mechanisms. It also affects a person's perception of need for orthodontic treatment, but these two associations are separate. The mismatch of need and desire for treatment is a problem for orthodontists.

BACKGROUND: Composite filling materials have been increasingly used for the restoration of posterior teeth in recent years as a tooth-coloured alternative to amalgam. As with any filling material composites have a finite life-span. Traditionally, replacement was the ideal approach to treat defective composite restorations, however, repairing composites offers an alternative more conservative approach to the tooth structure where restorations are partly still serviceable. Repairing the restoration has the potential of taking less time and may sometimes be performed without the use of local anaesthesia hence it may be less distressing for a patient when compared with replacement. OBJECTIVES: To evaluate the effects of replacing (with resin composite) versus repair (with resin composite) in the management of defective resin composite dental restorations in permanent molar and premolar teeth. SEARCH METHODS: For the identification of studies relevant to this review we searched the Cochrane Oral Health Group's Trials Register (to 24 July 2013); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 6); MEDLINE via OVID (1946 to 24 July 2013); EMBASE via OVID (1980 to 24 July 2013); BIOSIS via Web of Knowledge (1969 to 24 July 2013); Web of Science (1945 to 24 July 2013); and OpenGrey (to 24 July 2013). Researchers, experts and organisations known to be involved in this field were contacted in order to trace unpublished or ongoing studies. No restrictions were placed on the language or date of publication when searching the electronic databases. SELECTION CRITERIA: Trials were selected if they met the following criteria: randomised controlled trial (including split-mouth studies), involving replacement and repair of resin composite restorations in adults with a defective molar restoration in a permanent molar or premolar teeth. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed titles and abstracts for each article identified by the searches in order to decide whether the article was likely to be relevant. Full papers were obtained for relevant articles and both review authors studied these. The Cochrane Collaboration statistical guidelines were to be followed for data synthesis. MAIN RESULTS: The search strategy retrieved 298 potentially eligible studies, after de-duplication. After examination of the titles and abstracts, full texts of potentially relevant studies were retrieved but none of the retrieved studies met the inclusion criteria of the review. AUTHORS' CONCLUSIONS: There are no published randomised controlled trials relevant to this review question. There is therefore a need for methodologically sound randomised controlled trials that are reported according to the Consolidated Standards of Reporting Trials (CONSORT) statement (www.consort-statement.org/). Further research also needs to explore qualitatively the views of patients on repairing versus replacement and investigate themes around pain, anxiety and distress, time and costs.

BACKGROUND: Amalgam is a common filling material for posterior teeth, as with any restoration amalgams have a finite life‐span. Traditionally replacement was the ideal approach to treat defective amalgam restorations, however, repair offers an alternative more conservative approach where restorations are only partially defective. Repairing a restoration has the potential of taking less time and may sometimes be performed without the use of local anaesthesia hence it may be less distressing for a patient when compared with replacement. Repair of amalgam restorations is often more conservative of the tooth structure than replacement. OBJECTIVES: To evaluate the effects of replacing (with amalgam) versus repair (with amalgam) in the management of defective amalgam dental restorations in permanent molar and premolar teeth. SEARCH METHODS: For the identification of studies relevant to this review we searched the Cochrane Oral Health Group's Trials Register (to 5 August 2013); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 7); MEDLINE via OVID (1946 to 5 August 2013); EMBASE via OVID (1980 to 5 August 2013); BIOSIS via Web of Knowledge (1969 to 5 August 2013); Web of Science (1945 to 5 August 2013) and OpenGrey (to 5 August 2013). Researchers, experts and organisations known to be involved in this field were contacted in order to trace unpublished or ongoing studies. No restrictions were placed on the language or date of publication when searching the electronic databases. SELECTION CRITERIA: Trials were selected if they met the following criteria: randomised controlled trial (including split‐mouth studies), involving replacement and repair of amalgam restorations in adults with a defective restoration in a molar or premolar tooth/teeth. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed titles and abstracts for each article identified by the searches in order to decide whether the article was likely to be relevant. Full papers were obtained for relevant articles and both review authors studied these. The Cochrane Collaboration statistical guidelines were to be followed for data synthesis. MAIN RESULTS: The search strategy retrieved 201 potentially eligible studies after de‐duplication. After examination of the titles and abstracts, full texts of the relevant studies were retrieved but none of these met the inclusion criteria of the review. AUTHORS' CONCLUSIONS: There are no published randomised controlled trials relevant to this review question. There is therefore a need for methodologically sound randomised controlled trials that are reported according to the Consolidated Standards of Reporting Trials (CONSORT) statement (www.consort‐statement.org/). Further research also needs to explore qualitatively the views of patients on repairing versus replacement and investigate themes around pain, distress and anxiety, time and costs.

A comparative study of the subjective oral health status of 60-65-year-old residents was undertaken in two Liverpool electoral wards, Vauxhall, the most deprived, and Woolton, the most affluent in the city. The measuring instrument used was the Subjective Oral Health Status Indicators (SOHSI) questionnaire devised by Locker. The questionnaire was administered by post to random samples of 250 residents from each ward. The main aim of the study was to compare the reported impact of oral conditions on the lives of individuals living in deprived and affluent communities. Responses of 59.6% for the deprived ward and 77.7% for the affluent ward were achieved. The literature suggested that significant differences could be expected between the wards in the reporting of subjective impact. However, significantly greater impact for only one functional sub-scale and one psycho-social sub-scale was reported by residents from the deprived ward. Further analysis of the relationship between impact and socio-demographic variables revealed a strong association between self-reported general health status and the subjective oral health indicators. Finally, a stepwise regression analysis found that pain and chewing problems were the only significant predictors of psycho-social impact. This finding confirms that the individual's socio-economic circumstances are of secondary importance to pain and functional problems in determining the psycho-social effects of oral conditions, as predicted by the conceptual model on which the measuring instrument is based.

AIM: To identify variables influencing perceived treatment need of older individuals and to identify predictive variables for reported dental attendance. DESIGN: Cross-sectional study using a self-report, posted questionnaire. SETTING: Two electoral wards, one deprived and one affluent, in the city of Liverpool in 1994. SUBJECTS AND MATERIALS: Samples of older individuals (aged 60-65) were selected at random using the FHSA register as a sampling frame. A total of 500 questionnaires were distributed, 250 to each ward. The measuring instrument included the Subjective Oral Health Status Indicators (SOHSI). RESULTS: 342 questionnaires (68.4%) were returned. There was a highly significant (P < 0.001) association between living in a deprived area and reported poor dental attendance. Recent pain experience and concern about oral health and appearance were significant predictors for perceived treatment need. The main factor predicting subjective need for treatment was a reported history of regular, asymptomatic visiting. Such individuals were nearly six times more likely to have a perceived treatment need than poor attenders. CONCLUSIONS: Identification and quantification of these variables is necessary in order to promote regular, asymptomatic dental attendance and for the future planning of dental services for older individuals.

Objective To use a qualitative approach to examine the perceptions of policy makers, general dental practitioners, dental hygienists, dental students and dental hygiene students in the Netherlands following the introduction of a direct access policy in 2006. Methods Semi-structured interviews and focus groups were undertaken with a variety of policy makers and clinicians in the Netherlands. These were recorded and transcribed verbatim into MS Word documents. The transcripts were line numbered and subjected to thematic analysis to develop a coding frame using NVivo. Results Four main themes are reported, which represent a subset of a policy analysis of direct access in the Netherlands. These were entitled: 'The narrative of implementation', 'Working models of direct access', 'Relationship between old- and new-style hygienists' and 'Public attitudes'. Conclusions Working relationships within integrated practices in the Netherlands are positive, but attitudes towards independent practice are mixed. Good examples of collaborative working across practices were observed, but relationships between the professional bodies remain difficult seven years on since the introduction of the policy.

BACKGROUND: Methods of remuneration have been linked with the professional behaviour of primary care physicians. In dentistry, this can be exacerbated as clinicians operate their practices as businesses and take the full financial risk of the provision of services. The main methods for remunerating primary care dentists include fee-for-service, fixed salary and capitation payments. The aim of this review was to determine the impact that these remuneration mechanisms have upon primary care dentists' behaviour. OBJECTIVES: To evaluate the effects of different methods of remuneration on the level and mix of activities provided by primary care dentists and the impact this has on patient outcomes. SEARCH METHODS: We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 7, 2013); MEDLINE (Ovid) (1947 to 11 June 2013); EMBASE (Ovid) (1947 to 11 June 2013); EconLit (1969 to 11 June 2013); the NHS Economic Evaluation Database (EED) (11 June 2013); and the Health Economic Evaluations Database (HEED) (11 June 2013). We conducted cited reference searches for the included studies in ISI Web of Knowledge; searched grey literature sources; handsearched selected journals; and contacted authors of relevant studies. SELECTION CRITERIA: Primary care dentists were defined as clinicians that deliver routine or mainstream dental care in a primary care environment. We included randomised controlled trials (RCTs), non-randomised controlled clinical trials (NRCTs), controlled before-after (CBA) studies and interrupted time series (ITS) studies. The methods of remuneration that we considered were: fee-for-service, fixed salary and capitation payments.�Primary outcome measures were: measures of clinical activity; volume of clinical activity undertaken; time taken and clinical session length, or both; clinician type utilised; measures of health service utilisation; access and attendance as a proportion of the population; re-attendance rates; recall frequency; levels of oral health inequalities; non-attendance rates; healthcare costs; measures of patient outcomes; disease reduction; health maintenance; and patient satisfaction. We also considered measures of practice profitability/income and any reported unintended effects of the included methods of remuneration. DATA COLLECTION AND ANALYSIS: Three of the review authors (PRB, JP, AMG) independently reviewed titles and abstracts and resolved disagreements by discussion. The same three review authors undertook data extraction and assessed the quality of the evidence from all the studies that met the selection criteria, according to Cochrane Collaboration procedures. MAIN RESULTS: Two cluster-RCTs, with data from 503 dental practices, representing 821 dentists and 4771 patients, met the selection criteria. We judged the risk of bias to be high for both studies and the overall quality of the evidence was low/very low for all outcomes, as assessed using the GRADE approach.One study used a factorial design to investigate the impact of fee-for-service and an educational intervention on the placement of fissure sealants in permanent molar teeth. The authors reported a statistically significant increase in clinical activity in the arm that was incentivised with a fee-for-service payment. However, the study was conducted in the four most deprived areas of Scotland, so the applicability of the findings to other settings may be limited. The study did not report data on measures of health service utilisation or measures of patient outcomes.The second study used a parallel group design undertaken over a three-year period to compare the impact of capitation payments with fee-for-service payments on primary care dentists' clinical activity. The study reported on measures of clinical activity (mean percentage of children receiving active preventive advice, health service utilisation (mean number of visits), patient outcomes (mean number of filled teeth, mean percentage of children having one or more teeth extracted and the mean number of decayed teeth) and healthcare costs (mean expenditure). Teeth were restored at a later stage in the disease process in the capitation system and the clinicians tended to see their patients less frequently and tended to carry out fewer fillings and extractions, but also tended to give more preventive advice.There was insufficient information regarding the cost-effectiveness of the different remuneration methods. AUTHORS' CONCLUSIONS: Financial incentives within remuneration systems may produce changes to clinical activity undertaken by primary care dentists. However, the number of included studies is limited and the quality of the evidence from the two included studies was low/very low for all outcomes. Further experimental research in this area is highly recommended given the potential impact of financial incentives on clinical activity, and particular attention should be paid to the impact this has on patient outcomes.

Background Single visit scale and polish is frequently carried out in dental practices however there is little evidence to support (or refute) its clinical effectiveness. The purpose of this research was to compare patient-reported outcomes between groups receiving a scale and polish at 6-, 12-, and 24-month intervals. Outcomes recorded included participants’ subjective assessment of their oral cleanliness; the perceived importance of scale and polish for oral health and aesthetics; and frequency at which this treatment is required. Methods A practice-based randomised control trial was undertaken, with a 24-month follow-up period. Participants were healthy adults with no significant periodontal disease (BPE codes Results 369 participants were randomised: 125 to the 6-month group; 122 to the 12-month group; and 122 to the 24-month group. Complete data set analysis was carried out to include 107 (6-month group), 100 (12-month group) and 100 (24-month group) participants. Multiple imputation analyses were conducted where follow-up data was missing. The difference in the proportions of participants reporting a 'high’ level of oral cleanliness at follow-up was significant (Chi-squared P = 0.003): 52.3% (6-month group), 47.0% (12-month group) and 30.0% (24-month group). Scale and polish was thought to be important by the majority in each group for keeping mouths clean and gums healthy, whitening teeth, and preventing bad breath and tooth decay; there were no statistically significant differences between groups at follow-up. Most participants at follow-up thought that the frequency of scale and polish should be “every 6 months” or more frequently: 77.9% (6-month group), 64.6% (12-month group), 71.7% (24-month group); differences between groups were not statistically significant (Chi squared P = 0.126). The results suggest that participants in the 24-month trial group were more likely to choose a scale and polish interval of “once a year” or less frequently (OR 2.89; 95% CI 1.36, 6.13). Conclusions The majority of healthy adults regarded 6-monthly single-visit scale and polish as being beneficial for their oral health. Receiving the treatment at different frequencies did not alter this belief; and those with the longest interval between scale and polish provision perceived that their mouth was less clean. In the absence of a strong evidence base to support (or refute) the effectiveness of single-visit scale and polish, the beliefs and preferences of patients regarding scale and polish may be influential drivers for maintaining provision of this treatment.

Background The bulk of service delivery in dentistry is delivered by general dental practitioners, when a large proportion of patients who attend regularly are asymptomatic and do not require treatment. This represents a substantial and unnecessary cost, given that it is possible to delegate a range of tasks to dental care professionals, who are a less expensive resource. Screening for the common dental diseases by dental care professionals has the potential to release general dental practitioner’s time and increase the capacity to care for those who don't currently access services. The aim of this study is to compare the diagnostic test accuracy of dental care professionals when screening for dental caries and periodontal disease in asymptomatic adults aged eighteen years of age. Methods/design Ten dental practices across the North-West of England will take part in a diagnostic test accuracy study with 200 consecutive patients in each practice. The dental care professionals will act as the index test and the general dental practitioner will act as the reference test. Consenting asymptomatic patients will enter the study and see either the dental care professionals or general dental practitioner first to remove order effects. Both sets of clinicians will make an assessment of dental caries and periodontal disease and enter their decisions on a record sheet for each participant. The primary outcome measure is the diagnostic test accuracy of the dental care professionals and sensitivity, specificity, positive predictive value and negative predictive values will be reported. A number of clinical factors will be assessed for confounding. Discussion The results of this study will determine whether dental care professionals can screen for the two most prevalent oral diseases. This will inform the literature and is apposite given the recent policy change in the United Kingdom towards direct access.

Background:\ud Role-substitution describes a model of dental care where Dental Care Professionals (DCPs) provide some of the clinical activity previously undertaken by General Dental Practitioners. This has the potential to increase technical efficiency, the capacity to care and reduce costs. Technical efficiency is defined as the production of the maximum amount of output from a given amount of input so that the service operates at the production frontier i.e. optimal level of productivity. Academic research into technical efficiency is becoming increasingly utilised in health care, although no studies have investigated the efficiency of NHS dentistry or role-substitution in high-street dental practices. The aim of this study is to examine the barriers and enablers that exist for role-substitution in general dental practices in the NHS and to determine the most technically efficient model for role-substitution.\ud \ud Methods/design:\ud A screening questionnaire will be sent to DCPs to determine the type and location of role-substitutive models employed in NHS dental practices in the United Kingdom (UK). Semi-structured interviews will then be conducted with practice owners, DCPs and patients at selected sites identified by the questionnaire. Detail will be recorded about the organisational structure of the dental team, the number of NHS hours worked and the clinical activity undertaken. The interviews will continue until saturation and will record the views and attitudes of the members of the dental team. Final numbers of interviews will be determined by saturation.\ud \ud The second work-stream will examine the technical efficiency of the selected practices using Data Envelopment Analysis and Stochastic Frontier Modeling. The former is a non-parametric technique and is considered to be a highly flexible approach for applied health applications. The latter is parametric and is based on frontier regression models that estimate a conventional cost function.\ud \ud Discussion:\ud Maximising health for a given level and mix of resources is an ethical imperative for health service planners. This study will determine the technical efficiency of role-substitution and so address one of the key recommendations of the Independent Review of NHS dentistry in England.

Background Periodontal disease is the most common oral disease affecting adults, and although it is largely preventable it remains the major cause of poor oral health worldwide. Accumulation of microbial dental plaque is the primary aetiological factor for both periodontal disease and caries. Effective self-care (tooth brushing and interdental aids) for plaque control and removal of risk factors such as calculus, which can only be removed by periodontal instrumentation (PI), are considered necessary to prevent and treat periodontal disease thereby maintaining periodontal health. Despite evidence of an association between sustained, good oral hygiene and a low incidence of periodontal disease and caries in adults there is a lack of strong and reliable evidence to inform clinicians of the relative effectiveness (if any) of different types of Oral Hygiene Advice (OHA). The evidence to inform clinicians of the effectiveness and optimal frequency of PI is also mixed. There is therefore an urgent need to assess the relative effectiveness of OHA and PI in a robust, sufficiently powered randomised controlled trial (RCT) in primary dental care. Methods/Design This is a 5 year multi-centre, randomised, open trial with blinded outcome evaluation based in dental primary care in Scotland and the North East of England. Practitioners will recruit 1860 adult patients, with periodontal health, gingivitis or moderate periodontitis (Basic Periodontal Examination Score 0–3). Dental practices will be cluster randomised to provide routine OHA or Personalised OHA. To test the effects of PI each individual patient participant will be randomised to one of three groups: no PI, 6 monthly PI (current practice), or 12 monthly PI. Baseline measures and outcome data (during a three year follow-up) will be assessed through clinical examination, patient questionnaires and NHS databases. The primary outcome measures at 3 year follow up are gingival inflammation/bleeding on probing at the gingival margin; oral hygiene self-efficacy and net benefits. Discussion IQuaD will provide evidence for the most clinically-effective and cost-effective approach to managing periodontal disease in dentate adults in Primary Care. This will support general dental practitioners and patients in treatment decision making. Trial registration Protocol ID: ISRCTN56465715

Quality improvement differs from quality assurance (which is retrospective in nature) in that it attempts to use a quality assessment cycle and focuses on the organisation or system of production as a whole. In this paper, the third in a series of three published in this Journal, we discuss the concept and evidence base of quality improvement, the main approaches that have been used in other healthcare settings and the importance of a multi-faceted strategy to address this issue. These topics are then related to the context of primary dental care and the way dentistry currently addresses quality improvement. Finally, we set out an agenda and provide recommendations for a system-based quality improvement strategy for primary dental care and identify the likely barriers and facilitators for this approach.

In the second paper of a series exploring quality in primary dental care a way to measure quality in dentistry is considered. Unless there are valid and reliable tools to measure quality then quality can never be improved. Measurement tools need to be acceptable to patients if they are to be employed, as well as to busy practices in terms of practicality and costs. Examples such as the General Medical Practitioner's Quality Outcome Framework need to be understood to see if they can be translated to dentistry.

Background This was a method comparison study. The aim of study was to compare caries information obtained from a full mouth visual examination using the method developed by the British Association for the Study of Community Dentistry (BASCD) for epidemiological surveys with caries data obtained from eight, six and four intra-oral digital photographs of index teeth in two groups of children aged 5 years and 10/11 years. Methods Five trained and calibrated examiners visually examined the whole mouth of 240 5-year-olds and 250 10-/11-year-olds using the BASCD method. The children also had intra-oral digital photographs taken of index teeth. The same 5 examiners assessed the intra-oral digital photographs (in groups of 8, 6 and 4 intra-oral photographs) for caries using the BASCD criteria; dmft/DMFT were used to compute Weighted Kappa Statistic as a measure of intra-examiner reliability and intra-class correlation coefficients as a measure of inter-examiner reliability for each method. A method comparison analysis was performed to determine the 95% limits of agreement for all five examiners, comparing the visual examination method with the photographic assessment method using 8, 6 and 4 intra-oral photographs. Results The intra-rater reliability for the visual examinations ranged from 0.81 to 0.94 in the 5-year-olds and 0.90 to 0.97 in the 10-/11-year-olds. Those for the photographic assessments in the 5-year-olds were for 8 intra-oral photographs, 0.86 to 0.94, for 6 intra-oral photographs, 0.85 to 0.98 and for 4 intra-oral photographs, 0.80 to 0.96; for the 10-/11-year-olds were for 8 intra-oral photographs 0.84 to 1.00, for 6 intra-oral photographs 0.82 to 1.00 and for 4 intra-oral photographs 0.72 to 0.98. The 95% limits of agreement were −1.997 to 1.967, -2.375 to 2.735 and −2.250 to 2.921 respectively for the 5-year-olds and −2.614 to 2.027, -2.179 to 3.887 and −2.594 to 2.163 respectively for the 10-/11-year-olds. Conclusions The photographic assessment method, particularly assessment of 8 intra-oral digital photographs is comparable to the visual examination method in the primary dentition. With the additional benefits of archiving, remote scoring, allowing multiple scorers to score images and enabling longitudinal analysis, the photographic assessment method may be used as an alternative caries detection method in the primary dentition in situations where the visual examination method may not be applicable such as when examiner blinding is required and in practice based randomised controlled trials (RCTs).

Across the UK many thousands of young children regularly attend the GDS for routine dental care. Once in the dental surgery the same story is repeated countless times - preventive advice is delivered, reassurance given, caries is treated and the case notes are written up by the dentist. The whole interaction is a largely unremarkable event and is accepted by patient, parent and dentist. The records of all these individual clinical episodes remain within each practice and until a patient returns for further care can expect to lay undisturbed.

OBJECTIVES: A cross-sectional study was conducted to compare a visual dental examination method developed by the British Association for the Study of Community Dentistry with assessment of intra-oral photographs as means of detecting dental caries in 5-year-olds and 10- to 11-year-olds. METHOD: 130 5-year-olds and 140 10- to 11-year-olds were visually examined by five trained and calibrated examiners. The children also had intra-oral photographs of their teeth taken. The same five examiners assessed the photographs for caries. Both photographic and visual assessments were undertaken at 'caries into dentine' level. RESULTS: Weighted kappas for the outcome DMFT/dmft as a measure of intra-examiner reliability for the visual examinations ranged from 0.94 to 0.98 (median = 0.98) in the 5-year-olds and 0.80 to 1.00 (median = 0.93) in the 10- to 11-year-olds. Weighted kappas as a measure of intra-examiner reliability for the photographic assessments ranged from 0.83 to 1.00 (median = 0.93) in the 5-year-olds and 0.69 to 0.95 (median = 0.81) in the 10- to 11-year-olds. Sensitivity values for the photographic assessment method as compared to the gold standard of the visual examination scores of a benchmark examiner ranged from 87.8% to 95.8% in the 5-year-olds and 58.5% to 71.7% in the 10- to 11-year-olds. CONCLUSION: There was good intra-examiner reliability for both the visual and the photographic methods for all the examiners. There are no clinically significant differences between the photographic scores and the visual assessments using any of the metrics described. The photographic approach is therefore equivalent in diagnostic utility to the visual system and confers considerable advantages in terms of examiner bias reduction, remote scoring and archiving. These advantages must be weighed against the modest costs of the cameras and the increase time required to acquire the images.

UNLABELLED: The National Health Service (NHS) in England provides a comprehensive dental service funded largely from taxation but supplemented by co-payments. OBJECTIVES: This paper provides a historical overview of NHS dental services and some personal reflections on the main challenges over the next five years. METHODS: A narrative review of the literature and some subjective observations and comments. RESULTS: In 2006 there was a radical change to NHS dental sservices in England; central budgets were capped and general dental practitioners. Dentists who were previously paid on a fee-for-item basis moved to a new contract that required them to hit activity targets to maintain their historical income. This contract was unpopular with dentists and has been criticized for not improving access or quality. A new dental contract has been promised based on capitation. Against this background significant issues have to be addressed including: a rapidly growing gap in between demand and resources and a need to make substantial cost savings across the whole of the NHS; a significant decline in dental need; inequalities in utilisation of dental services; and provision of treatments of doubtful effectiveness. CONCLUSION: The NHS dental healthcare system faces significant challenges and consideration needs to be given to the consequences of a focus on need rather than demand. Logically this would require a needs-based resource allocation formula and a needs-based approach to service and workforce planning. A move to a needs-led service is a political decision with associated political risks.

This is the protocol for a review and there is no abstract. The objectives are as follows: Aim To assess the effectiveness of dental auxiliaries in providing care traditionally provided by dentists. Objectives To compare the effectiveness of dental auxiliaries compared with dentists in: the diagnosis of oral diseases and conditions; their technical competence in the delivery of some aspects of dental care; oral education and other oral health promotion measures; and delivering dental care that is acceptable to patients. the diagnosis of oral diseases and conditions; their technical competence in the delivery of some aspects of dental care; oral education and other oral health promotion measures; and delivering dental care that is acceptable to patients. To critically appraise and summarise current evidence on the costs and cost effectiveness of dental auxiliaries compared with dentists in providing care.

BACKGROUND: Recurrent aphthous stomatitis (RAS) is the most frequent form of oral ulceration, characterised by recurrent oral mucosal ulceration in an otherwise healthy individual. At its worst RAS can cause significant difficulties in eating and drinking. Treatment is primarily aimed at pain relief and the promotion of healing to reduce the duration of the disease or reduce the rate of recurrence. A variety of topical and systemic therapies have been utilised. OBJECTIVES: To determine the clinical effect of systemic interventions in the reduction of pain associated with RAS, a reduction in episode duration or frequency. SEARCH METHODS: We undertook electronic searches of: Cochrane Oral Health Group and PaPaS Trials Registers (to 6 June 2012); CENTRAL via The Cochrane Library (to Issue 4, 2012); MEDLINE via OVID (1950 to 6 June 2012); EMBASE via OVID (1980 to 6 June 2012); CINAHL via EBSCO (1980 to 6 June 2012); and AMED via PubMed (1950 to 6 June 2012). We searched reference lists from relevant articles and contacted the authors of eligible trials to identify further trials and obtain additional information. SELECTION CRITERIA: We included randomised controlled trials (RCTs) in which the primary outcome measures assess a reduction of pain associated with RAS, a reduction in episode duration or a reduction in episode frequency. Trials were not restricted by outcome alone. We also included RCTs of a cross-over design. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data in duplicate. We contacted trial authors for details of randomisation, blindness and withdrawals. We carried out risk of bias assessment on six domains. We followed The Cochrane Collaboration statistical guidelines and risk ratio (RR) values were to be calculated using fixed-effect models (if two or three trials in each meta-analysis) or random-effects models (if four or more trials in each meta-analysis). MAIN RESULTS: A total of 25 trials were included, 22 of which were placebo controlled and eight made head-to-head comparisons (five trials had more than two treatment arms). Twenty-one different interventions were assessed. The interventions were grouped into two categories: immunomodulatory/anti-inflammatory and uncertain. Only one study was assessed as being at low risk of bias. There was insufficient evidence to support or refute the use of any intervention. AUTHORS' CONCLUSIONS: No single treatment was found to be effective and therefore the results remain inconclusive in regard to the best systemic intervention for RAS. This is likely to reflect the poor methodological rigour of trials, and lack of studies for certain drugs, rather than the true effect of the intervention. It is also recognised that in clinical practice, individual drugs appear to work for individual patients and so the interventions are likely to be complex in nature. In addition, it is acknowledged that systemic interventions are often reserved for those patients who have been unresponsive to topical treatments, and therefore may represent a select group of patients.

The use of role substitution, where different levels of practitioner undertake the duties of the most qualified clinician, is common in medicine and dentistry. Proponents argue that role substitution has the potential to increase dentists' efficiency and effectiveness, thereby freeing up resources to improve access and reduce oral health inequalities. Given the current global economic climate, many countries are re-examining models of service provision to utilize role substitution. The objective of this study was to determine whether different members of the dental team could meet the diagnostic threshold set by the World Health Organization, when screening photographs of occlusal surfaces for dental caries.Participants were sampled purposively and included; final-year dental students, final-year hygiene-therapy students, primary care dentists, hygiene-therapists and dental nurses. Following a brief training package, participants were asked to score 102 clinical photographs of both carious and noncarious extracted teeth and determine whether the tooth was 'healthy' or had 'suspected decay'. The time delay between consecutive photographs was set at 8-s. Judgment decisions were compared against the International Caries Detection and Assessment System as the gold standard, with scores of two or less representing 'healthy'. Sensitivity, specificity and predictive values were determined for each participant and clinical group. Kappa was calculated to determine test-retest reliability.Dental nurses had the highest median sensitivity (87.9%), although all groups were comparable. The median specificity for the groups was lower than their sensitivity scores, with dentists scoring the highest (71.0%). Dentists also scored the highest median positive predictive value (57.8%), whilst dental nurses scored the highest negative predictive value (91.3%). The median level of agreement was high for all groups; the highest median score was for the final-year dental students (88.9%).Even with minimal training, different members of the dental team show the potential to screen for occlusal caries to a similar standard as primary care dentists. This requires further testing in vivo, but has important implications for the productivity and design of the future dental workforce.

To assist stakeholders (policy makers, dentists and patients) implementing the Patient Protection and Affordable Care Act of 2010 in the United States by providing information on conundrums arising from previous policies of the UK Labour government and emergent policies of the recently elected Coalition Government.The authors provide a background to the development of National Health Service dental services contrasted with US provision. Considerations are given from the different perspectives of stakeholders involved (policy makers, dentists, and patients).Policy makers must work under pressure for services to remain within boundaries of finite economic resources and what people are willing to pay for. The importance is stressed that they respond to public demands and workforce capability by clearly determining what the priorities should be, what services will be delivered, and defining responsibilities.

Risk assessment in general dental practice is becoming increasingly common and has led to the development of care protocols, which aim to act as a framework for decision making to produce an optimum level of care. However, many models of risk have been informed by research undertaken in academia and are based upon summary statistics of populations. In practice, a significant proportion of patients attend on a non-symptomatic, continuous and regular basis, often over long periods of time. This provides general dental practitioners with a wealth of knowledge about their patients to inform clinical decision making on an individual basis. The purpose of this paper is to highlight the important differences between an academic assessment of risk and one that is relevant to practice, before introducing a simple tool to screen out patients who are considered to be 'low risk'. The relevance of this tool is discussed, along with its potential uses and limitations as a means to promote discussion during the development of the pilots for the new dental contract to be introduced by the coalition government.

Background Practice-based general dental practitioners routinely provide "scale and polish" or "oral prophylaxis" to patients attending their practices. Despite its routine provision, there is no evidence to support the clinical effectiveness of single-visit scale and polish, nor the frequency at which it should be provided. A recent systematic review recommended that future trials investigating scale and polish should involve dental practice patients. Methods A practice-based parallel randomised controlled trial with 24-month follow-up was conducted. Healthy adults (Basic Periodontal Examination [BPE] codes Results Prevalence of gingival bleeding at follow-up was 78.5% (6-month), 78% (12-month) and 82% (24-month) (p = 0.746). There were no statistically significant differences between groups with respect to follow-up prevalence of plaque and calculus. Statistically significant differences detected in the amount (millimetres) of calculus were too small to be clinically significant. Seventeen (4.6%) participants were withdrawn from the trial to receive additional treatment. Conclusions This trial could not identify any differences in outcomes for single-visit scale and polish provided at 6, 12 and 24 month frequencies for healthy patients (with no significant periodontal disease). However, this is the first trial of scale and polish which has been conducted in a general practice setting and the results are not conclusive. Larger trials with more comprehensive measurement and long-term follow up need to be undertaken to provide a firm evidence base for this intervention. This trial informs the design of future practice-based trials on this subject.

Background There is a poor understanding of to how to recruit and involve primary care dentists in clinical trials. Aim To use a qualitative paradigm to explore the views of primary care dentists towards participating in clinical trials and develop an understanding of the factors that facilitate and prevent their involvement. Design, setting, subjects and methods An iterative approach was undertaken using a focus group (n = 6) followed by phased semi-structured interviews (n = 18). Data were analysed using thematic analysis and constant comparative analysis. Findings The semi-structured interviews generated nine codes which were organised into three themes: technical issues for trials in primary dental care, practical issues for research in primary dental care and primary care dentists as research consumers. Overall, primary care dentists had a poor understanding of research methodology and clinical research. Barriers to participation included loss of clinical freedom and control, practice disruption, patient welfare, staff workload, financial loss and time. Conclusions Barriers to primary dental care research need to be overcome through appropriate protocols, funding, training and support. Joint working of primary dental care teams and academic researchers is essential, along with a constructive and open dialogue, if clinical trials are to be successfully undertaken in a practice environment.

Background The purpose of this study was to compare diagnostic performance for the detection of caries using photographs with an established visual examination method and histological sections as the reference standard. Methods 50 extracted permanent teeth were assessed for the presence of occlusal caries by 9 examiners using two methods; traditional visual examination developed by BASCD and photographs produced by an intra-oral camera. For both methods, diagnoses were made at “caries into dentine” level. The teeth were histologically sectioned and the diagnostic decisions using visual and photographic assessment were compared to the histological reference standard. Inter- and intra- examiner reliability for the methods was assessed and weighted kappa values were calculated. Results The visual examination method had a median sensitivity value of 65.6% and a median specificity value of 82.4%. The photographic assessments method had a median sensitivity of 81.3% and a median specificity of 82.4%. Conclusions The photographic assessments method had a higher sensitivity for caries detection than the visual examination. The two methods had comparable specificities and good intra- and inter- examiner reliability.

There is a tension between financial incentives and professional codes and norms, both of which are believed to influence the behaviour of health care professionals. This study examined the impact of changes to financial incentive structures on the behaviour of dentists working in the English National Health Service (NHS) as a result of a new national contract.Comparison of six reference treatments delivered by all NHS dentists in England for the period 1992-2009.Large and abrupt changes in the provision of the reference treatments coincided with the introduction of changes in the incentive structure in 2006. Treatments which can be provided in the least amount of time (and therefore costs to dentists) such as extractions increased and treatments which are time consuming or have significant additional materials costs such as bridgework, crowns, root fillings and radiographs reduced substantially.Changes to financial incentive structures can produce large and abrupt changes in professional behaviours. In the context of multiple and conflicting goals, greater thought needs to be given to policies to change incentive structures to mitigate their unintended consequences.

ObjectivesTo explore the views of NHS dentists in England regarding reforms, which changed their incentive and payment structure.MethodsSemi-structured interviews with 35 dentists, digitally recorded, transcribed verbatim and analysed using a constant comparative method.ResultsDentists reported changing their behaviour in response to incentives in ways that were likely to have adverse impacts on patients. There was also a loss of trust in NHS paymasters, as well as a loss of faith in the ability to provide high quality care in NHS dentistry.ConclusionsResponses suggest that many dentists were quick to change behaviour following the introduction of a revised contractual structure in 2006. The coalition government in the UK has stated its intention to introduce a new NHS dental contract. Our data suggest that part of the process of changing behaviours, norms and attitudes will require the rebuilding of trust in the NHS amongst NHS dentists, as opposed to merely redesigning incentive structures, though the two are related.