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Objectives Assess the feasibility of using the Identification and Referral to Improve Safety (IRIS) intervention in a general dental practice setting and evaluating it using a cluster randomised trial design. IRIS is currently used in general medical practices to aid recognition and support referral into specialist support of adults presenting with injuries and other presenting factors that might have resulted from domestic violence and abuse. Also, to explore the feasibility of a cluster randomised trial design to evaluate the adapted IRIS.Design Feasibility study for a cluster randomised trial of a practice-based intervention.Setting Greater Manchester general dental practices.Results It was feasible to adapt the IRIS intervention used in general medical practices to general dental practices in terms of training the clinical team and establishing a direct referral pathway to a designated advocate educator. General dental practices were keen to adopt the intervention, discuss with patients when presented with the opportunity and utilise the referral pathway. However, we could not use practice IT software prompts and data collection as for general practitioners because there is no unified dental IT system and because coding in dentistry for diagnoses, procedures and outcomes is not developed in the UK.Conclusion While it was feasible to adapt elements of the IRIS intervention to general dental practice and there was general acceptability, we did not have enough empirical data to plan a definitive cluster randomised trial design to evaluate the IRIS-dentistry intervention within general dental practices.

Background: For health care services to address the health care needs of populations and respond to changes in needs over time, workforces must be planned. This requires quantitative models to estimate future workforce requirements that take account of population size, oral health needs, evidence-based approaches to addressing needs, and methods of service provision that maximize productivity. The aim of this scoping review was to assess whether and how these 4 elements contribute to existing models of oral health workforce planning. Methods: A scoping review was conducted. MEDLINE, Embase, HMIC, and EconLit were searched, all via OVID. Additionally, gray literature databases were searched and key bodies and policy makers contacted. Workforce planning models were included if they projected workforce numbers and were specific to oral health. No limits were placed on country. A single reviewer completed initial screening of abstracts; 2 independent reviewers completed secondary screening and data extraction. A narrative synthesis was conducted. Results: A total of 4,009 records were screened, resulting in 42 included articles detailing 47 models. The workforce planning models varied significantly in their use of data on oral health needs, evidence-based services, and provider productivity, with most models relying on observed levels of service utilization and demand. Conclusions: This review has identified quantitative workforce planning models that aim to estimate future workforce requirements. Approaches to planning the oral health workforce are not always based on deriving workforce requirements from population oral health needs. In many cases, requirements are not linked to population needs, while in models where needs are included, they are constrained by the existence and availability of the required data. It is critical that information systems be developed to effectively capture data necessary to plan future oral health care workforces in ways that relate directly to the needs of the populations being served. Knowledge Transfer Statement: Policy makers can use the results of this study when making decisions about the planning of oral health care workforces and about the data to routinely collect within health services. Collection of suitable data will allow for the continual improvement of workforce planning, leading to a responsive health service and likely future cost savings.

Objective The aim of this systematic review was to gain a greater insight into the incidence rates of distal surface caries (DSC) on second permanent molars. Data sources A literature search using the Cochrane Library, Lilacs, Embase and Medline via Ovid retrieved English and non-English language articles from inception to June 2016. The electronic searches were supplemented with reference searching and citation tracking. Reviewers independently and in duplicate performed data extraction and completed structured quality assessments using a validated risk of bias tool for observational studies and categorised the summary scores. Data selection The search yielded 81 records and, after application of inclusion and exclusion criteria, two incidence studies were included in this systematic review. Data extraction The DSC incidence was reported in one study as relative risk (RR = 2.53; 95% CI, 1.55 to 4.14) adjacent to erupted, (RR = 0.83; 95% CI, 0.11 to 6.04) soft tissue impacted and (RR = 1.44; 95% CI, 0.55 to 3.72) bony impacted third molars in comparison to when the third molar was absent with a 25-year follow-up. The second study reported a DSC incidence of 100 surface-years (1% of all sites) with an 18-month follow-up period. Conclusions Both cohort studies indicated that DSC incidence was higher when third molars were erupted in the intermediate term, but greater over the long term for an ageing male population. However, further high-quality research is required to improve the accuracy of these findings.

Background Online reviews may act as a rich source of data to assess the quality of dental practices. Assessing the content and sentiment of reviews on a large scale is time consuming and expensive. Automation of the process of assigning sentiment to big data samples of reviews may allow for reviews to be used as Patient Reported Experience Measures for primary care dentistry. Aim To assess the reliability of three different online sentiment analysis tools (Amazon Comprehend DetectSentiment API (ACDAPI), Google and Monkeylearn) at assessing the sentiment of reviews of dental practices working on National Health Service contracts in the United Kingdom. Methods A Python 3 script was used to mine 15800 reviews from 4803 unique dental practices on the NHS.uk websites between April 2018 –March 2019. A random sample of 270 reviews were rated by the three sentiment analysis tools. These reviews were rated by 3 blinded independent human reviewers and a pooled sentiment score was assigned. Kappa statistics and polychoric evalutaiton were used to assess the level of agreement. Disagreements between the automated and human reviewers were qualitatively assessed. Results There was good agreement between the sentiment assigned to reviews by the human reviews and ACDAPI (k = 0.660). The Google (k = 0.706) and Monkeylearn (k = 0.728) showed slightly better agreement at the expense of usability on a massive dataset. There were 33 disagreements in rating between ACDAPI and human reviewers, of which n = 16 were due to syntax errors, n = 10 were due to misappropriation of the strength of conflicting emotions and n = 7 were due to a lack of overtly emotive language in the text. Conclusions There is good agreement between the sentiment of an online review assigned by a group of humans and by cloud-based sentiment analysis. This may allow the use of automated sentiment analysis for quality assessment of dental service provision in the NHS.

We conducted a systematic review of epidemiological studies to assess the prevalence of distal surface caries (DSC) in second molars adjacent to third molars. We searched the Cochrane Library, Lilacs, Embase, and Medline through Ovid ® (Wolters Kluwer) to retrieve English and non-English papers from inception to June 2016, and supplemented this with a search of the references and by tracking citations. Three reviewers contributed: one reviewed all the papers, and the other two divided the rest between them. They extracted data, completed structured quality assessments with a validated risk of bias tool for observational studies, and categorised the summary scores. The search yielded 81 records and 11 studies were analysed. The considerable methodological diversity meant that five were not eligible for inclusion in the quantitative synthesis. A meta-analysis of six studies on the prevalence of DSC and a subgroup analysis of three on various third-molar angulations were indicated. The overall pooled prevalence estimate calculated with a random-effects model was 23% (95% CI 2% to 44%) among patients. Prevalence subtotals were 20% (95% CI 5% to 36%) for prospective, and 15% (95% CI 5% to 36%) for retrospective studies among teeth. A subgroup analysis of three studies with 1296 patients (1666 molars) yielded a prevalence of DSC of 36% (95% CI 5% to 67%) for mesial impactions and 22% (95% CI 1% to 42%) for horizontal impactions. DSC was present in 3% of distally-inclined impactions, (95% CI 1% to 5%) and in 7% (95% CI 1% to 13%) of vertical third molars. The studies varied. The risk of bias was low in one and moderate in two. European studies suggested that DSC may be present in about one in four referrals for the assessment of third molars, and that the risk is considerably higher in those with convergent third molar impactions.

Contains fulltext : 232783.pdf (Publisher’s version ) (Open Access) The levels and types of oral health problems occurring in populations change over time, while advances in technology change the way oral health problems are addressed and the ways care is delivered. These rapid changes have major implications for the size and mix of the oral health workforce, yet the methods used to plan the oral health workforce have remained rigid and isolated from planning of oral healthcare services and healthcare expenditures. In this paper, we argue that the innovation culture that has driven major developments in content and delivery of oral health care must also be applied to planning the oral health workforce if we are to develop 'fit for purpose' healthcare systems that meet the needs of populations in the 21st century. An innovative framework for workforce planning is presented focussed on responding to changes in population needs, service developments for meeting those needs and optimal models of care delivery.

Objectives A pilot NHS dental contract was introduced in Northern Ireland between 2015 and 2016, which involved changing the method for paying general dental practitioners working in the NHS from Fee-For-Service (FFS) to capitation-based payments, providing an opportunity for a robust evaluation. We investigated the impact of a change in payment methods on clinical activity and the quality of care provided. Design A difference-in-difference (DiD) evaluation was applied to clinical activity data from pilot NHS dental practices in Northern Ireland compared to matched control NHS practices, and applied to a questionnaire survey of patient-rated outcomes of health outcomes and care quality. We estimated the impact on access to care, treatment activity levels, practice finances and patient-rated outcomes of care of a change from FFS to a capitation-based system for one year, as well as the impact of a reversion back to FFS at the end of the pilot period. Results The monthly number of registered patients in the pilot practices increased more than the control practices during the capitation period, by 1.5 registrations per 1,000 registered patients. The monthly reductions in the volumes of all treatments in the pilot practices during the capitation period was much larger than the control practices, with 175 fewer treatment items. All measures rapidly returned to baseline levels following reversion from capitation back to FFS. NHS income per month increased in pilot practices, by £5,920 per month (calculated on FFS item cost basis) more than controls in the capitation period. The analysis of patient questionnaires suggest found that patients notices differences only in waiting times, skill-mix and number of radiographs, but not on other measures of healthcare process and quality. Conclusion General dental practitioners working in the NHS respond rapidly and consistently to changes in provider payment methods. A move from FFS to a capitation-based system had little impact on access to care, but did produce large reductions in clinical activity and patient charge income. Patients noticed little change in the service they received. This shows that changes in remuneration contracts have the potential to meet policy goals, such as meeting the expectations of patients within a predictable cost envelope. However, it is unlikely that all policy goals can be met simply by changing payment methods. Therefore, work is also needed to identify and evaluate interventions that can complement changes in remuneration to achieve desirable outcomes.

Aims To assess the training programme and future career choices of newly qualified dental trainees. Methods Mixed-methods study combining a national questionnaire with focus groups administered to dental foundation trainees (DFTs) in England. Two regions chose not to participate; therefore, the questionnaire was sent to 588 DFTs and 226 (38.4%) responded. Forty-one DFTs participated in six regional focus groups. Results Location was the primary factor when choosing a training post, with 86% wanting to live and work near friends and family. Other influencers included affordability, availability of good training facilities and transport links, and proximity to their dental school. Focus group data found that perceived higher-quality training schemes were chosen over location in some circumstances. Most trainees wanted a career as an associate (67%) rather than a practice partner (32%) or owner (27%). Thirty-one percent aimed to practise on a private basis and 40% wanted to remain within the NHS. Women were significantly more likely than men to consider part-time working patterns (X2(2) = 9.761, p = 0.002). Part-time working was attractive as many found full-time clinical dentistry too stressful. Conclusions Geographical location is the key influencer on where dentists want to work and consideration needs to be given to interventions to address geographical disparities in graduate destinations. The strong desire to work part-time raises concerns about current workforce planning.

From a formal evaluation of a capitation-based NHS dental contract, as part of a National Institute of Health Research funded project (HS&DR 14/19/12), data collected from a series of qualitative interviews suggest that general dental practitioners may behave differently in ways that vary from the results of previous studies. Drawing on realist methodology, a rapid realist review was conducted, enabling a programme to be developed to explain the effect of a capitation pilot on NHS dentists working in primary care. In essence, the theory postulates that general dental practitioners are affected by a number of competing interests and incentives and that this can influence their behaviour in a variety of ways. For example, a capitation-based contract may result in some general dental practitioners focusing more on prevention, as opposed to treatment, but for others it may not. It may, in practice, disincentivise some general dental practitioners to perform certain treatments, while for others no change to their clinical practice would occur. Further research is required to fully understand the causal mechanisms associated with divergent behaviour, as well as the underlying contextual conditions through which these mechanisms are activated.

Objectives 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. Methods 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. Results 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. Conclusion 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: Quality measures are increasingly used for quality measurement and improvement in primary dental care. Currently there is no consensus on a core set of quality measures that may be used in primary dental care or of the dimensions of quality important in dentistry. The objective of this study was to use a RAND/UCLA Appropriateness Method to help establish such a consensus.Methods: A RAND/UCLA Appropriateness Method was used to rate dimensions of quality and quality indicators derived from the literature. Nineteen dimensions of quality and 260 quality indicators were rated by a panel of 9 dentists using an online questionnaire and face to face meeting.Results: Seventy-nine quality statements were rated at clear necessary and feasible for use as a quality measure by the panel, from which 45 composite measures emerged. With regard to the dimensions of quality, the dimensions of the Institute of Medicine definition of Quality were rated highly, alongside further dimensions of Technical Quality, Appropriateness, Comprehensiveness and Coordination and Continuity of care.Conclusions: This consensus study has identified a core set of quality indicators. This is a key first step toward the development of a comprehensive set of quality indicators.

This paper sets out a conceptual framework by which quality improvement in primary dental care can be approached. We argue that seeking a unified definition for quality in dentistry is a distraction to the more important end of quality improvement. An approach to quality improvement that interfaces Donabedian’s domains of structure, process and outcome which various dimensions of quality gives a rational approach by which quality can be assessed and improved. The importance of valid, evidence driven indicators and methods for their implementation in primary dental care is described. Further work is required in order to identify which dimensions of dentistry are most important, but the Institute of Medicine’s dimensions of safety, effectiveness, patient centeredness, timeliness, equity, efficiency are a good starting point. Trying to develop an absolute list of dimensions of quality should not distract from implementing an approach based paradigm of quality improvement. Bioinformatics offers new solutions by which quality measures may be implemented and reported in the primary care setting. The focus of future research should be in implementing data-driven quality indicators at the level of the primary care practitioner.

Objectives: Quality measurement indicators are essential for quality improvement in primary dental care (PDC). Currently there are no consensus-based core quality indicators that may be used in PDC. Furthermore, understanding of the dimensions of quality that are applicable to an overarching definition of quality in dentistry is poor. The objective of this study was to use a RAND/UCLA Appropriateness method to establish consensus on the indicators that may be used to measure quality in PDC and the dimensions of quality that may inform an overarching definition of quality in dentistry.Methods: A RAND/UCLA Appropriateness method was used to rate 260 quality indicators identified by a systematic review of quality measures and 19 dimensions of quality identified in a literature review. These dimensions and indicators of quality were rated on their clarity, necessity and feasibility using an online questionnaire and face-to-face meeting of 9 dental professionals, following the RAND/UCLA protocol. Following rating of indicators, composite indicators were produced to develop an initial list of quality indicators.Results: Seventy-nine quality indicators were rated at clear, necessary and feasible for use as a quality measure. From these 47 composite measures emerged. A further 63 indicators were rated as necessary but require further development in terms of their feasibility or clarity. From these, 31 composite quality indicators for further development have been produced. Consensus on the appropriateness of the dimensions of quality described by the Institute of Medicine definition was reached. Further highly rated dimensions of quality were Technical Quality, Appropriateness, Comprehensiveness and Coordination and Continuity of care.Conclusions: This study has identified consensus on a core set of quality indicators derived from the literature. This is a key first step toward the development of a comprehensive set of quality indicators. It has also identified consensus that the Institute of Medicine definition of quality is applicable to PDC.

Objectives: There is a lack of evidence on the proportion and severity of fluorosis in adult populations exposed and not exposed to fluoridated water over their lifetimes. The aim of this study was to compare the proportion and severity of fluorosis in adults with lifetime exposure to water fluoridation with a non-exposed sample. A secondary aim was to report the gradient of fluorosis severity by age. Methods: A cross-sectional study recruited a sample with lifetime exposure to water fluoridation and a matched, non-exposed group. 580 participants, aged 18 to 52 years (mean 34.3, SD 9.4) and 64% female, were recruited in general dental practices located in fluoridated (Birmingham and County Durham) and non-fluoridated areas (Manchester). Three digital images were taken of their incisors and an experienced examiner who was blind to exposure status viewed the images remotely and allocated fluorosis scores using the Thylstrup and Fejerskov (TF) scale. Results: At TF ≥ 1 (any fluorosis), a significantly higher proportion of participants from the fluoridated area had fluorosis (F 39% NF 21.3%, p

Introduction 'Quality' in primary care dentistry is poorly defined. There are significant international efforts focussed on developing quality measures within dentistry. The aim of this research was to identify measures used to assess quality in primary care dentistry and categorise them according to which dimensions of quality they attempt to measure. Methods Quality measures were identified from the peer-reviewed and grey literature. Peer-reviewed papers describing the development and validation of measures were identified using a structured literature search. Measures from the grey literature were identified using structured searches and direct contact with dental providers and institutions. Quality measures were categorised according to domains of structure, process and outcome and by disaggregated dimensions of quality. Results From 22 studies, 11 validated measure sets (comprising nine patient satisfaction surveys and two practice assessment instruments) were identified from the peer-reviewed literature. From the grey literature, 24 measure sets, comprising 357 individual measures, were identified. Of these, 96 addressed structure, 174 addressed process and 87 addressed outcome. Only three of these 24 measure sets demonstrated evidence of validity testing. The identified measures failed to address dimensions of quality, such as efficiency and equity. Conclusions There has been a proliferation in the development of dental quality measures in recent years. However, this development has not been guided by a clear understanding of the meaning of quality. Few existing measures have undergone rigorous validity or reliability testing. A consensus is needed to establish a definition of quality in dentistry. Identification of the important dimension of quality in dentistry will allow for the production of a core quality measurement set.

OBJECTIVES: The NICPIP trial evaluated the costs and effects of a caries prevention intervention delivered to 2- to 3-year-old children attending dental practices in Northern Ireland. This supplementary study explored the oral health behaviours of children and their parents to help understand the reasons for the trial's findings.METHODS: A mixed methods study that included a questionnaire completed by all parents (n = 1058) at the time they brought their child for the NICPIP final clinical assessment. The questionnaire collected data on frequency of toothbrushing and sugar consumption. Questionnaire data were analysed by trial group and caries status. Parents of trial participants (n = 42) were invited to take part in telephone interviews. Parents were purposively sampled according to trial group and whether or not their child developed caries. The interviews explored how and why oral health behaviours happened. Interview data were audio-recorded, transcribed verbatim and analysed thematically.RESULTS: The questionnaire data indicated that toothbrushing and between-meal sugar snacking were common in the majority of children. The children of parents who automatically reminded their child to brush their teeth were more likely to remain caries-free (Odds Ratio 1.24; 95% CI 1.08, 1.41; P = .002). Frequency of sweet drink consumption was associated with the child developing caries (Odds Ratio 0.88; 95% CI 0.79, 0.98; P = .021). The interview data showed that parents had positive attitudes towards brushing both in terms of perceived importance and expected outcomes. Attitudes towards sugar snacking were more complex, with parents reporting difficulties in controlling this behaviour. Sugar was described as being something that was "ever present" in children's lives.CONCLUSIONS: Toothbrushing was widely adopted from a young age, but between-meal sugar consumption was highly prevalent. The results suggest that effective family-level and population-level interventions are needed to reduce sugar consumption if substantial improvements in caries prevention are to be achieved.

OBJECTIVE: Persistent pain in the face, mouth, and jaws is a common presentation to dental and medical services. The aetiology remains unclear, but a growing evidence base recognizes the effectiveness of psychological rather than biomedical interventions. To understand how this approach might be implemented into clinical practice, knowledge is needed of patients' and clinicians' experience of chronic orofacial pain (COFP). The aim of this study was to explore the experience and understanding of COFP by patients and primary and secondary care medical and dental practitioners. DESIGN: Qualitative interview study. METHODS: Audio-recorded semi-structured interviews with a purposive sample of 12 dentists, 11 general practitioners, and seven patients were thematically analysed. RESULTS: Clinicians and patients recognized the role that psychological factors could play in the development and maintenance of COFP, yet management and self-management strategies were largely limited to biomedical interventions. Achieving a diagnosis proved problematic but largely functional for both parties. GPs and dentists viewed COFP as a non-dental problem and felt inadequately equipped to manage the condition. GPs, unlike dentists, felt obligated to support patients using techniques for managing patients with other long-term conditions. Frustration at the current inadequacy of COFP management often led to conflict with (or disengagement from) the clinician-patient relationship. CONCLUSIONS: Current management of COFP is ineffective and unsatisfactory for patients and practitioners, which impacts on their relationship. Fundamental barriers to accessing and implementing psychological interventions for COFP arise from ineffective communication between physicians and patients, and between medical and dental practitioners. Statement of contribution What is already known on this subject? COFP is characterized by persistent pain in the face, mouth, or jaws that are not the result of organic disease or physical trauma. Patients with COFP present to both medical and dental services and receive sub-optimal care. No studies have examined the experiences of managing this problem from the perspectives of dentists, general practitioners and patients. What does this study add? Patients, dentists, and GPs recognize the role that psychological factors have in maintaining and addressing facial pain symptoms, yet principally manage it through biomedical interventions. Challenges exist over arriving at a diagnosis and managing the problem, and challenges are exacerbated by poor communication between doctors and medical services. Improvements are needed in liaison between medical and dental services and further training to support primary care clinicians to facilitate a stepped care approach to managing COFP.

Regularly attending adult patients are increasingly asymptomatic and not in need of treatment when attending for their routine dental examinations. As oral health improves further, using the general dental practitioner to undertake the “checkup” on regular “low-risk” patients represents a substantial and potentially unnecessary cost for state-funded systems. Given recent regulatory changes in the United Kingdom, it is now theoretically possible to delegate a range of tasks to hygiene-therapists. This has the potential to release the general dental practitioner’s time and increase the capacity to care. The aim of this study is to compare the diagnostic test accuracy of hygiene-therapists when screening for dental caries and periodontal disease in regularly attending asymptomatic adults who attend for their checkup. A visual screen by hygiene-therapists acted as the index test, and the general dental practitioner acted as the reference standard. Consenting asymptomatic adult patients, who were regularly attending patients at 10 practices across the Northwest of England, entered the study. Both sets of clinicians made an assessment of dental caries and periodontal disease. The primary outcomes measured were the sensitivity and specificity values for dental caries and periodontal disease. In total, 1899 patients were screened. The summary point for sensitivity of dental care professionals when screening for caries and periodontal disease was 0.81 (95% CI, 0.74 to 0.87) and 0.89 (0.86 to 0.92), respectively. The summary point for specificity of dental care professionals when screening for caries and periodontal disease was 0.87 (0.78 to 0.92) and 0.75 (0.66 to 0.82), respectively. The results suggest that hygiene-therapists could be used to screen for dental caries and periodontal disease. This has important ramifications for service design in public-funded health systems.

Introduction: The World Health Organization (WHO) has concluded that globally, dental caries is the most important oral condition. To develop effective prevention strategies requires an understanding of how this condition develops and progresses over time, but there are few longitudinal studies of caries onset and progression in children. Methods: The aim of the study was to establish the pattern of caries development from childhood into adolescence and to explore the role of potential risk factors (age, gender, ethnicity and social deprivation). Of particular interest was the disease trajectory of dentinal caries in the permanent teeth in groups defined by the presence or absence of dentinal caries in the primary teeth. Intra-oral examinations to assess oral health were performed at four time points by trained and calibrated dentist examiners using a standardized, national diagnostic protocol. Results: Clinical data were available from 6651 children. Mean caries prevalence (% D3MFT>0) was 16.7% at the first clinical examination (ages 7 to 9) increasing to 31.0%, 42.2% and 45.7% at subsequent examinations. A population-averaged model (generalized estimating equations) was used to model the longitudinal data. Estimated mean values indicated a rising D3MFT count as pupils aged (consistent with new teeth emerging) which was significantly higher (4.49 times, 95% CI 3.90 to 5.16) in those pupils with caries in their primary dentition than in those without. Conclusion: This study is one of the few large longitudinal studies to report the development of dental caries from childhood into adolescence. Children who developed caries in their primary dentition had a very different caries trajectory in their permanent dentition compared to their caries free contemporaries. In light of these results, caries free and caries active children should be considered as two separate populations, suggesting different prevention strategies are required to address their different risk profiles.

A 2-arm parallel-group randomized controlled trial measured the cost-effectiveness of caries prevention in caries-free children aged 2 to 3 y attending general practice. The setting was 22 dental practices in Northern Ireland. Participants were centrally randomized into intervention (22,600 ppm fluoride varnish, toothbrush, a 50-mL tube of 1,450 ppm fluoride toothpaste, and standardized prevention advice) and control (advice only), both provided at 6-monthly intervals during a 3-y follow-up. The primary outcome measure was conversion from caries-free to caries-active states assessed by calibrated and blinded examiners; secondary outcome measures included decayed, missing, or filled teeth surfaces (dmfs); pain; and extraction. Cumulative costs were related to each of the trial’s outcomes in a series of incremental cost effectiveness ratios (ICERs). Sensitivity analyses examined the impact of using dentist’s time as measured by observation rather than that reported by the dentist. The costs of applying topical fluoride were also estimated assuming the work was undertaken by dental nurses or hygienists rather than dentists. A total of 1,248 children (624 randomized to each group) were recruited, and 1,096 (549 in the intervention group and 547 in the control group) were included in the final analyses. The mean difference in direct health care costs between groups was £107.53 (£155.74 intervention, £48.21 control, P < 0.05) per child. When all health care costs were compared, the intervention group’s mean cost was £212.56 more than the control group (£987.53 intervention, £774.97 control, P < 0.05). Statistically significant differences in outcomes were only detected with respect to carious surfaces. The mean cost per carious surface avoided was estimated at £251 (95% confidence interval, £454.39–£79.52). Sensitivity analyses did not materially affect the study’s findings. This trial raises concerns about the cost-effectiveness of a fluoride-based intervention delivered at the practice level in the context of a state-funded dental service (EudraCT No: 2009-010725-39; ISRCTN: ISRCTN36180119).

Background In May 2009, the Northern Ireland government introduced General Dental Services (GDS) contracts based on capitation in dental practices newly set up by a corporate dental provider to promote access to dental care in populations that had previously struggled to secure service provision. Dental service provision forms an important component of general health services for the population, but the implications of health system financing on care delivered and the financial cost of services has received relatively little attention in the research literature. The aim of this study is to evaluate the policy effect capitation payment in recently started corporate practices had on the delivery of primary oral healthcare in Northern Ireland and access to services. Methods We analysed the policy initiative in Northern Ireland as a natural experiment to find the impact on healthcare delivery of the newly set up corporate practices that use a prospective capitation system to remunerate primary care dentists. Data was collected from GDS claim forms submitted to the Business Services Organisation (BSO) between April 2011 and October 2014. Health and Social Care Board (HSCB) practices operating within a capitation system were matched to a control group, who were remunerated using a retrospective fee-for-service system. Results No evidence of patient selection was found in the HSCB practices set up by a corporate provider and operated under capitation. However, patients were less likely to visit the dentist and received less treatment when they did attend, compared to those belonging to the control group (P

Background Total tooth loss (edentulism) can be a debilitating condition, impacting on ability to chew, speak and interact with others. The most common treatment is with complete removable dentures, which may be successful, but in the lower jaw, bone resorption that worsens over time makes denture-wearing difficult. Two dental implants in the mandible to retain the lower denture has been advocated as the gold standard of treatment, but has not been universally provided due largely to financial constraints and also patient fear. Mini implants (MI) are cheaper and less invasive than conventional implants (CI), but may not have equivalent longevity. Therefore, it is unknown whether they represent a cost-effective treatment modality over time. The aim of this pilot randomised controlled trial was to assess the feasibility of carrying out a trial on this cohort of patients, and to inform the study design of a large multicentre trial. Methods Forty-six patients were randomly allocated to receive either two mini implants or two conventional implants in the mandible to retain their lower dentures. Quality of life (QoL) questionnaires, pain and anxiety scores, and an objective “gummy jelly” chewing test were carried out at multiple timepoints, along with detailed health economics information. Implants were placed one-stage, and an early loading protocol was utilised. Patients were reviewed 8 weeks post-placement, and finally at 6 months. Implant failure, recruitment and retention rates were recorded and analysed. Results The pilot study demonstrated that it is possible to recruit, randomise and retain edentulous (mainly elderly) patients for an implant trial. We recruited to target and retention rates were acceptable. The large number of questionnaires was onerous for participants to complete, but the distribution of scores and feedback from participants helped inform the choice of primary and secondary outcomes in a full trial. The chewing test was time-consuming and inconsistent. Implant failure rate was low (1/46). The data on indirect costs gathered at every visit was viewed as repetitive and unnecessary, as there was little or no change between visits. Conclusions The pilot study has shown that acceptable recruitment and retention rates are achievable in this population of patients for this intervention. The results provide valuable information for selection of outcome variables and sample size calculations for future trials. Trial registration (ISRCTN): 87342238 Trial registration date: 05/07/2013. Electronic supplementary material The online version of this article (doi:10.1186/s12903-017-0333-1) contains supplementary material, which is available to authorized users.

In contemporary healthcare settings, ensuring patient safety must be an underlying principal through which systems, teams, individuals and environments work in tandem to strive for. The adoption of a culture in the NHS where patient safety is given greater priority is key to improvement. Recent events at Mid-Staffordshire hospitals among others have brought patient safety into the minds of the public and it increasingly demands attention from clinicians, the press and governments. However, much of the work into patient safety has been completed in the secondary care field with very little work completed in primary care settings. In primary care dentistry, improving patient safety is a relatively new concept with a distinct lack of evidence base. In this article, we discuss what patient safety is and debate its relevance to primary care dentistry. We also look at previous work completed in this field and make recommendations for future work to address the current lack of research.

OBJECTIVES: Direct access is a term that describes the ability of patients to seek health care from midlevel dental providers (MLDPs) without first seeing a dentist. The objective of this study was to synthesize the evidence for the effects and costs of direct access to MLDPs in a primary dental care environment and assess the attitudes of various stakeholders to this method of care delivery. METHODS: The literature was examined for descriptive, observational, and experimental study designs to examine the evidence for direct access in dentistry. Electronic searches were undertaken of the Database of Abstracts of Reviews of Effectiveness, bibliographic subscription databases, open access databases, and the gray literature. RESULTS: The search identified 371 records, although the extent of experimental evidence was limited. The majority of included studies were descriptive and recorded the subjective views of different stakeholders, following the introduction of the policy. CONCLUSIONS: The limited extent of experimental evidence regarding direct access to MLDPs contrasts with their widespread use across Europe, the United States, and the southern hemisphere. Suggestions are made for a research program to improve the evidence base for direct access.

In the first paper of a series exploring quality in primary dental care a definition for quality in dentistry is sought. There is a little agreement in academic literature as to what quality really means in primary dental care and without a true understanding it is difficult to measure and improve quality in a systematic way. 'Quality' of healthcare in dentistry will mean different things to practitioners, policy makers and patients but a framework could be modelled on other definitions within different healthcare sectors, with focus on access, equity and overall healthcare experience.

The concept of leadership means different things to different people. At present there is no single definition of leadership nor an established theoretical approach. Despite this, leadership in the clinical environment is becoming increasingly cited as an important component in the transition of the National Health Service (NHS) and in the development of clinician led services. In medicine, clinical commissioning groups (CCGs) will soon be operational and the Department of Health (DH) seeks to establish a similar approach in dentistry, where local clinicians drive forward a quality agenda with a focus on patient outcomes. To facilitate this, the NHS Commissioning Board (NHSCB) are in the process of developing Local Professional Networks (LPNs) for dentistry. Given this shift towards localism and clinician led services it would appear that leadership will have a significant role in both medicine and dentistry. This paper explores what leadership is, before determining why it might be important in providing a clinician-led, patient-based and outcomes-focused service.

OBJECTIVES: In many countries increasing use is being made of dental care professionals (DCPs) to provide aspects of clinical activity previously undertaken by dentists. This study evaluates the differences in practice efficiency associated with the utilisation of DCPs in the provision of General Dental Services in the National Health Service (NHS) in England.METHODS: One hundred twenty-one NHS practices completed a questionnaire and shared practice information held at the NHS Business Services Authority. Practice efficiency was estimated using data envelopment analysis with the robustness of the findings checked using Stochastic Frontier Model estimation.RESULTS: Dental practices operated at an estimated mean level of technical efficiency of 64%. Variations among practices in the use of DCPs were not associated with variations in practice efficiency after controlling for other staffing levels, patient population characteristics and practice variables.CONCLUSIONS: The current NHS dental contract limits the potential for efficiency improvements by setting annual practice activity targets that produce little incentive for role substitution. Whilst DCPs may by practising efficiently, this is not reflected in practice-level efficiency, possibly because of dentists using the time released for other non-NHS activity.

Background and objective: Some districts in the United Kingdom (UK), where the level of child dental caries is high and water fluoridation has not been possible, implement school-based fluoridated milk (FM) schemes. However, process variables, such as consent to drink FM and loss of children as they mature, impede the effectiveness of these schemes. The aim of this study was to investigate the views of lay participants in FM schemes on the barriers and potential solutions to optimizing schemes and understand how this may inform the implementation of other school-based health-promotion programmes. Design and setting: A qualitative study based on semi-structured interviews and focus groups was carried out in schools participating in FM schemes in the north west of England. Findings: Grounded theory analysis on interview data revealed that the overarching potential solution for optimizing schemes was the need for engagement by schools in the scheme. The degree of engagement with the scheme was related to (the interrelated categories of) acceptability and understanding of FM by the school community. Conclusion: The concept of the need for engagement by schools in health-promotion programmes may be useful for sensitizing health planners to the needs of the school community when developing strategies for the implementation of fluoridated-milk schemes and other school-based health-promotion programmes.

Brocklehurst P, Ashley J, Walsh T, Tickle M. Relative performance of different dental professional groups in screening for occlusal caries. Community Dent Oral Epidemiol 2012. � 2012 John Wiley & Sons A/S Abstract?-? Objectives:? 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. Methods:? 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. Results:? 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%). Conclusions:? 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.

Social marketing appears to offer a structured approach to the delivery of public health interventions. It uses the principles of marketing to understand health-related behaviour and tailor appropriate and effective interventions to population subgroups. Whilst commercial marketing capitalises on current demand for a tangible benefit, social marketing relies on stimulating behavioural change for future health gain. This means that the value placed on the product must be seen to be attractive enough to stimulate demand. In contrast, many public health interventions rely on ‘top-down’ diffusion of health information. As a result, the relevance of the message conveyed is often limited and does not produce exchange. As both individuals and communities should be placed at the centre of action to reduce health inequalities, this paper examines whether social marketing could provide a conceptual framework for behaviour change to improve oral health.

OBJECTIVES: The objective of the study was to investigate factors that influence pain intensities associated with routine dental procedures. METHOD: Four hundred and fifty-one dental patients self-reported pain experienced during the procedure immediately after undergoing a variety of common dental interventions and 1�day after the completion of the procedure. Pain character was measured using the McGill short-form pain questionnaire and intensity using a numerical rating (NRS) scale. Information was collected on a number of factors that could influence pain: dental anxiety was measured using the Corah Dental Anxiety Scale to categorize patients into four domains (fearless, some unease, nervous and very anxious). Dentists provided information regarding the type(s) of procedure and use of local anaesthetic (LA). RESULTS: Seventy-five percent of patients (339/451) reported no pain during their procedure when the data were collected immediately postoperatively (NRS score�=�0). Univariate analyses showed that dental anxiety, LA use and type of procedure (extractions) were significant (P�

OBJECTIVE: 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. METHODS: 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). CONCLUSIONS: 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.

We conducted a school-based parallel cluster randomized controlled trial with 36-month follow-up of children aged 7 to 8 years. Primary schools were randomly assigned to 2 groups: 3 applications of fluoride varnish (22,600 ppm) each year or no intervention. The primary outcome was DFS increment in the first permanent molars, with the hypothesis that 9 applications of varnish over 3 years would result in a lower increment in the test group. Follow-up measurements were recorded by examiners blind to the allocation. Ninety-five schools were randomized to the test and 95 to the reference groups; 1473 (test) and 1494 (reference) children participated in the trial. An intention-to-treat analysis was carried out with random effects models. The DFS increment was 0.65 (SD 2.15) in the test and 0.67 (SD 2.10) in the reference groups, respectively. There was no statistically significant difference between the groups. We were unable to demonstrate an effect for fluoride varnish when it was used as a public health intervention to prevent caries in the first permanent molar teeth (Inter-national Standard Randomized Controlled Trial Registration: ISRCTN: #72589426)

Aim: To explore the diagnosis, treatment and referral patterns of chronic oro-facial pain patients by generalist primary care dentists (GDPs) in the UK. Methods: A cross-sectional survey was conducted using a non-stratified random sample of 500 GDPs who were selected from the General Dental Council register. A self-complete postal questionnaire with four hypothetical clinical case scenarios describing sub-types of chronic oro-facial pain (COFP) was used to investigate diagnosis, treatment and referral options of GDPs. Results: Two hundred and twenty (44%) GDPs responded. The majority correctly diagnosed temporomandibular disorder (TMD; 88%) and burning mouth syndrome (BMS; 92%). There was more variation in the diagnosis of the other cases related to persistent oro-facial pain. For TMD there was a clear preference for treatment with occlusal splint therapy, and referral to a temporomandibular joint (TMJ) specialist. The BMS scenario showed drug therapy and referral to an oral medicine specialist to be most popular. The chronic oro-facial pain cases had greater variation in management and choice of psychotherapy was related to duration of pain symptoms. Conclusions: The greater variation in responses to scenarios based on patients with chronic oro-facial pain may reflect the difficulty clinicians face in diagnosing and treating this condition. Management appears to follow a biomedical model and most clinicians chose to refer patients for treatment. There are few specialist services to cater for such referrals, indicating a need to train primary care practitioners in management of chronic COFP, along with the establishment of evidence-based guidelines.

Workforce planning is essential if the future capacity of a state funded system and the supply of clinicians is to match the future need for care. Important aspects of this process are exploring the influences on productivity and the level of service that is necessary for a state funded system. Labour substitution has a direct impact upon the productivity of the workforce, yet the use of skill mix in dentistry is an area where the dental profession has lagged behind their medical colleagues. This brief paper explores the policy context for labour substitution, highlighting key barriers to its integration, potential drivers for change and future areas for research.

Tickle M, McDonald R, Franklin J, Aggarwal VR, Milsom K, Reeves D. Paying for the wrong kind of performance? Financial incentives and behaviour changes in NHS dentistry 1992-2009. Community Dent Oral Epidemiol 2011; 39: 465-473. � 2011 John Wiley & Sons A/S Abstract?-? Background:? 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. Methods:? Comparison of six reference treatments delivered by all NHS dentists in England for the period 1992-2009. Results:? 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. Conclusions:? 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.

Background: The two most common models of workforce planning are the ‘stock and flow’ and the demographic approach. The former balances future losses from a system against recruitment and retention, whilst the latter simply ‘grosses up’ current provision based on changes to population demographics. However, such approaches ignore the impact of improving health and can confuse demand with population need. On the supply side, they also assume that there will be no changes to working practice in respect of service levels and service delivery, or any improvements in medical technology. This paper aims to examine the complex interactions between these factors in order to take a more considered approach to workforce planning in dentistry.

The use of skill mix in medicine is now widespread, yet it appears that its use in dentistry is not as prominent. Unlike doctors, dentists are required to mitigate the financial risk produced by their capital investment and ensure an adequate cash flow to cover their annual running costs. Examining the financial incentives for employing dental care professionals is therefore an important step to understand why dentistry appears to lag behind medicine in skill mix. It is also apposite, given the announcement of the coalition government to develop a new contract, which could introduce incentives for the use of dental care professionals in this way. The purpose of this short paper is to examine whether skill mix is profitable for general dental practices under the existing NHS contract in England.