Gail Douglas

The use of the International Caries Detection and Assessment System (ICDAS) in a National Health Service General Dental Practice as part of an Oral Health Assessment

Introduction The Scottish Dental Clinical Effectiveness Programme (SDCEP) is developing guidance for oral health assessment and review that is intended for use in National Health Service (NHS) general dental practice. One section of this guidance is assessment of the teeth, including their caries status. The detailed caries assessment method identified by the guidance group is the International Caries Detection and Assessment System (ICDAS). Aim The aim of this study was to investigate the implications of using the ICDAS in an NHS general practice and, in particular, the time taken to use the system. Method After online and in-practice training and calibration, 50 adult and 50 child patients were randomly allocated for assessment using the ICDAS detection codes. The ICDAS protocol states that the teeth should be clean and dry. For this study, all patients had their teeth brushed by the dentist before the assessment and the results were recorded on draft ICDAS clinical pro forma sheets. The time taken for the assessment was assessed with a stopwatch and recorded in a spreadsheet program. Results The results showed that the mean time for the assessment of an adult was 3.80 minutes, or 4.99 minutes if the time for pre-examination cleaning and drying was included. For a child, the mean time was 2.53 minutes, or 3.99 minutes if pre-examination brushing time was included. Conclusions These results indicate that with training and experience, it is possible to carry out an ICDAS assessment in a time that is practical in general dental practice.

The management of dental caries in primary teeth - involving service providers and users in the design of a trial.

BackgroundThere is a lack of evidence for the effective management of dental caries in children’s primary teeth. The trial entitled ‘Filling Children’s Teeth: Indicated Or Not?’ (FiCTION) was designed to examine the clinical and cost effectiveness, in primary dental care, of three different approaches to the management of caries in primary teeth. However, before the FiCTION main trial commenced, a pilot trial was designed. Service provider (dentists and other members of the team including dental nurses and practice managers) and participant (child participants and their parents) involvement was incorporated into the pilot trial. The aim of this study is to describe service providers’ and users’ perspectives on the pilot trial to identify improvements to the conduct and design of the FiCTION main trial.MethodsQualitative interviews (individual and group) were held with dentists, dental team members, children and parents involved in the FiCTION pilot trial. Individual interviews were held with four dentists and a group interview was held with 17 dental team members. Face-to-face interviews were held with four parents and children (four- to eight-years old) representing the three arms of the trial and five telephone interviews were conducted with parents. All interviews were transcribed verbatim. Framework analysis was used.ResultsOverall, service providers, children and parents found the pilot trial to be well conducted and an interesting experience. Service providers highlighted the challenges of adhering to research protocols, especially managing the documentation and undertaking new clinical techniques. They indicated that the time and financial commitments were greater than they had anticipated. Particular difficulties were found recruiting suitable patients within the timeframe. For parents recruitment was apparently more related to trusting their dentist than the content of information packs. While some of the older children understood what a study was, others did not understand or were not aware they were enrolled.ConclusionsThe findings provided valuable recommendations to improve the method of recruitment of dental practices and patients, the timing and content of the training, the type of support dentists would value and ways to further engage children and parents in the FiCTION main trial.Trial registrationISRCTN77044005

The feasibility of data collection in dental practices, using codes for the International Caries Detection and Assessment System (ICDAS), to allow European general dental practitioners to monitor dental caries at local, national, and international levels.

Aim To determine whether or not European general dental practitioners can carry out comprehensive dental caries assessments of the teeth of selected quotas of their patients during routine dental check-ups, as an alternative or complement to the work of specialised, salaried, dental epidemiologists. Methods Dentists from several European countries were invited by local coordinators to be trained to carry out dental disease assessments. For caries, they used the International Caries Detection and Assessment System (ICDAS), as part of a wider oral health indicators project with a European perspective. They attended training events and recruited and examined patients in their own practices before completing questionnaires, which they returned to a central data-processing facility. Results Ninety-six dentists returned questionnaires giving their opinions of the data-collection system after performing ICDAS assessments on 1216 patients. Mean times for assessments varied between countries from 7.8 to 14.06 minutes and were dependent on the age of the patient and the number and general condition of the teeth present. Given a choice of six difficulty/ease options for both understanding and applying the system, 89% of the dental examiners chose one of the two categories indicating the least difficulty for understanding and 73% chose one of these two categories for applying. Conclusion Volunteer general dental practitioners (GDPs) from six European countries were able successfully to perform data collection for survey work in addition to their routine practice. If larger numbers of GDPs across Europe are prepared to undertake this type of work for selected quota samples, it should be possible to collect data to monitor caries levels among patients who attend dental practices at local, national, and international levels, provided that the time taken is considered and remunerated appropriately.

The INCENTIVE protocol: an evaluation of the organisation and delivery of NHS dental healthcare to patients—innovation in the commissioning of primary dental care service delivery and organisation in the UK

Introduction In England, in 2006, new dental contracts devolved commissioning of dental services locally to Primary Care Trusts to meet the needs of their local population. The new national General Dental Services contracts (nGDS) were based on payment for Units of Dental Activity (UDAs) awarded in three treatment bands based on complexity of care. Recently, contract currency in UK dentistry is evolving from UDAs based on volume and case complexity towards ‘blended contracts’ that include incentives linked with key performance indicators such as quality and improved health outcome. Overall, evidence of the effectiveness of incentive-driven contracting of health providers is still emerging. The INCENTIVE Study aims to evaluate a blended contract model (incentive-driven) compared to traditional nGDS contracts on dental service delivery in practices in West Yorkshire, England. Methods and analysis The INCENTIVE model uses a mixed methods approach to comprehensively evaluate a new incentive-driven model of NHS dental service delivery. The study includes 6 dental surgeries located across three newly commissioned dental practices (blended contract) and three existing traditional practices (nGDS contracts). The newly commissioned practices have been matched to traditional practices by deprivation index, age profile, ethnicity, size of practice and taking on new patients. The study consists of three interlinked work packages: a qualitative study to explore stakeholder perspectives of the new service delivery model; an effectiveness study to assess the INCENTIVE model in reducing the risk of and amount of dental disease and enhance oral health-related quality of life in patients; and an economic study to assess cost-effectiveness of the INCENTIVE model in relation to clinical status and oral health-related quality of life. Ethics and dissemination The study has been approved by NRES Committee London, Bromley. The results of this study will be disseminated at national and international conferences and in international journals.

Primary care dentists' experience of treating avulsed permanent teeth.

Introduction An avulsed permanent tooth is one of the few true emergencies in dentistry. Children who suffer this injury require urgent dental care and prompt follow-up care. There is very limited evidence available regarding the provision of treatment for avulsion injuries in primary dental care.Objectives To explore the experience of UK dentists in relation to the management of avulsed permanent teeth.Method A self-completion questionnaire was designed and piloted. Questionnaires were sent to a random selection of one thousand GDPs with a stamped addressed return envelope. A second mailshot was sent to non-responders after eight weeks. Simple descriptive analysis was undertaken using Microsoft Excel. The results were compared with those from an earlier, similar study in Wales.Results A total response rate of 61% was achieved. Just over 40% of responding dentists recalled replanting an avulsed permanent tooth in a child.Conclusions Many dentists have limited or no experience of treating children with avulsed permanent teeth. Thirty-four percent of dentists have children with avulsion injuries under their care. Children with these traumatic injuries may benefit from shared care involving an interdisciplinary specialist team, in line with recommendations from the British Society of Paediatric Dentistry National Clinical Guidelines for Management of Avulsed Permanent Teeth in Children.

Using High Fluoride Concentration Products in Public Policy: A Rapid Review of Current Guidelines for High Fluoride Concentration Products

Despite improvements in dental caries levels since the widespread introduction of fluoride toothpastes, it is still a disease which is considered to be a priority in many countries around the world. Individuals at higher risk of caries can be targeted with products with a high fluoride concentration to help reduce the amount and severity of the disease. This paper compares guidance from around the world on the use of products with a high fluoride concentration and gives examples of how guidance has been translated into activity in primary care dental practice. A rapid review of electronic databases was conducted to identify the volume and variation of guidance from national or professional bodies on the use of products with a high fluoride concentration. Fifteen guidelines published within the past 10 years and in English were identified and compared. The majority of these guidelines included recommendations for fluoride varnish use as well as for fluoride gels, while a smaller number offered guidance on high fluoride strength toothpaste and other vehicles. Whilst there was good consistency in recommendations for fluoride varnish in particular, there was sometimes a lack of detail in other areas of recommendation for other vehicles with a high fluoride concentration. There are good examples within the UK, such as the Childsmile project and Delivering Better Oral Health, which highlight that the provision of evidence-based guidance can be influential in directing scarce resources towards oral health improvements. Policy can be influenced by evidence-based national recommendations and used to help encourage dental professionals and commissioners and third-party payers to adopt higher levels of practices aimed at oral health improvement.

Investigating the management of carious primary teeth in general dental practice: an overview of the development and conduct of the Fiction Trial.

The management of carious primary teeth is a challenge for patients, parents and clinicians. Most evidence supporting different management strategies originates from a specialist setting and therefore its relevance to the primary care setting is questionable. The UK National Institute for Health Research (NIHR) Health Technology Assessment (HTA) has commissioned the FiCTION (Filling Childrens Teeth: Indicated Or Not?) trial; a multi-centre primary dental care randomised controlled trial (RCT) to determine the most clinically and cost-effective approach to managing caries in the primary dentition in the UK. This large trial began in 2012, is due to be completed in late 2017 and involves 72 practices and 1,124 children initially aged three to seven years with dentine caries, following randomisation to one of three caries management strategies. Clinical, radiographic, quality of life, treatment acceptability and health economics data are collected during the three-year follow up period. This article provides an overview of the development and conduct of FiCTION and discusses some approaches adopted to manage challenges and achieve the patient recruitment target.

Knowledge, attitude and practice among Health Visitors in the United Kingdom toward children's oral health

OBJECTIVES The purpose of this study was to determine knowledge, attitude, and practical behavior of health visitors regarding childrens oral health in the United Kingdom (UK). METHODS A web-based self-administered survey with 18 closed and 2 open ended questions was distributed to a convenience sample of approximately 9,000 health visitors who were currently employed in the United Kingdom and a member of the Institute of Health Visiting. RESULTS A total of 1,088 health visitors completed the survey, resulting in a response rate of 12%. One-third of the health visitors reported that they had not received oral health training previously. Almost all agreed that oral health advice/promotion should be included in their routine health visiting contacts. Previous oral health training/education was associated with an increase in oral health knowledge; confidence in entering a discussion with parents/caregivers and willingness to be involved in dental referral process. CONCLUSIONS The results of our study support the need for health visitors to receive oral health training in oral health promotion including oral health risk assessment, guidance on evidence based up-to-date prevention measures, increasing the dental attendance prevalence at early stages and awareness of including specific oral health guidelines/fact sheets into their regular practice.

Factors that influence delivery of tobacco cessation support in general dental practice: a narrative review

OBJECTIVES To review the literature reporting factors that are associated with the delivery of lifestyle support in general dental practice. METHODS A systematic review of the quantitative observational studies describing activities to promote the general health of adults in primary care general dental practice. Behavior change included tobacco cessation, alcohol reduction, diet, weight management, and physical activity. Tooth brushing and oral hygiene behaviors were excluded as the focus of this review was on the common risk factors that affect general health as well as oral health. RESULTS Six cross sectional studies met the inclusion criteria. Five studies only reported activities to support tobacco cessation. As well as tobacco cessation one study also reported activities related to alcohol usage, physical activity, and Body Mass Index. Perceptions of time availability consistently correlated with activities and beliefs about tobacco cessation, alongside the smoking status of the dental professional. Dentists who perceive having more available time were more likely to discuss smoking with patients, prescribe smoking cessation treatments and direct patients toward (signpost to) lifestyle support services. Dental professionals who smoke were less likely to give smoking cessation advice and counselling than nonsmokers. Finally, the data showed that professional support may be relevant. Professionals who work in solo practices or those who felt a lack of support from the wider professional team (peer support) were more likely to report barriers to delivering lifestyle support. CONCLUSION Organizational changes in dental practices to encourage more team working and professional time for lifestyle support may influence delivery. Dental professionals who are smokers may require training to develop their beliefs about the effectiveness of smoking cessation interventions.Objectives To review the literature reporting factors that are associated with the delivery of lifestyle support in general dental practice. Methods A systematic review of the quantitative observational studies describing activities to promote the general health of adults in primary care general dental practice. Behavior change included tobacco cessation, alcohol reduction, diet, weight management, and physical activity. Tooth brushing and oral hygiene behaviors were excluded as the focus of this review was on the common risk factors that affect general health as well as oral health. Results Six cross sectional studies met the inclusion criteria. Five studies only reported activities to support tobacco cessation. As well as tobacco cessation one study also reported activities related to alcohol usage, physical activity, and Body Mass Index. Perceptions of time availability consistently correlated with activities and beliefs about tobacco cessation, alongside the smoking status of the dental professional. Dentists who perceive having more available time were more likely to discuss smoking with patients, prescribe smoking cessation treatments and direct patients toward (signpost to) lifestyle support services. Dental professionals who smoke were less likely to give smoking cessation advice and counselling than nonsmokers. Finally, the data showed that professional support may be relevant. Professionals who work in solo practices or those who felt a lack of support from the wider professional team (peer support) were more likely to report barriers to delivering lifestyle support. Conclusion Organizational changes in dental practices to encourage more team working and professional time for lifestyle support may influence delivery. Dental professionals who are smokers may require training to develop their beliefs about the effectiveness of smoking cessation interventions.

A qualitative study of patients’ views of techniques to reduce dental anxiety

OBJECTIVES To explore the fear/anxiety inducing triggers associated with dental treatment, and what dentally anxious adults would like from their dental encounter. METHODS Two focus-groups and three interviews with fourteen dentally-anxious people were conducted in this qualitative study. All discussions were tape-recorded and transcribed verbatim. Content was categorised by common characteristics to identify underlying themes using thematic analysis. RESULTS Four themes were identified to bring general meaning within the content: 1. Preparedness, 2. Teamwork, 3. Reinforced trust, 4. Tailored treatment plan. CONCLUSIONS Preparatory information may need to be tailored and comprehensive, yet dissociative and reassuring. Dentally-anxious people might want a sense of control and shared-decision making. They may not want dentists to understate the treatment procedures and risks to make them feel better temporarily. CLINICAL SIGNIFICANCE Dental anxiety affects between 10 and 60% of the population. Participants in this study suggested different ways the dental team could help their anxiety. Therefore, it is key for whole dental team to find out what could be done to help dentally anxious patients.