Jenny Gallagher

Special Care Dentistry: a professional challenge

As a profession we have a responsibility to ensure that the oral health needs of individuals and groups who have a physical, sensory, intellectual, medical, emotional or social impairment or disability are met. In the UK, over 200,000 adults have profound learning disabilities and/or complex medical conditions. Adults with a disability often have poorer oral health, poorer health outcomes and poorer access to services than the rest of the population. This paper examines the need for Special Care Dentistry based on a review of published literature, surveys and health policy, and suggests how services might be delivered in the future.Existing models of good practice reveal that established clinicians working in this field have a patient base of between 850 and 1,500 patients per year and work across primary care and hospital settings, liaising with colleagues in health, social services and the voluntary sector to ensure integrated health care planning. On this basis, a conservative estimate of 133 specialists is suggested for the future, working in networks with Dentists with Special Interests (DwSIs) and primary dental care practitioners. A skilled workforce that can address the wider needs of people requiring Special Care Dentistry should be formally recognised and developed within the UK to ensure that the needs of the most vulnerable sections of the community are addressed in future.

Dental professionalism: definitions and debate

Professionalism has been identified as a core component of revalidation by the General Dental Council. However, analysis and debate over what it means to be a professional dentist is lacking in modern dentistry in the United Kingdom. The aim of this article is to open a debate on concepts of professionalism within dentistry, drawing on established thoughts in medicine and more limited material from the dental domain. The scope of discussion will extend to include definitions of professionalism, ethical issues within professionalism, professionalism in relation to revalidation and where all of these issues relate to dentistry perceived as a business. We can learn much from the medical community who have been driven to consider medical professionalism in a changing world, and in support of better patient care. However, we can also contribute to the wider debate on professionalism by tackling the business angle, which has been largely ignored by our medical counterparts, and adding greater weight to the ethical implications of being a professional.

Informing the debate on oral health care for older people: a qualitative study of older people’s views on oral health and oral health care

BACKGROUNDnOlder people represent a growing and diverse section of the population. As age increases, people are more likely to experience health and mobility problems and be at higher risk of developing oral disease. Nevertheless, few older people utilise primary oral healthcare services. It is therefore important to understand the value older people place on oral health and dental services to inform providers and planners of oral health care. This research was conducted as part of a study to identify potential ways of minimising barriers to oral health care in older people.nnnOBJECTIVESnTo explore perceptions of oral health and oral healthcare services amongst older people living in a socially deprived inner city area and how these are related to service utilisation.nnnMETHODSnA qualitative approach was utilised to explore the range of issues related to older peoples perceptions of oral health and their views on health care. This involved a combination of focus groups and semi-structured individual interviews with older people and their carers. Data analysis was conducted using the Framework approach.nnnRESULTSn*nnnRESPONSEnThirty-nine older people and/or their carers participated in focus groups. * Oral health perception: Oral health was associated with the presence of natural teeth, the absence of pain, practical/social functioning, preferably supported by positive assessment by a dentist. * Oral health life-course: Older people have a long and complex dental history. Past negative experiences with oral health care, especially in childhood, strongly influenced present attitudes towards dentistry and dental personnel. * Citizenship and right to health care: There was a strong perception that, as British citizens, older people should have a right to free health care and that the National Health Service (NHS) should support them in this phase of their life.nnnCONCLUSIONSnThe oral health life-course of older people is an important influence on their perceptions of oral health and dental attendance. They consider oral health of importance and place great emphasis on their citizenship and rights of access to state funded oral health care. This raises important issues for the funding and delivery of NHS oral health care for older people.

UK dentists' experience of iatrogenic trigeminal nerve injuries in relation to routine dental procedures: why, when and how often?

Objectives To estimate the frequency of trigeminal nerve injuries associated with local anaesthetic administration, as experienced by UK dentists.Method A convenience sample of clinicians attending 12 study days over the UK was invited to complete an anonymised questionnaire exploring the nature of professional practice, dentists practice demographics, experience of nerve injuries and related factors. Dental procedures related to reported trigeminal nerve injuries (TNIs) were divided into low risk, likely local anaesthetic (LA) related nerve injury, and high risk procedures, more likely to be direct nerve damage by the procedure (procedural related nerve injury). Data were analysed using Microsoft Excel and SPSS V17.Results Overall 79% of attendees completed a questionnaire (n = 415); clinicians held an average of 19 years clinical experience. The numbers of clinicians surveyed included general dental practitioners (n = 290; 64%) and oral surgery (OS) specialists (n = 125; 36%). The estimated incidence of TNIs for the UK GDP workforce was 3,770 TNIs per year or 0.13 TNI per dentist per year. For specialists the incidence was increased to 0.39 TNI per specialist per year. Of all injuries only half were reported, mainly to indemnity organisations. LA-related injuries were most common for GDPs and third molar surgery for OS specialists. It is estimated that TNIs will occur in 1 in 3,289 high risk procedures such as third molar surgery and 1 in 14,330 for low risk procedures, such as restorative dentistry, most likely LA-related. From 25% to 29% of these dental procedures related TNIs were permanent.Conclusions Nerve-related injuries in dentistry are not uncommon. Dental practitioners should be aware of the significant disability associated with iatrogenic nerve injuries and risk factors relating to LA-related trigeminal nerve injury. Clinicians should familiarise themselves with infiltration LA-techniques that may reduce these nerve injuries and with the Care Quality Commission regulations for reporting injuries to patients as a result of treatment.

Widening access? Characteristics of applicants to medical and dental schools, compared with UCAS

Aim The aim of this paper is to compare the demography (age, sex, ethnicity, social status) and academic experience (school type, tariff scores) of focused and successful applicants to preclinical dentistry with preclinical medicine, and with higher education in general in the UK.Method Retrospective analyses of anonymised University and College Admissions Services (UCAS) data for focused applicants whose preferred subject was preclinical dentistry or medicine, and accepted (successful) applicants to the same programmes in 2006. These data were compared with publicly available data on applicants and accepted applicants through UCAS. Information for each medical, dental and general UCAS applicant included age, sex, ethnicity, socio-economic group, region, school type and tariff score. Logistic regression was used to model the probability of being accepted in relation to all explanatory variables and interactions.Results In total there were 2,577 focused applicants to dentistry; 1,114 applicants were accepted, 4% (n = 46) of whom did not have it as their preferred subject choice. There were seven times as many focused applicants for medicine (18,943) when compared with dentistry; 8,011 applicants were accepted, 2.7% of whom did not have medicine as their preferred subject choice (n = 218). Just over half of the applicants to dentistry were from minority ethnic backgrounds (50.5%), exceeding medicine (29.5%), and higher education in general (19%). The proportion of female applicants was similar across all three groups at around 55%. Only one fifth (21%) of focused applicants to dentistry were mature compared with one third (33%) to medicine and one quarter (25.5%) of all UCAS applicants. Greater proportions of applicants to medicine (25.8%) and dentistry (23.5%) were from upper socio-economic backgrounds, compared with higher education in general (15.5%). When all other factors are controlled, the odds of being accepted for medicine, and for dentistry, are lower if mature, male, from a lower social class, from a minority ethnic group and have attended a further/higher education college.Conclusions Focused and successful applicants for preclinical medicine and dentistry are more likely to be from higher social classes and a minority ethnic background than applicants to higher education in general. Dentistry attracts twice the level of Asian applicants as medicine and four times that of universities in general. Controlling for other factors, there is evidence that gender, ethnicity, maturity, and school type are associated with probability of acceptance for medicine and dentistry. Higher social status is particularly associated with acceptance for medicine. The implications of these findings are discussed in terms of widening access and social justice.

The relationship between access to and use of dental services following expansion of a primary care service to embrace dental team training

OBJECTIVESnTo investigate changes in the patient population and treatment case-mix within an expanded primary care dental training facility in Southern England.nnnSTUDY DESIGNnCross-sectional analysis of patient management system data.nnnMETHODnElectronic data for patients with a closed/completed treatment plan in the 12-month period prior to, and following, dental service expansion were extracted for analysis (n = 4343). Descriptive analysis involved age, sex, payment status, deprivation status and treatment activity. Logistic regression was used to model the likelihood of treatment involving laboratory constructed devices (crowns, bridges, dentures), in relation to demography and deprivation in each time period.nnnRESULTSnThe volume of patients using the service increased by 48.3% (1749 cf 2594). The average age increased from 31.97 (95%CI: 30.8, 32.5) to 36.4 years (95%CI: 35.6, 37.1); greatest increase was in the over 75 years age-group (96%). The patient base became less deprived: patients exempt from payment reduced from 43.2% (n = 755) to 28.6% (n = 741) (P = 0.001) and the mean population deprivation score (IMD) reduced from 24.5 (95%CI: 23.8, 25.2) to 22.3 (95%CI: 21.7, 22.8). The volume and proportion of care involving laboratory constructed devices increased from 8.3% (n = 145) to 15.8% (n = 411) whilst assessments without interventive care decreased (34.5%-26.3%). On a logistic regression, the odds of having treatment involving laboratory constructed devices, increased with increasing age in both time periods 7% (95% CI: 1.06-1.08) and 6% (95% CI: 1.05-1.07) respectively. Furthermore, the odds increased by 38% OR: 1.38 (95% CI: 1.01-1.89) in period 2, for white patients. After adjusting for these effects, the odds of having care that involved laboratory constructed devices were less in period 2 than period 1 (100% cf 43%) for those who were technically exempt from payment (OR = 2.0; 95% CI 1.34 to 2.90 cf, OR = 1.43; 95% CI 1.13-1.81).nnnCONCLUSIONnThe patient population altered in relation to age and socio-economic status. The expanded service had greater uptake by older people while users were less likely to be deprived. The expanded service, free at the point of delivery, attracted a higher proportion of patients who would normally have to pay health service charges. The service also showed an increase in treatment case-mix that involved laboratory constructed dental devices.

The impact of fluoride application training: survey of trained dental nurses from King's College Hospital NHS Trust

Objectives To explore the perceived benefits of a fluoride varnish training scheme, subsequent use of extended skills and any barriers that exist, in order to inform future training and practice.Method Questionnaire survey of the first four cohorts of fluoride varnish training at one London dental hospital.Results Thirty-six (62%) nurses responded to the survey, 89% of whom were using fluoride varnishing. Personal development, NHS initiatives and having a supportive principal were key drivers for course attendance. Over 2,500 fluoride application treatments were carried out (range = 0-630) with six nurses providing 71% of the treatments. Twenty nurses (56%) worked in the salaried primary dental care service and provided 69% of treatments, the remaining 31% of treatments were provided by the 44% (n = 16) of nurses in general dental practice. Barriers were systems-related and professional, including lack of community programmes, consultant oversight, referrals, materials and concerns regarding insurance and consent. The majority felt that the course contributed to their professional career (97%), and expressed their confidence in conducting fluoride application (80%).Conclusion The findings highlight the potential for using extended roles to deliver evidence-based prevention and variation in their use; however, there is some evidence that organisational and professional barriers exist.

Evidence summary: The relationship between oral and cardiovascular disease

Aim This paper reports on one review of four rapid reviews undertaken to explore the relationships between oral health and general medical conditions, in order to support teams within Public Health England, health practitioners and policy makers. This review aimed to explore the most contemporary evidence on whether poor oral health and cardiovascular disease occurs in the same individuals or populations, to outline the nature of the relationship between these two health outcomes and to discuss the implication of any findings for health services and future research.Methods The review was undertaken by a group comprising consultant clinicians from medicine and dentistry, trainees, public health and academics. The methodology involved a streamlined rapid review process and synthesis of the data.Results The results identified a number of systematic reviews of low to high quality, which suggests that there is: (1) fairly robust evidence of an increased risk of atherosclerotic vascular disease (ASVD) amongst individuals with chronic periodontitis, independent of other established cardiovascular risk factors; (2) there is some evidence that the incidence of caries and tooth loss is higher in patients with cardiovascular disease; and (3) that orofacial pain can presents as the sole symptom of stroke in some patients. The findings are discussed in relation to implications for service and future research.Conclusion There is high quality evidence to support an association between cardiovascular disease and oral health. This evidence is mainly related to the association between chronic periodontitis and atherosclerotic heart disease, and is independent of confounding factors as drawn from epidemiological observational studies.

Attitudes of the first cohort of student groups trained together at the University of Portsmouth Dental Academy towards dental interprofessional education.

OBJECTIVEnThis study explored, and compared, the attitudes of student groups trained at the University of Portsmouth Dental Academy (UPDA) in 2010/2011 towards dental interprofessional education (IPE).nnnMETHODSnThe study population consisted of fifth-year student dentists (n = 80) from Kings College London Dental Institute, second- and third-year dental hygiene and therapy (n = 38) and first-year dental nursing (n = 14) students from UPDA. A 19-item, validated and dentally modified questionnaire, Readiness for Inter-Professional Learning Scale (RIPLS), was administered. RIPLS contains three subscales: teamwork and collaboration, professional identity and roles and responsibilities. Mean (x¯) and standard deviation (SD) of the scores were calculated, following reversal of negative items. All the analyses were carried out using SPSS version 20 and STATA version 11.nnnRESULTSnAn overall response rate of 71% (n = 94) was achieved. In reference to teamwork and collaboration, all groups strongly indicated that IPE can contribute to learning teamwork skills (x¯ = 24.98, SD = 3.5) and improving relationships with team members (x¯ = 12.93, SD = 1.63); however, the scores did not differ between the groups (P = 0.09 and P = 0.16, respectively). Concerning professional identity, student dentists had significantly higher preference for a discipline-based approach (P = 0.002); were more likely to agree that it is not necessary for undergraduate dental and dental care professional students to learn together (P = 0.01); and perceived that clinical problem-solving skills can only be learnt effectively with other students from their own discipline (P = 0.02) than dental hygiene and therapy students. In relation to roles and responsibilities, participants demonstrated a strong sense of their own professional role. Student dentists reported that they had to gain more knowledge and skills than dental hygiene and therapy (P = 0.01) and dental nursing (P = 0.01) students. Dental hygiene and therapy students were less likely than student dentists to agree that the role of dental nurses and hygienists was to mainly provide support for dentists (P = 0.001).nnnCONCLUSIONnThe findings suggest that IPE was perceived as beneficial in relation to teamwork; however, the study raises issues regarding professional identity and roles. Educators should consider differing perceptions of professional roles and identities when planning and delivering interprofessional programmes.

Widening participation – a comparison of the characteristics of successful UK applicants to the five-year and four-year dental programmes in 2007 and 2008

Aim To compare the demographics (age, sex, ethnicity, social status, disability, country/region) and academic experience (school type) of accepted UK applicants to the five-year and four-year dental programmes in 2007 and 2008.Methods Retrospective descriptive analysis was carried out on the University and College Admissions Services (UCAS) data for accepted UK applicants to the five- and four-year dental programmes at UK dental schools in the years 2007 and 2008. Logistic regression was used to model the outcome of dental admission to programmes (four-year vs five-year), controlling for the other explanatory variables. Data were analysed using SPSS v19.Results In the years 2007 and 2008 over 2,000 UK applicants were accepted on to a dental course (n = 2,274) within the UK. Of these accepted applicants, 84% (n = 1,903) were accepted onto a five-year and 14% (n = 322) onto a four-year, programme. Over half were female for both the five- and four-year programmes (58% cf 59% respectively). One tenth of students accepted to the five-year programme were mature (n = 173) and nearly all of the students to the four-year programme (n = 321). Similar proportions of accepted applicants to both programmes were from minority ethnic groups (46%), with the majority of students being of White or Asian background; however, the four-year programmes accepted a higher proportion of black (4% cf 1%) and other minority ethnic students (8% cf 3%) when compared with the five-year programme. A higher proportion of accepted students to the four-year programmes came from the lowest higher/further education participation areas (POLAR2 groups 1-3) than the five-year programmes (38% cf 28%). Proportionally more accepted applicants to the four-year programmes came from London than the five-year programmes (30%, cf 20%). In contrast, a greater proportion of accepted applicants to the five-year programmes came from Scotland (13% cf 6%), Northern Ireland (9% cf 0%) and Wales (4% cf 2%). When all other factors were controlled, the odds of being accepted to the four-year rather than the five-year programme were higher if the applicants were mature and from Greater London.Conclusion There is little definitive evidence that graduate entry programmes widen access to dentistry when compared with the traditional five-year programme; however, the findings do highlight geographic disparities in access to graduate entry programmes, which are important for policy makers and schools to consider.