Jenny Godson

Dental therapy in the United Kingdom: part 2. A survey of reported working practices.

Objectives To conduct a survey of current working practices of UK dental therapists following the changes in permitted duties, allowed clinical settings and the introduction of the new dental contract in England and Wales.Methods A piloted postal questionnaire was circulated in 2006 to all General Dental Council (GDC) registered therapists and those on the hygienists register possessing a dental therapy qualification. Two subsequent mailings were used to boost the response rate.Results There was an 80.6% response rate (n = 587). Ninety-eight percent of respondents were female. Average time since qualification was 17 years. Eighty percent (n = 470) of respondents were currently working as a dental therapist, 53% part-time. Of the 470, half were engaged entirely in general dental practice (GDP), one third in the salaried dental services (SDS), while others worked across different settings. Only 39% claimed to spend most of their time treating children. Recently qualified therapists more often worked in GDP (p <0.001). Overall, a wide range of clinical duties were performed, although there was concern about maintaining skills across all the competencies since qualification, while emphasis on hygiene work was a limiting factor for some. On the basis of the continued professional development (CPD) activities described over one year, only half would have met the GDC CPD requirements from August 2008 for dental care professionals (DCPs).Conclusions More than half of therapists now work in GDP, compared with none six years previously. Many undertake a full range of duties. However, there was concern that some dentists use them for hygiene skills rather than across the whole range of their competencies, risking deskilling, while others reported their inability to gain employment as a therapist.

Dental therapy in the United Kingdom: part 3. Financial aspects of current working practices

Objectives To enquire into current remuneration arrangements among UK dental therapists and to explore the nature of any financially related concerns. Methods Part of the postal survey of therapists described in the previous paper in this series. Results The majority of therapists (63%) often work in multiple locations and therefore may be in receipt of more than one type of payment mechanism. Two thirds of therapists are paid an hourly rate in at least one of the locations where they work; just over half are paid a fixed monthly amount and one third are self-employed. Nine percent of respondents were receiving performance-related pay, using goal setting, incentives and bonuses. A number of financially-related concerns were identified. Conclusion Diverse payment systems were reported. Some aspects could present important implications for future recruitment and retention.

What influences the use of dental services by adults in the UK

OBJECTIVES Optimizing access to and utilization of dental services remains a major public health challenge. The aim of this study was to use Andersens behavioural model to investigate the factors that influence utilization of dental services and predict oral health outcomes, and to identify how access could be improved. METHODS Secondary analysis was conducted of data from a regional postal survey (n = 10 864) of adults in the UK. Items were chosen to reflect variables of Andersens behavioural model including predisposing characteristics (deprivation), enabling resources (perceived difficulty accessing a dentist), need (perceived treatment need), health behaviours (reason for attendance and time since the last visit to the dentist) and oral health outcomes (oral health impacts (symptoms, functional limitation and social) and global oral health). Structural equation modelling was used to estimate the direct and indirect pathways between the variables within the model. RESULTS When a combination of indirect and direct effects were taken into account, perceived difficulty accessing the dentist was associated with higher perceived treatment need (β = 0.25, P < 0.01), increased oral health impacts (β = -0.23, P < 0.01) and worse global oral health (β = -0.21, P < 0.01). Overall, the variables included within this model explained 17.4% of the variance for dental attendance, 55.4% of the variance for the length of time since people had last visited the dentist, 21.7% of the variance for oral health impacts and 42.9% of the variance for peoples global oral health. CONCLUSIONS Perceived treatment need and difficulty accessing dental services were found to be key predictors of oral health outcomes. Further research is needed to develop and evaluate effective interventions to improve access to dental services.

The Self-Reported Oral Health Status and Dental Attendance of Smokers and Non-Smokers in England.

Smoking has been identified as the second greatest risk factor for global death and disability and has impacts on the oral cavity from aesthetic changes to fatal diseases such as oral cancer. The paper presents a secondary analysis of the National Adult Dental Health Survey (2009). The analysis used descriptive statistics, bivariate analyses and logistic regression models to report the self-reported oral health status and dental attendance of smokers and non-smokers in England. Of the 9,657 participants, 21% reported they were currently smoking. When compared with smokers; non-smokers were more likely to report ‘good oral health’ (75% versus 57% respectively, p<0.05). Smokers were twice as likely to attend the dentist symptomatically (OR = 2.27, CI = 2.02–2.55) compared with non-smoker regardless the deprivation status. Smokers were more likely to attend symptomatically in the most deprived quintiles (OR = 1.99, CI = 1.57–2.52) and perceive they had poorer oral health (OR = 1.77, CI = 1.42–2.20). The present research is consistent with earlier sub-national research and should be considered when planning early diagnosis and management strategies for smoking-related conditions, considering the potential impact dental teams might have on smoking rates.

School-based epidemiological surveys and the impact of positive consent requirements

A requirement to obtain positive consent for participants in school-based dental epidemiological surveys was introduced in 2006. Concern has been expressed about the impact of the changes on the validity of results as the need to obtain positive consent is likely to reduce the numbers participating. An additional concern is that the new requirement may also lead to samples that are biased, resulting in them being unrepresentative of the population from which they are drawn. This paper aims to discuss the implications of the changes on the quality of future school-based dental epidemiological surveys, and whether they threaten the validity of survey findings at a time when such information is critical in informing the local commissioning of dental services.

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.

Incidence of oral cancer among South Asians and those of other ethnic groups by sex in West Yorkshire and England, 2001–2006

In 2008 there were 11682 cases of oral cancer in the United Kingdom; this is 16.41/100000 population, and 3.7% of all cancers. Ethnic coding of these data is poor, and so databases were combined to report rates for the incidence of oral cancer in South Asians compared with those among other ethnic groups in West Yorkshire, 2001-2006. A total of 2157 patients with oral cancer were identified in West Yorkshire, 138 of whom were South Asian (6.4%). We analysed them by ethnicity, sex, area in which they lived, and site of cancer. Oral cancer was significantly more common among South Asian women than those from other ethnic groups in England and West Yorkshire, and in England alone it was significantly more common in men of other ethnic groups than those from South Asia. Patients from South Asia were at higher risk of being diagnosed with oral cancer than those of other ethnic groups within West Yorkshire, when data were adjusted for age at diagnosis and sex. In England and in West Yorkshire there was a significantly higher rate of oral cancer among Southern Asian women than among those of other ethnic groups, and men in other ethnic groups had a higher incidence than those from South Asia (England only). The excess of oral cancers gives further weight to the association between smokeless tobacco, smoking, alcohol, and dietary intake by ethnic group. This information is particularly pertinent in areas such as West Yorkshire where there are large groups of Asian people.

The oral health of adults in Yorkshire and Humber 2008

Background and aim Although national surveys are conducted of the oral health of adults in the UK, few data are available at regional and primary care trust levels to inform local commissioning. A postal survey was conducted to investigate the oral health and use of dental services by adults in the Yorkshire and Humber region.Method A questionnaire was developed and piloted, then sent to a random sample of 25,200 adults. Data were analysed by sex, gender, age and deprivation.Results 10,864 (43.0%) questionnaires were returned completed. Nearly three-quarters (71.6%) of respondents had 20 or more teeth and approximately one quarter (25.3%) rated their oral health as fair, poor or very poor. The percentage reporting painful aching, discomfort when eating and being self-conscious about their mouths (occasionally or more often in the last 12 months) were 28.8%, 32.8% and 29.1% respectively. Overall, 80.3% reported attending a dentist in the last two years, although nearly a quarter (22.6%) of respondents reported difficulties accessing routine care. However, there were marked inequalities between those living in the most and least deprived neighbourhoods.Conclusion This survey was the first to investigate the oral health and service use of adults in the Yorkshire and Humber region. The findings have implications for the local commissioning of dental services.

Dental auxiliaries for dental care

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

Shaping dental contract reform: a clinical and cost-effective analysis of incentive-driven commissioning for improved oral health in primary dental care

Objective To evaluate the clinical and cost-effectiveness of a new blended dental contract incentivising improved oral health compared with a traditional dental contract based on units of dental activity (UDAs). Design Non-randomised controlled study. Setting Six UK primary care dental practices, three working under a new blended dental contract; three matched practices under a traditional contract. Participants 550 new adult patients. Interventions A new blended/incentive-driven primary care dentistry contract and service delivery model versus the traditional contract based on UDAs. Main outcome measures Primary outcome was as follows: percentage of sites with gingival bleeding on probing. Secondary outcomes were as follows: extracted and filled teeth (%), caries (International Caries Detection and Assessment System (ICDAS)), oral health-related quality of life (Oral Health Impact Profile-14 (OHIP-14)). Incremental cost-effective ratios used OHIP-14 and quality adjusted life years (QALYs) derived from the EQ-5D-3L. Results At 24 months, 291/550 (53%) patients returned for final assessment; those lost to follow-up attended 6.46 appointments on average (SD 4.80). The primary outcome favoured patients in the blended contract group. Extractions and fillings were more frequent in this group. Blended contracts were financially attractive for the dental provider but carried a higher cost for the service commissioner. Differences in generic health-related quality of life were negligible. Positive changes over time in oral health-related quality of life in both groups were statistically significant. Conclusions This is the first UK study to assess the clinical and cost-effectiveness of a blended contract in primary care dentistry. Although the primary outcome favoured the blended contract, the results are limited because 47% patients did not attend at 24 months. This is consistent with 39% of adults not being regular attenders and 27% only visiting their dentist when they have a problem. Promotion of appropriate attendance, especially among those with high need, necessitates being factored into recruitment strategies of future studies.