Editorial - Beyond the individual: the need for team based and system-wide solutions to support improved mental health in dentistry.

While the COVID-19 pandemic may no longer dominate headlines, significant pressures on the UK health and social care sector remain. Within dentistry, a profession with a long-standing association with poor mental health, practitioners continue to feel significant strain in terms of working conditions and financial pressures. They now also face a severe backlog of routine care for NHS patients.

Risk stratification for poor health-related quality of life following head and neck cancer through the aid of a one-page item prompt list.

The aim of this work was to evaluate the usability of a single-page, patient-completed, condition-specific prompt list, the Patient Concerns Inventory (PCI-HN), to risk-stratify for poor health-related quality of life (HRQOL). Data were collected between 2008 and 2017. The main dataset comprised 310 patients first completing the PCI-HN and University of Washington Quality of Life questionnaire (UW-QOLv4) between 2012 and 2017. Another 201 patients first completing the PCI-HN between 2008 and 2011 provided a second dataset for independent validation. Subsequent completions of the PCI-HN in both groups and the distress thermometer (DT) were also used as further validation datasets. Associations between PCI-HN items selected by patients and a range of UW-QOLv4 outcomes were explored using conventional logistic regression and Chi-squared automated interaction detection (CHAID) analyses. One quarter of patients reported less than good HRQOL, range 26-29% across the four datasets. Several individual items from within the PCI-HN were predictive of adverse outcomes. The total number of items selected was also predictive. The single-sheet prompt list enables clinicians to identify patients at high risk of poor HRQOL. This simple approach has the potential to be integrated into routine clinical practice.

Editorial - The importance of studying communication processes in the dentist: patient interaction.

The delivery of dental services attracts continuing debate by health service management, public health specialists and public representatives. There is little argument, that communication among dental service providers and cli- ent groups is a vital component of exemplary services. However, the exact requirements of what constitutes good communication becomes problematic. Definitions can be applied to detailed observations of elements of dental staff behaviour. Such observational audits are rarely applied, due to the large resources required, and believing this approach is purely a research-only exercise. We acknowledge the demanding nature of any such endeavour in real-time by a trained observer. An alternative is to video-record clinical sessions. Although this has been possible for some decades, the widespread use of recording samples of clinical sessions, for example to assess staff engagement in prevention advice, is not realistic using current methodologies, even if the considerable ethical concerns could be assuaged. In addition, hitherto, there has been a wide ranging set of views of what would be considered poor, just good enough or excellent communication. Part of this difficulty is due to the complexity of the communication processes themselves. The variety of health service settings, staff experience and training received in the fi eld of communication and the sheer spectrum of patient types and problems that surface which require treatment, advice and instruction makes a universal framework of what constitutes acceptable communication skills difficult to specify. Furthermore, when no established standard can be agreed the status of rewarding good communication is therefore under-valued and simply ignored from service contracts.

Dental anxiety, child-oral health related quality of life and self- esteem in children and adolescents: a systematic review and meta-analysis.

AIM: To identify the directions, strength and associations between dental anxiety, COHRQoL and self-esteem in children and adolescents. BASIC RESEARCH DESIGN: PRISMA guidelines were followed and the review registered (PROSPERO CRD42019140037). MEDLINE, Cochrane Library, Scopus, Science Direct, CINAHL, Joanna Briggs Institute (JBI), Grey Literature Report, and British Library EThOS using MeSH terms and keywords were searched. Three reviewers examined the abstracts of all articles, excluded duplicates and those not meeting inclusion criteria. All full-text papers were read by all reviewers. Meta-analysis association data including Pearson's or Spearman's correlation coefficient were extracted and effect sizes estimated. RESULTS: Twelve papers met the inclusion criteria, 7 assessed the relationship between child dental anxiety and COHRQoL; four between COHRQoL and self-esteem and one between child dental anxiety and self-esteem. Significant relationships were found between COHRQoL and the other child-related outcomes measures. An inverse relationship was shown for dental anxiety and COHRQoL. The meta-analysis found small associations between child dental anxiety and COHRQoL and moderate associations between COHRQoL and self-esteem. High heterogeneity between COHRQoL and self-esteem was noted. The association between child dental anxiety and self-esteem was limited. No source reported associations between all three variables. CONCLUSION: The studies were of varying quality and the degree of heterogeneity meant that only limited conclusions were possible. There is a need for high-quality evidence to underpin intervention designs to promote COHRQoL and self-esteem to reduce child dental anxiety.

Using the Patient Concerns Inventory in the identification of fatigue following treatment for head and neck cancer.

Fatigue has a profound impact on health-related quality of life (HRQOL). The aim of this study was to describe the clinical characteristics and HRQOL of head and neck cancer patients who raised the issue of fatigue on the Patient Concerns Inventory (PCI) at their review consultation. Eight consultants were randomized to use the PCI as part of a cluster-controlled trial. Patients also completed the University of Washington Quality of Life version 4 (UWQOL), EQ-5D-5L (EuroQol Group), and Distress Thermometer questionnaires. The study included 140 patients who attended clinics at a median of 108 (interquartile range 70-165) days after the end of treatment. The PCI item 'fatigue' was the sixth most commonly selected, by 29% (n=40). Those with advanced tumours were more likely to have selected the item (30/84, 36% vs 10/56, 18%; P=0.02), as were those treated with radiotherapy±chemotherapy (34/87, 39% vs 6/53, 11%; P<0.001). The PCI fatigue group reported significantly worse overall quality of life, social-emotional and physical function composite scores (UWQOL), Distress Thermometer, and EQ-5D-5L. PCI fatigue was common in those with sleeping, nausea, mood, depression, mobility, breathing, and energy level concerns. In conclusion, given the problems associated with fatigue, it is appropriate to screen and seek interventions that might help patients address this.

Using a patient prompt list to raise concerns in oncology clinics does not necessarily lead to longer consultations.

Head and neck oncology post-treatment consultations form a critical component of care in terms of support and surveillance. They occur frequently in the first few years and can place substantial demands on healthcare resources. However, they provide useful opportunities for patients to raise issues and receive tailored information and support. The aim of this paper was to assess whether completion of a 56-item patient prompt list (PCI - the Patient Concerns Inventory) immediately prior to the consultation significantly increased its duration. This was a pragmatic cluster preference randomised controlled trial of 288 patients with 15 consultant clusters from two sites "using" (n=8) or "not using" (n=7) the PCI. Consultation times were known for 283 patients (136 PCI, 147 non-PCI) who attended their first post-treatment trial consultation a median (IQR) of 103 (70-160) days after the end of treatment. Consultations lasted a median (IQR) of 10 (7-13) minutes (mean 11) in non-PCI patients and a median (IQR) of 11 (8-15) minutes (mean 12) in PCI patients (p=0.07). After adjustment for patient clustering and significant case mix, the 95% confidence interval for the mean difference was between 1.45minutes shorter with the PCI and 2.98minutes longer (p=0.50). There was significant variation in duration by consultant, tumour stage, treatment mode, overall quality of life (QoL), and distress (all p<0.001). In those who completed the PCI, duration increased with the total number of items selected (p<0.001). In conclusion, the inclusion of a prompt list to help facilitate conversation with patients did not make a substantial difference to consultation times.

Loneliness and quality of life after head and neck cancer.

Loneliness is associated with a poor quality of life, mental illness, poor physical health, and premature mortality. Patients with head and neck cancer (HNC) are at risk of loneliness because of the effects of the disease and its treatment on important social interactive functions such as appearance, speech, facial expression, and eating. Patients treated for primary squamous cell HNC between January 2015 and December 2016 were surveyed in early 2019 using the University of Washington quality of life questionnaire version 4, the Cancer-related Loneliness Assessment Tool (C-LAT), and four nationally recommended indicator questions. The survey comprised 140 patients, with a mean (standard deviation) age at diagnosis of 63 (11) years. Tumour sites were oropharyngeal (42%), oral (35%), laryngeal (14%), and elsewhere (9%). In response to the question "How often do you feel lonely?" three-quarters said "hardly ever" and only 6% "often". Similar responses were obtained for the other three indicator questions. It is encouraging that a relatively small proportion had serious issues with loneliness. Similarly, responses to the C-LAT suggested that one-quarter had feelings of loneliness and a minority had serious problems. Patients who were younger, who lived in more deprived circumstances, who had advanced disease and had been treated with chemotherapy or radiotherapy reported greater levels of loneliness. Loneliness was associated with a worse overall quality of life, and worse physical and social-emotional function. Lonely patients need to be identified as early as possible so that support and interventions can be implemented and outcomes improved.

Best practice in reducing the suicide risk in head and neck cancer patients: a structured review.

The treatment of head and neck cancer (HNC) is often radical and the patient's journey challenging, especially for individuals who are struggling with pre-existing mental health problems and who lack social support. Patients frequently suffer from high levels of emotional distress at some point before, during, or after treatment, and their risk of suicide is markedly elevated. This structured review aimed to identify the extent of the problem, appropriate interventions, and areas for future research. We found that the incidence of suicide among HNC patients was significantly elevated above that of the demographically matched general population. Furthermore, the risk was frequently higher in patients with HNC than in those with cancers in other sites. Despite the clear burden of suicide in patients with HNC, there is an absence of evidence on interventions used to reduce suicidal ideation and the risk of suicide. Recommendations for practice are made, drawing from the wider literature on the prevention of suicide.

Community-based oral health interventions for people experiencing homelessness: a scoping review.

OBJECTIVE: To determine the characteristics of community-based oral health interventions for people experiencing homelessness. BASIC RESEARCH DESIGN: A scoping review was conducted, adhering to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses: Scoping Reviews) checklist. A search strategy was developed using MeSH terms and key words, and used to search the following electronic databases: Medline/PubMed, CINAHL, ProQuest Assia, Scopus, Web of Science and PsychNet. Key journals and reference lists were also hand-searched. Two reviewers then read the abstracts of all papers, excluding duplicates and papers that did not meet the eligibility criteria. The reviewers then read to full-texts of the studies to be included in the review. RESULTS: Eighteen studies met the inclusion criteria and were included in the study. These studies were predominantly evaluations of community-based dental services or other oral health interventions. Several recommendations were extracted. Interventions should involve co-design with homeless service users; multidisciplinary working, collaboration with dental practitioners, and working with educational establishments. The location of community-based services was also found to be of importance. CONCLUSION: This review has highlighted several recommendations, as well as gaps in the literature. These gaps suggest a need for more non-clinical oral health interventions for the homeless population, and a closer look at the role that non-dental practitioners can play in the delivery of oral health care.

Virtual Reality Relaxation to Decrease Dental Anxiety: Immediate Effect Randomized Clinical Trial.

INTRODUCTION: Dental anxiety is common and causes symptomatic use of oral health services. OBJECTIVES: The aim was to study if a short-term virtual reality intervention reduced preoperative dental anxiety. METHODS: A randomized controlled single-center trial was conducted with 2 parallel arms in a public oral health care unit: virtual reality relaxation (VRR) and treatment as usual (TAU). The VRR group received a 1- to 3.5-min 360° immersion video of a peaceful virtual landscape with audio features and sound supporting the experience. TAU groups remained seated for 3 min. Of the powered sample of 280 participants, 255 consented and had complete data. Total and secondary sex-specific mixed effects linear regression models were completed for posttest dental anxiety (Modified Dental Anxiety Scale [MDAS] total score) and its 2 factors (anticipatory and treatment-related dental anxiety) adjusted for baseline (pretest) MDAS total and factor scores and age, taking into account the effect of blocking. RESULTS: Total and anticipatory dental anxiety decreased more in the VRR group than the TAU group (ß = -0.75, P < .001, for MDAS total score; ß = -0.43, P < .001, for anticipatory anxiety score) in patients of a primary dental care clinic. In women, dental anxiety decreased more in VRR than TAU for total MDAS score (ß = -1.08, P < .001) and treatment-related dental anxiety (ß = -0.597, P = .011). Anticipatory dental anxiety decreased more in VRR than TAU in both men (ß = -0.217, P < .026) and women (ß = -0.498, P < .001). CONCLUSION: Short application of VRR is both feasible and effective to reduce preoperative dental anxiety in public dental care settings (ClinicalTrials.gov NCT03993080). KNOWLEDGE TRANSFER STATEMENT: Dental anxiety, which is a common problem, can be reduced with short application of virtual reality relaxation applied preoperatively in the waiting room. Findings of this study indicate that it is a feasible and effective procedure to help patients with dental anxiety in normal public dental care settings.

Emotional talk of patients with breast cancer during review appointments with therapeutic radiographers: effects on fears of cancer recurrence.

Fears of cancer recurrence (FCR) in patients with breast cancer may develop during radiotherapy. Radiographer communication with their patients may influence early survivorship FCR level. AIM: To investigate the management of emotional talk in patients with breast cancer attending their initial review appointments during radiotherapy and predict FCR at 6-8 weeks follow-up. METHODS: A mixed-methods observational study was conducted. Patients (consecutive sample, n = 60) with breast cancer, attending a major Scottish cancer centre, had their first two review appointments with their therapeutic radiographer (TR) audio-recorded. In addition, FCR was assessed (FCR7) at baseline and at 6-8 weeks following their final radiotherapy visit. Two TRs participated. Audio files were coded by the VR-CoDES system to identify emotional cues and therapeutic radiographer (TR) responses. Linear regression models were tested for fit and to identify factors associated with follow-up FCR, i.e. patient cues, responses by TR. RESULTS: Follow-up FCR was predicted negatively (robust estimator, p = .01) by level of patient emotional talk at the second review session. The provision of space by the TR, at the second session, to enable patients to expand their emotional utterances was also associated, but negatively (p = .01), with follow-up FCR. These effects were maintained after inclusion of covariates: age, treatment received and living conditions. CONCLUSIONS: Patient's emotional expression and TR responses at the second review meeting predicted follow-up FCR. The study shows the effect of communication processes on this specific distress component of the patient's survivorship experience. TRIAL REGISTRATION: NCT02599506.

Patient centred consultation, satisfaction and young patients: A cross-country analysis.

OBJECTIVES: The aim of this study was to investigate the link between perceived dimensions of patient centred care and the satisfaction of adolescents and young adults within the UK, USA, Australian, Italian, and Chinese healthcare systems. METHODS: One thousand and thirty-four participants (212 from China,206 from Australia,208 from UK, 202 from USA, and 206 from Italy) answered a self-report questionnaire assessing the perceived dimensions of patient centred care. Factor analysis (PFA) was conducted on the data to identify relevant dimensions. One-way ANOVAs were run to identify differences between country samples related to perceived dimensions of patient centredness, and a multi-level multiple regression model was computed to assess the link between satisfaction and dimensions of patient centred care. RESULTS: Countries' mean scores on 'Satisfaction with Care' (PF1) and on 'Psychosocial Context' (PF2) were statistically significant by inspecting the ANOVAs (p < .05). Satisfaction with care was predicted by PF2 and clinical utilization. CONCLUSION: An online survey collected meaningful data on perceptions of healthcare received by respondents from five countries. This initial international study highlights important associations worthy of closer investigation. PRACTICE IMPLICATIONS: Healthcare providers should assess comprehensively the psychosocial context of young patients during consultations.

Fear of cancer recurrence trajectory during radiation treatment and follow-up into survivorship of patients with breast cancer.

BACKGROUND: Fear of cancer recurrence (FCR) has been shown to be higher in patients treated with external beam radiotherapy (RT) compared to those untreated. However, little is known about the dynamics of patient's FCR during and after RT. The aim of this study was to examine FCR levels in a longitudinal panel design with breast cancer patients receiving RT. METHODS: Consecutive newly-diagnosed breast cancer patients (n = 94) attending a single cancer centre were invited to complete a 7-item FCR scale (FCR7) that was collected weekly by paper instrument and at a follow-up phone call 6-8 weeks after completion of RT. Descriptive statistics, and Latent Growth Curve Modelling (LGCM) were utilised to analyse the data. RESULTS: Women who were younger, single/separated, had chemotherapy, had extra boost radiation treatment, taking Herceptin and treated by 4-field technique reported higher recurrence fear at baseline. There was strong evidence of substantial variation in the trajectory of FCR (z = - 3.54, p < .0001). The average trajectory of FCR over RT was negative (unstandardized estimate = - 0.59) and associated with FCR follow-up level (standardised estimate = 0.36, z = 3.05, p < .002), independent of baseline recurrence fears. CONCLUSION: Patients vary in their trajectory of recurrence fears over RT which predicts FCR approximately 2 months following treatment. Review appointments by therapy radiographers presents an opportunity to intervene in FCR trajectories. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02599506 . Prospectively registered on 11th March 2015.

High levels of socioeconomic deprivation do not inhibit patients' communication of concerns in head and neck cancer review clinics.

To examine associations between socioeconomic status and the extent to which patients with cancer of the head and neck expressed concerns to surgeons during routine follow-up clinics, we analysed audio recordings of 110 consultations with one consultant. We used the Verona Coding Definitions of Emotional Sequences (VRCoDES) to measure communication between the doctor and the patient, and grouped the English indices of multiple deprivation (IMD) 2015 scores into deciles to compare the VRCoDES with socioeconomic status. There were no significant correlations between IMD decile and the number and type of cues and concerns, or the type of response by the consultant, but there was a positive correlation between IMD decile and duration of appointment (r=0.288, p<0.01). When the duration of appointment was controlled for, there was a negative correlation between IMD decile and number of cues and concerns (r=-0.221, p<0.05). These findings question the assumption that socioeconomic status is associated with a patient's willingness to express concerns. Shorter consultations suggest that less time is spent responding to their concerns or building a rapport. Clinicians might find it advantageous to adopt strategies that will improve their understanding of these patients and help them to communicate more effectively.

Does emotional talk vary with fears of cancer recurrence trajectory? A content analysis of interactions between women with breast cancer and their therapeutic radiographers.

Fears of cancer recurrence (FCR) in patients with breast cancer are hypothesised to develop over the period from diagnosis, through treatment and thereafter. A crucial point may be the contact that patients have with their therapeutic radiographer in review appointments. The study aimed to (1) describe and categorise the content of the identified emotional talk, and (2) consider the evidence for an association of content with FCR trajectory. METHODS: A concurrent mixed methods approach was applied as part of a larger investigation (FORECAST) of breast cancer patients (n=87). Patients completed a daily diary during their radiotherapy treatment. Audio recordings were collected of review appointments. The Verona Coding Definitions of Emotional Sequences (VR-CoDES) system was used to code patient emotional cues and concerns (CCs). Purposeful sampling of the daily diary ratings identified 12 patients (30 consultations) with an increasing (n=6) or decreasing (n=6) FCR trajectory. The emotional talk of these patients at their weekly reviews was content analysed. RESULTS: Four themes were identified from 185 CCs: Physical Symptoms, Factors External to Hospital, Treatment, and Labelling Cancer. FCR decreasing trajectory group consultations were longer (p<0.02), expressed twice as many CCs as the increasing trajectory group (p<0.001), and were more likely to refer to cancer directly (p<0.05). CONCLUSIONS: The emotional content expressed matched features outlined in the Lee-Jones et al. (1997) FCR model, and showed evidence of avoidance in increasing FCR trajectory patients.

Unidimensional scales for fears of cancer recurrence and their psychometric properties: the FCR4 and FCR7.

BACKGROUND: The assessment of fear of recurrence (FCR) is crucial for understanding an important psychological state in patients diagnosed and treated for cancer. The study aim was to determine psychometric details of a seven question self-report scale (FCR7) and a short form (FCR4) based upon items already used in various extensive measures of FCR. METHODS: Two consecutive samples of patients (breast and colorectal) were recruited from a single specialist cancer centre. The survey instrument contained the FCR7 items, Hospital Anxiety and Depression Scale (HADS), and demographic details. Clinical information was obtained from patient hospital records. Statistical analyses were performed using classical test and item response theory approaches, to demonstrate unidimensional factor structure and testing key parameters. Construct validity was inspected through nomological and theoretical prediction. RESULTS: Internal consistency was demonstrated by alpha coefficients (FCR4: 0.93 and FCR7: 0.92). Both scales (FCR7 & FCR4) were associated with the HADs subscales as predicted. Patients who experienced chemotherapy, minor aches/pains, thought avoidance of cancer and high cancer risk belief were more fearful. Detailed inspection of item responses profile provided some support for measurement properties of scales. CONCLUSION: The internal consistency, and pattern of key associations and discriminability indices provided positive psychometric evidence for these scales. The brief measures of FCR may be considered for audit, screening or routine use in clinical service and research investigations.

Fear of cancer recurrence in oral and oropharyngeal cancer patients: An investigation of the clinical encounter.

Fear of cancer recurrence (FCR) is common among individuals treated for cancer. Explorations of how this fear is expressed within an oncology setting and responded to are currently lacking. The aim was to investigate how head and neck cancer survivors in follow-up consultations express FCR, investigate how a healthcare professional addresses recurrence fears, and examine how survivors experience this interaction. We recorded the follow-up consultations of those participants who have reported FCR as a concern on the Patient Concerns Inventory. We also conducted a follow-up phone interview with the participants. We analysed the transcripts using thematic analysis. Five men and six women were recruited, aged 55-87 (mean age = 64). Follow-up consultation analyses revealed that the consultant used "normalising FCR," "reassurance," and "offer of referral to a counsellor." Interviews revealed themes around how they coped with FCR, relevance of personal history on FCR, and the impact of feeling gratitude towards the consultant on expression of FCR. Analyses indicate that patients may feel reluctant to raise their FCR with their clinician for fear of appearing "ungrateful" or of damaging a relationship that is held in high esteem. Findings indicate the initiation of FCR with patients can be beneficial for patient support.