Development of a Root Caries Prediction Model in a Population of Dental Attenders.

Root caries prevalence is increasing as populations age and retain more of their natural dentition. However, there is generally no accepted practice to identify individuals at risk of disease. There is a need for the development of a root caries prediction model to support clinicians to guide targeted prevention strategies. The aim of this study was to develop a prediction model for root caries in a population of regular dental attenders. Clinical and patient-reported predictors were collected at baseline by routine clinical examination and patient questionnaires. Clinical examinations were conducted at the 4-year timepoint by trained outcome assessors blind to baseline data to record root caries data at two thresholds - root caries present on any teeth (RC > 0) and root caries present on three or more teeth (RC ≥ 3). Multiple logistic regression analyses were performed with the number of participants with root caries at each outcome threshold utilized as the outcome and baseline predictors as the candidate predictors. An automatic backwards elimination process was conducted to select predictors for the final model at each threshold. The sensitivity, specificity, and c-statistic of each model's performance was assessed. A total of 1,432 patient participants were included within this prediction model, with 324 (22.6%) presenting with at least one root caries lesion, and 97 (6.8%) with lesions on three or more teeth. The final prediction model at the RC >0 threshold included increasing age, having ≥9 restored teeth at baseline, smoking, lack of knowledge of spitting toothpaste without rinsing following toothbrushing, decreasing dental anxiety, and worsening OHRQoL. The model sensitivity was 71.4%, specificity 69.5%, and c-statistic 0.79 (95% CI: 0.76, 0.81). The predictors included in the final prediction model at the RC ≥ 3 threshold included increasing age, smoking, and lack of knowledge of spitting toothpaste without rinsing following toothbrushing. The model sensitivity was 76.5%, specificity 73.6%, and c-statistic 0.81 (95% CI: 0.77, 0.86). To the authors' knowledge, this is the largest published root caries prediction model, with statistics indicating good model fit and providing confidence in its robustness. The performance of the risk model indicates that adults at risk of developing root caries can be accurately identified, with superior performance in the identification of adults at risk of multiple lesions.

"It's really no more difficult than putting on fluoride varnish": a qualitative exploration of dental professionals' views of silver diamine fluoride for the management of carious lesions in children.

BACKGROUND: Despite evidence that Silver Diamine Fluoride (SDF) can be effective in managing carious lesions in primary teeth, the use of SDF in the UK remains limited. This study explored dental professionals' views and experiences of using SDF for managing carious lesions in children. In addition, it explored what they perceived to be the advantages, disadvantages, barriers and enablers to the use of SDF in practice. METHODS: Fifteen semi-structured face-to-face or over-the-phone interviews were conducted with 14 dental professionals from NHS Tayside and NHS Grampian in Scotland. Interviews were transcribed verbatim, coded and analysed using a thematic approach. RESULTS: Thirteen of 14 dental professionals interviewed were familiar with, or had some existing knowledge of, SDF. Four had used it to treat patients. The majority of participants thought that the main advantage of SDF was that it required minimal patient cooperation. SDF was also perceived as a simple, pain-free and non-invasive treatment approach that could help acclimatise children to the dental environment. However, SDF-induced black staining of arrested carious lesions was most commonly reported as the main disadvantage and greatest barrier to using it in practice. Participants believed that this discolouration would concern some parents who may fear that the black appearance may instigate bullying at school and that others may judge parents as neglecting their child's oral health. Participants thought that education of clinicians about SDF use and information sheets for parents would enhance the uptake of SDF in dental practice. Participants believed that younger children might not be as bothered by the discolouration as older ones and they anticipated greater acceptance of SDF for posterior primary teeth by both parents and children. CONCLUSION: Dental professionals were aware that SDF can be used for arresting carious lesions. They pointed out that the staining effect of carious lesions is a major disadvantage and had preconceived ideas that this could be a barrier for many parents. Participants considered the application process to be simple and non-invasive and requires a minimum level of child cooperation. Participants appreciated the potential of SDF in paediatric dentistry and suggested actions that could help overcome the barriers they highlighted.

Silver diamine fluoride for managing carious lesions: an umbrella review.

BACKGROUND: This umbrella review comprehensively appraised evidence for silver diamine fluoride (SDF) to arrest and prevent root and coronal caries by summarizing systematic reviews. Adverse events were explored. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines, PubMed, Embase, Cochrane Library, PROSPERO register and Joanna Briggs Institute Database of Systematic Reviews were searched for systematic reviews investigating SDF for caries prevention or arrest (1970-2018) without language restrictions. Systematic reviews were selected, data extracted, and risk of bias assessed using ROBIS by two independent reviewers, in duplicate. Corrected covered area was calculated to quantify studies' overlap across reviews. RESULTS: Eleven systematic reviews were included; four focussing on SDF for root caries in adults and seven on coronal caries in children. These cited 30 studies (4 root caries; 26 coronal caries) appearing 63 times. Five systematic reviews were of "low", one "unclear" and five "high" risk of bias. Overlap of studies was very high (50% root caries; 17% coronal caries). High overlap and heterogeneity, mainly comparators and outcome measures, precluded meta-analysis. Results were grouped by aim and outcomes to present an overview of direction and magnitude of effect. SDF had a positive effect on prevention and arrest of coronal and root caries, consistently outperforming comparators (fluoride varnish, Atraumatic Restorative Treatment, placebo). For root caries prevention, the prevented fraction (PF) was 25-71% higher for SDF compared to placebo (two systematic reviews with three studies) and PF = 100-725% for root caries arrest (one systematic review with two studies). For coronal caries prevention, PF = 70-78% (two systematic reviews with two studies) and PF = 55-96% for coronal caries arrest (one systematic review with two studies) with arrest rates of 65-91% (four systematic reviews with six studies). Eight systematic reviews reported adverse events, seven of which reported arrested lesions black staining. CONCLUSION: Systematic reviews consistently supported SDF's effectiveness for arresting coronal caries in the primary dentition and arresting and preventing root caries in older adults for all comparators. There is insufficient evidence to draw conclusions on SDF for prevention in primary teeth and prevention and arrest in permanent teeth in children. No serious adverse events were reported.

Areas for improvement in community optometry: flashes and floaters take priority.

PURPOSE: A common response to rising demand for healthcare is to extend the role of health professionals and the range of their service provision. Community optometry in Scotland is a recent example of this. Within this context of innovation and change there are challenges to ensuring quality in optometry practice. The purpose of this research is to establish what the priorities are for practice improvement within community optometry and to start a programme to inform strategies to improve practice. METHODS: A four stage study was conducted: (1) a service-driven topic prioritisation exercise to identify priorities for optometry practice improvement; (2) a review of national and international guidance and UK protocols relating to the identified priority topic; (3) a national theory-based survey identifying current practice and the barriers and facilitators to the target behaviour; and (4) the identification of theory-based intervention options to improve practice. The Behaviour Change Wheel approach to behaviour change intervention development and Theoretical Domains Framework (TDF) provided the underlying theoretical framework. RESULTS: Stakeholders identified 'patients presenting with flashes and floaters' as an important priority for practice improvement. The decision about whether or not to refer patients on to secondary care for further examination is the target behaviour. Guidance for optometrists on this topic is lacking. Six TDF domains were related to the decision about whether or not to refer patients with flashes and floaters to secondary care - 'social influences', 'emotion', 'beliefs about capabilities', 'beliefs about consequences', 'behavioural regulation' and 'reinforcement'. CONCLUSIONS: This study has examined current practice in relation to the management of patients with flashes and floaters, identified the most salient targets for future strategies to improve optometry practice and highlighted what form these strategies may take. It demonstrates the use of a flexible, theory-informed approach, which can be used to engage with stakeholders and professionals to inform the design and development of efforts to improve practice in a variety of healthcare settings.

Sustainable oral healthcare: what is it and how do we achieve it?

In recent years, there has been an increase in interest in what environmental sustainability means for healthcare, including oral health and dentistry. To help facilitate discussions among key stakeholders in this area, the Scottish Dental Clinical Effectiveness Programme held a workshop in November 2022. The purpose of this workshop was to explore current thinking on the subject of sustainability as it relates to oral health and to help stakeholders identify how to engage with the sustainability agenda. This paper presents an overview of the presentations and discussions from the workshop and highlights potential avenues for future work and collaboration.

'Well, in dentistry the dentist is always the boss': a multi-method exploration of which organisational characteristics of dental practices most influence the implementation of evidence-based guidance.

OBJECTIVE: To investigate which organisational characteristics of primary care dental practices influence the implementation of evidence-based guidance. DESIGN: A multimethod study set within primary care dentistry in Scotland comprising: (1) Semistructured interviews with dental teams to inform development of a self-report questionnaire exploring the translation of guidance in primary care dentistry and (2) A questionnaire-based survey and case studies exploring which organisational characteristics influence knowledge translation. RESULTS: Interview data identified three themes: leadership, communication and context. Survey data revealed compliance with recommendations from three topics of dental guidance to be variable, with only 41% (emergency dental care), 19% (oral health assessment and review) and 4% (drug prescribing) of respondents reporting full compliance. Analysis revealed no significant relationship between practice characteristics and compliance with emergency dental care or drug prescribing recommendations. Positive associations were observed between compliance with oral health assessment and review recommendations and having a practice manager, as well as with the type of treatment offered, with fully private practices more likely, and fully National Health Service practices less likely to comply, when compared with those offering a mixture of treatment. Synthesis of the data identified leadership and context as key drivers of guidance uptake. CONCLUSIONS: Evidence-based dental recommendations are not routinely translated into practice, with variable leadership and differing practice contexts being central to poor uptake. Guidelines should aim to tailor recommendations and implementation strategies to reflect the complexities and varying contexts that exist in primary care dentistry, thus facilitating the implementation of evidence-based guidance.

An evaluation of the implementation of quality improvement (QI) in primary care dentistry: a multi-method approach.

OBJECTIVES: Ensuring that healthcare is patient-centred, safe and harm free is the cornerstone of the NHS. The Scottish Patient Safety Programme (SPSP) is a national initiative to support the provision of safe, high-quality care. SPSP promotes a coordinated approach to quality improvement (QI) in primary care by providing evidence-based methods, such as the Institute for Healthcare Improvement's Breakthrough Series Collaborative methodology. These methods are relatively untested within dentistry. The aim of this study was to evaluate the impact to inform the development and implementation of improvement collaboratives as a means for QI in primary care dentistry. DESIGN: A multimethod study underpinned by the Theoretical Domains Framework and the Kirkpatrick model. Quantitative data were collected using baseline and follow-up questionnaires, designed to explore beliefs and behaviours towards improving quality in practice. Qualitative data were gathered using interviews with dental team members and practice-based case studies. RESULTS: One hundred and eleven dental team members completed the baseline questionnaire. Follow-up questionnaires were returned by 79 team members. Twelve practices, including two case studies, participated in evaluation interviews. Findings identified positive beliefs and increased knowledge and skills towards QI, as well as increased confidence about using QI methodologies in practice. Barriers included time, poor patient and team engagement, communication and leadership. Facilitators included team working, clear roles, strong leadership, training, peer support and visible benefits. Participants' knowledge and skills were identified as an area for improvement. CONCLUSIONS: Findings demonstrate increased knowledge, skills and confidence in relation to QI methodology and highlight areas for improvement. This is an example of partnership working between the Scottish Government and NHSScotland towards a shared ambition to provide safe care to every patient. More work is required to evaluate the sustainability and transferability of improvement collaboratives as a means for QI in dentistry and wider primary care.

Qualitative study exploring the key determinants of information gathering to inform the management of over-the-counter (OTC) consultations in community pharmacies.

OBJECTIVES: Gathering relevant patient information during over-the-counter (OTC) consultations increases the likelihood of safe, effective and person-centred outcomes. The aim of this study was to explore the key determinants to information gathering during consultations for non-prescription medicine requests in community pharmacies in Scotland. DESIGN: Semi-structured interviews using the Theoretical Domains Framework (TDF), with community pharmacy teams across Scotland. Interviews explored participants' knowledge of current guidance, skills required to elicit information and barriers and facilitators associated with this behaviour. Theory-based content analysis was undertaken using the TDF as an initial coding framework to identify key determinants and map them to salient domains. Salience was determined by prominence or variation in views. Comparative analysis was undertaken by professional role. RESULTS: Thirty interviews were conducted with pharmacists (n=19) and medicine counter assistants (MCAs) (n=11). Eight salient domains were identified: environmental context and resources (privacy), beliefs about consequences (patient safety), skills (communication, decision-making), social influences (patient awareness of pharmacist role), knowledge (awareness and use of standard operating procedures), social professional role and identity (perception of own role), behavioural regulation (training) and intention (to gather information). Similar domains were salient for pharmacists and MCAs; however, different beliefs were associated with different roles. Overarching themes were identified: best practice, health literacy, decision-making and professionalism. CONCLUSIONS: Multiple influences and complexities affect the effective management of OTC consultations. While similar factors impact on both pharmacists and MCAs at a patient, professional and environmental level, subtle differences exist in how these influence their management of OTC consultations. This study highlights the importance of tailoring interventions to reflect different roles, functions and responsibilities of community pharmacy personnel.

Patient-, organization-, and system-level barriers and facilitators to preventive oral health care: a convergent mixed-methods study in primary dental care.

BACKGROUND: Dental caries is the most common chronic disease of adult and childhood, a largely preventable yet widespread, costly public health problem. This study identified patient-, organization-, and system-level factors influencing routine delivery of recommended care for prevention and management of caries in primary dental care. METHODS: A convergent mixed-methods design assessed six guidance-recommended behaviours to prevent and manage caries (recording risk, risk-based recall intervals, applying fluoride varnish, placing preventive fissure sealants, demonstrating oral health maintenance, taking dental x-rays). A diagnostic questionnaire assessing current practice, beliefs, and practice characteristics was sent to a random sample of 651 dentists in National Health Service (NHS) Scotland. Eight in-depth case studies comprising observation of routine dental visits and dental team member interviews were conducted. Patient feedback was collected from adult patients with recent checkups at case study practices. Key informant interviews were conducted with decision makers in policy, funding, education, and regulation. The Theoretical Domains Framework within the Behaviour Change Wheel was used to identify and describe patient-, organization-, and system-level barriers and facilitators to care. Findings were merged into a matrix describing theoretical domains salient to each behaviour. The matrix and Behaviour Change Wheel were used to prioritize behaviours for change and plan relevant intervention strategies. RESULTS: Theoretical domains associated with best practice were identified from the questionnaire (N-196), case studies (N = 8 practices, 29 interviews), and patient feedback (N = 19). Using the study matrix, key stakeholders identified priority behaviours (use of preventive fissure sealants among 6-12-year-olds) and strategies (audit and feedback, patient informational campaign) to improve guidance implementation. Proposed strategies were assessed as appropriate for immediate implementation and suitable for development with remaining behaviours. CONCLUSIONS: Specific, theoretically based, testable interventions to improve caries prevention and management were coproduced by patient-, practice-, and policy-level stakeholders. Findings emphasize duality of behavioural determinants as barriers and facilitators, patient influence on preventive care delivery, and benefits of integrating multi-level interests when planning interventions in a dynamic, resource-constrained environment. Interventions identified in this study are actively being used to support ongoing implementation initiatives including guidance, professional development, and oral health promotion.

The translation research in a dental setting (TRiaDS) programme protocol.

BACKGROUND: It is well documented that the translation of knowledge into clinical practice is a slow and haphazard process. This is no less true for dental healthcare than other types of healthcare. One common policy strategy to help promote knowledge translation is the production of clinical guidance, but it has been demonstrated that the simple publication of guidance is unlikely to optimise practice. Additional knowledge translation interventions have been shown to be effective, but effectiveness varies and much of this variation is unexplained. The need for researchers to move beyond single studies to develop a generalisable, theory based, knowledge translation framework has been identified.For dentistry in Scotland, the production of clinical guidance is the responsibility of the Scottish Dental Clinical Effectiveness Programme (SDCEP). TRiaDS (Translation Research in a Dental Setting) is a multidisciplinary research collaboration, embedded within the SDCEP guidance development process, which aims to establish a practical evaluative framework for the translation of guidance and to conduct and evaluate a programme of integrated, multi-disciplinary research to enhance the science of knowledge translation. METHODS: Set in General Dental Practice the TRiaDS programmatic evaluation employs a standardised process using optimal methods and theory. For each SDCEP guidance document a diagnostic analysis is undertaken alongside the guidance development process. Information is gathered about current dental care activities. Key recommendations and their required behaviours are identified and prioritised. Stakeholder questionnaires and interviews are used to identify and elicit salient beliefs regarding potential barriers and enablers towards the key recommendations and behaviours. Where possible routinely collected data are used to measure compliance with the guidance and to inform decisions about whether a knowledge translation intervention is required. Interventions are theory based and informed by evidence gathered during the diagnostic phase and by prior published evidence. They are evaluated using a range of experimental and quasi-experimental study designs, and data collection continues beyond the end of the intervention to investigate the sustainability of an intervention effect. DISCUSSION: The TRiaDS programmatic approach is a significant step forward towards the development of a practical, generalisable framework for knowledge translation research. The multidisciplinary composition of the TRiaDS team enables consideration of the individual, organisational and system determinants of professional behaviour change. In addition the embedding of TRiaDS within a national programme of guidance development offers a unique opportunity to inform and influence the guidance development process, and enables TRiaDS to inform dental services practitioners, policy makers and patients on how best to translate national recommendations into routine clinical activities.

Can't do it, won't do it! Developing a theoretically framed intervention to encourage better decontamination practice in Scottish dental practices.

BACKGROUND: Guidance on the cleaning of dental instruments in primary care has recently been published. The aims of this study are to determine if the publication of the guidance document was enough to influence decontamination best practice and to design an implementation intervention strategy, should it be required. METHODS: A postal questionnaire assessing current decontamination practice and beliefs was sent to a random sample of 200 general dental practitioners. RESULTS: Fifty-seven percent (N = 113) of general dental practitioners responded. The survey showed large variation in what dentists self-reported doing, perceived as necessary or practical to do, were willing to do, felt able to do, as well as what they planned to change. Only 15% self-reported compliance with the five key guideline-recommended individual-level decontamination behaviours; only 2% reported compliance with all 11 key practice-level behaviours. The results also showed that our participants were almost equally split between dentists who were completely unmotivated to implement best decontamination practice or else highly motivated. The results suggested there was scope for further enhancing the implementation of decontamination guidance, and that an intervention with the greatest likelihood of success would require a tailored format, specifically targeting components of the theory of planned behaviour (attitude, perceived behavioural control, intention) and implementation intention theory (action planning). CONCLUSION: Considerable resources are devoted to encouraging clinicians to implement evidence-based practice using interventions with erratic success records, or no known applicability to a specific clinical behaviour, selected mainly by means of researchers' intuition or optimism. The methodology used to develop this implementation intervention is not limited to decontamination or to a single segment of primary care. It is also in accordance with the preliminary stages of the framework for evaluating complex interventions suggested by the medical research council. The next phases of this work are to test the intervention feasibility and evaluate its effectiveness in a randomised control trial.