Behaviour support in dentistry: A Delphi study to agree terminology in behaviour management.

OBJECTIVES: Dental behaviour support (DBS) describes all specific techniques practiced to support patients in their experience of professional oral healthcare. DBS is roughly synonymous with behaviour management, which is an outdated concept. There is no agreed terminology to specify the techniques used to support patients who receive dental care. This lack of specificity may lead to imprecision in describing, understanding, teaching, evaluating and implementing behaviour support techniques in dentistry. Therefore, this e-Delphi study aimed to develop a list of agreed labels and descriptions of DBS techniques used in dentistry and sort them according to underlying principles of behaviour. METHODS: Following a registered protocol, a modified e-Delphi study was applied over two rounds with a final consensus meeting. The threshold of consensus was set a priori at 75%. Agreed techniques were then categorized by four coders, according to behavioural learning theory, to sort techniques according to their mechanism of action. RESULTS: The panel (n = 35) agreed on 42 DBS techniques from a total of 63 candidate labels and descriptions. Complete agreement was achieved regarding all labels and descriptions, while agreement was not achieved regarding distinctiveness for 17 techniques. In exploring underlying principles of learning, it became clear that multiple and differing principles may apply depending on the specific context and procedure in which the technique may be applied. DISCUSSION: Experts agreed on what each DBS technique is, what label to use, and their description, but were less likely to agree on what distinguishes one technique from another. All techniques were describable but not comprehensively categorizable according to principles of learning. While objective consistency was not attained, greater clarity and consistency now exists. The resulting list of agreed terminology marks a significant foundation for future efforts towards understanding DBS techniques in research, education and clinical care.

Does education in special care dentistry increase people's confidence to manage the care of a more diverse population?

Education in Special Care Dentistry (SCD) at undergraduate and postgraduate levels is often limited when compared with other dental specialities, even though dental professionals encounter people with Special Healthcare Needs (SHCNs) on a very regular basis. This literature review examined whether education at undergraduate and postgraduate level increases dental students' and professionals' confidence in managing a patient with SHCN. It also appraised whether there was a correlation between increased practitioner confidence and increased quality of care for people with SHCN. This review also examined educational efforts worldwide, and whether there is an increased emphasis on providing education in SCD to dental students. It was found that those who received high-quality practical and theoretical education on how to properly manage patients with SHCN reported having higher levels of confidence than those who did not. People also reported being far more likely to employ the proper behavior management techniques and were more likely to treat people with SHCN regularly. There has been an increased emphasis on providing education in SCD worldwide in recent years, but a number of barriers still exist to providing complete education in the area.

A need to increase von Willebrand disease awareness: vwdtest.com - A global initiative to help address this gap.

Von Willebrand disease (VWD) is an inherited bleeding disorder caused by quantitative or qualitative deficiencies in von Willebrand factor (VWF). People with VWD may experience excessive, recurrent or prolonged bleeding, particularly during menstruation, childbirth, surgery or following trauma. However, many VWD patients are undiagnosed, and therefore inadequately treated. Reasons for the underdiagnosis of VWD include its relatively mild symptoms, complex diagnosis, lack of awareness among non-specialist healthcare providers and the general population, and a lack of prioritisation of disorders disproportionately affecting females. The vwdtest.com platform was launched as part of a global initiative to raise awareness and improve diagnosis of VWD. Besides providing VWD-specific educational resources, the website includes an online bleeding self-assessment tool and offers diagnostic support for individuals, and their providers, who have a score suggestive of a bleeding disorder. vwdtest.com helps to address these unmet needs, especially in regions with limited access to educational and diagnostic resources.

Management of dental caries lesions in patients with disabilities: Update of a systematic review.

The aim of this systematic review was to update an existing review on the management of dental caries lesions in patients with disabilities so as to provide an up-to-date summary of the evidence. Randomized clinical trials and cohort studies related to preventive and restorative programmes for dental caries among people requiring special care, published in English, Spanish, Portuguese, French and German languages from February 1st 2011 to April 1st 2022, were retrieved from three databases ("updated review"). From the 1,105 titles identified using the search topic "Caries AND Disability", 17 papers informed in the analyses: 6 referring to caries preventive strategies and 11 related to restorative care strategies. Most of these studies targeted children and adults with intellectual/physical disability, although preventive and therapeutic strategies were also reported for frail older adults and onchohematological patients. Fluorides in tablets, gels or varnishes forms and the use of xylitol as a sugar substitute were reported as effective approach to prevent the onset of caries in high-risk groups. Minimally intervention treatment options such as the Hall technique, the ART approach and the use of SDF for arresting caries, were deemed suitable and effective strategies for treating existing lesions in-office. In conclusion, in the past decade (2011-2022) an increased number of articles reported strategies to prevent and manage caries among people requiring special care. Although an array of preventive and therapeutic strategies for dental caries exists, more and better-quality clinical evidence is needed to offer guidance to inform policy and practice for special care dentistry.

Single centre, real-world experience of perioperative rFIXFc use in adult patients with haemophilia B undergoing major and minor surgery.

INTRODUCTION: Recombinant factor IX fusion protein concentrate (rFIXFc) is increasingly used for prophylaxis in people with haemophilia B (PWHB), but experience in the perioperative setting is limited. AIMS: To evaluate real-world perioperative factor usage, bleeding and complications in PWHB (≥18 years) who received rFIXFc for surgical haemostasis and to describe the treatment regimens used. METHODS: Single centre, retrospective review of all PWHB who underwent a major or minor surgical procedure between June 2017 and July 2020 and received rFIXFc perioperatively for maintenance of surgical haemostasis. RESULTS: A total of 56 PWHB (45 male and 11 female), including people with mild (n = 32), moderate (n = 4) and severe (n = 20) haemophilia B, underwent 11 major and 131 minor procedures with rFIXFc for surgical haemostasis. Haemostasis was rated as excellent (9/11) or good (2/11) in all major procedures. Median total rFIXFc consumption for orthopaedic surgeries was 972 IU/kg (range 812-1031 IU/kg) and for other major (non-orthopaedic) surgeries was 323 IU/kg (range 167-760 IU/kg). The median number of perioperative rFIXFc infusions was 19 (range 17-26) for orthopaedic surgery and 7 (range 5-17) for other major surgeries. The number of infusions in the postoperative period was determined by procedure and patient factors. Complications included bowel ileus and wound infection. Most minor procedures were managed with single infusion of rFIXFc, with no bleeding complications in 95% of minor procedures. There were no thromboembolic events or inhibitor formation. CONCLUSION: This unique data provides real-world evidence that rFIXFc is safe and effective in achieving haemostasis in PWHB undergoing surgery.

The Impact of the First Wave of the COVID-19 Pandemic on Providing Special Care Dentistry: A Survey for Dentists.

This study aimed to investigate the impact of COVID-19 on the experiences of special care dentistry providers worldwide. An online survey was administered from 10 to 31 July 2020. Age, sex, years of professional activity, COVID-19 status, geographical area of origin and length of lockdown period were recorded for all participating dentists. The relationships between these variables and the changes in clinical activity, the treated patients' COVID-19 status and the implementation of protective measures in the dental clinic were analyzed. A total of 436 (70.6% women) dentists from 59 countries responded to the survey. Clinical activity was reduced or stopped for 79.1% of respondents. The most common change was to limit treatment to urgent care only (53.7%). Treatment under general anesthesia or deep sedation was discontinued (51.0%) or reduced (35.8%) for the majority of respondents. Male dentists were more likely to maintain their clinical activity than female dentists (p < 0.001), and respondents from North America were more likely to do so than participants from other geographical regions (p < 0.001). Dentists from Latin America and the Caribbean were more likely to report treatment of confirmed cases of COVID-19 than those from Europe (p < 0.001). The implementation of protective measures in the dental office was determined by the survey participant's sex, intensity of clinical activity and geographical area of origin. To conclude, the provision of special care dentistry was considerably reduced in response to the pandemic. Service maintenance was mainly related to the geographical area in which the surveyed dentists worked, further exacerbating pre-existing inequalities.

Management of elective procedures in low von Willebrand factor patients in the LoVIC study.

BACKGROUND: Most individuals with mild to moderate reductions in plasma von Willebrand factor (VWF) levels do not demonstrate increased bleeding. However, some patients with plasma VWF levels of 30-50 IU/dl do have a significant bleeding phenotype. Management of these "low VWF" patients, who may have significant bleeding scores >10, around times of elective procedures continues to pose a common clinical challenge because of a lack of evidence. OBJECTIVE: To investigate the safety and efficacy of different periprocedural management options for adult patients with low VWF. METHODS: Treatment and outcomes were retrospectively reviewed for 160 invasive procedures performed in 60 patients with well characterized low VWF enrolled in the previously described Low Von Willebrand factor Ireland Cohort study. RESULTS: We demonstrate that 1-desamino-8-D-arginine vasopressin is efficacious in preventing bleeding for both minor or major elective procedures in adult low VWF patients, even in those with significant bleeding histories. In addition, tranexamic acid alone is effective for low VWF patients undergoing nondental minor procedures. Importantly, age-related increases in plasma VWF:antigen levels above 50 IU/dl were not necessarily associated with complete correction of bleeding phenotype. Procedure-related bleeding complications were increased in low VWF patients who did not receive any hemostatic cover before their procedure. CONCLUSION: Elective procedures in adult patients with low VWF should be managed in liaison with a comprehensive care tertiary referral center so that personalized treatment plans may be implemented before all minor or major elective procedures.

Telehealth for delivery of haemophilia comprehensive care during the COVID-19 pandemic.

INTRODUCTION: The COVID-19 pandemic caused an unprecedented impact to haemophilia healthcare delivery. In particular, rapid implementation of telehealth solutions was required to ensure continued access to comprehensive care. AIMS: To explore patient and healthcare provider (HCP) experience of telehealth in a European Haemophilia Comprehensive Care Centre. METHOD: A systematic evaluation was performed to survey patient and HCP experience and compare clinical activity levels with telehealth to in-person attendances. RESULTS: Public health measures implemented in March 2020 to reduce COVID-19 spread resulted in a 63% decrease in medical/nursing clinic consultation activity compared to the same period in 2019. Implementation of digital care pathways resulted in marked increase in activity (52% greater than 2019). Importantly, enhanced patient engagement was noted, with a 60% reduction in non-attendance rates. Survey of patients who had participated in medical/nursing teleconsultations demonstrated that teleconsultations improved access (79%), reduced inconvenience (82%), was easy to use (94%) and facilitated good communication with the HCP (97%). A survey exploring the telemedicine experience of HCPs, illustrated that HCPs were satisfied with teleconsultation and the majority (79%) would like to continue to offer teleconsultation as part of routine patient care. In addition to medical/nursing reviews, continued access to physiotherapy with virtual exercise classes for people with haemophilia and teleconsultation for acute dental issues was equally successful. CONCLUSION: During an unprecedented public health emergency, telehealth has enabled continued access to specialized haemophilia comprehensive care. Our novel findings show that this alternative is acceptable to both patients and HCPs and offers future novel opportunities.

Current state of play regarding dental extractions in patients with haemophilia: Consensus or evidence-based practice? A review of the literature.

Due to the global prevalence of oral disease, tooth extraction is the most common surgical procedure required in general population thus likely to be similarly common in patients with haemophilia, especially those in older age and those living in countries with restricted resources. There are little or no consensus about optimal level and duration of factor replacement (FRP) therapy required to prevent bleeding complication following surgery and low levels of evidence to inform protocols and guidelines. The goal of this article was to review the literature regarding haematological treatment protocols and to assess their effectiveness in prevention of bleeding complications during and after tooth extractions in people with haemophilia. A total number of 29 articles were identified. Only two of the studies were randomized controlled trials, and meta-analysis was not possible. Significant heterogeneity regarding haematological regimes, dental surgical procedures, disease severity and sample size of published studies which are unable to reliably inform the provision of safe dental surgery was noted. Based on the haematological regimens, all studies were classified into one of three groups: pre- and postoperative FRP or DDAVP, single preoperative FRP or DDAVP, and no FRP treatment. The overall reported bleeding rate in case of both pre- and postoperative FRP and single dose FRP preoperative is similar, 11.9% and 11.4%, respectively, indicating that minimizing the use of clotting factor concentrate is possible if proper local haemostatic measures are provided. Strictly designed prospective studies with higher number of patients are necessary to get firm conclusions about optimal FRP treatment required to prevent bleeding complications during and after oral surgery in patients with haemophilia.

Safety of buccal infiltration local anaesthesia for dental procedures.

AIM: To assess the safety of buccal infiltration local anaesthetic (LA) without additional factor replacement in patients with haemophilia (PWH) and association with clinical experience of the operator. METHODS: A consecutive sample of participants with mild, moderate and severe haemophilia scheduled to have dental treatment were recruited from a comprehensive care centre in Ireland. Infiltration LA was administered using a standard technique. Safety was defined as any adverse event at time of administration, immediate postoperative, or postoperative period. Clinical experience was dichotomized into fewer or greater than three years clinical experience. RESULTS: N = 135 buccal infiltration LAs without additional factor replacement were provided to N = 71 participants with mild (n = 20; 28%) and moderate to severe haemophilia (n = 51; 72%). Successful local anaesthesia was achieved in n = 133 cases (99%). No (0%) adverse bleeding events were recorded for any participants at time of administration of LA or during follow-up. Three out of 135 (2.2%) LAs recorded superficial bleeding 30 seconds after administration of LA, all of which resolved within 2 minutes with application of pressure; 4 out of 135 (3%) LAs produced a superficial haematoma at the site of injection no greater than 2 mm all of which resolved at 4 minutes. There were no differences in bleeding rates between clinicians by level of experience (P = 0.435) or by severity of bleeding disorder (P = 1.0). CONCLUSION: Local anaesthetic is safe to administer via buccal infiltration for people with mild, moderate and severe haemophilia without additional factor cover. This finding holds true regardless of operator experience.

U.K. hemophilia treaters' knowledge of risk assessment for prolonged bleeding associated with dental procedures.

INTRODUCTION: Optimal delivery of dental care for adults with congenital bleeding disorders (CBD) requires close collaboration between hemophilia treaters and dentists. AIM: To explore U.K. hemophilia treaters' knowledge of dental procedures and associated hemostatic management in adults with CBD. METHOD: Staff (N = 180) from N = 60 hemophilia facilities in the United Kingdom were invited to participate in a questionnaire-based study using a web-based tool. The questionnaire assessed participants' knowledge, adherence and appropriateness of application of U.K. guidance on hemostatic management of common dental procedures. RESULTS: The response rate was 23% of treaters (n = 41) from 62% (n = 32) hemophilia facilities. Individual participants (87%; n = 34) reported they adhered to guidelines, though knowledge of guidance was poor with only 36% (n = 15) applying guidance appropriately in 3 common dental scenarios. There was a tendency for participants to assign the use of systemic hemostatic measures independent of the agreed bleeding risk associated with the proposed dental procedure. CONCLUSION AND RECOMMENDATIONS: While hemophilia treaters were aware of current guidelines, their knowledge of the guidelines and ability to risk assess dental procedures was poor. There was a tendency to overprescribe systemic hemostatic measures for dental procedures. Education initiatives to aid decision making are needed.

Identifying common factors of functioning, participation and environment amongst adults requiring specialist oral health care using the International Classification of Functioning, disability and health.

INTRODUCTION: Persons unable to access oral health care in the conventional primary health care setting suffer from inequalities in oral health, particularly in terms of unmet dental need. The International Classification of Functioning, disability and health (ICF) is designed to look beyond medical diagnosis and to describe individuals or populations in terms of their ability to function and participate in a social environment. The objective of the study was to describe an adult population requiring specialist oral health care using the ICF and to identify common factors of functioning, participation and environmental context. METHOD: The ICF Checklist for Oral Health was completed for 246 participants from five specialist dental services in five countries (mean age 36 ±16.44 years; 16-92). 'Developmental disability' and 'Medically compromised' groups were identified (72% and 28%). RESULTS: Participants presented with oral disease (92%) and dysfunction (66% impaired chewing). 33 ICF items were affected in over 50% of participants in both groups. Impaired body functions included 'ingestion functions', 'energy and drive functions' and 'emotional functions'. Participation was restricted for "Acquiring, keeping and terminating a job", "Intimate relationships", "Handling stress and psychological demands", "Economic self-sufficiency", "Carrying out a daily routine", "Recreation and leisure", "Community life" and "Looking after one's health". In the environment domain, "Support and relationships" and "Attitudes" were rated as facilitators. Environmental barriers reported for over 25% of the whole group were related to "Services, systems and policies" including, health, social security, general support, transportation, and labour and employment. DISCUSSION AND PERSPECTIVES: Common aspects of functioning, participation and environment were found amongst a heterogeneous population of adults attending specialist dental services, alongside poor oral health and function. The ICF may be used to describe populations that suffer inequality in oral health in order to develop services that effectively target those in need of additional means.

Child oral health from the professional perspective - a global ICF-CY survey.

BACKGROUND: The International Classification of Functioning, Disability and Health Children and Youth version (ICF-CY) (WHO) may serve as a tool for the application of holistic models of oral health. AIM: The ICF-CY Global Oral Health Survey explored international professional opinion regarding factors relating to child oral health, including social environment, functioning, activity, and participation. METHODS: Networking resulted in 514 professionals from 81 countries registering for a two-round Delphi survey online. Participants were pooled into 18 groups according to six WHO world regions and three professional groups. In a randomized stratification process, eight from each pool (n = 144) completed the survey. The first round consisted of eight open-ended questions. Open-expression replies were analysed for meaningful concepts and linked using established rules to the ICF-CY. In the second round, items were rated for their relevance to oral health (86% response rate). RESULTS: A total of 86 ICF-CY items and 31 other factors were considered relevant to child oral health and function by at least 80% of professionals. CONCLUSIONS: The ICF-CY can describe the holistic experience of oral health in children from the professional perspective. The data from this study will contribute to the development of an ICF-CY Core Set in Oral Health.

A Global Oral Health Survey of professional opinion using the International Classification of Functioning, Disability and Health.

OBJECTIVES: The concept of oral health is frequently reduced to the absence of disease, despite existing conceptual models exploring the wider determinants of oral health and quality of life. The International Classification of Functioning, Disability and Health (ICF) (WHO) is designed to qualify functional, social and environmental aspects of health. This survey aimed to reach a consensual description of adult oral health, derived from the ICF using international professional opinion. METHODS: The Global Oral Health Survey involved a two-round, online survey concerning factors related to oral health including functioning, participation and social environment. Four hundred eighty-six oral health professionals from 74 countries registered online. Professionals were pooled into 18 groups of six WHO world regions and three professional groups. In a randomised stratification process, eight professionals from each pool (n=144) completed the survey. The first round consisted of eight open-ended questions. Open expression replies were analysed for meaningful concepts and linked using established rules to the ICF. In Round 2, items were rated for their relevance to oral health (88% response rate). RESULTS: Eighty-nine ICF items and 30 other factors were considered relevant by at least 80% of participants. International professionals reached consensus on a holistic description of oral health, which could be qualified and quantified using the ICF. CONCLUSIONS: These results represent the first step towards developing an ICF Core Set in Oral Health, which would provide a practical tool for reporting outcome measures in clinical practice, for research and epidemiology, and for the improvement of interdisciplinary communication regarding oral health. CLINICAL SIGNIFICANCE: Professional consensus reached in this survey is the foundation stone for developing an ICF Core Set in Oral Health, allowing the holistic aspects of oral health to be qualified and quantified. This tool is necessary to widen our approach to clinical decision making, measurement of clinical outcomes, research and epidemiology.

What should dental services for people with disabilities be like? Results of an Irish Delphi panel survey.

BACKGROUND: This study aimed to generate prioritised goals for oral health services for people with disabilities as a first step in meeting the need for evidence based oral health services for people with disabilities in Ireland. METHODS: The study used a three round modified e-Delphi method, involving dental service professionals and people with disabilities or their representatives, in Ireland. Three rounds were completed online using SurveyMonkey. Round 1 asked: "List what you think dental services for people with disabilities in Ireland should be like." Items for subsequent rounds were generated from responses to Round 1. Round 2 and Round 3 used 5 point Likert scales to rank these items by priority: from No Priority (1) to Top Priority (5). Consensus was achieved on each item where at least 80% of respondents considered an item either High or Top Priority. A consensus meeting concluded the process. RESULTS: Sixty-one panelists started and 48 completed the survey. The Delphi panel agreed on level of priority for 69 items and generated 16 consensus statements. These statements covered a range of topics such as access to care, availability of information and training, quality of care, dental treatment and cost. A recurrent theme relating to the appropriateness of care to individual need arose across topics suggesting a need to match service delivery according to the individual's needs, wants and expectations rather than the disability type/diagnosis based service which predominates today. CONCLUSIONS: This process produced a list of prioritised goals for dental services for people with disabilities. This creates a foundation for building evidence-based service models for people with disabilities in Ireland.

Outcomes from the first mouth cancer awareness and clinical check-up day in the Dublin Dental University Hospital.

PURPOSE OF THE STUDY: To increase public awareness about mouth cancer, the Dublin Dental University Hospital (DDUH) hosted an awareness day and free mouth check-up in September 2010. The messages of information, self-examination and risk management, and the importance of early detection, were available to all attendees. The role of general dental and medical practitioners in examination of the mouth was stressed. MATERIAL AND METHODS: A questionnaire regarding knowledge about the causes of and risk factors for mouth cancer, and a clinical check-up, were completed. RESULTS: A total of 1,661 individuals (675 male, 986 female) were examined. The mean age was 59.6 years. Just over one-third (36.5%) of those examined required no action, and slightly less (30%) were advised to return to their general dental or medical practitioner (GDP/GMP). Some 21% were advised about self-examination of the mouth, and 8% about smoking cessation. Of the remainder, 52 people (3.5%) were sent for a second opinion. Of these, 30 individuals were referred for further investigation, including biopsy in 27 cases. Following biopsy, five individuals were diagnosed with carcinoma in situ or carcinoma. CONCLUSIONS: The diagnosis of five people with mouth cancers, who may not otherwise have been identified for early treatment, highlights the need for regular mouth examination. It is inappropriate that such an exercise would remain the preserve of the dental teaching hospitals, and it is vital that all dentists take on the responsibility for regular mouth checks for all of their patients. More should be done to encourage those identified as high risk to visit their dentist. There is a need for recognition of the additional resources required for the detection and timely management of such cancers.