Health workforce for oral health inequity: Opportunity for action.

Oral health is high on the global agenda following the adoption of the 2022 global strategy on oral health at the 75th World Health Assembly. Given the global burden of oral disease, workforce development to achieve universal health coverage [UHC] is crucial to respond to population needs within the non-communicable disease agenda. The aim of this paper is to present an overview of the oral health workforce [OHWF] globally in relation to key contextual factors. Data from the National Health Workforce Accounts and a survey of World Health Organization [WHO] member states were integrated for analysis, together with country-level data on population and income status. Data are presented using the WHO categorisation of global regions and income status categories established by the World Bank. Workforce densities for key OHWF categories were examined. Multiple regression was used to model workforce density and contextual influences. Challenges and possible solutions were examined by country income status. There are approximately 3.30 dentists per 10,000 population globally, and a combined OHWF [dentists, dental assistants/therapists and dental prosthetic technicians] of 5.31 per 10,000. Marked regional inequalities are evident, most notably between WHO European and African regions; yet both make greater use of skill mix than other regions. When adjusted by region, 'country income status' and 'population urbanization' are strong predictors of the workforce density of dentists and even more so for the combined OHWF. Maldistribution of the workforce [urban/rural] was considered a particular workforce challenge globally and especially for lower-income countries. Strengthening oral health policy was considered most important for the future. The global distribution of dentists, and the OHWF generally, is inequitable, with variable and limited use of skill mix. Creative workforce development is required to achieve the global oral health agenda and work towards equity using innovative models of care, supported by effective governance and integrated policies.

Health system strengthening in fragile and conflict-affected states: A review of systematic reviews.

BACKGROUND: Globally, there is growing attention towards health system strengthening, and the importance of quality in health systems. However, fragile and conflict-affected states present particular challenges. The aim of this study was to explore health system strengthening in fragile and conflict-affected states by synthesising the evidence from published literature. METHODS: We conducted a review of systematic reviews (Prospero Registration Number: CRD42022371955) by searching Ovid (Medline, Embase, and Global Health), Scopus, Web of Science, and the Cochrane Library databases. Only English-language publications were considered. The Joanna Briggs Institute (JBI) Critical Appraisal Tool was employed to assess methodological quality of the included studies. The findings were narratively synthesised and presented in line with the Lancet's 'high-quality health system framework'. RESULTS: Twenty-seven systematic reviews, out of 2,704 identified records, considered key dimensions of health systems in fragile and conflict-affected states, with the 'foundations' domain having most evidence. Significant challenges to health system strengthening, including the flight of human capital due to safety concerns and difficult working conditions, as well as limited training capacities and resources, were identified. Facilitators included community involvement, support systems and innovative financing mechanisms. The importance of coordinated and integrated responses tailored to the context and stage of the crisis situation was emphasised in order to strengthen fragile health systems. Overall, health system strengthening initiatives included policies encouraging the return and integration of displaced healthcare workers, building local healthcare workers capacity, strengthening education and training, integrating healthcare services, trust-building, supportive supervision, and e-Health utilisation. CONCLUSION: The emerging body of evidence on health system strengthening in fragile and conflict-affected states highlights its complexity. The findings underscore the significance of adopting a comprehensive approach and engaging various stakeholders in a coordinated manner considering the stage and context of the situation.

A typology of internationally qualified dentists in the United Kingdom.

Introduction: The Global Strategy for Human Resources for Health 2030, requires member states to half their dependency on an international workforce by 2030. In order to design policies towards that goal, country-specific research on migration motivations of the health workforce is required. The United Kingdom (UK) is a net importer of health professionals and whilst there is a body of research on doctors' and nurses' migration, there is no research on the migration motivations of migrant dentists in the UK. This research explored the migration motivations of internationally qualified dentists (IQDs) in the UK and presents a typology to understand the global migration of dentists in the context of oral health workforce. Methods: The paper presents qualitative data from semi-structured interviews conducted between August 2014 and October 2017, of IQDs working in the United Kingdom. The topic guide for interviews was informed by the literature, with new themes added inductively. A phenomenological approach involving an epistemological stance of interpretivism, was used with framework analysis. Results: A total of 38 internationally qualified dentists (M = 18, F = 20), migrating from the five World Health Organization regions, and working in general practice, NHS hospitals and in community dental services across the four nations of the UK were interviewed. Seven types of internationally qualified dentists were identified working in the UK. They were livelihood migrants, career-orientated migrants, dependant migrants, backpacker migrants, commuter migrants, undocumented migrants, and education-tourist migrant. The categories were based on their migration motivations, which were complex, multifactorial, and included personal, professional, national, and international drivers. The typology, based on their migration motivations, offered a structured, comprehensive understanding of the migrant dental workforce. This typology involving dentists provides additional dimensions to commuter and undocumented migrants described in the context of other health professionals. The education-tourist migrant is a new category proposed as an extension to existing typology in health professional migration. Conclusions: The typology of internationally qualified dentists has congruency with other health professionals' typology in categories previously described and demonstrates that each of these categories are complex, fluid and change in response to policy changes. The new category of education-tourist migrant along with oral health dimensions of commuter and undocumented migrants adds to the existing typology in health professional migration.

Perceptions of Surgical Drains Among Breast Reconstruction Patients and Health Care Staff: A Qualitative Survey Study.

BACKGROUND: Surgical drains are a key component for recovery in breast reconstruction procedures. However, they are often cumbersome and carry a risk for infection with prolonged use. Our aim was to develop a more thorough understanding of patient and health care provider perspectives on surgical drains, to inform future efforts in improving the breast reconstruction patient experience. METHODS: Twenty-nine breast reconstruction patients and eight plastic surgery providers were recruited to complete surveys focused on surgical drains. Likert scales ranging from 1-5 were developed to gauge how bothersome drains felt, as well as concern for infection. Ordinal variable and categorical multiple-choice analyses were applied as appropriate. RESULTS: Fifteen (51.7%) patients underwent implant-based breast reconstruction, and 14 (48.3%) patients underwent autologous breast reconstruction. The most common duration of drain placement was two weeks (N=13). The surgical site infection rate requiring antibiotics was 28% (N=8). On a scale of 1-5, both patients (median = 3) and providers (median = 2.5) viewed drains as bothersome. Patients were "frequently" concerned about infection risk (median = 3). Other high-frequency patient concerns included general pain and discomfort. CONCLUSIONS: Surgical drains are a common component of breast reconstruction procedures and are viewed as cumbersome by both patients and providers. Patients expressed concerns about drain site pain, discomfort, and tugging on clothing. Patients and providers both believed that drains could contribute to surgical site infection. Overall, this data provides insight to drive future improvements in the patient drain experience.

Impact of dental visiting patterns on oral health: A systematic review of longitudinal studies.

AIM: To systematically review longitudinal studies investigating the impact of dental visiting patterns on oral health across the life course. METHODS: Five databases (MEDLINE, Embase, Scopus, Web of Science, CINAHL) were searched up to March 2023. Results were screened based on eligibility criteria in a two-stage process: title and abstract, and full-text review. A backward search of reference lists and a forward search of citations of the included papers was also conducted. The quality of the included papers was assessed using the Newcastle-Ottawa Scale. Key study information was extracted and a narrative synthesis of the findings was performed. RESULTS: Eleven papers from five longitudinal studies in five countries (Australia, Brazil, China, New Zealand, Sweden) met the inclusion criteria. Studies of moderate to high quality consistently reported that regular dental attendance was associated with having less dental caries experience, fewer missing teeth and better oral health-related quality of life. Inconsistent findings were observed for decayed teeth, and no association was found for periodontal condition. CONCLUSIONS: This review highlights an association between regular dental visiting pattern and improved oral health, notably less dental caries experience and better oral health-related quality of life. Dental attendance emerges as an important predictor of oral health across the life course, underscoring the importance of routine dental care. REGISTRATION INFORMATION: The PROSPERO registration number is CRD42023396380.

How to have healthy conversations: Contemporary Evidence and Behaviour Change Tools in support of Delivering Better (Oral) Health.

The aim of this paper is to provide dental professionals with insight into how the science of behaviour change can be used to support patients to change their oral health behaviours. The paper describes how the fourth version of Delivering Better Oral Health (DBOHv4) published in November 2021, brings together the theory plus key principles and practical tools in Chapter 3 "Behaviour change", to help front-line clinicians achieve the best effect. DBOH is freely available to all online at gov.uk and is a key resource for dental teams for the prevention of oral diseases.

A color-based tumor segmentation method for clinical ex vivo breast tissue assessment utilizing a multi-contrast brightfield imaging strategy.

We demonstrate an automated two-step tumor segmentation method leveraging color information from brightfield images of fresh core needle biopsies of breast tissue. Three different color spaces (HSV, CIELAB, YCbCr) were explored for the segmentation task. By leveraging white-light and green-light images, we identified two different types of color transformations that could separate adipose from benign and tumor or cancerous tissue. We leveraged these two distinct color transformation methods in a two-step process where adipose tissue segmentation was followed by benign tissue segmentation thereby isolating the malignant region of the biopsy. Our tumor segmentation algorithm and imaging probe could highlight suspicious regions on unprocessed biopsy tissue to guide selection of areas most similar to malignant tissues for tissue pathology whether it be formalin fixed or frozen sections, expedite tissue selection for molecular testing, detect positive tumor margins, or serve an alternative to tissue pathology, in countries where these services are lacking.

Red cell transfusion thresholds in outpatients with myelodysplastic syndromes: Results of a pilot randomized trial RBC-ENHANCE.

BACKGROUND: The optimal hemoglobin (Hb) threshold for red blood cell transfusions in adult patients with myelodysplastic syndromes (MDS) has not been defined. STUDY DESIGN AND METHODS: We conducted a pilot randomized multi-center study of two transfusion algorithms (liberal, to maintain Hb 110-120 g/L, transfuse 2 units if Hb < 105 g/L and 1 unit if Hb 105-110 g/L vs. restrictive, 85-105 g/L, transfuse 2 units when Hgb < 85 g/L). Primary objectives were 70% compliance in maintaining the q2 week hemoglobin within the targeted range and the achievement of a 15 g/L difference in pre-transfusion Hb. Secondary outcomes included measures of quality of life (QOL), iron studies and safety. RESULTS: Twenty-eight patients were randomized between February 2015-2020, 13 to the restrictive arm and 15 to the liberal arm in three tertiary care centers. The compliance was 66% and 45% and the mean pre-transfusion Hb thresholds were 86 (standard deviation [SD] 8) and 98 g/L (SD 10) in the restrictive and liberal arms, (mean difference 11.8 g/L, p < .0001), respectively. Patients in the liberal arm experienced a mean of 3.4 (SD 2.6) more transfusion visits and received a mean of 5.3 (SD 5.5) more units of blood during the 12-week study. Ferritin increased by 1043 (SD 1516) IU/L and 148 (SD 1319) IU/L in the liberal and restrictive arms, respectively. Selected QOL scores were superior pre-transfusion and more patients achieved clinically important improvements in the liberal arm compared with the restrictive arm for selected symptoms and function domains. CONCLUSION: The results establish that policies for transfusion support can be delivered in practice at multiple hospitals, but further research is required to understand the full clinical effects and safety of liberal transfusion policies in MDS outpatients.

Learning in conversation-A feasibility pilot study involving dental students and older people.

INTRODUCTION: Older people represent a growing proportion of the population in most high-income countries. The impact of oral diseases on health and well-being is far-reaching, and future graduates should be able to meet their needs in this phase of life. This research tested the feasibility of involving dental students in direct community engagement to explore older peoples' oral health concerns and information needs. MATERIALS AND METHODS: Seventeen older people were recruited locally to attend workshops with eight dental students in a health and well-being centre. First, older people selected oral health-related topics important to them, raising relevant questions and concerns. Students provided evidence-informed feedback on these selected topics at a subsequent workshop. Participants (students and older people) reflected on their involvement (via questionnaires, discussions and personal reflections). Qualitative data were analysed using thematic analysis. The structure, process and outcome of the study were explored. RESULTS: Structure: Both students and older people were willing to participate in workshops. Workshops in the community facilitated active engagement between both groups without the constraints of clinics. PROCESS: Students considered pre-workshop preparations adequate but raised issues about their ability to manage 'strong characters' within discussion groups. OUTCOME: Older people welcomed the initiative. Important topics raised by them were addressed by students giving them advice on maintaining their oral health. Students reported an improved understanding of how older people can be supported and expected a significant impact on future practice. CONCLUSION: Student involvement in direct community engagement was welcomed by all, demonstrating the feasibility and positive impact of the design whilst highlighting issues of importance for older people's oral health.

Telehealth technologies in care homes: a gap for dentistry?

BACKGROUND: Telehealth technologies are playing an increasing role in healthcare. This study aimed to review the literature relating to the use of telehealth technologies in care homes with a focus on teledentistry. METHODS: Khangura et al.'s (Evidence summaries: the evolution of a rapid review approach. Syst Rev 2012;1:10) rapid review method included an electronic database search on Embase, PubMed, Web of Science and OpenGrey. Out of 1525 papers, 1108 titles and abstracts were screened, and 75 full texts assessed for eligibility. Risk of bias was assessed using the Mixed Methods Assessment Tool 2018. RESULTS: Forty-seven papers (40 studies) from 10 countries, published 1997-2021, were included in the review, four studies related to teledentistry. Whilst some preferred in-person consultations, perceived benefits by stakeholders included reduced hospitalization rates (n = 14), cost-savings (n = 8) and high diagnostic accuracy (n = 7). Studies investigating teledentistry using intra-oral cameras reported that teleconsultations were feasible with potentially high diagnostic accuracy (n = 2), cost-savings (n = 1) and patient acceptability (n = 1). CONCLUSION: There is limited published research on teledentistry, but wider telehealth research is applicable to teledentistry, with findings suggesting that telehealth technologies play a role in care homes consultations that are acceptable, cost-saving and with potential diagnostic accuracy. Further research is needed on the mode, utility and acceptability of teledentistry in care homes.

Reconciling duty: a theory and typology of professionalism.

BACKGROUND: Professionalism is expected of health professionals and advocated by professional regulators in the United Kingdom (UK). Concepts of professionalism have evolved in sociological discourse and its meaning for dentistry is unclear. It is, none-the-less, considered a core domain of dental education and professional practice by the United Kingdom regulator, the General Dental Council. This paper reports the sense-making process, or social process, of professionalism in practice within England. AIM: To explore the research question 'What does dental professionalism mean in practice? METHODS: Taking a constructivist grounded theory approach, involving purposive and theoretical sampling, 24 dental professionals were recruited to participate in this qualitative study. In-depth, semi-structured interviews were conducted by one interviewer (AT). Interviews were recorded, transcribed verbatim, and analysed leading to the development of a theory grounded in the data. RESULTS: A focus on the social-professional constructs used by participants to make sense of their experiences, resulted in a grounded theory where Reconciling Duty emerged as the core category. This represents a process of meeting professional duties to different parties that are often mutually exclusive. It is comprised of three supporting categories: Applying order to the system, where individuals attempt to identify what constitutes professional attitudes and behaviours, Rationalising what is fair, where individuals make judgements on how the conflict between duties should be resolved, and finally Responding to the System, where individuals attempt to actualise these desired resolutions in the context of the complex social system in which they practice. Three dentist archetypes (typologies) emerged, which involved a personal (Type 1), patient (Type 2), or a societal (Type 3) compromise. CONCLUSION: Professionalism can be conceptualised as process of reconciling multiple, competing, legitimate duties to different parties, in seeking a fair solution. Once this has been identified, individuals need to work within the complex system of dentistry to make their identified outcome a reality. The findings suggest that using the theory of Reconciling Duty helps us to engage with the meaning that the participants drew from the term 'professionalism', and anchors it in the lived, everyday professional experiences and challenges faced. A novel typology is proposed, commensurate with calls for a systems approach to the topic.

Metformin increases the uptake of glucose into the gut from the circulation in high-fat diet-fed male mice, which is enhanced by a reduction in whole-body Slc2a2 expression.

OBJECTIVES: Metformin is the first line therapy recommended for type 2 diabetes. However, the precise mechanism of action remains unclear and up to a quarter of patients show some degree of intolerance to the drug, with a similar number showing poor response to treatment, limiting its effectiveness. A better understanding of the mechanism of action of metformin may improve its clinical use. SLC2A2 (GLUT2) is a transmembrane facilitated glucose transporter, with important roles in the liver, gut and pancreas. Our group previously identified single nucleotide polymorphisms in the human SLC2A2 gene, which were associated with reduced transporter expression and an improved response to metformin treatment. The aims of this study were to model Slc2a2 deficiency and measure the impact on glucose homoeostasis and metformin response in mice. METHODS: We performed extensive metabolic phenotyping and 2-deoxy-2-[18F]fluoro-d-glucose ([18F]FDG)-positron emission tomography (PET) analysis of gut glucose uptake in high-fat diet-fed (HFD) mice with whole-body reduced Slc2a2 (Slc2a2+/-) and intestinal Slc2a2 KO, to assess the impact of metformin treatment. RESULTS: Slc2a2 partial deficiency had no major impact on body weight and insulin sensitivity, however mice with whole-body reduced Slc2a2 expression (Slc2a2+/-) developed an age-related decline in glucose homoeostasis (as measured by glucose tolerance test) compared to wild-type (Slc2a2+/+) littermates. Glucose uptake into the gut from the circulation was enhanced by metformin exposure in Slc2a2+/+ animals fed HFD and this action of the drug was significantly higher in Slc2a2+/- animals. However, there was no effect of specifically knocking-out Slc2a2 in the mouse intestinal epithelial cells. CONCLUSIONS: Overall, this work identifies a differential metformin response, dependent on expression of the SLC2A2 glucose transporter, and also adds to the growing evidence that metformin efficacy includes modifying glucose transport in the gut. We also describe a novel and important role for this transporter in maintaining efficient glucose homoeostasis during ageing.

Oral Health and Community Nursing: a Practical Guide to the Delivering Better Oral Health Toolkit for Adults.

Despite being largely preventable, oral diseases are the major contributor to chronic conditions nationally and globally. If left untreated, oral diseases have many harmful effects throughout life on our patients including pain and infection, and can lead to difficulties with eating, sleeping, socialising and wellbeing. Oral health inequalities exist across our population, and particularly affect vulnerable, disadvantaged and socially excluded groups in society. Oral health is a key indicator for overall health, and is inextricably interlinked with general health. Hence, existing health messages that community nursing teams provide contribute towards oral health. Community nurses are in an established position to provide and reinforce positive oral health messages to their patients, as well as signpost to available dental services. This paper aims to support community nurses with a practical resource for key evidence-based oral health preventative advice, and input into how their patients can access dental care.

Journey towards a dental career: the career decision-making journey and perceived obstacles to studying dentistry identified by London's secondary school pupils and teachers.

Objective To explore the career decision-making journey towards dentistry and identify possible challenges and supports in this process as perceived by academically able, science-minded, London school pupils and their careers teachers.Methods A mixed-methods study was conducted using a purposive sample of London schools. Focus groups (n = 13) with 91 pupils aged 14-18 years and a survey of career teachers (n = 12) were conducted at a range of school-types. A topic guide, informed by the literature and previous research, guided discussions. Ethical approval was obtained from King's College London Research Ethics Committee (BDM/10/11-17 and 14/15-40). School, teacher, parental and pupil written informed consent were obtained. Data were transcribed and analysed thematically using framework methodology.Results Four distinct phases of the career decision-making journey were identified: 1) initiation of aspiration, with wider influences promoting medicine as a primary aspirational career option; 2) exposure to dentistry as a career, leading to recognition of dentistry as an alternative; 3) exploration of the career; and 4) the application process. Dentistry received little early consideration in this process. Greater representation of dental professionals within the school, access to work experience, and support in the student application process were identified as possible supports.Conclusions The findings suggest a four-phase journey towards a dental career, which may be enhanced by engagement of dental professionals at each stage. This may be particularly helpful in widening participation from under-represented groups.

JournalMate: An Accessible Academic Reading Tool for Third-Level Students with ADHD.

This paper outlines the research activities undertaken to design and evaluate an accessible academic reading tool to support third-level students with attention deficit hyperactivity disorder (ADHD). This research project was conducted in three phases, using a User Centred design (UCD) approach. The initial research phases explored cognitive processing difficulties related to reading habits and user needs that are associated with ADHD. A series of interviews with 3 subject matter experts and 8 students with ADHD aimed to identify pain points and problems hindering users from carrying out academic reading efficiently and confidently. Phase two involved ideating solutions based on data collected in the first phase and applying universal design principles while focusing on developing an electronic reading tool. After the ideation activity, the resulting prototyped solution was evaluated by 10 users. The data gathered during this evaluation provides insight into the performance of the application and will aid in any subsequent design iteration. The output of the study is an accessible academic reading tool for third-level students with ADHD, using a user-centred design process. Future practical implications and limitations are discussed. Results will provide additional data to build on current study findings and existing theories.