Evaluation of UK paediatric nephrology teams' understanding, experience and perceptions of oral health outcomes and accessibility to dental care: a mixed-methods study.

BACKGROUND: Oral health conditions are common in children and young people (CYP) with kidney disorders. There is currently limited literature on how confident paediatric nephrology teams feel to identify and manage oral health concerns for their patients. METHOD: An exploratory mixed-method survey was distributed across all 13 UK specialist paediatric nephrology centres with responses received from consultants, registrars, specialist nurses and special interest (SPIN) paediatricians. RESULTS: Responses received from 109 multidisciplinary team members of 13/13 (100%) UK tertiary units. Ninety-two percent (n = 100) of respondents reported they had never received any training in oral health and 87% (n = 95) felt that further training would be beneficial to optimise care for patients and improve communication between medical and dental teams. Most respondents reported that they did not regularly examine, or enquire about, their patients' oral health. Only 16% (n = 17) reported that all their paediatric kidney transplant recipients underwent routine dental assessment prior to transplant listing. Severe adverse oral health outcomes were rarely reported and only 11% (n = 12) of respondents recalled having a patient who had a kidney transplant delayed or refused due to concerns about oral infection. Seventy-eight percent (n = 85) felt that joint working with a dental team would benefit patients at their unit; however, 17% (n = 18) felt that current infrastructure does not currently support effective joint working. CONCLUSIONS: Across the UK, paediatric kidney health professionals report lack of confidence and training in oral health. Upskilling subspecialty teams and creating dental referral pathways are recommended to maximise oral health outcomes for CYP with kidney diseases.

The MAGIC trial: a pragmatic, multicentre, parallel, noninferiority, randomised trial of melatonin versus midazolam in the premedication of anxious children attending for elective surgery under general anaesthesia.

BACKGROUND: Child anxiety before general anaesthesia and surgery is common. Midazolam is a commonly used premedication to address this. Melatonin is an alternative anxiolytic, however trials evaluating its efficacy in children have delivered conflicting results. METHODS: This multicentre, double-blind randomised trial was performed in 20 UK NHS Trusts. A sample size of 624 was required to declare noninferiority of melatonin. Anxious children, awaiting day case elective surgery under general anaesthesia, were randomly assigned 1:1 to midazolam or melatonin premedication (0.5 mg kg-1, maximum 20 mg) 30 min before transfer to the operating room. The primary outcome was the modified Yale Preoperative Anxiety Scale-Short Form (mYPAS-SF). Secondary outcomes included safety. Results are presented as n (%) and adjusted mean differences with 95% confidence intervals. RESULTS: The trial was stopped prematurely (n=110; 55 per group) because of recruitment futility. Participants had a median age of 7 (6-10) yr, and 57 (52%) were female. Intention-to-treat and per-protocol modified Yale Preoperative Anxiety Scale-Short Form analyses showed adjusted mean differences of 13.1 (3.7-22.4) and 12.9 (3.1-22.6), respectively, in favour of midazolam. The upper 95% confidence interval limits exceeded the predefined margin of 4.3 in both cases, whereas the lower 95% confidence interval excluded zero, indicating that melatonin was inferior to midazolam, with a difference considered to be clinically relevant. No serious adverse events were seen in either arm. CONCLUSION: Melatonin was less effective than midazolam at reducing preoperative anxiety in children, although the early termination of the trial increases the likelihood of bias. CLINICAL TRIAL REGISTRATION: ISRCTN registry: ISRCTN18296119.

Characteristics of orthognathic multidisciplinary team clinics in England. Part 1: A questionnaire survey.

BACKGROUND: Orthognathic clinics across England are currently run in a multidisciplinary team (MDT) format. It is, however, likely that there is a large variation in the style of these clinics and care pathways for orthognathic patients across the country. This was a cross-sectional, online questionnaire with a primary aim to obtain information on the way orthognathic care is currently delivered throughout England. The secondary objectives were to determine the compliance to the minimum dataset for record collection. The questionnaire, disseminated to orthodontic consultants, detailed 27 items split into waiting lists for new patients, mechanics of the clinic, support for patients and record collection. RESULTS: A total of 36 participants responded (one was excluded) to give a total of 35 questionnaire responses. Descriptive statistics were used to analyse the data. Of the participants, 34% followed up their patients as per the commissioning guidelines at 1, 2 and 5 years after treatment. Of the participants, 20% said patients' mental health would be screened before adding them to a waiting list, with 26% of participants stating screening was not undertaken for all patients. Of the participants, 11% had available access to psychological support during the MDT meeting and 20% recorded the minimum dataset at the follow-up intervals. CONCLUSION: There are inconsistencies in the orthognathic MDT design across England. Acceptance criteria, support services available and records collected for patients showed substantial variation, highlighting the limited guidance offered by the commissioning guidelines and the potential need to revise the minimum dataset.

The CALM trial protocol: a randomised controlled trial of a guided self-help cognitive behavioural therapy intervention to reduce dental anxiety in children.

BACKGROUND: Globally, around 13% of children experience dental anxiety (DA). This group of patients frequently miss dental appointments, have greater reliance on treatment under general anaesthesia (GA) and have poorer oral health-related quality of life (OHRQoL) than their non-dentally anxious peers. Recently, a low-intensity cognitive behavioural therapy (CBT)-based, self-help approach has been recommended for management of childhood anxiety disorders. A feasibility study conducted in secondary care found this guided self-help CBT resource reduced DA and a randomised controlled trial was recommended. The present study aims to establish the clinical and cost-effectiveness of a guided self-help CBT intervention to reduce DA in children attending primary dental care sites compared to usual care. METHODS: This 4-year randomised controlled trial will involve 600 children (aged 9-16 years) and their parent/carers in 30 UK primary dental care sites. At least two dental professionals will participate in each site. They will be assigned, using random allocation, to receive the CBT training and deliver the intervention or to deliver usual care. Children with DA attending these sites, in need of treatment, will be randomly allocated to be treated either by the intervention (CBT) or control (usual care) dental professional. Children will complete questionnaires relating to DA, OHRQoL and HRQoL before treatment, immediately after treatment completion and 12 months post-randomisation. Attendance, need for sedation/GA and costs of the two different approaches will be compared. The primary outcome, DA, will be measured using the Modified Child Dental Anxiety Scale. Scores will be compared between groups using a linear mixed model. DISCUSSION: Treating dentally anxious patients can be challenging and costly. Consequently, these children are frequently referred to specialist services for pharmacological interventions. Longer waiting times and greater travel distances may then compound existing healthcare inequalities. This research will investigate whether the intervention has the potential to reduce DA and improve oral health outcomes in children over their life-course, as well as upskilling primary dental healthcare professionals to better manage this patient group. TRIAL REGISTRATION: This clinical trial has been registered with an international registry and has been allocated an International Standard Randomised Controlled Trial Number (ISRCTN27579420).

Paediatric dentistry provision in the North East of England: workforce confidence and attitudes.

Background Exploration of workforce confidence and attitudes towards the provision of paediatric dental care has the potential to inform targeted workforce development to address the oral health needs of children.Aims To explore: workforce confidence in providing paediatric dentistry; attitudes towards existing paediatric dental service provision; and perceived capacity and willingness to deliver Level 2 paediatric dental services.Methods An anonymous online survey was distributed to regional primary care and early-career dentists. It was distributed via Local Dental Committee Chairs, Community Dental Service Clinical Directors, a regional research collaborative and social media for a six-week period.Results Eighty-eight respondents self-reported confidence in 28 paediatric dental skills/competencies. Overall, 64% of respondents rated themselves as confident or very confident, with the least confidence reported in endodontic treatment of immature teeth and prescribing removable orthodontic appliances. In addition, 66% of respondents felt that the current provision of paediatric dental services was inadequate and 44% expressed willingness to provide Level 2 paediatric dental services.Conclusion High levels of confidence were reported in most paediatric dental skills/competencies. Current regional provision of paediatric dental services was described as inadequate. There is willingness and capacity within the existing workforce to provide Level 2 paediatric dental services.

From inputs to outputs: an analysis of the changes to learning outcomes for dental undergraduate education in the UK.

Introduction/aims Preparing for practice (PfP) was thought to represent a significant shift in the expectations of dental undergraduates compared to its predecessor, The first five years (TFFY). This project aimed to explore requirement changes by comparing learning outcomes for undergraduate dentists in these two documents. Changes in curriculum requirements defining clinical, professional, or a blend of these skills were also investigated.Methods Curriculum mapping was used to compare learning outcomes in PfP to requirements in TFFY.Results The total number of learning outcomes increased from 101 to 149 in PfP compared to TFFY. There was a proportional reduction in outcomes describing clinical skills and an increase in the proportion of outcomes describing professional and blended skills. Three TFFY requirements did not appear in PfP and a further 23 learning outcomes in PfP were absent in TFFY.Conclusions In the transition from TFFY to PfP, there has been an overall increase in the number of outcomes graduates must attain before they can register with the General Dental Council. There are more outcomes defining professionalism which subsequently has resulted in proportional but not actual decrease in outcomes related to clinical skills. While there is uncertainty over how schools have managed curricula to incorporate these changes and thus whether the perception of graduate preparedness can be directly attributable to these changes, it is timely to consider any changes within dental learning outcomes in the context of preparedness concerns.

Development of a United Kingdom-centric cost-effectiveness model for denture cleaning strategies.

STATEMENT OF PROBLEM: Denture stomatitis is a prevalent condition in denture wearers. Economic evaluations of health care can help stakeholders, including patients, make better decisions about treatments for a given condition. Economic models to assess the costs and benefits of different options for managing denture stomatitis are lacking. PURPOSE: The purpose of this study was to explore the feasibility of developing a cost-effectiveness model to assess denture cleaning strategies aimed at preventing denture stomatitis from a denture-wearer perspective in the United Kingdom. MATERIAL AND METHODS: A model was developed to identify and estimate the costs and effects associated with 3 denture cleaning strategies. These were low care (LC)-cleaning by brushing and soaking overnight in water; medium care (MC)-brushing with toothpaste and soaking overnight in water; and optimum care (OC)-brushing and soaking overnight in water and antimicrobial denture cleanser. Costs, outcome measures (denture stomatitis-free days), and probabilities (incidence of stomatitis, unscheduled dentist visits, prescription charges, self-medication) associated with each strategy were defined. A sensitivity analysis was used to identify key drivers and test the robustness of the model. RESULTS: The model showed that the total costs for 2015 ranged from £1.07 (LC) to £18.42 (OC). Costs associated with LC were derived from unscheduled dentist visits and use of medication and/or prescription charges. Incremental costs per denture stomatitis-free day were £0.64 (MC) and £1.81 (OC) compared with LC. A sensitivity analysis showed that varying either or both key parameters (baseline incidence of denture stomatitis and relative effectiveness of MC and OC strategies) had a substantial effect. Incremental cost-effectiveness ratios ranged from £4.11 to £7.39 (worst-case scenario) and from £0.21 to £0.61 (best-case scenario). CONCLUSIONS: A model was developed to assess the relative cost-effectiveness of different denture cleaning strategies to help improve denture hygiene. An important finding of the study was the lack of evidence on the relative effectiveness of different cleaning strategies, meaning that several assumptions had to be incorporated into the model. The model output would therefore likely be considerably improved and more robust if these evidence gaps were filled.

The value of adult orthodontics: Do the public's willingness-to-pay values reflect the profession's?

OBJECTIVE: To explore how the public and dental professionals would value an orthodontic service for adults by eliciting their willingness-to-pay (WTP), a standardised health economics technique which quantifies 'strength of preference' in monetary terms. Despite increasing demand, adults in the UK are only eligible for NHS orthodontic treatment if there is severe dental health or complex multidisciplinary need. Orthodontic services are provided to children aged under 18 years who are eligible by their Index of Orthodontic Treatment Need (IOTN) score. Consequently, many adults who may have a need for treatment as determined by IOTN are unable to access this service. DESIGN: Cross-sectional survey. SETTING: General dental practices in North East England and national specialists approached through the British Orthodontic Society (BOS). PARTICIPANTS: Public participants were recruited from general dental practices. Dentists were recruited from local dental lists and members of the BOS. METHODS: Participants were asked if they would be willing to pay to see an orthodontic service extended to all adults in England with a qualifying IOTN. Clinical photographs of three malocclusions were presented and maximum WTP in additional tax per household per year was elicited using shuffled payment cards. RESULTS: A total of 205 dentists and 206 public participants were recruited. Pairwise tests showed a statistically significant difference in WTP between the public and professionals for all malocclusions, with the public giving higher valuations. In both groups, the Class III scenario elicited a higher WTP than the class I or II malocclusion. However, when all other factors were controlled for using a regression analysis, the group (public or profession) and the other variables did not significantly influence WTP. CONCLUSION: The public and professionals were willing to pay for an adult orthodontic service. Due to this variability and unpredictability the allocation of healthcare resources will remain contentious.

Dental Policy Lab 1 - towards a cavity-free future.

Although many dental professionals argue that prevention of oral diseases, including dental caries, will benefit both the patient and public finances, a paradigm shift has yet to happen in most countries. The literature has demonstrated that caries prevention and control is possible, but authorities have yet to implement health systems that allow patients to stay in a good health state. 'Policy Labs' are an innovative policy-making initiative that allow a positive collaboration between the many stakeholders around a given policy issue. In July 2017, 24 international experts, including representatives of both international and European Chief Dental Officers associations, were gathered for the first Alliance for a Cavity-Free Future/King's College London Dental Policy Lab to identify the main barriers for a change, and concrete actions to facilitate a policy shift towards increased resource allocation in prevention. A comprehensive report and well-received infographic summarising the key recommendations (explored in this paper) were produced to explain the situation and highlight the value of a cavity-free world to policymakers, demonstrating where change is needed. The first Dental Policy Lab proved to be an efficient way to generate new ideas and concrete ways to implement them, and has led to several subsequent initiatives worldwide.

An Examination of Consistency in the Incremental Approach to Willingness to Pay: Evidence Using Societal Values for NHS Dental Services.

INTRODUCTION: Willingness to pay (WTP) is used to generate information about value. However, when comparing 2 or more services using standard WTP techniques, the amounts elicited from participants for the services are often similar, even when individuals state a clear preference for one service over another. An incremental approach has been suggested, in which individuals are asked to first rank interventions and provide a WTP value for their lowest-ranked intervention followed by then asking how much more they are willing to pay for their next preferred choice and so on. To date, evaluation of this approach has disregarded protest responses, which may give information on consistency between stated and implicit rankings. METHODS: A representative sample of the English population (n = 790) were asked to value 5 dental services adopting a societal perspective, using a payment vehicle of additional household taxation per year. The sample was randomized to either the standard or the incremental approach. Performance for both methods is assessed on discrimination between values for interventions and consistency between implicit and stated ranks. The data analysis is the first to retain protest responses when considering consistency between ranks. RESULTS: The results indicate that neither approach provides values that discriminate between interventions. Retaining protest responses reveals inconsistencies between the stated and implicit ranks are present in both approaches but much reduced in the incremental approach. CONCLUSION: The incremental approach does not improve discrimination between values, yet there is less inconsistency between ranks. The protest responses indicate that objections to giving values to the dental interventions are dependent on a multitude of factors beyond the elicitation process.

Exploring the use of mouth guards in Muay Thai: a questionnaire survey.

OBJECTIVE: To identify Muay Thai participants' attitudes towards use of mouth guards and their experiences of dental trauma. MATERIALS AND METHODS: An online cross-sectional survey was used to record Muay Thai participants' experiences and opinions regarding use of mouth guards. Participants were recruited from a Muay Thai gym in the north east of England. RESULTS: 92 respondents took part in the survey. 3% reported having never worn a mouth guard, whereas 61% reported routinely wearing mouth guards during a fight. Significantly more (73%) younger participants (18-29 years) reported wearing mouth guards during fights compared to those aged 30 years and older (50%) (p < 0.05). Mouth-formed ('boil and bite') were the most frequently used type of mouth guard (60% of users), followed by custom-made mouth guards provided by a dentist (32%). Factors such as protection, breathing, good fit and comfort were all considered important in the choice of mouth guard. 14% of respondents had experienced dental injuries, with chipped/broken teeth being the most common. CONCLUSION: Given the risk for dental trauma in Muay Thai, it is important that participants are advised regarding mouth guard use, particularly those that do not routinely wear them.

Economic evaluations in paediatric dentistry clinical trials.

Economic evaluations play an important role in identifying the cost-effectiveness of alternative healthcare programmes, informing decisions surrounding funding and the allocation of resources. This paper outlines the basic principles of economic evaluation and how it can be conducted alongside a clinical trial. Furthermore, it considers the ways in which evidence from these studies can be used, and the challenges researchers are faced with when conducting economic evaluations in the field of children's oral health.

Success of endodontic management of compromised first permanent molars in children: A systematic review.

BACKGROUND: Endodontic therapies may be required in the management of compromised first permanent molar teeth; their success in children, however, is unknown. AIM: To determine the success of endodontic therapies used on first permanent molar teeth in children aged sixteen and under. DESIGN: MEDLINE, Embase, Cochrane library, CENTRAL, Clinicaltrials.gov, and the ISRCTN registry as well as relevant paediatric, endodontic, and traumatology journal were searched using a detailed search strategy. References of included studies were hand-searched. A PICOS question was formulated: (P): children aged sixteen and under; (I): endodontic therapies (not pulp capping) on a first permanent molar tooth; (C): no treatment; (O): clinical success of endodontic therapy; and (S): all study types included. Bias was assessed using the Cochrane and Robins-I risk tools. Quality of evidence was assessed using the GRADE approach. Significant heterogeneity precluded meta-analysis. RESULTS: 4172 studies were retrieved and eleven were included in the narrative review. Partial and coronal pulpotomies have high success rates in the short term and long term. Limited evidence is available for conventional pulpectomy or regenerative techniques. CONCLUSIONS: Partial and coronal pulpotomies are successful endodontic therapies for use in a compromised child's first permanent molar.

Developing oral health risk assessment as routine practice during early stages of clinical careers: A cross-sectional study of dental students using the NoMAD questionnaire.

BACKGROUND: Effective implementation of healthcare initiatives is of key importance for ensuring high-quality clinical and health outcomes. Using Normalization Process Theory, this study investigates the implementation behaviour of dental students in relation to a novel oral health risk assessment tool. It considers the impact of advancing learning on normalisation of innovative healthcare practice. METHODS: Students completed the NoMAD (normalisation of complex interventions-measure development) questionnaire and an additional scale to assess perceived value of the oral health risk assessment tool, after having used the tool for nearly one academic year. The sample comprised third- (n = 75), fourth- (n = 77) and fifth-year (n = 37) students. Differences between groups in relation to the four generative processes of normalisation were analysed using ANOVA. Cohen's d effect sizes were calculated between groups. Multiple linear regression was undertaken to investigate the impact of normalisation level on value/utility judgements. RESULTS: There were significant group differences for three of the four generative processes of normalisation (coherence, cognitive participation and reflexive monitoring). Third- and fourth-year students were highly similar but these groups showed lower normalisation compared to fifth years. Normalisation assessment predicted perceived value and utility of the oral health risk assessment tool. CONCLUSIONS: The findings suggest that dental students show lower normalisation of novel tools at earlier stages in their course, possibly due to increased cognitive load, and that perceived value and utility of a novel tool is related to increased normalisation.

Patients' and Parents' Valuation of Fluoride.

PURPOSE: This study aimed to elicit willingness to pay (WTP) values for fluoride varnish application from participants using the publically-funded health services in Brazil and the UK, and to identify differences in the variables impacting these values. A secondary aim was to compare WTP values from parents for their own preventive treatment and their child's. MATERIALS AND METHODS: This was a cross-sectional analysis of quantitative data collected from participants attending routine dental appointments. The clinics were hosted by the Pontifical Catholic University of Rio Grande do Sul (PUCRS), Brazil and Newcastle Dental Hospital, UK. RESULTS: The mean WTP for Brazilian adults was R$60.37 (=£15.97). WTP was highly variable and factors affecting it were difficult to identify. UK parents valued fluoride varnish at mean values of £28.21 and £28.12 for themselves and their child, respectively. Regression modelling found those with higher incomes had higher WTP in both samples. In the UK, parental and child WTP increased when parents had higher self-perceived need for dental treatment, had experienced recent dental pain, or their child had received restorations in the last 2 years. CONCLUSIONS: WTP for fluoride varnish varied dramatically between individuals. In both countries, it was difficult to predict this variance, as factors which would likely impact upon on WTP had a limited effect and were sometimes counter-intuitive. WTP values for a parent and their child were not statistically significantly different.

How does priority setting for resource allocation happen in commissioning dental services in a nationally led, regionally delivered system: a qualitative study using semistructured interviews with NHS England dental commissioners.

OBJECTIVES: To understand approaches to priority setting for healthcare service resource allocation at an operational level in a nationally commissioned but regionally delivered service. DESIGN: Qualitative study using semistructured interviews and a Framework analysis. SETTING: National Health Service dentistry commissioning teams within subregional offices in England. PARTICIPANTS: All 31 individuals holding the relevant role (dental lead commissioner in subregional offices) were approached directly and from this 14 participants were recruited, with 12 interviews completed. Both male and female genders and all regions were represented in the final sample. RESULTS: Three major themes arose. First, 'Methods of priority setting and barriers to explicit approaches' was a common theme, specifically identifying the main methods as: perpetuating historical allocations, pressure from politicians and clinicians and use of needs assessments while barriers were time and skill deficits, a lack of national guidance and an inflexible contracting arrangements stopping resource allocation. Second, 'Relationships with key stakeholders and advisors' were discussed, showing the important nature of relationships with clinical advisors but variation in the quality of these relationships was noted. Finally, 'Tensions between national and local responsibilities' were illustrated, where there was confusion about where power and autonomy lay. CONCLUSIONS: Commissioners recognised a need for resource allocation but relied on clinical advice and needs assessment in order to set priorities. More explicit priority setting was prevented by structure of the commissioning system and standard national contracts with providers. Further research is required to embed and simplify adoption of tools to aid priority setting.

Assessing the cost-effectiveness of a fluoride varnish programme in Chile: The use of a decision analytic model in dentistry.

OBJECTIVES: This study illustrates the use of a decision analytic model (DAM) to evaluate whether fluoride varnish application (FV) increases the proportion of caries-free children in the Chilean preschool population, at an acceptable cost. METHODS: Different FV interventions were compared with an oral health counselling-only intervention. The FV interventions were tested (with and without screening) every 6 months over 2 years, in either a preschool setting or during a well-child programme appointment in a primary care setting. A Markov model was developed to simulate the FV performance. The model was populated with data obtained from Chilean epidemiologic studies, a systematic review and a costing study. The counselling-only intervention was compared with FV interventions to estimate the incremental cost per child. As there was uncertainty in terms of precise parameter values both probabilistic and deterministic sensitivity analyses were performed. RESULTS: Delivery of FV in a primary care setting without screening was the most effective and the least costly intervention. Compared with counselling-only intervention, this intervention increased the prevalence of caries-free children in the population by 3.7%, with an extra cost (in March 2015) of £3 per caries-free child. The results were sensitive to the starting age of FV application; increasing age would reduce the cost-effectiveness of the FV intervention. Furthermore, cost-effectiveness improves if some equipment such as an oral hygiene kit was not used and if less costly but qualified staff applied FV rather than dentists. CONCLUSIONS: This analysis allowed the comparison of the performance of FV in realistic scenarios incorporating important aspects of health and education policies. The application of FV in a primary care setting was the most cost-effective strategy. The work demonstrated that both the methodology and results are useful for decision-makers.

Medical emergency department attendance of under 16-year-olds with dental problems.

BACKGROUND: Medical emergency departments (MED) are under increasing pressure in the UK with suggestions that unnecessary attendances to MED, which may include dental problems, are to blame. OBJECTIVES: The aim of this cross-sectional study was to examine the period prevalence of under 16-year-olds attendance to medical emergency departments (MED) with oral and dental problems over a 5-year period and investigate reason for attendance. This cross-sectional study was carried out as part of a service evaluation at the Newcastle upon Tyne Hospitals NHS Foundation Trust. METHODS: Retrospective data were collected between 1 January 2012 and 31 December 2016 from the MED database using coding and a free text search of all paediatric attendances. The data were then analysed using descriptive statistics. RESULTS: Over the 5-year period, 135 760 under 16-year-olds attended the MED. Of these, 868 (0.6%) attended for dental problems. The most common dental reasons for attendance were as follows: Candida accounted for 22.6% of the 0- to 5-year-olds; dental trauma accounted for 29.5% of 6- to 11-year-olds; and mandibular fractures accounted for 18.9% of the 12- to 16-year-olds. Of those who attended the MED for dental problems, 28.5% resided in areas with an Index of Multiple Deprivation decile of 1, the areas of highest deprivation in the UK. CONCLUSION: Many of the diagnoses may have been appropriately managed elsewhere in the community, which may result in improved treatment provision and tailored care pathways, as well as reducing strain on the MED. Further research is needed to investigate why patients attend MED with dental problems.