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 DBS is roughly synonymous with behaviour management, which is an outdated concept.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.

Models of dental care for people experiencing homelessness in the UK: a scoping review of the literature.

Background People who experience homelessness have poor oral health and face barriers to accessing care. Recommendations have been outlined for health services to address their needs, termed 'inclusion health'. The Smile4Life report recommended three 'tiers' of dental service: emergency, ad hoc and routine care. Other medical services have developed into different models of care, for example mainstream practices with enhanced services for people who experience homelessness. There is little understanding of how inclusion health recommendations have been implemented across dental settings.Aims To describe and compare dental services that exist for people who experience homelessness in the UK.Methods Two Medline searches were performed in October 2020 to assess the models of dental care for people who experience homelessness in the UK.Results Nine dental services in the UK were identified who treated people who experience homelessness. Most did not explore definitions of homelessness. There were a mixture of models, including using blended approaches, such as different sites and appointment types, to flex to the needs of their population.Conclusion Many services that are dedicated to treat this population are based in the community dental services which allows for flexible models of care due to sporadic patient attendance, high treatment requirements and complex needs. More research is required to determine how other settings can accommodate these patients, as well as understanding how more rural populations access dental care.

Socioeconomic and Ethnic Inequalities in the Progress of Multimorbidity and the Role of Health Behaviors.

OBJECTIVES: To assess socioeconomic and ethnic inequalities in the progress of multimorbidity and whether behavioral factors explain these inequalities among older Americans. DESIGN: Health and Retirement Study, a longitudinal survey of older American adults. SETTING AND PARTICIPANTS: Data pooled from 2006 to 2018 (waves 8-14), which include 38,061 participants. METHODS: We used 7 waves of the survey from 2006 to 2018. Socioeconomic factors were indicated by education, total wealth, poverty-income ratio (income), and race/ethnicity. Multimorbidity was indicated by self-reported diagnoses of 5 chronic conditions: diabetes, heart conditions, lung diseases, cancer, and stroke. Behavioral factors were smoking, excessive alcohol consumption, physical activity, and body mass index (BMI). Multilevel mixed effects generalized linear models were constructed to assess socioeconomic and ethnic inequalities in the progress of multimorbidity and the role of behavior. All variables included in the analysis were time-varying except gender, race/ethnicity, and education. RESULTS: African American individuals had higher rates of multimorbidity than White individuals; however, after adjusting for income and education, the association was reversed. There were clear income, wealth, and education gradients in the progress of multimorbidity. After adjusting for behavioral factors, the relationships were attenuated. The rate ratio (RR) of multimorbidity attenuated by 9% among participants with the lowest level of education after accounting for behavior (RR 1.21; 95% CI 1.18-1.23 and 1.11; 95% CI 1.17-1.14) in the models unadjusted and adjusted for behaviors, respectively. Similarly, RR for multimorbidity among those in the lowest wealth quartile attenuated from 1.47 (95% CI 1.44-1.51) and 1.31 (95% CI 1.26-1.36) after accounting for behaviors. CONCLUSION AND IMPLICATIONS: Ethnic inequalities in the progress of multimorbidity were explained by wealth, income, and education. Behavioral factors partially attenuated socioeconomic inequalities in multimorbidity. The findings are useful in identifying the behaviors that should be included in health promotion programs aiming at tackling inequalities in multimorbidity.

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).

Oral health characteristics of patients living with intellectual disability at transition phase from pediatric dental service to adult dental service: A systematic review.

AIM: A systematic review was conducted to evaluate the available literature to ascertain the oral health characteristics of patients living with intellectual disability when they transfer from pediatric dental service to adult dental service. MATERIAL AND METHODS: The electronic search was performed between June 2020 and July 2020 using the following databases: MEDLINE and EMBASE. Cochrane database, gray literature, and Google Scholar were also searched. References of articles obtained from the electronic searches were scanned through. Journals and regulation agency websites were also hand searched. This systematic review used a defined search strategy keywords for all the electronic databases. The strength of evidence in these studies was evaluated using the British Medical Journal quality assessment tool. RESULTS: The search process identified 45 eligible articles. Of these, 35 studies were excluded, and 10 observational studies were included. CONCLUSION: It seems that a considerable percentage of patients living with intellectual disability in their transition phase, aged between 18 and 25 years, have a high prevalence of dental caries, gingivitis, and periodontal disease when compared to the general population.

Learning Clinical Skills Using Haptic vs. Phantom Head Dental Chair Simulators in Removal of Artificial Caries: Cluster-Randomized Trials with Two Cohorts' Cavity Preparation.

Dental task trainer simulators using haptics (virtual touch) offers a cost-effective method of teaching certain clinical skills. The purpose of this study is to evaluate students' performance in removing artificial caries after training with either a haptic dental chair simulator with virtual reality or a traditional dental chair simulator with a mannequin head. Cluster Randomized Controlled Trials in two cohorts, both Year 1 dental students. Students taught using traditional dental chair simulators were compared with students taught using haptic-based simulators on their ability to cut a cavity in a plastic tooth following training. Across both cohorts, there was no difference in the quality of cavity cut, though students' technique differed across the two simulator groups in some respects. No difference was seen across both cohorts in the quality of cavity cut for a simple preparation, though students in the haptic condition performed less well in the more demanding task. Moreover, students in the haptic group were also less likely to be perceived to be 'holding the instrument appropriately'. These findings suggest further investigation is needed into the differences in handling of instruments and level of clinical task difficulty between the simulators.

The impact of priming on dentally induced social judgements: An experimental study.

OBJECTIVE: To ascertain the effects of priming to consider tooth appearance (i.e. exposure to a 'tooth whitening television advert') versus control (a 'non-dental' television advert) on social judgements of tooth colour in a group of Caucasians. METHODS: Two groups of Caucasians randomly assigned to watch either a tooth-whitening advert (experimental, N = 67) or a bread advert (control, N = 62). All rated the measures of social perceptions: friendliness, popularity, social life, success, intelligence, graduation, introversion/extroversion, happiness, self-confidence, attractiveness, age-estimation and satisfaction, after watching either of the adverts and viewing three digitally modified photographs (Darkened, natural and whitened teeth) of different Caucasian adults (males and females) separately. RESULTS: There were no statistically significant differences for all the measures of social perception between the groups. Nevertheless, the questions that inquired about popularity, friendliness, success, intelligence, happiness, self-confidence, attractiveness and satisfaction were consistently rated higher for all three tooth shades in the experimental than the control groups. Further, within the experimental and control groups, higher ratings were given to the faces with whitened teeth than the natural and darkened teeth. CONCLUSIONS: Priming has little impact on dentally induced social judgements as this study failed to demonstrate statistically significant differences. Nevertheless, both groups gave the highest subjective ratings for the faces with whitened teeth and the tooth-whitening advert group associated the faces in the photographs with higher subjective ratings than the non-dental advert group irrespective of the tooth shade. One reason for this could be the way media affects the psychological well-being. CLINICAL SIGNIFICANCE STATEMENT: The almost universal exposure to idealised tooth appearance in the media may increase demand for aesthetic treatments. Standardising the colour of the tooth plays a huge impact and making individuals to view a tooth whitening advert just prior to a procedure might influence patient choices.

Labial frenectomy: current clinical practice of orthodontists in the United Kingdom.

OBJECTIVES: To obtain views of orthodontists in the United Kingdom on frenectomy in terms of its indications and timing and a recommended retention regimen after correction of median diastema. MATERIALS AND METHODS: A 14-item online questionnaire was sent to orthodontic specialists for completion. The questionnaire covered demographics and orthodontists' experience and views on frenectomy. RESULTS: Three hundred and fifty-three orthodontists with various background and experience responded to the survey. Three-quarters of respondents routinely performed a blanche test to aid diagnosis of the abnormal frenum; however, only 15% carried out radiographic investigation. Three-quarters of the orthodontists would consider frenectomy as a part of orthodontic treatment, and variation existed among the clinicians in terms of its timing. Frenectomy without orthodontic treatment was not preferred. There was much variation in the retention regimen after diastema closure regardless of frenectomy. CONCLUSIONS: Complete consensus among the orthodontists was not obtained; however, some agreement was found regarding the development of a logical diagnosis and treatment approach. High-quality studies are required to produce national protocols or UK guidelines.

A survey of dental services in England providing targeted care for people experiencing social exclusion: mapping and dimensions of access.

Introduction Poor oral health and barriers to accessing dental services are common among people experiencing social exclusion. This population experience a disproportionate and inequitable burden of oral disease. A small number of dental services have published models of care that target this population, but no national surveys have been conducted.Aims This study aims to identify what types of services are providing dental and oral healthcare for people experiencing social exclusion in England and the models of delivery adopted by these services.Methods A snowballing sampling strategy was used to identify services that provide targeted for adults experiencing social exclusion. The study used a survey to collect data about the location, service models and barriers and enablers of these services.Results In total, 74 responses from different services met the inclusion criteria for the study. Seventy one were included in the mapping exercise and 53 provided free-text comments that contributed to an understanding of barriers and enablers of services.Discussion Most services operated to meet the needs of the mainstream population and described inflexibilities in their service design models as barriers to providing care for socially excluded groups.Conclusion Limitations of current models of service delivery create frustrations for providers and people experiencing social exclusion. Creative commissioning and organisational flexibility are key to facilitating adaptable services.

Inequalities in the progress of multiple chronic conditions: A systematic review of longitudinal studies.

The objective of this review is to assess the impact of socioeconomic factors on the progress of multiple chronic health conditions (MCC) in Adults. Two independent investigators searched three databases (MEDLINE, EMBASE and LILACS) up to August 2021 to identify longitudinal studies on inequalities in progress of MCC. Grey literature was searched using Open Grey and Google Scholar. Inclusion criteria were retrospective and prospective longitudinal studies; adult population; assessed socioeconomic inequalities in progress of MCC. Quality of included studies and risk of bias were assessed using the Newcastle Ottawa Quality Assessment Scale for longitudinal studies. Nine longitudinal studies reporting socioeconomic inequalities in progress of MCC were included. Two of the studies had poor quality. Studies varied in terms of follow-up time, sample size, included chronic conditions and socioeconomic indicators. Due to high heterogeneity meta-analysis was not possible. The studies showed positive association between lower education (five studies), lower income and wealth (two studies), area deprivation (one study), lower job categories (two studies) and belonging to ethnic minority (two study) and progress of MCC. The review demonstrated socioeconomic inequality in progress of multiple chronic conditions. trial registratiom: The review protocol was registered in the International Prospective Register of Systematic Reviews (CRD42021229564).

BeSiDe time to move behavior support in dentistry from an art to a science: A position paper from the BeSiDe (Behavior Support in Dentistry) Group.

AIMS: To share the need for agreement in terminology around how people are supported to receive dental care. METHOD: In this position paper, we make the case for a shift in behavior support in dentistry from an art to a science. RESULTS: We outline why we need agreement on the definition of behavior support across dentistry, agreement on underlying theory, aims and values, and why we need agreement on terms for specific techniques. CONCLUSIONS: We share how patients and dental teams can benefit through better science, education and practice of dental behaviour support.

A Short Form of the Children's Experiences of Dental Anxiety Measure (CEDAM): Validation and Evaluation of the CEDAM-8.

BACKGROUND: The Children's Experiences of Dental Anxiety Measure (CEDAM-14) is a child-centred measure of dental anxiety which assesses a range of behaviours, thoughts and feelings/physical symptoms related to dental anxiety. A short form of the CEDAM-14, which places less time burden on patients and clinicians, could promote the feasibility and applicability of the CEDAM in clinical settings. The aim of the study was to develop a short version of the CEDAM that can be used to assess children's dental anxiety in clinical practice. METHODS: A short version of the CEDAM was developed using a combination of item impact and regression methods. Measurement properties including floor/ceiling effects, variance, criterion validity, construct validity and internal consistency was calculated for the short form. RESULTS: An eight-item CEDAM short form was developed (CEDAM-8) that had good psychometric properties, was significantly correlated with the CEDAM measure (r = 0.90; p < 0.01), had minimal floor and ceiling effects (3.5% and 1.2%, respectively) and was sensitive to change. CONCLUSION: The CEDAM-8 is a useful assessment tool for clinicians that is easy and quick to administer and could help to understand children's experiences of dental anxiety and changes in anxiety over time and following intervention.

COVID-19, social media use and anxiety: more complex than it might appear?

Design Cross-sectional questionnaire survey of 403 dental healthcare workers.Sample selection Snowball sampling via social media.Data analysis Descriptive analysis of sample. Bivariate analysis of the relationship between demographic variables, social media use and anxiety. Binary logistic regression analysis predicting: 1) use of social media; and 2) general anxiety.Results 1) Social media use was predicted by moderate/severe anxiety level; 2) general anxiety level was predicted by being female and more frequent social media use.Conclusions The authors conclude that social media reporting of COVID-19 information had adversely affected the psychological wellbeing of dental healthcare workers.

Use of AUDIT-C alcohol screening tool in NHS general dental practices in North London.

Background The numerous health risks of excessive alcohol consumption are well documented. Individuals at risk of harm from alcohol consumption can be identified through alcohol screening tools; however, there is limited research regarding their use in general dental practices.Methods Data were collected as part of a feasibility trial evaluating delivery of brief alcohol advice in general dental practices in North London. Patient demographics and health-related behaviours were collected, and the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) tool was used to assess alcohol consumption patterns.Results The analytical sample comprised 552 dental patients, of whom approximately half (46%) were drinking alcohol at hazardous levels. Males, younger adults, those who consumed red meat weekly and smokers all had significantly increased risks of excessive alcohol consumption. Smokers were more likely to consume excessive levels of alcohol irrespective of smoking frequency. Notable sex differences in alcohol consumption were identified, with males being more likely to consume alcohol frequently and in larger quantities than females.Conclusion The AUDIT-C tool can be used in general dental practice to screen for harmful levels of alcohol consumption. Clear associations exist between patient demographics, health behaviours and excessive alcohol consumption.

Communication, Trust and Dental Anxiety: A Person-Centred Approach for Dental Attendance Behaviours.

Effective communication forges the dentist-patient treatment alliance and is thus essential for providing person-centred care. Social rank theory suggests that shame, trust, communication and anxiety are linked together, they are moderated by socio-economic position. The study is aimed to propose and test an explanatory model to predict dental attendance behaviours using person-centred and socio-economic position factors. A secondary data analysis was conducted on a cross-sectional representative survey of a two-stage cluster sample of adults including England, Wales and Northern Ireland. Data were drawn from structured interview. Path analysis of proposed model was calculated following measurement development and confirmation of reliable constructs. The findings show model fit was good. Dental anxiety was predicted negatively by patient's trust and positively by reported dentist communication. Patient's shame was positively associated with dental anxiety, whereas self-reported dental attendance was negatively associated with dental anxiety. Both patient's trust and dentist's communication effects were moderated by social class. Manual classes were most sensitive to the reported dentist's communications. Some evidence for the proposed model was found. The relationships reflected in the model were illuminated further when social class was introduced as moderator and indicated dentists should attend to communication processes carefully across different categories of patients.

Patients' expectations: is there a typical patient?

OBJECTIVES: To qualitatively explore, and analyse, patients' expectations before the start of fixed appliance orthodontic treatment and determine whether typologies exist. DESIGN: A prospective cross-sectional qualitative study, which involved 13 patients (aged 12-15 years). SETTING: NHS Hospital Orthodontic Department (UK). MATERIALS AND METHODS: In-depth interviews were conducted with patients who consented to participate before the start of fixed appliance orthodontic treatment. The in-depth interview data were transcribed and then managed using a framework approach, followed by associative analysis. RESULTS: The in-depth interviews revealed two major themes and associated subthemes which were: first, patients' expectations about the treatment process and outcome; and second, patients' expectations of themselves during and after treatment. Three typologies related to patients' expectations of the orthodontic treatment process were also identified. The first group of participants had minimal expectations of the treatment process, did not anticipate discomfort or pain and did not anticipate that treatment would cause disruption to their daily life. The second group of participants had expectations that treatment would involve arch wire changes, dental extractions and result in some discomfort/pain, which would cause some limited disruption to their daily life (moderate expectations). The third type of participant had expectations of the treatment process involving arch wire changes and dental extractions, and anticipated that the discomfort and pain experienced would significantly affect their daily life (marked expectations). CONCLUSIONS: These results provide the clinician with information about patient typologies and provide the clinician with some direction when communicating with their patients and managing their expectations before the start of treatment.

A systematic review to assess interventions delivered by mobile phones in improving adherence to oral hygiene advice for children and adolescents.

Background Mobile phones are potentially an invaluable tool in addressing the global challenge associated with dental caries as they may elicit behaviour change by incorporating numerous behaviour change techniques (BCTs) to address an individual's capability, opportunity and motivation.Methods The methodology for this review is published on the PROSPERO database (CRD42017078414).Results Two randomised controlled trials were included, both were undertaken with orthodontic patients and both reported significantly reduced plaque scores in the intervention group compared with the control at final follow-up. One study also reported statistically significantly lower gingival bleeding scores and caries in the intervention group at final follow-up. The risk of bias was 'unclear' for both studies and neither study intervention appeared to be based on specific theories of behaviour change. Of 93 BCTs available, only six were utilised across the two trials. The overall strength of evidence for the effectiveness of mobile phones in reducing plaque score was rated as moderate using GRADE, while the effectiveness in reducing bleeding scores was considered to be high.Conclusion There is some evidence that mobile phones are effective in improving adherence to oral hygiene advice in orthodontic patients. The generalisability of this review is limited due to the small number of trials and the unclear risk of bias of included studies.