Experiences of dental behaviour support techniques: A qualitative systematic review.

BACKGROUND: Little is known about patients' or carers' reported experiences of dental care provided using dental behaviour support (DBS) techniques. Qualitative literature can provide unique insight into these experiences. AIM: To explore and synthesize qualitative literature related to patient experience of dental behaviour support. METHODS: A PROSPERO-registered systematic review of qualitative articles was undertaken. Studies were identified through MEDLINE, Embase and PsycINFO. Abstracts were screened by two reviewers and data were extracted to summarize the qualitative findings included within them. A thematic summary approach was used to synthesize the qualitative data identified. RESULTS: Twenty-three studies were included. Studies primarily explored experiences of dental care of children by speaking to their parents (n = 16), particularly regarding paediatric dental general anaesthesia (DGA) (n = 8). Studies of adults' experiences of DBS (n = 7) covered a range of techniques. Nine studies explored broader dental care experiences and did not study specific DBS approaches. A thematic synthesis identified five themes applicable across the studies identified: Trust and the therapeutic alliance supporting effective care delivery; considered information sharing often alleviated anticipatory anxiety; control and autonomy-reduced anxieties; variations in the perceived treatment successes and failures of DBS techniques; and DBS techniques produced longer positive and negative impacts on patients beyond direct care provision. CONCLUSION: Qualitative research has been under-utilized in research on DBS techniques. Care experiences of most DBS techniques outside of paediatric DGA are poorly understood. Building trust with patients and enabling autonomy appear to support positive patient-reported experiences of care.

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 DBS is roughly synonymous with behaviour management, which is an outdated concept.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

Exploring dental treatment decision-making experiences of people living with dementia and family carers.

INTRODUCTION: People living with dementia can have complex dental care needs. Dentists and patients should make treatment decisions together, yet some people living with dementia may be unable to make their own decisions about their dental care. Dental treatment decision-making and patients' experiences of this process have not been comprehensively researched. OBJECTIVE: This study aimed to explore the dental treatment decision-making perspectives and experiences of people living with dementia and their family members. METHODS: Semi-structured interviews were undertaken with 8 people living with dementia and 17 family caregivers. A constructivist grounded theory approach was adopted, using a maximum variation sample. Qualitative data collection and analysis occurred concurrently. Data underwent initial open coding followed by more focused coding, supported by reflexive memo writing, which supported data categorisation. RESULTS: People living with dementia reported wanting to be understood as unique individuals with specific needs. All participants described wanting to be actively involved in dental treatment decisions. However, many felt that they were insufficiently involved in treatment decision-making. This perceived underinvolvement meant that some people living with dementia and family members felt the treatment outcomes they sought were neither discussed nor considered. CONCLUSION: People living with dementia and carers had specific expectations of dental care yet felt passive in decision-making despite their desire to be involved in this process. Dentists should seek to actively establish patients' preferences, regardless of mental capacity and consider these in discussions and decisions about dental treatment.

A scoping review of interventions and outcome measures in trials of dental behavior support.

BACKGROUND: Dental behavior support (DBS) describes all techniques used by dental professionals to ensure that dental care is safe, effective, and acceptable. There is a need to standardize outcome measures across DBS techniques to reduce heterogeneity, limit selective reporting, promote consistency, and optimize outcomes across DBS research. A comprehensive review of existing measures is a prerequisite to understanding potential outcomes related to the area of interest. AIM: This review had three aims: first, to identify the outcome measures (OMs) reported in trials of dental behavior support; second, to categorize the component DBS techniques reported within interventions according to emerging agreed terminology; and, third, to map outcome measures to intervention type. METHODS: A scoping review of trials evaluating DBS techniques was undertaken from 2012 to 2022. The review was prospectively registered. Studies were identified through Medline, Embase, and PsycINFO. Study abstracts were screened by two reviewers. Data were extracted by single selector. Outcome measures were sorted according to measurement domains (physiological, behavioral, psychological, and treatment). Responses were assimilated and summed to produce a refined list of distinguishable outcome measures. Intervention types were categorized according to accepted descriptors. Frequencies were presented; associations between outcome domain and DBS type were also reported (Chi-square test of independence). RESULTS: A total of 344 trials were included in the review from an initial 14,793 titles / title and abstracts screened. Most involved children (n = 215), most were from India (n = 104), involving basic dental care (n = 117). The median number of outcome measures per trial was four (range = 1-12); 1,317 individual outcomes were reported, categorized as: psychological (n = 501, 38.0%); physiological (n = 491, 37.3%), behavioral (n = 123, 9.3%) or, treatment-related (n = 202, 15.3%). DBS interventions were split between 239 (45.7%) pharmacological and 283 (54.1%) non-pharmacological; 96.6% of interventions mapped to accepted descriptors. A significant relationship was noted between the type of intervention and the outcome domain reported. CONCLUSION: The findings demonstrate massive variation in outcome measures of DBS interventions that likely lead to unnecessary heterogeneity, selective reporting, and questionable relevance in the literature. A large range of DBS interventions were mapped according to BeSiDe list. There is a need for consensus on a core outcome set across the spectrum of DBS techniques.

Putting guidelines into practice: Using co-design to develop a complex intervention based on NG48 to enable care staff to provide daily oral care to older people living in care homes.

OBJECTIVES: (1) Explore the challenges of providing daily oral care in care homes; (2) understand oral care practices provided by care home staff; (3) co-design practical resources supporting care home staff in these activities. METHODS: Three Sheffield care homes were identified via the "ENRICH Research Ready Care Home Network," and three to six staff per site were recruited as co-design partners. Design researchers led three co-design workshops exploring care home staff's experiences of providing daily oral care, including challenges, coping strategies and the role of current guidelines. New resources were prototyped to support the use of guidelines in practice. The design researchers developed final resources to enable the use of these guidelines in-practice-in-context. FINDINGS: Care home staff operate under time and resource constraints. The proportion of residents with dementia and other neurodegenerative conditions is rapidly increasing. Care home staff face challenges when residents adopt "refusal behaviours" and balancing daily oral care needs with resident and carer safety becomes complex. Care home staff have developed many coping strategies to navigate "refusal behaviours." Supporting resources need to "fit" within the complexities of practice-in-context. CONCLUSIONS: The provision of daily oral care practices in care homes is complex and challenging. The co-design process revealed care home staff have a "library" of context-specific practical knowledge and coping strategies. This study offers insights into the process of making guidelines usable for professionals in their contexts of practice, exploring the agenda of implementing evidence-based guidelines.

The use of general anaesthesia in special care dentistry: A clinical guideline from the British Society for Disability and Oral Health.

BACKGROUND: General anaesthesia (GA) may be required to support the care of those seen in Special Care Dentistry (SCD) services for various reasons, such as enabling extensive dental care for people with severe learning disabilities or severe dental phobia. Guidance is needed for teams delivering SCD using GA due to the potential risks, implications, and costs of using GA to deliver dental care. AIM: To present evidence-based recommendations, where possible, for teams involved in providing GA for dental care for adults within SCD services. METHODS: A multidisciplinary working group, supported by a formal literature search and stakeholder involvement, iteratively produced and refined the recommendations presented. RESULTS: There was little evidence to inform the guidelines. Recommendations are therefore based mainly on the working group's expert consensus opinion. Clinical guidelines are presented as a set of overarching principles followed by six key sections reflecting patients' pathways from referral to dental services through to their care during and after GA. CONCLUSION: Guidelines are presented to support those providing GA to provide SCD. The need for comprehensive and person-centered assessment and planning is emphasized.

Could optimising periodontal health in expectant mothers reduce the risk of babies being born prematurely?

Data sources The systematic review has used various databases (EMBASE, Medline, ScienceDirect, Google Scholar), as well as hand searching, to collect its data sample. There is no mention of the authors' affiliations or any funding declaration. In addition, there is no mention of an information specialist/search strategist in the team. There is mention of two review authors who have been blinded to the authors of the studies, and their publication years, but there is no mention as to whether they could concur among themselves. In addition, they have mentioned a third expert when needed, but do not mention when or in what circumstance they were needed, as well as their credentials. This has the potential to introduce bias.Study selection The abstract analyses 31 studies, of which 20 met the quality assurance criteria. The papers searched for were those in both Spanish and English, which may potentially increase the number of relevant studies that contribute to data synthesis. The original searches identified 3,104 articles, yet the search strategy has not been adequately detailed by the authors; only a basic description of the type of phrases which were entered into the databases is provided. Table 1 clearly displays the databases and sources for the data collection, but it does not show how many papers were utilised from each database and there is no detail as to whether the search strategy was amended to align with the requirements of each database. A detailed strategy would be essential for transparency and reproducibility, and is a significant omission to the review. The authors have also observed that the literature search was performed in 2017 and the paper was published in 2018. However, the search strategies are only up until 2016, and due to this, there is potentially missing data from 2016-2018. In this missing data, one of the most important factors is the new international guidelines on periodontal disease diagnosis, which would have been instrumental in defining what the author describes as 'periodontitis'.Data extraction and synthesis This study excluded papers that used ambiguous definitions for periodontitis, but fails to define what 'ambiguous' means and what the criteria or diagnostic process were. In addition, the PRISMA diagram excludes studies that are 'short', with no mention of how this has been determined or justification for this exclusion. In addition, in the diagram, there is an incomplete sentence: 'Did not include a description of the...' - the description is incomplete and it is unclear what the authors were eluding to.Results Positive association does not equal causation and this is poorly defined. The results display an odds ratio of 2.01, 95% CI 1.81-2.36, which, if the methods were reproducible, would be a very statistically significant result.Conclusion Women with chronic periodontitis who are expecting children are at a twofold increase in the risk of their baby being born prematurely. Assessment of periodontal diseases in expectant mothers is not defined by professional consensus.

Enhancing shared and surrogate decision making for people living with dementia: A systematic review of the effectiveness of interventions.

BACKGROUND: Dementia can have a profound impact on decision making. People living with dementia (PLwD) often need to make decisions about health care, and, as dementia progresses, decisions may need to be made on their behalf. Specific interventions may support this process. REVIEW QUESTION: What interventions are effective in improving shared decision making or surrogate decision making on the health care of PLwD? METHODS: A narrative systematic review of existing literature was conducted. Seven databases, grey literature and key journals were searched. After exclusion by title, abstracts then full texts were reviewed collaboratively to manage any disagreements. RESULTS: Eight studies met the inclusion criteria. Two articles, including one RCT, evaluated decision aids regarding the use of enteral feeding in advanced dementia. Six further articles, including five RCTs, were found which evaluated the effectiveness of interventions supporting patients or carers with advance care planning. CONCLUSION: Decision-making interventions typically consist of multiple components which aim to establish preferences for future health care. Advance care planning interventions supported aspects of the decision-making processes but their impact on decision quality was rarely evaluated. Interventions did not increase the concordance of decisions with a person's values. The decision-specific interventions are unlikely to produce benefit in other decision contexts. PATIENT INVOLVEMENT: Two caregivers, a public stakeholder group and a carer group were consulted in the design of the wider study to which this review relates. Six PLwD refined the research questions addressed in this paper.

The Impact of Dementia on Oral Health and Dental Care, Part 1: Setting the Scene for Dental Care Provision.

There are over 850,000 people living with dementia in the UK and this figure is expected to rise to over a million by 2021. Increasingly, oral healthcare professionals in primary care will see more patients affected by dementia at varying stages of the disease, and it is therefore crucial that they have a basic understanding of the disease and how these patients can be managed in a primary care environment. The first article in this series of two provides a definition of dementia and describes the symptoms of the disease along with the key issues related to oral health, such as oral pain. Oral pain can have far reaching consequences, but identifying it can be problematic, particularly in the latter stages of the disease. This article will therefore cover how to diagnose pain in patients with dementia. Information is also provided about how to make dental surgeries more 'dementia friendly'.

The Impact of Dementia on Oral Health and Dental Care, Part 2: Approaching and Planning Treatment.

Dementia has been described as the biggest health and social care challenge of this century; its impact on dental care cannot be ignored. Dementia affects cognitive ability and decision making, so it is important that oral healthcare professionals are conversant with current mental capacity legislation and issues that may be raised when treatment planning for patients living with the condition. This second article in the series considers the impact of dementia on dental care provision and covers a range of issues which are relevant to both general and specialist practice. These include assessment of capacity, use of different treatment modalities, such as sedation and general anaesthesia, and the factors that may be relevant when deciding to offer treatment or to refer to a secondary care setting for dental treatment. Advanced care planning is detailed to support general dental practitioners considering the longer-term wishes of their patients with an early diagnosis of dementia.

Care pathways and provision in bariatric dental care: an exploration of patients' and dentists' experiences in the North East of England.

Introduction Levels of obesity in the UK are increasing. The suitability and safety of dental care delivery can be affected by obesity. When patients' weight exceeds that of a normal dental chair, referral to specialist settings can be appropriate, yet no research has explored the process of care for this group.Aims This study aimed to explore the experiences of patients and dentists regarding referral to bariatric dental care facilities.Method Semi-structured interviews were completed with patients referred to a bariatric dental service and referring dentists. Interview transcripts were analysed thematically.Results Twelve dentists and eight patients participated. Both groups were aware that obesity influenced care and had concerns about the safety of treatment. Dentists were cautious about discussing weight though patients were willing to discuss this. The challenges in identifying weight and organising appropriate care were key issues affecting both patients and dentists.Conclusion Dentists should engage in discussions regarding obesity without hesitation, where appropriate. Redesigned patient-focused care pathways to direct patients to accessible services would help reduce stigma and improve safety for patients with obesity.

Orofacial pain assessment and management for patients with dementia: A meta-ethnography.

Delivering dental treatment for patients with dementia can be challenging, and the complexity of treatment provision can increase as dementia progresses. Treatment at the later stages of dementia can be associated with ethical challenges and procedural risk meaning that a comprehensive patient assessment is crucial; the presence of orofacial pain is a key indication for active intervention from dental teams. To explore the process of oro-facial pain assessment and management, a comprehensive review of qualitative literature was undertaken by searching six electronic databases. No literature specific to orofacial pain assessment was identified. The inclusion criteria were widened to explore assessment and management of pain in general for patients with dementia. Meta-ethnography with reciprocal translation was used to identify key concepts and themes and synthesise information applicable to the dental setting. Three major themes arose as follows: challenges with pain assessment, challenges with pain management and logistics and education. Healthcare teams struggle with pain identification in patients with dementia though many signs were identified which may suggest a patient is experiencing pain. The long-term knowledge of individual patients held by family members and care teams can allow identification of deviation from patients' normal states; this knowledge can assist healthcare professionals in determining whether to provide specific treatments or interventions. Pain assessment tools were found to be problematic and are unlikely to be a practical solution to use for complex patients in dental settings. Education for dental and wider care teams on orofacial pain would be highly valuable; yet, this needs to be based on suitable evidence.