Editorial - Delivering Better Oral Health 2021 - What's new and where next?

Delivering Better Oral Health (DBOH) was fi rst published in 2007 (Department of Health et al., 2007) at the request of the Department of Health to the British Association of Community Dentistry (BASCD). It was led by Dr Sue Gregory, who was at that time President of BASCD; and, thereafter, appointed Deputy Chief Dental Officer for England. The purpose of the document was to support dental teams in a more preventive approach to dental care based on the best available evidence. Practitioners have access to an enormous amount of information, and it was intended that DBOH would provide a simple guide to the evidence, explaining what the research meant in practical terms for the preventive advice and treatment of their patients. The approach promoted preventive care for all patients and additional support for those most at risk of poor oral health. DBOH was to be a living document, regularly updated. It was revised in 2009 and 2014, when after the Health and Social Care Act (2012), Public Health England took on the leadership of its development. In 2017 revisions responsed to changes in guidance; the publication by the Scientific Advisory Committee on Nutrition of the Carbohydrates and Health Report (SACN, 2015) which led to a revised healthier eating section and the Chief Medical Officers' (2016) new guidelines on alcohol were also incorporated.

Effectiveness of school-based behavioural interventions to improve children's oral health by reducing sugar intake and promoting oral hygiene: A rapid review of randomised controlled trials.

OBJECTIVE: To evaluate evidence of the effectiveness of school-based behavioural interventions to improve the oral health of children aged 3-18 years in a rapid review of randomised controlled trials (RCTs). METHODS: Three independent reviewers searched MEDLINE, EMBASE, Web of Science and other sources between January 2000 and December 2020 for eligible published and unpublished studies in English and extracted data. Primary outcomes were caries increment, plaque levels, gingival health, reported frequency and/or amount of free sugars intake and oral hygiene behaviour. Risk of bias was assessed using the Cochrane criteria. RESULTS: Eight cluster RCTs met the inclusion criteria and had substantial heterogeneity. Three trials assessed caries increment and one found significant reductions in the intervention group. Another trial found similar benefits, but these were limited to children from high socioeconomic groups. The third trial found an increase in dental caries in the intervention group. Three studies reported significant reductions in plaque scores and improvements in gingival health with modest effects. Interventions delivered by peers (at adolescence) or with parents' involvement (at pre-adolescence) showed significant reductions in plaque scores compared to those delivered by dentists or teachers only. Most interventions showed significant improvements in self-reported behaviours. CONCLUSIONS: There is limited evidence of clinical benefit to dental health from school-based behavioural interventions. There is a need to conduct well-designed trials of behavioural interventions that are theory-derived and include environmental elements (e.g. supervised toothbrushing). Future trials would benefit from cost-effectiveness analysis and assessment of interventions' effect on oral health inequalities amongst children.

Shaping dental contract reform: a clinical and cost-effective analysis of incentive-driven commissioning for improved oral health in primary dental care.

OBJECTIVE: To evaluate the clinical and cost-effectiveness of a new blended dental contract incentivising improved oral health compared with a traditional dental contract based on units of dental activity (UDAs). DESIGN: Non-randomised controlled study. SETTING: Six UK primary care dental practices, three working under a new blended dental contract; three matched practices under a traditional contract. PARTICIPANTS: 550 new adult patients. INTERVENTIONS: A new blended/incentive-driven primary care dentistry contract and service delivery model versus the traditional contract based on UDAs. MAIN OUTCOME MEASURES: Primary outcome was as follows: percentage of sites with gingival bleeding on probing. Secondary outcomes were as follows: extracted and filled teeth (%), caries (International Caries Detection and Assessment System (ICDAS)), oral health-related quality of life (Oral Health Impact Profile-14 (OHIP-14)). Incremental cost-effective ratios used OHIP-14 and quality adjusted life years (QALYs) derived from the EQ-5D-3L. RESULTS: At 24 months, 291/550 (53%) patients returned for final assessment; those lost to follow-up attended 6.46 appointments on average (SD 4.80). The primary outcome favoured patients in the blended contract group. Extractions and fillings were more frequent in this group. Blended contracts were financially attractive for the dental provider but carried a higher cost for the service commissioner. Differences in generic health-related quality of life were negligible. Positive changes over time in oral health-related quality of life in both groups were statistically significant. CONCLUSIONS: This is the first UK study to assess the clinical and cost-effectiveness of a blended contract in primary care dentistry. Although the primary outcome favoured the blended contract, the results are limited because 47% patients did not attend at 24 months. This is consistent with 39% of adults not being regular attenders and 27% only visiting their dentist when they have a problem. Promotion of appropriate attendance, especially among those with high need, necessitates being factored into recruitment strategies of future studies.

The prevalence of incisor hypomineralisation and its relationship with the prevalence of molar incisor hypomineralisation.

AIM: To establish the prevalence of incisor hypomineralisation (IH) in a cohort of 12-year-old children in Northern England and to relate the prevalence to gender, socioeconomic status, and the prevalence of molar incisor hypomineralisation (MIH). METHOD: The study population comprised 12-year-old children participating in the 2008-2009 National Dental Epidemiological Programme in five regions in Northern England. Participating dentists were trained and calibrated in the use of the modified Developmental Defects of Enamel Index. Children were examined at school under direct vision with the aid of a dental mirror. First permanent molars and incisors were recorded for the presence and type of enamel defects greater than 2 mm. A diagnosis of MIH was ascribed to any child with a demarcated defect in any first permanent molar. A diagnosis of IH was ascribed to any child with a demarcated defect in an incisor but with molar sparing. RESULTS: 3,233 children were examined. The prevalence of IH was 11.0 % (95 % CI 11.0-12.2 %). There was a strong positive correlation between the prevalence of MIH and IH in different regions which reached significance (r = 0.9, p = 0.037) according to Spearman's rho test of correlation. There was a similar pattern of prevalence in the different socioeconomic quintiles although this correlation did not reach significance. The most common teeth affected in IH were the maxillary central incisors, followed by the maxillary lateral incisors and followed by the mandibular incisors. There was no difference in the prevalence of IH by gender. CONCLUSIONS: The prevalence of IH was 11.0 %. The variation of prevalence between regions and socioeconomic groups and the distribution of lesions in the teeth were very similar to observations seen in MIH children from the same cohort.

The effect of premature extraction of primary teeth on the subsequent need for orthodontic treatment.

AIM: To investigate if premature extraction of primary teeth was associated with orthodontic need in the permanent dentition. STUDY DESIGN: This was a case-control study based on retrospective dental records. METHODS: As part of NHS (UK) Dental Epidemiology Programme a sample of 366, 12-year-old children from Bradford and Airedale were examined. The survey collected data on patient demographics, dental health status including orthodontic need. Data linkage was undertaken for those children participating in the NHS Dental Epidemiology Programme who had previously accessed the local Salaried Dental Service (SDS). For these children, retrospective dental information was collected about premature extraction of primary teeth. RESULTS: From the 366 children who were surveyed, 116 children had received treatment at the local SDS in the past. Significantly more children from ethnic minorities, low socioeconomic backgrounds and high caries rate (p < 0.001) were seen in the SDS. For the 107 children who attended SDS, an increased total number of primary teeth extractions was positively associated with orthodontic need (odds ratio:1.18, CI -1.01 to 1.37). STATISTICS: Multilevel modelling was undertaken to identify variables associated with orthodontic need. CONCLUSIONS: In the study group, orthodontic need was significantly associated with the number of primary teeth extracted.

The self-reported oral health status and dental attendance of smokers and non-smokers.

AIM: To report the oral health status and dental attendance of smokers and non-smokers. METHODS: A postal survey enquiring about smoking status, stop smoking advice, dental attendance and perceptions of oral health was conducted in Yorkshire and the Humber, U.K., in 2008. To address potential biases data were weighted to account for variations in gender, age and deprivation. Data were analysed using descriptive statistics, chi-square tests and binary logistic regression. RESULTS: A response rate of 43.1% was achieved (n=10,864). Across all deprivation quintiles, smokers (17.5% of respondents) were more likely than non-smokers to report fair, poor or very poor oral health (p<0.001). Smokers in the least deprived areas were more likely than non-smokers to attend the dentist symptomatically (p<0.001). Advice to quit was most frequently gained from GP services followed by NHS Stop Smoking Services and dental teams. CONCLUSIONS: Smokers were more likely than non-smokers to have a poor self-rated oral health status and attend the dentist symptomatically, irrespective of deprivation.

Summary of: job satisfaction among dually qualified dental hygienist-therapists in UK primary care: a structural model.

OBJECTIVE: To investigate job satisfaction among hygienist-therapists. Increasing numbers of hygienist-therapists work in UK primary dental care teams. Earlier studies suggest a clinical remit/clinical activity mismatch, without investigating any link with job satisfaction. METHODS: A UK-wide survey of dental hygienist-therapists using a random sample of the General Dental Council Register of Dental Care Professionals. Factors associated with job satisfaction (measured by the Warr-Cook-Wall ten-dimension scale) were entered into a series of multiple regression analyses to build up a path model. RESULTS: Analysis was undertaken on 183 respondents (response rate: 60%). Mean score for overall satisfaction was 5.36 (SD 1.28) out of a range of 1-7. Multiple regression analysis confirmed the following direct predictors of overall job satisfaction: satisfaction with colleagues, remuneration, variety of work; rating of hygiene work as rewarding; and not being self-employed (R(2) = 0.69). Satisfaction with variety of work was the strongest predictor, itself strongly predicted by the extent the clinical remit was undertaken. Dentists' recognition of their remit, quality of clinical work and qualifications had a strong indirect effect on overall job satisfaction. CONCLUSIONS: The study suggests both greater use of the therapy skills these individuals possess, and better recognition of their remit, qualifications and quality of work by their dentist colleague, may be linked to higher job satisfaction. The implications for the policy of greater team working in dental primary care are discussed.

The oral health of adults in Yorkshire and Humber 2008.

BACKGROUND AND AIM: Although national surveys are conducted of the oral health of adults in the UK, few data are available at regional and primary care trust levels to inform local commissioning. A postal survey was conducted to investigate the oral health and use of dental services by adults in the Yorkshire and Humber region. METHOD: A questionnaire was developed and piloted, then sent to a random sample of 25,200 adults. Data were analysed by sex, gender, age and deprivation. RESULTS: 10,864 (43.0%) questionnaires were returned completed. Nearly three-quarters (71.6%) of respondents had 20 or more teeth and approximately one quarter (25.3%) rated their oral health as fair, poor or very poor. The percentage reporting painful aching, discomfort when eating and being self-conscious about their mouths (occasionally or more often in the last 12 months) were 28.8%, 32.8% and 29.1% respectively. Overall, 80.3% reported attending a dentist in the last two years, although nearly a quarter (22.6%) of respondents reported difficulties accessing routine care. However, there were marked inequalities between those living in the most and least deprived neighbourhoods. CONCLUSION: This survey was the first to investigate the oral health and service use of adults in the Yorkshire and Humber region. The findings have implications for the local commissioning of dental services.

Dental therapy in the United Kingdom: part 4. Teamwork--is it working for dental therapists?

OBJECTIVES: To determine whether practising dental therapists, including dually qualified hygienist/therapists, considered themselves to be part of the clinical team and whether clinical work referred to them met with their expectations. METHODS: A postal survey enquired about work experiences of UK dental therapists, as previously described earlier in the series. RESULTS: While they certainly considered themselves to be part of the clinical team, the majority of respondents did not feel 'fully utilised'. Seventy percent of respondents felt that the dentist had more patients that could be referred and 55% thought that they could do more extensive work. There was concern that dentists lacked awareness of therapists' clinical potential, although some respondents highlighted very positive experiences in practice. CONCLUSIONS: Dental therapists feel that they are part of the clinical team but consider that their skills are not fully utilised in many cases. There is scope for raising awareness among dentists regarding the therapists' clinical potential as well as sharing ideas for good working practice both within individual clinical settings and between different practices.

Dental therapy in the United Kingdom: part 2. A survey of reported working practices.

OBJECTIVES: To conduct a survey of current working practices of UK dental therapists following the changes in permitted duties, allowed clinical settings and the introduction of the new dental contract in England and Wales. METHODS: A piloted postal questionnaire was circulated in 2006 to all General Dental Council (GDC) registered therapists and those on the hygienists register possessing a dental therapy qualification. Two subsequent mailings were used to boost the response rate. RESULTS: There was an 80.6% response rate (n = 587). Ninety-eight percent of respondents were female. Average time since qualification was 17 years. Eighty percent (n = 470) of respondents were currently working as a dental therapist, 53% part-time. Of the 470, half were engaged entirely in general dental practice (GDP), one third in the salaried dental services (SDS), while others worked across different settings. Only 39% claimed to spend most of their time treating children. Recently qualified therapists more often worked in GDP (p <0.001). Overall, a wide range of clinical duties were performed, although there was concern about maintaining skills across all the competencies since qualification, while emphasis on hygiene work was a limiting factor for some. On the basis of the continued professional development (CPD) activities described over one year, only half would have met the GDC CPD requirements from August 2008 for dental care professionals (DCPs). CONCLUSIONS: More than half of therapists now work in GDP, compared with none six years previously. Many undertake a full range of duties. However, there was concern that some dentists use them for hygiene skills rather than across the whole range of their competencies, risking deskilling, while others reported their inability to gain employment as a therapist.

Dental therapy in the United Kingdom: part 3. Financial aspects of current working practices.

OBJECTIVES: To enquire into current remuneration arrangements among UK dental therapists and to explore the nature of any financially related concerns. METHODS: Part of the postal survey of therapists described in the previous paper in this series. RESULTS: The majority of therapists (63%) often work in multiple locations and therefore may be in receipt of more than one type of payment mechanism. Two thirds of therapists are paid an hourly rate in at least one of the locations where they work; just over half are paid a fixed monthly amount and one third are self-employed. Nine percent of respondents were receiving performance-related pay, using goal setting, incentives and bonuses. A number of financially-related concerns were identified. CONCLUSION: Diverse payment systems were reported. Some aspects could present important implications for future recruitment and retention.

Dental therapy in the United Kingdom: part 1. Developments in therapists' training and role.

The number of students entering training for dental therapy has been increasing rapidly over the last few years. In practice, the scope of their work has increased, both in terms of permitted duties and their range of clinical settings. The possibilities for dental practitioners to work with therapists is therefore increasing, so it is important for them to be clear about therapists' potential capacity to provide added value to the dental team. This paper, which is the first of four covering aspects of dental therapy in the UK, traces the history of dental therapy together with the development of therapists' training opportunities and emerging competencies, up to the present. The subsequent three papers will describe aspects of a survey of dental therapists undertaken in late 2006.

School-based epidemiological surveys and the impact of positive consent requirements.

A requirement to obtain positive consent for participants in school-based dental epidemiological surveys was introduced in 2006. Concern has been expressed about the impact of the changes on the validity of results as the need to obtain positive consent is likely to reduce the numbers participating. An additional concern is that the new requirement may also lead to samples that are biased, resulting in them being unrepresentative of the population from which they are drawn. This paper aims to discuss the implications of the changes on the quality of future school-based dental epidemiological surveys, and whether they threaten the validity of survey findings at a time when such information is critical in informing the local commissioning of dental services.

Oral health and health related behaviours among three-year-old children born to first and second generation Pakistani mothers in Bradford, UK.

Many young Muslim children whose families originated from the Indian sub-continent have poorer levels of oral health than their indigenous White peers, but it is unclear whether and to what extent subsequent generations may be similarly disadvantaged. This study aimed to compare dental health and associated behavioural attributes among United Kingdom-born three-year-old children of first and second generation Pakistani Muslim mothers resident in areas of social deprivation in Bradford, West Yorkshire. Multi-lingual interviews completed a home-based, semi-structured questionnaire, and a dental examination was conducted at a subsequent visit on 226 children, 117 with Pakistan-born mothers and 109 born in the UK. When the two generation groups were compared, no differences were observed in infant feeding practices, oral hygiene routines or dental attendance patterns, in mothers' attendance at ante-natal classes, or their knowledge of caries prevention. However, a higher proportion of UK-born mothers were able to speak English and reported that they had attended a dentist themselves, had received advice there, and were better informed of categories exempt from dental charges. A 24-hour retrospective qualitative dietary recall indicated that children of UK-born mothers consumed, on average, more frequent intakes of foods classified in the 'bread and cereal' group and of sweet drinks at meal times. While there were no significant differences in the proportion who were cavity free, children of UK-born mothers had higher mean caries experience (dmft=2.30) compared with those of Pakistan-born mothers (dmft=1.38). It was concluded that the total burden of dental caries experience among a subsequent generation of Pakistani children was higher than that of the previous generation. Poor dental health is likely to remain a challenge in this community for the foreseeable future.

Dentists' perceptions of difficulties encountered in providing dental care for British Asians.

British Asians represent a substantial proportion of the population in some parts of the United Kingdom, yet many fail to use dental services regularly. This study aimed to investigate dentists' concerns about providing care for this client group. Following a pilot study, a postal questionnaire was sent to general dental practitioners and community dental officers working in seven family health services authority localities. Of 1546 questionnaires circulated, 639 (41 per cent) were returned. The language barrier was most frequently identified as a major impediment to care (78 per cent), followed by patients' understanding of treatment proposed (67 per cent), while 64 per cent found difficulty obtaining medical histories. Only 20 per cent considered that gaining consent for treatment was a problem. Other issues concerned attendance as casual patients (65 per cent) and, in terms of treatment provided, difficulties with preventive (77 per cent), periodontal (66 per cent) and orthodontic care (27 per cent). The proportion of dentists identifying barriers to care reflected the English-speaking abilities of different Asian populations. Compared with the high percentage mentioning language, understanding and medical history, the small proportion of dentists who thought that consent was of concern suggests that concepts of consent may need to be questioned. Despite the low response rate, the high proportion of respondents identifying these issues implies that the present position may put patients' health at risk, restrict treatment options and offer a potential for litigation. Future initiatives to overcome barriers to appropriate care must address the perspectives of dentists treating British Asians, as well as that of the client group.