The CATFISH study: An evaluation of a water fluoridation program in Cumbria, UK.

OBJECTIVES: The objective was to assess the effectiveness of a Water Fluoridation program on a contemporary population of children. METHODS: The study used a longitudinal prospective cohort design. In Cumbria, England, two groups of children were recruited and observed over a period of 5-6 years. The Birth Cohort consisted of families recruited from two hospitals in Cumbria where children were conceived after water fluoridation was reintroduced. The systemic and topical effects of community water fluoridation were evaluated in the Birth Cohort. The Older Cohort were approximately 5 years old and recruited from primary schools in Cumbria, shortly after water fluoridation was reintroduced. The predominantly topical effects of fluoridated water were evaluated in the Older Cohort. The primary outcome was the proportion of children with clinical evidence of caries experience in their primary (Birth Cohort) or permanent teeth (Older Cohort). Unadjusted and adjusted regression models were used for analysis. RESULTS: The final clinical examinations for the Birth Cohort involved 1444 participants (mean age 4.8 years), where 17.4% of children in the intervention group were found to have caries experience, compared to 21.4% in the control group. A beneficial effect of water fluoridation was observed adjusting for deprivation (a socioeconomic measure), sex, and age, (adjusted odds ratio 0.74 95% CI 0.55 to 0.98). The final Older Cohort clinical examinations involved 1192 participants (mean age 10.8 years) where 19.1% of children in the intervention group were found to have caries experience compared to 21.9% in the control group (adjusted odds ratio 0.80, 95% CI 0.58 to 1.09). For both the Birth Cohort and Older Cohort there was evidence of a beneficial effect on dmft/DMFT count (IRR 0.61, 95% CI 0.44, 0.86) and (IRR 0.69, 95% CI 0.52, 0.93) respectively. No conclusive proof was found to indicate that the effectiveness of water fluoridation differed across area deprivation quintiles. CONCLUSIONS: In the contemporary context of lower caries levels and widespread use of fluoride toothpaste, the impact of water fluoridation on the prevalence of caries was smaller than previous studies have reported. It is important to consider the clinical importance of the absolute reduction in caries prevalence against the use of other dental caries preventive measures.

Effect of fluoridated water on invasive NHS dental treatments for adults: the LOTUS retrospective cohort study and economic evaluation.

Background: Most water fluoridation studies were conducted on children before the widespread introduction of fluoride toothpastes. There is a lack of evidence that can be applied to contemporary populations, particularly adolescents and adults. Objective: To pragmatically assess the clinical and cost effectiveness of water fluoridation for preventing dental treatment and improving oral health in a contemporary population of adults, using a natural experiment design. Design: Retrospective cohort study using routinely collected National Health Service dental claims (FP17) data. Setting: National Health Service primary dental care: general dental practices, prisons, community dental services, domiciliary settings, urgent/out-of-hours and specialised referral-only services. Participants: Dental patients aged 12 years and over living in England (n = 6,370,280). Intervention and comparison: Individuals exposed to drinking water with a fluoride concentration ≥ 0.7 mg F/l between 2010 and 2020 were matched to non-exposed individuals on key characteristics using propensity scores. Outcome measures: Primary: number of National Health Service invasive dental treatments (restorations/'fillings' and extractions) received per person between 2010 and 2020. Secondary: decayed, missing and filled teeth, missing teeth, inequalities, cost effectiveness and return on investment. Data sources: National Health Service Business Services Authority dental claims data. Water quality monitoring data. Primary outcome: Predicted mean number of invasive dental treatments was 3% lower in the optimally fluoridated group than in the sub/non-optimally fluoridated group (incidence rate ratio 0.969, 95% CI 0.967 to 0.971), a difference of -0.173 invasive dental treatments (95% CI -0.185 to -0.161). This magnitude of effect is smaller than what most stakeholders we engaged with (n = 50/54) considered meaningful. Secondary outcomes: Mean decayed, missing and filled teeth were 2% lower in the optimally fluoridated group, with a difference of -0.212 decayed, missing and filled teeth (95% CI -0.229 to -0.194). There was no statistically significant difference in the mean number of missing teeth per person (0.006, 95% CI -0.008 to 0.021). There was no compelling evidence that water fluoridation reduced social inequalities in treatments received or missing teeth; however, decayed, missing and filled teeth data did not demonstrate a typical inequalities gradient. Optimal water fluoridation in England in 2010-20 was estimated to cost £10.30 per person (excluding original setup costs). Mean National Health Service treatment costs for fluoridated patients 2010-20 were 5.5% lower per person, by £22.26 (95% CI -£23.09 to -£21.43), and patients paid £7.64 less in National Health Service dental charges per person (2020 prices). Limitations: Pragmatic, observational study with potential for non-differential errors of misclassification in fluoridation assignment and outcome measurement and residual and/or unmeasured confounding. Decayed, missing and filled teeth data have not been validated. Water fluoridation cost estimates are based on existing programmes between 2010 and 2020, and therefore do not include the potentially significant capital investment required for new programmes. Conclusions: Receipt of optimal water fluoridation between 2010 and 2020 resulted in very small health effects, which may not be meaningful for individuals, and we could find no evidence of a reduction in social inequalities. Existing water fluoridation programmes in England produced a positive return on investment between 2010 and 2020 due to slightly lower National Health Service treatment costs. These relatively small savings should be evaluated against the projected costs and lifespan of any proposed capital investment in water fluoridation, including new programmes. Future work: National Health Service dental data are a valuable resource for research. Further validation and measures to improve quality and completeness are warranted. Trial registrations: This trial is registered as ISRCTN96479279, CAG: 20/CAG/0072, IRAS: 20/NE/0144. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: NIHR128533) and is published in full in Public Health Research; Vol. 12, No. 5. See the NIHR Funding and Awards website for further award information.

Fluoride is a natural mineral that prevents tooth decay. It is added to some drinking water and toothpastes to improve dental health. Water with fluoride added is known as 'optimally fluoridated'. Most research on water fluoridation was carried out before fluoride was added to toothpastes in the 1970s and only included children. We wanted to know if water fluoridation still produced large reductions in tooth decay, now that decay levels are much lower because of fluoride in toothpaste. We also wanted to look at its effect on adults and teenagers. Dental patients we spoke to told us they worried about needing treatment with the 'drill', or 'injection', losing their teeth and paying for their dental care. To see if water fluoridation helped with these concerns, we compared the National Health Service dental records of 6.4 million adults and teenagers who received optimally fluoridated or non-optimally fluoridated water in England between 2010 and 2020. We found water fluoridation made a very small difference to each person. Between 2010 and 2020, the number of NHS fillings and extractions was 3% lower per person for those who received optimally fluoridated water. We found no difference in the number of teeth lost per person and no strong sign that fluoridation reduced differences in dental health between rich and poor areas. Between 2010 and 2020, the cost of optimal water fluoridation was £10.30 per person (not including setup costs). National Health Service dental patients who received optimally fluoridated water cost the National Health Service £22.26 (5.5%) less and paid £7.64 (2%) less per person in National Health Service dental charges over the 10 years. The benefits we found are much smaller than in the past, when toothpastes did not contain fluoride. The cost to set up a new water fluoridation programme can be high. Communities may need to consider if these smaller benefits would still outweigh the costs.

Economic evaluation of a water fluoridation scheme in Cumbria, UK.

OBJECTIVES: The addition of fluoride to community drinking water supplies has been a long-standing public health intervention to improve dental health. However, the evidence of cost-effectiveness in the UK currently lacks a contemporary focus, being limited to a period with higher incidence of caries. A water fluoridation scheme in West Cumbria, United Kingdom, provided a unique opportunity to study the contemporary impact of water fluoridation. This study evaluates the cost-effectiveness of water fluoridation over a 5-6 years follow-up period in two distinct cohorts: children exposed to water fluoridation in utero and those exposed from the age of 5. METHODS: Cost-effectiveness was summarized employing incremental cost-effectiveness ratios (ICER, cost per quality adjusted life year (QALY) gained). Costs included those from the National Health Service (NHS) and local authority perspective, encompassing capital and running costs of water fluoridation, as well as NHS dental activity. The measure of health benefit was the QALY, with utility determined using the Child Health Utility 9-Dimension questionnaire. To account for uncertainty, estimates of net cost and outcomes were bootstrapped (10 000 bootstraps) to generate cost-effectiveness acceptability curves and sensitivity analysis performed with alternative specifications. RESULTS: There were 306 participants in the birth cohort (189 and 117 in the non-fluoridated and fluoridated groups, respectively) and 271 in the older school cohort (159 and 112, respectively). In both cohorts, there was evidence of small gains in QALYs for the fluoridated group compared to the non-fluoridated group and reductions in NHS dental service cost that exceeded the cost of fluoridation. For both cohorts and across all sensitivity analyses, there were high probabilities (>62%) of water fluoridation being cost-effective with a willingness to pay threshold of £20 000 per QALY. CONCLUSIONS: This analysis provides current economic evidence that water fluoridation is likely to be cost-effective. The findings contribute valuable contemporary evidence in support of the economic viability of water fluoridation scheme.

How effective and cost-effective is water fluoridation for adults and adolescents? The LOTUS 10-year retrospective cohort study.

OBJECTIVE: To pragmatically assess the clinical and cost-effectiveness of water fluoridation for preventing dental treatment and improving oral health in a contemporary population of adults and adolescents, using a natural experiment design. METHODS: A 10-year retrospective cohort study (2010-2020) using routinely collected NHS dental treatment claims data. Participants were patients aged 12 years and over, attending NHS primary dental care services in England (17.8 million patients). Using recorded residential locations, individuals exposed to drinking water with an optimal fluoride concentration (≥0.7 mg F/L) were matched to non-exposed individuals using propensity scores. Number of NHS invasive dental treatments, DMFT and missing teeth were compared between groups using negative binomial regression. Total NHS dental treatment costs and cost per invasive dental treatment avoided were calculated. RESULTS: Matching resulted in an analytical sample of 6.4 million patients. Predicted mean number of invasive NHS dental treatments (restorations 'fillings'/extractions) was 3% lower in the optimally fluoridated group (5.4) than the non-optimally fluoridated group (5.6) (IRR 0.969, 95% CI 0.967, 0.971). Predicted mean DMFT was 2% lower in the optimally fluoridated group (IRR 0.984, 95% CI 0.983, 0.985). There was no difference in the predicted mean number of missing teeth per person (IRR 1.001, 95% CI 0.999, 1.003) and no compelling evidence that water fluoridation reduced social inequalities in dental health. Optimal water fluoridation in England 2010-2020 was estimated to cost £10.30 per person (excludes initial set-up costs). NHS dental treatment costs for optimally fluoridated patients 2010-2020 were 5.5% lower, by £22.26 per person (95% CI -£21.43, -£23.09). CONCLUSIONS: Receipt of optimal water fluoridation 2010-2020 resulted in very small positive health effects which may not be meaningful for individuals. Existing fluoridation programmes in England produced a positive return on investment between 2010 and 2020 due to slightly lower NHS dental care utilization. This return should be evaluated against the projected costs and lifespan of any proposed capital investment in water fluoridation, including new programmes.

Dentistry responding to domestic violence and abuse: a dental, practice-based intervention and a feasibility study for a cluster randomised trial.

Objectives Assess the feasibility of using the Identification and Referral to Improve Safety (IRIS) intervention in a general dental practice setting and evaluating it using a cluster randomised trial design. IRIS is currently used in general medical practices to aid recognition and support referral into specialist support of adults presenting with injuries and other presenting factors that might have resulted from domestic violence and abuse. Also, to explore the feasibility of a cluster randomised trial design to evaluate the adapted IRIS.Design Feasibility study for a cluster randomised trial of a practice-based intervention.Setting Greater Manchester general dental practices.Results It was feasible to adapt the IRIS intervention used in general medical practices to general dental practices in terms of training the clinical team and establishing a direct referral pathway to a designated advocate educator. General dental practices were keen to adopt the intervention, discuss with patients when presented with the opportunity and utilise the referral pathway. However, we could not use practice IT software prompts and data collection as for general practitioners because there is no unified dental IT system and because coding in dentistry for diagnoses, procedures and outcomes is not developed in the UK.Conclusion While it was feasible to adapt elements of the IRIS intervention to general dental practice and there was general acceptability, we did not have enough empirical data to plan a definitive cluster randomised trial design to evaluate the IRIS-dentistry intervention within general dental practices.

Unlocking the potential of NHS primary care dental datasets.

Introduction Maximising the use of routinely collected health data for research is a key part of the UK Government's Industrial Strategy. Rich data are generated by NHS primary care dental services, but the extent of their use in research is unknown.Aims To profile the utility of the post-2006 NHS dental datasets for research, map how they have been used to date and develop recommendations to maximise their utility.Methods The content of and access to the four UK NHS dental datasets was collated using publicly available information and a free-text questionnaire, completed by the relevant data controllers. A scoping review was carried out to identify and map literature that has utilised NHS dental activity data.Results The contents of the UK NHS dental activity datasets are described, alongside how they may be accessed for research. Strengths and weaknesses of these datasets for research are highlighted. The scoping review identified 33 studies which had utilised NHS dental activity data since 2006. We classified 15 as public health practice, 11 as service evaluation and 7 as research.Conclusion In comparision to other NHS activity datasets, it appears that the UK dental datasets have been underutilised for research. We make 11 recommendations on how their utility for research may be increased.

Assessing the reliability of automatic sentiment analysis tools on rating the sentiment of reviews of NHS dental practices in England.

BACKGROUND: Online reviews may act as a rich source of data to assess the quality of dental practices. Assessing the content and sentiment of reviews on a large scale is time consuming and expensive. Automation of the process of assigning sentiment to big data samples of reviews may allow for reviews to be used as Patient Reported Experience Measures for primary care dentistry. AIM: To assess the reliability of three different online sentiment analysis tools (Amazon Comprehend DetectSentiment API (ACDAPI), Google and Monkeylearn) at assessing the sentiment of reviews of dental practices working on National Health Service contracts in the United Kingdom. METHODS: A Python 3 script was used to mine 15800 reviews from 4803 unique dental practices on the NHS.uk websites between April 2018 -March 2019. A random sample of 270 reviews were rated by the three sentiment analysis tools. These reviews were rated by 3 blinded independent human reviewers and a pooled sentiment score was assigned. Kappa statistics and polychoric evalutaiton were used to assess the level of agreement. Disagreements between the automated and human reviewers were qualitatively assessed. RESULTS: There was good agreement between the sentiment assigned to reviews by the human reviews and ACDAPI (k = 0.660). The Google (k = 0.706) and Monkeylearn (k = 0.728) showed slightly better agreement at the expense of usability on a massive dataset. There were 33 disagreements in rating between ACDAPI and human reviewers, of which n = 16 were due to syntax errors, n = 10 were due to misappropriation of the strength of conflicting emotions and n = 7 were due to a lack of overtly emotive language in the text. CONCLUSIONS: There is good agreement between the sentiment of an online review assigned by a group of humans and by cloud-based sentiment analysis. This may allow the use of automated sentiment analysis for quality assessment of dental service provision in the NHS.

An eReferral Management & Triage System for minor Oral surgery referrals from primary care dentists: a cost-effectiveness evaluation.

OBJECTIVE: Oral surgery referrals from NHS dental practices are rising, increasing the pressures on available hospital resources. We assess if an electronic referral system with consultant or peer (general dental practitioner) led triage of patient referrals from general dental practices can effectively divert patients requiring minor oral surgery into specialist led primary care settings at a reduced cost whilst providing care of the same or enhanced quality. One year of no triage (all referrals treated in secondary care) was followed by one-year of consultant led triage, which in turn was followed by year of peer-led triage. METHOD: A health economic evaluation of all patient referrals from 27 UK dental practices for oral surgery procedures. The follow-up is over a three-year period at hospital dental services in two general hospitals, one dental hospital, and a single specialist oral surgeon based in two primary care practices. The evaluation is a comparison of mean outcomes in the hospitals and in specialist primary care dental services between the study periods (i.e. periods with and without the triage system). The main outcomes of interest are mean NHS cost saving per referral (costs to the NHS and costs to broader society), proportion of diverted referrals, case-mix of referrals and patient reports of the quality of dentistry services received at their referral destination. RESULTS: The proportion of referrals diverted to specialist primary care was similar during both periods (45% under consultant-led triage and 43% under GDP-led triage). Statistically significant savings per referral diverted were found (£116.11 under consultant-led triage, £90.25 under GDP-led triage). There were no statistically significant changes in the case-mix of referrals. Cost savings varied according to the coding (and hence tariff) of referred cases by the provider hospitals. Patients reported similarly high levels of satisfaction scores for treatment in specialist primary care and secondary care settings. CONCLUSIONS: Implementation of electronic referral management in primary care, when combined with triage, led to appropriate diversions to specialist primary care. Although cost savings were realised by referral diversion these savings are dependent on the particular tariff allocation (coding) practices of provider hospitals.

Factors influencing dental trainees' choice of training programme and working patterns: a mixed-methods study.

Aims To assess the training programme and future career choices of newly qualified dental trainees.Methods Mixed-methods study combining a national questionnaire with focus groups administered to dental foundation trainees (DFTs) in England. Two regions chose not to participate; therefore, the questionnaire was sent to 588 DFTs and 226 (38.4%) responded. Forty-one DFTs participated in six regional focus groups.Results Location was the primary factor when choosing a training post, with 86% wanting to live and work near friends and family. Other influencers included affordability, availability of good training facilities and transport links, and proximity to their dental school. Focus group data found that perceived higher-quality training schemes were chosen over location in some circumstances. Most trainees wanted a career as an associate (67%) rather than a practice partner (32%) or owner (27%). Thirty-one percent aimed to practise on a private basis and 40% wanted to remain within the NHS. Women were significantly more likely than men to consider part-time working patterns (X2(2) = 9.761, p = 0.002). Part-time working was attractive as many found full-time clinical dentistry too stressful.Conclusions Geographical location is the key influencer on where dentists want to work and consideration needs to be given to interventions to address geographical disparities in graduate destinations. The strong desire to work part-time raises concerns about current workforce planning.

How effective and cost-effective is water fluoridation for adults? Protocol for a 10-year retrospective cohort study.

BACKGROUND: Tooth decay can cause pain, sleepless nights and loss of productive workdays. Fluoridation of drinking water was identified in the 1940s as a cost-effective method of prevention. In the mid-1970s, fluoride toothpastes became widely available. Since then, in high-income countries the prevalence of tooth decay in children has reduced whilst natural tooth retention in older age groups has increased. Most water fluoridation research was carried out before these dramatic changes in fluoride availability and oral health. Furthermore, there is a paucity of evidence in adults. The aim of this study is to assess the clinical and cost-effectiveness of water fluoridation in preventing invasive dental treatment in adults and adolescents aged over 12. METHODS/DESIGN: Retrospective cohort study using 10 years of routinely available dental treatment data. Individuals exposed to water fluoridation will be identified by sampled water fluoride concentration linked to place of residence. Outcomes will be based on the number of invasive dental treatments received per participant (fillings, extractions, root canal treatments). A generalised linear model with clustering by local authority area will be used for analysis. The model will include area level propensity scores and individual-level covariates. The economic evaluation will focus on (1) cost-effectiveness as assessed by the water fluoridation mean cost per invasive treatment avoided and (2) a return on investment from the public sector perspective, capturing the change in cost of dental service utilisation resulting from investment in water fluoridation. DISCUSSIONS: There is a well-recognised need for contemporary evidence regarding the effectiveness and cost-effectiveness of water fluoridation, particularly for adults. The absence of such evidence for all age groups may lead to an underestimation of the potential benefits of a population-wide, rather than targeted, fluoride delivery programme. This study will utilise a pragmatic design to address the information needs of policy makers in a timely manner.

Planning the oral health workforce: Time for innovation.

The levels and types of oral health problems occurring in populations change over time, while advances in technology change the way oral health problems are addressed and the ways care is delivered. These rapid changes have major implications for the size and mix of the oral health workforce, yet the methods used to plan the oral health workforce have remained rigid and isolated from planning of oral healthcare services and healthcare expenditures. In this paper, we argue that the innovation culture that has driven major developments in content and delivery of oral health care must also be applied to planning the oral health workforce if we are to develop 'fit for purpose' healthcare systems that meet the needs of populations in the 21st century. An innovative framework for workforce planning is presented focussed on responding to changes in population needs, service developments for meeting those needs and optimal models of care delivery.

The impact of changing provider remuneration on clinical activity and quality of care: Evaluation of a pilot NHS contract in Northern Ireland.

OBJECTIVES: A pilot NHS dental contract was introduced in Northern Ireland between 2015 and 2016, which involved changing the method for paying general dental practitioners working in the NHS from fee-for-service (FFS) to capitation-based payments, providing an opportunity for a robust evaluation. We investigated the impact of a change in payment methods on clinical activity and the quality of care provided. DESIGN: A difference-in-difference (DiD) evaluation was applied to clinical activity data from pilot NHS dental practices in Northern Ireland compared to matched control NHS practices and applied to a questionnaire survey of patient-rated outcomes of health outcomes and care quality. We estimated the impact on access to care, treatment activity levels, practice finances and patient-rated outcomes of care of a change from FFS to a capitation-based system for 1 year, as well as the impact of a reversion back to FFS at the end of the pilot period. RESULTS: The monthly number of registered patients in the pilot practices increased more than the control practices during the capitation period, by 1.5 registrations per 1000 registered patients. The monthly reductions in the volumes of all treatments in the pilot practices during the capitation period were much larger than the control practices, with 175 fewer treatment items. All measures rapidly returned to baseline levels following reversion from capitation back to FFS. NHS income per month increased in pilot practices, by £5920 per month (calculated on FFS item cost basis) more than controls in the capitation period. The analysis of patient questionnaires suggest found that patients notice differences only in waiting times, skill-mix and number of radiographs, but not on other measures of healthcare process and quality. CONCLUSION: General dental practitioners working in the NHS respond rapidly and consistently to changes in provider payment methods. A move from FFS to a capitation-based system had little impact on access to care, but did produce large reductions in clinical activity and patient charge income. Patients noticed little change in the service they received. This shows that changes in remuneration contracts have the potential to meet policy goals, such as meeting the expectations of patients within a predictable cost envelope. However, it is unlikely that all policy goals can be met simply by changing payment methods. Therefore, work is also needed to identify and evaluate interventions that can complement changes in remuneration to achieve desirable outcomes.

Increasing questionnaire response: evidence from a nested RCT within a longitudinal birth cohort study.

BACKGROUND: High response rates are essential when questionnaires are used within research, as representativeness can affect the validity of studies and the ability to generalise the findings to a wider population. The study aimed to measure the response rate to questionnaires from a large longitudinal epidemiological study and sought to determine if any changes made throughout data collection had a positive impact on the response to questionnaires and addressed any imbalance in response rates by participants' levels of deprivation. METHODS: Data were taken from a prospective, comparative study, designed to examine the effects of the reintroduction of water fluoridation on children's oral health over a five-year period. Response rates were analysed for the first year of data collection. During this year changes were made to the questionnaire layout and cover letter to attempt to increase response rates. Additionally a nested randomised control trial compared the effect on response rates of three different reminders to complete questionnaires. RESULTS: Data were available for 1824 individuals. Sending the complete questionnaire again to non-responders resulted in the highest level of response (25%). A telephone call to participants was the only method that appeared to address the imbalance in deprivation, with a mean difference in deprivation score of 2.65 (95% CI -15.50 to 10.20) between the responders and non-responders. CONCLUSIONS: Initially, low response rates were recorded within this large, longitudinal study giving rise to concerns about non-response bias. Resending the entire questionnaire again was the most effective way of reminding participants to complete the questionnaire. As this is a less labour intensive method than for example, calling participants, more time can then be spent targeting groups who are underrepresented. In order to address these biases, data can be weighted in order to draw conclusions about the population.

A systematic review of second molar distal surface caries incidence in the context of third molar absence and emergence.

Objective The aim of this systematic review was to gain a greater insight into the incidence rates of distal surface caries (DSC) on second permanent molars.Data sources A literature search using the Cochrane Library, Lilacs, Embase and Medline via Ovid retrieved English and non-English language articles from inception to June 2016. The electronic searches were supplemented with reference searching and citation tracking. Reviewers independently and in duplicate performed data extraction and completed structured quality assessments using a validated risk of bias tool for observational studies and categorised the summary scores.Data selection The search yielded 81 records and, after application of inclusion and exclusion criteria, two incidence studies were included in this systematic review.Data extraction The DSC incidence was reported in one study as relative risk (RR = 2.53; 95% CI, 1.55 to 4.14) adjacent to erupted, (RR = 0.83; 95% CI, 0.11 to 6.04) soft tissue impacted and (RR = 1.44; 95% CI, 0.55 to 3.72) bony impacted third molars in comparison to when the third molar was absent with a 25-year follow-up. The second study reported a DSC incidence of 100 surface-years (1% of all sites) with an 18-month follow-up period.Conclusions Both cohort studies indicated that DSC incidence was higher when third molars were erupted in the intermediate term, but greater over the long term for an ageing male population. However, further high-quality research is required to improve the accuracy of these findings.

A RAND/UCLA appropriateness method study to identify the dimensions of quality in primary dental care and quality measurement indicators.

Objectives Quality measures are increasingly used for quality measurement and improvement in primary dental care. Currently there is no consensus on a core set of quality measures that may be used in primary dental care or of the dimensions of quality important in dentistry. The objective of this study was to use a RAND/UCLA Appropriateness Method to help establish such a consensus.Methods A RAND/UCLA Appropriateness Method was used to rate dimensions of quality and quality indicators derived from the literature. Nineteen dimensions of quality and 260 quality indicators were rated by a panel of nine dentists using an online questionnaire and face-to-face meeting.Results Seventy-nine quality statements were rated as clear, necessary and feasible for use as a quality measure by the panel, from which 45 composite measures emerged. With regard to the dimensions of quality, the dimensions of the Institute of Medicine definition of quality were rated highly, alongside further dimensions of technical quality, appropriateness, comprehensiveness and coordination, and continuity of care.Conclusions This consensus study has identified a core set of quality indicators. This is a key first step toward the development of a comprehensive set of quality indicators.

Conceptualising a framework for improving quality in primary dental care.

This paper sets out a conceptual framework by which quality improvement in primary dental care can be approached. We argue that seeking a unified definition for quality in dentistry is a distraction to the more important end of quality improvement. An approach to quality improvement that interfaces Donabedian's domains of structure, process and outcome with various dimensions of quality gives a rational approach by which quality can be assessed and improved. The importance of valid, evidence driven indicators and methods for their implementation in primary dental care is described. Further work is required in order to identify which dimensions of dentistry are most important, but the Institute of Medicine's dimensions of safety, effectiveness, patient centreedness, timeliness, equity, efficiency are a good starting point. Trying to develop an absolute list of dimensions of quality should not distract from implementing an approach-based paradigm of quality improvement. Bioinformatics offers new solutions by which quality measures may be implemented and reported in the primary care setting. The focus of future research should be in implementing data-driven quality indicators at the level of the primary care practitioner.

A systematic review of quality measures used in primary care dentistry.

INTRODUCTION: 'Quality' in primary care dentistry is poorly defined. There are significant international efforts focussed on developing quality measures within dentistry. The aim of this research was to identify measures used to assess quality in primary care dentistry and categorise them according to which dimensions of quality they attempt to measure. METHODS: Quality measures were identified from the peer-reviewed and grey literature. Peer-reviewed papers describing the development and validation of measures were identified using a structured literature search. Measures from the grey literature were identified using structured searches and direct contact with dental providers and institutions. Quality measures were categorised according to domains of structure, process and outcome and by disaggregated dimensions of quality. RESULTS: From 22 studies, 11 validated measure sets (comprising nine patient satisfaction surveys and two practice assessment instruments) were identified from the peer-reviewed literature. From the grey literature, 24 measure sets, comprising 357 individual measures, were identified. Of these, 96 addressed structure, 174 addressed process and 87 addressed outcome. Only three of these 24 measure sets demonstrated evidence of validity testing. The identified measures failed to address dimensions of quality, such as efficiency and equity. CONCLUSIONS: There has been a proliferation in the development of dental quality measures in recent years. However, this development has not been guided by a clear understanding of the meaning of quality. Few existing measures have undergone rigorous validity or reliability testing. A consensus is needed to establish a definition of quality in dentistry. Identification of the important dimension of quality in dentistry will allow for the production of a core quality measurement set.

A comparison of dental fluorosis in adult populations with and without lifetime exposure to water fluoridation.

OBJECTIVES: There is a lack of evidence on the proportion and severity of fluorosis in adult populations exposed and not exposed to fluoridated water over their lifetimes. The aim of this study was to compare the proportion and severity of fluorosis in adults with lifetime exposure to water fluoridation with a nonexposed sample. A secondary aim was to report the gradient of fluorosis severity by age. METHODS: A cross-sectional study recruited a sample with lifetime exposure to water fluoridation and a matched, nonexposed group. 580 participants, aged 18-52 years (mean 34.3, SD 9.4) and 64% female, were recruited in general dental practices located in fluoridated (Birmingham and County Durham) and nonfluoridated areas (Manchester). Three digital images were taken of their incisors and an experienced examiner who was blind to exposure status viewed the images remotely and allocated fluorosis scores using the Thylstrup and Fejerskov (TF) scale. RESULTS: At TF ≥ 1 (any fluorosis), a significantly higher proportion of participants from the fluoridated area had fluorosis (F 39% NF 21.3%, P < 0.001), at the threshold TF ≥ 3 ("aesthetic concern"), the difference was no longer statistically significant (F 4.1%, NF 2.2%, P = 0.25). There was a gradient by age, whereby fluorosis was highest in the youngest and lowest in the oldest age group. CONCLUSIONS: Although fluorosis is more common in adults with lifetime exposure to water fluoridation than those with no exposure, the aesthetic impact of fluorosis seems to diminish with age.

Exploring implementation of an electronic referral management system and enhanced primary care service for oral surgery: perspectives of patients, providers and practitioners.

BACKGROUND: A specialist primary care oral surgery service combined with an electronic referral management and triage system was developed in response to concerns raised around overburdened secondary care services in the UK. Whilst the system has the potential to manage conflicting demand for oral surgery services against an objective need, the new pathway represents a number of challenges to existing working practices and could compromise the sustainability of existing hospital services. The aim of this research was to carry out a qualitative exploration of implementation of a new intervention to gain insight into how these challenges have manifested and been addressed. METHODS: Views were sought from stakeholders (dentists, hospital staff, commissioners and patients) at various time points over 3 years during and after implementation using semi-structured interviews. Normalization Process Theory informed a qualitative thematic analysis which was carried out using data from interview transcripts to identify important emerging issues. RESULTS: Themes emerging from the data were; amenability to change and assimilation into practice (primary care dentists), compliance and governance, changing perceptions of impact (secondary care staff and commissioners) understanding change in service provision and priorities for treatment (patients). The new pathway impacted stakeholders at different stages of implementation. CONCLUSION: Electronic referral management with a primary care advanced service for oral surgery was successfully implemented in a specific area of the UK. The service model evaluated has the potential to be expanded across a wider geographical footprint and to support demand management in other specialist services.

Implementing and evaluating a primary care service for oral surgery: a case study.

BACKGROUND: A primary care oral surgery service was commissioned alongside an electronic referral management system in England, in response to rising demand for Oral Surgery services in secondary care. It is important to ensure that standards of quality and safety are similar to those in existing secondary care services, and that the new service is acceptable to stakeholders. The aim of this study is therefore to conduct an in depth case study to explore safety, quality, acceptability and implementation of the new service. METHODS: This case study draws on multiple sources of evidence to report on the commissioning process, implementation, treatment outcomes and acceptability to patients relating to a new oral surgery service in a primary care setting. A combination of audit data and interviews were analysed. RESULTS: Most referrals to the new service consisted of tooth extractions of appropriate complexity for the service. There were issues with lack of awareness of the new service in a primary care setting within referring primary care practices and patients at the start of implementation, however over time the service became a fully integrated part of the service landscape. Complications reported following surgery were low. CONCLUSION: Patients liked the convenience of the new service in terms of shorter waiting time and geographical location and their patient reported experience measures and outcomes were similar to those reported in secondary care. Providing appropriate clinical governance was in place, oral surgery could safely be provided in a primary care setting for patients without complex medical needs. Attention needs to be paid to communication with general dental practices around changes to the service pathway during the early implementation period to ensure all patients can receive care in the most appropriate setting.