A scoping review of dental practitioners' perspectives on perceived barriers and facilitators to preventive oral health care in general dental practice.

BACKGROUND: Oral health has an important role in the general health and well-being of individuals. Dental teams are ideally placed to support patients in preventing ill-health. Understanding the barriers and facilitators to the adoption, promotion and facilitation of preventive advice and treatment is key to improving oral health services. The Theoretical Domains Framework (TDF) is a useful psychological framework to help identify individual, interpersonal and environmental issues which could be impacting clinicians' ability to provide preventive advice and care. The aim of this review was to identify the perceived barriers and facilitators to preventive oral health care from the perspectives of the oral healthcare team within the general dental practice. METHODS: A search strategy was developed, piloted, and run in: Medline via Ovid, PsycInfo, Web of Science, SCOPUS, EMBASE, Conference Proceedings Citation Index- Science, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews and followed PRISMA guidelines. Identified records were screened independently by two researchers. Data were coded using the Theoretical Domains Framework (TDF) and analysed using narrative data synthesis. RESULTS: 5610 papers were identified, and 19 included in this review. Thirteen papers focussed on dentists. Of the 106 items mapped onto the TDF, 48 were facilitators. The domains most frequently represented were, environmental context and resources, beliefs about consequences, social professional role and identity, skills, beliefs about capabilities and knowledge. Six studies focussed on dental hygienists. There were 47 items mapped onto the TDF, 18 were facilitators. The domains most frequently represented were environmental context and resources, social influences, beliefs about consequences and knowledge. CONCLUSIONS: The review identified that the delivery of preventive activities did not focus solely on the patient and dental professional interaction as many previous studies have highlighted. The review found that multiple factors influence whether prevention is delivered to patients. The largest barrier and facilitator for the dental professionals identified in this review was the environmental context and resources. Further research is needed to evaluate the effectiveness of interventions that aim to promote preventive oral health care in primary care settings to understand whether they address the barriers identified in this review.

Whose Responsibility Is It Anyway? Exploring Barriers to Prevention of Oral Diseases across Europe.

INTRODUCTION: Dental caries, gum disease, and tooth loss are all preventable conditions. However, many dental care systems remain treatment oriented rather than prevention oriented. This promotes the treatment of oral diseases over preventive treatments and advice. Exploring barriers to prevention and understanding the requirements of a paradigm shift are the first steps toward delivering quality prevention-focused health care. OBJECTIVES: To qualitatively explore perceived barriers and facilitators to oral disease prevention from a multistakeholder perspective across 6 European countries. METHODS: A total of 58 interviews and 13 focus groups were undertaken involving 149 participants from the United Kingdom, Denmark, Germany, the Netherlands, Ireland, and Hungary. Interviews and focus groups were conducted in each country in its native language between March 2016 and September 2017. Participants were patients (n = 50), dental team members (n = 39), dental policy makers(n = 33), and dental insurers (n = 27). The audio was transcribed, translated, and analyzed via deductive thematic analysis. RESULTS: Five broad themes emerged that were both barriers and facilitators: dental regulation, who provides prevention, knowledge and motivation, trust, and person-level factors. Each theme was touched on in all countries; however, cross-country differences were evident surrounding the magnitude of each theme. CONCLUSION: Despite the different strengths and weaknesses among the systems, those who deliver, organize, and utilize each system experience similar barriers to prevention. The findings suggest that across all 6 countries, prevention in oral health care is hindered by a complex interplay of factors, with no particular dental health system offering overall greater user satisfaction. Underlying the themes were sentiments of blame, whereby each group appeared to shift responsibility for prevention to other groups. To bring about change, greater teamwork is needed in the commissioning of prevention to engender its increased value by all stakeholders within the dental system. KNOWLEDGE TRANSFER STATEMENT: The results from this study provide an initial first step for those interested in exploring and working toward the paradigm shift to preventive focused dentistry. We also hope that these findings will encourage more research exploring the complex relationship among dental stakeholders, with a view to overcoming the barriers. In particular, these findings may be of use to dental public health researchers, dentists, and policy makers concerned with the prevention of oral diseases.

Barriers and facilitators to health visiting teams delivering oral health promotion to families of young children: a mixed methods study with vignettes.

OBJECTIVE: To explore the potential barriers and facilitators to health visiting (HV) teams delivering oral health promotion during the 9-12-month old child mandated visit in Ealing, England. BACKGROUND: HV schemes and their counterparts worldwide share similar priorities to discuss oral health at 6-12 months of age. The HV programme in England stipulates at 9-12 months old, diet and dental health should be discussed. HVs believe dental decay is important however oral health knowledge is varied. Further, little is understood about what drives HVs to deliver oral health advice. An appropriate theoretical model to explore these factors is the Theoretical Domains Framework (TDF). METHODS: An opportunistic sample of HV team members was drawn from three hubs to allow for maximum variation. First, participants completed a questionnaire to establish baseline knowledge. Secondly, participants were invited to take part in focus groups (FGs) with vignettes. Thirdly, face-to-face interviews were conducted. FGs were subject to thematic analysis and the interviews to framework analysis. RESULTS: Thirty-six participants provided written informed consent and completed baseline questionnaires. Three FGs were conducted with an average of seven participants (n=21) followed by 13 interviews. Perceived facilitators: good levels of knowledge and skills, sense of professional role, emotions, belief in capability, organisational structure and resources. Perceived barriers: gaps in knowledge, conflicting advice from other professionals, conflicting issues for parents/ carers, use of interpreters. CONCLUSIONS: These findings can be harnessed to support oral health promotion delivered by HV teams.

Identifying the barriers and facilitators for homeless people to achieve good oral health.

OBJECTIVE: A qualitative exploration of the barriers and facilitators for people experiencing homelessness achieving good oral health. PARTICIPANTS: Adults using two homeless centres in Leeds. METHODS: Focus group discussions were convened with homeless people using support services. Both an inductive and deductive approach to data analysis was taken. Themes were identified and then a framework applied to analysis using Nvivo software. RESULTS: Three focus group discussions with 16 participants were conducted with people experiencing homelessness. The barriers identified were insufficient information on local dental services, negative attitudes of oral health professionals, low priority of dental care, anxiety and cost of dental treatments. Facilitators included single dental appointments, accessible dental locations and being treated with respect. CONCLUSIONS: Despite the barriers that prevent people experiencing homelessness from maintaining and improving their oral health, the participants were aware that they needed oral healthcare and requested that dental services were made available to them and were accessible in line with their socioeconomic status and needs.

Barriers and facilitators for prevention in Danish dental care.

Objective: To explore barriers and facilitators to oral disease prevention in Danish dental care from a multi-stakeholder perspective. Methods: Eleven semi-structured focus groups and interviews about Danish oral healthcare were conducted with 27 stakeholders (general public, dental teams, dental policy makers) in Copenhagen. Transcripts were analyzed using deductive thematic analysis independently by KR and HL, supervised by JC and KVC. Results: Seven broad themes were identified, including both barriers and facilitators: Knowledge and attitudes, Education and training, Regulation, Incentivization, Multidisciplinary approach, Access to care and the Dental professional-patient relationship. Whilst all themes were relevant to each group of stakeholders, the salient driver within each theme was different for each group. Conclusions: Stakeholder perspectives on the Danish Oral health care system suggest the following are important features for a preventively focused system: (a) Involving all stakeholders in oral healthcare planning. (b) Securing sufficient and ongoing briefing regarding disease prevention for all stakeholders. (c) Regulatory support and creation of incentives to promote and facilitate implementation of disease prevention. (d) Appropriate prevention for disadvantaged groups within society which may be possible to a higher degree by means of multidisciplinary collaboration. (e) Personal relations between the patient and the professional based on mutual trust.

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.

Accessibility of chewing tobacco products in England.

BACKGROUND: The carcinogenicity of chewing tobacco is well established. It is predominantly used by the South Asian community in England. Little is known about the accessibility of the products available for use in England. METHODS: Wards with high proportions or numbers of residents from the South Asian community were identified using 2001 Census data. Within each ward product purchasers identified retail outlets and purchased chewing tobacco products from them. RESULTS: Chewing tobacco products were found in a broad variety of premises in all but one ward, and were easily accessible. Ninety-eight products were identified and purchased with a mean price of pound1.82. Of the ninety four pre-packaged products purchased only 15% (95% CI: 8%, 22%) complied with legal health warning requirements. CONCLUSION: The study indicates the need to improve compliance with legal controls and enforcement to protect the South Asian community from health risks associated with chewing tobacco products.

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.