The Associations among Dental Anxiety, Self-Esteem, and Oral Health-Related Quality of Life in Children: A Cross-Sectional Study.

BACKGROUND: The current evidence on the relationships among child oral health-related quality of life, dental anxiety, and self-esteem indicates that we need to investigate these relationships to improve our understanding of the associations. Therefore, the current research aimed to enhance this evidence and provide an overview of the participating children's oral-health-related quality of life (as measured by the CPQ8-10), self-esteem (as measured by the Coopersmith SEI-SF), and dental anxiety (as measured by the CFSS_DS) and how these child-related outcome measures interacted and were related to one another. METHOD: A cross-sectional survey was conducted on a random sample of school children (n = 1900) aged 8 to 10 years. The questionnaire was collected through validated self-report measures: dental anxiety, COHRQoL, and self-esteem. Structural equation modelling (SEM) was used to test the strength of the association of our model to explore the relationships among these three psychological constructs. The moderating effects of age, gender, location, and the educational board were analysed for their possible influence on these relationships. RESULTS: Significant relationships between COHRQoL and child dental anxiety and between COHRQoL and SE were detected. The relationship subscale between COHRQoL and child dental anxiety was 0.24, (p < 0.001). A stronger correlation between COHRQoL, and SE was found, with B = -0.77, (p < 0.001). Although the association between CDA and SE was small, it was statistically significant (p = 0.03). These findings provide some important background information for designing effective educational programs for children.

Health Coaching-Based Interventions for Oral Health Promotion: A Scoping Review.

BACKGROUND: Health coaching-based interventions can support behaviour change to improve oral health. This scoping review aims to identify key characteristics of health coaching-based interventions for oral health promotion. METHODS: The Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews checklist and the Joanna Briggs Institute manual for evidence synthesis were used in this review. A search strategy using medical subject heading terms and keywords was developed and applied to search the following databases: CINAHL, Ovid, PubMed, Cochrane Library and Scopus. Thematic analysis was used to synthesise the data. RESULTS: Twenty-three studies met the inclusion criteria and were included in this review. These studies were predominantly based on health coaching and motivational interviewing interventions applied to oral health promotion. The following are the characteristics of health coaching-based interventions extracted from themes of the included studies: (a) Health professionals should be trained on the usage of motivational interviewing/health coaching interventions; (b) oral health professionals should acquire motivational techniques in their practice to engage patients and avoid criticisms during the behaviour change process; (c) routine brief motivational interviewing/health coaching intervention sessions should be introduced in dental clinics; (d) traditional oral health education methods should be supplemented with individually tailored communication; and (e) for cost-effectiveness purposes, motivational interviewing/health coaching strategies should be considered. CONCLUSIONS: This scoping review reveals that health coaching-based techniques of health coaching and motivational interviewing can significantly impact oral health outcomes and behaviour change and can improve oral health professional-patient communication. This calls for the use of health coaching-based techniques by dental teams in community and clinical settings. This review highlights gaps in the literature, suggesting the need for more research on health coaching-based intervention strategies for oral health promotion.

Exploring the engagement behaviours of Smile4life practitioners: lessons from an evaluation of the national oral health improvement programme for people experiencing homelessness in Scotland.

Introduction: Smile4life is Scotland's national oral health improvement programme for people experiencing homelessness, aimed at reducing oral health inequalities experienced by this population. This study forms part of an evaluation of how the Smile4life intervention was being implemented within Scottish NHS Boards. The aim was to investigate the influence of the Smile4life intervention upon the engagement behaviours of Smile4life practitioners. Methods: Focus groups were conducted with Smile4life practitioners, to provide an insight into how the Smile4life intervention affected their skills, attitudes and experiences while interacting with people experiencing homelessness and their services providers. A purposive sample of oral health practitioners, including dental health support workers, oral health promoters/educators, and oral health improvement coordinators working in three NHS Boards were invited to take part. One focus group was conducted in each of the three NHS Boards. The focus groups were audio-recorded and transcribed. The COM-B model of behaviour was used as a framework for analysis. Results: Eleven Smile4life practitioners took part in the focus groups. All had first-hand experience of working with the Smile4life intervention. The average focus group length was 67 min. Working on the Smile4life intervention provided the Smile4life practitioners with: (i) the capability (physical and psychological), (ii) the opportunity (to establish methods of communication and relationships with service providers and service users) and (iii) the motivation to engage with Third Sector homelessness services and service users, by reflecting upon their positive and negative experiences delivering the intervention. Enablers and barriers to this engagement were identified according to each of the COM-B categories. Enablers included: practitioners' sense of responsibility, reflecting on positive past experiences and success stories with service users. Barriers included: lack of resources, negative past experiences and poor relationships between Smile4life practitioners and Third Sector staff. Conclusion: The Smile4life programme promoted capability, provided opportunities and increased motivation in those practitioners who cross disciplinary boundaries to implement the Smile4life intervention, which can be conceptualised as "boundary spanning". Practitioners who were found to be boundary spanners often had a positive mindset and proactive attitude towards the creation of strategies to overcome the challenges of implementation by bridging the gaps between the NHS and the Third Sector, and between oral health and homelessness, operating across differing fields to achieve their aims.

Factors Associated With Dental Caries: Differential Experiences Among Incarcerated Individuals in Scotland.

Incarcerated individuals experience poorer health, including dental health, when compared with the general population. Although interventions that target multiple determinants of health are more effective, there are limited investigations of the determinants of dental health, and how these differ, among incarcerated individuals. This article describes a secondary data analysis to investigate caries (dental decay) experience and associated risk indicators from a survey of females, adult males, and young males incarcerated in Scotland. Substance misuse significantly explained caries risk for adults, and tailored interventions are warranted to address smoking and dental attitudes among females, and for adult males housing support alongside oral health education are indicated.

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

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

Critically engaging vulnerability: Rethinking oral health with vulnerabilized populations.

This paper is the third in a series of narrative reviews challenging core concepts in oral health research and practice. Our series started with a framework for Inclusion Oral Health. Our second review explored one component of this framework, looking at how intersectionality adds important complexity to oral public health. This current manuscript drills into a second component of Inclusion Oral Health, exploring how labels can lead to 'othering' thereby misrepresenting populations and (re)producing harms. Specifically, we address a common oral public health label: vulnerable populations. This term is commonly used descriptively: an adjective (vulnerable) is used to modify a noun (population). What this descriptor conceals is the 'how,' 'why,' and 'therefore' that leads to and from vulnerability: How and why is a population made vulnerable; to what are they vulnerable; what makes them 'at risk,' and to what are they 'at risk'? In concealing these questions, we argue our conventional approach unwittingly does harm. Vulnerability is a term that implies a population has inherent characteristics that make them vulnerable; further, it casts populations as discrete, homogenous entities, thereby misrepresenting the complexities that people live. In so doing, this label can eclipse the strengths, agency and power of individuals and populations to care for themselves and each other. Regarding oral public health, the convention of vulnerability averts our research gaze away from social processes that produce vulnerability to instead focus on the downstream product, the vulnerable population. This paper theorizes vulnerability for oral public health, critically engaging its production and reproduction. Drawing from critical public health literature and disability studies, we advance a critique of vulnerability to make explicit hidden assumptions and their harmful outcomes. We propose solutions for research and practice, including co-engagement and co-production with peoples who have been vulnerabilized. In so doing, this paper moves forward the potential for oral public health to advance research and practice that engages complexity in our work with vulnerabilized populations.

Longitudinal online diaries with dental practitioners and dental care professionals during the COVID-19 pandemic: A trajectory analysis.

Introduction: The COVID-19 pandemic resulted in a series of significant changes and adjustments within dentistry, as dental professionals dealt with temporary closures of dental practices, increased use of personal protective equipment, a reduction of clinical procedures, and extensions to training programmes. Recent research has illustrated the impact of the pandemic on the dental profession, indicating that many dental professionals felt emotionally exhausted and experienced significant uncertainty and anxiety. This qualitative study aimed to understand how these experiences and emotions changed over the course of six months, in dental trainees and primary dental care staff in Scotland. Methods: A longitudinal diary study was conducted (June-December 2020) with dental trainees and primary dental care staff. The diary asked respondents to answer three questions related to their emotional exhaustion, on a weekly basis. There was also an open question asking respondents to describe any significant issues or concerns they had experienced during the preceding week because of the impact of the COVID-19 pandemic on their work or training. This qualitative data was explored using a trajectory analysis approach to determine specifically changes over time. Results: The trajectory analysis revealed several key concerns prevalent amongst respondents, and how they fluctuated over the six months. Concerns included: the impact of the pandemic on respondents' future careers and on dentistry more generally; adapting to new working environments; the impact on their patients' dental treatment and oral health; the impact on their health and wellbeing; financial considerations and adjusting to new safety measures as part of the remobilization of dental services. Discussion: In the second half of 2020, as the UK was adjusting to the introduction of new COVID-19 safety measures in everyday life, the dental profession were grappling with significant changes to their working environment, including PPE, redeployment, use of aerosol generating procedures (AGPs), and timelines for re-opening practices. This longitudinal diary study has shown some parts of the dental profession in Scotland expressed very varied and personal concerns and anxieties related to COVID-19. Respondents' candor in their diary entries revealed explicit, frequent and high levels of uncertainty and worry related to their training and career. Collectively, the data corpus highlighted the emotional toll these anxieties have taken on the dental professions in Scotland. Conclusion: These findings demonstrate the need for (a) increased provision of mental health and wellbeing support services for dental staff and (b) the study of the linkage between organization of pandemic management to the working practices of staff delivering services. Interventions, at various levels, should take into consideration the fluctuating nature of dental professionals' concerns and anxieties over time, to address both immediate and longer-term issues.

Investigating the Effectiveness and Acceptability of Oral Health and Related Health Behaviour Interventions in Adults with Severe and Multiple Disadvantage: Protocol for a Mixed-Methods Systematic Review.

Increasing numbers of people in England experience homelessness, substance use, and repeated offending (known as 'severe and multiple disadvantage'; SMD). Populations experiencing SMD often have extremely poor oral health, which is closely inter-linked with high levels of substance use, smoking, and poor diet. This study aims to undertake an evidence synthesis to identify the effectiveness, resource requirements, and factors influencing the implementation and acceptability of oral health and related health behaviour interventions in adults experiencing SMD. Two systematic reviews will be conducted using mixed-methods. Review 1 will investigate the effectiveness and resource implications of oral health and related health behaviours (substance use, smoking, diet) interventions; Review 2 will investigate factors influencing the implementation of such interventions. The population includes adults (≥18 years) experiencing SMD. Standard review methods in terms of searches, screening, data extraction, and quality appraisal will be conducted. Narrative syntheses will be conducted. If feasible, a meta-analysis will be conducted for Review 1 and a thematic synthesis for Review 2. Evidence from the two reviews will then be synthesised together. Input from people with experience of SMD will be sought throughout to inform the reviews. An initial logic model will be iteratively refined during the review.

Implementing the Smile4life intervention for people experiencing homelessness: a path analytical evaluation.

BACKGROUND: People experiencing homelessness have high levels of dental decay, oral cancer and poor oral health-related quality of life. The Scottish Government sought to address these issues by developing a national oral health improvement programme for people experiencing homelessness, named Smile4life. The aim was to investigate implementation behaviours and the role of work-related beliefs upon the delivery of the Smile4life programme across NHS Board areas in Scotland. METHODS: Non-probability convenience sampling, supplemented by snowball sampling, was used to recruit practitioners working across the homelessness sector. The overall evaluation of the implementation of the Smile4life programme was theoretically informed by the Behaviour Change Wheel. The questionnaire was informed by the Theoretical Domains Framework and was divided into three sections, demography and Smile4life Awareness; Smile4life Activities; and Smile4life work-related beliefs. A psychometric assessment was used to develop Smile4life Awareness, Smile4life Activities, Ability to Deliver and Positive Beliefs and Outcomes subscales. The data were subjected to K-R20, exploratory factor analysis, Cronbach's alpha, t-tests, ANOVA, Pearson's correlation analysis and a multivariate path analysis. RESULTS: One hundred participants completed the questionnaire. The majority were female (79%) and worked in NHS Boards across Scotland (55%). Implementation behaviour, constructed from the Delivering Smile4life scale and the summated Smile4life activities variable, was predicted using a linear model a latent variable. The independent variables were two raw variables Positive Beliefs and Outcomes, and Ability to deliver Smile4life. Results showed relatively good model fit (chi-square (1.96; p > 0.15), SRMR (< 0.08) and R2 (0.62) values). Positive and highly significant loadings were found describing the Implementation Behaviour latent variable (0.87 and 0.56). The two independent variables were associated (p < 0.05) with Implementation Behaviour. CONCLUSIONS: Work-related factors, such as positive beliefs and outcomes and ability to deliver are required for implementation behaviours associated with the delivery of the Smile4life programme. Future work should include training centred on the specific needs of those involved in the homelessness sector and the development of accessible training resources, thereby promoting implementation behaviours to assist the progression and sustainability of the Smile4life programme.

Communicating With Parents and Preschool Children: A Qualitative Exploration of Dental Professional-Parent-Child Interactions During Paediatric Dental Consultations to Prevent Early Childhood Caries.

The aim of this study was to explore communication interactions and identify phases adopted by dental professionals with parents and their young children and to examine the hypothesis that successful social talking between the actors together with the containment of worries allows the formation of a triadic treatment alliance, which leads to achieving preventive dental treatment goals. Conversation analysis of the transcribed data from video recordings of dental professionals, parents and preschool children when attending for preventive dental care was conducted. The transcriptions were read, examined and analysed independently to ensure the trustworthiness of the analysis. The transcriptions were explored for interactive patterns and sequences of interaction. Forty-four individual consultations between dental professionals, parents, and preschool children were recorded. The number of communication behaviours was 7,299, with appointment length ranging from 2 min 10 s to 29 min 18 s. Two patterns of communication were identified as dyadic (between two people) and triadic (between three people) interactions within a continuous shifting cycle. The three phases of communication were social talking, containing worries and task-focusing. Social talking was characterised by shifts between dyadic and triadic communication interactions and a symmetry of communication turns and containing worries. This typified the cyclical nature of the triadic and dyadic communication interactions, the adoption of talk-turn pairs, and triadic treatment alliance formation. Task-focusing pattern and structure were different for dentists and extended-duty dental nurses. For dentists, task-focusing was characterised by a dyadic interaction and as an asymmetrical communication pattern: for extended-duty dental nurses, task-focusing was typified by symmetrical and asymmetrical communication patterns within dyadic and triadic interactions. Empathy and understanding of the young child's emotional needs during containing worries allowed the formation of the triadic treatment alliance and with this treatment alliance, the acceptance of interventions to prevent early childhood caries during "task-focusing." This qualitative exploration suggests that dyadic and triadic communication interactions are of a dynamic and cyclical quality and were exhibited during paediatric dental consultations. The communication phases of social talking, containing worries and task-focusing were evident. Successful social talking signalled the entry to containing worries and triadic treatment alliance formation which permitted the preventive goals of the consultation to be achieved (task-focusing). Future work should generate additional data to support the hypotheses created here namely that, social talking and containing worries triggers an integral pathway to task-focusing and the achievement of preventive dental goals.

An ADePT evaluation for incorporating the TIPPS periodontal health intervention into primary care antenatal programmes to enhance infant birth weight in Palestine: a feasibility study.

BACKGROUND: A feasibility study was conducted to implement the Talk, Instruct, Practice, Plan and Support (TIPPS) intervention for pregnant women to enhance infant birth weight in a conflict area in Low- and Middle-Income Countries (LMIC). The decision tool, A process for Decision-making after Pilot and feasibility Trials (ADePT), examines the methodological factors identified in a feasibility study, that may require modification for a full trial. Thus, this study aimed to use the ADePT decision tool to evaluate if the feasibility study had achieved its objectives and to identify the need for intervention, clinical context and trial design modification. METHODS: A one-arm, pretest-posttest feasibility study recruited 25 pregnant women in their first trimester and clinic staff from a primary healthcare clinic located in Gaza City, Palestine. The TIPPS periodontal health intervention was delivered by antenatal care nurses to the pregnant women during their regular follow-up appointments. The ADePT framework was applied to evaluate the findings from the feasibility study. The ADePT checklist demonstrated sample size estimation, recruitment, consent, intervention adherence, intervention acceptability, costs and duration, completion and appropriateness of outcome assessments, retention, logistics, and synergy between protocol components. RESULTS: All recruited pregnant women (25, aged 16-35 years old) consented to participate in the study, and the adherence to the intervention was 88% (22 women). The TIPPS intervention was acceptable, but there was ambivalence over who should deliver it in the clinic. Only the cost of toothbrushing and TIPPS information materials was calculated, while the cost of nurses' time was not included. The missing values of data were few (12% of gingival bleeding data and 22% from infant birth weight data). This intervention significantly reduced the mean percentage of plaque and bleeding scores after 3 months. The sample size for future randomised controlled trial was estimated around 400 participants. The participants stated the value of the intervention. The clinic staff voiced concerns regarding time and the cost of nurses providing the TIPPS intervention. This allowed suggestions to be made regarding the modification of trial design and context of implementation. CONCLUSIONS: The ADePT evaluation showed it was possible to progress to full trial with modifications in the trial design.

Examining the effectiveness of different dental recall strategies on maintenance of optimum oral health: the INTERVAL dental recalls randomised controlled trial.

Objective To compare the clinical effectiveness of different frequencies of dental recall over a four-year period.Design A multi-centre, parallel-group, randomised controlled trial with blinded clinical outcome assessment. Participants were randomised to receive a dental check-up at six-monthly, 24-monthly or risk-based recall intervals. A two-strata trial design was used, with participants randomised within the 24-month stratum if the recruiting dentist considered them clinically suitable. Participants ineligible for 24-month recall were randomised to a risk-based or six-month recall interval.Setting UK primary dental care.Participants Practices providing NHS care and adults who had received regular dental check-ups.Main outcome measures The percentage of sites with gingival bleeding on probing, oral health-related quality of life (OHRQoL), cost-effectiveness.Results In total, 2,372 participants were recruited from 51 dental practices. Of those, 648 were eligible for the 24-month recall stratum and 1,724 participants were ineligible. There was no evidence of a significant difference in the mean percentage of sites with gingival bleeding on probing between intervention arms in any comparison. For those eligible for 24-month recall stratum: the 24-month versus six-month group had an adjusted mean difference of -0.91%, 95% CI (-5.02%, 3.20%); the 24-month group versus risk-based group had an adjusted mean difference of 0.07%, 95% CI (-3.99%, 4.12%). For the overall sample, the risk-based versus six-month adjusted mean difference was 0.78%, 95% CI (-1.17%, 2.72%). There was no evidence of a difference in OHRQoL (0-56 scale, higher score for poorer OHRQoL) between intervention arms in any comparison. For the overall sample, the risk-based versus six-month effect size was -0.35, 95% CI (-1.02, 0.32). There was no evidence of a clinically meaningful difference between the groups in any comparison in either eligibility stratum for any of the secondary clinical or patient-reported outcomes.Conclusion Over a four-year period, we found no evidence of a difference in oral health for participants allocated to a six-month or a risk-based recall interval, nor between a 24-month, six-month or risk-based recall interval for participants eligible for a 24-month recall. However, patients greatly value and are willing to pay for frequent dental check-ups.

Communication strategies to encourage child participation in an oral health promotion session: An exemplar video observational study.

BACKGROUND: The oral health promotion sessions for young children and parents in a clinical setting pose challenges to the dental team. AIM: To apply PaeD-TrICS (Paediatric dental triadic interaction coding scheme) to investigate the interaction of child, parent and dental nurse and determine the effect of nurse and parental behaviours on child participation within an oral health promotion session. METHOD: A video observational study was applied. The sample consisted of a dental nurse and 22 children aged 2-5 years in a general dental practice in Scotland. Behaviours were catalogued with time stamps using PaeD-TrICS. Analysis of behavioural sequences with child participation as the dependent variable was conducted using multilevel modelling. RESULTS: Children varied significantly in their participation rate. The statistical model explained 28% of the variance. The older the child and longer consultations significantly increased child participation. Both nurse and parental behaviour had immediate influence on child participation. Parental facilitation had a strong moderating effect on the influence of the nurse on child participation. CONCLUSIONS: Child participation was dependent on nurse and parent encouragement signalling an important triadic communication process. The coding scheme and analysis illustrates an important tool to investigate these advisory sessions designed for delivering tailored messages to young children and parents. PATIENT OR PUBLIC CONTRIBUTION: The dental staff, child patients and their parents were involved closely in the conduct and procedures of the present study.

Exploring the Effect of the COVID-19 Pandemic on the Dental Team: Preparedness, Psychological Impacts and Emotional Reactions.

Background: The COVID-19 pandemic has placed increased demands on clinical staff in primary dental care due to a variety of uncertainties. Current reports on staff responses have tended to be brief enquiries without some theoretical explanation supported by developed measurement systems. Aim: To investigate features of health and well-being as an outcome of the uncertainties surrounding COVID-19 for dentists and dental health professionals in primary dental care and for those in training. In addition, the study examined the well-being indices with reference to normative values. Finally a theoretical model was explored to explain depressive symptoms and investigate its generalisability across dentists and dental health professionals in primary dental care and those in postgraduate training. Methods: A cross-sectional survey of dental trainees and primary dental care staff in Scotland was conducted in June to October 2020. Assessment was through "Portal," an online tool used for course bookings/management administered by NHS Education for Scotland. A non-probability convenience sample was employed to recruit participants. The questionnaire consisted of four multi-item scales including: preparedness (14 items of the DPPPS), burnout (the 9 item emotional exhaustion subscale and 5 items of the depersonalisation subscale of the MBI), the 22 item Impact of Event Scale-Revised, and depressive symptomatology using the Patient Health Questionnaire-2. Analysis was performed to compare the levels of these assessments between trainees and primary dental care staff and a theoretically based path model to explain depressive symptomology, utilising structural equation modelling. Results: Approximately, 27% of all 329 respondents reported significant depressive symptomology and 55% of primary care staff rated themselves as emotionally exhausted. Primary care staff (n = 218) felt less prepared for managing their health, coping with uncertainty and financial insecurity compared with their trainee (n = 111) counterparts (all p's < 0.05). Depressive symptomology was rated higher than reported community samples (p < 0.05) The overall fit of the raw data applied to the theoretical model confirmed that preparedness (negative association) and trauma associated with COVID-19 (positive association) were significant factors predicting lowered mood (chi-square = 46.7, df = 21, p = 0.001; CFI = 0.98, RMSEA = 0.06, SRMR = 0.03). Burnout was indirectly implicated and a major path from trauma to burnout was found to be significant in primary care staff but absent in trainees (p < 0.002). Conclusion: These initial findings demonstrate the possible benefit of resourcing staff support and interventions to assist dental staff to prepare during periods of high uncertainty resulting from the recent COVID-19 pandemic.

Uncertainty and Fears Around Sustainability: A Qualitative Exploration of the Emotional Reactions of Dental Practitioners and Dental Care Professionals During COVID-19.

INTRODUCTION: Recent cross-sectional surveys have shown the detrimental impact of COVID-19 on the health and well-being of dental practitioners and dental care professionals. This qualitative study complements the growing quantitative evidence base with an in-depth exploration of the lived experiences of those working in primary care dental teams in Scotland. METHODS: Focus groups were carried out with primary care dental team members and trainees between July and October 2020. Olsen's tripartite framework of health service sustainability was operationalised to explore how participants experienced uncertainty and their attempts to sustain dental services. RESULTS: Analysis revealed significant concerns surrounding the sustainability of dental services and dental training programmes as a consequence of the emergency level response to the pandemic. Restrictions on dentistry were seen to be severely impeding desirable clinical outcomes, particularly for the most vulnerable groups. Participants experienced being unable to deliver high quality care to their patients as both confusing and distressing. The capability of the dental health care system to meet a growing backlog of dental need and manage this effectively in a pandemic era was called in to serious question. Ongoing uncertainties were affecting how participants were thinking about their professional futures, with stress about income and employment, along with heightened experiences of professional isolation during the pandemic, resulting in some looking at possibilities for retraining or even considering leaving their profession altogether. DISCUSSION: The impact of the pandemic has produced considerable uncertainty regarding the sustainability of dental services in the medium to longer term. It has also served to expose the uncertainties practitioners grapple with routinely as they attempt to sustain their NHS dental service delivery. CONCLUSION: This study brings in to sharp focus the diversity of challenges, confusions and uncertainties experienced by dental practitioners and dental care professionals during the COVID-19 pandemic and the need for suitable and ongoing measures to be put in place to support their mental well-being.

Risk-based, 6-monthly and 24-monthly dental check-ups for adults: the INTERVAL three-arm RCT.

BACKGROUND: Traditionally, patients are encouraged to attend dental recall appointments at regular 6-month intervals, irrespective of their risk of developing dental disease. Stakeholders lack evidence of the relative effectiveness and cost-effectiveness of different recall strategies and the optimal recall interval for maintenance of oral health. OBJECTIVES: To test effectiveness and assess the cost-benefit of different dental recall intervals over a 4-year period. DESIGN: Multicentre, parallel-group, randomised controlled trial with blinded clinical outcome assessment at 4 years and a within-trial cost-benefit analysis. NHS and participant perspective costs were combined with benefits estimated from a general population discrete choice experiment. A two-stratum trial design was used, with participants randomised to the 24-month interval if the recruiting dentist considered them clinically suitable. Participants ineligible for 24-month recall were randomised to a risk-based or 6-month recall interval. SETTING: UK primary care dental practices. PARTICIPANTS: Adult, dentate, NHS patients who had visited their dentist in the previous 2 years. INTERVENTIONS: Participants were randomised to attend for a dental check-up at one of three dental recall intervals: 6-month, risk-based or 24-month recall. MAIN OUTCOMES: Clinical - gingival bleeding on probing; patient - oral health-related quality of life; economic - three analysis frameworks: (1) incremental cost per quality-adjusted life-year gained, (2) incremental net (societal) benefit and (3) incremental net (dental health) benefit. RESULTS: A total of 2372 participants were recruited from 51 dental practices; 648 participants were eligible for the 24-month recall stratum and 1724 participants were ineligible. There was no evidence of a significant difference in the mean percentage of sites with gingival bleeding between intervention arms in any comparison. For the eligible for 24-month recall stratum: the 24-month (n = 138) versus 6-month group (n = 135) had an adjusted mean difference of -0.91 (95% confidence interval -5.02 to 3.20); the risk-based (n = 143) versus 6-month group had an adjusted mean difference of -0.98 (95% confidence interval -5.05 to 3.09); the 24-month versus risk-based group had an adjusted mean difference of 0.07 (95% confidence interval -3.99 to 4.12). For the overall sample, the risk-based (n = 749) versus 6-month (n = 737) adjusted mean difference was 0.78 (95% confidence interval -1.17 to 2.72). There was no evidence of a difference in oral health-related quality of life between intervention arms in any comparison. For the economic evaluation, under framework 1 (cost per quality-adjusted life-year) the results were highly uncertain, and it was not possible to identify the optimal recall strategy. Under framework 2 (net societal benefit), 6-month recalls were the most efficient strategy with a probability of positive net benefit ranging from 78% to 100% across the eligible and combined strata, with findings driven by the high value placed on more frequent recall services in the discrete choice experiment. Under framework 3 (net dental health benefit), 24-month recalls were the most likely strategy to deliver positive net (dental health) benefit among those eligible for 24-month recall, with a probability of positive net benefit ranging from 65% to 99%. For the combined group, the optimal strategy was less clear. Risk-based recalls were more likely to be the most efficient recall strategy in scenarios where the costing perspective was widened to include participant-incurred costs, and in the Scottish subgroup. LIMITATIONS: Information regarding factors considered by dentists to inform the risk-based interval and the interaction with patients to determine risk and agree the interval were not collected. CONCLUSIONS: Over a 4-year period, we found no evidence of a difference in oral health for participants allocated to a 6-month or a risk-based recall interval, nor between a 24-month, 6-month or risk-based recall interval for participants eligible for a 24-month recall. However, people greatly value and are willing to pay for frequent dental check-ups; therefore, the most efficient recall strategy depends on the scope of the cost and benefit valuation that decision-makers wish to consider. FUTURE WORK: Assessment of the impact of risk assessment tools in informing risk-based interval decision-making and techniques for communicating a variable recall interval to patients. TRIAL REGISTRATION: Current Controlled Trials ISRCTN95933794. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme [project numbers 06/35/05 (Phase I) and 06/35/99 (Phase II)] and will be published in full in Health Technology Assessment; Vol. 24, No. 60. See the NIHR Journals Library website for further project information.

Traditionally, dentists have encouraged both patients at low risk and patients at high risk of developing dental disease to attend their dental practices for regular 6-month 'check-ups'. There is, however, little evidence available for either patients or dentists to use when deciding on the best dental recall interval (i.e. time between dental check-ups) for maintaining oral health. In this study, we wanted to find out, for adult patients who regularly attend the dentist, what interval of time between dental check-ups maintains optimum oral health and represents value for money. A total of 2372 adults who regularly attended 51 different dental practices across Scotland, Northern Ireland, England and Wales were involved. Patients aged 18 years or over who received all or part of their care as NHS patients were randomly allocated to groups to receive a check-up either every 6 months, at an individualised recall interval based on their own risk of oral disease (risk-based recall), or every 24 months (if considered at low risk by their dentist). The recruited adults completed questionnaires at their first trial appointment and then every year of the 4-year study. Their attendance at recall appointments was recorded and they received a clinical assessment taken by study staff at the end of their involvement at year 4. After 4 years, there was no evidence of a difference in the oral health of patients allocated to a 6-month or variable risk-based recall interval. For patients considered by their dentists to be suitable for a 24-month recall interval, there was no difference between those in the 24-month, 6-month or risk-based recall intervals. However, people greatly value and are willing to pay for frequent dental check-ups. The recall strategy that offers the best value for money to patients and the NHS, therefore, depends on what people and decision-makers wish to value within a health-care system.

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

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

What is intersectionality and why is it important in oral health research?

This paper is the second of two reviews that seek to stimulate debate on new and neglected avenues in oral health research. The first commissioned narrative review, "Inclusion oral health: Advancing a theoretical framework for policy, research and practice", published in February 2020, explored social exclusion, othering and intersectionality. In it, we argued that people who experience social exclusion face a "triple threat": they are separated from mainstream society, stigmatized by the dental profession, and severed from wider health and social care systems because of the disconnection between oral health and general health. We proposed a definition of inclusion oral health and a theoretical framework to advance the policy, research and practice agenda. This second review delves further into the concept of intersectionality, arguing that individuals who are socially excluded experience multiple forms of discrimination, stigma and disadvantage that reflect intersecting social identities. We first provide a theoretical and historical overview of intersectionality, rooted in Black feminist ideologies in the United States. Our working definition of intersectionality, requiring the simultaneous appreciation of multiple social identities, an examination of power and inequality, and a recognition of changing social contexts, then sets the scene for examining existing applications of intersectionality in oral health research. A critique of the sparse application of intersectionality in oral health research highlights missed opportunities and shortcomings related to paradigmatic and epistemological differences, a lack of robust theoretically engaged quantitative and mixed methods research, and a failure to sufficiently consider power from an intersectionality perspective. The final section proposes a framework to guide future oral health research that embraces an intersectionality agenda consisting of descriptive research to deepen our understanding of intersectionality, and transformative research to tackle social injustice and inequities through participatory research and co-production.

The FiCTION trial: Child oral health-related quality of life and dental anxiety across three treatment strategies for managing caries in young children.

OBJECTIVES: The FiCTION trial compared co-primary outcomes (dental pain and/or infection) and secondary outcomes (child oral health-related quality of life [COHRQOL], child dental anxiety, cost-effectiveness, caries development/progression and acceptability) across three treatment strategies (Conventional with Prevention [C + P]; Biological with Prevention [B + P]; Prevention Alone [PA]) for managing caries in children in primary care. COHRQOL and child dental anxiety experiences are reported upon here. METHODS: A multi-centre, 3-arm, parallel-group, unblinded patient-randomized controlled trial of 3- to 7-year-olds treated under NHS contracts was conducted in 72 general dental practices in England, Wales and Scotland. Child participants (with at least one primary molar with dentinal caries) were randomized (1:1:1) to one of three treatment arms with the intention of being managed according to allocated arm for 3 years (minimum 23 months). Randomization was via a centrally administered system using random permuted blocks of variable length. At baseline and final visit, accompanying parents/caregivers completed a parental questionnaire including COHRQOL (16 item P-CPQ-16), and at every visit, child- and parental-questionnaire-based data were collected for child-based dental trait and state anxiety. Statistical analyses were conducted on complete cases from the modified intention-to-treat (mITT) analysis set. RESULTS: A total of 1144 children were randomized (C + P: 386; B + P: 381; PA: 377). The mITT analysis set included the 1058 children who attended at least one study visit (C + P: 352; B + P: 352; PA: 354). Median follow-up was 33.8 months (IQR: 23.8, 36.7). The P-CPQ-16 overall score could be calculated after simple imputation at both baseline and final visit for 560 children (C + P: 189; B + P: 189; PA: 182). There was no evidence of a difference in the estimated adjusted mean P-CPQ-16 at the final visit which was, on average, 0.3 points higher (97.5% CI: -1.1 to 1.6) in B + P than C + P and 0.2 points higher, on average, (97.5% CI: -1.2 to 1.5) in PA than for C + P. Child dental trait anxiety and child dental state anxiety, measured at every treatment visit, showed no evidence of any statistically or clinically significant difference between arms in adjusted mean scores averaged over all follow-up visits. CONCLUSIONS: The differences noted in COHRQOL and child-based dental trait and dental state anxiety measures across three treatment strategies for managing dental caries in primary teeth were small, and not considered to be clinically meaningful. The findings highlight the importance of including all three strategies in a clinician's armamentarium, to manage childhood caries throughout the young child's life and achieve positive experiences of dental care.