Behaviour support in dentistry: A Delphi study to agree terminology in behaviour management.

OBJECTIVES: Dental behaviour support (DBS) describes all specific techniques practiced to support patients in their experience of professional oral healthcare. DBS is roughly synonymous with behaviour management, which is an outdated concept. There is no agreed terminology to specify the techniques used to support patients who receive dental care. This lack of specificity may lead to imprecision in describing, understanding, teaching, evaluating and implementing behaviour support techniques in dentistry. Therefore, this e-Delphi study aimed to develop a list of agreed labels and descriptions of DBS techniques used in dentistry and sort them according to underlying principles of behaviour. METHODS: Following a registered protocol, a modified e-Delphi study was applied over two rounds with a final consensus meeting. The threshold of consensus was set a priori at 75%. Agreed techniques were then categorized by four coders, according to behavioural learning theory, to sort techniques according to their mechanism of action. RESULTS: The panel (n = 35) agreed on 42 DBS techniques from a total of 63 candidate labels and descriptions. Complete agreement was achieved regarding all labels and descriptions, while agreement was not achieved regarding distinctiveness for 17 techniques. In exploring underlying principles of learning, it became clear that multiple and differing principles may apply depending on the specific context and procedure in which the technique may be applied. DISCUSSION: Experts agreed on what each DBS technique is, what label to use, and their description, but were less likely to agree on what distinguishes one technique from another. All techniques were describable but not comprehensively categorizable according to principles of learning. While objective consistency was not attained, greater clarity and consistency now exists. The resulting list of agreed terminology marks a significant foundation for future efforts towards understanding DBS techniques in research, education and clinical care.

Process-related Factors Are as Important as Outcomes for Patients Undergoing Nonsurgical Root Canal Treatment, Nonsurgical Root Canal Retreatment, and Endodontic Microsurgery.

INTRODUCTION: There is considerable variation in the reporting of treatment outcomes in endodontics. Patient-centered outcomes are often inadequately reported in endodontic outcome studies. This paper explores patients' expectations and reported outcomes in nonsurgical root canal treatment (NS-RCT), nonsurgical root canal retreatment (NS-ReTx), and endodontic microsurgery (EMS). METHODS: We used a qualitative description approach and conducted telephone and virtual semi-structured interviews with participants who had the following treatments within the preceding 3-12 months: NS-RCT (n = 10), NS-ReTx (n = 10), or EMS (n = 10). Half of these treatments were performed by senior endodontic residents in an academic setting and the other half by a community-based endodontist at a private practice. RESULTS: Participants identified several outcomes that were important to them and integral to treatment success, such as tooth survival, resolution of symptoms, aesthetics, and radiographic healing. Process-related factors were as important as treatment outcomes for participants. Communicating with and educating patients during treatment increased participants' satisfaction and lowered their stress. Dissatisfaction was linked to the lack of a comprehensive treatment and follow-up plan. Thorough planning ensured that patients were fully informed and had a structured approach to achieving their desired outcomes. CONCLUSIONS: This study provides a list of outcomes that are important for patients undergoing NS-RCT, NS-ReTx, and EMS. These outcomes should be considered when developing a core outcome set related to endodontic treatments. Additionally, this study reports patients' expectations regarding process-related factors that are essential for providing patient-centered care and improving patient experience.

Experiences of dentists and caregivers of patients with special care needs-A qualitative study.

BACKGROUND: Patients with special care needs (developmental disabilities) have unique and complex needs regarding their oral health and care. This qualitative study aimed to identify the experiences, preferences and challenges of dentists and caregivers regarding behavior guidance techniques for dental care in persons with special care needs. METHODS: Relying on qualitative description as articulated by Sandelowski, we conducted telephone interviews with a purposeful sample of five special care dentists and seven caregivers. We analyzed the data using thematic analysis. RESULTS: Four themes were highlighted: (1) Neither pharmacological or non-pharmacological behavior guidance techniques was universally suitable, (2) A patient-centered approach was critical, (3) The dental environment triggered patients' behaviors and anxiety levels, (4) There was more demand for, than supply of, qualified dentists to treat patients with special care needs. CONCLUSIONS: Persons with special care needs are heterogeneous and respond to various behavioral techniques required to deliver their treatment. Behavior guidance planning should be negotiated carefully with patients and caregivers and then individualized based on patients' capabilities and needs for treatment. The necessity to manage complex behaviors has contributed to the limitation of access to dental care for persons with special care needs. Dentistry as a profession has the obligation to uphold the social contract and meet its responsibility to the dental care needs of this population.

Labels and descriptions of dental behaviour support techniques: A scoping review of clinical practice guidelines.

INTRODUCTION: There is no agreed taxonomy of the techniques used to support patients to receive professional oral healthcare. This lack of specification leads to imprecision in describing, understanding, teaching and implementing behaviour support techniques in dentistry (DBS). METHODS: This review aims to identify the labels and associated descriptors used by practitioners to describe DBS techniques, as a first step in developing a shared terminology for DBS techniques. Following registration of a protocol, a scoping review limited to Clinical Practice Guidelines only was undertaken to identify the labels and descriptors used to refer to DBS techniques. RESULTS: From 5317 screened records, 30 were included, generating a list of 51 distinct DBS techniques. General anaesthesia was the most commonly reported DBS (n = 21). This review also explores what term is given to DBS techniques as a group (Behaviour management was most commonly used (n = 8)) and how these techniques were categorized (mainly distinguishing between pharmacological and non-pharmacological). CONCLUSIONS: This is the first attempt to generate a list of techniques that can be selected for patients and marks an initial step in future efforts at agreeing and categorizing these techniques into an accepted taxonomy, with all the benefits this brings to research, education, practice and patients.

Can a virtual learning module foster empathy in dental undergraduate students?

BACKGROUND: Empathy is an essential part of patient-centred health care, which positively benefits both patients and clinicians. There is little agreement regarding how best to design and deliver training for healthcare trainees to impart the skills and behaviours of clinical empathy. The study aimed to inform the field by sharing an educational intervention where we aimed to improve empathy amongst dental undergraduate students in Trinity College Dublin using a virtual learning module. METHODS: Adopting pre-post-repeat pre-experimental design, dental professional students completed the Jefferson Scale of Empathy (JSE) for Health Professional Students immediately prior to and after a three-week virtual programme designed to increase clinical empathy. Using a three-factor model described for the JSE in the literature, scores were evaluated for internal consistency and paired tests were performed on scores appropriate to their distributions. Seven-point Likert scales were scored to record student experience of training and technology, which are reported descriptively. RESULTS: Most of the 37 participants were female (76%) and represented dental science (N = 27) and dental hygiene roles (N = 7). Results revealed a mean JSE-HPS scale score rise from 110.0 (SD = 10.4) to 116.4 (SD = 11.1), which represented a rise of 5.8% (t (36) = 3.6, p = 0.001). The three factors associated with cognitive empathy, namely perspective-taking (T(36) = 3.931, p < 0.001; walking in the patient's shoes T(36) = 2.093, p = 0.043); and compassionate care (Z = 2.469, p = 0.014) were all found to have increased after the intervention. Students reported a positive experience of discipline-specific and generic videos as part of the module. CONCLUSION: The study demonstrated that a virtual educational module was associated with an increase in empathy amongst dental undergraduate students. The design of a blended module incorporating the Massive Open Online Course (MOOC) and virtual learning are beneficial and have a promising future.

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.

Efficacy and Safety of Postoperative Medications in Reducing Pain after Nonsurgical Endodontic Treatment: A Systematic Review and Network Meta-analysis.

INTRODUCTION: The purpose of this study was to evaluate the efficacy and safety of postoperative medications in decreasing pain after nonsurgical endodontic treatment using a network meta-analytic approach. METHODS: MEDLINE, Embase, CENTRAL, CINAHL, and Scopus were searched (until July 31, 2019). Two reviewers selected eligible randomized controlled trials and extracted and meta-analyzed data to estimate the treatment effects of pain assessed on a 0-100 scale (mean difference [MD]); 95% credible interval [CrI], and surface under the cumulative ranking curve [SUCRA]) at 6-8, 12, 24, and 48 hours postoperatively after the administration of various interventions. The Cochrane risk of bias tool was applied to eligible trials. The overall quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach obtained from the CINeMA Web application (University of Bern, Bern, Switzerland). RESULTS: Eight interventions among 11 studies were identified: nonsteroidal anti-inflammatory drugs (NSAIDs), NSAIDs + acetaminophen, NSAIDs + benzodiazepines, NSAIDs + opioids, corticosteroids, opioids, acetaminophen, and placebo. Compared with placebo, nonsurgical endodontic treatment pain 6-8 hours postoperatively improved with NSAIDs + acetaminophen (MD = -22; 95% CrI, -38 to -7.2; SUCRA = 73%; moderate confidence) and NSAIDs (MD = -21; 95% CrI, -34 to -7.6; SUCRA = 68%; very low confidence). At 12 and 24 hours, only NSAIDs were effective in decreasing postoperative pain. At 48 hours, no treatment resulted in significant pain reduction. Corticosteroids and opioids did not significantly decrease pain. No major safety concerns were reported. CONCLUSIONS: Very low- to moderate-quality evidence suggests that NSAIDs or NSAIDs + acetaminophen administered after nonsurgical endodontic treatment lead to a clinically relevant decrease in postoperative pain for patients with irreversible pulpitis or pulpal necrosis and are the most effective treatments available. Postoperative corticosteroids or opioids did not significantly decrease postoperative pain.

Efficacy and Safety of Pulpal Anesthesia Strategies during Endodontic Treatment of Permanent Mandibular Molars with Symptomatic Irreversible Pulpitis: A Systematic Review and Network Meta-analysis.

INTRODUCTION: Several strategies have been investigated for achieving successful pulpal anesthesia during endodontic treatment of mandibular molars with symptomatic irreversible pulpitis. However, comprehensive evaluation and identification of the most efficacious and safe intervention are lacking. We aimed to determine this using network meta-analysis. METHODS: MEDLINE, Embase, Cochrane Central, CINAHL, and Scopus databases were searched. Study selection and data extraction were performed in duplicate. Eligible randomized controlled trials were meta-analyzed to estimate the treatment effects (odd ratios [ORs]; 95% credible interval (CrI) and surface under the cumulative ranking curve (SUCRA)]. CINeMA software (University of Bern, Bern, Switzerland) was used to assess the quality of results. RESULTS: Thirty-seven interventions from 46 studies were identified. Compared with the common practice of an inferior alveolar nerve block with 2% lidocaine, a supplemental intraosseous injection was ranked the most efficacious with very low to moderate confidence (2% lidocaine + preoperative nonsteroidal anti-inflammatory drugs [NSAIDs] + acetaminophen [OR = 74; 95% CrI, 15-470; SUCRA = 97%], 2% lidocaine + preoperative NSAIDs [OR = 46; 95% CrI, 8-420; SUCRA = 94%], 2% lidocaine [OR = 33; 95% CrI, 14-80; SUCRA = 93%], 2% lidocaine + preoperative opioids + acetaminophen [OR = 20; 95% CrI, 4.4-98; SUCRA = 86%], and 4% articaine [OR = 20; 95% CrI, 6.3-96; SUCRA = 87%]) followed by supplemental buccal and lingual infiltrations using 4% articaine + preoperative NSAIDs (OR = 18; 95% CrI, 6-56; SUCRA = 86%; very low confidence). No major safety concerns were reported. CONCLUSIONS: Very low- to moderate-quality evidence suggests intraosseous injection using 2% lidocaine with 1:100,000 epinephrine or 4% articaine with 1:100,000 epinephrine or buccal and lingual infiltrations of 4% articaine with 1:100,000 epinephrine are superior strategies to achieve pulpal anesthesia during endodontic treatment of mandibular molars with symptomatic irreversible pulpitis. Preoperative NSAIDs or opioids with or without acetaminophen may increase the efficacy of these injections.

Mortality and Morbidity in Office-Based General Anesthesia for Dentistry in Ontario.

Our objective was to estimate the prevalence of mortality and serious morbidity for office-based deep sedation and general anesthesia (DS/GA) for dentistry in Ontario from 1996 to 2015. Data were collected retrospectively in 2 phases. Phase I involved the review of incidents, and phase II involved a survey of DS/GA providers. In phase I, cases involving serious injury or death for dentistry under DS/GA, sourced from the Office of the Chief Coroner of Ontario and from the Royal College of Dental Surgeons of Ontario (RCDSO), were reviewed. Phase II involved a survey of all RCDSO-registered providers of DS/GA in which they were asked to estimate the number of DS/GAs administered in 2015 and the number of years in practice since 1996. Clinician data were pooled to establish an overall number of DS/GAs administered in dental offices in Ontario from 1996 to 2015. Prevalence was calculated using phase I (numerator) and phase II (denominator) findings. The estimated prevalence of mortality in the 20-year period from 1996 to 2015 was 3 deaths in 3,742,068 cases, with an adjusted mortality rate of 0.8 deaths per 1 million cases. The estimated prevalence of serious morbidity was 1 injury in 3,742,068 cases, which adjusts to a serious morbidity rate of 0.25 per 1 million cases. The mortality rate found in this study was slightly lower than those published by earlier studies conducted in Ontario. The risk of serious morbidity was found to be low and similar to other studies investigating morbidity in office-based dental anesthesia.

Use of and Access to Deep Sedation and General Anesthesia for Dental Patients: A Survey of Ontario Dentists.

OBJECTIVE: This study aims to assess barriers to the use of deep sedation/general anesthesia (DS/GA) identified by dentists in Ontario. METHODS: An email invitation to a web-based survey was distributed to all licensed dentists and specialists who have provided an email address to the provincial regulator (n = 5507). Descriptive and regression analyses were performed to explore practice and demographic factors associated with the use of DS/GA. RESULTS: The response rate was 18.3%. A quarter (24.8%) of respondents reported inadequate access to DS/GA. Access was poorest in rural communities and greatest in the Greater Toronto Area (GTA). Overall, 74.5% of dentists indicated that they had used DS/GA in the past 12 months. Use was defined as having provided the service or referred a patient in the past 12 months. Non-use was most likely among general dentists, part-time dentists, dentists > 64 years and dentists in urban locations. Wait times and travel distances were reported as longer for medically complex patients. The most common reasons for non-use of DS/GA were a lack of perceived demand and additional costs to patients. For DS/GA users, the greatest barrier was additional costs to patients. CONCLUSION: Access to DS/GA in Ontario is not uniform; it remains a challenge in rural communities and regions outside the GTA, especially in the north. Use is lowest among general dentists and urban dentists despite adequate access, with dentists' perception of need for DS/GA and cost to the patient acting as major barriers. Education for dentists and better insurance coverage for patients may improve access for these patients.

Changes in dental student empathy during training.

Because empathic patient interactions by dentists are associated with improved patient outcomes, self-reported declines in empathy during dental student training are a concern. This study examined differences in empathy in 178 dental students at the University of Toronto and the University of Western Ontario from years one through four using an anonymous self-report web-based survey in a cross-sectional design. To localize the effects of training on empathy, an instrument that separately evaluated emotive (Emo) and cognitive (Cog) types of empathy in both personal (Per) and professional (Pro) contexts was developed, using items modified from previously validated scales and resulting in an empathy scale with four thirteen-item subscales (Per-Emo, Per-Cog, Pro-Emo, Pro-Cog). The response rate was 36.5 percent, and all subscales showed good reliability and validity. A 2x2x4 mixed design ANOVA tested differences in mean scores among the four subscales across the four years of training. Following a significant three-way interaction, subanalyses demonstrated no significant effects in the Per-context, but a significant year by empathy-type interaction in the Pro-context. Post hoc analyses of Pro measures indicated year three emotive empathy scores were significantly lower than earlier years, whereas years three and four cognitive empathy scores were significantly higher. This isolated decrease in Pro-Emo empathy with an increase in Pro-Cog empathy is consistent with the development of "professional empathy," described elsewhere as detached concern.