Editorial - Beyond the individual: the need for team based and system-wide solutions to support improved mental health in dentistry.

While the COVID-19 pandemic may no longer dominate headlines, significant pressures on the UK health and social care sector remain. Within dentistry, a profession with a long-standing association with poor mental health, practitioners continue to feel significant strain in terms of working conditions and financial pressures. They now also face a severe backlog of routine care for NHS patients.

Editorial - The importance of studying communication processes in the dentist: patient interaction.

The delivery of dental services attracts continuing debate by health service management, public health specialists and public representatives. There is little argument, that communication among dental service providers and cli- ent groups is a vital component of exemplary services. However, the exact requirements of what constitutes good communication becomes problematic. Definitions can be applied to detailed observations of elements of dental staff behaviour. Such observational audits are rarely applied, due to the large resources required, and believing this approach is purely a research-only exercise. We acknowledge the demanding nature of any such endeavour in real-time by a trained observer. An alternative is to video-record clinical sessions. Although this has been possible for some decades, the widespread use of recording samples of clinical sessions, for example to assess staff engagement in prevention advice, is not realistic using current methodologies, even if the considerable ethical concerns could be assuaged. In addition, hitherto, there has been a wide ranging set of views of what would be considered poor, just good enough or excellent communication. Part of this difficulty is due to the complexity of the communication processes themselves. The variety of health service settings, staff experience and training received in the fi eld of communication and the sheer spectrum of patient types and problems that surface which require treatment, advice and instruction makes a universal framework of what constitutes acceptable communication skills difficult to specify. Furthermore, when no established standard can be agreed the status of rewarding good communication is therefore under-valued and simply ignored from service contracts.

Dental anxiety, child-oral health related quality of life and self- esteem in children and adolescents: a systematic review and meta-analysis.

AIM: To identify the directions, strength and associations between dental anxiety, COHRQoL and self-esteem in children and adolescents. BASIC RESEARCH DESIGN: PRISMA guidelines were followed and the review registered (PROSPERO CRD42019140037). MEDLINE, Cochrane Library, Scopus, Science Direct, CINAHL, Joanna Briggs Institute (JBI), Grey Literature Report, and British Library EThOS using MeSH terms and keywords were searched. Three reviewers examined the abstracts of all articles, excluded duplicates and those not meeting inclusion criteria. All full-text papers were read by all reviewers. Meta-analysis association data including Pearson's or Spearman's correlation coefficient were extracted and effect sizes estimated. RESULTS: Twelve papers met the inclusion criteria, 7 assessed the relationship between child dental anxiety and COHRQoL; four between COHRQoL and self-esteem and one between child dental anxiety and self-esteem. Significant relationships were found between COHRQoL and the other child-related outcomes measures. An inverse relationship was shown for dental anxiety and COHRQoL. The meta-analysis found small associations between child dental anxiety and COHRQoL and moderate associations between COHRQoL and self-esteem. High heterogeneity between COHRQoL and self-esteem was noted. The association between child dental anxiety and self-esteem was limited. No source reported associations between all three variables. CONCLUSION: The studies were of varying quality and the degree of heterogeneity meant that only limited conclusions were possible. There is a need for high-quality evidence to underpin intervention designs to promote COHRQoL and self-esteem to reduce child dental anxiety.

Community-based oral health interventions for people experiencing homelessness: a scoping review.

OBJECTIVE: To determine the characteristics of community-based oral health interventions for people experiencing homelessness. BASIC RESEARCH DESIGN: A scoping review was conducted, adhering to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses: Scoping Reviews) checklist. A search strategy was developed using MeSH terms and key words, and used to search the following electronic databases: Medline/PubMed, CINAHL, ProQuest Assia, Scopus, Web of Science and PsychNet. Key journals and reference lists were also hand-searched. Two reviewers then read the abstracts of all papers, excluding duplicates and papers that did not meet the eligibility criteria. The reviewers then read to full-texts of the studies to be included in the review. RESULTS: Eighteen studies met the inclusion criteria and were included in the study. These studies were predominantly evaluations of community-based dental services or other oral health interventions. Several recommendations were extracted. Interventions should involve co-design with homeless service users; multidisciplinary working, collaboration with dental practitioners, and working with educational establishments. The location of community-based services was also found to be of importance. CONCLUSION: This review has highlighted several recommendations, as well as gaps in the literature. These gaps suggest a need for more non-clinical oral health interventions for the homeless population, and a closer look at the role that non-dental practitioners can play in the delivery of oral health care.

Emotional talk of patients with breast cancer during review appointments with therapeutic radiographers: effects on fears of cancer recurrence.

Fears of cancer recurrence (FCR) in patients with breast cancer may develop during radiotherapy. Radiographer communication with their patients may influence early survivorship FCR level. AIM: To investigate the management of emotional talk in patients with breast cancer attending their initial review appointments during radiotherapy and predict FCR at 6-8 weeks follow-up. METHODS: A mixed-methods observational study was conducted. Patients (consecutive sample, n = 60) with breast cancer, attending a major Scottish cancer centre, had their first two review appointments with their therapeutic radiographer (TR) audio-recorded. In addition, FCR was assessed (FCR7) at baseline and at 6-8 weeks following their final radiotherapy visit. Two TRs participated. Audio files were coded by the VR-CoDES system to identify emotional cues and therapeutic radiographer (TR) responses. Linear regression models were tested for fit and to identify factors associated with follow-up FCR, i.e. patient cues, responses by TR. RESULTS: Follow-up FCR was predicted negatively (robust estimator, p = .01) by level of patient emotional talk at the second review session. The provision of space by the TR, at the second session, to enable patients to expand their emotional utterances was also associated, but negatively (p = .01), with follow-up FCR. These effects were maintained after inclusion of covariates: age, treatment received and living conditions. CONCLUSIONS: Patient's emotional expression and TR responses at the second review meeting predicted follow-up FCR. The study shows the effect of communication processes on this specific distress component of the patient's survivorship experience. TRIAL REGISTRATION: NCT02599506.

Fear of cancer recurrence trajectory during radiation treatment and follow-up into survivorship of patients with breast cancer.

BACKGROUND: Fear of cancer recurrence (FCR) has been shown to be higher in patients treated with external beam radiotherapy (RT) compared to those untreated. However, little is known about the dynamics of patient's FCR during and after RT. The aim of this study was to examine FCR levels in a longitudinal panel design with breast cancer patients receiving RT. METHODS: Consecutive newly-diagnosed breast cancer patients (n = 94) attending a single cancer centre were invited to complete a 7-item FCR scale (FCR7) that was collected weekly by paper instrument and at a follow-up phone call 6-8 weeks after completion of RT. Descriptive statistics, and Latent Growth Curve Modelling (LGCM) were utilised to analyse the data. RESULTS: Women who were younger, single/separated, had chemotherapy, had extra boost radiation treatment, taking Herceptin and treated by 4-field technique reported higher recurrence fear at baseline. There was strong evidence of substantial variation in the trajectory of FCR (z = - 3.54, p < .0001). The average trajectory of FCR over RT was negative (unstandardized estimate = - 0.59) and associated with FCR follow-up level (standardised estimate = 0.36, z = 3.05, p < .002), independent of baseline recurrence fears. CONCLUSION: Patients vary in their trajectory of recurrence fears over RT which predicts FCR approximately 2 months following treatment. Review appointments by therapy radiographers presents an opportunity to intervene in FCR trajectories. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02599506 . Prospectively registered on 11th March 2015.

Unidimensional scales for fears of cancer recurrence and their psychometric properties: the FCR4 and FCR7.

BACKGROUND: The assessment of fear of recurrence (FCR) is crucial for understanding an important psychological state in patients diagnosed and treated for cancer. The study aim was to determine psychometric details of a seven question self-report scale (FCR7) and a short form (FCR4) based upon items already used in various extensive measures of FCR. METHODS: Two consecutive samples of patients (breast and colorectal) were recruited from a single specialist cancer centre. The survey instrument contained the FCR7 items, Hospital Anxiety and Depression Scale (HADS), and demographic details. Clinical information was obtained from patient hospital records. Statistical analyses were performed using classical test and item response theory approaches, to demonstrate unidimensional factor structure and testing key parameters. Construct validity was inspected through nomological and theoretical prediction. RESULTS: Internal consistency was demonstrated by alpha coefficients (FCR4: 0.93 and FCR7: 0.92). Both scales (FCR7 & FCR4) were associated with the HADs subscales as predicted. Patients who experienced chemotherapy, minor aches/pains, thought avoidance of cancer and high cancer risk belief were more fearful. Detailed inspection of item responses profile provided some support for measurement properties of scales. CONCLUSION: The internal consistency, and pattern of key associations and discriminability indices provided positive psychometric evidence for these scales. The brief measures of FCR may be considered for audit, screening or routine use in clinical service and research investigations.

Fear of cancer recurrence in oral and oropharyngeal cancer patients: An investigation of the clinical encounter.

Fear of cancer recurrence (FCR) is common among individuals treated for cancer. Explorations of how this fear is expressed within an oncology setting and responded to are currently lacking. The aim was to investigate how head and neck cancer survivors in follow-up consultations express FCR, investigate how a healthcare professional addresses recurrence fears, and examine how survivors experience this interaction. We recorded the follow-up consultations of those participants who have reported FCR as a concern on the Patient Concerns Inventory. We also conducted a follow-up phone interview with the participants. We analysed the transcripts using thematic analysis. Five men and six women were recruited, aged 55-87 (mean age = 64). Follow-up consultation analyses revealed that the consultant used "normalising FCR," "reassurance," and "offer of referral to a counsellor." Interviews revealed themes around how they coped with FCR, relevance of personal history on FCR, and the impact of feeling gratitude towards the consultant on expression of FCR. Analyses indicate that patients may feel reluctant to raise their FCR with their clinician for fear of appearing "ungrateful" or of damaging a relationship that is held in high esteem. Findings indicate the initiation of FCR with patients can be beneficial for patient support.

Using the simplified case mix tool (sCMT) to identify cost in special care dental services to support commissioning.

To commission dental services for vulnerable (special care) patient groups effectively, consistently and fairly an evidence base is needed of the costs involved. The simplified Case Mixed Tool (sCMT) can assess treatment mode complexity for these patient groups. OBJECTIVE: To determine if the sCMT can be used to identify costs of service provision. CLINICAL SETTING: Patients (n=495) attending the Sussex Community NHS Trust Special Care Dental Service for care were assessed using the sCMT. MAIN MEASURES: sCMT score and costs (staffing, laboratory fees, etc.) besides patient age, whether a new patient and use of general anaesthetic/intravenous sedation. METHOD: Statistical analysis (adjusted linear regression modelling) compared sCMT score and costs then sensitivity analyses of the costings to age, being a new patient and sedation use were undertaken. Regression tables were produced to present estimates of service costs. RESULTS: Costs increased with sCMT total scale and single item values in a predictable manner in all analyses except for 'cooperation'. Costs increased with the use of IV sedation; with each rising level of the sCMT, and with complexity in every sCMT category, except cooperation. CONCLUSION: Costs increased with increase in complexity of treatment mode as measured by sCMT scores. Measures such as the sCMT can provide predictions of the resource allocations required when commissioning special care dental services.

Does dental undergraduate education and postgraduate training enable intention to provide inhalation sedation in primary dental care? A path analytical exploration.

AIM: To examine how quality standards of dental undergraduate education, postgraduate training and qualifications together with confidence and barriers could be utilised to predict intention to provide inhalation sedation. METHODS: All 202 dentists working within primary dental care in NHS Highland were invited to participate. The measures in the questionnaire survey included demographic information, undergraduate education and postgraduate qualifications, current provision and access to sedation service, attitudes towards confidence, barriers and intention to provide inhalation sedation. A path analytical approach was employed to investigate the fit of collected data to the proposed mediational model. RESULTS: One hundred and nine dentists who completed the entire questionnaire participated (response rate of 54%). Seventy-six per cent of dentists reported receiving lectures in conscious sedation during their undergraduate education. Statistically significantly more Public Dental Service dentists compared with General Dental Service (GDS) dentists had postgraduate qualification and Continuing Professional Development training experience in conscious sedation. Only twenty-four per cent of the participants stated that they provided inhalation sedation to their patients. The findings indicated that PDS dentists had higher attitudinal scores towards inhalation sedation than GDS practitioners. The proposed model showed an excellent level of fit. A multigroup comparison test confirmed that the level of association between confidence in providing inhalation sedation and intention varied by group (GDS vs. PDS respondents). Public Dental Service respondents who showed extensive postgraduate training experience in inhalation sedation were more confident and likely to provide this service. CONCLUSION: The quality standards of dental undergraduate education, postgraduate qualifications and training together with improved confidence predicted primary care dentists' intention to provide inhalation sedation.

The Video Interaction Guidance approach applied to teaching communication skills in dentistry.

PURPOSE: To examine dentists' views of a novel video review technique to improve communication skills in complex clinical situations. MATERIALS AND METHODS: Dentists (n = 3) participated in a video review known as Video Interaction Guidance to encourage more attuned interactions with their patients (n = 4). Part of this process is to identify where dentists and patients reacted positively and effectively. Each dentist was presented with short segments of video footage taken during an appointment with a patient with intellectual disabilities and communication difficulties. Having observed their interactions with patients, dentists were asked to reflect on their communication strategies with the assistance of a trained VIG specialist. RESULTS: Dentists reflected that their VIG session had been insightful and considered the review process as beneficial to communication skills training in dentistry. They believed that this technique could significantly improve the way dentists interact and communicate with patients. The VIG sessions increased their awareness of the communication strategies they use with their patients and were perceived as neither uncomfortable nor threatening. DISCUSSION: The VIG session was beneficial in this exploratory investigation because the dentists could identify when their interactions were most effective. Awareness of their non-verbal communication strategies and the need to adopt these behaviours frequently were identified as key benefits of this training approach. One dentist suggested that the video review method was supportive because it was undertaken by a behavioural scientist rather than a professional counterpart. CONCLUSION: Some evidence supports the VIG approach in this specialist area of communication skills and dental training.

Validating a measure of the prevalence of dental anxiety as applied to Kuwaiti adolescents.

OBJECTIVES: To assess self-reported dental anxiety (DA) among Kuwaiti adolescents and to test whether different dental anxiety scales are valid for measuring DA in Kuwait. BASIC RESEARCH DESIGN: Cross-sectional, structured, anonymous questionnaire survey in Arabic completed at government schools. PARTICIPANTS: 757 pupils aged 13-15 years from three schools filled the questionnaire. Useable response rate was 93.0%. MAIN MEASURES: DA was assessed by: 1, a single-item dental fear question (DF); 2, the Modified Dental Anxiety Scale (MDAS); and 3, the Modified Child Dental Anxiety Scale: faces (MCDAS(f)). RESULTS: A third of the girls and 6% of boys reported being very much afraid of visiting a dentist. Use of the drill and injection in the gum were the most anxiety arousing MDAS items; tooth extraction and injection of the MCDAS(f) items. Total mean for MDAS was 11.4 (sd 4.6) and for MCDAS(f) 16.6 (sd 6.5). A tenth of the children were highly dentally anxious when measured by MDAS (score ≥ 19). Girls reported statistically significantly higher DA scores with all the measures. There was a high correlation between the total score of the MDAS and the total score of the MCDAS(f) (p = 0.855). Statistically significant relationship (p < 0.001) was found between the single-item DF and the total score of the MDAS and a single item and the total score of the MCDAS(f). CONCLUSIONs: A tenth of children were highly dentally anxious; girls reporting higher scores. A single-item dental fear question, MDAS and MCDAS(f) were valid tools for measuring DA among Kuwaiti adolescents.

Weighing up the weighted case mix tool (WCMT): a psychometric investigation using confirmatory factor analysis.

OBJECTIVE: To assess the use of the WCMT in two Scottish health boards and to consider the impact of simplifying the tool to improve efficient use. DESIGN: A retrospective analysis of routine WCMT data (47,276 cases). CLINICAL SETTING: Public Dental Service (PDS) within NHS Lothian and Highland. METHOD: The WCMT consists of six criteria. Each criterion is measured independently on a four-point scale to assess patient complexity and the dental care for the disabled/impaired patient. Psychometric analyses on the data-set were conducted. Conventional internal consistency coefficients were calculated. Latent variable modelling was performed to assess the 'fit' of the raw data to a pre-specified measurement model. A Confirmatory Factor Analysis (CFA) was used to test three potential changes to the existing WCMT that included, the removal of the oral risk factor question, the removal of original weightings for scoring the Tool, and collapsing the 4-point rating scale to three categories. RESULTS: The removal of the oral risk factor question had little impact on the reliability of the proposed simplified CMT to discriminate between levels of patient complexity. The removal of weighting and collapsing each item's rating scale to three categories had limited impact on reliability of the revised tool. The CFA analysis provided strong evidence that a new, proposed simplified Case Mix Tool (sCMT) would operate closely to the pre-specified measurement model (the WMCT). CONCLUSIONS: A modified sCMT can demonstrate, without reducing reliability, a useful measure of the complexity of patient care. The proposed sCMT may be implemented within primary care dentistry to record patient complexity as part of an oral health assessment.

Dentists' training and willingness to treat adolescents with learning disabilities: the mediating role of social and clinical factors.

AIM: To test a theoretical model based on Cohen's dental profession factors (training; practitioner attitudes; geography) to investigate practitioners' willingness to treat adolescents with learning disabilities (LD) in primary dental care. PARTICIPANTS: A sample of all 537 primary care dentists working in a mainly urban area of Northern Ireland and a more rural area of Scotland. MAIN OUTCOME MEASURE: Willingness to treat adolescents with LD. METHOD: Questionnaire survey of demographic profile, undergraduate education, current knowledge, attitudes towards individuals with LD and willingness to treat this patient group. A path analytical approach (multiple meditational model) was used. RESULTS: Three hundred dentists participated giving a valid response rate of 61%. Undergraduate education and current knowledge (training) strengthened a social model perspective promoting positive attitudes and willingness to treat adolescents with LD. Undergraduate education and current knowledge about disability did not significantly contribute to dentists whose attitudes were underpinned by the medical model of disability. Therefore geography (rural or urban location) was not an influential factor in willingness to treat adolescents with LD. This does not exclude the possibility that area of work may have an influence as a consequence of undergraduate university attended. CONCLUSION: This model identifies the importance of undergraduate and continuing dental education with regard to modifying professional attitudes (social and clinical factors) to assist practitioners treat adolescents with LD and provide them with inclusive dental services in primary dental care.

Risk stratification for poor health-related quality of life following head and neck cancer through the aid of a one-page item prompt list.

The aim of this work was to evaluate the usability of a single-page, patient-completed, condition-specific prompt list, the Patient Concerns Inventory (PCI-HN), to risk-stratify for poor health-related quality of life (HRQOL). Data were collected between 2008 and 2017. The main dataset comprised 310 patients first completing the PCI-HN and University of Washington Quality of Life questionnaire (UW-QOLv4) between 2012 and 2017. Another 201 patients first completing the PCI-HN between 2008 and 2011 provided a second dataset for independent validation. Subsequent completions of the PCI-HN in both groups and the distress thermometer (DT) were also used as further validation datasets. Associations between PCI-HN items selected by patients and a range of UW-QOLv4 outcomes were explored using conventional logistic regression and Chi-squared automated interaction detection (CHAID) analyses. One quarter of patients reported less than good HRQOL, range 26-29% across the four datasets. Several individual items from within the PCI-HN were predictive of adverse outcomes. The total number of items selected was also predictive. The single-sheet prompt list enables clinicians to identify patients at high risk of poor HRQOL. This simple approach has the potential to be integrated into routine clinical practice.

The perceived sexual health needs of looked after young people: findings from a qualitative study led through a partnership between public health and health psychology.

BACKGROUND: Looked after young people (LAYP) have poorer sexual health outcomes than their peers. However, research seldom examines the health needs of, or intervenes with, this group. The aim of the current study was to identify LAYP's perceived sexual health needs and explore sources of sexual health information, knowledge levels, concerns and service preferences. METHODS: Looked after young people within Fife, Scotland, were recruited through their workers and carers to participate in qualitative semi-structured interviews. Those aged 12-19 years were targeted for recruitment. National Health Services ethics approval was granted. Thematic analysis was conducted using NVivo. RESULTS: Interviews were conducted with 10 LAYP. Key themes included gaps in knowledge, and gaps between knowledge and behaviour. Being 'looked after' may have negative consequences on knowledge, sources of support and safer sex. A flexible, one-to-one service, aimed at several lifestyle issues, not solely sexual health, was preferred by respondents. CONCLUSION: Looked after young people require support to bridge the gap between knowledge and behaviour and several theories relevant to the findings have been identified. Participants desired more support around a range of health issues, which may come from school, workers and carers, as well as health professionals. Further research examining effective interventions with this group is crucial to improve outcomes.

Using the Patient Concerns Inventory in the identification of fatigue following treatment for head and neck cancer.

Fatigue has a profound impact on health-related quality of life (HRQOL). The aim of this study was to describe the clinical characteristics and HRQOL of head and neck cancer patients who raised the issue of fatigue on the Patient Concerns Inventory (PCI) at their review consultation. Eight consultants were randomized to use the PCI as part of a cluster-controlled trial. Patients also completed the University of Washington Quality of Life version 4 (UWQOL), EQ-5D-5L (EuroQol Group), and Distress Thermometer questionnaires. The study included 140 patients who attended clinics at a median of 108 (interquartile range 70-165) days after the end of treatment. The PCI item 'fatigue' was the sixth most commonly selected, by 29% (n=40). Those with advanced tumours were more likely to have selected the item (30/84, 36% vs 10/56, 18%; P=0.02), as were those treated with radiotherapy±chemotherapy (34/87, 39% vs 6/53, 11%; P<0.001). The PCI fatigue group reported significantly worse overall quality of life, social-emotional and physical function composite scores (UWQOL), Distress Thermometer, and EQ-5D-5L. PCI fatigue was common in those with sleeping, nausea, mood, depression, mobility, breathing, and energy level concerns. In conclusion, given the problems associated with fatigue, it is appropriate to screen and seek interventions that might help patients address this.

A qualitative study of pharmacists' views on offering chlamydia screening to women requesting Emergency Hormonal Contraception.

This was a qualitative study to understand why pharmacists, asked to offer free chlamydia postal screening to Emergency Hormonal Contraception clients, had not offered screening to all eligible women. Twenty-six pharmacists completed exit interviews and 12 agreed to semi-structured in-depth interviews. Although pharmacists were keen to expand their services, they were reluctant to offer chlamydia screening to women who were married or in a long term relationship. To avoid offence they selected women based on age, education and ethnicity. The rationale for chlamydia screening in pharmacy-based EHC schemes is compromised if pharmacists do not offer screening comprehensively.

Fear of recurrence following head and neck cancer in the outpatient clinic.

Fear of recurrence (FOR) following head and neck cancer is one of the most frequent concerns of patients and is associated with psychological distress. The aims of this study were, first, to report the clinical characteristics of patients selected for FOR concerns on a patient concerns inventory (PCI) and, second, to compare the degree of FOR using a FOR questionnaire of those patients expressing FOR concerns on the PCI with those who did not. Two cohorts were used. The first comprised consecutive oncology patients attending clinics from August 2007 for 9 months (N = 123). These patients completed the PCI only. The second comprised patients attending the same clinic for over 4 months from October 2008 (N = 68), and this group completed both the PCI and the FOR questionnaire. FOR was the most frequently selected issue on the PCI (42%). There were no obvious differences in selecting FOR by patient characteristics. Those who scored 'a lot' or 'all the time' for questions 1-6 in the FOR questionnaire and responses (on a 10-point scale) of 7-10 for question 7 were deemed as having 'significant' FOR. In those raising the issue of FOR on the PCI, 79% (15/19) had significant problems compared to 24% (12/49) if they did not. FOR is a common concern and because it is not possible to identify patients based on clinical parameters, it is important to screen for FOR to direct patients to appropriate support and intervention.