Is Dichotomization into Regular versus Irregular Dental Attenders Valid? A Qualitative Analysis.

AIMS: To discover whether dental visiting behavior can be understood as a dichotomy of planned versus problem based, or whether there were a range of different types of understanding and patient behavior, recognizable as patterns of dental visiting behavior. METHODS: Secondary analysis drawing on 2 qualitative studies of patients' accounts of dental attendance and oral health, with 1) opportunistic interviews with people attending urgent dental care services (n = 43; including 19 with follow-up) and 2) home-based, in-depth interviews with people attending a dental practice with a mixture of improved or deteriorated/poor periodontal health (n = 25). RESULTS: Four distinguishable patterns of dental visiting were identified in patients' accounts: Accepting and Active Monitoring, as well as Ambivalent and Active Problem-based dental visiting behavior. Individuals' patterns were relatively stable over time but could shift at turning points. Accepting Monitors were characterized as accepting dentists' recommendations and dental practice policies relating to oral health and visits, whereas Active Monitors were more independent in judging how often to attend for preventive appointments, while still valuing anticipatory care. Ambivalent Problem-based visitors placed a relatively low value on anticipatory care for oral health maintenance and drifted into lapsed attendance, in part because of service-related factors. This contrasted with Active Problem-based visitors, for whom using services only in an emergency was a conscious decision, with low value placed on anticipatory care. CONCLUSION: This article demonstrates the dynamic nature of patterns of dental visiting where the dental system itself is partly instrumental in shaping patterns of utilization in an ecological way. Thus, service-related factors tend to combine with patients' behavior in expanding inequalities. This illuminates the reasons why risk-based recalls are challenging to implement as a dental policy. KNOWLEDGE TRANSFER STATEMENT: The results of this analysis can be used by clinicians and policymakers to inform policy around supporting uptake of preventive health care visits, contributing in particular to understanding how risk-based preventive visiting policies may be better adapted to patients' understanding of the purpose of visits, taking into account that this is in part shaped by service-related factors in an ecological way, arising from patients' and dental teams' expectations.

Interventions to reduce socio-economic inequalities in dental service utilisation - a systematic review.

OBJECTIVE: A gradient exists where people with lower socio-economic status (SES) use dental services less regularly than others. Evidence suggests these SES differences may contribute to inequalities in oral health. A variety of approaches have been tried to increase regular dental service use, although it is possible that some are ineffective or may even widen SES inequalities. We aimed to undertake a systematic review of interventions to reduce SES differences in dental visiting. BASIC RESEARCH DESIGN: Interventions limited to those influencing dental service use by adults. Any type of experimental design, investigating interventions aiming to reduce SES inequalities in dental service use, was included. Primary outcome was a measure of dental utilisation. RESULTS: Electronic search of 8 databases, with citation snowballing, identified 14,396 titles and abstracts. Paper eligibility screening identified 63 full papers, of which 6 met the inclusion criteria. All included studies were conducted in the United States. Of these, three were targeted to parents, and two towards pregnant women. Two studies incorporated mailing postcards as (at least) one component of the intervention, although results were mixed. Another three studies included scheduling dental appointments as part of a multi-component approach, again with mixed results. The remaining study, involving community health advisors undertaking activities aimed at raising community awareness, found no significant intervention effect. CONCLUSIONS: Evidence in this area is limited and results are mixed. More work is needed to investigate the effectiveness of interventions to reduce SES inequalities, especially in different healthcare systems and involving a wider participant range.

A systematic review of interventions using cue-automaticity to improve the uptake of preventive healthcare in adults: applications to dental visiting.

OBJECTIVE: Since behaviour is underpinned by both cognitive and automatic processes, psychological interventions aiming to instigate or modify habitual behaviour (cue-automaticity interventions) offer an alternative to the more commonly used (mainly educational) strategies to increase preventive healthcare use. Theory suggests that low socio-economic (SES) groups are especially likely to benefit. Cue-automaticity describes how repetition of behaviour, initiated by a particular 'cue', in a constant context, leads to the automatic instigation and/or execution of behaviour. Our primary objective was to assess the effectiveness of cue-automaticity interventions to improve the uptake of adult preventive healthcare, and to consider how this might be applied to the design of interventions to promote preventive dental visiting. BASIC RESEARCH DESIGN: An electronic search, with citation snowballing, of cue-automaticity interventions to influence adult preventive healthcare use was undertaken. RESULTS: Searching identified 11,888 titles and abstracts. Paper screening left 26 papers, of which 6 RCTs met the inclusion criteria. All 6 incorporated an Implementation Intention (I-I) component. Four studies involved cancer screening and 2 involved vaccination programmes. Five studies showed a significantly positive increase in preventive healthcare use, while one did not. CONCLUSIONS: Whilst few studies using cue-automaticity to underpin the promotion of preventive care use have been undertaken, studies that do exist have promising results. As cue-automaticity interventions may be of particular benefit to low SES groups, research is needed to investigate whether cue-automaticity interventions can translate into reducing inequalities in attendance for dental check-ups.

The development and psychometric properties of the Arabic version of the child oral health impact profile-short form (COHIP- SF 19).

BACKGROUND: This study aims to cross-culturally adapt the original English-language COHIP-SF 19 to Arabic culture and to test its psychometric properties in a community sample. METHODS: The Arabic COHIP-SF 19 was developed and its psychometric properties were examined in a population-based sample of 876 schoolchildren who were aged 12 years of age, in Benghazi, Libya. The Arabic COHIP-SF 19 was tested for its internal consistency, reproducibility, construct validity, factorial validity and floor as well as ceiling effects. A Mann-Whitney U test was used to compare the mean scores of COHIP-SF 19 by participants' caries status and self-reported oral health rating, satisfaction and treatment need. RESULTS: The Arabic COHIP-SF 19 was successfully and smoothly developed. It showed an acceptable level of equivalence to the original version. Overall, the internal consistency and reproducibility were acceptable to excellent, with a Cronbach's alpha of 0.84 and an intra-class correlation coefficient (ICC) of 0.76. All hypotheses predefined to test construct validity were confirmed. That is, children who had active dental caries, and who rated their oral health as poor, were not satisfied with their oral health or indicated the need of treatment had lower COHIP-SF 19 scores (P < 0.05). Floor or ceiling effects were not observed. The exploratory Factorial analysis suggested a 4-component solution and deletion of one item. CONCLUSION: The Arabic COHIP-SF 19 was successfully developed. The measure demonstrated satisfactory reliability and validity to estimate OHRQoL in a representative sample of 12-year-old schoolchildren.

Do 'poor areas' get the services they deserve? The role of dental services in structural inequalities in oral health.

All over the world, we see that communities with the greatest dental need receive the poorest care--a truism first summarised by the Inverse Care Law in 1971. Despite efforts to attract dentists to under-served areas with incentives such as 'deprivation payments', the playing field is still uphill because of the fundamental inequalities which exist in society itself Deep-seated cultural values which are accepting of a power difference between the 'haves' and 'have nots', and that emphasise individualism over collectivism, are hard to shift. The marketization of health care contributes, by reinforcing these values through the commodification of care, which stresses efficiency and the transactional aspects of service provision. In response, practitioners working in deprived areas develop 'scripts' of routines that deliver 'satisfactory care', which are in accord with the wishes of patients who place little value on oral health but which also maintain the viability of the practice as a business. A compliance framework contrasting types of organisational (dental practice) power (coercive, utilitarian, normative) with types of patient orientation (alienative, calculative, moral) identifies where certain combinations 'work' (e.g. normative power--moral orientation), but where others struggle. Thus institutional structures combine with patients' and the wider community's demands, to generate a model of dental care which leaves little scope for ongoing, preventive dental treatment. This means that in poor areas, all too often, not only is less care available, it is of lower quality too--just where it is needed most.

The use of diet diaries in general dental practice in England.

OBJECTIVES: Diet diaries are recommended as a tool to support behaviour change in dental patients at high risk of dental diseases. However, little is known about their use in dental practice. This study aimed to investigate whether and how general dental practitioners (GDPs) use diet diaries and identify factors which influence their use. METHODS: A postal questionnaire was sent to a stratified random sample of general dental practitioners. The questionnaire asked about demographic and professional characteristics of the GDPs and their practices regarding diet advice, collection of dietary information, diet diaries usage (e.g. frequency, considerations and barriers), and interpretation of diet diaries. Descriptive, bivariate and multivariate analyses were conducted. RESULTS: From 972 eligible GDP participants, 250 (26%) responses were received. Whilst almost all of these GDPs reported giving diet advice to patients routinely, and 40% reported also referring to dental care professionals in the practice to deliver dietary advice, only 28% (70) reported that they are involved in using diet diaries. GDPs appeared to target patients for dietary advice: GDPs reported they personally gave diet advice to an estimated 63% of their patients, and referred patients to DCPs for diet advice for 11% of their (GDPs') patients. GDPs used diet diaries more often for child than adult patients. Diet diaries usage was lower among younger dentists and in practices with higher percentages of NHS patients (p⟨0.05). Perceived insufficient remuneration for time involved in using diet diaries was the main reason given for their lack of use. CONCLUSION: Although recommended as best practice, most English GDPs do not frequently use diet diaries to collect diet information in dental practice, mainly due to perceived financial and time constraints. Development of a more efficient tool to assess the dietary habits of dental patients is needed.

Operationalisation of the construct of access to dental care: a position paper and proposed conceptual definitions.

BACKGROUND: 'Access' is a term readily used in a political and policy context, but one which has not leant itself to measurement of progress towards policy goals or comparisons between health systems. Like 'quality', 'access' is a multi-dimensional construct, but currently often remains a vague and abstract concept which is difficult to translate into something specific, concrete and therefore measureable. METHODS: The paper describes previous work and identifies a need for a greater consensus and conceptual clarity in the selection of metrics for dental access. RESULTS: The construct of dental access is described as involving the concepts of 1: opportunity for access; 2, realised access (utilisation); 3, equity and 4, outcomes. Proposed conceptual definitions are given and a case made for measuring 'initial utilisation' separately from 'continued utilisation', reflecting modern approaches which distinguish 'entry access' (gaining entry to the dental care system), from the process of gaining access to higher levels of care. Using a distinction between 'entry access' and 'effective access' allows a choice of whether to restrict measurement to mainly supply side considerations, or alternatively to extend the measurement to include whether there is equity in the proportion of patients who are able obtain effective needed interventions. CONCLUSIONS: A development of conceptual definitions of dental access could facilitate measurement of progress towards policy goals and operationalisation of the construct.

Models of practice organisation using dental therapists: English case studies.

INTRODUCTION: A new dental remuneration system based on bands of activity has changed the reward system operating in dental practices and influenced practitioner behaviour in relation to the delegation of tasks to English dental therapists (DTs). Since dental practitioners operate as independent contractors they are free to innovate. A variety of models incorporating DTs in general practice teams exist, some of which may overcome the apparent delegation constraints embedded within this system of remuneration. OBJECTIVES: To describe the way different practices are organised to take account of DTs in their teams and identify whether any of these models address delegation disincentives arising from the system of remuneration. METHOD: A purposive sample of six dental practices was identified, comprising two small, two medium and two large dental practices, including a variety of models of practice organisation. Semi-structured interviews were carried out with principal dentists, associate dentists, DTs, practice managers and dental hygienists (35 participants in total). A thematic analysis was applied to interview transcripts. RESULTS: The six dental practices demonstrated six different models of practice organisation which could be grouped into 'practice payment' and 'dentist payment' models according to whether the salary costs of the DT were met by a central practice fund or from the income of individual dentists in the team. In both of the large practices only some of the dentists in the team referred work to the DT because of reimbursement issues. In two practices the system was perceived to be satisfactory to all parties, one of these being a single-handed practice with two DTs. CONCLUSION: Although the remuneration system contained some potential disincentives to DT delegation, some practices innovated in their organisations to overcome these issues.

The use of conversation mapping to frame key perceptual issues facing the general dental practice system in England.

OBJECTIVE: To demonstrate the use of a novel qualitative methodology namely conversation mapping, which can be used to capture differences in stakeholder perspectives and give a root definition of the problem in a complex policy area. The methodology is used in the context of the changes introduced in the English general dental practice system in April 2006, to investigate the key issues facing the system, as perceived by general dental practitioners (GDPs). BASIC RESEARCH DESIGN: From a broad trigger statement, three transformational statements were produced. Each participant recorded their contribution on a hard diagrammatic form as a 'map', with others responding with their own written comment, thus generating three conversation maps. Thematic analysis resulted in the generation of a preliminary model summarising key perceptual issues. RESULTS: The five emergent themes identified were: financing, dentists' wants/needs, the role of the public and patients, system goals and policy level decision making. Financing was identified as the core category to which all other categories were related. CONCLUSIONS: Conversation mapping, a methodology arising from a systems approach, can be used to develop a 'rich picture' of an oral health care system in order to define the core problem within this policy area. Findings suggest that GDPs identify the financing of the system as a fundamental source of problems within the general dental practice system. This appears to be at variance with the perception of policy makers, who report a more limited view, identifying the system of remuneration as the 'heart of the problem'.

Measurement of attitudes of U.K. dental practitioners to core job constructs.

OBJECTIVES: To develop a measure to identify dental practitioner attitudes towards core job dimensions relating to job satisfaction and motivation and to test this against practice characteristics and provider attributes of U.K. practitioners. RESEARCH DESIGN: an 83-item questionnaire was developed from open-ended interviews with practitioners and use of items in previously used dentist job satisfaction questionnaires. This was subsequently sent to 684 practitioners. Item analysis reduced the item pool to 40 items and factor analysis (PCA) was undertaken. RESULTS: 440 (64%) dentists responded. Factor analysis resulted in six factors being identified as distinguishable job dimensions, overall Cronbach's alpha = 0.88. The factors were: 'restriction in being able to provide quality care (F1)', 'respect from being a dentist (F2)', 'control of work (F3)', 'running a practice (F4)', 'clinical skills (F5)', and 'caring for patients (F6)'. All six factors were correlated with a global job satisfaction score, although F1 was most strongly related (r = 0.60). Regression model analysis revealed that 'whether the dentist worked within the National Health Service or wholly or partly in the private sector' (p < 0.001), 'time since qualification' (p = 0.009), and the position of the dentist within the practice (whether a practice owner or associate dentist), (p = 0.047) were predictive of this factor. CONCLUSIONS: Six core job constructs of U.K. practitioners have been identified, together with several practice characteristics and practitioner attributes which predict these factors. The study demonstrates the importance of refining measures of dentists' job satisfaction to take account of the culture and the system in which the practitioner works.

Facets of job satisfaction of dental practitioners working in different organisational settings in England.

INTRODUCTION: Before April 2006, English dentists were either working as an NHS general dental service (GDS) practitioner (fee-per-item, no local contractual obligations); an NHS personal dental service (PDS) practitioner (block contract with the primary care trust (PCT)); a private practitioner (either fee-per-item or capitation-based, independent of the PCT); or in a situation where they were mixing their NHS work (either under the GDS or PDS arrangements) with private work. OBJECTIVES: To a) investigate the extent of the mix of NHS and private work in English dentists working in the GDS and PDS, b) to compare global job satisfaction, and c) to compare facets of job satisfaction for practitioners working in the different organisational settings of PDS practices, GDS practices and practices where there is a mix of NHS and private provision. Method A questionnaire was sent to 684 practitioners, containing 83 attitudinal statements relating to job facets, a global job satisfaction score and questions concerning workload. RESULTS: Response rate was 65.2%. More PDS than GDS dentists were found to treat the majority of their patients under the NHS. GDS dentists working fully in the NHS were least likely to be satisfied with their job, followed by PDS practitioners and then GDS dentists working in mixed NHS/private practices. Private practitioners were the most satisfied. CONCLUSION: Differences between GDS, PDS and private practitioners were found in global job satisfaction and in the facets of job satisfaction related to restriction in being able to provide quality care, control of work and developing clinical skills.

An investigation of the relationship between untreated decayed teeth and dental sepsis in 5-year-old children.

OBJECTIVES: To investigate the prevalence of dental sepsis in 5-year-old children in Scotland and the relationship between sepsis, treated and untreated decayed teeth, oral cleanliness (visible plaque on anterior teeth) and socio-economic deprivation. SUBJECTS AND METHODS: Six thousand, nine hundred and ninety-four children of mean age 5.3 years were examined as part of a survey conducted under the Scottish Health Board's Dental Epidemiological Programme. The presence of dental sepsis was recorded, in addition to caries status, and presence of plaque. Postal code information was used to obtain a measure of material deprivation. Relationships between sepsis and its possible contributory factors were explored using stepwise logistic regression. MAIN RESULTS: In the whole sample, 4.8% of children examined had dental sepsis, ranging from 2% in the most affluent areas to 11% in the most deprived. Children with sepsis had much higher caries experience (mean dmft 6.30) than those without sepsis (mean dmft 2.36). However, when these factors and the presence of plaque were entered into a logistic regression model to predict presence or absence of dental sepsis, the most important factor was not deprivation, but untreated decay. CONCLUSIONS: The proportion of children with sepsis increases markedly with caries experience. This disadvantage can be mitigated if more of the caries experience is treated. These findings would not support a policy of non-intervention for deciduous caries if oral sepsis is to be minimised.

Recording and understanding social histories by dental undergraduates in a community-based clinical programme.

Although social inequalities are known to account for large differences in dental health, attitudes to dental attendance and the type of treatment received by the patient, the taking of a patient's social history receives little emphasis in dental undergraduate teaching. Social history is defined as recording the social and family circumstances of the patient. An exercise undertaken by undergraduate dental students on clinical placements in the Community Dental Service (CDS) is described. Students write a profile of the community in which the clinic is situated, write case histories for two of their patients and then highlight issues illustrated by the case histories with reference to information on the wider community and published literature on inequalities in health and barriers to care. Students completing the exercise in April 2000 and their tutors were given additional information, including a checklist to help in the completion of the social histories of the two patients. A comparison with the reports submitted in the previous year showed that this significantly improved the recording and understanding of social history. This exercise provides a means whereby dental public health issues can be taught to undergraduates whilst maintaining relevance to the clinical setting.

General dental practitioner advice regarding the use of fluoride toothpaste in two areas with a school-based milk fluoridation programme and one without such a programme.

OBJECTIVE: To describe the knowledge and practice of general denta practitioners (GDPs) working in Liverpool (where there is no milk fluoridation programme) and St Helens and Knowsley, and the Wirral (where children have fluoridated milk in schools and pre-schools) relating to the advice given for child patients regarding the use of fluoridated toothpaste. DESIGN: Data were collected via a postal questionnaire sent to all 329 GDPs working within the three areas. GDPs working in more than one of the areas and those working in specialist orthodontic or oral surgery practices were excluded. RESULTS: Two hundred and thirty-four (71%) questionnaires were completed and returned. Only 3% of dentists said that no-one in their practice gave advice on the concentration of fluoride toothpaste to be used. For caries free children under 7 years of age only 64% of GDPs gave advice concerning the concentration of toothpaste which coincided with the available clinical guidelines. Twenty eight per cent of GDPs also contradicted the guidelines by advising children under 7 with high caries to use a low fluoride toothpaste. Although 59% of GDPs in the fluoridated milk areas asked the child whether they had fluoridated milk at school, they did not appear to alter the advice given regarding the use of fluoridated toothpaste. CONCLUSION: The study showed that a significant number of GDPs did not adhere to clinical guidelines relating to the use of fluoride toothpaste when giving advice to their child patients. For evidence-based dentistry to become a reality in this area, ways must be found to disseminate the available guidelines more fully and increase their acceptance and use by practitioners.

Clinical record keeping by general dental practitioners piloting the Denplan 'Excel' accreditation programme.

BACKGROUND: Denplan is a private capitation-based system of providing primary dental care in the UK. An additional programme called Denplan Excel has been developed which requires General Dental Practitioners to instigate various quality processes within their practices in order to become accredited. Clinical record keeping is one area where standards are monitored. This study reports changes in record keeping at patient recall appointments following the implementation of the Denplan Excel programme. METHOD: Fifty dentists participating in the Denplan Excel pilot programme from different areas of the UK were sampled by means of cluster sampling. Twenty records for each dentist were sampled and items recorded for patients recalled both pre- and post-pilot were compared. RESULTS: The majority of dentists recorded presenting complaint, diagnosis and treatment plan both pre- and post-pilot. However, post-pilot there were a number of improvements in record keeping. Caries recorded on a grid increased from 7% of records to 46%, basic periodontal examination increased from 48% to 85% of records and the updating of medical history increased from 51% to 65% of records. These findings were all significant at the p<0.01 level. CONCLUSION: Changes can be achieved by voluntary participation in a system of structured record keeping.

The development and use of a triage protocol for patients with dental problems contacting an out-of-hours general medical practitioner cooperative.

PURPOSE OF THE STUDY: The number of patients contacting general medical practitioner (GMP) out-of-hours services with dental problems is perceived to be a significant problem by the medical profession. This study was undertaken to design and pilot a triage protocol that could be used by non-dental staff to refer callers with dental complaints for appropriate treatment. BASIC PROCEDURES: A triage protocol was designed to address the patient conditions considered to be relevant to emergency dental care. The triage protocol was piloted for three months at a GMP cooperative in North Wales, which provided an out-of-hours service for 61 GMPs. Baseline data were collected for three months prior to the introduction of the triage protocol. MAIN FINDINGS: The study showed that the number of dental callers contacting the out-of-hours service was not as great as GMPs imagined, and was similar to other studies. The introduction of the triage protocol resulted in a rise in the number of callers asked to call the general dental practitioner (GDP) support line. The number of unregistered patients given the name of a dentist also increased. The need to make a second telephone call seemed not to affect patient satisfaction since when patients were later questioned on their experience, those who had used the service since the introduction of the triage protocol were more likely to be satisfied with the service. PRINCIPAL CONCLUSIONS: This study provides some evidence that a triage protocol can be used successfully by non-dental staff to sift requests for out-of-hours emergency dental care.

The role of team dentistry in improving access to dental care in the UK.

The role of professionals complementary to dentistry (PCDs) in improving access to NHS primary dental care is discussed. The pattern of under-supply of dentists in poor socio-economic areas is highlighted and identified, in drawing a parallel to the workings of primary medical teams, as a possible area where PCDs could be used.

The stereochemistry of desaturations of long-chain fatty acids in Chlorella vulgaris.

1. A study was made of the stereospecificity of hydrogen removal in the sequential desaturations performed by intact cells of Chlorella vulgaris in the biosynthesis of oleic acid, linoleic acid and alpha-linolenic acid. 2. By use of erythro- and threo-9,10-(2)H(2)-, -12,13-(2)H(2)- and -15,16-(2)H(2)-labelled precursors, it was demonstrated that the pair of hydrogen atoms removed from each of these positions had the cis relative configuration. 3. That the hydrogen atoms removed in oleic acid and linoleic acid formation were of the d absolute configuration was proved by use of d- and l-9-(3)H-and -12-(3)H-labelled precursors. 4. The presence of a substantial kinetic isotope effect of deuterium at both positions of the putative double bond was indicated, suggesting that the mechanism of desaturation involves simultaneous concerted removal of the pair of hydrogen atoms.