Perspectives of community-dwelling older adults with dementia and their carers regarding their oral health practices and care: rapid review.

AIM: To review evidence on oral health practices, beliefs/views and experiences of community-dwelling older adults living with dementia, including their carers. MATERIALS AND METHODS: A search of key terms across six databases including Pubmed, Web of Science and OVID (Embase, MEDLINE [R] and PsycINFO) and Google Scholar was conducted, supplemented by reference screening. The Mixed Methods Appraisal Tool (MMAT) 2018 was used to assess the methodological quality. RESULTS: Eighteen studies reported across 19 papers were included in the review. Papers largely focused on normative needs (n = 13), whilst also reporting oral health-related experiences (n = 2), practices (n = 7), and beliefs/views (n = 9), of community dwellers with dementia. Generally, people living with dementia presented with poor oral and dental health, the exception being one study where dental care was integrated with memory clinic services. Maintenance of oral health focused only on toothbrushing. Overall, people living with dementia have reduced capacity for self-performed oral hygiene and high reliance on caregivers. There was a paucity of evidence on their perceptions of oral health and quality of life, the findings of which were equivocal, with weak evidence suggesting possible difficulty in identifying and communicating their needs. Experiences of accessing dental care, when explored, appear to be system dependent. CONCLUSION: There was limited research evidence on oral health-related practices, beliefs/views and experiences of people with dementia. Recommendations for future research are presented.

Family Functioning and Dental Behaviours of Pre-school Children.

OBJECTIVES: To examine the association of family functioning with child dental behaviours and to identify family functioning domains associated with those behaviours. METHODS: Cross-sectional data from the East London Oral Health Inequalities (ELOHI) study were analysed in a subsample of 733 parent-child (3-4-years-olds) dyads. Family functioning was measured with the 60-item Family Assessment Device that yielded a general functioning score and six domain scores (roles, communication, problem solving, affective involvement, affective responsiveness, and behaviour control). Child dental behaviours were sugar intake, dental attendance and toothbrushing frequency. The association of family functioning with each dental behaviour was assessed in logistic regression models adjusted for confounders (parental sociodemographic and child demographic factors). RESULTS: Unhealthy general functioning was associated with greater odds of reporting high child intake of sugars (OR: 1.78, 95%CI: 1.01-3.13) as well as lower odds of reporting frequent child brushing (OR: 0.76, 95%CI: 0.50-1.18) and a child visit for dental check-up in the past year (OR: 0.98; 95%CI: 0.62-1.53), after adjustment for confounders. Unhealthy functioning in roles, affective involvement and behaviour control were associated with high child sugar intake whereas unhealthy functioning in roles was inversely associated with frequent child toothbrushing. No family functioning domain was associated with child dental attendance pattern. CONCLUSIONS: Healthy family functioning was associated with more favourable child dental behaviours. How a family functions, particularly in terms of how they define roles and support each other emotionally, is likely to be relevant to child oral health.

Is there a healthy migrant effect in relation to oral health among adults in England?

OBJECTIVE: The aim of the study was to assess the healthy migrant effect in relation to oral health among adults in England. STUDY DESIGN: This is a secondary data analysis of a nationally representative survey. METHODS: Data from 13,373 adults of Irish, black Caribbean, Indian, Pakistani, Bangladeshi and Chinese ethnicity, who participated in the Health Survey for England, were analysed. The proportions of edentate and dentate adults with toothache in the last 6 months in first- and second-generation migrants within each ethnic group were compared with those in the white British (reference group) ethnic group in logistic regression models after adjusting for demographic factors and socio-economic position. Among first-generation migrants, the associations of age at arrival and length of residence with each oral health outcome were assessed in logistic regression models after adjusting for sociodemographic factors. RESULTS: Compared with white British migrants, first-generation black Caribbean (odds ratio [OR]: 1.42) and second-generation Pakistani (OR: 3.16) migrants had higher odds of being edentulous, whereas first-generation Indian (OR: 0.62), Pakistani (OR: 0.62), Bangladeshi (OR: 0.41) and Chinese (OR: 0.49) migrants had lower odds. Among dentate adults, second-generation Irish (OR: 1.51) migrants, first- and second-generation black Caribbean (OR: 1.61 and 1.54, respectively) migrants, first-generation Indian (OR: 1.24) migrants and second-generation Pakistani (OR: 1.34) migrants had higher odds of having toothache in the past 6 months, whereas second-generation Bangladeshi (OR: 0.51) migrants had lower odds than white British. Age at arrival and length of residence were positively associated with being edentulous among first-generation black Caribbean, Pakistani and Bangladeshi migrants. CONCLUSION: Evidence on the healthy migrant effect was mixed, with more consistent findings seen for edentulousness among Asian groups. Black Caribbean migrants were generally the ethnic group with the worst oral health when compared with white British.

Defining patient-centred care in dentistry? A systematic review of the dental literature.

Objective This paper presents the results of a systematic review, designed to explore how patient-centred care (PCC) is defined in the dental literature.Method An electronic search of MEDLINE (1946-2012), Embase (1980-2012) PsycINFO (1806-2012), the Cochrane Library and non-peer reviewed literature was conducted using a standardised search protocol. Definitions of patient centred care were identified and scored on two criteria to evaluate quality of definition and quality/type of evidence.Results Of the 28 papers included in the review the majority provided definitions of PCC synonymous with good quality general care (holistic, humanitarian). Only three mentioned the provision of information and the tools to facilitate informed choice. Less than a third of the papers included in this review were based on empirical evidence, and of those that were, only one was an RCT study.Conclusion The evidence suggests that the concept of PCC is neither clearly understood nor empirically and systematically assessed in dental settings. Whilst most authors seem to suggest that PCC is about delivering care that is humane, involving good communication and shared decision-making, there is no work assessing these concepts empirically or relating them to practical outcomes.

Characteristics of patients attending for cognitive behavioural therapy at one UK specialist unit for dental phobia and outcomes of treatment.

AIM: To describe the characteristics of patients attending a psychologist-led cognitive behavioural therapy (CBT) service for individuals with dental phobia and the outcomes of treatment. METHOD: Analysis of routinely collected assessment and outcome data from 130 patients attending a single secondary service providing CBT for dental phobia. FINDINGS: The patients comprised 99 women and 31 men, with an average age of 39.9 years (SD 14.8). Approximately 77% of the patients scored at levels suggestive of dental phobia on the Modified Dental Anxiety Scale (MDAS). Fear of dental injections and the dental drill were the most common high scoring items on the MDAS. Ninety four percent of patients reported one or more impacts of their mouth, teeth and gums on their life using the OHIP-14. A minority of patients had co-morbid psychological conditions - 36.9% had high levels of general anxiety and 12.3% had clinically significant levels of depression. Suicidal ideation was reported by 12% of patients and four (3%) reported recent intent to commit suicide. Of all patients referred 79% went on to have dental treatment without sedation and 6% had their dental treatment under sedation. The average number of CBT appointments required before a patient received dental treatment without sedation was five. CONCLUSIONS: CBT offers an effective technique for helping dentally anxious patients receive treatment without sedation. Those interested in running such services should be cognizant of the moderately high level of co-morbid psychological conditions in this group.

A model of patient-centred care - turning good care into patient-centred care.

This paper builds on previous work reviewing patient-centred care in dentistry and acknowledges work that has questioned the measurement and effectiveness of patient-centredness in practice. In an attempt to move the debate from rhetoric to practice and enhance the practical utility of the concept, we present a practical hierarchy of patient-centredness that may aid the practical application of patient-centred care in clinical practice by making explicit a series of stages that a dental care professional needs to move through in order to provide care that is patient-centred. The model presented is illustrated through practical examples. The various stages inherent in it are described with the aim of making clear the perhaps automatic and taken for granted assumptions that are often made by dental care professionals and patients through the course of a consultation. Our aim is to encourage dental consultations to have more open, unambiguous communication, both about the risks and benefits of courses of action and about the choices available to patients.

Parental views on delivering preventive advice to children referred for treatment of dental caries under general anaesthesia: a qualitative investigation.

OBJECTIVES: To: 1, Explore opinions of parents of children undergoing caries treatment under general anaesthesia (GA) regarding delivery of oral health advice; 2, Discover current oral health practices and beliefs; 3, Inform further research and action. METHODS: Qualitative study using semi-structured interviews and thematic data analysis, sampling parents of children aged 3-10 years undergoing GA tooth extraction due to dental caries. RESULTS: Twenty nine parents were interviewed (mean age 38.9 years, range 28-50, sd 6.4). The mean age of their children was seven years (range 3-10, sd 2.1). All children required deciduous tooth extractions (5.1 teeth on average). Those that also required permanent tooth extractions had on average 2.1 permanent teeth extracted. Many parents knew the importance of oral hygiene and sugar limitation, describing it as 'general knowledge' and 'common sense'. However, few understood that fruit juice is potentially cariogenic. Parenting challenges seemed to restrict their ability to control the child's diet and establish oral hygiene. Many reported not previously receiving oral health advice and reported never having fluoride varnish applied. There were requests for more caries prevention information and advice via the internet, schools or video games. CONCLUSION: Parental oral health knowledge, parenting skills, and previous advice received seem to all be issues related to the oral health of those children. Providing advice, especially in respect to fruit juice cariogenicity and the benefits of fluoride application through a child-friendly website, including a video game, as well as the use of school programmes might be an acceptable approach.

Why individuals with HIV or diabetes do not disclose their medical history to the dentist: a qualitative analysis.

INTRODUCTION: Evidence shows that some individuals with HIV or diabetes do not report their medical history to the dentist. Disclosure is important because these individuals can be at greater risk of oral disease. AIMS AND OBJECTIVES: The aim of this study is to provide greater understanding of why some individuals do not disclose HIV or diabetes to the dentist.Methods In-depth interviews were conducted with 20 participants (10 HIV & 10 diabetes) based around the participant's diagnosis and disclosure history. Data were analysed using framework analysis. RESULTS: While a lack of disclosure can be found among those with a diagnosis of HIV and diabetes, it appears that the reasons behind disclosure, or lack thereof, are different for each. The reasons are based around: differences in age, understanding of diagnosis, experience of stigma, past disclosure behaviour, trust in dentists and experience of healthcare. Few individuals had discussed the effects of their diagnosis with their dentist or were advised on the importance of seeing a dentist. DISCUSSION: Individuals with chronic illness should be advised why it is important for the dentist to know their medical history and should be made to feel comfortable to disclose.

The management of dental anxiety: time for a sense of proportion?

Dental anxiety and fear are common and potentially problematic, both for the patient and for the dental team in managing such patients. Furthermore, dental fear still presents a major barrier to the uptake of dental treatment. This article will take as its premise an assumption that anxiety manifests at different levels and that consequently management of dental anxiety involves both assessment and proportionate intervention. Methods for undertaking both assessment and management are outlined.

Barriers and opportunities of empowerment as applied in diabetes settings: a focus on health care professionals' experiences.

This exploratory study examines the opportunities and barriers health care professionals (HCPs) working with diabetes patients face when they try to implement the rhetoric of patient empowerment in practice. A small sample of diabetes HCPs (N=13), from National Health Service (NHS) hospital, walk-in and general practitioner (GP) clinics in South-East England, was interviewed through in-depth semi-structured interviews. Interviews were recorded, transcribed verbatim and analysed thematically. The analysis showed that empowerment was seen as beneficial for patients and HCPs. Time and resources could be moved from successfully empowered patients and focussed on more complex patients, this was termed 'selective empowerment'. The main barriers to empowerment were identified as a lack of resources, time and HCPs trained in empowerment techniques. Empowerment is a popular concept in theory, and presents HCPs with several opportunities but also important barriers in its practical, clinical implementation day-to-day.

Health care professionals' understanding and day-to-day practice of patient empowerment in diabetes; time to pause for thought?

This exploratory study examines what Health Care Professionals (HCPs) working with diabetes patients, understand by the term 'empowerment', their attitudes towards it and whether they believe they practise in ways consistent with empowerment principles. A small sample of diabetes HCPs (N=13), from National Health Service (NHS) hospital, walk-in and General Practitioner (GP) clinics in South-East England, was interviewed. In-depth semi-structured interviews established attitudes towards and use of empowerment in day-to-day practice. Interviews were recorded, transcribed verbatim and analysed thematically. There was no clear specific understanding of what empowerment is and what it involves, although there was broad reporting of factors around education and informed choices. Disagreement was evident about the level of freedom patients should have in making choices - from leading them to the 'right' choice to an acceptance that they may have the right to choose not to be empowered. No consensus emerged on what is successful empowerment and how it is measured. The resistance of some patients to the process of empowerment in its original definition of active partnership in care, was seen as problematic by HCPs. Although empowerment is a popular concept in theory, its practical, clinical implementation day to day, can be problematic.

Antibiotic prophylaxis in dentistry: part I. A qualitative study of professionals' views on the NICE guideline.

BACKGROUND: The NICE guideline for antibiotic prophylaxis before dental treatment has made a substantive change and fundamental departure from previous practice that affects long-standing beliefs and practice patterns. There is potential difficulty for healthcare professionals explaining the new guidance to patients who have long believed that they must receive antibiotics before their dental treatment. AIM: To explore clinicians' attitudes towards the NICE guidance on antibiotic prophylaxis, their use of the guideline in clinical practice, barriers to the implementation of the guideline, and how best to overcome any perceived barriers. METHODS: In-depth interviews were conducted with seven dental care professionals, two cardiologists and a cardiac care nurse. The data were analysed using the framework method to extract central themes and opinions. RESULTS: Clinicians generally perceived that initially patients would be reluctant to follow the NICE guidance. This was felt to be particularly true of the patient cohort that had previously been prescribed prophylactic antibiotics. They found it difficult to explain the new guidance to patients who have had infective endocarditis and have long believed that they must receive antibiotics before their dental treatment. Concerns were also raised about the legal position of a clinician who did not follow the guidance. Clinicians generally suggested that the provision of accurate information in the form of leaflets and valid websites would be the best way to advise patients about the new guidance. CONCLUSIONS: Clinicians anticipated difficulties in explaining to patients the change in clinical practice necessitated by adherence to the NICE guidance, most notably for patients with a history of infective endocarditis or where the patient's cardiologist did not agree with the NICE guidance. They placed particular emphasis on the provision of accurate information in order to reassure patients.

Antibiotic prophylaxis in dentistry: part II. A qualitative study of patient perspectives and understanding of the NICE guideline.

BACKGROUND: The National Institute for Health and Clinical Excellence (NICE) recommendations in 2008 for antibiotic prophylaxis before dental treatment contradict previous practice. There is a potential difficulty in explaining the new guidance to patients who have long believed that they must receive antibiotics before their dental treatment. AIM: This study investigated the patient-related barriers and facilitating factors in implementation of the NICE guidance. METHODS: In-depth interviews were conducted with nine patients concerning their views about barriers and factors that could influence the implementation of the NICE guidance on antibiotic prophylaxis before dental treatment. Data were analysed using framework analysis. RESULTS: For patients the rationale for the NICE guidance was unclear. They understood that at the population level the risk of infective endocarditis was less than the risk of adverse reaction to antibiotics. However, on an individual level they felt that the latter risk was negligible given their previous experience of antibiotics. They were aware that standards of care change over time but were concerned that this may be an example where a mistake had been made. Patients felt that the characteristics of the person advising them about the new guidance were important in whether or not they would accept them - they wished to be advised by a clinician that they knew and trusted, and who was perceived as having appropriate expertise. CONCLUSIONS: Patients generally felt that they would be most reassured by information provided by a clinician who they felt they could trust and who was qualified to comment on the issue by respecting their autonomy. The implications of the findings for the development of patient information are discussed.

Informing the debate on oral health care for older people: a qualitative study of older people's views on oral health and oral health care.

BACKGROUND: Older people represent a growing and diverse section of the population. As age increases, people are more likely to experience health and mobility problems and be at higher risk of developing oral disease. Nevertheless, few older people utilise primary oral healthcare services. It is therefore important to understand the value older people place on oral health and dental services to inform providers and planners of oral health care. This research was conducted as part of a study to identify potential ways of minimising barriers to oral health care in older people. OBJECTIVES: To explore perceptions of oral health and oral healthcare services amongst older people living in a socially deprived inner city area and how these are related to service utilisation. METHODS: A qualitative approach was utilised to explore the range of issues related to older people's perceptions of oral health and their views on health care. This involved a combination of focus groups and semi-structured individual interviews with older people and their carers. Data analysis was conducted using the Framework approach. RESULTS: * RESPONSE: Thirty-nine older people and/or their carers participated in focus groups. * Oral health perception: Oral health was associated with the presence of natural teeth, the absence of pain, practical/social functioning, preferably supported by positive assessment by a dentist. * Oral health life-course: Older people have a long and complex dental history. Past negative experiences with oral health care, especially in childhood, strongly influenced present attitudes towards dentistry and dental personnel. * Citizenship and right to health care: There was a strong perception that, as 'British citizens', older people should have a right to free health care and that the National Health Service (NHS) should support them in this phase of their life. CONCLUSIONS: The oral health life-course of older people is an important influence on their perceptions of oral health and dental attendance. They consider oral health of importance and place great emphasis on their citizenship and rights of access to state funded oral health care. This raises important issues for the funding and delivery of NHS oral health care for older people.