A scoping review of dental practitioners' perspectives on perceived barriers and facilitators to preventive oral health care in general dental practice.

BACKGROUND: Oral health has an important role in the general health and well-being of individuals. Dental teams are ideally placed to support patients in preventing ill-health. Understanding the barriers and facilitators to the adoption, promotion and facilitation of preventive advice and treatment is key to improving oral health services. The Theoretical Domains Framework (TDF) is a useful psychological framework to help identify individual, interpersonal and environmental issues which could be impacting clinicians' ability to provide preventive advice and care. The aim of this review was to identify the perceived barriers and facilitators to preventive oral health care from the perspectives of the oral healthcare team within the general dental practice. METHODS: A search strategy was developed, piloted, and run in: Medline via Ovid, PsycInfo, Web of Science, SCOPUS, EMBASE, Conference Proceedings Citation Index- Science, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews and followed PRISMA guidelines. Identified records were screened independently by two researchers. Data were coded using the Theoretical Domains Framework (TDF) and analysed using narrative data synthesis. RESULTS: 5610 papers were identified, and 19 included in this review. Thirteen papers focussed on dentists. Of the 106 items mapped onto the TDF, 48 were facilitators. The domains most frequently represented were, environmental context and resources, beliefs about consequences, social professional role and identity, skills, beliefs about capabilities and knowledge. Six studies focussed on dental hygienists. There were 47 items mapped onto the TDF, 18 were facilitators. The domains most frequently represented were environmental context and resources, social influences, beliefs about consequences and knowledge. CONCLUSIONS: The review identified that the delivery of preventive activities did not focus solely on the patient and dental professional interaction as many previous studies have highlighted. The review found that multiple factors influence whether prevention is delivered to patients. The largest barrier and facilitator for the dental professionals identified in this review was the environmental context and resources. Further research is needed to evaluate the effectiveness of interventions that aim to promote preventive oral health care in primary care settings to understand whether they address the barriers identified in this review.

Whose Responsibility Is It Anyway? Exploring Barriers to Prevention of Oral Diseases across Europe.

INTRODUCTION: Dental caries, gum disease, and tooth loss are all preventable conditions. However, many dental care systems remain treatment oriented rather than prevention oriented. This promotes the treatment of oral diseases over preventive treatments and advice. Exploring barriers to prevention and understanding the requirements of a paradigm shift are the first steps toward delivering quality prevention-focused health care. OBJECTIVES: To qualitatively explore perceived barriers and facilitators to oral disease prevention from a multistakeholder perspective across 6 European countries. METHODS: A total of 58 interviews and 13 focus groups were undertaken involving 149 participants from the United Kingdom, Denmark, Germany, the Netherlands, Ireland, and Hungary. Interviews and focus groups were conducted in each country in its native language between March 2016 and September 2017. Participants were patients (n = 50), dental team members (n = 39), dental policy makers(n = 33), and dental insurers (n = 27). The audio was transcribed, translated, and analyzed via deductive thematic analysis. RESULTS: Five broad themes emerged that were both barriers and facilitators: dental regulation, who provides prevention, knowledge and motivation, trust, and person-level factors. Each theme was touched on in all countries; however, cross-country differences were evident surrounding the magnitude of each theme. CONCLUSION: Despite the different strengths and weaknesses among the systems, those who deliver, organize, and utilize each system experience similar barriers to prevention. The findings suggest that across all 6 countries, prevention in oral health care is hindered by a complex interplay of factors, with no particular dental health system offering overall greater user satisfaction. Underlying the themes were sentiments of blame, whereby each group appeared to shift responsibility for prevention to other groups. To bring about change, greater teamwork is needed in the commissioning of prevention to engender its increased value by all stakeholders within the dental system. KNOWLEDGE TRANSFER STATEMENT: The results from this study provide an initial first step for those interested in exploring and working toward the paradigm shift to preventive focused dentistry. We also hope that these findings will encourage more research exploring the complex relationship among dental stakeholders, with a view to overcoming the barriers. In particular, these findings may be of use to dental public health researchers, dentists, and policy makers concerned with the prevention of oral diseases.

Barriers and facilitators to health visiting teams delivering oral health promotion to families of young children: a mixed methods study with vignettes.

OBJECTIVE: To explore the potential barriers and facilitators to health visiting (HV) teams delivering oral health promotion during the 9-12-month old child mandated visit in Ealing, England. BACKGROUND: HV schemes and their counterparts worldwide share similar priorities to discuss oral health at 6-12 months of age. The HV programme in England stipulates at 9-12 months old, diet and dental health should be discussed. HVs believe dental decay is important however oral health knowledge is varied. Further, little is understood about what drives HVs to deliver oral health advice. An appropriate theoretical model to explore these factors is the Theoretical Domains Framework (TDF). METHODS: An opportunistic sample of HV team members was drawn from three hubs to allow for maximum variation. First, participants completed a questionnaire to establish baseline knowledge. Secondly, participants were invited to take part in focus groups (FGs) with vignettes. Thirdly, face-to-face interviews were conducted. FGs were subject to thematic analysis and the interviews to framework analysis. RESULTS: Thirty-six participants provided written informed consent and completed baseline questionnaires. Three FGs were conducted with an average of seven participants (n=21) followed by 13 interviews. Perceived facilitators: good levels of knowledge and skills, sense of professional role, emotions, belief in capability, organisational structure and resources. Perceived barriers: gaps in knowledge, conflicting advice from other professionals, conflicting issues for parents/ carers, use of interpreters. CONCLUSIONS: These findings can be harnessed to support oral health promotion delivered by HV teams.

Assessing the perceived impact of post Minamata amalgam phase down on oral health inequalities: a mixed-methods investigation.

BACKGROUND: Data from countries that have implemented a complete phase out of dental amalgam following the Minamata agreement suggest increased costs and time related to the placement of alternatives with consumers absorbing the additional costs. This aim of this study was to investigate the impact of a complete phase out of dental amalgam on oral health inequalities in particular for countries dependent on state run oral health services. METHODS: A mixed methods component design quantitative and qualitative study in the United Kingdom. The quantitative study involved acquisition and analysis of datasets from NHS Scotland to compare trends in placement of dental amalgam and a survey of GDPs in Yorkshire, UK. The qualitative study involved analysis of the free text of the survey and a supplementary secondary analysis of semi-structured interviews and focus groups with GDPs (private and NHS), dental school teaching leads and NHS dental commissioners to understand the impact of amalgam phase down on oral health inequalities. RESULTS: Time-trends for amalgam placement showed that there was a significant (p < 0.05) reduction in amalgam use compared with composites and glass ionomers. However dental amalgam still represented a large proportion (42%) of the restorations (circa 1.8 million) placed in the 2016-2017 financial year. Survey respondents suggest that direct impacts of a phase down were related to increased costs and time to place alternative restorations and reduced quality of care. This in turn would lead to increased tooth extractions, reduced access to care and privatisation of dental services with the greatest impact on deprived populations. CONCLUSION: Amalgam is still a widely placed material in state run oral health services. The complete phase down of dental amalgam poses a threat to such services and threatens to widen oral health inequalities. Our data suggest that a complete phase out is not currently feasible unless appropriate measures are in place to ensure cheaper, long-lasting and easy to use alternatives are available and can be readily adopted by primary care oral health providers.

Identifying the barriers and facilitators for homeless people to achieve good oral health.

OBJECTIVE: A qualitative exploration of the barriers and facilitators for people experiencing homelessness achieving good oral health. PARTICIPANTS: Adults using two homeless centres in Leeds. METHODS: Focus group discussions were convened with homeless people using support services. Both an inductive and deductive approach to data analysis was taken. Themes were identified and then a framework applied to analysis using Nvivo software. RESULTS: Three focus group discussions with 16 participants were conducted with people experiencing homelessness. The barriers identified were insufficient information on local dental services, negative attitudes of oral health professionals, low priority of dental care, anxiety and cost of dental treatments. Facilitators included single dental appointments, accessible dental locations and being treated with respect. CONCLUSIONS: Despite the barriers that prevent people experiencing homelessness from maintaining and improving their oral health, the participants were aware that they needed oral healthcare and requested that dental services were made available to them and were accessible in line with their socioeconomic status and needs.

Barriers and facilitators for prevention in Danish dental care.

Objective: To explore barriers and facilitators to oral disease prevention in Danish dental care from a multi-stakeholder perspective. Methods: Eleven semi-structured focus groups and interviews about Danish oral healthcare were conducted with 27 stakeholders (general public, dental teams, dental policy makers) in Copenhagen. Transcripts were analyzed using deductive thematic analysis independently by KR and HL, supervised by JC and KVC. Results: Seven broad themes were identified, including both barriers and facilitators: Knowledge and attitudes, Education and training, Regulation, Incentivization, Multidisciplinary approach, Access to care and the Dental professional-patient relationship. Whilst all themes were relevant to each group of stakeholders, the salient driver within each theme was different for each group. Conclusions: Stakeholder perspectives on the Danish Oral health care system suggest the following are important features for a preventively focused system: (a) Involving all stakeholders in oral healthcare planning. (b) Securing sufficient and ongoing briefing regarding disease prevention for all stakeholders. (c) Regulatory support and creation of incentives to promote and facilitate implementation of disease prevention. (d) Appropriate prevention for disadvantaged groups within society which may be possible to a higher degree by means of multidisciplinary collaboration. (e) Personal relations between the patient and the professional based on mutual trust.

Shaping dental contract reform: a clinical and cost-effective analysis of incentive-driven commissioning for improved oral health in primary dental care.

OBJECTIVE: To evaluate the clinical and cost-effectiveness of a new blended dental contract incentivising improved oral health compared with a traditional dental contract based on units of dental activity (UDAs). DESIGN: Non-randomised controlled study. SETTING: Six UK primary care dental practices, three working under a new blended dental contract; three matched practices under a traditional contract. PARTICIPANTS: 550 new adult patients. INTERVENTIONS: A new blended/incentive-driven primary care dentistry contract and service delivery model versus the traditional contract based on UDAs. MAIN OUTCOME MEASURES: Primary outcome was as follows: percentage of sites with gingival bleeding on probing. Secondary outcomes were as follows: extracted and filled teeth (%), caries (International Caries Detection and Assessment System (ICDAS)), oral health-related quality of life (Oral Health Impact Profile-14 (OHIP-14)). Incremental cost-effective ratios used OHIP-14 and quality adjusted life years (QALYs) derived from the EQ-5D-3L. RESULTS: At 24 months, 291/550 (53%) patients returned for final assessment; those lost to follow-up attended 6.46 appointments on average (SD 4.80). The primary outcome favoured patients in the blended contract group. Extractions and fillings were more frequent in this group. Blended contracts were financially attractive for the dental provider but carried a higher cost for the service commissioner. Differences in generic health-related quality of life were negligible. Positive changes over time in oral health-related quality of life in both groups were statistically significant. CONCLUSIONS: This is the first UK study to assess the clinical and cost-effectiveness of a blended contract in primary care dentistry. Although the primary outcome favoured the blended contract, the results are limited because 47% patients did not attend at 24 months. This is consistent with 39% of adults not being regular attenders and 27% only visiting their dentist when they have a problem. Promotion of appropriate attendance, especially among those with high need, necessitates being factored into recruitment strategies of future studies.