Clinical research in primary dental care

Using Theoretical Domains Framework (TDF) to understand implementation of a pragmatic clinical trial in Public Dental Service in Norway

Background

Most dental research in Norway has traditionally been conducted by universities, and the involvement of clinicians in research projects has not been a common practice.

The aim of the present study was to identify behavioral factors that influence effective implementation of a pragmatic clinical trial in the Public Dental Service (PDS) in Norway and to understand which of these factors result in higher patient recruitment.

Methods

Dentists, dental hygienists, and dental assistants at nine Public Dental Service clinics in three counties in Norway involved in an ongoing pragmatic clinical trial were asked to complete an electronically distributed questionnaire based on the Theoretical Domains Framework (TDF).

Results

Thirty-seven out of 69 dentists and dental hygienists (54 %) and seventeen out of 57 dental assistants (30 %) answered the questionnaire. “Knowledge” was the domain with the highest mean response, suggesting strong confidence in personal knowledge and practical skills among the clinicians. Together with “beliefs about consequences,” “organizational resources,” and “environmental context,” “knowledge” was the one of five domains identified as important behavioral determinants in patient recruitment to clinical trials by dental professionals.

Conclusions

The findings suggest that TDF was useful to understand factors affecting implementation of clinical trials in PDS and that several factors such as clinical relevance of trial to be implemented, organizational resources, and communication with the research team require more attention when planning and implementing clinical trials in PDS.

Best-practice prevention alone or with conventional or biological caries management for 3- to 7-year-olds: the FiCTION three-arm RCT

BACKGROUND

Historically, lack of evidence for effective management of decay in primary teeth has caused uncertainty, but there is emerging evidence to support alternative strategies to conventional fillings, which are minimally invasive and prevention orientated.

OBJECTIVES

The objectives were (1) to assess the clinical effectiveness and cost-effectiveness of three strategies for managing caries in primary teeth and (2) to assess quality of life, dental anxiety, the acceptability and experiences of children, parents and dental professionals, and caries development and/or progression.

DESIGN

This was a multicentre, three-arm parallel-group, participant-randomised controlled trial. Allocation concealment was achieved by use of a centralised web-based randomisation facility hosted by Newcastle Clinical Trials Unit.

SETTING

This trial was set in primary dental care in Scotland, England and Wales.

PARTICIPANTS

Participants were NHS patients aged 3-7 years who were at a high risk of tooth decay and had at least one primary molar tooth with decay into dentine, but no pain/sepsis.

INTERVENTIONS

Three interventions were employed: (1) conventional with best-practice prevention (local anaesthetic, carious tissue removal, filling placement), (2) biological with best-practice prevention (sealing-in decay, selective carious tissue removal and fissure sealants) and (3) best-practice prevention alone (dietary and toothbrushing advice, topical fluoride and fissure sealing of permanent teeth).

MAIN OUTCOME MEASURES

The clinical effectiveness outcomes were the proportion of children with at least one episode (incidence) and the number of episodes, for each child, of dental pain or dental sepsis or both over the follow-up period. The cost-effectiveness outcomes were the cost per incidence of, and cost per episode of, dental pain and/or dental sepsis avoided over the follow-up period.

RESULTS

A total of 72 dental practices were recruited and 1144 participants were randomised (conventional arm, n = 386; biological arm, n = 381; prevention alone arm, n = 377). Of these, 1058 were included in an intention-to-treat analysis (conventional arm, n = 352; biological arm, n = 352; prevention alone arm, n = 354). The median follow-up time was 33.8 months (interquartile range 23.8-36.7 months). The proportion of children with at least one episode of pain or sepsis or both was 42% (conventional arm), 40% (biological arm) and 45% (prevention alone arm). There was no evidence of a difference in incidence or episodes of pain/sepsis between arms. When comparing the biological arm with the conventional arm, the risk difference was -0.02 (97.5% confidence interval -0.10 to 0.06), which indicates, on average, a 2% reduced risk of dental pain and/or dental sepsis in the biological arm compared with the conventional arm. Comparing the prevention alone arm with the conventional arm, the risk difference was 0.04 (97.5% confidence interval -0.04 to 0.12), which indicates, on average, a 4% increased risk of dental pain and/or dental sepsis in the prevention alone arm compared with the conventional arm. Compared with the conventional arm, there was no evidence of a difference in episodes of pain/sepsis among children in the biological arm (incident rate ratio 0.95, 97.5% confidence interval 0.75 to 1.21, which indicates that there were slightly fewer episodes, on average, in the biological arm than the conventional arm) or in the prevention alone arm (incident rate ratio 1.18, 97.5% confidence interval 0.94 to 1.48, which indicates that there were slightly more episodes in the prevention alone arm than the conventional arm). Over the willingness-to-pay values considered, the probability of the biological treatment approach being considered cost-effective was approximately no higher than 60% to avoid an incidence of dental pain and/or dental sepsis and no higher than 70% to avoid an episode of pain/sepsis.

CONCLUSIONS

There was no evidence of an overall difference between the three treatment approaches for experience of, or number of episodes of, dental pain or dental sepsis or both over the follow-up period.

FUTURE WORK

Recommendations for future work include exploring barriers to the use of conventional techniques for carious lesion detection and diagnosis (e.g. radiographs) and developing and evaluating suitable techniques and strategies for use in young children in primary care.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN77044005.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 1. See the NIHR Journals Library website for further project information.

Willingness of general dental practices in South East London to engage with research

This study assessed the willingness of general dental practices (GDPs) to participate in research. All 263 GDPs in South East London that provide dental care under National Health Service (NHS) contracts were invited. The survey instrument was adapted from previous studies and piloted before administration. Geographical factors and practice characteristics associated with willingness to participate in research were explored in logistic regression models. A total of 77 responses were received (response rate: 29%). Of them, 40 (53%) expressed interest in being involved in primary care research. They saw their main role as collecting data and facilitating access to patients. Time, bureaucracy and lack of energy were the main reasons behind a decision not to engage with research. Those spending more time in NHS services were more likely to be willing to participate in research. Other possible indicators were single-handed GDPs, participation in the dental foundation training programme and location in more affluent areas.

Feasibility of assessing training of primary care dental practitioners in endodontics of moderate complexity: mapping process and learning

Objectives

To explore the feasibility of measuring quality of endodontic care provided by general dental practitioners (GDPs), using clinical, radiographic and patient-related outcomes, as well as understanding practitioner views and estimating financial costs.

Methods

Multi-faceted mixed-methods two-part study involving retrospective analysis of the educational component (course assessments, endodontic training blocks and analysis of a sample of teeth treated at the beginning and end of training), and prospective analysis of patients treated by these dentists after completion of training.

Participant

Dentists working in and patients treated in primary dental care in London.

Intervention

Twenty-four-month training in endodontics.

Comparison

Dentists enrolled in the training at different time points.

Outcome

Measuring outcome of endodontic treatment.

Results

Eight dentists (mean 36 years, SD = 8.2 years) participated in training. Subsequently, five of these dentists (mean 34.2 years, SD = 7.08 years) contributed to the prospective study and recruited 135 patients. Thirty-five patients completed all patient-related outcome questionnaires, and of these there were 16 cases with complete clinical and radiographic data (12%) at follow-up (10.1–36.4 months). Preliminary analysis revealed that a minimum of 45 cases of complete data would be required for multivariate analysis, requiring the recruitment of in excess of 375 patients to future studies to account for this level of loss to follow-up.

Conclusions

Findings suggest it is possible to carry out mixed-methods and treatment-related outcome-based research in primary care. Measurement/data capture tools developed were tested and used successfully in measuring the adherence to treatment processes and outcome of endodontic treatment.