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Brocklehurst P, Hoare Z, Woods C, Williams L, Brand A, Shen J, Breckons M, Ashley J, Jenkins A, Gough L, Preshaw P, Burton C, Shepherd K, Bhattarai N. Dental therapists compared with general dental practitioners for undertaking check-ups in low-risk patients: pilot RCT with realist evaluation. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background
Many dental ‘check-ups’ in the NHS result in no further treatment. The patient is examined by a dentist and returned to the recall list for a further check-up, commonly in 6 or 12 months’ time. As the oral health of regular dental attenders continues to improve, it is likely that an increasing number of these patients will be low risk and will require only a simple check-up in the future, with no further treatment. This care could be delivered by dental therapists. In 2013, the body responsible for regulating the dental profession, the General Dental Council, ruled that dental therapists could see patients directly and undertake check-ups and routine dental treatments (e.g. fillings). Using dental therapists to undertake check-ups on low-risk patients could help free resources to meet the future challenges for NHS dentistry.
Objectives
The objectives were to determine the most appropriate design for a definitive study, the most appropriate primary outcome measure and recruitment and retention rates, and the non-inferiority margin. We also undertook a realist-informed process evaluation and rehearsed the health economic data collection tool and analysis.
Design
A pilot randomised controlled trial over a 15-month period, with a realist-informed process evaluation. In parallel, we rehearsed the health economic evaluation and explored patients’ preferences to inform a preference elicitation exercise for a definitive study.
Setting
The setting was NHS dental practices in North West England.
Participants
A total of 217 low-risk patients in eight high-street dental practices participated.
Interventions
The current practice of using dentists to provide NHS dental check-ups (treatment as usual; the control arm) was compared with using dental therapists to provide NHS dental check-ups (the intervention arm).
Main outcome measure
The main outcome measure was difference in the proportion of sites with bleeding on probing among low-risk patients. We also recorded the number of ‘cross-over’ referrals between dentists and dental therapists.
Results
No differences were found in the health status of patients over the 15 months of the pilot trial, suggesting that non-inferiority is the most appropriate design. However, bleeding on probing suffered from ‘floor effects’ among low-risk patients, and recruitment rates were moderately low (39.7%), which suggests that an experimental design might not be the most appropriate. The theory areas that emerged from the realist-informed process evaluation were contractual, regulatory, institutional logistics, patients’ experience and logistics. The economic evaluation was rehearsed and estimates of cost-effectiveness made; potential attributes and levels that can form the basis of preference elicitation work in a definitive study were determined.
Limitations
The pilot was conducted over a 15-month period only, and bleeding on probing appeared to have floor effects. The number of participating dental practices was a limitation and the recruitment rate was moderate.
Conclusions
Non-inferiority, floor effects and moderate recruitment rates suggest that a randomised controlled trial might not be the best evaluative design for a definitive study in this population. The process evaluation identified multiple barriers to the use of dental therapists in ‘high-street’ practices and added real value.
Future work
Quasi-experimental designs may offer more promise for a definitive study alongside further realist evaluation.
Trial registration
Current Controlled Trials ISRCTN70032696.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 3. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | - Zoe Hoare
- School of Health Sciences, Bangor University, Bangor, UK
| | - Chris Woods
- School of Health Sciences, Bangor University, Bangor, UK
| | - Lynne Williams
- School of Health Sciences, Bangor University, Bangor, UK
| | - Andrew Brand
- School of Health Sciences, Bangor University, Bangor, UK
| | - Jing Shen
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Matthew Breckons
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Alison Jenkins
- School of Health Sciences, Bangor University, Bangor, UK
| | | | - Philip Preshaw
- Faculty of Dentistry, National University of Singapore, Singapore
- Faculty of Dentistry, Newcastle University, Newcastle upon Tyne, UK
| | - Christopher Burton
- School of Allied and Public Health Professions, Canterbury Christ Church University, Canterbury, UK
| | - Karen Shepherd
- Patient and public involvement representative, Bangor, UK
| | - Nawaraj Bhattarai
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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Barnes E, Bullock A, Chestnutt IG, Cowpe J, Moons K, Warren W. Dental therapists in general dental practice. A literature review and case-study analysis to determine what works, why, how and in what circumstances. EUROPEAN JOURNAL OF DENTAL EDUCATION : OFFICIAL JOURNAL OF THE ASSOCIATION FOR DENTAL EDUCATION IN EUROPE 2020; 24:109-120. [PMID: 31618492 DOI: 10.1111/eje.12474] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 10/08/2019] [Accepted: 10/14/2019] [Indexed: 06/10/2023]
Abstract
INTRODUCTION In the United Kingdom, policy and guidance changes regarding the role of dental therapists (DTs) were implemented in recent years with a view to changing dental care to a more preventive-focussed, teamwork approach. However, success in the adoption of this model of working has been varied. AIMS Adopting a realist approach, our aim was, to examine the use of DTs in general dental practices in Wales, exploring what works, why, how and in what circumstances. MATERIALS AND METHODS The research comprised two stages. (a) A structured literature search, dual-coding papers for high-level factors describing the conditions or context(s) under which the mechanisms operated to produce outcomes. From this, we derived theories about how skill-mix operates in the general dental service. (b) Six case studies of general dental practices (three with a dental therapist/three without a dental therapist) employing a range of skill-mix models incorporating semi-structured interviews with all team members. We used the case studies/interviews to explore and refine the theories derived from the literature. RESULTS Eighty-four papers were coded. From this coding, we identified seven theories which reflected factors influencing general dental practices within three broad contexts: the dental practice as a business, as a healthcare provider and as a workplace. We tested these theories in interviews with 38 dental team members across the six care studies. As a result, we amended five of the theories. CONCLUSION Our analysis provides theory about outcomes that DTs may facilitate and the mechanisms that may assist the work of DTs within different contexts of general dental practice.
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Affiliation(s)
- Emma Barnes
- Cardiff Unit for Research and Evaluation in Medical and Dental Education (CUREMeDE) Cardiff University, Cardiff, UK
| | - Alison Bullock
- Cardiff Unit for Research and Evaluation in Medical and Dental Education (CUREMeDE) Cardiff University, Cardiff, UK
| | - Ivor G Chestnutt
- College of Biomedical and Life Sciences, Cardiff University School of Dentistry, Cardiff, UK
| | - Jonathan Cowpe
- College of Biomedical and Life Sciences, Cardiff University School of Dentistry, Cardiff, UK
| | - Kirstie Moons
- The Dental Postgraduate Section, Health Education and Improvement Wales, Cardiff, UK
| | - Wendy Warren
- Aneurin Bevan University Health Board, Cardiff, UK
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