An investigation into the implementation of clinical guidelines in the general dental services

Background: An evidence-based approach to clinical practice is advocated to improve the quality of patient care. However there is often a gap between research findings and clinical practice. To address this deficiency there is the need to assist clinicians in accessing and adopting research findings. One possible method of facilitating change in practice is clinical guidelines. It has been shown in medicine that a change in clinical practice in favour of published guidelines is dependent on an active implementation strategy. Consistently effective implementation strategies have not been identified in either medicine or dentistry. Aim: to investigate the effectiveness of different implementation strategies for evidence based guidelines, using the Scottish Intercollegiate Guidelines Network(SIGN) for appropriate removal of third molar teeth (SIGN 43, 2000).Design: a randomised-controlled trial employing a 2x2 factorial design linked to multidisciplinary evaluation. Subjects: 51 volunteer dental practices across Scotland.Method: Practices were randomly allocated to one of four groups. Pre-intervention data were collected from 49 dental practices. The clinical records of all 16-24 year old patients who attended the practice over a four-month period (August to December 1999) were searched by clinical researchers who were blind to the randomisation. The data extracted included the reason for their attendance and treatment received. This process was repeated following publication of the SIGN Guideline in April 2000. The postintervention phase of the project took place between June and October 2000. Data were collected from 46 practices.Interventions: Mailing of guideline (as control/non-intervention strategy), Audit and feedback (A&F); Computer-aided learning with decision support (CAL-DS), and A&F together with CAL-DS. In addition all practitioners had an opportunity to attend a postgraduate continuation education (PGCE) course on the guideline. Thus the nonintervention/control group mirrored current practice in the dissemination and implementation of the SIGN guideline in primary dental care. Outcome Measurement: The principle outcome was adherence to the guideline as assessed independently by two researchers. Any disagreement between these evaluators was discussed and an agreement reached.Results: The overall recruitment rate of practices was 11 % of those invited to take part(63 of 565) but this decreased to 80/0 following the intervention. Prior to the intervention the percent of patients with a problem with their third molar teeth was 70/0 compared with 220/0 after intervention. This occurred at the same time as a reduction in the overall number of patients seen by the practices (3342 compared with 1935). A statistically significant reduction in the percentage of patients treated with extraction was detected between the pre- (370/0) and post-intervention (270/0) phase of this study,(P=O.02), where this reduction was not significant for different groups (P>0.05).Compliance with the guideline was 74% of patients pre-intervention and this increased to 780/0 post-intervention. However, this difference was not statistically significant(P=0.25). The weighted t-test for audit versus no audit (P=0.62) and CAL-DS versus no CAL-DS was not significant (P=0.76). From the multilevel analysis the odds ratio of compliance with the guideline for dentists who experienced audit versus those who did not was 1.28 (95% CI 0.62 to 2.63) and this compares with an odds ratio of 0.84 (95% CI 0.88 to 1.74) for the CAL-DS dentists versus no CAL-DS. For neither was the difference statistically significant. The study was not sufficiently powered to detect an interaction effect so analyses of the main effects only were undertaken. There was however a weak correlation between pre and post cluster level compliance rates (Product Moment Correlation = -0.125, t = 0.81, n = 43, P>OA). Therefore all analyses were performed on the post intervention compliance rate. All analyses were carried out on an "intention to treat" (ITT) basis.Conclusion: There was no statistically significant effect of either CAL-DC or A&F on implementation of these guidelines. This study was unable to show if the CALDC and A&F independently had any effect in increasing the general dental practitioners compliance with the guideline but it may have acted as a reinforcement of the guideline messages.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

An investigation into the implementation of clinical guidelines in the general dental services

Background: An evidence-based approach to clinical practice is advocated to improve the quality of patient care. However there is often a gap between research findings and clinical practice. To address this deficiency there is the need to assist clinicians in accessing and adopting research findings. One possible method of facilitating change in practice is clinical guidelines. It has been shown in medicine that a change in clinical practice in favour of published guidelines is dependent on an active implementation strategy. Consistently effective implementation strategies have not been identified in either medicine or dentistry. Aim: to investigate the effectiveness of different implementation strategies for evidence based guidelines, using the Scottish Intercollegiate Guidelines Network(SIGN) for appropriate removal of third molar teeth (SIGN 43, 2000).Design: a randomised-controlled trial employing a 2x2 factorial design linked to multidisciplinary evaluation. Subjects: 51 volunteer dental practices across Scotland.Method: Practices were randomly allocated to one of four groups. Pre-intervention data were collected from 49 dental practices. The clinical records of all 16-24 year old patients who attended the practice over a four-month period (August to December 1999) were searched by clinical researchers who were blind to the randomisation. The data extracted included the reason for their attendance and treatment received. This process was repeated following publication of the SIGN Guideline in April 2000. The postintervention phase of the project took place between June and October 2000. Data were collected from 46 practices.Interventions: Mailing of guideline (as control/non-intervention strategy), Audit and feedback (A&F); Computer-aided learning with decision support (CAL-DS), and A&F together with CAL-DS. In addition all practitioners had an opportunity to attend a postgraduate continuation education (PGCE) course on the guideline. Thus the nonintervention/control group mirrored current practice in the dissemination and implementation of the SIGN guideline in primary dental care. Outcome Measurement: The principle outcome was adherence to the guideline as assessed independently by two researchers. Any disagreement between these evaluators was discussed and an agreement reached.Results: The overall recruitment rate of practices was 11 % of those invited to take part(63 of 565) but this decreased to 80/0 following the intervention. Prior to the intervention the percent of patients with a problem with their third molar teeth was 70/0 compared with 220/0 after intervention. This occurred at the same time as a reduction in the overall number of patients seen by the practices (3342 compared with 1935). A statistically significant reduction in the percentage of patients treated with extraction was detected between the pre- (370/0) and post-intervention (270/0) phase of this study,(P=O.02), where this reduction was not significant for different groups (P>0.05).Compliance with the guideline was 74% of patients pre-intervention and this increased to 780/0 post-intervention. However, this difference was not statistically significant(P=0.25). The weighted t-test for audit versus no audit (P=0.62) and CAL-DS versus no CAL-DS was not significant (P=0.76). From the multilevel analysis the odds ratio of compliance with the guideline for dentists who experienced audit versus those who did not was 1.28 (95% CI 0.62 to 2.63) and this compares with an odds ratio of 0.84 (95% CI 0.88 to 1.74) for the CAL-DS dentists versus no CAL-DS. For neither was the difference statistically significant. The study was not sufficiently powered to detect an interaction effect so analyses of the main effects only were undertaken. There was however a weak correlation between pre and post cluster level compliance rates (Product Moment Correlation = -0.125, t = 0.81, n = 43, P>OA). Therefore all analyses were performed on the post intervention compliance rate. All analyses were carried out on an "intention to treat" (ITT) basis.Conclusion: There was no statistically significant effect of either CAL-DC or A&F on implementation of these guidelines. This study was unable to show if the CALDC and A&F independently had any effect in increasing the general dental practitioners compliance with the guideline but it may have acted as a reinforcement of the guideline messages.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

A scoping review of interventions to improve oral health in prison settings

OBJECTIVE: To describe the characteristics of oral health interventions implemented in prison settings and explore the barriers and facilitators towards implementation. METHODS: Following Joanna Briggs Institute scoping review methodology, six databases were searched including Medline (R), Emcare, Embase, AMED, Cochrane and PsycINFO. A total of 978 studies were returned and screened. The inclusion criteria were those studies conducted in a prison population, with an intervention to address oral health and published since 2000. RESULTS: Ten studies published between 2008 and 2021 were included. All were conducted in high-income countries. Three intervention types were identified: health education (n = 5), teledentistry (n = 3) and screening or triaging (n = 2). The barriers and facilitators to successful implementation were grouped into a framework of four overarching concepts. These included prison environment, population makeup, compliance and staffing. CLINICAL SIGNIFICANCE: Evidence suggests that oral health interventions in prisons are focused on improving access to services and oral health messages. A range of drivers including the prison environment, staffing levels, recruitment and intervention compliance influence implementation and the success of interventions

Recall intervals for oral health in primary care patients

Publisher Copyright: Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Copyright: This record is sourced from MEDLINE/PubMed, a database of the U.S. National Library of MedicinePeer reviewedPublisher PD

Interventions for the treatment of oral and oropharyngeal cancers:Surgical treatment

Background: Surgery is an important part of the management of oral cavity cancer with regard to both the removal of the primary tumour and removal of lymph nodes in the neck. Surgery is less frequently used in oropharyngeal cancer. Surgery alone may be treatment for early‐stage disease or surgery may be used in combination with radiotherapy, chemotherapy and immunotherapy/biotherapy. There is variation in the recommended timing and extent of surgery in the overall treatment regimens of people with these cancers. This is an update of a review originally published in 2007 and first updated in 2011. Objectives: To determine which surgical treatment modalities for oral and oropharyngeal cancers result in increased overall survival, disease‐free survival and locoregional control and reduced recurrence. To determine the implication of treatment modalities in terms of morbidity, quality of life, costs, hospital days of treatment, complications and harms. Search methods: Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 20 December 2017), the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 11), MEDLINE Ovid (1946 to 20 December 2017) and Embase Ovid (1980 to 20 December 2017). We searched the US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. There were no restrictions on the language or date of publication. Selection criteria: Randomised controlled trials where more than 50% of participants had primary tumours of the oral cavity or oropharynx, or where separate data could be extracted for these participants, and that compared two or more surgical treatment modalities, or surgery versus other treatment modalities. Data collection and analysis: Two or more review authors independently extracted data and assessed risk of bias. We contacted study authors for additional information as required. We collected adverse events data from included studies. Main results: We identified five new trials in this update, bringing the total number of included trials to 12 (2300 participants; 2148 with cancers of the oral cavity). We assessed four trials at high risk of bias, and eight at unclear. None of the included trials compared different surgical approaches for the excision of the primary tumour. We grouped the trials into seven main comparisons. Future research may change the findings as there is only very low‐certainty evidence available for all results. Five trials compared elective neck dissection (ND) with therapeutic (delayed) ND in participants with oral cavity cancer and clinically negative neck nodes, but differences in type of surgery and duration of follow‐up made meta‐analysis inappropriate in most cases. Four of these trials reported overall and disease‐free survival. The meta‐analyses of two trials found no evidence of either intervention leading to greater overall survival (hazard ratio (HR) 0.84, 95% confidence interval (CI) 0.41 to 1.72; 571 participants), or disease‐free survival (HR 0.73, 95% CI 0.25 to 2.11; 571 participants), but one trial found a benefit for elective supraomohyoid ND compared to therapeutic ND in overall survival (RR 0.40, 95% CI 0.19 to 0.84; 67 participants) and disease‐free survival (HR 0.32, 95% CI 0.12 to 0.84; 67 participants). Four individual trials assessed locoregional recurrence, but could not be meta‐analysed; one trial favoured elective ND over therapeutic delayed ND, while the others were inconclusive. Two trials compared elective radical ND with elective selective ND, but we were unable to pool the data for two outcomes. Neither study found evidence of a difference in overall survival or disease‐free survival. A single trial found no evidence of a difference in recurrence. One trial compared surgery plus radiotherapy with radiotherapy alone, but data were unreliable because the trial stopped early and there were multiple protocol violations. One trial comparing positron‐emission tomography‐computed tomography (PET‐CT) following chemoradiotherapy (with ND only if no or incomplete response) versus planned ND (either before or after chemoradiotherapy), showed no evidence of a difference in mortality (HR 0.92, 95% CI 0.65 to 1.31; 564 participants). The trial did not provide usable data for the other outcomes. Three single trials compared: surgery plus adjunctive radiotherapy versus chemoradiotherapy; supraomohyoid ND versus modified radical ND; and super selective ND versus selective ND. There were no useable data from these trials. The reporting of adverse events was poor. Four trials measured adverse events. Only one of the trials reported quality of life as an outcome. Authors' conclusions: Twelve randomised controlled trials evaluated ND surgery in people with oral cavity cancers; however, the evidence available for all comparisons and outcomes is very low certainty, therefore we cannot rely on the findings. The evidence is insufficient to draw conclusions about elective ND of clinically negative neck nodes at the time of removal of the primary tumour compared to therapeutic (delayed) ND. Two trials combined in meta‐analysis suggested there is no difference between these interventions, while one trial (which evaluated elective supraomohyoid ND) found that it may be associated with increased overall and disease‐free survival. One trial found elective ND reduced locoregional recurrence, while three were inconclusive. There is no evidence that radical ND increases overall or disease‐free survival compared to more conservative ND surgery, or that there is a difference in mortality between PET‐CT surveillance following chemoradiotherapy versus planned ND (before or after chemoradiotherapy). Reporting of adverse events in all trials was poor and it was not possible to compare the quality of life of people undergoing different surgical treatments