The diagnosis & management of non-carious cervical lesions by dental practitioners from the South Yorkshire and Bassetlaw regions of England

A survey-based study, utilising qualitative and quantitative questions was used to investigate the diagnosis and the management of non-carious cervical lesions (NCCLs), including an overview to the working and gender demographics of primary dental care practitioners in South Yorkshire. To establish the contributing factors associated with NCCLs; to identify the most common approach used by dentists on how to manage NCCLs, and to identify what restorative materials dentists used and why. Objectives: To investigate, by the use of a questionnaire, the diagnosis & management of non-carious cervical lesions by dental practitioners. Materials and Methods: A sample size calculation yielded a survey size of 149, following initial returns (non-responders) the questionnaire was posted to 300 randomly chosen participants. The questionnaire contained an initial demographic section to ascertain; gender, time since graduation and working times (8 questions), and the second section focused 6 questions upon; NCCL diagnosis, management and treatment options. Likert scale (5 point responses: greatly agree to greatly disagree), freetext boxes, closed-ended and multiple-choice questions were used to collect data from respondents. The response rate was (53.3%). Results: Abrasion, particularly tooth brushing, was believed to be the main cause of NCCLs (87%). An initial monitor/preventative (fluoride application) approach was taken first, with the rationale to restore being based upon patient reported symptoms, first, and then followed by any aesthetic concerns/ preservation of tooth tissue. When NCCLs were being treated there was a wide range of numbers: modal value of 2, and median value of 5 NCCLs being restored per week. Composite was the aesthetic material of choice to restore NCCLs (57%), followed by (30%) for glass polyalkenoate (GI cements) restorations. Conclusion: Our demographic data indicated that the survey cohort could be considered as a representative sample of primary care dental practitioners in terms; of gender, time since qualification (as a proxy of age), and working practice (NHS vs. Private), and sessions worked per week. There was a strong agreement between dentists that tooth brushing abrasion is the main causes of NCCLs., and while the majority of NCCLs are managed conservatively, composite is the most frequent restorative material used by dentists to restore NCCLs followed by GIC. Dentists are more likely to restore NCCLs to improve sensitivity or to preserve remaining tooth structure, than to improve patients’ aesthetics. The size of the cavity, the anatomical position of the tooth, the nature of the cause, the aesthetic consideration and the materials’ technical properties had an effect on deciding the choice of restorative material

Remote clinical consultations in restorative dentistry

Specialist consultations are routine in medical and oral healthcare provision. These take place as an 'in-person' event in the secondary care centres. The primary outcome of the specialist consultation is to provide the dentist and the patient with a specialist assessment, diagnosis, prognosis and a proposed care plan. This in-person procedure remains the gold-standard as it is a considered safe and effective. It presents a number of shortcomings: (1) The referring clinician is not actively involved in the decision-making process. (2) The patient must travel to the secondary care centre for the consultation, creating inequalities of care provision. (3) The patient travel has a carbon footprint. (4) The setting of the referral centre can be unfamiliar and intimidating to the patient. (5) The outbreak of COVID-19 highlighted the need for alternative system to address this need. This clinical study assessed the feasibility and effectiveness of undertaking remote clinical consultations in restorative dentistry between a patient and dentist co-located in a clinical primary care dental practice and a specialist consultant in a remote secondary care centre. Method: A remote clinical consultation in restorative dentistry was conducted that enabled full engagement between the remote consultant and the patient/General Dental Practitioner (GDP) in the dental surgery. A comprehensive bespoke high-speed secure internet connected hardware and software platform was used. Each participant completed a semi-structured interview and a validated questionnaire covering four domains: Patient safety, communication between different parties, formulation of a treatment plan, and effectiveness of the technology. Results: Effective and safe clinical consultations were carried out in all the cases, regardless of gender, age and presenting complaint. Neither the process nor the outcomes were inferior to an in-person consultation. Conclusion: This pilot in-practice clinical effectiveness study identified that Remote Clinical Consultations (RCCs), as conducted in this study, are effective for the delivery of specialist consultations in restorative dentistry. They are not inferior to an in-person consultation. Secondary outcomes: Three-way discussion was very positive; high levels of acceptability from the patients and the referring GDPs; an alternative to patient travel, reducing travel inconvenience, cost and the environmental burden from the associated carbon dioxide emissions

Utilisation of an operative difficulty grading scale for laparoscopic cholecystectomy

Background A reliable system for grading operative difficulty of laparoscopic cholecystectomy would standardise description of findings and reporting of outcomes. The aim of this study was to validate a difficulty grading system (Nassar scale), testing its applicability and consistency in two large prospective datasets. Methods Patient and disease-related variables and 30-day outcomes were identified in two prospective cholecystectomy databases: the multi-centre prospective cohort of 8820 patients from the recent CholeS Study and the single-surgeon series containing 4089 patients. Operative data and patient outcomes were correlated with Nassar operative difficultly scale, using Kendall’s tau for dichotomous variables, or Jonckheere–Terpstra tests for continuous variables. A ROC curve analysis was performed, to quantify the predictive accuracy of the scale for each outcome, with continuous outcomes dichotomised, prior to analysis. Results A higher operative difficulty grade was consistently associated with worse outcomes for the patients in both the reference and CholeS cohorts. The median length of stay increased from 0 to 4 days, and the 30-day complication rate from 7.6 to 24.4% as the difficulty grade increased from 1 to 4/5 (both p < 0.001). In the CholeS cohort, a higher difficulty grade was found to be most strongly associated with conversion to open and 30-day mortality (AUROC = 0.903, 0.822, respectively). On multivariable analysis, the Nassar operative difficultly scale was found to be a significant independent predictor of operative duration, conversion to open surgery, 30-day complications and 30-day reintervention (all p < 0.001). Conclusion We have shown that an operative difficulty scale can standardise the description of operative findings by multiple grades of surgeons to facilitate audit, training assessment and research. It provides a tool for reporting operative findings, disease severity and technical difficulty and can be utilised in future research to reliably compare outcomes according to case mix and intra-operative difficulty

Population‐based cohort study of outcomes following cholecystectomy for benign gallbladder diseases

Background The aim was to describe the management of benign gallbladder disease and identify characteristics associated with all‐cause 30‐day readmissions and complications in a prospective population‐based cohort. Methods Data were collected on consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing all‐cause 30‐day readmissions and complications were analysed by means of multilevel, multivariable logistic regression modelling using a two‐level hierarchical structure with patients (level 1) nested within hospitals (level 2). Results Data were collected on 8909 patients undergoing cholecystectomy from 167 hospitals. Some 1451 cholecystectomies (16·3 per cent) were performed as an emergency, 4165 (46·8 per cent) as elective operations, and 3293 patients (37·0 per cent) had had at least one previous emergency admission, but had surgery on a delayed basis. The readmission and complication rates at 30 days were 7·1 per cent (633 of 8909) and 10·8 per cent (962 of 8909) respectively. Both readmissions and complications were independently associated with increasing ASA fitness grade, duration of surgery, and increasing numbers of emergency admissions with gallbladder disease before cholecystectomy. No identifiable hospital characteristics were linked to readmissions and complications. Conclusion Readmissions and complications following cholecystectomy are common and associated with patient and disease characteristics

The development and validation of a scoring tool to predict the operative duration of elective laparoscopic cholecystectomy

Background: The ability to accurately predict operative duration has the potential to optimise theatre efficiency and utilisation, thus reducing costs and increasing staff and patient satisfaction. With laparoscopic cholecystectomy being one of the most commonly performed procedures worldwide, a tool to predict operative duration could be extremely beneficial to healthcare organisations. Methods: Data collected from the CholeS study on patients undergoing cholecystectomy in UK and Irish hospitals between 04/2014 and 05/2014 were used to study operative duration. A multivariable binary logistic regression model was produced in order to identify significant independent predictors of long (> 90 min) operations. The resulting model was converted to a risk score, which was subsequently validated on second cohort of patients using ROC curves. Results: After exclusions, data were available for 7227 patients in the derivation (CholeS) cohort. The median operative duration was 60 min (interquartile range 45–85), with 17.7% of operations lasting longer than 90 min. Ten factors were found to be significant independent predictors of operative durations > 90 min, including ASA, age, previous surgical admissions, BMI, gallbladder wall thickness and CBD diameter. A risk score was then produced from these factors, and applied to a cohort of 2405 patients from a tertiary centre for external validation. This returned an area under the ROC curve of 0.708 (SE = 0.013, p  90 min increasing more than eightfold from 5.1 to 41.8% in the extremes of the score. Conclusion: The scoring tool produced in this study was found to be significantly predictive of long operative durations on validation in an external cohort. As such, the tool may have the potential to enable organisations to better organise theatre lists and deliver greater efficiencies in care

The Cholecystectomy As A Day Case (CAAD) Score: A Validated Score of Preoperative Predictors of Successful Day-Case Cholecystectomy Using the CholeS Data Set

Background Day-case surgery is associated with significant patient and cost benefits. However, only 43% of cholecystectomy patients are discharged home the same day. One hypothesis is day-case cholecystectomy rates, defined as patients discharged the same day as their operation, may be improved by better assessment of patients using standard preoperative variables. Methods Data were extracted from a prospectively collected data set of cholecystectomy patients from 166 UK and Irish hospitals (CholeS). Cholecystectomies performed as elective procedures were divided into main (75%) and validation (25%) data sets. Preoperative predictors were identified, and a risk score of failed day case was devised using multivariate logistic regression. Receiver operating curve analysis was used to validate the score in the validation data set. Results Of the 7426 elective cholecystectomies performed, 49% of these were discharged home the same day. Same-day discharge following cholecystectomy was less likely with older patients (OR 0.18, 95% CI 0.15–0.23), higher ASA scores (OR 0.19, 95% CI 0.15–0.23), complicated cholelithiasis (OR 0.38, 95% CI 0.31 to 0.48), male gender (OR 0.66, 95% CI 0.58–0.74), previous acute gallstone-related admissions (OR 0.54, 95% CI 0.48–0.60) and preoperative endoscopic intervention (OR 0.40, 95% CI 0.34–0.47). The CAAD score was developed using these variables. When applied to the validation subgroup, a CAAD score of ≤5 was associated with 80.8% successful day-case cholecystectomy compared with 19.2% associated with a CAAD score >5 (p < 0.001). Conclusions The CAAD score which utilises data readily available from clinic letters and electronic sources can predict same-day discharges following cholecystectomy

Exploring experiences of living with removable dentures—A scoping review of qualitative literature

Objective Examine the literature on the experiences of living with removable dentures (complete or partial) to identify any gaps and provide a map for future research. Background Increasing proportions of society are living partially dentate with some form of restoration, including removable dentures. Previous studies have reported on the location, materials and usage of these prostheses, along with effects on oral-health-related quality of life (OHRQoL). However, less is known about experiences with removable dentures from a patient-centred perspective. Methods A scoping review of the qualitative literature was undertaken using the framework of Arksey and O'Malley, updated by Levac et al. Literature searches were carried out using Medline and Web of Science. Papers were screened by title and abstract using inclusion and exclusion criteria. Remaining papers were read in full and excluded if they did not meet the required criteria. Nine papers were included in the final review. Findings Key themes from these papers were: impact of tooth loss and living without teeth, and its impacts in relation to social position, appearance, confidence and function (chewing and speaking); social norms and tooth loss, including attitudes to tooth retention and treatment costs, and changes in intergenerational norms towards dentures; expectations of treatment, including patients being more involved in decision making, viewing the denture as a “gift” and dentures helping to achieve “an ideal”; living with a removable denture (complete or partial), including patient preparedness for a denture, adaptation and impacts on activities and participation; and the dentist-patient relationship, including issues with information and communication, and differing priorities between patients and dentists. Conclusion Little qualitative research exists on experiences of living with a removable denture. Existing literature demonstrates the importance of dispersed activities in differing social, spatial and temporal contexts when wearing removable dentures. Focusing on processes of positive adaptation to dentures and OHRQoL, rather than deficits, is also required to fully understand patients' experiences. Additionally, more complex technological advances may not always be in the best interest of every patient

‘It's like being in a tunnel’: Understanding the patient journey from tooth loss to life with removable dentures

Introduction The aim of this study was to conceptualise the key stages of the patient journey in the provision of a new denture and examine the factors leading to successful patient-related outcomes. Methods Two partially dentate patient samples were included: (i) Denture wearers - patients who had a denture fitted within the previous five years and (ii) New dentures - patients receiving treatment for a new or replacement denture. The methods involved direct targeted participant observations of the denture fitting process, debriefing interviews and a follow-up focus group exploring the patient journey. Data were analysed through the use of phenomenology and grounded theory. Results Interviews were completed with twenty participants of the denture-wearing sample (11 males and nine females, age range 22 to 86 years). Thirteen participants were included in the treatment journey sample in two primary care settings (six males and seven females, age range 55 to 101 years). Tooth loss and recovery was described as being in an ‘emotional tunnel’ resulting from ‘bodyphonic processes’ associated with tooth loss. ‘Bodyphonia’ subsequently became the context for ‘taking control’ and ‘managing disclosure’ when living with a removable denture. Different courses through this process can be readily observed, moderated by different variables (i.e., previous experience, working knowledge, a good fit, the treatment alliance, negotiated compromises and bounded responsibility). Conclusions An ‘integrating framework’ that seeks to describe the patient journey from the experience of tooth loss to recovery with a denture is proposed. This framework could be used to aid development of a clinical pathway to guide treatment options. Clinical Significance This paper conceptualises the patient journey. It stresses the importance of understanding the stages patients go through and highlights that for the dental team, the try-in stage is perhaps the best stage to give information about the denture and plans for continued care