Experiences of dental behaviour support techniques: a qualitative systematic review

Background Little is known about patients' or carers' reported experiences of dental care provided using dental behaviour support (DBS) techniques. Qualitative literature can provide unique insight into these experiences. Aim To explore and synthesize qualitative literature related to patient experience of dental behaviour support. Methods A PROSPERO-registered systematic review of qualitative articles was undertaken. Studies were identified through MEDLINE, Embase and PsycINFO. Abstracts were screened by two reviewers and data were extracted to summarize the qualitative findings included within them. A thematic summary approach was used to synthesize the qualitative data identified. Results Twenty-three studies were included. Studies primarily explored experiences of dental care of children by speaking to their parents (n = 16), particularly regarding paediatric dental general anaesthesia (DGA) (n = 8). Studies of adults' experiences of DBS (n = 7) covered a range of techniques. Nine studies explored broader dental care experiences and did not study specific DBS approaches. A thematic synthesis identified five themes applicable across the studies identified: Trust and the therapeutic alliance supporting effective care delivery; considered information sharing often alleviated anticipatory anxiety; control and autonomy-reduced anxieties; variations in the perceived treatment successes and failures of DBS techniques; and DBS techniques produced longer positive and negative impacts on patients beyond direct care provision. Conclusion Qualitative research has been under-utilized in research on DBS techniques. Care experiences of most DBS techniques outside of paediatric DGA are poorly understood. Building trust with patients and enabling autonomy appear to support positive patient-reported experiences of care

A scoping review of interventions and outcome measures in trials of dental behavior support

Background Dental behavior support (DBS) describes all techniques used by dental professionals to ensure that dental care is safe, effective, and acceptable. There is a need to standardize outcome measures across DBS techniques to reduce heterogeneity, limit selective reporting, promote consistency, and optimize outcomes across DBS research. A comprehensive review of existing measures is a prerequisite to understanding potential outcomes related to the area of interest. Aim This review had three aims: first, to identify the outcome measures (OMs) reported in trials of dental behavior support; second, to categorize the component DBS techniques reported within interventions according to emerging agreed terminology; and, third, to map outcome measures to intervention type. Methods A scoping review of trials evaluating DBS techniques was undertaken from 2012 to 2022. The review was prospectively registered. Studies were identified through Medline, Embase, and PsycINFO. Study abstracts were screened by two reviewers. Data were extracted by single selector. Outcome measures were sorted according to measurement domains (physiological, behavioral, psychological, and treatment). Responses were assimilated and summed to produce a refined list of distinguishable outcome measures. Intervention types were categorized according to accepted descriptors. Frequencies were presented; associations between outcome domain and DBS type were also reported (Chi-square test of independence). Results A total of 344 trials were included in the review from an initial 14,793 titles / title and abstracts screened. Most involved children (n = 215), most were from India (n = 104), involving basic dental care (n = 117). The median number of outcome measures per trial was four (range = 1–12); 1,317 individual outcomes were reported, categorized as: psychological (n = 501, 38.0%); physiological (n = 491, 37.3%), behavioral (n = 123, 9.3%) or, treatment-related (n = 202, 15.3%). DBS interventions were split between 239 (45.7%) pharmacological and 283 (54.1%) non-pharmacological; 96.6% of interventions mapped to accepted descriptors. A significant relationship was noted between the type of intervention and the outcome domain reported. Conclusion The findings demonstrate massive variation in outcome measures of DBS interventions that likely lead to unnecessary heterogeneity, selective reporting, and questionable relevance in the literature. A large range of DBS interventions were mapped according to BeSiDe list. There is a need for consensus on a core outcome set across the spectrum of DBS techniques

Association of anticholinergic burden with adverse effects in older people with intellectual disabilities:an observational cross-sectional study

BACKGROUND: No studies to date have investigated cumulative anticholinergic exposure and its effects in adults with intellectual disabilities. AIMS: To determine the cumulative exposure to anticholinergics and the factors associated with high exposure. METHOD: A modified Anticholinergic Cognitive Burden (ACB) scale score was calculated for a representative cohort of 736 people over 40 years old with intellectual disabilities, and associations with demographic and clinical factors assessed. RESULTS: Age over 65 years was associated with higher exposure (ACB 1-4 odds ratio (OR) = 3.28, 95% CI 1.49-7.28, ACB 5+ OR = 3.08, 95% CI 1.20-7.63), as was a mental health condition (ACB 1-4 OR = 9.79, 95% CI 5.63-17.02, ACB 5+ OR = 23.74, 95% CI 12.29-45.83). Daytime drowsiness was associated with higher ACB (P<0.001) and chronic constipation reported more frequently (26.6% ACB 5+ v. 7.5% ACB 0, P<0.001). CONCLUSIONS: Older people with intellectual disabilities and with mental health conditions were exposed to high anticholinergic burden. This was associated with daytime dozing and constipation

Oral health of adults with intellectual disabilities: A systematic review

Background: There have been several past reports that adults with intellectual disabilities experience poor oral health (tooth loss, periodontal health and untreated dental caries). Loss of a functional dentition has serious consequences, including problems with chewing, swallowing, nutrition, speech, temporomandibular joint osteoarthritis and pain and systemic health conditions. Poor oral health is largely preventable through proactive oral care support. In recent years, social care provision for adults has changed, with deinstitutionalisation and home‐based personalised care now being the typical provision in high income countries. Hence, oral health inequalities might be reducing. However, there is limited recent evidence‐synthesis on the topic. We aimed to address this. Method: PROSPERO registration number: CRD42018089880. We conducted a preferred reporting items for systematic reviews and meta‐analyses systematic review of publications since 2008. Four databases were searched with a clear search strategy, strict inclusion criteria for selection of papers, double scoring (two raters), systematic data extraction and quality appraisal of included papers. Results: A total of 33/3958 retrieved articles were included, of which 14 were drawn from dental service users and 10 from Special Olympic athletes, therefore not necessarily being representative of the wider population with intellectual disabilities. Despite this limitation, adults with intellectual disabilities were still shown to experience poor oral health. High levels of poor oral hygiene and gingivitis were found, with many also affected by periodontitis and untreated dental decay. There is clear unmet need relating to both periodontal (gum) and tooth health, leading to tooth loss. Conclusions: Despite reports in the past of poor oral health amongst adults with intellectual disabilities, and despite it being preventable, there remains a high burden of poor oral health. This highlights the need to raise awareness, and for polices on effective daily oral care, and appropriate service provision. The importance of oral health and its possible negative sequelae needs to be elevated amongst carers and professionals

Labels and descriptions of dental behaviour support techniques: A scoping review of clinical practice guidelines

Introduction: There is no agreed taxonomy of the techniques used to support patients to receive professional oral healthcare. This lack of specification leads to imprecision in describing, understanding, teaching and implementing behaviour support techniques in dentistry (DBS). Methods: This review aims to identify the labels and associated descriptors used by practitioners to describe DBS techniques, as a first step in developing a shared terminology for DBS techniques. Following registration of a protocol, a scoping review limited to Clinical Practice Guidelines only was undertaken to identify the labels and descriptors used to refer to DBS techniques. Results: From 5317 screened records, 30 were included, generating a list of 51 distinct DBS techniques. General anaesthesia was the most commonly reported DBS (n = 21). This review also explores what term is given to DBS techniques as a group (Behaviour management was most commonly used (n = 8)) and how these techniques were categorized (mainly distinguishing between pharmacological and non‐pharmacological). Conclusions: This is the first attempt to generate a list of techniques that can be selected for patients and marks an initial step in future efforts at agreeing and categorizing these techniques into an accepted taxonomy, with all the benefits this brings to research, education, practice and patients

Behaviour support in dentistry: A Delphi study to agree terminology in behaviour management

Objectives: Dental behaviour support (DBS) describes all specific techniques practiced to support patients in their experience of professional oral healthcare. DBS is roughly synonymous with behaviour management, which is an outdated concept. There is no agreed terminology to specify the techniques used to support patients who receive dental care. This lack of specificity may lead to imprecision in describing, understanding, teaching, evaluating and implementing behaviour support techniques in dentistry. Therefore, this e‐Delphi study aimed to develop a list of agreed labels and descriptions of DBS techniques used in dentistry and sort them according to underlying principles of behaviour. Methods: Following a registered protocol, a modified e‐Delphi study was applied over two rounds with a final consensus meeting. The threshold of consensus was set a priori at 75%. Agreed techniques were then categorized by four coders, according to behavioural learning theory, to sort techniques according to their mechanism of action. Results: The panel (n = 35) agreed on 42 DBS techniques from a total of 63 candidate labels and descriptions. Complete agreement was achieved regarding all labels and descriptions, while agreement was not achieved regarding distinctiveness for 17 techniques. In exploring underlying principles of learning, it became clear that multiple and differing principles may apply depending on the specific context and procedure in which the technique may be applied. Discussion: Experts agreed on what each DBS technique is, what label to use, and their description, but were less likely to agree on what distinguishes one technique from another. All techniques were describable but not comprehensively categorizable according to principles of learning. While objective consistency was not attained, greater clarity and consistency now exists. The resulting list of agreed terminology marks a significant foundation for future efforts towards understanding DBS techniques in research, education and clinical care

Using the International Classification of Functioning, Disability and Health (ICF) to Describe Children Referred to Special Care or Paediatric Dental Services.

Children in dentistry are traditionally described in terms of medical diagnosis and prevalence of oral disease. This approach gives little information regarding a child\u27s capacity to maintain oral health or regarding the social determinants of oral health. The biopsychosocial approach, embodied in the International Classification of Functioning, Disability and Health - Child and Youth version (ICF-CY) (WHO), provides a wider picture of a child\u27s real-life experience, but practical tools for the application of this model are lacking. This article describes the preliminary empirical study necessary for development of such a tool - an ICF-CY Core Set for Oral Health. An ICF-CY questionnaire was used to identify the medical, functional, social and environmental context of 218 children and adolescents referred to special care or paediatric dental services in France, Sweden, Argentina and Ireland (mean age 8 years ?3.6yrs). International Classification of Disease (ICD-10) diagnoses included disorders of the nervous system (26.1%), Down syndrome (22.0%), mental retardation (17.0%), autistic disorders (16.1%), and dental anxiety alone (11.0%). The most frequently impaired items in the ICF Body functions domain were \u27Intellectual functions\u27, \u27High-level cognitive functions\u27, and \u27Attention functions\u27. In the Activities and Participation domain, participation restriction was frequently reported for 25 items including \u27Handling stress\u27, \u27Caring for body parts\u27, \u27Looking after one\u27s health\u27 and \u27Speaking\u27. In the Environment domain, facilitating items included \u27Support of friends\u27, \u27Attitude of friends\u27 and \u27Support of immediate family\u27. One item was reported as an environmental barrier - \u27Societal attitudes\u27. The ICF-CY can be used to highlight common profiles of functioning, activities, participation and environment shared by children in relation to oral health, despite widely differing medical, social and geographical contexts. The results of this empirical study might be used to develop an ICF-CY Core Set for Oral Health - a holistic but practical tool for clinical and epidemiological use

Labels and descriptions of dental behaviour support techniques: A review and agreement among experts.

The aim of this research process is to improve the practice, teaching and science of dental behaviour support (DBS) by first developing a universally accepted hierarchically structured list of DBS techniques to then develop clinical guidance, inform research methods and develop educational resources for the application, study and teaching of such techniques. These aims will be achieved in three phases of planning, development and application. This protocol relates to the development phase and defines the criteria for the first two of three studies therein, representing two of three integrated studies adopting multiple methods to answer our research question. The protocol for the third study will be published later

Total tooth loss and oral health service use among older people with intellectual disabilities in Ireland

Background and rationale As the population with Intellectual Disabilities (ID) age, the challenges to their successful ageing are unclear. It is important to understand how this population age: how their health changes into later life and how they and society, can respond to ensure successful ageing for all, while minimizing disparities. Total tooth loss is an accumulative disabling condition that reflects the burden of oral disease and the effectiveness of disease management over the life course, which increases in older age and seems to be more common among adults with ID than the general population. Research into the oral health of people with ID, has often explored both oral health and service use together, often with an emphasis on behaviour support, to allow appropriate health monitoring, service planning and policy. Given current oral health policy development in Ireland, research of this type is timely. Aim The aim of this study was to explore total tooth loss and oral health service use among older adults with intellectual disabilities in Ireland. To achieve this aim, two objectives were met by answering seven questions. The objectives of this study were to understand the prevalence, sequelae and impact of edentulism and to understand the frequency of dental attendance and use of behavioural supports among older adults with intellectual disabilities in Ireland. Methods This multi-methods study adopts quantitative, mixed methods and qualitative methodologies, conducted within the context of a larger longitudinal study on ageing and ID. The Intellectual Disability Supplement to The Irish LongituDinal study on Ageing (IDS-TILDA) is a unique longitudinal cohort study designed to explore features of ageing among older adults with ID. This study is comparable with The Irish Longitudinal Study on Ageing (TILDA). IDS-TILDA includes a nationally representative sample of adults with ID over 40 years of age who completed pre-interview questionnaires and interviews over two waves (concluding 2011 and 2014) of data collection. Six dentists, who treat people with ID regularly, were also interviewed to explain some of the quantitative findings from IDS-TILDA in a sequential-explanatory mixed-methods design and to explore their experiences of behaviour support used in providing this care, in a small qualitative descriptive study. Results A total of 753 people participated in Wave 1 and 708 in Wave 2. Relating to Objective 1, the reported prevalence of edentulism was 34% among adults with ID over fifty years of age in Ireland. This compared to 14.9% of the general population. Once edentulous, two thirds of adults with ID did not wear dentures. This compared to between 5% and 9% of edentulous adults without ID. Nine out of ten participants without teeth did not wear dentures because they did not want them. Only 8 out of 117 people without dentures reportedly wanted them. Reliance on carers to respond on participants? behalf was associated with not having dentures. Compared to people who have teeth, the odds of reporting difficulty eating was twice as high (OR=2.01, 95%CI=1.02-4.03) among edentulous participants without teeth or dentures and one fifth as high among edentulous participants who reportedly had dentures (OR =0.21, 95%CI=0.06-0.64), controlling for likely covariates. Edentulism is therefore a risk factor for difficulty eating among adults with ID, only if not treated with complete removable dentures. In fact, complete denture wear predicts a reduction in difficulty eating, relative to those who have teeth. Relating to Objective 2, the majority of older adults with ID in Ireland attended dental services regularly. This included 86.5% of the total sample, ranging from 95% of dentate and 60.5% of edentulous participants. This compared to literature based comparisons of 44% of dentate and 2.3% of edentulous adults over 65 years in Ireland. Most older adults who did not attend dental services, did so because they saw no need. This, in turn, was seen to be associated with the absense of both pain and teeth. Most older adults with ID reported the use of non-pharmacological support to receive dental care: 1% reported use of inhalation sedation; 2% Intravenous (IV) sedation; 8% general anaesthesia (GA) and 14% oral sedation for dental care. Expert dentists, who partook in the qualitative phase of this study, felt that these figures represented the unavailability of sedation and GA and inappropriate treatment. Compared to those who were not, participants reporting challenging behaviour (OR=2.3, 95%CI=1.43-3.20), significant difficulty speaking (OR=3.5, 95%CI=2.19-5.57) and obvious oral problems (OR=2.53, 95% (1.56-4.10) had greater odds of reporting treatment with GA or sedation rather than non-pharmacological supports. Experts applied behaviour support strategies, that they mostly learned ad hoc, to reduce reliance on, or increase the effectiveness of, pharmacological supports. Support strategies were selected through both rationalist and intuitive processes and were applied by the dentist iteratively assessing, applying, reassessing and adapting this approach. In this way the process formed through co-regulatory communication between dentist and patient. Discussion This study set out to study two seemingly distantly related phenomena: oral disease burden and oral health service use among adults with ID. This thesis considers edentulism as a barometer of both the experience of and the outcomes from oral disease. For adults with ID, this study demonstrates that oral health service use is high but outcomes are poor. This has a negative functional impact. This study suggests that GA and IV sedation are inaccessible, possibly making treatment inappropriate. Conclusion The oral health outcomes for people with ID are poor despite regular use of dental care. People with ID should be prioritised for appropriate services, through equitable policy. This thesis makes recommendations for practice, policy and research to ensure healthy ageing with appropriate support for all people in Ireland