"He was distraught, I was distraught.." Parents' experiences of accessing emergency care following an avulsion injury to their child

Objective To explore how parents access emergency care for their children following avulsion of a permanent tooth. Method Semi-structured qualitative interviews were undertaken with parents of children who had suffered a tooth avulsion injury in the previous two years. The interviews were recorded and transcribed verbatim. Framework analysis was used to analyse the data and interpret the core concepts from the interviews. Results Nine parents participated in the study. None of the children received the appropriate emergency dental care within the timeframe identified by national and international guidelines. The core themes that emerged following the analysis were knowledge, access and emotion. Discussion & Conclusions The parents who were interviewed for this study had poor knowledge of what to do in the event of a tooth avulsion injury. This lack of knowledge directly impaired their ability to navigate emergency dental care for their child. They described their upset and distress following their child's injury, but also feelings of frustration and disappointment in relation to the emergency care their child received. There is a need to develop appropriate support and clinical pathways to enable parents to rapidly access appropriate and timely care for their child following a complex dental trauma

Using High Fluoride Concentration Products in Public Policy – A Rapid Review of Current Guidelines for High Fluoride Concentration products

Despite improvements in dental caries levels since the widespread introduction of fluoride toothpastes, it is still a disease which is considered to be a priority in many countries around the world. Individuals at higher risk of caries can be targeted with products with a high fluoride concentration to help reduce the amount and severity of the disease. This paper compares guidance from around the world on the use of products with a high fluoride concentration and gives examples of how guidance has been translated into activity in primary care dental practice. A rapid review of electronic databases was conducted to identify the volume and variation of guidance from national or professional bodies on the use of products with a high fluoride concentration. Fifteen guidelines published within the past 10 years and in English were identified and compared. The majority of these guidelines included recommendations for fluoride varnish use as well as for fluoride gels, while a smaller number offered guidance on high fluoride strength toothpaste and other vehicles. Whilst there was good consistency in recommendations for fluoride varnish in particular, there was sometimes a lack of detail in other areas of recommendation for other vehicles with a high fluoride concentration. There are good examples within the UK, such as the Childsmile project and Delivering Better Oral Health, which highlight that the provision of evidence-based guidance can be influential in directing scarce resources towards oral health improvements. Policy can be influenced by evidence-based national recommendations and used to help encourage dental professionals and commissioners and third-party payers to adopt higher levels of practices aimed at oral health improvement

Whose Responsibility Is It Anyway? Exploring Barriers to Prevention of Oral Diseases across Europe

Introduction: Dental caries, gum disease, and tooth loss are all preventable conditions. However, many dental care systems remain treatment oriented rather than prevention oriented. This promotes the treatment of oral diseases over preventive treatments and advice. Exploring barriers to prevention and understanding the requirements of a paradigm shift are the first steps toward delivering quality prevention-focused health care. Objectives: To qualitatively explore perceived barriers and facilitators to oral disease prevention from a multistakeholder perspective across 6 European countries. Methods: A total of 58 interviews and 13 focus groups were undertaken involving 149 participants from the United Kingdom, Denmark, Germany, the Netherlands, Ireland, and Hungary. Interviews and focus groups were conducted in each country in its native language between March 2016 and September 2017. Participants were patients (n = 50), dental team members (n = 39), dental policy makers(n = 33), and dental insurers (n = 27). The audio was transcribed, translated, and analyzed via deductive thematic analysis. Results: Five broad themes emerged that were both barriers and facilitators: dental regulation, who provides prevention, knowledge and motivation, trust, and person-level factors. Each theme was touched on in all countries; however, cross-country differences were evident surrounding the magnitude of each theme. Conclusion: Despite the different strengths and weaknesses among the systems, those who deliver, organize, and utilize each system experience similar barriers to prevention. The findings suggest that across all 6 countries, prevention in oral health care is hindered by a complex interplay of factors, with no particular dental health system offering overall greater user satisfaction. Underlying the themes were sentiments of blame, whereby each group appeared to shift responsibility for prevention to other groups. To bring about change, greater teamwork is needed in the commissioning of prevention to engender its increased value by all stakeholders within the dental system. Knowledge Transfer Statement: The results from this study provide an initial first step for those interested in exploring and working toward the paradigm shift to preventive focused dentistry. We also hope that these findings will encourage more research exploring the complex relationship among dental stakeholders, with a view to overcoming the barriers. In particular, these findings may be of use to dental public health researchers, dentists, and policy makers concerned with the prevention of oral diseases. Keywords oral health, dental public health, qualitative, preventive dentistry, health services research, European Unio

Remuneration of primary dental care in England: a qualitative framework analysis of perspectives of a new service delivery model incorporating incentives for improved access, quality and health outcomes

Objective: This study aimed to describe stakeholder perspectives of a new service delivery model in primary care dentistry incorporating incentives for access, quality and health outcomes. Design: Data were collected through observations, interviews and focus groups. Setting: This was conducted under six UK primary dental care practices, three working under the incentive-driven contract and three working under the traditional activity-based contract. Participants: Observations were made of 30 dental appointments. Eighteen lay people, 15 dental team staff and a member of a commissioning team took part in the interviews and focus groups. Results: Using a qualitative framework analysis informed by Andersen’s model of access, we found oral health assessments influenced patients’ perceptions of need, which led to changes in preventive behaviour. Dentists responded to the contract, with greater emphasis on prevention, use of the disease risk ratings in treatment planning, adherence to the pathways and the utilisation of skill-mix. Participants identified increases in the capacity of practices to deliver more care as a result. These changes were seen to improve evaluated and perceived health and patient satisfaction. These outcomes fed back to shape people’s predispositions to visit the dentist. Conclusion: The incentive-driven contract was perceived to increase access to dental care, determine dentists’ and patients’ perceptions of need, their behaviours, health outcomes and patient satisfaction. Dentists face challenges in refocusing care, perceptions of preventive dentistry, deployment of skill mix and use of the risk assessments and care pathways. Dentists may need support in these areas and to recognise the differences between caring for individual patients and the patient-base of a practice

Barriers and facilitators for prevention in Danish dental care

Objective: To explore barriers and facilitators to oral disease prevention in Danish dental care from a multi-stakeholder perspective. Methods: Eleven semi-structured focus groups and interviews about Danish oral healthcare were conducted with 27 stakeholders (general public, dental teams, dental policy makers) in Copenhagen. Transcripts were analyzed using deductive thematic analysis independently by KR and HL, supervised by JC and KVC. Results: Seven broad themes were identified, including both barriers and facilitators: Knowledge and attitudes, Education and training, Regulation, Incentivization, Multidisciplinary approach, Access to care and the Dental professional-patient relationship. Whilst all themes were relevant to each group of stakeholders, the salient driver within each theme was different for each group. Conclusions: Stakeholder perspectives on the Danish Oral health care system suggest the following are important features for a preventively focused system: (a) Involving all stakeholders in oral healthcare planning. (b) Securing sufficient and ongoing briefing regarding disease prevention for all stakeholders. (c) Regulatory support and creation of incentives to promote and facilitate implementation of disease prevention. (d) Appropriate prevention for disadvantaged groups within society which may be possible to a higher degree by means of multidisciplinary collaboration. (e) Personal relations between the patient and the professional based on mutual trust

Patient Preferences for Pain Management in Advanced Cancer: Results from a Discrete Choice Experiment

Background: Pain from advanced cancer remains prevalent, severe and often under-treated. Aim: The aim of this study was to conduct a discrete choice experiment with patients to understand their preferences for pain management services and inform service development. Methods: Focus groups were used to develop the attributes and levels of the discrete choice experiment. The attributes were: waiting time, type of healthcare professional, out-of-pocket costs, side-effect control, quality of communication, quality of information and pain control. Patients completed the discrete choice experiment along with clinical and health-related quality of life questions. Conditional and mixed logit models were used to analyse the data. Results: Patients with cancer pain (n = 221) and within palliative care services completed the survey (45% were female, mean age 64.6 years; age range 21–92 years). The most important aspects of pain management were: good pain control, zero out-of-pocket costs and good side-effect control. Poor or moderate pain control and £30 costs drew the highest negative preferences. Respondents preferred control of side effects and provision of better information and communication, over access to certain healthcare professionals. Those with lower health-related quality of life were less willing to wait for treatment and willing to incur higher costs. The presence of a carer influenced preferences. Conclusions: Outcome attributes were more important than process attributes but the latter were still valued. Thus, supporting self-management, for example by providing better information on pain may be a worthwhile endeavour. However, service provision may need to account for individual characteristics given the heterogeneity in preferences