General dental practitioners' perceptions of, and attitudes towards, improving patient safety through a multidisciplinary approach to the prevention of medication-related osteonecrosis of the jaw (MRONJ):A qualitative study in the North East of England

Objective To explore general dental practitioners’ (GDPs’) perceptions of, and attitudes towards, the risks of medication-related osteonecrosis of the jaw (MRONJ) and the current/potential multidisciplinary approach(es) to prevention of the condition. Design Interpretivist methodology using a grounded theory approach and constant comparative analysis to undertake an iterative series of semistructured interviews. Ritchie and Spencer’s framework analysis facilitated the identification and prioritisation of salient themes. Setting Primary care general dental practices in the North East of England. Participants 15 GDPs. Results GDPs are aware of the risk of MRONJ with commonly implicated medicines; however, they report limited collaboration between professional groups in person-centred avoidance of complications, which is a key requirement of the preventive advice recommended in extant literature. Four salient and inter-related themes emerged: (1) perception of knowledge; indicating the awareness of the risk, limited knowledge of implicated medications and experience of managing the condition; (2) risk; indicating the importance of accurate medication histories, the treatment of low risk patients in primary dental care, counselling of poorly informed patients, the fear of litigation and perceived low priority of oral health in the context of general health and well-being; (3) access and isolation; referring to access to general medical records, professional isolation and somewhat limited and challenging professional collaborative relationships; (4) interprofessional working; indicating oral health education of other professional groups, collaboration and communication, and a focus on preventive care. Conclusions Patients continue to be at risk of developing MRONJ due to limited preventive interventions and relatively disparate contexts of multidisciplinary team healthcare. Effective collaboration, education and access to shared medical records could potentially improve patient safety and reduce the potential risk of developing MRONJ

'We do not seem to engage with dentists':A qualitative study of primary healthcare staff and patients in the North East of England on the role of pharmacists in oral healthcare

Objective: To explore the attitudes towards, and perceptions of, primary care healthcare staff and patients, regarding the role of clinical pharmacists in the provision of oral health advice and collaboration with dentists in general practice. Design: Interpretivist methodology using qualitative semi-structured interviews and focus groups. Participants 22 participants; 10 pharmacists; 3 general practitioners; 2 nurses; 1 practice manager; 6 patients. Setting Primary care general medical practices in the North East of England and the University of Sunderland Patient Carer and Public Involvement group. Methods: One-to-one semi-structured interviews were performed with primary care healthcare staff. An iterative approach using constant comparative analysis facilitated the ongoing enrichment of data; salient themes were identified using Framework Analysis and related back to extant literature. A focus group was held with patients to further explore key themes. Results: Four salient and inter-related themes emerged: enhanced clinical roles; indicating rapidly changing roles of pharmacists working in general practice, increased responsibility and accountability of pharmacist prescribers and the delivery of advanced clinical services; limited knowledge; indicating basic understanding of appropriate oral health advice, but limited insight and provision of advice to patients with regards to links with systemic diseases and medication; geographical/situational isolation of the dental team; indicating the disparate contexts and challenges of multidisciplinary working in oral health, and patients’ attitudes towards dental care; integration of oral health advice; indicating the potential of pharmacists to integrate oral health advice into current roles and to target specific patient groups in practice. Conclusions: The lack of integration between oral and general healthcare services potentially impacts negatively on patient care, requiring further interprofessional oral health education. The developing role of the pharmacist in general practice represents an opportunity to integrate oral health advice and/or interventions into the management of patients in this setting

A critical synthesis of the role of the pharmacist in oral healthcare and management of medication-related osteonecrosis of the jaw

Abstract: Objective: To consolidate extant published evidence in relation to the potential of integrating oral healthcare for patients at risk of developing medication-related osteonecrosis of the jaw (MRONJ). Methods: A critical synthesis and consolidation of five publications was undertaken. As a mechanism of situating the extant work within the context of primary healthcare provision, the Rainbow Model of Integrated Care was applied as a theoretical lens through which the conceptual findings could be collectively applied to practice. Results: The critical synthesis revealed a thematic emergence relating to both formative and normative integration. The most salient of these were the identification of limited shared clinical records, and disconnection of oral healthcare provision from patients’ general medical care. The three levels of the Rainbow Model of Integrated Care reflected a series of issues for address. Conclusion: In the context of collaborative, multi-disciplinary working for patients at risk of development of MRONJ, pharmacists are a professional group which this research reveals to be an underutilised resource. Reduction of oral health inequality at all levels of patient care is a key priority and this research highlights areas for address in relation to requirements for interprofessional education, optimal communication and policies reflective and facilitative of these

Multidisciplinary prevention of medication related osteonecrosis of the jaw

Background: Medication related osteonecrosis of the jaw (MRONJ), is a rare adverse effect of anti-resorptive or anti-angiogenic drug therapy that can cause significant morbidity; commonly prescribed drugs, such as bisphosphonates, used to treat a variety of cancers and osteoporosis have been associated with MRONJ (1). A multidisciplinary approach to the promotion and prioritisation of preventative strategies to ensure patients are dentally fit prior to the prescription of implicated medications is recommended; current evidence suggests that patients have limited knowledge relating to MRONJ and that preventative strategies are rarely implemented (2,3,4). Objective: To explore the impact of MRONJ on quality of life and to explore the attitudes and perceptions of patients towards the multidisciplinary approach to the prevention of the condition. Method: Using a Grounded Theory approach and integrating a process of constant comparison in the iterative enrichment of data sets, semi-structured interviews were undertaken, transcribed and analysed using Ritchie and Spencer’s (2002) Framework Analysis(7). 23 patients; 6 patients with MRONJ, 13 patients prescribed a bisphosphonate and 4 patients with osteoporosis not currently prescribed any medication were recruited from primary care general medical practices and secondary care dental services in England. Salient themes were identified and related back to extant literature in the field. Results: Five salient and inter-related themes emerged: (1) quality of life, indicating the physical, psychological and social impact of MRONJ; (2) limited knowledge, indicating limited awareness of the condition, risk factors and preventative strategies; (3) patient specific, referring to the complexity of patients, polypharmacy, prioritising aspects of care and personal responsibility; (4) inter-professional management, indicating a perceived organisational hierarchy, professional roles and responsibilities, articulation of risk and communication; (5) wider context, indicating potential demands on NHS resources, and barriers to dental care. Conclusions: MRONJ has a significant impact on quality of life yet appropriate preventative education is not apparent. Effective inter-professional patient education and prevention to mitigate against the risk of developing MRONJ is required

Uptake of best practice recommendations in the management of patients with diabetes and periodontitis:A cross-sectional survey of healthcare professionals in primary care

10.1136/bmjopen-2019-032369BMJ Open1013236

A qualitative study exploring strategies to improve the inter-professional management of diabetes and periodontitis

Aims: To explore inter-professional communication and collaboration in guideline-concordant diabetes and periodontitis care. Methods: Qualitative design using iterations of workshops to identify ways to improve multidisciplinary working attended by staff from medical and dental primary care practices, and people with diabetes (n = 43). Workshops were semi-structured around a topic guide. Recruitment was via the UK Clinical Research Network, and a patient and public involvement group in the North of England. Results: Medical practice participants were unaware of the bidirectional evidence linking diabetes and periodontitis and stated that they had never received a referral from a dental professional in this context. The patient participants with diabetes reported never having been informed about the links between diabetes and periodontitis from either their family physician or dentist. Medical and dental practice participants gave negative accounts of inter-professional communication, with claims of inappropriate requests and defensive or non-responses that stymied future interaction. Indirect communication through the patient was suggested as an alternative to direct communication. Conclusions: Indirect referral, whereby the patient is signposted to a healthcare professional, was suggested by medical and dental professionals as a useful alternative to the traditional (and time consuming) letter or telephone call, particularly in the case of suspected diabetes or periodontitis

An Unexplored Pharmacologic/Diagnostic Strategy for Peri-Implantitis: A Protocol Proposal

Dental implants are widely utilized for the replacement of missing teeth and are increasingly being placed in patients with systemic diseases, as well as in those who are medically healthy. Furthermore, it is recognized that peri-implant mucositis and peri-implantitis are highly prevalent, affecting large numbers of patients with implants, and it is pertinent to consider whether there may be any systemic impact of these conditions, given that there are known links between periodontitis and a number of chronic inflammatory diseases. In this article, we propose that the potential systemic complications of peri-implant diseases should be investigated in future clinical research, together with studies to identify whether systemically-administered host modulation therapies (HMTs) may be of benefit in the treatment of peri-implant diseases. These “HMTs” may prove a useful adjunct to routinely employed debridement and disinfection protocols, as well as potentially being of benefit in reducing risks of systemic complications. We also consider the use of chair-side diagnostic tests for active matrix metalloproteinase-8 (aMMP-8) in the detection of peri-implant disease given the ability of such tests to detect active tissue breakdown associated with peri-implantitis and periodontitis before conventional clinical and radiographic measurements indicate pathologic changes. These novel diagnostic and therapeutic strategies are relevant to consider as they may improve the management of peri-implant disease (beyond local debridement procedures), especially in those patients in whom systemic inflammation might be of concern

An Unexplored Pharmacologic/Diagnostic Strategy for Peri-Implantitis: A Protocol Proposal

Dental implants are widely utilized for the replacement of missing teeth and are increasingly being placed in patients with systemic diseases, as well as in those who are medically healthy. Furthermore, it is recognized that peri-implant mucositis and peri-implantitis are highly prevalent, affecting large numbers of patients with implants, and it is pertinent to consider whether there may be any systemic impact of these conditions, given that there are known links between periodontitis and a number of chronic inflammatory diseases. In this article, we propose that the potential systemic complications of peri-implant diseases should be investigated in future clinical research, together with studies to identify whether systemically-administered host modulation therapies (HMTs) may be of benefit in the treatment of peri-implant diseases. These “HMTs” may prove a useful adjunct to routinely employed debridement and disinfection protocols, as well as potentially being of benefit in reducing risks of systemic complications. We also consider the use of chair-side diagnostic tests for active matrix metalloproteinase-8 (aMMP-8) in the detection of peri-implant disease given the ability of such tests to detect active tissue breakdown associated with peri-implantitis and periodontitis before conventional clinical and radiographic measurements indicate pathologic changes. These novel diagnostic and therapeutic strategies are relevant to consider as they may improve the management of peri-implant disease (beyond local debridement procedures), especially in those patients in whom systemic inflammation might be of concern

Exploring the use of mouth guards in Muay Thai:a questionnaire survey

10.1038/s41405-020-00048-zBDJ Open612