Introduction: Supervised toothbrushing programmes (STP) are a cost-effective public health interv... more Introduction: Supervised toothbrushing programmes (STP) are a cost-effective public health intervention reducing tooth decay and health inequalities in children. However, the uptake of STP in England is unknown. This study aimed to establish the current provision of STP across England and summarise the barriers and facilitators to their implementation. Methods: An online survey was sent to dental public health consultants, local authority (LA) oral health leads, and public health practitioners across England. Quantitative data was analysed using descriptive statistics. Barriers and facilitators were analysed using the Consolidated Framework for Implementation Research (CFIR). Results: Information was received for 141 LAs across England. Approximately half implemented a STP (N=68/141). Most STPs were commissioned by LAs (N=44/68) and adopted a targeted approach (N=54/68). Barriers to implementation were: (1) Funding; (2) Communication & Engagement; (3) Relative priority; (4) Logistics; (5) Capacity. Facilitators were: (1) Integrated & mandated public health approach; (2) Collaboration & Ongoing Support; (3) Clarity; (4) Flexibility; (5) Available resources; (6) Ownership & Empowerment. Conclusion: The current provision of STPs is varied, and although there are challenges to their implementation, there are also areas of good practice where these challenges have been overcome. In Brief Identi es the variation in the current provision of supervised toothbrushing programmes across England. Summarises the barriers and facilitators to the implementation of supervised toothbrushing programmes. Provides evidence to support the need for further exploration on the implementation of supervised toothbrushing programmes and the development of efforts to improve their uptake and sustainability.
Objective: Evaluate an NHS in- and out-of-hours urgent dental service (UDS) including both a tele... more Objective: Evaluate an NHS in- and out-of-hours urgent dental service (UDS) including both a telephone triage provider (TTP) and a sole clinical provider (CP) using a quality framework. Basic research design: Analysis of activity and patient experience data. Main outcome measures: Ratio of volume of services to activity provided; distance and time travelled; appropriateness of referrals and treatments; equity of utilisation; patient experience; cost per patient. Results: Almost all calls (96.6%) to the TTP were answered within 60 seconds and of people referred to the CP 96.0% needed treatment. Proportionately more people from deprived areas used the TTP. Highest utilisation of the TTP was by people aged 20 to 44 years and lowest was by people over 54 years. Cost per patient utilising the TTP was £5.06. Of the available appointments provided by the CP, 90.9% were booked the TTP. Travel time to the CP was less than 30 minutes for 78.0% of patients. Of treatments provided, 77.9% were clinical interventions and 18.1% were prescription only. Proportionately more people from deprived areas attended the CP. Highest utilisation was by people aged 20 to 44 years and lowest by people over 54 years. Nearly half (47.0%) of those attending reported they did not have a dentist. There was a high level of patient satisfaction. Cost per course of treatment at the CP was £67.41. Conclusion: Overall the UDS provided a high quality service in line with Maxwell's dimensions of quality. Timely advice and treatment was provided with high levels of patient satisfaction with the CP. Comparison with other urgent dental service models would determine the relative efficiency of the UDS.
Background: Economic evaluations provide policy makers with information to facilitate efficient r... more Background: Economic evaluations provide policy makers with information to facilitate efficient resource allocation. To date, the quality and scope of economic evaluations in the field of child oral health has not been evaluated. Furthermore, whilst the involvement of children in research has been actively encouraged in recent years, the success of this movement in dental health economics has not yet been explored. This review aimed to determine the quality and scope of published economic evaluations applied to children's oral health and to consider the extent of children's involvement. Methods: The following databases were searched: CINAHL, Cochrane Library, Econlit, EThOS, MEDLINE, NHS EED, OpenGrey, Scopus, Web of Science. Full economic evaluations, relating to any aspect of child oral health, published after 1997 were included and appraised against the Drummond checklist and the Consolidated Health Economic Evaluation Reporting Standards by a team of four calibrated reviewers. Data were also extracted regarding children's involvement and the outcome measures used. Results: Two thousand seven hundred fifteen studies were identified, of which 46 met the inclusion criteria. The majority (n = 38, 82%) were cost-effectiveness studies, with most focusing on the prevention or management of dental caries (n = 42, 91%). One study quantified outcomes in Quality Adjusted Life Years (QALYs), and one study utilised a child-reported outcome measure. The mean percentage of applicable Drummond checklist criteria met by the studies in this review was 48% (median = 50%, range = 0-100%) with key methodological weaknesses noted in relation to discounting of costs and outcomes. The mean percentage of applicable CHEERS criteria met by each study was 77% (median = 83%, range = 33-100%), with limited reporting of conflicts of interest. Children's engagement was largely overlooked. Conclusions: There is a paucity of high-quality economic evaluations in the field of child oral health. This deficiency could be addressed through the endorsement of standardised economic evaluation guidelines by dental journals. The development of a child-centred utility measure for use in paediatric oral health would enable researchers to quantify outcomes in terms of quality adjusted life years (QALYs) whilst promoting child-centred research.
Background Dental caries is common in young people and has wide-ranging ramifications for health ... more Background Dental caries is common in young people and has wide-ranging ramifications for health and quality of life. Text messaging interventions show promise as a means to promote oral health behaviour change among young people. This paper reports the internal pilot of the Brushing RemInder 4 Good oral HealTh (BRIGHT) trial, which is evaluating an intervention comprising an oral health classroom lesson and text messages about toothbrushing, on caries in young people. Pilot trial objectives were to evaluate the feasibility and appropriateness of recruitment and data collection methods, the randomisation strategy, and intervention delivery against progression criteria for the main trial. Methods This is an internal pilot trial embedded within an assessor-blinded, two-arm, cluster randomised controlled trial. Participants were pupils aged 11-13 years (in year 7/S1 or year 8/S2) in secondary schools in England, Scotland, and Wales with above average pupil eligibility for free school meals. Following completion of pupil baseline questionnaires and dental assessments, year groups within schools were randomised to the intervention or control arm. Approximately 12 weeks later, participants completed a follow-up questionnaire, which included questions about sources of oral health advice to assess intervention contamination between year groups. At the end of the pilot phase, trial conduct was reviewed against pre-specified progression criteria. Results Ten schools were recruited for the pilot, with 20 year groups and 1073 pupils randomised (average of 54 pupils per year group). Data collection methods and intervention delivery were considered feasible, the response rate to the follow-up questionnaire was over 80%, there was an indication of a positive effect on self-reported toothbrushing, and interest was obtained from 80% of the schools required for the main trial. Despite partial intervention contamination between year groups, within-school randomisation at the level of the year-group was considered appropriate for the main trial, and the sample size was revised to account for partial contamination. Facilitators and barriers to recruitment and data collection were identified and strategies refined for the main trial. Conclusions Progression to the main trial of BRIGHT, with some design refinements, was concluded. The internal pilot was an efficient way to determine trial feasibility and optimise trial processes.
Introduction Despite being largely preventable, dental caries in permanent teeth is the most comm... more Introduction Despite being largely preventable, dental caries in permanent teeth is the most common chronic disease globally, and the tenth most common in the primary dentition, affecting 621 million children worldwide. 1 In the UK, it affects approximately one third of fiveyear-olds, rising to nearly half of children surveyed by age eight. 2 Although the number
Objective: To summarise the literature on urgent dental care and to identify research priorities ... more Objective: To summarise the literature on urgent dental care and to identify research priorities on the organisation and delivery of urgent dental services. Basic research design: Scoping review using Andersen's behavioural model of health service utilisation for a framework analysis of the data. Main outcome measures: Gaps in the literature, defined as those factors and interactions identified by Andersen's model as having a contributory role in access to health services that were not evident in the source papers. Results: Fifty-six papers met the inclusion criteria for the review. The factors most often considered were; demographic, socioeconomic, perceived and evaluated need, and health behaviours. Patient outcomes of evaluated health and quality of life following urgent dental care were the least studied variables, with the exception of patient satisfaction. No studies were identified on community values/norms of people accessing urgent dental care, on health economic evaluations or on studies of how urgent dental services mitigate use of other medical services. No studies were identified on urgent need for populations living in water fluoridated areas or on the relationship between service design and efficient or effective access as measured by patient outcomes. Conclusion: Future research on patient outcomes and the comparison of different service models for urgent dental care through measures of equity, effectiveness and efficiency of access are needed to inform future policy and organisation of these services.
Background: Dental caries (tooth decay) in children is a national public health problem with impa... more Background: Dental caries (tooth decay) in children is a national public health problem with impacts on the child, their family and wider society. Toothbrushing should commence from the eruption of the first primary tooth. Health visitors are a key provider of advice for parents in infancy and are ideally placed to support families to adopt optimal oral health habits. HABIT is a co-designed complex behaviour change intervention to support health visitors' oral health conversations with parents during the 9-12-month universal developmental home visit. Methods: A seven stage co-design process was undertaken: (1) Preparatory meetings with healthcare professionals and collation of examples of good practice, (2) Co-design workshops with parents and health visitors, (3) Resource development and expert/peer review, (4) Development of an intervention protocol for health visitors, (5) Early-phase testing of the resources to explore acceptability, feasibility, impact and mechanism of action, (6) Engagement with wider stakeholders and refinement of the HABIT intervention for wider use, (7) Verification, Review and Reflection of Resources. Results: Following preparatory meetings with stakeholders, interviews and co-design workshops with parents and health visitors, topic areas and messages were developed covering six key themes. The topic areas provided a structure for the oral health conversation and supportive resources in paper-based and digital formats. A five-step protocol was developed with health visitors to guide the oral health conversation during the 9-12 month visit. Following training of health visitors, an early-phase feasibility study was undertaken with preliminary results presented at a dissemination event where feedback for further refinement of the resources and training was gathered. The findings, feedback and verification have led to further refinements to optimise quality, accessibility, fidelity and behaviour change theory. Conclusion: The co-design methods ensured the oral health conversation and supporting resources used during the 9-12 month visit incorporated the opinions of families and Health Visitors as well as other key stakeholders throughout the development process. This paper provides key learning and a framework that can be applied to other
Dental anxiety is common in adolescents and is associated with poor oral health status and worse ... more Dental anxiety is common in adolescents and is associated with poor oral health status and worse oral health-related quality of life. As these patients move into adulthood, they may continue to be reliant on pharmocological approaches in order to cope with dental treatment and only attend when they have a problem. Managing anxious adolescents is also a source of stress for dental practitioners. This article describes how cognitive behavioural therapy (CBT) can be used to reduce dental anxiety in this group of patients. Clinical relevance: This article provides an overview of cognitive behavioural therapy and gives practical guidance on how such approaches can be used with adolescents.
Background: Dental caries in adolescents remains a significant public health problem with few ora... more Background: Dental caries in adolescents remains a significant public health problem with few oral health promotion interventions aimed at reducing dental caries in secondary school-aged students. Previous oral health and mobile health (mHealth) research has suggested the need for the development of a school-based behaviour change intervention incorporating a digital component. This study aimed to describe the development process of a behaviour change intervention to improve the oral health of students aged 11-16 years attending secondary schools in the UK. Methods: A six-step process was used to develop the complex intervention informed by behaviour change theory and involving students, young people, parents and teachers in the process. The steps were: (1) identifying the target behaviours, namely tooth brushing with a fluoride toothpaste (2) identifying the theoretical basis and developing the causal model (3) reviewing the relevant literature and developing the logic model (4) designing the intervention with young people, parents and school staff (5) specifying the intervention content and (6) translating this content into features of the intervention and piloting. Results: The resultant intervention included a quality-assured classroom-based session (CBS) (guided by a lesson plan and teaching resources), delivered by school teachers which was embedded within the school curriculum. This CBS was followed by a series of (Short Message Service) SMS texts delivered twice daily to student's mobile telephones with the content, duration and timing of the messages informed by involvement of students and young people. Conclusions: An intervention to improve the oral health of secondary school students through improved tooth brushing was rigorously developed based on behaviour change theory and work with young people, parents and school staff. Further research is needed to evaluate the outcomes and processes involved following the delivery of this intervention.
Objectives: This study develops an adolescent value set for a child-centred dental caries-specifi... more Objectives: This study develops an adolescent value set for a child-centred dental caries-specific measure of oral health-related quality of life (OHRQoL) based upon CARIES-QC (Caries Impacts and Experiences Questionnaire for Children). This study develops a new approach to valuing child health by eliciting adolescent preferences and anchoring these onto the 1-0 full health-dead QALY (quality adjusted life year) scale using ordinal adult preferences. Methods: Two online surveys were created to elicit preferences for the CARIES-QC classification system. The first comprised best-worst scaling (BWS) tasks for completion by adolescents aged 11-16 years. The second comprised discrete choice experiment tasks with a duration attribute (DCE TTO) for completion by adults aged over 18 years. Preferences were modelled using the conditional logit model. Mapping regressions anchored the adolescent BWS data onto the QALY scale using adult DCE TTO values, since the BWS survey data alone cannot generate anchored values. Results: 723 adolescents completed the BWS survey and 626 adults completed the DCE TTO survey. The samples were representative of UK adolescent and adult populations. Fully consistent and robust models were produced for both BWS and DCE TTO data. BWS preferences were mapped onto DCE TTO values, resulting utility estimates for each health state defined by the classification system. Conclusion: This is the first measure with predetermined scoring based on preferences to be developed specifically for use in child oral health research, and uses a novel technique to generate a value set using adolescent preferences. The estimates can be used to generate QALYs in economic evaluations of interventions to improve children's oral health.
Study selection Two independent and calibrated reviewers selected randomised controlled trials in... more Study selection Two independent and calibrated reviewers selected randomised controlled trials investigating cognitive behavioural therapy use in dentally anxious children.
Background Dental caries in childhood is a burden on the daily lives of children and their famili... more Background Dental caries in childhood is a burden on the daily lives of children and their families, and associated with poor oral health in adulthood. In England, dental caries is the most common reason for young children to be admitted to hospital. It is believed that most tooth extractions (due to decay) for children aged 10 years and under, could be avoided with improved prevention and early management. National public health policy recommendations in England include specific oral health initiatives to tackle tooth decay. One of these initiatives is delivered as part of the Healthy Child Programme and includes providing workforce training in oral health, integrating oral health advice into home visits, and the timely provision of fluoride toothpaste. This protocol seeks to assess the delivery of the First Dental Steps intervention and uncertainties related to the acceptability, recruitment, and retention of participants. Methods This study seeks to explore the feasibility and ac...
Objectives To conduct an early-phase feasibility study of an oral health intervention, Health vis... more Objectives To conduct an early-phase feasibility study of an oral health intervention, Health visitors delivering Advice on Britain on Infant Toothbrushing (HABIT), delivered by Health Visitors to parents of children aged 9-12 months old. Design A mixed-methods, early-phase, non-controlled, feasibility study. Participants Recruitment consisted of Group A-HABITtrained Health Visitors (n=11) and Group B-parents of children aged 9-12 months old about to receive their universal health check (n=35). Setting Bradford, West Yorkshire, UK. Intervention A multidisciplinary team co-developed digital and paper-based training resources with health visitors and parents of young children. The intervention comprised of two components: (A) training for health visitors to deliver the HABIT intervention and (B) HABIT resources for parents, including a website, videos, toothbrushing demonstration and a paper-based leaflet with an oral health action plan. Primary and secondary outcome measures Recruitment, retention and intervention delivery were analysed as key process outcomes for Groups A and B. Group B demographics, self-reported toothbrushing behaviours, dietary habits and three objective measures of toothbrushing including plaque scores were collected at baseline, 2 weeks and 3 months post intervention. Results HABIT intervention delivery was feasible. Although the intended sample size was recruited (Group A=11 and Group B=35) it was more challenging than anticipated. Retention of Group B participants to final data collection was satisfactory (n=26). Total compliance with toothbrushing guidelines at baseline was low (30%), but significantly improved and was maintained 3 months after the intervention (68%). Plaque scores improved post intervention and participants found video recording of toothbrushing acceptable. Dietary habits remained largely unchanged. Conclusion This feasibility study has demonstrated that HABIT is an appropriate oral health intervention. Adaptions to the study design are recommended to maximise recruitment and data collection in a definitive study. These quantitative findings have demonstrated an early signal of impact for improved oral health behaviours for young children at high risk of decay. Trial registration number ISRCTN55332414.
Introduction: Supervised toothbrushing programmes (STP) are a cost-effective public health interv... more Introduction: Supervised toothbrushing programmes (STP) are a cost-effective public health intervention reducing tooth decay and health inequalities in children. However, the uptake of STP in England is unknown. This study aimed to establish the current provision of STP across England and summarise the barriers and facilitators to their implementation. Methods: An online survey was sent to dental public health consultants, local authority (LA) oral health leads, and public health practitioners across England. Quantitative data was analysed using descriptive statistics. Barriers and facilitators were analysed using the Consolidated Framework for Implementation Research (CFIR). Results: Information was received for 141 LAs across England. Approximately half implemented a STP (N=68/141). Most STPs were commissioned by LAs (N=44/68) and adopted a targeted approach (N=54/68). Barriers to implementation were: (1) Funding; (2) Communication & Engagement; (3) Relative priority; (4) Logistics; (5) Capacity. Facilitators were: (1) Integrated & mandated public health approach; (2) Collaboration & Ongoing Support; (3) Clarity; (4) Flexibility; (5) Available resources; (6) Ownership & Empowerment. Conclusion: The current provision of STPs is varied, and although there are challenges to their implementation, there are also areas of good practice where these challenges have been overcome. In Brief Identi es the variation in the current provision of supervised toothbrushing programmes across England. Summarises the barriers and facilitators to the implementation of supervised toothbrushing programmes. Provides evidence to support the need for further exploration on the implementation of supervised toothbrushing programmes and the development of efforts to improve their uptake and sustainability.
Objective: Evaluate an NHS in- and out-of-hours urgent dental service (UDS) including both a tele... more Objective: Evaluate an NHS in- and out-of-hours urgent dental service (UDS) including both a telephone triage provider (TTP) and a sole clinical provider (CP) using a quality framework. Basic research design: Analysis of activity and patient experience data. Main outcome measures: Ratio of volume of services to activity provided; distance and time travelled; appropriateness of referrals and treatments; equity of utilisation; patient experience; cost per patient. Results: Almost all calls (96.6%) to the TTP were answered within 60 seconds and of people referred to the CP 96.0% needed treatment. Proportionately more people from deprived areas used the TTP. Highest utilisation of the TTP was by people aged 20 to 44 years and lowest was by people over 54 years. Cost per patient utilising the TTP was £5.06. Of the available appointments provided by the CP, 90.9% were booked the TTP. Travel time to the CP was less than 30 minutes for 78.0% of patients. Of treatments provided, 77.9% were clinical interventions and 18.1% were prescription only. Proportionately more people from deprived areas attended the CP. Highest utilisation was by people aged 20 to 44 years and lowest by people over 54 years. Nearly half (47.0%) of those attending reported they did not have a dentist. There was a high level of patient satisfaction. Cost per course of treatment at the CP was £67.41. Conclusion: Overall the UDS provided a high quality service in line with Maxwell's dimensions of quality. Timely advice and treatment was provided with high levels of patient satisfaction with the CP. Comparison with other urgent dental service models would determine the relative efficiency of the UDS.
Background: Economic evaluations provide policy makers with information to facilitate efficient r... more Background: Economic evaluations provide policy makers with information to facilitate efficient resource allocation. To date, the quality and scope of economic evaluations in the field of child oral health has not been evaluated. Furthermore, whilst the involvement of children in research has been actively encouraged in recent years, the success of this movement in dental health economics has not yet been explored. This review aimed to determine the quality and scope of published economic evaluations applied to children's oral health and to consider the extent of children's involvement. Methods: The following databases were searched: CINAHL, Cochrane Library, Econlit, EThOS, MEDLINE, NHS EED, OpenGrey, Scopus, Web of Science. Full economic evaluations, relating to any aspect of child oral health, published after 1997 were included and appraised against the Drummond checklist and the Consolidated Health Economic Evaluation Reporting Standards by a team of four calibrated reviewers. Data were also extracted regarding children's involvement and the outcome measures used. Results: Two thousand seven hundred fifteen studies were identified, of which 46 met the inclusion criteria. The majority (n = 38, 82%) were cost-effectiveness studies, with most focusing on the prevention or management of dental caries (n = 42, 91%). One study quantified outcomes in Quality Adjusted Life Years (QALYs), and one study utilised a child-reported outcome measure. The mean percentage of applicable Drummond checklist criteria met by the studies in this review was 48% (median = 50%, range = 0-100%) with key methodological weaknesses noted in relation to discounting of costs and outcomes. The mean percentage of applicable CHEERS criteria met by each study was 77% (median = 83%, range = 33-100%), with limited reporting of conflicts of interest. Children's engagement was largely overlooked. Conclusions: There is a paucity of high-quality economic evaluations in the field of child oral health. This deficiency could be addressed through the endorsement of standardised economic evaluation guidelines by dental journals. The development of a child-centred utility measure for use in paediatric oral health would enable researchers to quantify outcomes in terms of quality adjusted life years (QALYs) whilst promoting child-centred research.
Background Dental caries is common in young people and has wide-ranging ramifications for health ... more Background Dental caries is common in young people and has wide-ranging ramifications for health and quality of life. Text messaging interventions show promise as a means to promote oral health behaviour change among young people. This paper reports the internal pilot of the Brushing RemInder 4 Good oral HealTh (BRIGHT) trial, which is evaluating an intervention comprising an oral health classroom lesson and text messages about toothbrushing, on caries in young people. Pilot trial objectives were to evaluate the feasibility and appropriateness of recruitment and data collection methods, the randomisation strategy, and intervention delivery against progression criteria for the main trial. Methods This is an internal pilot trial embedded within an assessor-blinded, two-arm, cluster randomised controlled trial. Participants were pupils aged 11-13 years (in year 7/S1 or year 8/S2) in secondary schools in England, Scotland, and Wales with above average pupil eligibility for free school meals. Following completion of pupil baseline questionnaires and dental assessments, year groups within schools were randomised to the intervention or control arm. Approximately 12 weeks later, participants completed a follow-up questionnaire, which included questions about sources of oral health advice to assess intervention contamination between year groups. At the end of the pilot phase, trial conduct was reviewed against pre-specified progression criteria. Results Ten schools were recruited for the pilot, with 20 year groups and 1073 pupils randomised (average of 54 pupils per year group). Data collection methods and intervention delivery were considered feasible, the response rate to the follow-up questionnaire was over 80%, there was an indication of a positive effect on self-reported toothbrushing, and interest was obtained from 80% of the schools required for the main trial. Despite partial intervention contamination between year groups, within-school randomisation at the level of the year-group was considered appropriate for the main trial, and the sample size was revised to account for partial contamination. Facilitators and barriers to recruitment and data collection were identified and strategies refined for the main trial. Conclusions Progression to the main trial of BRIGHT, with some design refinements, was concluded. The internal pilot was an efficient way to determine trial feasibility and optimise trial processes.
Introduction Despite being largely preventable, dental caries in permanent teeth is the most comm... more Introduction Despite being largely preventable, dental caries in permanent teeth is the most common chronic disease globally, and the tenth most common in the primary dentition, affecting 621 million children worldwide. 1 In the UK, it affects approximately one third of fiveyear-olds, rising to nearly half of children surveyed by age eight. 2 Although the number
Objective: To summarise the literature on urgent dental care and to identify research priorities ... more Objective: To summarise the literature on urgent dental care and to identify research priorities on the organisation and delivery of urgent dental services. Basic research design: Scoping review using Andersen's behavioural model of health service utilisation for a framework analysis of the data. Main outcome measures: Gaps in the literature, defined as those factors and interactions identified by Andersen's model as having a contributory role in access to health services that were not evident in the source papers. Results: Fifty-six papers met the inclusion criteria for the review. The factors most often considered were; demographic, socioeconomic, perceived and evaluated need, and health behaviours. Patient outcomes of evaluated health and quality of life following urgent dental care were the least studied variables, with the exception of patient satisfaction. No studies were identified on community values/norms of people accessing urgent dental care, on health economic evaluations or on studies of how urgent dental services mitigate use of other medical services. No studies were identified on urgent need for populations living in water fluoridated areas or on the relationship between service design and efficient or effective access as measured by patient outcomes. Conclusion: Future research on patient outcomes and the comparison of different service models for urgent dental care through measures of equity, effectiveness and efficiency of access are needed to inform future policy and organisation of these services.
Background: Dental caries (tooth decay) in children is a national public health problem with impa... more Background: Dental caries (tooth decay) in children is a national public health problem with impacts on the child, their family and wider society. Toothbrushing should commence from the eruption of the first primary tooth. Health visitors are a key provider of advice for parents in infancy and are ideally placed to support families to adopt optimal oral health habits. HABIT is a co-designed complex behaviour change intervention to support health visitors' oral health conversations with parents during the 9-12-month universal developmental home visit. Methods: A seven stage co-design process was undertaken: (1) Preparatory meetings with healthcare professionals and collation of examples of good practice, (2) Co-design workshops with parents and health visitors, (3) Resource development and expert/peer review, (4) Development of an intervention protocol for health visitors, (5) Early-phase testing of the resources to explore acceptability, feasibility, impact and mechanism of action, (6) Engagement with wider stakeholders and refinement of the HABIT intervention for wider use, (7) Verification, Review and Reflection of Resources. Results: Following preparatory meetings with stakeholders, interviews and co-design workshops with parents and health visitors, topic areas and messages were developed covering six key themes. The topic areas provided a structure for the oral health conversation and supportive resources in paper-based and digital formats. A five-step protocol was developed with health visitors to guide the oral health conversation during the 9-12 month visit. Following training of health visitors, an early-phase feasibility study was undertaken with preliminary results presented at a dissemination event where feedback for further refinement of the resources and training was gathered. The findings, feedback and verification have led to further refinements to optimise quality, accessibility, fidelity and behaviour change theory. Conclusion: The co-design methods ensured the oral health conversation and supporting resources used during the 9-12 month visit incorporated the opinions of families and Health Visitors as well as other key stakeholders throughout the development process. This paper provides key learning and a framework that can be applied to other
Dental anxiety is common in adolescents and is associated with poor oral health status and worse ... more Dental anxiety is common in adolescents and is associated with poor oral health status and worse oral health-related quality of life. As these patients move into adulthood, they may continue to be reliant on pharmocological approaches in order to cope with dental treatment and only attend when they have a problem. Managing anxious adolescents is also a source of stress for dental practitioners. This article describes how cognitive behavioural therapy (CBT) can be used to reduce dental anxiety in this group of patients. Clinical relevance: This article provides an overview of cognitive behavioural therapy and gives practical guidance on how such approaches can be used with adolescents.
Background: Dental caries in adolescents remains a significant public health problem with few ora... more Background: Dental caries in adolescents remains a significant public health problem with few oral health promotion interventions aimed at reducing dental caries in secondary school-aged students. Previous oral health and mobile health (mHealth) research has suggested the need for the development of a school-based behaviour change intervention incorporating a digital component. This study aimed to describe the development process of a behaviour change intervention to improve the oral health of students aged 11-16 years attending secondary schools in the UK. Methods: A six-step process was used to develop the complex intervention informed by behaviour change theory and involving students, young people, parents and teachers in the process. The steps were: (1) identifying the target behaviours, namely tooth brushing with a fluoride toothpaste (2) identifying the theoretical basis and developing the causal model (3) reviewing the relevant literature and developing the logic model (4) designing the intervention with young people, parents and school staff (5) specifying the intervention content and (6) translating this content into features of the intervention and piloting. Results: The resultant intervention included a quality-assured classroom-based session (CBS) (guided by a lesson plan and teaching resources), delivered by school teachers which was embedded within the school curriculum. This CBS was followed by a series of (Short Message Service) SMS texts delivered twice daily to student's mobile telephones with the content, duration and timing of the messages informed by involvement of students and young people. Conclusions: An intervention to improve the oral health of secondary school students through improved tooth brushing was rigorously developed based on behaviour change theory and work with young people, parents and school staff. Further research is needed to evaluate the outcomes and processes involved following the delivery of this intervention.
Objectives: This study develops an adolescent value set for a child-centred dental caries-specifi... more Objectives: This study develops an adolescent value set for a child-centred dental caries-specific measure of oral health-related quality of life (OHRQoL) based upon CARIES-QC (Caries Impacts and Experiences Questionnaire for Children). This study develops a new approach to valuing child health by eliciting adolescent preferences and anchoring these onto the 1-0 full health-dead QALY (quality adjusted life year) scale using ordinal adult preferences. Methods: Two online surveys were created to elicit preferences for the CARIES-QC classification system. The first comprised best-worst scaling (BWS) tasks for completion by adolescents aged 11-16 years. The second comprised discrete choice experiment tasks with a duration attribute (DCE TTO) for completion by adults aged over 18 years. Preferences were modelled using the conditional logit model. Mapping regressions anchored the adolescent BWS data onto the QALY scale using adult DCE TTO values, since the BWS survey data alone cannot generate anchored values. Results: 723 adolescents completed the BWS survey and 626 adults completed the DCE TTO survey. The samples were representative of UK adolescent and adult populations. Fully consistent and robust models were produced for both BWS and DCE TTO data. BWS preferences were mapped onto DCE TTO values, resulting utility estimates for each health state defined by the classification system. Conclusion: This is the first measure with predetermined scoring based on preferences to be developed specifically for use in child oral health research, and uses a novel technique to generate a value set using adolescent preferences. The estimates can be used to generate QALYs in economic evaluations of interventions to improve children's oral health.
Study selection Two independent and calibrated reviewers selected randomised controlled trials in... more Study selection Two independent and calibrated reviewers selected randomised controlled trials investigating cognitive behavioural therapy use in dentally anxious children.
Background Dental caries in childhood is a burden on the daily lives of children and their famili... more Background Dental caries in childhood is a burden on the daily lives of children and their families, and associated with poor oral health in adulthood. In England, dental caries is the most common reason for young children to be admitted to hospital. It is believed that most tooth extractions (due to decay) for children aged 10 years and under, could be avoided with improved prevention and early management. National public health policy recommendations in England include specific oral health initiatives to tackle tooth decay. One of these initiatives is delivered as part of the Healthy Child Programme and includes providing workforce training in oral health, integrating oral health advice into home visits, and the timely provision of fluoride toothpaste. This protocol seeks to assess the delivery of the First Dental Steps intervention and uncertainties related to the acceptability, recruitment, and retention of participants. Methods This study seeks to explore the feasibility and ac...
Objectives To conduct an early-phase feasibility study of an oral health intervention, Health vis... more Objectives To conduct an early-phase feasibility study of an oral health intervention, Health visitors delivering Advice on Britain on Infant Toothbrushing (HABIT), delivered by Health Visitors to parents of children aged 9-12 months old. Design A mixed-methods, early-phase, non-controlled, feasibility study. Participants Recruitment consisted of Group A-HABITtrained Health Visitors (n=11) and Group B-parents of children aged 9-12 months old about to receive their universal health check (n=35). Setting Bradford, West Yorkshire, UK. Intervention A multidisciplinary team co-developed digital and paper-based training resources with health visitors and parents of young children. The intervention comprised of two components: (A) training for health visitors to deliver the HABIT intervention and (B) HABIT resources for parents, including a website, videos, toothbrushing demonstration and a paper-based leaflet with an oral health action plan. Primary and secondary outcome measures Recruitment, retention and intervention delivery were analysed as key process outcomes for Groups A and B. Group B demographics, self-reported toothbrushing behaviours, dietary habits and three objective measures of toothbrushing including plaque scores were collected at baseline, 2 weeks and 3 months post intervention. Results HABIT intervention delivery was feasible. Although the intended sample size was recruited (Group A=11 and Group B=35) it was more challenging than anticipated. Retention of Group B participants to final data collection was satisfactory (n=26). Total compliance with toothbrushing guidelines at baseline was low (30%), but significantly improved and was maintained 3 months after the intervention (68%). Plaque scores improved post intervention and participants found video recording of toothbrushing acceptable. Dietary habits remained largely unchanged. Conclusion This feasibility study has demonstrated that HABIT is an appropriate oral health intervention. Adaptions to the study design are recommended to maximise recruitment and data collection in a definitive study. These quantitative findings have demonstrated an early signal of impact for improved oral health behaviours for young children at high risk of decay. Trial registration number ISRCTN55332414.
Objectives: To explore the accessibility, usability and relevance of the British Orthodontic Soci... more Objectives: To explore the accessibility, usability and relevance of the British Orthodontic Society (BOS) online information resource (OIR), " Your Jaw Surgery ". Design: Qualitative, cross-sectional study. Setting: 5 UK sites. Participants: Patients before, during and after treatment for non-cleft skeletal discrepancy. Methods: Patients were identified at joint clinics, sent a link to the online information resource " Your Jaw Surgery " and recruited after having time to view the OIR. Semi-structured interviews were conducted with 17 patients (aged 16 – 46 years). Interviews covered the information patients received, and looked for, about orthognathic treatment, and their views of the OIR. The interviews were transcribed and framework analysis was undertaken. Results: The main themes identified were the overall usefulness, personal relevance and positive perceptions of the OIR. Participants reported the OIR was clearly laid out and easy to use. Having a resource online was appreciated and the information and patient experiences provided were valued. The OIR was seen to be useful for patients considering treatment, and potentially useful for patients undergoing treatment. Participants were looking for a personally relevant resource that would give them the best possible idea of how they would look and feel after surgery. The OIR was perceived as trusted, positive and reassuring. Conclusions: Patients at different stages of treatment found the OIR helpful and reassuring. Clinicians may find it useful to direct patients to the OIR to complement a professional consultation, but should be aware that patients may perceive it as presenting a positive image of the long-term benefits of orthognathic treatment. 2 Following this research, an evaluation questionnaire has been designed to allow future viewers to feedback and improve the resource.
Globally, dental caries is one of the most prevalent diseases and is more common in children livi... more Globally, dental caries is one of the most prevalent diseases and is more common in children living in deprived areas. Dental caries is preventable, and guidance in the United Kingdom recommends parental supervised brushing (PSB): a collection of behaviors—including twice-daily toothbrushing with fluoridated toothpaste—that should begin upon eruption of the first tooth (approximately 6 to 12 mo of age) and for which children need to be helped or supervised by an adult until at least 7 y of age. The aim of this study was to explore parents' experiences of toothbrushing with their young children and to establish barriers and facilitators to PSB at individual, interpersonal, and environmental levels according to the theoretical domains framework. Qualitative semistructured interviews guided by the framework were conducted with 27 parents of young children (<7 y) in 2 deprived areas of the United Kingdom. Framework analysis was used. Parents were not aware of national guidance concerning their active involvement in toothbrushing; however, they did have detailed knowledge of toothbrushing practices for children, and their intentions were to brush their children's teeth themselves twice every day as part of a family routine. Nonetheless, parents' difficulties experienced in managing their children's challenging behavior and the environmental context of their stressful lives meant that many parents adopted a role of simply reminding their children to brush or watching them brush. As such, the main barriers to PSB among parents living in deprived areas were skills in managing their children's behavior and environmental influences on family life. The results of our study have clear implications for the development of appropriate interventions to address the modifiable barriers to improve parental adoption of PSB. Knowledge Transfer Statement: The results of this study will be used to develop a behavior change intervention to encourage parental supervised brushing. The intervention—which is likely to be delivered through health practitioners rather than dental teams—will be developed to reduce dental caries among young children and will require evaluation in terms of its clinical and cost effectiveness.
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