Come together

It is vital that primary care practitioners are encouraged to work in partnership with academics to develop the innovative treatments of the future

31 March, 2015 / indepth
Jeremy Bagg, Mark Hector, Jan Clarkson, Linda Young

Jeremy Bagg stresses the importance of partnerships between primary and secondary care professionals

The majority of new dental graduates ultimately develop their careers in primary care practice. According to the 2012 Annual Report of Scotland’s Chief Dental Officer1, on 31 March 2012 there were 3,115 GDPs, both independent and salaried, contracted to provide NHS dental services in Scotland within the NHS general dental services framework. These primary care practitioners delivered over four million courses of treatment during 2011/12, representing by far the greatest proportion of dental care in the country. However, a commonly held perception is that oral health research, from which emerges the novel treatment concepts and procedures of the future, is the exclusive domain of academics in dental schools. This is a troubling and unhelpful divide on many levels:

The evidence base for much of our practice in clinical dentistry is woefully inadequate – the Oral Health Cochrane Collaboration2 makes this very clear.
Dental practitioners have extensive experience of clinical and health-care delivery challenges, which is of great value in generating ideas for hypothesis-driven research.
Clinical trials undertaken with secondary care patients may be of limited relevance and applicability to treatments required and performed in primary care dentistry.
Many patients attending for primary care dental treatment have fantastic general health and can be a source of normal, healthy control cohorts of individuals in a wide range of areas of biomedical research.
Oral health research implies far more than simply consideration of the mouth, as our understanding of the interactions between oral and systemic disease continue to develop.

The view of the authors, which is shared by many dental academics, is that partnership working between primary and secondary care is essential if we are to make significant progress in establishing a more robust evidence base for oral health care in this country.

Opportunities already exist in Scotland through the Scottish Dental Practice Based Research Network (SDPBRN)3 and UK-wide support is provided through the Oral & Dental Specialty Group of the UK Clinical Research Collaboration4.

A commonly held perception is that oral health research ... is the exclusive domain of academics

Jeremy Bagg, University of Glasgow dental school

More recently, there have been further exciting developments in Scotland which could help to support further strengthening of the primary/secondary care interface in oral health care research.

The feature in this issue on the new Clinical Research Facility at Glasgow Dental School is part of an ongoing expansion of dental research, which is to be supported by a full-time Research Dental Nurse and half-time Research Dental Hygienist/Therapist, funded in the first instance for two years. Just as there is a need for primary and secondary care providers to collaborate in research delivery, the dental schools have recognised that they also are stronger when working closely together in subject areas where there are complementary strengths. Dundee Dental School will also receive funding for a Research Dental Nurse and Research Dental Hygienist/Therapist under the same package from NHS R&D.

These collaborative arrangements are managed through the Scottish Oral Health Research Collaboration5, which is supported by a full-time Research Administrator.

So what progress has already been made at the primary/secondary care oral health research interface and why should Scottish dental practitioners be interested, even excited, by these developments?

Well, a significant number are already off the blocks. Throughout Scotland primary care dentists are currently participating in a range of practice-based research studies that will provide much-needed evidence to support dentists in their day-to-day clinical decision making. These include a suite of randomised controlled trials that are funded by the National Institute for Health Research, Health Technology Assessment (HTA) Programme6. These trials are gathering evidence to help dentists decide the most clinically effective recall interval for their patients (the INTERVAL7 trial), how often patients should be provided a scale and polish (the IQuaD8 trial) and the most clinically effective method for the management of dental caries in children’s deciduous teeth (the FiCTION9 trial).

More than 100 primary care dentists in Scotland are taking part in at least one of these three trials. Support for dentists is provided by the trials’ research teams in the University of Dundee and this includes training and support in recruiting patients, arranging trial appointments, delivering the trial interventions and managing any paperwork. Dentists also receive financial recompense through the payment of NHS R&D support costs.

In another national project, (the HOPSCOTCH10 study), managed through the Scottish Oral Health Research Collaboration, the feasibility of undertaking an epidemiological study, within dental practice settings, of the prevalence, incidence, and determinants of oral Human Papillomavirus infection is being examined.

Participating dentists have found research to be less onerous and their patients to be more interested in taking part than they had anticipated:

“So far I have found being involved in the research very interesting and not too onerous time-wise. We’ve been able to incorporate the research with very little interference to our normal day-to-day patient treatments.”

“In the beginning, I felt a bit nervous but once I’d done it a couple of times, I got into a pattern and my confidence grew.”

“Our IQuaD recruitment went really well – our patients were an awful lot more enthusiastic about signing up for the whole process than I feared they might be.”

A recent development to support dentists’ participation in research is the inclusion of practice-based research in the new arrangements for clinical audit11.

Recognising the contribution of research participation to improving the quality of care delivered to patients, dentists taking part in many types of practice-based research studies will now be eligible to claim up to five research audit hours in any three-year audit cycle12.

The first study to be awarded research audit hours is already under way. Dentists in 100 practices across Scotland have been invited to help develop and pilot a safety climate measure for use in primary care dental practice.

Without the participation of dentists in this research it would not be possible to provide a relevant and effective resource to support dentists to improve safety in their practices for patients and dental teams.

Dentists participating in this research can claim three hours of audit credit, and in the first four weeks of the study more than 80 dentists have agreed to take part.

Rapid Evaluation Practitioners

One way dentists can find out more about opportunities for participation in practice-based research is to become a SDPBRN Rapid Evaluation Practitioner (REP). REPs are dentists who have an interest in, or want to be involved in, research and who have indicated a willingness to participate in approximately four projects a year. SDPBRN is committed to providing REPs with a range of feasible research projects to help improve the evidence base for primary care dental teams and bridge the gap that exists between research and practice.

Projects include some on a smaller scale, such as telephone interviews to help inform the development and implementation of SDCEP guidance, and larger projects that may attract financial recompense such as piloting processes for collecting epidemiological oral health data in general dental practice.

In addition to the suite of HTA trials described above, recent projects where REPs have participated include piloting of the national antibiotic audit and the dental safety climate measure, informing the scope of the proposed SDCEP guidance for the dental management of patients taking anticoagulant and antiplatelet drugs and helping to explore the economic impact of role substitution among general dental practices. REPs also have the opportunity to attend SDPBRN’s postgraduate research training events. Dentists wishing to become REPs or who wish to find out more about the REP initiative can do so by completing the REP enrolment form that is available at www.sdpbrn.org.uk or by emailing sdpbrn@nes.scot.nhs.uk.

In summary, we recognise that research into improving the quality of care in dentistry will only be really effective if innovations can be shown to work in the primary care setting.

Encouraging dental professionals in the primary care sector to engage with the research groups is critical if we are to enhance the scope and quality of the research questions, demonstrate that ideas can work in practice and ultimately improve the care provided for patients.

As we have said above, this approach is already well under way, but we are calling on your assistance to help make it even more effective.

About the authors

Prof Jeremy Bagg, Head of University of Glasgow Dental School
Prof Mark Hector, Head of University of Dundee Dental School
Prof Jan Clarkson, Co-Director Dental Health Services Research Unit; Director, Effective Dental Practice Programme, University of Dundee Dental School
Linda Young, Research Manager, Scottish Dental Practice Based Research Network, NHS Education for Scotland.