Dental Care Pathway Research Articles

Knowledge, Attitudes, and Practices of Dental Practitioners in Providing Care to Children in Out-of-Home Care: A Scoping Review.

A scoping review was conducted to synthesize available evidence of knowledge, attitudes, and practices of dental practitioners in providing care to children in out-of-home care (OOHC). Scientific databases and the grey literature were searched: 855 studies were screened after removing duplicates; 800 studies were excluded based on the title and/or abstract, and the full text of 55 studies was reviewed, with 7 included in the analysis. These included three peer-reviewed articles regarding the knowledge, attitudes, and practices of dental practitioners in providing care to children in OOHC, as well as four guidelines. Dental practitioners had some knowledge of the high health care needs of OOHC children, but knowledge regarding when children entering care received dental assessment and about OOHC dental care pathways was low. Practices of dental practitioners were varied, most gave oral hygiene instructions, but there was inconsistency in practices regarding continuity of care following placement changes and failure to attend policies. There was more consensus with dental practitioner attitudes, with practitioners in private settings seeming to prefer not to treat children in OOHC. Three of the identified guidelines provided logistical information about OOHC and consent. The final guideline gave practical information on treating children with a background of adverse childhood events (ACEs), including children in OOHC. Further research and education is warranted to aid dental practitioners in providing care to children in OOHC.

Access to dental care is still complex in 2022 for patients living with HIV despite the need for careful monitoring of pathologies of the oral mucosa. Results of a monocentric cross-sectional study in the Infectious Diseases Department of Clermont-Ferrand University Hospital.

Describe the dental care pathway of people living with HIV (PLHIV) and their oral pathologies. A monocentric cross-sectional study involving adult PLHIVs followed (October 2021/April 2022) in our department. Socio-demographic and medical data, course of dental care, and presence of pathologies of the oral mucosa were recorded. 112 PLHIV (71% men, 54 ± 14years) were included. Of the 112, 96% had already consulted a dentist, and 78% had a referring dentist; 73% had disclosed their seropositivity; for 84%, the visit proceeded normally, 7% refused treatment; for 8%, the dentist was not comfortable, and for 4% the dentist's attitude became negative; 21% of the PLHIV had already encountered difficulties in finding a dentist including 37% because of their viral status. Among the oral pathologies listed, 23 lesions were identified: 15 (65%) were unrelated to HIV, 4 (17%) were classified stages B/C (1 Kaposi's sarcoma, 1 oral villous leukoplakia, 2 chronic candidiasis), and 4 (17%) were lesions with evolution specifically due to HIV (2 inhomogeneous leukoplakias, 1 cancer, 1 verrucous papilloma). Although 78% of the PLHIV included had a referring dentist, discrimination by dentists toward PLHIV still persists (16% of the PLHIV concerned). 27% of participants did not feel ready to disclose their infection. The resulting lack of follow-up is also a loss of opportunity because while most of the small number of oral lesions diagnosed in this population are related to age or comorbidities, some are serious and need to be identified.

The experiences of people living with environmental sensitivities concerning oral health and access to dental services

Purpose Because people living with environmental sensitivities are poorly acknowledged in our society, we still know very little about their experiences navigating in the health care system, especially with respect to dental services. Our objective, therefore, was to describe their dental care pathway and better understand their experiences accessing oral health services. Materials and methods A qualitative descriptive study was conducted in partnership with organizations supporting people with environmental sensitivities. Through a criterion sampling technique, 12 people living with environmental sensitivities in Quebec (Canada) were invited to participate in individual semi-structured interviews. These interviews lasted around 90 min and were transcribed to be thematically analysed. Results Participants faced major barriers accessing dental services and thus lived for long periods of time with unmet dental needs. Their dental care pathways were often delayed or even interrupted for several reasons. First because they were exposed to pollutants upon leaving their house, which rendered their trip to the dentist perilous. Second because dentists lacked knowledge about environmental sensitivities and seemed reluctant to accommodate them. Conclusions We invite governments, dental professionals, and researchers to develop policies and clinical approaches for improving people living with environmental sensitivities’ quality of life and access to dental services.

The Dental Health of Looked After Children in the UK and Dental Care Pathways: A Scoping Review.

There has been a 37% increase in the number of Looked After Children (LAC) in England over the past decade. Although LAC have more health and social problems than their peers, little is known about their dental needs, barriers to dental care, and pathways used to access it. This scoping review assessed the evidence on the dental health needs of LAC in the UK and their different dental care pathways. Embase, MedLine(R), Scopus, Web of Science, PubMed and CINAHL, grey literature databases and third-sector organisation websites were searched up to February 2022. Included studies were any study type involving UK resident LAC aged 0-18 with no limits placed on time in care/placement. Thematic analysis identified access barriers and dental care pathways. Twenty-eight articles were included (nine publications, 11 abstracts and 8 grey literature). Oral health surveys, population linkages studies and service evaluations described the poor oral health of LAC and their unmet needs. Barriers included the lack of dental care and irregular attendance; the lack of integrated working between health and social care teams, lack of self-care and oral health promotion, and psychological issues complicating dental treatment. Four dental care pathway models were identified: care navigation, facilitated access, nurse-led triage and referral, and signposting to local dentist with multi-agency information sharing. LAC are a vulnerable group with barriers to care suggesting the need for integrated working between health and social care teams, specialist services and an evaluation of pathways to identify best practice.

Advancing Our Understanding of Dental Care Pathways of Refugees and Asylum Seekers in Canada: A Qualitative Study

The burden of oral diseases and need for dental care are high among refugees and asylum seekers (humanitarian migrants). Canada’s Interim Federal Health Program (IFHP) provides humanitarian migrants with limited dental services; however, this program has seen several fluctuations over the past decade. An earlier study on the experiences of humanitarian migrants in Quebec, Canada, developed the dental care pathways of humanitarian migrants model, which describes the care-seeking processes that humanitarian migrants follow; further, this study documented shortfalls in IFHP coverage. The current qualitative study tests the pathway model in another Canadian province. We purposefully recruited 27 humanitarian migrants from 13 countries in four global regions, between April and December 2019, in two Ontario cities (Toronto and Ottawa). Four focus group discussions were facilitated in English, Arabic, Spanish, and Dari. Analysis revealed barriers to care similar to the Quebec study: Waiting time, financial, and language barriers. Further, participants were unsatisfied with the IFHP’s benefits package. Our data produced two new pathways for the model: transnational dental care and self-medication. In conclusion, the dental care needs of humanitarian migrants are not currently being met in Canada, forcing participants to resort to alternative pathways outside the conventional dental care system.

A scoping review on dental clinic accessibility for people using wheelchairs.

We aimed to explore the scientific literature on accessible dental clinics for wheelchair users. More specifically, we sought out literature addressing how the human environment and physical space shape the dental services of accessible dental clinics. We conducted a scoping review (May 2019) in Embase, PubMed, Web of Science, and the Avery index of architectural Periodicals (3994 articles). We followed Arksey and O'Malley's recommended procedures; after screening, we retained 17 articles. We performed a critical appraisal, followed by thematic content analyses of extracted data. The articles originated mainly from the United States and United Kingdom. Only three reported original research. We illustrated the results within a three-step dental care pathway cycle. In each step, the interaction between accessibility of the physical and human environments (ie, the layout/design of the clinic and the attitudes and skills of the dental professional, respectively) contributed to the overall accessibility. We also found that empirical evidence on clinics' accessibility was lacking: many articles resorted to broad "one size fits all" recommendations and fragmented information on accessibility. Finally, the voice of wheelchair users was missing. There are knowledge gaps in terms of dental clinics' accessibility. We thus invite researchers to conduct original studies with dental professionals, wheelchair users, and their caregivers.

Dental care pathways for adult inpatients in an acute hospital: a five-year service evaluation.

Introduction The oral health of adult inpatients has been found to deteriorate during hospital admissions, which can impact on eating and drinking, risk of hospital-acquired infections and overall recovery, thus extending the length of admission.Aim The aim of this paper was to evaluate the reasons for inpatient referrals to the dental and maxillofacial department and the treatment outcomes through analysis of referrals over a five-year period collected prospectively.Method Data were collected from inpatient referrals to the dental and maxillofacial department at East Surrey Hospital over five years from January 2014 to December 2018. Information about reason for referral and treatment outcomes was reflected on.Results In total, 851 referrals were received from hospital staff over five years. The most common reason for referral was related to acute dental pain and potential analgesic overdose (16%), followed by suspected dental abscess or facial swelling (12%) and dental assessment for cardiac inpatients (11%). The most common treatment outcomes included consultation and advice only (16%) or dental extraction (16%). A large proportion of outcomes related to management of oral pain due to dry mouth (9%), oral ulceration (6%), broken dentures (8%) or fillings (5%).Conclusion The data collected show there is a clear need and benefit for hospitals to commission dental services for inpatients.

Community Dentistry: A Service Evaluation Study for 'Looked After Children' in England and Wales.

Historically, the healthcare needs of 'Looked After Children' (LAC) within the UK have been relatively neglected and there is no universally adopted designated dental care pathway (DDCP) in place to ensure their care. This paper aims to discover the contribution of the community dental service (CDS) to the dental health of LAC throughout England and Wales. An electronic questionnaire was sent to CDS Clinical Directors in England and local health boards in Wales between November 2011 and January 2012. Ten questions were included with 5-point Likert scale responses and the option for free text comments. In Wales, 41 questionnaires were returned (35% response rate) of which 37 services provided care for LAC. In England, 67 questionnaires were returned (44% response rate), of which 59 services provided care for LAC. The study found that the majority of CDSs in the UK provide care for LAC, However, we cannot ascertain if the CDS is the most appropriate service to provide dental care for this group of patients. The use of DDCPs, non-attendance and other care policies varied markedly amongst respondents, which may suggest that provision of dental care for LAC within the CDS in England and Wales is inconsistent. The authors believe that the utilisation of an LAC-specific and universally accepted DDCP that has been developed could help to reduce these inconsistencies. Further surveys are planned in order to monitor the care of this vulnerable group of patients and assess the impact of these recommendations.

A dental care pathway for children with inherited bleeding disorders

Abstract Royal London Hospital is a major referral centre for children with inherited bleeding disorders (IBD). Dental caries and periodontal disease can be prevented, which is especially important in these children to avoid invasive treatment. For this reason a care pathway has been established, focusing on appropriate prevention advice and treatment A Paediatric Dental Specialist attends the monthly Paediatric Haematology clinics. Children are screened for untreated dental decay and preventive dental advice is given verbally along with a patient information leaflet. At the clinic, a letter is sent out to the patient’s general dental practitioner (GDP). Nonregistered patients are directed to NHS Choices website to find a local NHS GDP. Liaison of GDPs with both haematology and hospital paediatric dental services is actively encouraged to support the provision of dental care within the primary care setting, particularly routine preventive care. Depending on the severity of the bleeding diathesis and the degree of invasive dental treatment required, the GDP may undertake simple treatment or, in more complex cases, may arrange a referral to the Royal London Dental Hospital. A consultation process takes place between paediatric dentist, paediatric haematologist and specialist nurse to determine the most appropriate haematological cover for each patient. This will depend on the severity of the bleeding disorder, the complexity of dental treatment and the need for local anaesthesia. The date of the dental visits and the haemostatic cover are requested via the electronic patient record so that it is accessible to all clinicians involved in their care without the need to retrieve their paper notes. This pathway encourages active involvement of the patients’ GDP and allows the patient to be treated as safely as possible in a timely manner. The care pathway has helped to formalise dental treatment for children with IBD and to improve every health care professional’s understanding of their role in this care.

Summary of: The development of a designated dental pathway for looked after children

To explore the impact of a community-based dental care pathway on the dental care of children entering residential or foster care. The study used qualitative data collected during interviews with children who used the service, their carers and key professionals involved in the pathway, and routine quantitative data concerned with care entry and the dental service use. The dental pathway facilitated dental care access for children entering statutory care, met the dental needs of service users even when dental care provision proved challenging, and offered a consistent dental service regardless of care moves. Improved interagency integration and support was reported by key professionals as was better dissemination and documentation of dental assessments and outcomes. The dental care pathway had a beneficial impact on the dental access and experiences of children who used it, promoted better interagency working and facilitated record keeping. These findings call for extension of the service to a wider population to allow further evaluation of its impact and efficacy in different regional areas and contexts.

The development of a designated dental pathway for looked after children

To explore the impact of a community-based dental care pathway on the dental care of children entering residential or foster care. The study used qualitative data collected during interviews with children who used the service, their carers and key professionals involved in the pathway, and routine quantitative data concerned with care entry and the dental service use. The dental pathway facilitated dental care access for children entering statutory care, met the dental needs of service users even when dental care provision proved challenging, and offered a consistent dental service regardless of care moves. Improved interagency integration and support was reported by key professionals as was better dissemination and documentation of dental assessments and outcomes. The dental care pathway had a beneficial impact on the dental access and experiences of children who used it, promoted better interagency working and facilitated record keeping. These findings call for extension of the service to a wider population to allow further evaluation of its impact and efficacy in different regional areas and contexts.

Developing care pathways – lessons from the Steele Review implementation in England

This paper sets out to discuss the concept of care pathways, review their definition, features and implementation and using an example from the NHS dental system in England guide the development of an elder care pathway. Care pathways have developed from quality management approaches in industry and focus on a number of steps which are intended to lead to expected outcomes. The existing definition and descriptors of care pathways serve well, but miss the complex process underlying the development of pathways, their structure, implementation and evaluation. The literature identifies key features of clinical pathways and from the developing field of implementation science, the factors likely to support pathway implementation. Pathways must be generic enough to enable them to be applicable broadly, but specific enough for them to be locally relevant and population specific. The development of care pathways in the National Health Service (NHS) Dental Service in England is described and when compared with the implementation science literature exhibits features identified as positive factors for implementation. As a result a contribution to the pathway definition literature is offered. Learning from the literature and the practical experience described from England, the process for developing dental care pathways for dependent elders should begin with the creation of a high level pathway, which is cognisant of the clinical and implementation science evidence base.

A pilot of a school-based dental treatment programme for vulnerable children with possible dental neglect: the Back2School programme

The general dental practitioners and community dental services of Barts Health NHS Trust in City and Hackney and Tower Hamlets PCTs in East London currently provide a school-based oral health prevention programme. The programme provides dental screening for three- to six-year-olds, fluoride varnish application twice during the school year and engaging with the families to encourage dental attendance. An evaluation of the programme suggested that children with a dental treatment need, identified by the screening, were not being taken for further dental care. The aim of this 'Back2School' pilot was to evaluate the use of mobile dental units in the provision of care to this group of children. The objectives were to assess if this care was acceptable to the children and their families, to evaluate dental treatment provided, patient attendance, costs of the service and whether it would be a viable method to provide dental care. The rotation of the mobile dental unit in this pilot offered ten sessions of dental care over five days in three different locations. The locations were chosen near the five schools covered by the community dental service. A total of 63 children were seen; 33 females and 30 males, which included 7 walk-in patients. Five children had extractions and the number of fillings ranged from one to six. Of the 63 children seen only 8 (13%) had attended a dentist before, 59 (93%) of the children were rated 'high risk' for dental disease, 61 (97%) of the children received a fluoride varnish application and 95.2 UDAs were achieved. Feedback was positive overall. The use of a community-based mobile dental unit has the potential to be a cost-effective method to remove barriers to dental care access, both for the treatment of vulnerable children and as a first point of contact in the dental care pathway.

Summary of: Introducing care pathway commissioning to primary dental care: measuring performance

Care pathways have been used in a variety of ways: firstly to support quality improvement through standardising clinical processes, but also for secondary purposes, by purchasers of healthcare, to monitor activity and health outcomes and to commission services. This paper describes a secondary use of dental care pathways: to commission and monitor performance of primary dental care services. Findings of a project involving three dental practices implementing a system based on rating patients according to their risk of disease and need for care are outlined. Data from surgery-based clinical databases and interviews from commissioners and providers are reported. The use of both process and outcome key performance indicators in this context is discussed, as well as issues which arise such as attributability of outcome measures and strategic approaches to improving quality of care.

Developing the First Dental Care Pathway: The Oral Health Assessment

In this paper the authors define the concept of care pathways and explain what they are and how they have been applied in various areas of healthcare. The authors discuss the benefits of the care pathway approach and outline the first national dental NHS (clinical) care pathway and its link to National Institute for Clinical Excellence (NICE) guidance on dental recall intervals. The authors go on to explain that as a result of one of the key recommendations of Options for Change, the concept of care pathways will be extended to the primary dental services of the NHS. The first care pathway will be the Oral Health Assessment (OHA). The authors describe the development of, and rationale for, the OHA and provide details of its planned introduction. The authors conclude that the OHA should act as the initial interface between the primary care team and the dental patient. In so doing it should enable a change in the focus of care, from treatment-based to more prevention-led, personalised care appropriate to the specific needs of individual patients.

The dental care pathway of welfare recipients in Quebec

In Quebec (Canada), the utilization of dental care services varies greatly from one social class to another: whereas the well-to-do visit the dentist often for check-ups, those most in need demonstrate a “wait-and-see” attitude. The objective of our research was to describe the dental care pathway of the underprivileged when confronted with symptoms, and to understand how this pathway might be interrupted and possibly lead to tooth extractions. We arranged 16 one-on-one interviews with adult Montrealers who had experienced a dental problem during the 12 months preceding the interview. These participants, 9 women and 7 men aged between 30 and 48, lived in great poverty: all were welfare recipients, and as such, enjoyed the benefits of a government programme that entitled them to free basic dental care. During the interviews, the interviewers asked the participants to describe their latest dental problem and their subsequent behaviour. The dental care pathway of our participants was characterized by a strategy of adapting to the symptoms. This process of adapting, which can last several months, is essentially an individual process in which the individuals often resort to self-medication to soothe their pain. They decide to visit a dentist when the pain is too great and self-medication is no longer effective. Once this decision is made, their dental care pathway may nevertheless be interrupted in two ways: first, in the failure to find a dentist, and second, later, in the failure to complete treatments that are not covered by the welfare program, such as endodontic treatment. The fragmented character of these dental care pathways refers us to two features of accessibility: financial accessibility and acceptability. With regard to financial accessibility, our study shows that the public coverage intended for welfare recipients presents major gaps. As for acceptability , our participants are strongly critical of the dental profession, and develop a culture of rejection of it.