Scottish Dental Clinical Effectiveness Programme Research Articles

Sustainable oral healthcare: what is it and how do we achieve it?

In recent years, there has been an increase in interest in what environmental sustainability means for healthcare, including oral health and dentistry. To help facilitate discussions among key stakeholders in this area, the Scottish Dental Clinical Effectiveness Programme held a workshop in November 2022. The purpose of this workshop was to explore current thinking on the subject of sustainability as it relates to oral health and to help stakeholders identify how to engage with the sustainability agenda. This paper presents an overview of the presentations and discussions from the workshop and highlights potential avenues for future work and collaboration.

A retrospective study to identify the compliance with SDCEP guidelines of exodontia patients taking oral anticoagulant and antiplatelet medication

AbstractIntroductionExodontia treatment plans for oral anticoagulant and antiplatelet patients should consider Scottish Dental Clinical Effectiveness Programme (SDCEP) management guidelines. No previous literature has identified SDCEP guidelines compliance. The aim of this study was to determine how Oral Surgery staff manage exodontia patients who take antithrombotic medication, and the extent to which management principles consider SDCEP guidelines.Materials and MethodsAll clinical records were retrospectively analysed to identify patients who matched our criteria and had an exodontia procedure undertaken at Birmingham Dental Hospital over a 3‐month period.ResultsInitial records (n = 2961) of exodontia patients identified that 7.8% (n = 231) of patients were taking oral antithrombotic medication; 163 patients on Antiplatelet medication, 42 on Novel Oral Anticoagulants (NOAC) and 24 on Warfarin. No Antiplatelet or Warfarin patient had their medication regime interrupted. All Warfarin patients had their INR performed and recorded within 72 h of the procedure. A notable difference was found between managing high and low‐risk bleeding procedures for NOAC patients, although this was not statistically significant. Local intra‐operative haemostatic measures applied were significantly different between each of the drug groups (p < 0.001). No local haemostatic measures were recorded in 45% of Antiplatelet patients, compared to 4.8% of NOAC and 12.5% of Warfarin cases. Self‐referrals are presented more commonly on a Thursday or Friday (p = 0.037).ConclusionsEach treatment plan should be considered on an individual basis, combining clinician expertise and clinical guidelines to optimise patient care. Areas of poor compliance were identified with further research being required to comprehend how compliance with the literature alters post‐operative haemostatic complications.

The practices and beliefs of dental professionals regarding the management of patients taking anticoagulant and antiplatelet drugs

AimThis study aimed to inform the implementation of the updated Scottish Dental Clinical Effectiveness Programme (SDCEP) guidance, ‘Management of Dental Patients taking Anticoagulant or Antiplatelet Drugs’, and to determine training needs by investigating dental professionals’ current practice and beliefs regarding management of patients taking these medications.MethodsDental professionals were recruited via the NHS Education for Scotland Portal. The online questionnaire collected demographic information, data on current practice and information about beliefs regarding behaviours related to the management of patients on anticoagulant or antiplatelet medication. Quantitative data were analysed using SPSS and subjected to frequency calculations, t-tests, one-way ANOVA and linear regression. Qualitative data were collected via free text boxes and analysed using thematic analysis.ResultsOne hundred and fifty-seven participants responded to the questionnaire. The majority of respondents stated they were aware of the guidance and always based their practice on it. The majority of respondents always assessed the patient’s individual bleeding risk prior to dental procedures. Most respondents felt that they did not know how to appropriately manage patients taking low doses of low molecular weight heparins (LMWH), and only 38% of respondents always followed SDCEP guidance about direct oral anticoagulants (DOAC) medication and procedures with a low associated risk of bleeding.DiscussionThis study demonstrates a need for further educational support surrounding LMWHs and management of patients on DOAC medication. Time and remuneration represent barriers to guidance implementation in primary care.ConclusionThere is good awareness and adherence to the guidance in primary care settings, however training needs were identified to support implementation.

Fallow Time and Managing Aerosol Generation in Dental Clinics–Current Evidence and Financial Investment Implications

Recently, the Scottish Dental Clinical Effectiveness Programme (SDCEP) was tasked to perform a rapid review on the guidelines related to factors mitigating the effect of aerosol generation during dental procedures and reduction in fallow-time. Review1, reflecting the tireless work by the SDCEP review board can be truly considered as a report that the profession has been looking for. The SDCEP’s review comes at a time when the science has not been comprehensive and doesn’t outline how to best ensure public and staff safety in the dental clinic.2 He hopes that the government policy and any new instructions will now reflect the recommendations made in this review.Considering the issues of continued frustration of the dental profession, towards the end of June, the Office of the Chief Dental Officers (CDOs) in the UK tasked the SDCEP to get to grips with the matter. It is worth-noting that SDECP3 has been held in high regard for its outstanding work on antimicrobial resistance, antibiotic prophylaxis, dental amalgam, and periodontal care, and has been praised by all the CDOs in the UK four countries including England, Scotland, Wales, and Northern Ireland. In response, the SDCEP immediately convened a multidisciplinary working group to identify and appraise all the available evidence concerning the generation and mitigation of aerosol dentistry and the associated risk of COVID-19 transmission. The aim was to reach a number of agreed position statements informing policy and clinical guidance.The review members’ dedication, commitment, and clinical and academic expertise have been hugely impressive.2 All worked for almost three months and there were; remarkable academics, virologists, physicists, public health officials, and other wet-fingered dentists. The process required hours of virtual meetings piled on top of intensive review work. To complete the review, everyone almost felt like being a student again waking up to spend hours on physics of relevance to aerosol and epidemiology of airborne viral diseases.

Dental education at Dundee Dental Hospital and School - a notable past and inspiring future.

Dundee Dental Hospital and School has been present on Park Place, Dundee for over 100 years. During this time, it has been at the forefront of dental care and education, first as part of the University of St Andrews and subsequently the University of Dundee. This innovation continues with novel undergraduate curricula for dental and dental therapy students, providing early clinical experience and integrating clinical teaching with the appropriate sciences. We also offer several taught postgraduate programmes, popular particularly with international students. Dundee was at the forefront of the response to the COVID-19 pandemic, with the Scottish Dental Clinical Effectiveness Programme leading the world on guidance for safe clinical practice. Innovative solutions for the ongoing delivery of teaching and assessment also were developed. Research underpins teaching and the delivery of dental care and Dundee has an international reputation for its research portfolio. All of the above can only be achieved by close working relationships between the University and NHS, which will be strengthened further by the creation of the Dundee Dental Research Hospital and School. Our international reputation will continue to attract students and staff from across the world.

Managing direct oral anticoagulants in accordance with the Scottish Dental Clinical Effectiveness Programme guidance for patients undergoing dentoalveolar surgery

Introduction The Scottish Dental Clinical Effectiveness Programme (SDCEP) guidance on the management of dental patients taking anticoagulant or antiplatelet drugs provides recommendations on the management of patients taking direct oral anticoagulants (DOACs). This guidance was developed by a multidisciplinary Guidance Development Group, based on available resources at the time of publication. We aim to describe our experience of managing a cohort of adult patients prescribed DOACs, undergoing dentoalveolar procedures in accordance with the SDCEP guidance, between April 2017 and March 2020.Methods As part of our routine practice, patients received a telephone consultation one week following treatment, to assess any post-operative bleeding. Review of the clinical notes was used to assess clinician adherence to the guidance recommendations.Results In total, 98 patients underwent 119 dentoalveolar procedures. Persistent bleeding followed 17 (14.3%) procedures, of which 11 (9.2%) procedures required specific intervention. Absolute compliance with the recommendations was 43.7%, supporting the recommendation for audit and staff education.Discussion A diagnosis of heart failure and advanced age were identified as contributory factors to post-operative bleeding.Conclusions The SDCEP guidance is safe to follow, with no patients experiencing major haemorrhage. Consulting a medical specialist for patients with heart failure of likely significance, based on the medical or drug history, in addition to those who report an advanced heart failure diagnosis and the frail/older person, could reduce the incidence of post-operative bleeding.

Dental sedation—Airing a concept

AbstractAimTo establish current practices and experiences of dental practitioners, who are carrying out procedures under sedation in primary care, relating to assessment and management of the airway. We also review current recommendations and consider a need for further clinical guidance to standardise practice.MaterialsThe survey was created using Survey Monkey and distributed through social media channels such as WhatsApp, Facebook and via emailing a local sedation group.MethodsA service evaluation was carried out in the form of an online survey. This was distributed via social media and by emailing previous and current attendees of Dental Sedation Courses. This link remained active for 3 months with a minimum target of 50 completed responses. During this period, a total of 64 responses were received.Results51 of 64 respondents stated they complete airway assessments, of which, less than half used a pro‐forma for this purpose. Within this cohort, 21.9% of respondents acknowledged a compromised airway incident requiring initial management, with the most favoured adjunct/manoeuvre being a head tilt chin lift of the patient.ConclusionAs sedation operators, dentists carry the responsibility for the provision of dental treatment alongside the management of the airway. Conscious intravenous sedation is usually carried out using midazolam, a short acting and amnesic benzodiazepine. Whilst this is widely used, risks such as respiratory depression or loss of the airway remain. To prevent this, it is vital for an airway assessment to be carried out pre‐operatively as echoed by the Intercollegiate Advisory Committee for Sedation in Dentistry (IACSD) and Scottish Dental Clinical Effectiveness Programme (SDCEP). This article highlights the need for guidance to support general dental practitioners in the pre‐operative assessment of airways to further streamline and improve patient care.

A qualitative analysis of dental professionals\u2019 beliefs and concerns about providing aerosol generating procedures early in the COVID-19 pandemic

IntroductionIn response to the COVID-19 pandemic, the Scottish Dental Clinical Effectiveness Programme (SDCEP) initiated a rapid review of the evidence related to the generation and mitigation of aerosols in dental practice. To support this review, a survey was distributed to better understand the provision of aerosol generating procedures (AGPs) in dentistry.MethodsAn online questionnaire was distributed to dental professionals asking about their current practice and beliefs about AGPs. Data were analysed using qualitative content analysis.ResultsAnalysis revealed confusion and uncertainty regarding mitigation of AGPs. There was also frustration and scepticism over the risk of SARS-COV-2 transmission within dental settings, the evidence underpinning the restrictions and the leadership and guidance being provided, as well as concern over financial implications and patient and staff safety.DiscussionThe frustration and concerns expressed by respondents mirrored findings from other recent studies and suggest there is a need for reflection within the profession so that lessons can be learned to better support staff and patients.ConclusionUnderstanding the profession’s views about AGP provision contributed to the SDCEP rapid review and provides insights to help inform policymakers and leaders in anticipation not only of future pandemics but in considering the success of any large scale and/or rapid organisational change.

Perceptions of general dental practitioners in Northern Ireland on the clinical management of patients taking direct oral anticoagulants

##Statement of the problem Despite guidance advocating the management of patients taking direct oral anticoagulants (DOACs) in primary dental care settings, evidence from clinical audit in Northern Ireland suggested that a high proportion of patients were being referred to secondary and tertiary care settings for dental procedures with a bleeding risk. ##Purpose of the study The aim of this study was to evaluate the perceptions of general dental practitioners (GDPs) working in the health service in Northern Ireland on the clinical management of patients taking DOACs in primary dental care. ##Materials and methods: A questionnaire was distributed to the 1,167 registered GDPs in Northern Ireland, assessing perceptions of the clinical management of DOAC patients in primary dental care. The data obtained was analysed using SPSS statistical software. Qualitative data underwent thematic analysis. ##Results A total of 344 questionnaires were analysed. Some 83% (285) of responding GDPs were aware of the Scottish Dental Clinical Effectiveness Programme (SDCEP) guidance. Some 98% (337) believed that patients taking DOAC medication could potentially be managed in primary care but that additional training was required. Some 80% (275) of GDPs had referred patients to secondary care. Procedures presenting a low risk of postoperative bleeding complications accounted for 12% (41) of referrals. ##Conclusions A lack of GDP confidence and experience in the management of DOAC patients are motivating factors in referral to secondary care settings for treatment. Some 12% of the referrals analysed were potentially inappropriate, given the low risk of associated postoperative bleeding complications. Additional training and support for GDPs, as well as enhanced awareness of the SDCEP guidance, is essential.

Prescribing antibiotics in an urgent dental care service during the COVID-19 pandemic

Introduction There was a notable increase in dental antibiotic prescribing during the first wave of the COVID-19 pandemic. During this time, the dental and maxillofacial department at East Surrey Hospital opened an urgent dental care service to adapt to demands placed on community services. There were also growing concerns around antimicrobial resistance, initiating an investigation of the use of antibiotics, which continues to be a vital public health issue. The aim of this audit was to assess the compliance of antibiotic prescribing with Scottish Dental Clinical Effectiveness Programme guidance as well as evaluating the adequacy of record keeping. Methods AData were collected retrospectively from all patients triaged by the East Surrey Hospital urgent dental care service between 8 April and 24 July 2020. The Faculty of General Dental Practice (UK) antibiotic prescribing audit tool was modified and used for data collection and analysis. Results A total of 335 patients were triaged while East Surrey Hospital operated the urgent dental care. During this period, 38 patients were prescribed antibiotics (which was a 17% decrease compared with the same time period during 2019). Twenty-seven of these patients had prescription records that were clearly legible and so were included in our audit. There was 74% compliance with the gold standard in appropriate antibiotic prescribing. Conclusions The majority of the antibiotic prescriptions authorised by East Surrey Hospital were deemed compliant with national guidance. It is reasonable to consider interventions for greater compliance with the gold standard in order to maintain high quality care for patients. Appropriate use of antibiotics is mandatory to prevent future antibiotic resistance.

A Review of Guidelines for Antibiotic Prophylaxis before Invasive Dental Treatments

Bacteraemia associated with invasive dental treatments can propagate infective endocarditis in high-risk cardiac patients. Over the past decade, antibiotic prophylaxis before dental treatment has been questioned. This review aims to compare the variations between the UK, European and American antibiotic prophylaxis guidelines before dental treatments. Antibiotic prophylaxis guidelines by the National Institute for Health and Care Excellence (NICE)—Clinical Guideline 64, Scottish Dental Clinical Effectiveness Programme (SDCEP), American Heart Association (AHA), European Society of Cardiology (ESC), European Society of Endodontology (ESE) and Belgian Health Care Knowledge Centre (KCE) position statements were compared regarding the indications, high-risk patients and prophylaxis regimens before dental treatments. In the United Kingdom, the NICE—Clinical Guideline 64 and SDCEP—Implementation Advice do not advise the prescription of prophylactic antibiotics for the majority of high-risk cardiac patients undergoing routine dental treatments. On the contrary, the AHA, ESC and KEC recommend the prescription of antibiotics prior to invasive dental procedures in high-risk cardiac individuals. The ESE also indicates prophylaxis before endodontic procedures for patients with other conditions, including impaired immunologic function, prosthetic joint replacement, high-dose jaw irradiation and intravenous bisphosphonates. Among these guidelines, there are variations in antibiotic prophylaxis regimens. There are variations regarding the indications and antibiotic prophylaxis regimens before invasive dental treatments among these available guidelines.

Managing Patients at Risk of Medication Related Complications Requiring Dental Extractions in Primary Care.

When undertaking dental extractions in modern dental practice, two of the complications that have the potential to cause most apprehension for clinicians are the risks of osteonecrosis of the jaws and uncontrollable haemorrhage. This is especially the case when treating older patients because of the increased likelihood of co-morbidities and accompanying polypharmacy which can predispose patients to these problems. Specific medications of concern to practitioners in relation to osteonecrosis risk are antiangiogenic and antiresorptive drugs. Patients taking dual antiplatelet therapy and direct oral anticoagulants require consideration in relation to bleeding risk. With these medications coming increasingly to the forefront over recent years, guidance has been developed by organisations such as the Scottish Dental Clinical Effectiveness Programme (SDCEP). Appropriate use of these guideline should ensure that patients felt to be at particular risk of these complications can frequently be safely managed in primary care. This article aims to provide advice on recognising patients at risk, and to discuss how to utilise key messages within published guidelines when making treatment decisions. The overall intent is to help primary care clinicians who are likely to encounter these patients more and more.

Novel oral anticoagulants and exodontia: the evidence.

Background Haemostasis is crucial for the success of oral surgical treatment as bleeding problems can cause complications both pre- and post-operatively. Patients on anticoagulant drugs present a challenge due to their increased risk of bleeding.Aims To review the evidence for the management of oral surgery patients on novel oral anticoagulant therapy.Methods A literature review was conducted in May 2016 of free-text and MESH searches (keywords: apixaban, dabigatran, rivaroxaban and dental extractions) in the Cochrane Library, PubMed and CINAHL. Trial registers, professional bodies for guidelines and OpenGrey for unpublished literature were also searched. Studies were selected for appraisal after limits were applied (adult, human and English only studies) and inclusion/exclusion criteria imposed.Results Five studies were identified for critical appraisal using the CASP tools. These were a combination of systematic reviews and case series. Two case series were excluded due to low quality evidence. Curtin et al., Davis et al. and Constantinides et al. together with guidelines from the Scottish Dental Clinical Effectiveness Programme, have highlighted a protocol in managing these patients in a dental surgical setting.Conclusion Patients on novel anticoagulant therapy requiring dental surgery can be managed appropriately either without discontinuation of therapy or a delay in dose. For those patients at higher risks of postoperative bleeding complications, it is advised to liaise with the specialist physician.

Antimicrobial prescribing by dentists in Wales, UK: findings of the first cycle of a clinical audit

Objective To describe the findings of the first cycle of a clinical audit of antimicrobial use by general dental practitioners (GDPs).Setting General dental practices in Wales, UK.Subjects and methods Between April 2012 and March 2015, 279 GDPs completed the audit. Anonymous information about patients prescribed antimicrobials was recorded. Clinical information about the presentation and management of patients was compared to clinical guidelines published by the Scottish Dental Clinical Effectiveness Programme (SDCEP).Results During the data collection period, 5,782 antimicrobials were prescribed in clinical encounters with 5,460 patients. Of these 95.3% were antibiotic preparations, 2.7% were antifungal agents, and 0.6% were antivirals. Of all patients prescribed antibiotics, only 37.2% had signs of spreading infection or systemic involvement recorded, and 31.2% received no dental treatment. In total, 79.2% of antibiotic, 69.4% of antifungal, and 57.6% of antiviral preparations met audit standards for dose, frequency, and duration. GDPs identified that failure of previous local measures, patient unwillingness or inability to receive treatment, patient demand, time pressures, and patients' medical history may influence their prescribing behaviours.Conclusions The findings of the audit indicate a need for interventions to support GDPs so that they may make sustainable improvements to their antimicrobial prescribing practices.

Scottish Dental Clinical Effectiveness Programme (SDCEP) achieves NICE accreditation.

Scottish Dental Clinical Effectiveness Programme (SDCEP) achieves NICE accreditation.

Antibiotic prescribing in UK general dental practice: a cross-sectional study.

To assess the extent to which antibiotic prescribing in general dental practice conforms to clinical guidelines and to describe factors associated with antibiotic prescription in the absence of spreading infection or systemic involvement. A cross-sectional study of the management of adult patients with acute dental conditions by General Dental Practitioners (GDPs) in Wales, UK. Clinical information on the management of patients was compared to clinical and prescribing guidelines published by the Scottish Dental Clinical Effectiveness Programme and the Faculty of General Dental Practice (UK). Multilevel logistic regression was used to identify patient, practitioner and consultation characteristics predictive of antibiotic prescribing in the absence of infection. Antibiotics were prescribed to 57.4% of 568 patients. Over half of antibiotics (65.6%) were prescribed in situations where there was no evidence of spreading infection, and 70.6% were used without the provision of an operative intervention. Only 19.0% of antibiotics were prescribed in situations where their use was indicated by clinical guidelines. Factors associated (P < 0.05) with antibiotic prescription in the absence of infection were failure of previous operative treatment (Odds Ratio (OR) 13.57), shortage of clinical time to undertake treatment (OR 10.21), patients who were unable or unwilling to accept operative treatment (OR 4.89), patient requests for antibiotics (OR 3.69) and acute periodontal conditions (OR 3.37). A high level of inappropriate antibiotic prescribing was observed amongst the GDPs studied. Features of the healthcare environment, such as clinical time pressures, and patient-related characteristics, such as expectations for antibiotics and refusal of operative treatment, are associated with antibiotic prescribing in the absence of infection. Individuals responsible for the commissioning and delivery of dental services should seek to develop targeted interventions addressing these issues in order to ensure optimal antimicrobial stewardship within dentistry.

Outcome measures in Cochrane reviews and protocols for the prevention and treatment of periodontal disease

Background Periodontal disease (gum disease) is the most common oral disease to affect adults. The importance of core outcome sets for effectiveness trials is well established. However, despite the significant health and economic burden there is still great debate in the field as to the most appropriate clinical outcomes to measure when investigating the effectiveness & cost effectiveness of interventions. The recently published Scottish Dental Clinical Effectiveness Programme Guidelines “Prevention and Treatment of Periodontal Diseases in Primary Care” [1], highlighted the need for a set of core outcome measures for periodontal outcomes. This study was conducted to assess the variability of outcome measures reported in periodontal Cochrane reviews and protocols prior to the development of a set of core outcomes involving patients and key stakeholders.

Is further intervention required to translate caries prevention and management recommendations into practice?

In April 2010, the Scottish Dental Clinical Effectiveness Programme (SDCEP) published guidance on the Prevention and management of dental caries in children. The aims of this study were to determine if further intervention is required to translate the SDCEP guidance recommendations into practice and to identify salient beliefs associated with recommended practice. Two postal surveys circulated to two independent random samples of dentists working in general dental practices in Scotland, before and after the publication of the guidance. The questionnaire items assessed current practice and beliefs relating to the prevention and management of dental caries in children. Response rates of 40% (n = 87) and 45% (n = 131) were achieved. The results highlight a gap between current practice and recommended practice. The majority of dentists do not 'always' perform recommended behaviours and many are following treatment strategies specifically not recommended in the guidance. More positive attitude, greater capability and motivation were significantly associated with performing more guidance recommended risk assessment and prevention behaviours. These findings highlight the need for further intervention to translate the SDCEP guidance recommendations into practice and give initial insight into the salient beliefs that may serve as targets for future interventions.

Summary of: is further intervention required to translate caries prevention and management recommendations into practice?

In April 2010, the Scottish Dental Clinical Effectiveness Programme (SDCEP) published guidance on the Prevention and Management of Dental Caries in Children. The aims of this study were to determine if further intervention is required to translate the SDCEP guidance recommendations into practice and to identify salient beliefs associated with recommended practice. Two postal surveys circulated to two independent random samples of dentists working in general dental practices in Scotland, before and after the publication of the guidance. The questionnaire items assessed current practice and beliefs relating to the prevention and management of dental caries in children. Response rates of 40% (n = 87) and 45% (n = 131) were achieved. The results highlight a gap between current practice and recommended practice. The majority of dentists do not 'always' perform recommended behaviours and many are following treatment strategies specifically not recommended in the guidance. More positive attitude, greater capability and motivation were significantly associated with performing more guidance recommended risk assessment and prevention behaviours. These findings highlight the need for further intervention to translate the SDCEP guidance recommendations into practice and give initial insight into the salient beliefs that may serve as targets for future interventions.

Managing patients on bisphosphonates: the practice of primary care dentists before and after the publication of national guidance.

In April 2011 the Scottish Dental Clinical Effectiveness Programme published the Oral health management of patients prescribed bisphosphonates guidance document. The aims of this study were to examine whether dentists' practice and beliefs changed after guidance publication to determine whether a knowledge translation intervention was required, and to inform its development. Three postal surveys sent to three independent, random samples of dentists throughout Scotland pre- and post-guidance publication. The questionnaire, framed using the theoretical domains framework (TDF), assessed current practice and beliefs relating to recommended management of patients on bisphosphonates. The results (N = 420) suggest that any significant impact the guidance may have had on the recommended management of patients on bisphosphonates by primary care dentists, had reached its peak ten months post publication. A more positive attitude, greater perceived ability, and greater motivation were all associated with significantly more performing of all recommended behaviours at every time point. Prior to this study, there was little available information about how patients on bisphosphonates were being managed in primary dental care, or what beliefs may be influencing management decisions. This study was able to identify levels of compliance pre- and post-guidance publication and determine that further intervention was necessary to enable sustained uptake of recommendations. Using the TDF to identify beliefs associated with best practice made it possible to suggest theoretically informed strategies for service improvement. The next step is to test the intervention(s) in a randomised controlled trial.