Building foundations for oral and dental research

Delivering research in community dental practices has presented a number of unique challenges in the past. Insight magazine learns how the Network’s Oral and Dental Specialty has been paving the way for future research in this area.

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Oral and dental research has historically taken place in dental schools (secondary care) yet 95 per cent of patients experiencing oral and dental conditions are treated in a primary care setting by dentists, dental hygienists and other oral health practitioners. It makes sense then that research addressing oral and dental health questions should seek to recruit patients in community dental practices. But this isn’t quite as straightforward as it might seem. Jimmy Steele, the Network’s Oral and dental Specialty National Lead, explains:

“The business model in dentistry is different from other aspects of healthcare. Dental practices operate as small businesses that own the estate in which they work and have traditionally been paid on the basis of procedures performed. The payment of the money goes through different routes too, resulting in those responsible for commissioning dentistry having no mechanism for covering research costs. NHS dentistry also carries a patient charge in many cases, unlike almost all of the rest of the NHS, so deciding how that should be covered was another complication. We have had to find new ways of addressing the funding issues and remunerating dental practitioners.

“Another major problem was that each study was slightly different and raised new challenges. Variations between health systems in devolved nations also caused additional headaches. We began by sharing intelligence and setting out some principles and using them to underpin all of the business arrangements. And now, by using accumulated experience and shared templates for costing research support costs, we have a foundation to work on.

“A further challenge was a lack of links between primary and secondary care practices. For the last decade or more there have been many efforts to engage dental practices in research. For small practices, finding time to deliver the research is a real challenge. A number of academic centres have started to make inroads with schemes to train primary care dentists in research. But it was the arrival of the Clinical Research Network that has made the biggest difference. By supporting some high quality studies it has enabled the transformation of embryonic groups of research-interested dentists into established networks of research professionals delivering properly funded and reimbursed research trials.”

This work is beginning to bear fruit. Clinical Research Network figures show a steady increase in the number of oral and dental studies over the last five years. In 2010/11 just 12 studies were recruiting compared to almost three times that amount (35) last year. This is great news for the oral dental community, many of whom are keen to get involved in research that can provide evidence-based answers to questions about their everyday practice.

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Professor Janet Clarkson is Co-Chief Investigator of three Network supported-studies: FiCTIoN, Interval and IQUAD – all recruiting in dental practices across the UK. Janet has first-hand experience of working with Network staff to overcome some of the challenges described by Professor Steele:

“These studies were conceived and planned in Scotland where the rules around service support costs and remuneration in dentistry are different… there was huge support from the Network to implement changes for the studies to go ahead in England. Then, promotion of the studies included information events and evenings. Network staff in Scotland and England provided extra support and literature to dental practice staff… that generous offer of practical, hands-on Network-support was always there.”

The FiCTIoN study compares three commonly used approaches to managing decay in baby teeth. Over 1100 patients have been recruited across 66 practices in Scotland, Newcastle, Leeds, Manchester, Sheffield, London and Cardiff. Kathryn Houlding, dentist and owner of The Devonshire Quarter Dental Practice in Sheffield, sees over 120 patients per week. Her dedication combined with support from the study team and the Network resulted in recruiting the first patient in Yorkshire. Kathryn is an advocate for research and shares her views on bringing this kind of research into the comunity:

“It’s important that you do research in places where there is real everyday work – it’s important that you see what happens. The majority of patients access surgeries not hospitals. It’s not [easy] for a small surgery, but we are proof it’s not impossible. I think research is very positive and I will always be interested in helping – it’s for the greater good.”

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Seven year old Amy took part in FiCTIoN at Kathryn’s practice. She has been nervous about going to the dentist since she was a toddler. Amy’s mum seized the opportunity of having more regular (three monthly) contact with the dentist to help Amy overcome her fears. Taking part in the study has yielded additional benefits for Amy and her mum, she says:

“…Keeping a closer eye on her [teeth] – rather than just every six months – and also being less afraid, can only be good things. I think research in dental practices is important because treatments won’t progress unless you do research – it’s an advantage and certainly has been for Amy. It will help change attitudes to children’s dental care.”

Oral and dental research is also reaching out into rural communities. Timothy Cooke is a dental practitioner in Nairn (a rural area of Scotland) and has a background in public health. He’s conducting the Interval study which is investigating the optimum intervals in between patient recall appointments. Despite having a few teething problems, Timothy is positive about the advantages of delivering dental research:
“…it benefits us when we know the answers to clinical based questions, and this type of study will help us. It’s satisfying to know the answer. Research is the only way we can find the answers and participating in research has also helped to make my patients more aware about their dental health, which is always a positive thing.”

Louise Woodman, who participated in the Interval study in Nairn, liked the fact she was helping to answer a question that could improve practice:

“They briefly explained what the study was about and I was really interested. It made sense and will make a difference. Generally research should benefit you and the wider community. If [ultimately] it frees up resources… then it’s better for everyone.”

Professor Jimmy Steele agrees and is confident that the foundations for future research are now in place:

“The NHS has the capacity to be an excellent test bed for large scale trials in primary care dentistry. Following work over the last few years, we are now in a position to use the expertise we have built to expand our portfolio of commercial and non-commercial trials.”