Dental therapists compared with general dental practitioners for undertaking check-ups in low-risk patients: pilot RCT with realist evaluation

Journal article


Brocklehurst, P., Hoar. Z., Woods, C., Williams, L., Brand, A., Shen, J., Breckons, M., Ashley, J., Jenkins, A., Gough, L., Preshaw, P., Burton, C., Shepherd, K. and Bhattarai, N. 2021. Dental therapists compared with general dental practitioners for undertaking check-ups in low-risk patients: pilot RCT with realist evaluation. Health Services and Delivery Research. 9 (3). https://doi.org/10.3310/hsdr09030
AuthorsBrocklehurst, P., Hoar. Z., Woods, C., Williams, L., Brand, A., Shen, J., Breckons, M., Ashley, J., Jenkins, A., Gough, L., Preshaw, P., Burton, C., Shepherd, K. and Bhattarai, N.
Abstract

Background
Many dental ‘check-ups’ in the NHS result in no further treatment. The patient is examined by a dentist and returned to the recall list for a further check-up, commonly in 6 or 12 months’ time. As the oral health of regular dental attenders continues to improve, it is likely that an increasing number of these patients will be low risk and will require only a simple check-up in the future, with no further treatment. This care could be delivered by dental therapists. In 2013, the body responsible for regulating the dental profession, the General Dental Council, ruled that dental therapists could see patients directly and undertake check-ups and routine dental treatments (e.g. fillings). Using dental therapists to undertake check-ups on low-risk patients could help free resources to meet the future challenges for NHS dentistry.

Objectives
The objectives were to determine the most appropriate design for a definitive study, the most appropriate primary outcome measure and recruitment and retention rates, and the non-inferiority margin. We also undertook a realist-informed process evaluation and rehearsed the health economic data collection tool and analysis.

Design
A pilot randomised controlled trial over a 15-month period, with a realist-informed process evaluation. In parallel, we rehearsed the health economic evaluation and explored patients’ preferences to inform a preference elicitation exercise for a definitive study.

Setting
The setting was NHS dental practices in North West England.

Participants
A total of 217 low-risk patients in eight high-street dental practices participated.

Interventions
The current practice of using dentists to provide NHS dental check-ups (treatment as usual; the control arm) was compared with using dental therapists to provide NHS dental check-ups (the intervention arm).

Main outcome measure
The main outcome measure was difference in the proportion of sites with bleeding on probing among low-risk patients. We also recorded the number of ‘cross-over’ referrals between dentists and dental therapists.

Results
No differences were found in the health status of patients over the 15 months of the pilot trial, suggesting that non-inferiority is the most appropriate design. However, bleeding on probing suffered from ‘floor effects’ among low-risk patients, and recruitment rates were moderately low (39.7%), which suggests that an experimental design might not be the most appropriate. The theory areas that emerged from the realist-informed process evaluation were contractual, regulatory, institutional logistics, patients’ experience and logistics. The economic evaluation was rehearsed and estimates of cost-effectiveness made; potential attributes and levels that can form the basis of preference elicitation work in a definitive study were determined.

Limitations
The pilot was conducted over a 15-month period only, and bleeding on probing appeared to have floor effects. The number of participating dental practices was a limitation and the recruitment rate was moderate.

Conclusions
Non-inferiority, floor effects and moderate recruitment rates suggest that a randomised controlled trial might not be the best evaluative design for a definitive study in this population. The process evaluation identified multiple barriers to the use of dental therapists in ‘high-street’ practices and added real value.

Future work
Quasi-experimental designs may offer more promise for a definitive study alongside further realist evaluation.

Trial registration
Current Controlled Trials ISRCTN70032696.

Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 3. See the NIHR Journals Library website for further project information.

KeywordsDental treatment; Dentists; Dental therapists
Year2021
JournalHealth Services and Delivery Research
Journal citation9 (3)
PublisherNational Institute for Health Research
ISSN2050-4349
2050-4357
Digital Object Identifier (DOI)https://doi.org/10.3310/hsdr09030
Official URLhttps://doi.org/10.3310/hsdr09030
FunderNational Institute for Health Research (NIHR)
Publication dates
OnlineFeb 2021
Publication process dates
Deposited25 Feb 2021
Output statusPublished
Permalink -

https://repository.canterbury.ac.uk/item/8x317/dental-therapists-compared-with-general-dental-practitioners-for-undertaking-check-ups-in-low-risk-patients-pilot-rct-with-realist-evaluation

  • 11
    total views
  • 0
    total downloads
  • 1
    views this month
  • 0
    downloads this month

Export as

Related outputs

‘Function First’: how to promote physical activity and physical function in people with long-term conditions managed in primary care? A study combining realist and co-design methods
Law, Rebecca Jane, Langley, Joseph, Hall, Beth, Burton, Christopher, Hiscock, Julia, Williams, Lynne, Morrison, Val, Lemmey, Andrew, Lovell-Smith, Candida, Gallanders, John, Cooney, Jennifer Kate and Williams, Nefyn 2021. ‘Function First’: how to promote physical activity and physical function in people with long-term conditions managed in primary care? A study combining realist and co-design methods. BMJ Open. 11 (7). https://doi.org/10.1136/bmjopen-2020-046751
Pro-judge study: Nurses’ professional judgement in nurse staffing systems
Burton, Chris, Hale, Rachel, Jones, Aled, Lloyd, Amy, Rafferty, Anne-Marie and Allen, Davina 2021. Pro-judge study: Nurses’ professional judgement in nurse staffing systems. Journal of Advanced Nursing. https://doi.org/10.1111/jan.14921
Theory and practical guidance for effective de-implementation of practices across health and care services: a realist synthesis
Burton, C., Williams, L., Bucknall, T., Fisher, D., Hall, B., Harris, G., Jones, P., Makin, M., Mcbride, A., Meacock, R., Parkinson, J., Rycroft-Malone, J. and Waring, J. 2021. Theory and practical guidance for effective de-implementation of practices across health and care services: a realist synthesis. Health Services and Delivery Research. 9 (2). https://doi.org/10.3310/hsdr09020
Making authentic: exploring boundary objects and bricolage in knowledge mobilisation through National Health Service-university partnerships
Melville-Richards, L., Rycroft-Malone, J., Burton, C. and Wilkinson, J. 2020. Making authentic: exploring boundary objects and bricolage in knowledge mobilisation through National Health Service-university partnerships. Evidence & Policy: A Journal of Research, Debate and Practice. https://doi.org/10.1332/174426419X15623134271106
A multicentre, randomised controlled trial to compare the clinical and cost-effectiveness of Lee Silverman Voice Treatment versus standard NHS Speech and Language Therapy versus control in Parkinson’s disease: a study protocol for a randomised controlled trial
Sackley, C. M., Rick, C., Au, P., Brady, M. C., Beaton, G., Burton, C., Caulfield, M., Dickson, S., Dowling, F., Hughes, M., Ives, N., Jowett, S., Masterton-Algar, P., Nicoll, A., Patel, S., Smith, C. H., Woolley, R. and Clarke, C. E. 2020. A multicentre, randomised controlled trial to compare the clinical and cost-effectiveness of Lee Silverman Voice Treatment versus standard NHS Speech and Language Therapy versus control in Parkinson’s disease: a study protocol for a randomised controlled trial. Trials. 21 (436). https://doi.org/10.1186/s13063-020-04354-7
'Function first—be active, stay independent’—Promoting physical activity and physical function in people with long-term conditions by primary care: a protocol for a realist synthesis with embedded co-production and co-design
Law, R-J, Williams, L., Langley, J., Burton, C., Hall, B., Hiscock, J., Morrison, V., Lemmey, A., Partridge, R., Lovell-Smith, C., Gallanders, J. and Williams, N. 2020. 'Function first—be active, stay independent’—Promoting physical activity and physical function in people with long-term conditions by primary care: a protocol for a realist synthesis with embedded co-production and co-design. BMJ Open. 10 (2). https://doi.org/10.1136/bmjopen-2019-035686
Sleep hygiene education and children with developmental disabilities: Findings from a co-design study
Sutton, J.E., Huws, J.C. and Burton, C. 2019. Sleep hygiene education and children with developmental disabilities: Findings from a co-design study. Journal of Intellectual Disabilities. https://doi.org/10.1177/1744629518818950
Towards safe nurse staffing in England’s National Health Service: progress and pitfalls of policy evolution
Lawless, J., Couch, R., Griffiths, P., Burton, C. and Ball, J. 2019. Towards safe nurse staffing in England’s National Health Service: progress and pitfalls of policy evolution. Health Policy. 123 (6), pp. 590-594. https://doi.org/10.1016/j.healthpol.2019.03.011
Brief smoking cessation in acute Welsh hospitals: A realist approach
Davies, S., Burton, C., Williams, L. and Tinkler, A. 2019. Brief smoking cessation in acute Welsh hospitals: A realist approach. Health Promotion International. 35 (2), pp. 244-254. https://doi.org/10.1093/heapro/daz020
Understanding how and why de-implementation works in health and care: research protocol for a realist synthesis of evidence
Burton, C., Williams, L., Bucknall, T., Edwards, S., Fisher, D., Hall, B., Harris, G., Jones, P., Makin, M., McBride, A., Meacock, R., Parkinson, J., Rycroft-Malone, J. and Waring, J. 2019. Understanding how and why de-implementation works in health and care: research protocol for a realist synthesis of evidence. Systematic Reviews. 8 (194). https://doi.org/doi.org10.1186/s13643-019-1111-8
NHS managers’ use of nursing workforce planning and deployment technologies: a realist synthesis
Burton, C., Rycroft-Malone, J., Williams, L., Davies, S., McBride, A., Hall, B., Rowlands, A., Jones, A., Fisher, D., Jones, M. and Caulfield, M. 2018. NHS managers’ use of nursing workforce planning and deployment technologies: a realist synthesis. Health Services and Delivery Research. 6 (36). https://doi.org/10.3310/hsdr06360
The generation of consensus guidelines for carrying out process evaluations in rehabilitation research
Masterson-Algar, P., Burton, C. and Rycroft-Malone, J. 2018. The generation of consensus guidelines for carrying out process evaluations in rehabilitation research. BMC Medical Research Methodology. 18 (1), pp. 1-11. https://doi.org/10.1186/s12874-018-0647-y
Getting back to life after stroke: co-designing a peer-led coaching intervention to enable stroke survivors to rebuild a meaningful life after stroke
Masterson-Algar, P., Williams, S., Burton, C., Arthur, C., Hoare, Z., Morrison, V., Radford, K., Seddon, D. and Elghenzai, S. 2018. Getting back to life after stroke: co-designing a peer-led coaching intervention to enable stroke survivors to rebuild a meaningful life after stroke. Disability and Rehabilitation. 42 (10), pp. 1359-1372.
Arts-based palliative care training, education and staff development: A scoping review
Turton, B.M., Williams, S., Burton, C.R. and Williams, L. 2018. Arts-based palliative care training, education and staff development: A scoping review. Palliative Medicine. 32 (2). https://doi.org/10.1177/0269216317712189
The PD COMM trial: a protocol for the process evaluation of a randomised trial assessing the effectiveness of two types of SLT for people with Parkinson's disease.
Masterson-Algar, P, Burton, C., Brady, M.C., Nicoll, A., Clarke, C.E., Rick, C., Hughes, M., Au, P., Smith, C.H. and Sackley, C.M. 2017. The PD COMM trial: a protocol for the process evaluation of a randomised trial assessing the effectiveness of two types of SLT for people with Parkinson's disease. Trials. 18 (397), p. 2017. https://doi.org/10.1186/s13063-017-2130-1
Managing diabetes in people with dementia: a realist review
Bunn, F., Goodman, C., Jones, P.R., Russell, B., Trivedi, D., Sinclair, A., Bayer, A., Rait, G., Rycroft-Malone, J. and Burton, C. 2017. Managing diabetes in people with dementia: a realist review. Perth, Scotland NIHR Journals Library. https://doi.org/10.3310/hta21750
Implementation and trial evidence: a plea for fore-thought
Brocklehurst, P.R., Williams, L., Burton, C., Goodwin, T. and Rycroft-Malone, J. 2017. Implementation and trial evidence: a plea for fore-thought. British Dental Journal. 222 (5), pp. 331-335. https://doi.org/10.1038/sj.bdj.2017.213
What works for whom in the management of diabetes in people living with dementia: a realist review
Bunn, F., Goodman, C., Jones, P. R., Russell, B., Trivedi, D., Sinclair, A., Bayer, A., Rait, G., Rycroft-Malone, J. and Burton, C. 2017. What works for whom in the management of diabetes in people living with dementia: a realist review. BMC Medicine. 15 (141). https://doi.org/10.1186/s12916-017-0909-2
Improving skills and care standards in the support workforce for older people: a realist synthesis of workforce development interventions
Rycroft-Malone, J., Burton, C., Williams, L., Edwards, S., Fisher, D., Hall, B., McCormack, B., Nutley, S., Seddon, D. and Williams, R. 2016. Improving skills and care standards in the support workforce for older people: a realist synthesis of workforce development interventions. National Institute of Health Research. https://doi.org/10.3310/hsdr04120
Implementing a Systematic Voiding Program for Patients With Urinary Incontinence After Stroke
French, B., Thomas, L.H., Harrison, J., Burton, C., Forshaw, D., Booth, J., Britt, D., Cheater, F.M., Roe, B. and Watkins, C.L. 2016. Implementing a Systematic Voiding Program for Patients With Urinary Incontinence After Stroke. Qualitative Health Research. 26 (10). https://doi.org/10.1177/1049732316630975
Implementing best practice in infection prevention and control. A realist evaluation of the role of intermediaries
Williams, L., Rycroft-Malone, J. and Burton, C. 2016. Implementing best practice in infection prevention and control. A realist evaluation of the role of intermediaries. International Journal of Nursing Studies. 60, pp. 156-167. https://doi.org/10.1016/j.ijnurstu.2016.04.012
Bringing critical realism to nursing practice: Roy Bhaskar's contribution
Williams, L., Rycroft-Malone, J. and Burton, C. 2016. Bringing critical realism to nursing practice: Roy Bhaskar's contribution. nursing philosophy: an international journal for healthcare professionals. 18 (2). https://doi.org/10.1111/nup.12130
Managers' use of nursing workforce planning and deployment technologies: protocol for a realist synthesis of implementation and impact
Burton, C., Rycroft-Malone, J., Williams, L., Davies, S., McBride, A., Hall, B., Rowlands, A.M. and Jones, A. 2016. Managers' use of nursing workforce planning and deployment technologies: protocol for a realist synthesis of implementation and impact. BMJ Open. 6 (8). https://doi.org/10.1136/bmjopen-2016-013645
Improving skills and care standards in the support workforce for older people: a realist synthesis of workforce development interventions
Williams, L., Rycroft-Malone, J., Burton, C., Edwards,S., Fisher, D., Hall, B., McCormack, B., Nutley, S.M., Seddon, D. and Williams, R. 2016. Improving skills and care standards in the support workforce for older people: a realist synthesis of workforce development interventions. BMJ Open. 6 (8). https://doi.org/10.1136/bmjopen-2016-011964
Strategies to prevent oral disease in dependent older people
Brocklehurst, P., Williams, L., Hoare, Z., Goodwin, T., McKenna, G., Tsakos, G., Chestnutt, I.G., Pretty, I., Wassall, R., Jerkovic-Cosic, K., Hayes, M., Watt, R.G. and Burton, C. 2016. Strategies to prevent oral disease in dependent older people. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD012402
Process evaluations in neurological rehabilitation: a mixed-evidence systematic review and recommendations for future research
Masterson-Algar, P., Burton, C. and Rycroft-Malone, J. 2016. Process evaluations in neurological rehabilitation: a mixed-evidence systematic review and recommendations for future research. BMJ Open. 6 (11). https://doi.org/10.1136/bmjopen-2016-013002
Managing diabetes in people with dementia: protocol for a realist review
Bunn, F., Goodman, C., Rycroft Malone, J., Reece Jones, P., Burton, C., Rait, G., Trivedi, D., Bayer, A. and Sinclair, A. 2016. Managing diabetes in people with dementia: protocol for a realist review. Systematic Reviews. 5 (5). https://doi.org/10.1186/s13643-015-0182-4
Collaboration and co-production knowledge in healthcare: opportunities and challenges
Rycroft-Malone, J., Burton, C.R., Bucknall , T., Graham, I.D., Hutchinson, A. and Stacey, D. 2016. Collaboration and co-production knowledge in healthcare: opportunities and challenges. International Journal of Health Policy and Management. 5 (4), pp. 221-223. https://doi.org/10.15171/IJHPM.2016.08
Collective action for implementation: a realist evaluation of organisational collaboration in healthcare
Rycroft-Malone, J., Burton, C.R., Wilkinson, J., Harvey, G., McCormack, B., Baker, R., Dopson, S., Graham, I.D., Staniszewska, S., Thompson, C., Ariss, S., Melville-Richards, L. and Williams , L. 2016. Collective action for implementation: a realist evaluation of organisational collaboration in healthcare. Implementation Science : IS. 11 (17). https://doi.org/10.1186/s13012-016-0380-z
An occupational therapy intervention for residents with stroke-related disabilities in UK care homes (OTCH): cluster randomised controlled trial with economic evaluation
Sackley, C.M., Walker, M.F., Burton, C.R., Watkins,C.L, Mant, J., Roalfe, A.K., Wheatley, K., Sheehan, B., Sharp, L., Stant, K.E., Fletcher-Smith, J., Steel, K., Barton, G.R., Irvine, L. and Peryer, G. 2016. An occupational therapy intervention for residents with stroke-related disabilities in UK care homes (OTCH): cluster randomised controlled trial with economic evaluation. Health Technology Assessment. 20 (15). https://doi.org/10.3310/hta20150
Identifying Continence OptioNs after Stroke (ICONS): an evidence synthesis, case study and exploratory cluster randomised controlled trial of the introduction of a systematic voiding programme for patients with urinary incontinence after stroke in secondary care
Thomas, L. H., French, B., Sutton, C. J., Forshaw, D., Leathley, M. J., Burton, C., Roe, B., Cheater, F. M., Booth, J., McColl, E., Carter, B., Walker, A., Brittain, K., Whiteley, G., Rodgers, H., Barrett, J. and Watkins, C. L. 2015. Identifying Continence OptioNs after Stroke (ICONS): an evidence synthesis, case study and exploratory cluster randomised controlled trial of the introduction of a systematic voiding programme for patients with urinary incontinence after stroke in secondary care. NIHR Journals Library.
Collective action for knowledge mobilisation: a realist evaluation of the collaborations for leadership in applied health research and care
Rycroft-Malone, J., Burton, C., Wilkinson, J., Harvey, G., McCormack, B., Baker, R., Dopson, S., Graham, I., Staniszewska, S., Thompson, C., Ariss, S., Melville-Richards, L. and Williams, L. 2015. Collective action for knowledge mobilisation: a realist evaluation of the collaborations for leadership in applied health research and care. UK NIHR Journals Library. https://doi.org/10.3310/hsdr03440
An untapped resource: patient and public involvement in implementation comment on "Knowledge mobilization in healthcare organizations": a view from the resource-based view of the firm
Burton, C. and Rycroft-Malone, J. 2015. An untapped resource: patient and public involvement in implementation comment on "Knowledge mobilization in healthcare organizations": a view from the resource-based view of the firm. International Journal of Health Policy and Management. 4 (12), pp. 845-847. https://doi.org/10.15171/ijhpm.2015.150
Investigating preferences for support with life after stroke: a discrete choice experiment
Burton, C., Fargher, E., Plumpton, C., Roberts, G.W, Owen, H. and Roberts, E. 2014. Investigating preferences for support with life after stroke: a discrete choice experiment. BMC Health Services Research. 14 (63). https://doi.org/10.1186/1472-6963-14-63
Evaluating a systematic voiding programme for patients with urinary incontinence after stroke in secondary care using soft systems analysis and Normalisation Process Theory: findings from the ICONS case study phase.International journal of nursing studies
Thomas, L.H, French, B., Burton, C., Sutton, C., Forshaw, D., Dickinson, H., Leathley, M.J., Britt, D., Roe, B., Cheater, F.M, Booth, J., Watkins, C.L, ICONS Project Team, ICONS Patient and Public and Carer Involvement Groups 2014. Evaluating a systematic voiding programme for patients with urinary incontinence after stroke in secondary care using soft systems analysis and Normalisation Process Theory: findings from the ICONS case study phase.International journal of nursing studies. International Journal of Nursing Studies. 51 (10), pp. 1308-1320. https://doi.org/10.1016/j.ijnurstu.2014.02.009
Improving skills and care standards in the support workforce for older people: a realist review
Rycroft-Malone, J., Burton, C., Hall, B., McCormack, B., Nutley, S., Seddon, D. and Williams, L. 2014. Improving skills and care standards in the support workforce for older people: a realist review. BMJ Open. 4 (5). https://doi.org/10.1136/bmjopen-2014-005356
Does self-efficacy influence recovery and well-being in osteoarthritis patients undergoing joint replacement? A systematic review
Magklara, E., Burton, C. and Morrison, V. 2014. Does self-efficacy influence recovery and well-being in osteoarthritis patients undergoing joint replacement? A systematic review. Clinical Rehabilitation. 28 (9). https://doi.org/10.1177/0269215514527843
Towards a programme theory for fidelity in the evaluation of complex interventions.
Masterson-Algar, P., Burton, C., Rycroft-Malone, J., Sackley, C.M. and Walker, M.F. 2014. Towards a programme theory for fidelity in the evaluation of complex interventions. Journal of Evaluation in Clinical Practice . 20 (4), pp. 445 - 452. https://doi.org/10.1111/jep.12174
Investigating the organisational impacts of quality improvement: a protocol for a realist evaluation of improvement approaches drawing on the Resource Based View of the Firm.
Burton, C., Rycroft Malone, J., Robert, G., Willson, A. and Hopkins, A. 2014. Investigating the organisational impacts of quality improvement: a protocol for a realist evaluation of improvement approaches drawing on the Resource Based View of the Firm. BMJ Open. 4:e005650. https://doi.org/10.1136/bmjopen-2014-005650
Resource based view of the firm as a theoretical lens on the organisational consequences of quality improvement.
Burton, C. and Rycroft-Malone, J. 2014. Resource based view of the firm as a theoretical lens on the organisational consequences of quality improvement. International Journal of Health Policy and Management. 3 (3), pp. 113 - 115. https://doi.org/10.15171/ijhpm.2014.74
The study protocol of: 'Initiating end of life care in stroke: clinical decision-making around prognosis'.
Burton, C., Payne, S., Turner, M., Bucknall, T., Rycroft-Malone, J., Tyrell, P., Horne, M., Ntambwe, L.I., Tyson, S., Mitchell, H., Williams, S. and Elghenzai, S. 2014. The study protocol of: 'Initiating end of life care in stroke: clinical decision-making around prognosis'. BMC Palliative Care. 13 (55). https://doi.org/10.1186/1472-684X-13-55
Identifying continence options after stroke (ICONS): a cluster randomised controlled feasibility trial.
Thomas, L.H., Watkins, C.L., Sutton, C.J., Forshaw, D., Leathley, M.J., French, B., Burton, C., Cheater, F., Roe, B., Britt, D., Booth, J., McColl, E., The ICONS Project Team and The ICONS Patient, Public and Carer Involvement Groups 2014. Identifying continence options after stroke (ICONS): a cluster randomised controlled feasibility trial. Trials. 15 (509). https://doi.org/10.1186/1745-6215-15-509
What is rehabilitation potential? Development of a theoretical model through the accounts of healthcare professionals working in stroke rehabilitation services
Burton, C.R., Horne, M., Woodward-Nutt, K., Bowen, A. and Tyrrell, P. 2014. What is rehabilitation potential? Development of a theoretical model through the accounts of healthcare professionals working in stroke rehabilitation services. Disability and Rehabilitation. 37 (21), pp. 1955-1960. https://doi.org/10.3109/09638288.2014.991454