Research
Symposium Reports - 6th Symposium 2008
Soft Tissue Management and Research in Dental Primary Care
A very successful 6th symposium was held in Dundee in March 2008. The following are just a few notes to give a small flavour of some of the fine presentations given during the day. (Errors and omissions are not the responsibility of the presenters.) Full Programme
Read selected findings from the post-symposium feedback exercise.
Soft Tissue Management
Dr Jan Clarkson, SDPBRN - "Welcome and introduction"
Ms Margie Taylor, Chief Dental Officer - "Better health, better care"
Margie Taylor, recently appointed Chief Dental Officer, emphasised that, whilst she would never attempt to under-estimate the value of inspiration-driven research, it is very important that a large proportion of research efforts are focused upon carefully identified gaps in current knowledge.
Those involved in the production of evidence-based recommendations to practitioners, such as SIGN Guidelines or SNAP Reports, quickly become aware of uncertainties in current clinical knowledge.
Not all deficiencies in evidence deserve the same priority from a finite research resource. It is important to decide which avenue of investigation will result in the biggest impact upon health management. Factors to take into account are the prevalence of the condition where there is a lack of research evidence in its management, how much of a problem the particular condition causes, and what is the economic cost of the condition to the sufferer and to the health service.
It is a telling fact that nearly a quarter of hospital admissions for children are dentally related.
Then of course, having carried out the research and produced good evidence, there is the problem of ensuring that treatments are evidence-based where it can be improved by adherence to this good evidence. It is well known that the transition from evidence to change of practice is a protracted one.
Dr John Gibson, Dundee Dental Hospital and School - "Between a rock and a hard place. Oral tissue lesions in primary care"
John Gibson said he wanted people to leave the symposium understanding that they have a key evolutionary role as holistic oral healthcare practitioners and not thinking that they were lost in the vast sea of evidence-based data and new information. Every dental practitioner has an immense part to play in the diagnosis of systemic diseases from oral soft tissue lesions.
Patients with diabetes are at more risk of developing periodontal disease, those with periodontal disease may show a systemic inflammatory response, and with the systemic inflammatory response there may be an increased risk of cardiovascular disease.
20% of the population have Recurrent Aphthous Stomatitis of varying severity. This condition has been poorly researched as have treatment strategies for people with this condition. Other tissue sites are also involved, apart from the oral mucosa.
The dentist is in a pivotal screening position. Don’t proscribe to the doctrine “Don’t bother about it – everyone gets mouth ulcers!”
Research questions suggested by John:-
- Why does taking a child’s tonsils out make some forms of the mouth ulceration go away?
- Does breast-feeding protect?
- What is the role of SLS in RAS?
- Why do some studies support high doses of B-vitamins when deficiencies are not noted?
- How should we best screen for systemic diseases in patients with RAS?
- Should we be more rigorous in addressing allergy in patients with RAS?
- Do drug-induced ulcers give us a good model for further study?
- Are we sure that all members of the healthcare team understand the symptoms and signs of mouth cancer?
- Are we sure that the “continuing surveillance” of patients with potentially malignant lesions of the oral mucosa isn't simply “supervised neglect”?
- How does the use of correct clinical descriptors enhance diagnosis? e.g. papules
Mr Joe McManners, NHS Forth Valley - "Getting patients seen - developments in rapid access and referral arrangements"
Iain Hutchison, John Gibson, and Joe McManners
fielding questions at the end of the first session.
Professor Iain Hutchinson, Barts and the London Hospital NHS Trust - Soft tissue surgery: scope and implications for the primary care team.
Iain started out by reminding the audience that prevention was the key feature. None of his patients had any desire to undergo soft tissue surgery, he said. All would rather their conditions were diagnosed and treated at the earliest possible stage.
Having reached the stage where invasive surgery is necessary, the patients tend, initially, to be concerned how the surgery will affect their appearance. Later in the course of treatment they broaden their concerns when they realise that eating and speaking, for example, can become difficult. Patients are often left with dry mouths which can lead to persistent coughing or they may not be able to obtain a good seal between their lips or open their mouths widely and this makes eating a chore and an embarrassment. These are areas where there is potential to improve the outcome by carrying out well-designed research.
Iain noted that a series of short presentations to 13 to 14-year-old children emphasising the potential outcomes of smoking and over indulgence in alcohol had had very positive results in terms of changing the children’s attitudes towards these vices.
Further research potential exists in exploring the colour and texture of skin grafts used in the restoration of excised tissues. Patients are constantly raising the bar by having increased expectations about the quality of the final outcome. We should also be studying the social aspects surrounding those unfortunate enough to need soft-tissue surgery. Sufferers worry about such concerns as:
- Will I speak?
- Will I eat normally?
- Will I be disfigured?
- Will I be able to socialise?
- Will my friends recognise me?
- Will I get a job?
- Will I get a partner?
After showing graphic illustrations of the severity of the problem in some of his patients, iain ended on an optimistic note, saying “The Challenges don’t change but our understanding and ability to improve the patient’s lot does”
Dr Petrina Sweeney, Glasgow Dental Hospital - "Oral cancer patients in primary care"
Patricia re-iterated the statement by Iain Hutchison that early detection of soft-tissue lesions was vitally important to minimise suffering.
One complication is that the time from detection to the start of treatment is often so short that the primary care dentist has little time to sort out urgently needed dental treatment. Such preparation is of important though. If the teeth and gums are in poor condition, these are going to be a potential source of infection during the post-operation recovery phase. Unfortunately, it quite often happens that this is the case and the problem then is that the GDP may have difficulty finding an appointment slot in their practice to see the patient before their surgery. Bacteria are not usually a problem but yeasts and viruses frequently are.
Post surgery there is an important role for the patient’s dentist. Dry mouth and erosion are two major problems. Radiation therapy can lead to severe problems at the gingival margin. There is a need for a more acceptable synthetic saliva.
Patricia’s closing remarks were that:
- Maintenance of oral health is an essential element of holistic care
- Many oral health problems are preventable
- Input of the dental team should be available at all stages of the cancer patient’s journey
Dr Terry Simpson, Edinburgh Dental Institute - "Oral health and diabetes: lessons for primary care"
Dr Jan Clarkson, SDPBRN - "SDPBRN: new developments in research"
Current Scottish Research Activity
Parallel Sessions | |
Session 1:
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Session 2:
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Professor Gerry Humphris, St. Andrews University/NHS Fife - "Are communication skills vital to the success of the ChildSmile Programme?"
Mr Steve Turner, Dental Health Services Research Unit - The ERUPT Study: three years on.
Steve began by describing the ERUPT study and its impact. The study was a three year RCT which aimed to encourage dentists to place more fissure sealants on children’s teeth as a preventive measure when the child was felt to be at risk of developing caries. The study did this by running workshops on evidence based practice, and by offering a direct fee for each tooth treated. The direct fee proved to be an effective incentive, and was incorporated into the dental contract in 2006. Take-up of the new fee has been impressive, indicating up to 40,000 children received sealant in the first year the new fee was in operation.
However, the effectiveness of fissure sealants as a preventive measure, while well established in clinical trials, may be reduced when they are applied in sub-optimal conditions. In a recent paper Tickle et al concluded ‘the placement of fissure sealants by GDPs was not effective in preventing pit and fissure caries in these high risk children’
Steve then presented evidence from the 133 dentists and 2867 patients in the ERUPT study, drawing on anonymous treatment data from the NHS database of treatment claims. This suggested there were fewer subsequent fillings among children who had received sealants, but that the relationship was not very strong. Those who had all eight molars sealed were best protected – but this applied to only 5% of the children in the study.
Steve emphasised the weaknesses in the data – for example we do not know which teeth were filled in the period following the study – and ended by outlining plans to conduct a more precise follow-up of the ERUPT study.
Dr Jan Clarkson - Closing remarks
More photographs from the symposium
Selected results from feedback forms
Speaker Biographies
Brief background information on the speakers
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