Oral Research in Primary Care

Oral Research in Primary Care I n 1901, Dr. Frederick S. McKay, a dentist in Colorado Springs, noted a mottled appearance on the teeth of the local population. He initiated a study on this phenomenon and identified the condition now known as fluorosis. He also noted a relationship between the fluorosis and reduced levels of dental caries (McKay, 1916). Over the next 30 years, Dr. McKay and his co-workers authored over 40 papers on the effects of fluoride and tooth-mottling. This provided a stimulus for Dr. H. Trendley Dean's study of fluoride in the water supply (Dean, 1938). The outcome of this study helped provide the stimulus for the fluoridation of water supplies to reduce levels of dental caries. Now, a century later, Dr. McKay's observations on the use of fluoride have had a profound effect on oral health. Dr. McKay's activity was an early example of research in primary dental care—research carried out in the primary care setting: the dental surgery (or office) or in the community. In the years that have passed since 1901, the contribution of primary care research to the overall body of oral research has been minimal. Questions arise as to how oral research in primary care can be developed. Most oral research is institutionalized. Fundamental research in basic science ranges from molecular biology to materials science. By its nature, it requires specialized equipment, materials, and techniques. Much of this research is carried out by scientists who may have had little exposure to clinical dentistry. The potential exists for a considerable gulf to exist between basic science researchers and primary care researchers. Many commercial companies have their own Research and Development programs, with dedicated researchers to develop new products and refine existing ones, so that the optimum product is delivered to the consumer. Applied clinical research is based mainly in the dental schools. Academics are encouraged to carry out research to advance scholarship, inform their teaching, and enhance their professional development. Closely intertwined with this is the mentoring of young researchers, especially graduate students, who undertake research as part of their post-graduate programs. Research is facilitated in dental schools, since this activity forms part of the job specification for academics and researchers. A considerable amount of essential research is epidemiologically based, with populations studied at a point in time or over a discrete time period to determine levels of oral health, changes in oral health, responses in oral health to intervention(s), and predictors of oral health. Many of these studies involve participation of large cohorts of people over a prolonged period. In many instances, there is considerable overlap and synergy between researchers in basic sciences, clinical researchers, population-based research, and industry. Research projects are often multi-centered and multi-skilled, and there is some common ground for the dissemination of research findings. However, most of clinical dentistry is carried out in the primary care setting—whether general practice or in the community service. Primary oral health care providers are confronted with a variety of oral diseases, patterns of oral disease, patient attitudes and expectations, medical conditions, and systems of remuneration. These may affect the care provided for patients and the treatment outcomes. Elucidation of the clinical issues confronting primary care workers is difficult to determine. The primary care setting has advantages for research, in that it is grounded in the real world, and it has a large pool of patients. Given that the primary focus of primary care is the delivery of patient care, research may be further down the agenda, especially since many primary care workers exist in isolation, compared with other research cohorts. Some thought-provoking data are emerging. It is particularly noteworthy that a considerable proportion of repeat restorations are placed in clinical practice (Mjör, 2001; Burke et al., 2002). Is this due to material defects, patterns of disease, diagnostic criteria, or systems of payment? These may affect the care provided for patients and/or their outcome. It would be beneficial to determine, from primary care workers, what barriers they perceive toward carrying out research. Possible barriers could include: a perceived lack of relevance of research to clinical care, funding, lack of training/expertise/confidence in research methodology, fear of losing patients from practice if subjected to experimental techniques, lack of recognition for research efforts, lack of time in clinical practice to carry out research, a lack of infrastructure and administrative support, and absence of outreach from research bodies to collaborate in research. Addressing these issues and especially providing support for and recognition of the efforts of primary care researchers may provide a pathway for encouraging more primary care researchers. Given the paucity of primary care research relative to that carried out by research bodies, it is difficult to state conclusively that there are substantial differences between research outcomes in these two spheres. Comparison of research between primary care and controlled clinical trials has highlighted some differences in outcomes (Mjör, 2001). One of the critical dilemmas is the application of new research findings and methodologies to primary care research. A particular concern is the volume of research, carried out in Basic Sciences, of which primary care workers and researchers are unaware. There is little communication of these research outcomes, since there is little common ground for attendance at scientific meetings, publication in journals, or even understanding of the technical language or concepts. Facilitation of this process presents a particular challenge. Oral Research in Primary Care