Title: uSing rolE-substitutioN In care hOmes to improve oRal health (SENIOR)
Funder: Health and Care Research Wales (Welsh Government)

Abstract: Aim: The aim of this study is to undertake a randomised controlled trial to determine whether the use of Dental Care Professionals instead of dentists, could offer an alternative to NHS dental provision for residents in care-homes. _x000D_ _x000D_ Background: As highlighted by the Care Quality Commission and featured on BBC news in mid-June 2019, older people residing in care-homes have great difficulty in accessing routine NHS dental care provided by dentists. This means that treatment is often sought by professionals and informal carers, when the residents are in pain. In emergencies, staff often have to call a doctor (General Practitioner), NHS 111 or take the resident to Accident and Emergency. This puts an added burden on NHS services that are already under pressure. This situation is likely to deteriorate further; more people will be residing in care-homes in the future and many will have their own teeth. Given that almost three-quarters of residents have active tooth decay at any one time (compared to their community dwelling peers), the importance of designing services that meet these needs and focus on prevention is critical. _x000D_ _x000D_ Dental Care Professionals have many of the skills and training that dentists have, but focus more on prevention and are potentially cheaper to commission. There is increasing evidence that Dental Care Professionals can offer a viable (and potentially more cost-effective) alternative to using NHS dentists to provide dental care for residents in care-homes. The research team have already shown that they can identify tooth decay and gum disease and are safe as front-line health care workers (e.g. can screen for oral cancer). The use of Dental Care Professionals within residential homes has the potential to improve the provision of preventive care and improve access to services. This would address calls from a number of professional bodies including NICE, who argue that there is a real need to increase the level of research in this area. Despite these calls, the numbers of studies that have examined how we can better provide care for care-home residents is very limited. _x000D_ _x000D_ Design: Three work-streams (WSs) are proposed. WS1 will be a cluster-randomised controlled trial. In the intervention arm, Dental Care Professionals will proactively inspect eligible care-home residents with natural teeth for tooth decay, gum disease and other oral conditions. They will then provide advice, preventive care and any simple operative treatment that is necessary (and refer on to dentists when necessary). This will be contrasted to current practice (which is likely to be varied). Visits to each home will form part of a regular and routine programme of care. WS2 will use semi-structured interviews and focus groups with residents, informal carers, care-home managers and staff and commissioners of care, to understand how different stakeholders respond to the idea of using Dental Care Professionals proactively in care-homes. WS3 will determine the cost-effectiveness of the proposed intervention._x000D_ _x000D_ Patient and public involvement: Older people will be involved at every stage of the design, management and dissemination of the study, which is an approach that we have adopted for all our studies in this area. Two of our co-applicants are PPI members._x000D_ _x000D_ Dissemination: The research team will disseminate the results of the study to the scientific community, clinicians, commissioners of services and policy-makers across the United Kingdom.

Lay abstract: Aim: To undertake a cluster-randomised controlled trial to determine whether Dental Care Professionals (DCPs) can reduce plaque levels (improve oral cleanliness) of dentate older adults in care-homes over a six-months, compared to ‘treatment as usual’ and whether this effect is sustainable._x000D_ _x000D_ Background: The oral health of care-home residents is much worse than their community living peers (e.g. caries prevalence is 73% vs 40%) and about half of all care-home residents now retain some of their natural teeth. Poor oral health may also exacerbate a range of medical conditions including pneumonia and delirium, increasing healthcare costs and leading to poorer outcomes. Despite this high level of need, dental service provision in residential care is poor, with little emphasis on prevention. Access to domiciliary services is difficult and unscheduled care for dental problems (including hospital admissions) is common, complex to deliver and expensive. The World Health Organisation argues that the design of long-term care systems that are fit for ageing populations should take priority and the Royal College of Surgeons of England, Public Health England and the National Institute of Clinical Excellence (NICE NG48) have all called for more high quality research. The recent report from the Care Quality Commission in June 2019, highlighted the paucity of NHS dental provision in care-homes. _x000D_ _x000D_ There is increasing evidence that DCPs offer an alternative to using dentists to meet future challenges in dental public health. DCPs are a broad range of professionals, which include Hygiene-Therapists (H-Ts) and Dental Nurses (DNs). Lead applicant PRB has demonstrated that H-Ts can identify and screen for dental caries and periodontal disease and are safe as front-line health care workers. The feasibility, productivity and effectiveness of using H-Ts has been tested in primary care, but not in a care-home environment. Use of DCPs (H-Ts and DNs) within residential homes has the potential to improve the provision of care, improve access to services and preventive advice. This study complements a number of on-going studies being undertaken by many of the same team, including NIHR PHR 17/3/11 'Improving the Oral Health of Older People in Care-homes: a Feasibility Study (TOPIC)'. _x000D_ _x000D_ Design: Three work-streams (WSs) are proposed. WS1 will be a two-arm cluster-randomised controlled trial, with a three-month internal pilot. In the intervention arm, DCPs (H-Ts and DNs) will proactively oversee the clinical management of eligible dentate residents. They will promulgate advice to improve the day-to-day prevention offered to residents by formal carers (DNs), provide preventive care and any simple operative treatment for individual residents (H-Ts), within their Scope of Practice. Dentists will be referred onto when necessary. This will be contrasted with current practice (which is likely to be very heterogeneous). WS2 will be a parallel process evaluation, using semi-structured interviews with key stakeholders, exploring the intervention’s acceptability and determining the factors that influence the interventions pathway-to-impact. WS3 will be-a cost-effectiveness analysis._x000D_ _x000D_ Dissemination: The research team have substantive links with the Chief Dental Officers across the UK, commissioners, Consultants in Dental Public Health and Restorative Dentistry, Platform of Better Oral Health in Europe and national and international academics.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: ORAL AND GASTROINTESTINAL