Title: InteRventions to rEduce inequaliTies in the Uptake of Routine deNtal care (RETURN)
Funder: Department of Health and Social Care

Abstract: Background Adults with low socio-economic (SES) backgrounds are less likely to use dental services for planned dental care. There is good evidence that this is a reason why they have fewer teeth, experience more toothache and have higher reported impacts such as difficulty eating. Since poor oral health is a common problem, this is a significant health issue. It also increases cost to the NHS in the inappropriate use of general practice/ A&E/ hospital in-patient care for dental problems. Acute dental problems often also result in antibiotic prescriptions and this adds to the problem of antimicrobial resistance. We have 3 research questions: 1. What are the most common barriers to planned dental care, and personal strategies which can help overcome them? 2. Can an opportunistic intervention for urgent care users be successfully delivered in NHS dental practices and Dental Hospitals? 3. Is a psychological intervention effective and cost-effective at increasing the uptake of planned dental care? Research Plan Developing the intervention (Work Package 1) Our intervention will have both persuasive and behavioural enactment components, but will mainly feature an Implementation Intentions (IIs) intervention. This approach is selected because 1) it is brief, and simple to administer; 2) Implementation Intentions are known to assist people to overcome significant barriers to behaviour change; and 3) IIs can achieve an improvement in uptake of planned care appointments to the order of 10%. The intervention will be delivered by dental nurses supported by intervention material on a Tablet PC, with further intervention material supplied to patients with an online link sent by text message; or in a booklet/leaflet - according to patients preference. In the first phase of the research, we will undertake ethnographic work to help determine the most salient barriers patients are likely to identify; and the IIs which are likely to be both acceptable and effective. This will also help generate relevant images, quotes and narratives for the intervention material which are in accord with the in group identity of the population targeted. We will then iteratively test and further develop the intervention material and delivery format during a pilot phase by undertaking qualitative interviews with dental staff and patients. Testing the intervention (Work Package 2) We will undertake a 9 month feasibility study involving 60 patients randomised to intervention and control groups. The feasibility study will include a comparison of three different methods of collecting clinical outcome data: 1) dental practice clinical records; 2) photographs and 3) a clinical examination by a trained researcher. We will then recruit 1,180 urgent dental care users to a RCT of a psychological intervention at 47 dental practices with Urgent Dental Care contracts and a Dental Hospital. Based on previous data we estimate that 30% of urgent dental care users return for planned dental care within 12 months. Based on a minimum clinically significant difference of 10 percentage points (i.e. an improvement to 40% of patients attending a dentist), our sample size calculation gives 80% power at &alpha;=0.025 (to allow for joint primary outcomes) to detect this improvement in the intervention group, while allowing for a potential contamination between groups of 10% and 5% unavailable outcome data. Co-primary outcomes are attendance at a dental practice for a planned care appointment within 12 months (routinely available Business Health Services Authority data), and a summary score of self-reported oral health impact at 12 months collected by telephone/e mail follow up. Secondary outcomes include these measures at 18 months, as well as clinical outcomes (number of teeth and number of untreated, decayed teeth); and the use of NHS services for acute dental problems and antibiotic prescriptions and/or analgesics. Regression analysis will allow us to investigate the differential effect of SES. We will use incremental cost effectiveness ratios to estimate the cost effectiveness of the intervention compared with usual care. Projected outputs & dissemination plans At 12 months we will hold an engagement event with NHS stakeholders to present our ethnographic work and intervention, where we will discuss how transferable and sustainable the intervention would be in other NHS contexts across the country. We will present findings at 9 conferences (including 3 INVOLVE), publish several peer-reviewed journal articles, and make intervention resources widely available. Benefits to patients and the NHS This is the first time interventions in this area have been developed and tested in the UK. With our high level support obtained we will be able to translate findings into practice within a short time-frame, for the benefit of low SES patients while saving cost to the NHS.

Lay abstract: People living in deprived areas often put off going to a dentist until they have a problem. But leaving it this late often means that decay is too far gone to save the tooth and extraction is necessary. This affects peoples dental health for the rest of their life and can leave them embarrassed about their appearance (avoiding smiling etc). Since over half of people with urgent dental problems receive antibiotics for infection, leaving dental visits until there is pain and infection adds to the problem of antibiotics being less effective against bacteria because they are used so widely. Although there has been a lot of research observing that people in deprived areas are more likely to visit a dentist for urgent care than for check-ups, there has been little research (none in this country) on what can be DONE about it. So our AIM is to develop and test a way to improve the routine use of dental services by deprived populations We will develop a prevention package for people who only go to the dentist when they have a problem. The prevention package will involve a dental nurse talking through the planning processes involved in making and keeping appointments for dental check-ups, and people s barriers to change. This will be based on material we develop on a Tablet PC. We also plan that patients will receive a follow up text message with links to information they identify as relevant (for example, a link to an online video providing advice about completing NHS charge exemption forms). We will work with a group of 13 members of the public and 4 dental practitioners to develop the prevention package material, using information gathered from observations and interviews with about 40 urgent dental care users. After 12 months we will hold a workshop to explore whether our package would be practical if it was to be rolled out nationally. We will then test to see if our prevention package is effective. We will set up an experiment where some people contacting urgent dental services get the prevention package, and some do not. We will follow these people for 18 months to see if receivers of the package are more likely than the others to take up routine care at a dental practice, and whether this improves their dental health and saves the NHS money. Our team is composed of researchers, health managers and service users from the North of England. We have a great deal of experience in research of this kind. We are well connected with health service planners and local dentists who can help us turn our findings into positive ACTION.

Research activity codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING
Health categories: ORAL AND GASTROINTESTINAL