Title: The implementation and acceptability of a Minimum Intervention Care pathway for children with carious permanent teeth attending NHS dental practice – a feasibility study.
Funder: Department of Health and Social Care

Abstract: The ProblemDental caries presents a significant public health problem for the United Kingdom. It is one of the most common diseases affecting childhood with nearly a half (46%) of 15 year olds and a third (34%)of 12 year olds having obvious decay experience in their permanent teeth. It also follows social gradients with the most deprived being the most affected. Dental caries can cause considerable pain and morbidity for the individual, as well as anxiety and concern from relatives. Recent estimates put the NHS costs for treating decayed permanent teeth in 12 year olds alone at approximately 33 million per year. Traditional treatment for permanent teeth affected by dental caries involves local anaesthetic injections, removal of all the caries affected tooth substance, and provision of restorations. Factors including injections and the dental drill are reasons that invoke fear and dread in patients, and are barriers to dental attendance. Dental restorations require periodic replacement and hence on children's permanent teeth they leave a lasting burden.Minimum Intervention dentistry (MID) is a evidence-based approach to managing dental caries. MID comprises comprehensive detection, diagnosis, prevention, restoration and review. Early stage caries when detected can be treated with preventive MID strategies without the need surgical operative intervention. For advanced stages of tooth decay where cavitation is present, MID will involve restoring by removing the minimal amount of tooth substance prior to restoration thereby preserving as much of the natural tooth as possible. This MID approach being patient centred and tooth preserving, has several potential major benefits over the current traditional approach used in general dental practice to treat children with caries affected permanent teeth.In order to test if an MID approach to treating tooth decay in children's permanent teeth is clinically and cost effective to the NHS, a randomised control trial is required. A definitive trial would assess the proposed intervention (MID) in comparison to current standard practice. However, a number of uncertainties exist about the feasibility of running such a study in NHS primary care and the work proposed here will investigate these uncertainties.AimTo assess the feasibility of running a cluster-randomised trial to investigate the clinical and cost effectiveness of a MID care pathway to children with dental caries in their permanent teeth.Project plan.A scoping study will be undertaken to identify literature that will give insight into the MID care plan, implementation and behavioural patterns of dentists and associated factors, to help develop data collection instruments, practice training workshops, and implementation.Next I will recruit and cluster randomize six NHS dental practices. Data from three practices will give insight into current standard practice. Three other practices, after undertaking training workshops, will implement a MID care approach to children aged 6 to 16 years with caries in their permanent teeth. We will use a threshold of caries detection based on the International Caries Detection and Assessment System (ICDAS).Case report forms and patient questionnaires will be used to investigate the feasibility of collecting process data, clinical and cost data for the intervention. An accompanying nested qualitative investigation (including focus groups) will accompany to highlight any further issues including acceptability of the MID care plan, that may affect the running of a larger trial.I will share and disseminate the results with all stakeholders including presentations at conferences, journal articles, patient newsletters, posters, websites, healthcare professionals, commissioners and policy makers. Finally we will decide if a larger trial is feasible.

Lay abstract: Background Tooth decay is an important health issue in the UK. It is one of the most common diseases affecting children with over a half of twelve year olds and two thirds of fifteen year olds having experience of decay in their permanent (adult) teeth. In over half of these the decay is at an advanced stage. Tooth decay causes children pain, difficulty eating and time missed from school and treating decay in adult teeth in 12 year olds alone costs the NHS approximately 33million per year. Dentists normally treat tooth decay by removing all parts of a tooth affected by decay and replacing it with a filling material. This involves using an anaesthetic injection to numb the tooth and the use of a dental drill. The dental drill and injections are the two main aspects that invoke fear in patients, can be painful, and deter them from visiting the dentist. Furthermore, dental fillings do not last a lifetime and periodic replacement may be required, especially for those teeth filled during childhood. Minimum Intervention Dentistry (MID) is an alternative approach to managing tooth decay. It involves early detection and diagnosis, preventative measures, and (when necessary) less invasive forms of treatment. Identifying tooth decay in its early stages before it forms a hole helps to assess the likelihood of further tooth decay, and provide early appropriate prevention and treatment. Tooth decay when detected in its early stages can be stopped with preventive MID strategies, such as sealing to stop it growing bigger, without the need to drill or fill. For advanced stages of tooth decay where a hole is present MID fillings will be smaller than usual (not requiring removal of all the affected tooth), thereby keeping as much of the natural tooth as possible. This MID approach being patient friendly and tooth preserving, has potential major benefits over the traditional approach when treating tooth decay in children's' adult teeth. There is a need to show how well MID works in normal dental practices. A large scale study where dental practices are asked to provide either their normal care or to use MID methods is the best way to do this. However, before this is possible a number of uncertainties about the study have to be addressed. Firstly, we need to understand what most dental practices would normally do to manage and treat decay in children's teeth, and also to identify any differences in what practices consider normal treatment. We also need to establish that practices are able to use an MID approach within their current systems and organization. Finally, we need to test our research procedures, such as collecting health economic data, so that we know they will work in a larger study.Project plan Firstly I will carry out a scoping review to find literature that will give insight into the MID care pathway. This will help to identify things that are already known, and will uncover areas where there are gaps in our knowledge about the use of MID in normal dental practices. This will enable the active study to be finalized and will also inform the sort of information that is given to dentists and patients involved in the study. The next stage will involve recruiting six dental practices. In three of these we will review patient records and use simple data recording forms to monitor how decay in children's teeth is managed. In the other practices training in MID will be provided and they will be asked to use an MID approach with children aged 6 -16 years. This will be monitored. Practices will be selected to deliver MID or normal care randomly, A range of data will be collected in the study. Case report forms, patient questionnaires, and practice feedback will provide insight into how well MID worked in the practices. Interviews and focus groups with dental professionals and patients (and their families) will help to highlight issues about how MID works and whether people like this type of approach. The results will help us to design a larger study where we will establish whether MID is a better (and cheaper) way to manage dental decay in children. Our findings will be shared with everyone involved, the dental profession, other healthcare professionals, the general public, commissioners and decision makers, using conference presentations, journal articles, patient newsletters, and websites.

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