Title: Investigating Problem Orientated Patient Pathways, Toothache to Treatment: ImPacT Study
Funder: Department of Health and Social Care

Abstract: BackgroundAlmost one-third of adults in the UK will only seek professional help when suffering from acute dental pain (ADP) rather than engaging in routine dental care (problem orientated attenders [POA]). These individuals can wait a long time before seeking help resulting in: greater impacts on their everyday activities, and greater potential for serious adverse events.These POA often present to a range of services including: emergency dental services, accident and emergency (A&E) departments, and general medical practitioners (GPs). From our published research we know that one-third of attenders at dental emergency services are repeat POA, with over one in ten re-attending for the same complaint. In addition, 0.7% of A&E attendances, and 600,000 GP consultations per year are for dental complaints.This is likely to have a significant economic impact on the NHS and wider society, with the British Dental Association estimating these NHS costs at 44 million. Seeking care from non-dental health care providers results in temporary treatment, often analgesics and antibiotics, potentially placing these patients into a cycle of repeat emergency attendance. Ensuring patients are treated in the most appropriate care settings, by the right clinical team is essential for both the patient and the wider public, not just to ensure appropriate diagnosis and treatment, but also to reduce unnecessary healthcare utilisation and cost. The reasons behind POA attendance patterns and choice of care pathway are under researched, but may include dental anxiety, finance, and language barriers. In order to encourage POA to engage in routine dental care it is important that we build an understanding of: i) why they only attend when in ADP; ii) where they present. Addressing these questions will help inform the development of an intervention and or changes to service delivery in order to encourage routine dental attendance over problem orientated attendance.Overall aim: To build an understanding of POA and use this to develop an intervention to encourage routine dental attendance.AimsThe specific aims are:To explore POA perspectives and decision-making processes on seeking care for ADPTo examine attendance profiles, patterns and demographics of patients attending GPs with ADP and the relationship to policy change.To use data from aims 1 and 2 to help inform the development of an intervention for POA to encourage regular dental care. DesignThis is a three-work package (WP) mixed-methods programme of research. The first WP is a qualitative study using semi-structured interviews to explore the reasons and decision-making processes for problem orientated care for ADP. POA (n=45) will be recruited from primary and secondary emergency care settings and general medical and dental practices, in the North and South of England. WP two is an observational epidemiological study, using database searches to quantify the number of patients who attend their GP with ADP over forty years, with analysis in relation to key policy change dates.WP3 is an iterative co-design process working with patients, health care providers and other stakeholders, building on the results from WP 1, 2, and a systematic review. The aim being to develop and mock up an intervention to encourage regular dental attendance in POA.Expected Outcomes and Anticipated BenefitThe intended outcome will be an intervention ready for feasibility trial, which has had patient and stakeholder input and feedback and preliminary economic evaluation.By encouraging POA to engage in routine dental care we will be tackling oral health inequalities, encouraging preventative healthcare, and reducing the burden on already overstretched emergency care NHS resources thereby addressing the NHS Five-Year Forward View, helping patients get the right care, at the right time, in the right place.

Lay abstract: Background: Approximately 3.8 million people in the UK suffer from toothache fairly, or very, often. Anyone who has experienced toothache knows it is a very intense pain, which causes significant impacts on everyday life and research data bear this out. However, despite the level of pain and its impacts on everyday lives, research suggests that people in the UK still wait a long time before seeking help, which can put them at risk of serious infections and the need for an operation and or a hospital stay. In addition, patients can often accidentally overdose on painkillers whilst trying to manage the toothache themselves and therefore need hospital treatment. Almost one third of adults in the UK only see a dentist when in pain rather than attending regular dental check-ups (problem orientated attenders). Instead they may use the dental emergency service, visit their general medical practitioner (GP) or attend accident and emergency departments when they are in dental pain. They can often use these services repeatedly, sometimes for the same problem. These dental attendances to accident and emergency departments and GPs are estimated by the British Dental Association to cost the NHS 44 million per year. Recent media coverage has suggested that approximately 600,000 patients a year see their GP for dental problems, and almost 1% of A&E attendances are for dental pain. Seeking help from non-dental medical professionals means that these patients do not receive dental treatment, and instead are often given painkillers and or antibiotics. These only provide temporary relief, and, in the case of antibiotics inappropriate use may lead to antibiotic resistance. This may lead to these patients seeking repeated care for their toothache, rather than obtaining definitive dental treatment. The reason why patients only seek care when they are in dental pain, and the impact this has on wider society, is unknown. In addition, use of services on a repeated basis is likely to have a large economic burden. If we could establish why these patients don't interact with routine dental care, and why they visit emergency services and medical care for dental pain we may be able to develop an intervention, or healthcare policy, to encourage patients to attend a dentist and receive appropriate treatment. Aims: This is a mixed methods study, the aims being to: Explore the reasons why patients seek repeated emergency dental, or medical care rather than routine dental care. Develop an intervention to encourage use of routine dental services over and above emergency or medical care Design and Methods: This project will form two work packages: The first work package is a qualitative study aiming at understanding the reasons why patients can be problem orientated attenders rather than routine dental attenders. Up to forty-five problem orientated attenders from the North and South of England will be recruited after attending either an emergency medical or dental service or their GP with toothache, and the services they attended, and reasons behind their attendance patterns explored using a telephone or face-to-face interview. The second work package will involve development of an intervention to encourage problem orientated attenders to engage with regular dental care. The results from the first work package will be used to identify the reasons patients attend for problem orientated dental care, and therefore the behaviours and populations to target for the intervention. A co-design process will then be used to develop an intervention, whereby patients and relevant stakeholders will work alongside the research team in a number of co-design workshops, developing intervention ideas, refining them, and then mocking-up the final intervention to ensure it is acceptable and likely to have a positive behavioural effect. The final intervention will be then trialled further in a feasibility study following the doctoral fellowship. Dissemination: The results of this study will be key to planning the design and conduct a trial of an intervention to encourage problem orientated attenders to become regular dental attenders. The findings will therefore be disseminated via conferences and peer reviewed journals, and also to relevant stakeholders such as the Chief Dental Officer, British Dental Association, and the Faculty of General Dental Practitioners.

Research activity codes: 2.3 PSYCHOLOGICAL, SOCIAL AND ECONOMIC FACTORS;7.1 INDIVIDUAL CARE NEEDS
Health categories: ORAL AND GASTROINTESTINAL