Introduction:In the United Kingdom, policy and guidance changes regarding the role of dental therapists (DTs) were implemented in recent years with a view to changing dental care to a more preventive-focussed, teamwork approach. However, success in the adoption of this model of working has been varied.Aims: Adopting a realist approach, our aim was, to examine the use of DTs in general dental practices in Wales, exploring what works, why, how and in what circumstances. Materials and Methods:The research comprised two stages. (a) A structured literature search, dual-coding papers for high-level factors describing the conditions or context(s) under which the mechanisms operated to produce outcomes. From this, we derived theories about how skill-mix operates in the general dental service. (b) Six case studies of general dental practices (three with a dental therapist/three without a dental therapist) employing a range of skill-mix models incorporating semi-structured interviews with all team members. We used the case studies/interviews to explore and refine the theories derived from the literature. Results:Eighty-four papers were coded. From this coding, we identified seven theories which reflected factors influencing general dental practices within three broad contexts: the dental practice as a business, as a healthcare provider and as a workplace. We tested these theories in interviews with 38 dental team members across the six care studies. As a result, we amended five of the theories. Conclusion:Our analysis provides theory about outcomes that DTs may facilitate and the mechanisms that may assist the work of DTs within different contexts of general dental practice. K E Y W O R D S dental therapists, development, general practice, qualitative, realist evaluation, skill-mix, team-work, workforce development How to cite this article: Barnes E, Bullock A, Chestnutt IG, Cowpe J, Moons K, Warren W. Dental therapists in general dental practice. A literature review and case-study analysis to determine what works, why, how and in what circumstances. Eur J Dent Educ. 2020;24:109-120. https ://doi.

Policy changes regarding the role of Dental Hygienist-Therapists (DTs) have been implemented in recent years with a view to promoting delivery of oral health-care through a more preventive-focussed, team work approach. AimsTo explore i) treatments led by dentists and DTs, and ii) patients' satisfaction with the care they received. Materials and MethodsSix case-studies of general dental practices in Wales, UK: three with and three without a DT.For each participant, a patient-satisfaction questionnaire and a staff-member-completed appointment record form were completed. We sought to recruit 150 patients seeing a dentist and 100 patients seeing a DT, per case-study practice. Results1224 patients were recruited in total (314 DT and 910 dentist appointments). Preventive work accounted for nearly half of all treatments. Dentists, in practices with a DT, undertook significantly less preventive and restorative work, and significantly more extractions and advanced treatment (p<0.005, χ²=15.352). Patient satisfaction and confidence in dentists' or DTs' ability was uniformly high (97% and 99% each group respectively). ConclusionPractices with DTs provided a more preventive-focussed approach to oral health-care delivery; dentists in these practices performed more complex work. Positive patient satisfaction and confidence in practitioners' ability suggest patient acceptability of a preventive model.

Introduction Studies across the health service reveal benefits of teamwork and barriers to its optimal use. Drawing upon the established Maturity Matrix Dentistry method, Skills Optimisation Self-Evaluation Toolkit (SOSET) was developed to enable the whole dental team to critically review how they address skill-mix in delivery of patient-centred oral healthcare in their practice. This paper outlines the development of the SOSET and explores its usefulness to general dental practice teams. Methods Research literature and interview data from general dental practice teams were coded for high-level factors (positive and negative) influencing teamwork. We used this coding to identify skill-mix domains, and within each, define criteria. The SOSET process was refined following consultations with dental professionals and piloting. Results Eighty-four papers were coded, and 38 dental team members were interviewed across six sites. The SOSET matrix was developed containing 9 domains reflecting the use of skill-mix, each containing 6 development level criteria. The domains addressed factors such as team beliefs on skill-mix and knowledge of team members' scope of practice, patient demand, the business case, staffing and training, and the practice premises. The process was piloted in 11 practices across South Wales and feedback was received from 92 staff members. Results showed that the SOSET process was straightforward, that the whole team could contribute to discussion and that it would be used to improve practice. Following piloting, four domains were merged into 2 new domains and the number of criteria within all domains was reduced and the wording simplified (7 domains, with 4 criteria each). Conclusion We used a systematic and rigorous process to develop SOSET to support dental teams to progress their teamwork practices. Its usefulness was demonstrated in the pilot. The SOSET is now being offered to general dental practices across Wales.

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Background Dental service provision in the care home sector is poor, with little emphasis on prevention. Emerging evidence suggests that the use of Dental Care Professionals (dental therapists and dental nurses) as an alternative to dentists has the potential to improve preventive advice, the provision of care and access to services within care homes. However, robust empirical evidence from definitive trials on how to successfully implement and sustain these interventions within care homes is currently lacking. The aim of the study is to determine whether Dental Care Professionals could reduce plaque levels of dentate older adults (65 + years) residing in care homes. Methods This protocol describes a two-arm cluster-randomised controlled trial that will be undertaken in care homes across Wales, Northern Ireland and England. In the intervention arm, the dental therapists will visit the care homes every 6 months to assess and then treat eligible residents, where necessary. All treatment will be conducted within their Scope of Practice. Dental nurses will visit the care homes every month for the first 3 months and then three-monthly afterwards to promulgate advice to improve the day-to-day prevention offered to residents by carers. The control arm will be ‘treatment as usual’. Eligible care homes (n = 40) will be randomised based on a 1:1 ratio (20 intervention and 20 control), with an average of seven residents recruited in each home resulting in an estimated sample of 280. Assessments will be undertaken at baseline, 6 months and 12 months and will include a dental examination and quality of life questionnaires. Care home staff will collect weekly information on the residents’ oral health (e.g. episodes of pain and unscheduled care). The primary outcome will be a binary classification of the mean reduction in Silness-Löe Plaque Index at 6 months. A parallel process evaluation will be undertaken to explore the intervention’s acceptability and how it could be embedded in standard practice (described in a separate paper), whilst a cost-effectiveness analysis will examine the potential long-term costs and benefits of the intervention. Discussion This trial will provide evidence on how to successfully implement and sustain a Dental Care Professional-led intervention within care homes to promote access and prevention. Trial registration ISRCTN16332897. Registered on 3 December 2021.

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