Promoting regular dental attendance in problem‐orientated dental attenders: A systematic review of potential interventions

Abstract Background Problem‐orientated dental attenders account for around one‐third of the UK population, these being patients who do not seek regular dental care, instead only attending with dental pain. In order to develop intervention(s) to encourage regular dental attendance in these patients, any previous intervention development should be identified to aid idea generation or retrofitting of interventions. Objective To identify previous interventions which have been developed targeted at problem‐orientated dental attenders to facilitate the development and co‐design of a new intervention. Methods Eight electronic databases were searched for studies which included an intervention targeted at adult problem‐orientated or irregular dental attenders to encourage regular dental attendance. Data on the intervention design mapped to the theoretical domains framework were extracted, alongside effectiveness and patient views where available. Results Three studies fitted the inclusion criteria for the review. Interventions identified were attendance at a dental anxiety clinic, and a large advertising campaign promoting a free dental update where members of the public could visit local dental practices to look around and meet the dentists. One study looked at the effect of policy change by introducing free dental check‐ups in Scotland. Interventions were poorly reported, with significant omissions in their description and a lack of clear identification of what composed the intervention. Conclusion There are very few interventions developed targeted at problem‐orientated dental attendance, but important areas to consider in future intervention development include the following: dentist communication; dentist‐patient relationship; increasing the awareness of need; the effect of free dental check‐ups.


| INTRODUC TI ON
Almost one-third of the UK population do not seek regular dental care, instead only attending when suffering with acute dental pain or dental problems 1 often suffering for a prolonged period of time beforehand. 2 These problem-orientated attenders can present to a range of healthcare professionals, including dentists, 3 general medical practitioners 4 and medical emergency departments 5 often on a repeated basis. 3 Seeking treatment from non-dental providers often results in temporary treatment, such as a prescription for analgesics or potentially inappropriate antibiotics and advice to see a dentist, thus putting these patients into a cycle of repeat attendance. This attendance pattern is not exclusive to the UK with estimates of regular/preventive utilisation being 54% globally. 6 Despite this, there is a scarcity of research developing and examining interventions to encourage regular over problem-orientated dental attendance in all age groups. In addition, social inequalities are known to exist within regular/preventive dental care utilisation, and there is also a lack of research into interventions aiming to reduce this. 7 Little is known about the healthcare seeking behaviour of problemorientated dental attenders, although it is acknowledged that a 'web of causation' 8 and social inequalities 9 are likely to influence this attendance pattern. These complexities underpinning problem-orientated dental attendance make designing and developing interventions challenging in this patient group. To successfully develop any new interventions, it is important to consider existing interventions which have already been designed and trialled to identify components which could be improved or incorporated (retrofitted) or discounted as ideas. 10 To facilitate this, any previous interventions need to be mapped to their theoretical basis to facilitate the description of its mechanism of action and active ingredients. The Theoretical Domains Framework (TDF) 11 is a framework aimed at aggregating under broader domains a multitude of behavioural theories and the constructs associated with these.
Understanding what domain(s) an intervention is aimed at targeting allows the generation of evidence informed hypothesis on the basic mechanisms of action underlying the intervention. This, in turn, can link it to its active ingredients.
The aim of this systematic review was to investigate previous interventions or healthcare policy which have been developed for, and targeted at, problem-orientated dental attenders to facilitate the development and co-design of a new intervention. Where possible secondary aims were to establish the effectiveness and to consider views or opinions of any patients or healthcare providers on any existing interventions and healthcare policy identified.

| MATERIAL S AND ME THODS
This systematic review was conducted with an a priori protocol, which was published online on PROSPERO 12 and reported following PRISMA guidance. 13 The criteria for considering studies for the systematic review were (PICOS): • Participants: patients above the age of 18 years old of any gender who were problem-orientated or irregular dental attenders.
Studies of patients below 18 years old and of patients attending with chronic oro-facial pain were excluded.
• Interventions: any form of intervention (brief or complex) or policy change that encouraged regular dental attendance instead of problem-orientated attendance were included.
• Comparators/Control: No comparator was mandatorily required for inclusion. Where effectiveness was to be specifically considered the comparator or control group was set as patients not receiving the intervention, or for policy change the effect before and after.
• Outcomes: Primary outcomes were an increase in regular or preventive dental care visiting/utilisation or an increase in emergency attendance at a dentist instead of other healthcare providers.
• Studies: All peer-reviewed English language studies of any design were included. Where effectiveness was to be specifically considered, only studies using a comparative design for interventions and controlled before-after studies for policy change were included.

| Data collection and analysis
Eligible studies were selected by the first reviewer (CC) according to the inclusion and exclusion criteria based upon the study title and abstract (where available). If it was unclear whether a study should be included or not the full text was reviewed. A second reviewer (JD) reviewed the full text of all potential studies for inclusion, blinded to the journal title, institutions involved and the authors. Any disagreement regarding the inclusion of any study were resolved by discussion and inclusion of a third reviewer.

| Data extraction and management
A standardised form was created in Microsoft Word (Microsoft Office Professional Plus 2016) and used to extract data from the included studies. The first reviewer (CC) extracted and entered the data onto the form. To ensure reliability, all of the extracted data were cross-checked by the second reviewer (JD), again blinded to the study details as described above. Any disagreement was resolved as previously described. Data extracted included the following: • Intervention/policy change design, type and details, classified

| Data synthesis
Studies were tabulated to describe the intervention or policy change and to map to the TDF domains where possible. This provided a descriptive analysis to display ideas for further development. Due to substantial heterogeneity between the eligible studies effectiveness was summarised by study and integrated into a narrative synthesis of the main findings with a descriptive analysis only. Where patient or provider views and opinions were available these were considered alongside the intervention or policy change and integrated into a narrative synthesis.

| RE SULTS
The search strategy initially identified 4803 articles (Figure 1), of which 2857 were identified as duplicates leaving 1946 studies for initial review. Fifty-five papers were excluded as they were non-English, however from their English title or abstract did not appear relevant to the review. Following screening for inclusion and exclusion criteria, eight studies were reviewed as a full text, with three being included in the final review. 15-17 A list of the 5 excluded studies 18-22 is given in Appendix S3 with the reasons for exclusion.

| Description of studies included in the review
The included study characteristics are reported in Table 1. Two of the studies reported an intervention, 15,17 and one looked at the effect of policy change. 16 One study looked specifically at irregular dental attenders with dental anxiety. 17 The other two studies included a defined geographical population looking at the effect on the whole population as well as irregular dental attenders. 15,16 Two studies were set in England, 15,17 and one in Scotland. 16 All studies used the broad outcome of attendance for a dental check-up however measured differently. 15-17

| Narrative review of interventions
To summarise the three interventions: • Dailey et al. 17 interviewed patients following attendance at a dental anxiety clinic. Treatment at this clinic included behaviour management techniques (including desensitisation, modelling and semi hypnotic suggestion), and dental treatment with nitrous oxide sedation. Patients could also attend an optional dental support group which was described as 'mutual support in a nonclinical environment'.
• Anderson and Morgan 15 reported a generic advertising campaign which aimed to overcome the publics' perceived barriers to dental care. The promotion also included the option to attend a 'dental update', which allowed potential patients to visit a participating dental surgery to meet the dentist and look around the clinic (this did not include dental examination).
• Ikenwilo et al. 16 looked at the effect of the introduction of a free dental check-up in Scotland.
A summary of the interventions or policy change mapped to the TDF is provided in Table 2. One study examined the effect of a change in policy to provide free dental check-ups, 16 and the other two studies examined interventions. 15,17 Only one study 15

| Effectiveness of the Interventions
Key findings from the studies are summarised in Table 2. Following attendance at a dental anxiety clinic, almost half of participants became regular dental attenders; 17 however, only 23 participants out of a total of 41 who received the intervention were included.
Only 13% of the population attended for a dental update following a large advertising campaign; 15 however, there were issues with practice compliance in reporting this outcome; therefore, the true number of attendances could be underestimated. In Scotland, introducing a free dental check-up resulted in a 3.2% increase in number of dental check-ups; 16 however, there was also an increase in the number of patients attending for a private check-up, and in those who would have been exempt from NHS dental charges before the policy change. A self-reported outcome measure was also used in this study, which could have introduced reporting bias.

| Patient views of interventions
Two studies 15,17 included a qualitative component to provide patient views on the intervention. Participants attending a dental anxiety clinic who subsequently became regular dental attenders reported behaviour change due to: a transfer of treatment alliance; positive dentist-patient communication; no resistance formation; positive health beliefs; development of coping mechanisms. 17 Contrasting viewpoints were reported from those who did not become regular dental attenders. Whilst attending the dental anxiety clinic all participants reported developing a positive relationship with the dentist, which resulted in them being able to receive dental treatment whilst at the clinic; however, this was not always transferred outside of the clinic as participants did not want to receive treatment from another dentist.
A large advertising campaign was used to improve the image of dental services to the general public and promote the opportunity to attend for a free dental update; however, this was largely misinterpreted as 'visit your dentist', or 'there's no need to be frightened of the dentist'. 15 The dental update was also misunderstood and believed to be the same as a regular dental check-up. This could partly explain the low uptake of dental updates as approximately half of those interviewed said they would have attended for an update had they been aware. Of those who did attend for a dental update two groups emerged: acknowledgers who reported fear of attending the dentist but felt guilty for not going; opportunists who had toothache at the time of the campaign which prompted them to attend. All were motivated by the opportunity to talk to dentists and being given the chance to discuss any problems or fears, and the fact that dentists agreed to take part in the dental update scheme was considered an indicator that they were friendly and approachable. Interestingly, many had different experiences or could not recall what actually happened at the dental update including if they paid. Those who had no interest in attending a dental update reported no perceived need for seeking dental care, apathy and cost as barriers.

| D ISCUSS I ON
This systematic review highlighted two interventions aiming to increase regular dental attendance in irregular dental attenders and both studies provide areas for consideration in intervention development. Whether attendance at a dental anxiety clinic had a positive behavioural change effect is undeterminable given only half of the patients contacted had changed their attendance behaviour in the longer term, in addition to a large number of patients being lost to follow-up. However, what was highlighted as having the biggest self-reported effect on dental anxiety and move into regular dental attendance was the dentist's communication skills and establishing a good dentist-patient relationship. 17 It appears that the clinic helped patients receive dental treatment at the time of the intervention, but subsequently transferring care outside of the clinic to a different dentist was a barrier to establishment of routine dental care. This intervention would also only target problem-orientated attenders who report dental anxiety as a barrier to care seeking, and if this intervention was to be developed further then transfer of care following the intervention would need to be carefully considered in the design process.
A large advertising campaign to promote the image of dental services and offer a free dental update was largely unsuccessful due to public misinterpretation of intervention. 15 Interestingly, this is the only study identified which reported the theoretical basis for de- This review also identified one study examining the effect of policy change by introducing a free dental check-up in Scotland in 2006. 16 An increase in utilisation of dental check-ups was noted following this policy change, however, this varied between patient groups, including those accessing private dental care and those who would have been exempt from dental charges prior to the policy change. This therefore raises the question as to whether the observed self-reported behaviour change was a direct result of the policy change, or whether this indirectly raised awareness of dental services and therefore increased attendance. This study also highlights the wider implications of policy change such as this, including increased workforce requirements and the cost to the NHS and government and raises concerns over sustainability of continued free dental check-ups. As a result, the authors recommend refining the policy to target more vulnerable groups to maintain an optimal benefit.
As per the a priori protocol, a formal risk of bias assessment aim was to persuade non-users or irregular users of dental services to change their behaviour and visit the dentist more regularly by use of a promotional campaign advertising a free 'dental update'.
The dental update was described as allowing potential patients to visit dental surgeries and ask about treatment, have a look around and meet the dentist. On examples of the advertisements used they also suggested that patients could make an appointment for a check-up whilst at their dental update, which could map to environmental context and resources if this supported appointment making, however, this was not clear in the intervention description and was therefore omitted as a potential TDF domain. Indeed, patients reported different experiences at the dental update in this study, and this could be explained by the poor description to the dentists delivering the intervention.

| CON CLUS ION
This systematic review identified a lack of interventions targeted at problem-orientated dental attendance, however, data within the studies identified highlights the potential importance of considering dentist communication, the dentist-patient relationship, in-

CO N FLI C T O F I NTE R E S T
The authors have no conflicts of interest to declare.

AUTH O R CO NTR I B UTI O N S
C Currie contributed to conception, design, data acquisition and interpretation, analysis, drafted and critically revised the manuscript.
V Araujo-Soares and J Durham contributed to conception, design, data acquisition and interpretation, analysis and critically revised the manuscript. SJ Stone and F Beyer contributed to conception, design, data interpretation, and critically revised the manuscript. All authors gave their final approval and agree to be accountable for all aspects of the work.

PE E R R E V I E W
The peer review history for this article is available at https://publo ns.com/publo n/10.1111/joor.13244.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.