PHRN Dental ThemePHRN Dental Theme

Two Years OnTwo Years On

PHRN Dental ThemePHRN Dental Theme

Two Years OnTwo Years On

Martin TickleMartin Tickle Research Director Research Director

Oral Health Unit - National Primary Care R&D CentreOral Health Unit - National Primary Care R&D Centre

Professor of Dental Public Health & Primary CareProfessor of Dental Public Health & Primary CareSchool of Dentistry: The University of ManchesterSchool of Dentistry: The University of Manchester

StructureStructureStructureStructure

• Why do we need research in prisons? Why do we need research in prisons? • Progress on the research programme of the Progress on the research programme of the

dental theme of PHRNdental theme of PHRN• Demonstration project – preliminary resultsDemonstration project – preliminary results• Reflections Reflections • Next steps Next steps

Why do we need research in Why do we need research in prisons?prisons?

Why do we need research in Why do we need research in prisons?prisons?

ChallengesChallengesChallengesChallenges

• PCTs responsible for commissioning prison PCTs responsible for commissioning prison dental servicesdental services

• Major issuesMajor issues– High need populations– Need to provide equivalent care but with restricted

resources– Unique environment – security concerns– Workforce issues – recruitment, professional

isolation

• Poor evidence basePoor evidence base

Contribution from researchContribution from researchContribution from researchContribution from research

• Provides knowledgeProvides knowledge

– To inform commissioning decisionsTo inform commissioning decisions

– To inform clinical care delivery To inform clinical care delivery

Spin off benefits of researchSpin off benefits of research Spin off benefits of researchSpin off benefits of research

• Reduces professional isolation and supports Reduces professional isolation and supports professional developmentprofessional development

• Improves quality of careImproves quality of care

• Helps recruitment and retentionHelps recruitment and retention

Progress on the research Progress on the research programme of the dental theme programme of the dental theme

of PHRNof PHRN

Progress on the research Progress on the research programme of the dental theme programme of the dental theme

of PHRNof PHRN

PHRN programme PHRN programme PHRN programme PHRN programme • Formal launch – Formal launch – Sharing Good PracticeSharing Good Practice

ConferenceConference York 4-5 York 4-5thth May 2005 May 2005• Network of research supportive prisons Network of research supportive prisons • Network of research active individuals working Network of research active individuals working

in prisons - in prisons - http://www.phrn.nhs.uk/http://www.phrn.nhs.uk/

• Scoping exerciseScoping exercise• Small demonstration projects in each areaSmall demonstration projects in each area

Scoping exerciseScoping exerciseScoping exerciseScoping exercise

• Systematic reviewsSystematic reviews• Listening exerciseListening exercise

– WorkshopsWorkshops– InterviewsInterviews

• Identify and prioritise research needsIdentify and prioritise research needs• Feed into DH research commissioning Feed into DH research commissioning

frameworksframeworks

Dental Theme scoping exerciseDental Theme scoping exerciseDental Theme scoping exerciseDental Theme scoping exercise

• Systematic review of literature – completeSystematic review of literature – complete

• Very few papers - all descriptive epidemiologyVery few papers - all descriptive epidemiology

• No information about effectiveness of No information about effectiveness of interventionsinterventions

Research prioritiesResearch prioritiesResearch prioritiesResearch priorities• What interventions are effective in improving What interventions are effective in improving

health of prisoners? health of prisoners? • How can promotion of healthy eating\smoking How can promotion of healthy eating\smoking

cessation be supported?cessation be supported? • How can the surgery down time be How can the surgery down time be minimisedminimised??• Is screening of prisoners effective?Is screening of prisoners effective?• Effective use of skill-mixEffective use of skill-mix• A society for prison dentistsA society for prison dentists

• Specific request from CDOSpecific request from CDO

• Strategy for Modernising Dental Services for Strategy for Modernising Dental Services for Prisoners in England – Prisoners in England – April 2003April 2003– Standards for service deliveryStandards for service delivery

• Over £4.5M injected into prison dental servicesOver £4.5M injected into prison dental services

• Has strategy\additional funding improved prison Has strategy\additional funding improved prison dental services?dental services?

Evaluation of Prison Dental ServicesEvaluation of Prison Dental ServicesEvaluation of Prison Dental ServicesEvaluation of Prison Dental Services

Demonstration ProjectDemonstration ProjectDemonstration ProjectDemonstration Project

Developing and testing a screening Developing and testing a screening tool to identify prisoners with urgent tool to identify prisoners with urgent

treatment needstreatment needs

Aims of demonstration project Aims of demonstration project Aims of demonstration project Aims of demonstration project

• Development and testing of a standardised Development and testing of a standardised assessment tool to identify prisoners with assessment tool to identify prisoners with urgent treatment needsurgent treatment needs

• Identify and catalogue difficulties of running Identify and catalogue difficulties of running research projects in the prison setting research projects in the prison setting

BackgroundBackgroundBackgroundBackground

• Recently admitted prisoners have severe Recently admitted prisoners have severe dental problemsdental problems

• Remand and short stay prisoners have Remand and short stay prisoners have difficulty keeping appointments difficulty keeping appointments

• Most services run on a part time basisMost services run on a part time basis• On admission all prisoners have 24 hour, On admission all prisoners have 24 hour,

then 48 hour health assessment then 48 hour health assessment • No standardised system of dental No standardised system of dental

assessmentassessment

Screening as a processScreening as a processScreening as a processScreening as a process

Identify the target population

Identify the population at risk via a screening test

Attendance for a diagnostic test

Identify individuals in need of treatment via a

diagnostic test

Those in need of treatment receive

appropriate treatment

BackgroundBackgroundBackgroundBackground

• Collaboration with Queen Mary’s and GKTCollaboration with Queen Mary’s and GKT• Dental Pain Questionnaire (DePaQ)Dental Pain Questionnaire (DePaQ)• 2 page questionnaire2 page questionnaire• Categorises patients with pain into three Categorises patients with pain into three

groupsgroups– Irreversible pulpitis and periapical periodontitis– Reversible pulpitis and dentine sensitivity– Pericoronitis

• Successfully tested in NHS – enables Successfully tested in NHS – enables categorisation into Urgent and Non-Urgentcategorisation into Urgent and Non-Urgent

MethodsMethodsMethodsMethods

• All patients on urgent treatment list attending All patients on urgent treatment list attending dental services of Brixton and Belmarsh dental services of Brixton and Belmarsh prisons – aimed for N=200prisons – aimed for N=200

• Pilot questionnaire – literacy issuesPilot questionnaire – literacy issues• Administered by nurses who deliver 48 hour Administered by nurses who deliver 48 hour

assessment (screening test)assessment (screening test)• Clinical examinations by trained and Clinical examinations by trained and

calibrated examiners (diagnostic test) blinded calibrated examiners (diagnostic test) blinded to screening test outcomes to screening test outcomes

ResultsResultsResultsResults

• Lost Belmarsh due to increased security Lost Belmarsh due to increased security • Fieldwork planned for 6 weeks – took 4 Fieldwork planned for 6 weeks – took 4

monthsmonths• Stopped when N=100Stopped when N=100• Principal problems Principal problems

– Lack of authorised staff– Prison Officers – Behaviour of prisoners

Flow DiagramFlow DiagramFlow DiagramFlow Diagram96 subjects96 subjects in total in total

69 categorised at screening & clinical 69 categorised at screening & clinical examinationexamination

15 stated they had pain at screening but no 15 stated they had pain at screening but no urgent need at clinical examinationurgent need at clinical examination

4 no pain at screening and no urgent need at 4 no pain at screening and no urgent need at clinical examinationclinical examination

1 no pain at screening but urgent need at 1 no pain at screening but urgent need at clinical examinationclinical examination

5 had an incomplete questionnaire5 had an incomplete questionnaire and and urgent need at clinical examinationurgent need at clinical examination

2 prisoners had incomplete questionnaire 2 prisoners had incomplete questionnaire and no urgent need at clinical examinationand no urgent need at clinical examination

Results - frequency distribution at Results - frequency distribution at screeningscreening

Results - frequency distribution at Results - frequency distribution at screeningscreening

44

27

4

21

0

5

10

15

20

25

30

35

40

45

50

acute periapicalperiodontitis or irreversible

pulpitis

revesible pulpitis or dentinesensitivity

pericoronitis no pain

MethodsMethodsMethodsMethodsIrreversible Irreversible

pulpitis, periapical pulpitis, periapical periodontitis and periodontitis and

pericoronitispericoronitis

Reversible pulpitis Reversible pulpitis and dentine and dentine sensitivitysensitivity

Incomplete Incomplete questionnaire questionnaire

no painno pain

Urgent treatmentUrgent treatment

needneed

Non UrgentNon Urgent

Treatment NeedTreatment Need

==

==

Two by two table for expressing the results of validation study for any screening test

Result of screening test

Diagnose positive (a+c)

Diagnose negative (b+d)

Test positive (a+b) True positive (a) False positive (b)

Test negative (c+d) False negative (c) True negative (d)

Screening Test ValidationScreening Test Validation

Result of gold standard

(diagnostic) test

Screening TestsScreening Tests

SensitivitySensitivity = True positive rate = True positive rate

How good is the test at picking up people who haveHow good is the test at picking up people who havethe condition? a/ (a+c)the condition? a/ (a+c)

SpecificitySpecificity = True negative rate = True negative rate

How good is the test at correctly excluding peopleHow good is the test at correctly excluding peoplewithout the condition? d/ (b+d)without the condition? d/ (b+d)

Results – sensitivity and specificityResults – sensitivity and specificityResults – sensitivity and specificityResults – sensitivity and specificityDiagnosedDiagnosed

Urgent Treatment Urgent Treatment needneed

DiagnosedDiagnosed

Non-Urgent Non-Urgent Treatment needTreatment need

TotalTotal

ScreenedScreened

Urgent Urgent Treatment needTreatment need

39 (39 (81%81%)) 32 32 (67%)(67%) 7171(74%)(74%)

ScreenedScreened

Non-Urgent Non-Urgent Treatment needTreatment need

9 9 (19%)(19%) 16 (16 (33%33%)) 25 25 (26%)(26%)

TotalTotal 4848 4848 9696

ConclusionsConclusionsConclusionsConclusions

• High sensitivity –efficient at picking up individuals with an urgent High sensitivity –efficient at picking up individuals with an urgent

needneed

• Poor specificity – inefficient at excluding individuals who have Poor specificity – inefficient at excluding individuals who have

non-urgent treatment needsnon-urgent treatment needs

• Lack of candour will always be a problem?Lack of candour will always be a problem?

• Subjective vs professional judgement of need?Subjective vs professional judgement of need?

• Is this test useful? Is this test useful?

– Only need to see ¾ of population but miss 1/5 of those with

urgent treatment needs

Difficulties of running research Difficulties of running research projects in the prison settingprojects in the prison setting

Difficulties of running research Difficulties of running research projects in the prison settingprojects in the prison setting

ProblemsProblemsProblemsProblems

• No problems with healthcare staff, or the prisonsNo problems with healthcare staff, or the prisons• Prisoners – unpredictable behaviour and Prisoners – unpredictable behaviour and

unpredictable attendanceunpredictable attendance• Security – getting subjects to the health care facility Security – getting subjects to the health care facility • Staffing – recruitment of staff with security clearanceStaffing – recruitment of staff with security clearance• Prison officers – institutionalised resistance?Prison officers – institutionalised resistance?• Research a low priority - interferes with prison targetsResearch a low priority - interferes with prison targets• Dental Issues – low priority compared to other health Dental Issues – low priority compared to other health

problems problems

Reflections after 2 yearsReflections after 2 yearsReflections after 2 yearsReflections after 2 years

Thoughts on research in prisonsThoughts on research in prisonsThoughts on research in prisonsThoughts on research in prisons

• Prison dentistry needs a research basePrison dentistry needs a research base• The PHRN is a first stepThe PHRN is a first step• Significant difficulties of deliverySignificant difficulties of delivery• Are research outputs worth the effort?Are research outputs worth the effort?• RAE – main driver RAE – main driver

– High quality outputs

Pros and Cons for an AcademicPros and Cons for an Academic Pros and Cons for an AcademicPros and Cons for an Academic

ProsPros• Adherence to protocols by Adherence to protocols by

prison healthcare staffprison healthcare staff• High disease adult High disease adult

populationspopulations• Accessible populationAccessible population• High consent ratesHigh consent rates

ConsCons• Bizarre behaviourBizarre behaviour

– Adherence to protocols by subjects

– Response bias• Additional complexities of Additional complexities of

ethical approval process ethical approval process • Extended recruitment Extended recruitment

periodsperiods• Loss to follow upLoss to follow up• Lack of controlLack of control• Unpredictability Unpredictability

What next?What next?What next?What next?

Next StepsNext StepsNext StepsNext Steps

• Complete demonstration project – qualitative Complete demonstration project – qualitative research identifying barriers to undertaking high research identifying barriers to undertaking high quality researchquality research

• Network of research hosting prisons – can they Network of research hosting prisons – can they provide solutions and deliver?provide solutions and deliver?

• Will funding materialise?Will funding materialise?– PHRN– Other DH funding streams

• Will other academics become active in this field?Will other academics become active in this field?