Training Primary Care Practitioners in Endodontics of Moderate Complexity
: Feasibility and Pilot Data on Skills Enhancement and Treatment Outcomes

Student thesis: Doctoral ThesisDoctor of Philosophy


Background: With rising emphasis on pathways of patient care in dentistry, a pilot initiative involving collaboration by the London Deanery and London National Health Service (NHS) Commissioners provided training for general dental practitioners to upskill to the level of a 'Dentist with Enhanced Skills' (DES), in order to expand the availability of intermediate endodontic care to patients and improve the quality of endodontics in primary dental care. This provided the opportunity to test the feasibility of assessing the outcome of additional training in terms of treatment outcome in primary care dental services. 
Aims: To explore the impact of dedicated training and experience on the quality of endodontic care provided by general dental practitioners (GDPs) working in primary care settings, using clinical, radiographic and patient related outcomes, as well as ascertaining patient and practitioner views, with estimated financial costs of the training. 
Methods: This research involved a mixed methods approach with five components: 1: Pre-Post-test design of quality was used, with assessments of participants’ (GDPs) technical ability: pre-, during- and post-intervention. The quality of endodontic treatment performed at the beginning and end of training, on endodontic training blocks (in vitro) and clinical cases (in vivo) from self-reported logbooks containing clinical notes and radiographs were assessed. A measurement tool for Process (clinical treatment process, quality of root canal filling as seen radiographically) and Outcome (healing as seen clinically and radiographically) was developed and tested. Inter- and intra-examiner reliability was calculated for all domains scored using radiographs. Statistical analysis involved McNemar, Z- and Mann-Whitney U tests to calculate the statistical significance for the change from Year 0 to Year 2. 2: Quality of endodontic care post-training, by these DES was measured using the same measures of process and outcome including post-treatment healing. Patient related outcomes 3 were measured using Oral Health Impact Profile - Endodontic Outcome Measure (OHIP-EOM). Descriptive analysis was carried out. A comparison was made between the Process scores at Year 2 of the training course and post-training. 3: Perspectives of participating patients were collected pre- and post-treatment using self-completed questionnaires and quantitatively analysed. 4: Perspectives of participating dentists were collected using anonymised self-completed written questionnaires and qualitatively analysed using framework analysis. 5: Cost of providing this service with training was estimated from available NHS data and compared to the cost of this treatment being provided in different settings such as a hospital (secondary care) or within primary care by a specialist endodontist. 
Results: 1: Eight participants (dentists) completed the programme. Improvement in Process was seen for all domains in vitro (p<0.05), as well as in vivo for all domains of clinical treatment process (p<0.05) and improvement in achieving the correct working length of the root filling as seen by radiography (p<0.05). 2: DES recruited 135 patients requiring endodontics of intermediate complexity to the post-educational study. The quality of the process of providing endodontics was maintained following training (p=0.081 for clinical treatment process and p=0.242 for quality of root canal filling as seen by radiography). There were positive patient outcome [OHIP-EOM] scores after completion of treatment (mean score of 34.72, SD=10.74, n=120 pre-treatment and 25.85, SD=7.74, n=47 at follow-up). 4 3: The majority of patients reported they were satisfied, or very satisfied, with the service they received (72.5%, n=98); would use the service again (68.1%, n=92); and would recommend the service to friends and family (74.8%, n=101). 4: The DES perceptions of the training course were positive regarding the education and experience they received. They valued the supportive teaching and provision of educational materials; providing suggestions for development including more case discussions and teaching of more of the practical skills earlier in the course. Positive impacts were identified at individual (gains in knowledge, skills, confidence and personal development), patient (more teeth saved and quality of care) and system levels (access, value for money). 5: The total cost of this initiative was estimated at £664,400 including the purchase of necessary equipment (a training cost of £83,050 per dentist for both years). Within their NHS contract 1600 teeth were treated during the course (cost of treating each tooth during training approximates to £415.25 per tooth). 
Conclusions: The findings of this study suggest that it is possible to carry out outcome based research in primary care, and that a training programme for General Dental Practitioners working within the National Health System (NHS) can be successful in changing practice and skills enhancement, with evidence of good clinical practice and patient related outcomes. The training and service provided were acceptable to practitioners and patients. Furthermore, process and outcome measures have been developed and tested for use in future training as well as for use as a stand-alone measurement tool for outcome of root canal treatment in any clinical setting.
Date of Award1 Feb 2017
Original languageEnglish
Awarding Institution
  • King's College London
SupervisorJenny Gallagher (Supervisor) & Tim Newton (Supervisor)

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