Scottish Oral Health Research Collaboration

NIHR HTA Project Number 17/127/07, £2,305,509, 56 months

Tooth decay is very common with the majority of teenagers and adults having some decay in their back teeth. Treating tooth decay costs the NHS over £3.4 billion each year. There are different ways of treating decayed teeth where the decay has spread deep into the tooth close to the nerve. The most common way is to take away all of the decay before placing a filling in the tooth. This is known as “complete decay removal”. Removing all the decay can result in serious damage to the nerve making root canal treatment or tooth loss (extraction) likely. Also drilling the tooth to remove all the decay can weaken the tooth so it is more likely to break and need further treatment.

Dentists want to compare the complete removal of decay with a new way that does not remove all of the decay. In the new way, some of the decay is left behind and sealed under the filling. This is known as “partial decay removal”. There is research in children’s teeth that supports this new way. However, there are gaps in our knowledge about partial decay removal in adult teeth. SCRIPT will test “partial decay removal” compared to “complete decay removal” to establish if further follow-up treatment was needed, the costs incurred, the pain experienced by the patients and the impact on their lives.

We have designed a study where patients will be given one of the two treatments at random. We will do the trial in two stages. In the first we will check we can recruit a sufficient number of dentists and patients to generate enough data to draw meaningful conclusions and that what we are planning is acceptable to patients. If so, we will then go on to the second stage and do a large trial.  We will recruit 65 dental practices in England and Scotland. The dentists will recruit a total of 623 NHS dental patients over 12 years old who have deep decay in a back adult tooth and who agree to take part.

We will measure how well the treatment works over three years. We will look for evidence of serious damage to the nerve of the tooth. We will measure if the tooth needs root canal treatment or the tooth is lost (extracted by dentist) because the tooth has died. We will also measure damage to the nerve during treatment, patients’ pain, the impact of the mouth on patient’s daily lives,survival of the filling, need for more treatment and costs. We will use questionnaire surveys of patients, X-rays and data from dentists to test the success of the two ways to treat deep decay. We will also interview dental staff and patients about their views on the two ways to treat deep decay.

Many patients and members of the public have helped plan the study. They were keen we tested newer ways of treating tooth decay. They wanted us to look at pain, tooth loss, need for treatment and cost of treatment. The patients and public will continue to be involved as members of the study team and others will be external advisors to the study.

Collaboration: Dundee, Sheffield, Glasgow, Aberdeen, NES, KCL

Research team
Prof Janet Clarkson - Dundee
Prof David Ricketts - Dundee
Dr Thomas Lamont - Dundee
Prof Craig Ramsay - Aberdeen
Prof Chris Deery - Sheffield
Prof Zoe Marshman - Sheffield
Prof Sarah Baker - Sheffield
Dr Bhupinder Dawett - Sheffield
Prof Avijit Banerjee - KCL
Prof David Conway - Glasgow
Dr Linda Young - NES

NIHR HTA Project: NIHR129230, £1,996,745, 49 months

Severe toothache can be caused by tooth decay. Tooth decay is very common; almost all adults have experienced some decay in their back teeth. When tooth decay spreads deep into the tooth it can cause irreversible damage to the nerve of the tooth. There are different treatments available when this occurs. The most common treatments are root canal treatment or taking out the tooth. Root canal treatment involves removing all the nerve from within the tooth and sealing the tooth to protect it. However, it is costly for both the patient and the NHS. It can be time consuming meaning multiple trips to the dentist, as well as being technically demanding treatment. An alternative to a root canal treatment is to remove only the damaged part of the nerve and seal the tooth, which can be an easier and quicker treatment. This technique is called pulpotomy.
Research has already been conducted in children's teeth that supports using pulpotomy instead of root canal treatment. However, there are gaps in our knowledge about using pulpotomy in adult's teeth, specifically in a general dental care setting, such as in a local dental practice. We will compare pulpotomy with root canal treatment in adult patients. We will compare several aspects of the treatments including: the pain experienced by patients the impact of the treatment on their lives whether further treatment is needed the time and financial costs incurred.

We have designed a study for patients who have severe tooth ache who would normally receive root canal treatment or have their tooth removed. We will first run a feasibility study with a small group of patients and dentists to assess the training needs of dentists for conducting pulpotomy; identify any issues around recruiting participants and delivering the treatments; and to develop patient materials for the main trial. If the feasibility stage is successful, we will progress to do a larger study. In the larger study, if patients are eligible and willing to take part, they will be given one of the two treatments (root canal treatment or pulpotomy) allocated at random.

The first part of our study (the feasibility stage) will recruit 10 dental practices and 40 patients. If after the feasibility study, we believe we can deliver the full study, we will recruit 50 dental practices in England and Scotland. The dentists will recruit a total of 530 NHS adult dental patients who have irreversible damage of the nerve of a tooth in adult back teeth and who agree to take part.
We will measure how well the treatments work over one year. We will look for evidence of treatment success and compare symptoms associated with each treatment. We will measure if the tooth needs further treatment, for example a new or repeat root canal treatment or if the tooth needs to be removed. We will also measure patients' pain and anxiety, how their oral health affects their quality of life, the costs of treatment and patient satisfaction with their dental treatment.
We will ask patients to complete questionnaire surveys to gather this information. In addition, dentists will take X-rays and provide us with other information about the two treatments. We will also interview dental staff and patients about their views on the two treatments.
We worked with patients and members of the public to develop this study from the start. The patients we worked with were keen for us to test newer ways of treating tooth decay. They felt it was important to measure pain, tooth loss, need for and cost of treatment. A group of patient and public partners will continue to be involved as members of the study team and as external advisors. They will inform the design, conduct, interpretation and dissemination of the results of the study and are supported by a Patient and Public Involvement co-ordinator within the research team.

Collaboration: Dundee, Aberdeen, Liverpool, Sheffield, Glasgow, KCL

Research Team
Prof Janet Clarkson - Dundee
Prof David Ricketts - Dundee
Dr Thomas Lamont - Dundee
Prof Craig Ramsay – Aberdeen
Dr Beatriz Goulao - Aberdeen
Dr Dwayne Boyers – Aberdeen
Dr Ekta Gupta - Aberdeen
Dr Katie Banister - Aberdeen
Prof Marjon van der Pol - Aberdeen
Prof Avijit Banerjee - KCL
Prof Francesco Mannocci - KCL
Prof David Conway - Glasgow
Dr Douglas Robertson - Glasgow
Prof Chris Deery - Sheffield
Prof Zoe Marshman - Sheffield
Dr Linda Young – NES
Ms Tina Mcguff - Lay member
Prof Fadi Jarad – Liverpool
Prof Sondos Albadri - Liverpool

CSO CGA/19/24, £34877, 6 months

The FACTORS study tests the application of Human Factors to Quality Improvement via an interactive toolkit, designed in partnership with practitioners and the public through rigorous systems research. It will initially support dentists to examine their own systems in prevention of dental decay in young children, part of the Scottish and UK Governments’ preventive vision for NHS dental care. The tool includes performance data visualisation, suggestions from practice, interactive exercises, and a worksheet which generates an action plan. This project has tested the feasibility of delivering the tool, and gathered feedback from practitioners, to support a full UK trial. Application in other important areas of care is anticipated if successful.

Collaboration: Glasgow, Dundee, NES

Research Team
Dr Alastair Ross - Glasgow
Prof Lorna Macpherson - Glasgow
Prof David Conway - Glasgow
Prof Janet Clarkson - Dundee
Dr Linda Young - NES

Dunhill Medical Trust grant, R462/0216, £132796, 2016, 24 months

In seeking to improve the oral health and quality of life of older people living in Scottish care homes, it is important to recognise how oral health fits into a wider system of care, and the many challenges facing care homes in providing safe, high quality care for older people to improve health and wellbeing. The I-SCOPE project thus examines the care home system holistically, taking a Human Factors approach recommended by key bodies in healthcare. Many important elements influence quality care provision, including: staff recruitment and training; protocols and regulation; the physical environment and resources; and organisational culture and leadership. The vital benefit of this project is that it will identify how all these aspects best fit together, and discover what trade-offs and priority decisions staff make when under pressure. We will make recommendations about how systems can function more smoothly, teams can communicate more effectively and competing demands can be met within existing resources. This will be very useful for the TORCH oral health project and a whole range of safety and quality improvement efforts. 

Research Team

Dr Al Ross – University of Glasgow
Dr Janet Anderson – King’s College London
Dr Debbie Bonetti – University of Dundee
Dr Paul Bowie – NHS Education for Scotland
Heather Edwards – Care Inspectorate
Dr Evridiki Fioratou – University of Dundee
Prof Ruth Freeman – University of Dundee
Prof Lorna Macpherson – University of Glasgow
Dr Andrea Sherriff – University of Glasgow
Dr Linda Young – NHS Education for Scotland

CSO CGA/19/83, £33616, 6 months

This study has examined the current national clinical audit process that all dentists in Scotland are required to participate in. In partnership with healthcare professionals, patients, and policy stakeholders we have redesigned the national clinical audits for a specific example topic: the provision of preventive treatment for child dental decay, one of the highest oral health priorities in Scotland. The impact of these co-designed audits will now be examined in the proposed next stage of this research. An application for a larger project has been submitted to NIHR, RECODE: A Randomised Controlled Trial to Evaluate Co-designed National Quality
Improvement Interventions.

Collaboration: Dundee, Glasgow, Aberdeen, NES

Research team
Prof Janet Clarkson - Dundee
Dr Laura Beaton - Dundee
Dr Heather Cassie - Dundee
Dr Eilidh Duncan - Aberdeen
Dr Linda Young - NES
Dr Alastair Ross - Glasgow

Application submitted to HTA, NIHR, 2018, £2,193,543. (currently under negotiation)

Tooth decay costs around £1.3 billion in England with over 7 million fillings placed in permanent teeth during 2016. The same situation is seen in Scotland. The project will operate a cluster randomised control trial in dental practice settings across Scotland and the UK. It will compare traditional treatment involving the complete removal of decay before placing a filling against selective caries removal where some decay is left in the tooth to establish clinical and cost effectiveness as well as the preferences of patients and dentists.

Research Team

Prof Janet Clarkson – University of Dundee
Prof Craig Ramsay – University of Aberdeen
Prof Avijit Banerjee – King’s College London
Prof David Ricketts – University of Dundee
Prof Chris Deery – University of Sheffield
Dr Zoe Marshman, University of Sheffield
Prof David Conway – University of Glasgow
Mr Thomas Lamont – University of Dundee
Dr Bhupinder Dawett –  University of Sheffield
Dr Linda Young, NHS Education for Scotland
Prof Graeme MacLennan – University of Aberdeen
Mr Dwayne Boyers – University of Aberdeen
Prof Marjon van der Pol, University of Aberdeen
Dr Andrea Sherriff – University of Glasgow
Ms Tina Halford Maguff – University of Aberdeen