Albert Einstein said “Learn from yesterday, live for today, hope for tomorrow. The important thing is not to stop questioning.” But, how many of us actually query what we do and the care that we provide to our patients? When do we ask and justify: What is the best way to treat a cavity on this patient? What contemporary treatments can I provide for a patient who has recurrent periodontal disease? What is the optimal way of treating a carious lesion in a lower left D for that particular patient? How can I change the way I work in our practice to improve care for patients and enhance the working day for my team? These are just a few simple, but very important questions, which may arise every day in primary care dentistry, but,
justifications, which I suspect few of us ever, consider.
The treatment that we provide is most likely born of our experiences at dental school, or perhaps CPD and postgraduate courses, but how many of us check that what we do is justified and supported by the current evidence-base?
Care delivered within the National Health Service (NHS) should be clinically effective and also cost-effective to ensure that public finances are being used to the greatest effect for the population. Care provision must be supported by advances in both science and clinical practice; it should be evidence-based and supported by clinical research. But, here’s the rub; clinical (or applied health) research in primary care dentistry is still relatively rare. It is increasing, but the majority of studies which inform our clinical practice have been conducted in academic institutions and secondary care environments. Translation of
findings from one sector to another and the implementation of recommendations to daily practice in primary care can be slow and difficult at best, and at worst, totally inappropriate. It either does not see the light of day or has to be tweaked and squeezed into the real-world environment, which often ultimately compromises its effect.
Mike Schmoker, a best selling author on educational change says of research, “The research we do at the local level - collaboratively - is what makes formal, outside research work. Outside research cannot be installed like a car part - it has to be fitted, adjusted, and refined for the school contexts we worked in.”
Whilst the dental clinic might be a million miles from the school or classroom, there would seem some sense in this notion that research findings cannot simply be dropped in from afar. Indeed there is growing acknowledgement that primary care (including NHS general dental practice) is very different to the secondary care environment where research has traditionally been conducted. The significance of primary care practice-based research is increasingly recognised and with it need for dental practices to engage with the research process. Audit and evaluation can be valuable as part of this process, but what
is really required is high quality, academically informed, practicebased research.
Practice-based research can only proceed with the collaboration of primary care practices and clinical academia. How primary care dental professionals get engaged in research can range from identifying and recruiting patients into studies to helping instigate and run major multi-centre trials. Involvement can range from collecting data for others to proposing the intervention, setting the question and designing the study. Few practices have the infrastructure, and practitioners the necessary skills for designing and leading clinical studies, so getting started can appear daunting, but there is support available should you wish to embark on such a path.
The National Institute for Health Research, which is in essence the R&D division of the NHS, has support structures in place to aid primary care practitioners in getting involved in research. These range from helping design projects, obtaining permissions such as ethical approval, involving patients and the public, to actually funding studies. It also offers training and development awards for practitioners that support time away from practice, postgraduate tuition fees, and conference presentations. The benefits of getting involved in research are numerous: variety in daily practice, the idea that you’re involved in changing clinical practice for the better, supporting a change in career direction, extra income stream for your practice, and so on. Also by participating at the outset you could influence which areas of practice are researched that are relevant to primary care. This could look at for example if it is possible to use novel diagnostic and therapeutic technologies in our clinical practice and best way of utilising these interventions.
It is said that clinicians engaged with research are more likely to implement findings, and that patients on clinical trials have generally better health outcomes. Add to this that patients should be made aware of any clinical trials in which they can participate, then the added value to practices being involved in research is evident and appealing.
One study that our NHS practice is currently a part of is a large trial funded by the NIHR called FiCTION. This project aims to assess the best way of treating dental caries in deciduous teeth using either an operative traditional, a biological, or a non-operative prevention-only approach. Participation in such trials has certainly proved very stimulating
and a positive experience for all our practice and patients. Practice based research is also being recognised in postgraduate
programmes such as the Advanced Masters in Minimal Intervention Dentistry at King’s College London, which aims to develop research skills and promote research studies in primary care.
Currently there are only a few large practice-based studies ongoing but if we are to have influence on changing our clinical working practices to not only benefit patients but also all stakeholders including our practice team and ourselves then engagement in practicebased research is paramount. By getting involved we may be able to ultimately influence the national
and local policy-making decisions, which affect us all.
References available on request.