Odontogenic pain from various dental issues significantly impacts quality of life, necessitating effective treatment during emergency dental care. Endodontic access cavity preparation is essential for alleviating symptoms and preventing further infection. This procedure aims to achieve symptom relief while conserving as much tooth structure as possible. This paper discusses the importance of proper endodontic access, emphasising the balance between adequate disinfection and preserving tooth integrity. It also identifies challenges in endodontic access cavity preparation. This study reviews existing literature on endodontic access, examining different approaches to access cavity preparation and the tools and techniques used. Factors affecting access difficulty, including tooth anatomy, patient-related challenges and operator skills, are evaluated, alongside advancements in imaging and instrumentation. The review shows conservative techniques, like minimally invasive access cavities, which helps to preserve tooth structure but requires advanced skills and may risk incomplete disinfection. Cone beam computed tomography (CBCT) aids in complex cases, improving canal location accuracy. Operator skills and proper equipment are key to success. Traditional cavities offer better access but can weaken the tooth, while conservative approaches maintain structure but demand more expertise. Imaging tools, including CBCT, are beneficial for complex anatomy but can be costly. To conclude, effective endodontic access cavity preparation requires a balanced approach tailored to each case. While conservative methods offer advantages in preserving tooth structure, their success depends on operator expertise and equipment. Incorporating imaging advancements like CBCT can enhance access success, especially in anatomically complex cases, but careful assessment of case complexity remains crucial.

Different dental schools assess ‘finals' in different ways. Assessment of applied clinical knowledge and skills are commonly based on either objective structured clinical examinations or multiple ‘long cases'. While iterative changes naturally occur throughout education and assessment, it is important to step back and question what skills should be assessed and either identify or develop new assessment methods. At the point of graduation, these should capture the professional attributes expected of a ‘qualified dentist'. New graduate attributes we consider valuable, which can often be challenging to assess summatively in a high-stakes examination, include effective communication skills in a variety of contexts, the ability to be reactive and responsive, and to manage case complexity appropriately for the graduate level. Here, we report a dynamic assessment incorporating candidate interaction with a range of stakeholders. To reflect progression of changing clinical situations, we move away from solely traditional case-based discussions, which principally assess interaction with an examiner, and have introduced multiple scenarios with rapid situation changes, long-term follow-up, treatment complications and challenging communications. A cross-cutting assessment rubric was developed to assess candidates' information gathering/giving, communication, clinical and diagnostic reasoning, applied knowledge, management and professionalism.

AimTo investigate patient outcomes from either pulpotomy or pulpectomy for the management of symptomatic irreversible pulpitis, with and without application of antibiotic/corticosteroid pastes in urgent primary dental care settings in the United Kingdom.MethodologyAll patients receiving intervention for symptomatic irreversible pulpitis in three different primary care settings were invited to participate. Pre-operatively, data regarding patients' numerical ratings scale (NRS), pain score (0-10), analgesic use, oral-health impact profile-14 (OHIP-14) and need for time away from work were collected. For 7 days post-operatively, participants recorded their NRS pain score, global rating of change score, medication use and their ability to work. Analysis used a mixed-effects model with post hoc Tukey's multiple comparisons test for continuous data and chi-squared or Fisher's exact test for categorical data. To test the effect of the corticosteroid/antibiotic paste, pulpectomy and pulpotomy groups were combined following Mantel-Haenszel stratified analysis or a weighted average of the difference between pulpotomy and pulpectomy with and without the use of corticosteroid/antibiotic paste. A binary composite score was constructed using pre- and post-operative data, whereby overall treatment success was defined as: (i) patients did not return for treatment due to pain by day seven; (ii) at day three, there was a 33% (or 2-points) reduction in NRS pain score; (iii) there was a change score of +3 in global rating; (iv) the patient was no longer using analgesia and able to return to work.ResultsEighty-five participants were recruited, with 83 completing follow up. Overall treatment success was 57%, with 25% of participants returning for more treatment due to inadequate pain relief. Overall treatment success did not differ between the two groups (p = .645), although patients self-reported greater improvement with an antibiotic/corticosteroid dressing for global rating of change (p = .015).ConclusionsThis study identified limited evidence of improved outcomes using antibiotic/corticosteroid dressings in the management of symptomatic irreversible pulpitis in the emergency setting. Further clinical research is needed to understand if these medications are beneficial in affording pain relief, above that of simple excision of irreversibly inflamed pulp tissue.

OBJECTIVES:This study aimed to explore trends and predictors for antibiotic prescriptions and referrals for patients seeking dental care at General Medical Practitioners (GMPs) over a 44-year period in Wales, UK.METHODS:This retrospective observational study analysed data from the nationwide Secure Anonymised Information Linkage Databank of visits to GMPs. Read codes associated with dental diagnoses were extracted from 1974-2017. Data were analysed using descriptive statistics, univariate and multivariable logistic regression.RESULTS:Over the 44-year period, there were a total of 160,952 antibiotic prescriptions and 2,947 referrals associated with a dental attendance. Antibiotic prescriptions were associated with living in the most deprived (OR 0.91, 95% CI 0.89-0.93) or rural (OR 0.83, 95% CI 0.82-0.84) areas, whereas referrals were associated with living in an urban area (OR 2.16, 95% CI 1.99-2.35) or rural and less deprived area (OR 1.71, 95% CI 1.26-2.33). The number of antibiotic prescriptions decreased over time whereas the number of referrals increased.CONCLUSIONS:These changes coincide with dental attendance rates at GMPs over the same period and indicate that appointment outcome and repeat patient attendance are linked. Rurality and deprivation may also influence care provided.CLINICAL SIGNIFICANCE:General medical practices are not the most appropriate place for patients seeking dental care to attend, and efforts should be made to change current practice and policy to support patients to seek care from dental practices. When patients do seek dental care from GMPs they should be encouraged to refer the patient to a dentist rather than prescribe antibiotics as an important element of national antimicrobial stewardship efforts, as well as to discourage repeat attendance.

AIM:This study aimed to: (i) calculate personal financial costs associated with urgent dental attendance; and (ii) investigate the pain-related disability and quality of life impact of dental conditions which result in urgent dental attendance. METHODOLOGY:Data were collected from those presenting with urgent dental conditions to an out-of-hours dental service, a dental emergency clinic (DEC) and five primary care general dental practices across North-East England. A pre-operative questionnaire explored the impact of urgent dental conditions on oral health-related quality of life (OHRQoL) using Oral Health Impact Profile-14 (OHIP-14) and a modified Graded Chronic Pain Scale (GCPS). OHIP-14 yields a maximum score of 56, with a higher score indicating a lower OHRQoL. Personal financial costs were summed to provide a total. These included travel, appointment fees, childcare costs, medication use and time away from work. Data were analysed using one-way anova and multivariable modelling. RESULTS:In total, 714 participants were recruited. The mean OHIP-14 score was 25.73; 95% CI [24.67, 26.79], GCPS CPI was 71.69; 95% CI [70.09, 73.28] and GCPS interference was 49.56; 95% CI [47.24, 51.87]. Symptomatic irreversible pulpitis was the most frequently managed dental emergency and was associated with the highest mean OHIP-14 score (31.67; 95% CI [30.20, 33.15]). The mean personal financial cost of urgent dental care (UDC) was £85.81; 95% CI [73.29, 98.33]. Differences in travel time (F[2, 691] = 10.24, p < .001), transport costs (F[2, 698] = 4.92, p = .004), and appointment time (F[2, 74] = 9.40, p < .001) were significant between patients attending an out-of-hours dental service, DEC and dental practices for emergency care, with a DEC being associated with the highest costs and dental practices the lowest. CONCLUSIONS:Diseases of the pulp and associated periapical disease were the most common reason for patients to present for UDC and were the most impactful in terms of OHRQoL and pain in the present sample. Personal financial costs are significant from urgent dental conditions, with centralized services increasing the burden to patients of attending appointments.

Introduction Around one-third of the UK population are 'problem-orientated dental attenders', only seeking care when suffering with dental pain and often on a repeated basis to secondary care. Little is known about attendance in primary care. The aim here was to examine the period prevalence of repeat urgent care attenders and establish predictors of repeat attendance in primary care. Methods Data on urgent and emergency dental care attendances in primary dental care in the North East and Cumbria were analysed from 2013-2019. Variables included: patient sex; ten-year age band; lower super output area; and Index of Multiple Deprivation. Period prevalence was calculated and data were considered year by year to identify trends in attendances. Analysis was with descriptive statistics and predictors of repeat attendance were identified using logistic regression modelling. Results Over the six-year period, there were 601,432 attendances for urgent primary dental care, equating to a period prevalence of 2.76% for the geographic population studied. In total, 16.15% of attendances were repeat attendances (period prevalence 0.45%) and predictors included being a woman and residence in deprived and rural areas. All urgent care attendances decreased over the six-year period, with one-off attendances beginning to increase again in 2019, while repeat attendances stabilised. Conclusion Interventions to encourage regular dental attendances should be targeted at patients from the most deprived and rural areas of the North East and Cumbria; however, a decrease in repeat attendance was noted in these areas.

Introduction: Amalgam use has recently been phased down, and the potential for a phase-out is being investigated. Objectives: The study aimed to identify knowledge of the phase-down and opinions of a potential phase-out of amalgam by UK primary care clinicians and assess their confidence in using different materials in different situations. Methods: An anonymized, prepiloted cross-sectional e-survey was used to assess primary care clinicians' knowledge and opinions of the amalgam phase-down and potential phase-out and their confidence in using amalgam and the alternatives in different situations. In total, 11,902 invitations were distributed through British dentist and therapist associations. Prior hypotheses were tested alongside descriptive statistics. Results: Response rate was 13% (n = 1,513). Knowledge of the amalgam phase-down was low, with just 3% clinicians correctly identifying all patient groups in whom amalgam use should be avoided in the United Kingdom. Postgraduate education on posterior composite placement was high (88%), but a large majority had personal and patient-centered concerns over the suitability of the alternatives and lacked confidence when placing composite in comparison to amalgam in difficult situations (P < 0.0001). Logistic regressions revealed that the best predictors of high confidence in placing mesio-occluso-distal composites and composites in difficult situations were being a private general dentist or being primarily a composite user. Conclusion: Primary care clinicians have major personal and patient-centered concerns regarding the amalgam phase-down (of which they have limited knowledge) and potential phase-out. Many lack confidence in using the alternative, composite, to restore posterior teeth in difficult situations, whereas confidence in using amalgam in similar situations is high. Effective education of clinicians and understanding patients' needs, alongside policy changes, are required to enable a successful amalgam phase-down and potential phase-out. Knowledge Transfer Statement: This study shows that UK primary care clinicians are worried about the phase-down of amalgam for themselves and their patients. Many lack confidence in the alternative, composite, when used in difficult situations, which is in stark contrast to amalgam. Knowledge of the phase-down is limited. There is a need for more effective education of clinicians, an understanding of patients' values, and policy changes to ensure the success of the phase-down and potential phase-out of amalgam.

One-third of the UK population is composed of problem-oriented dental attenders, seeking dental care only when they have acute dental pain or problems. Patients seek urgent dental care from a range of health care professionals, including general medical practitioners. This study aimed to identify trends in dental attendance at Welsh medical practices over a 44-y period, specifically in relation to dental policy change and factors associated with repeat attendance. A retrospective observational study was completed via the nationwide Secure Anonymised Information Linkage (SAIL) Databank of visits to general medical practice in Wales. Read codes associated with dental diagnoses were extracted for patients attending their general medical practitioner between 1974 and 2017. Data were analyzed with descriptive statistics and univariate and multivariable logistic regression. Over the 44-y period, there were 439,361 dental Read codes, accounting for 288,147 patient attendances. The overall attendance rate was 2.60 attendances per 1,000 patient-years (95% CI, 2.59 to 2.61). The attendance rate was negligible through 1987 but increased sharply to 5.0 per 1,000 patient-years in 2006 (95% CI, 4.94 to 5.09) before almost halving to 2.6 per 1,000 in 2017 (95% CI, 2.53 to 2.63) to a pattern that coincided with changes to National Health Service policies. Overall 26,312 patients were repeat attenders and were associated with living in an area classified as urban and deprived (odds ratio [OR], 1.22; 95% CI, 1.19 to 1.25; P < 0.0001) or rural (OR, 0.84; 95% CI, 0.83 to 0.85; P < 0.0001). Repeat attendance was associated with greater odds of having received an antibiotic prescription (OR, 2.53; 95% CI, 2.50 to 2.56; P < 0.0001) but lower odds of having been referred to another service (OR, 0.75; 95% CI, 0.70 to 0.81; P < 0.0001). Welsh patients' reliance on medical care for dental problems was influenced by social deprivation and health policy. This indicates that future interventions to discourage dental attendance at medical practitioners should be targeted at those in the most deprived urban areas or rural areas. In addition, health policy may influence attendance rates positively and negatively and should be considered in the future when decisions related to policy change are made.

Patients with persistent orofacial pain (POFP) can go through complex care pathways to receive a diagnosis and management, which can negatively affect their pain. This study aimed to describe 44-y trends in attendances at Welsh medical practices for POFP and establish the number of attendances per patient and referrals associated with orofacial pain and factors that may predict whether a patient is referred. A retrospective observational study was completed using the nationwide Secure Anonymised Information Linkage Databank of visits to general medical practices in Wales (UK). Data were extracted using diagnostic codes (“Read codes”). Orofacial and migraine Read codes were extracted between 1974 and 2017. Data were analyzed using descriptive statistics and univariate and multivariable logistic regression. Over the 44-y period, there were 468,827 POFP and migraine diagnostic codes, accounting for 468,137 patient attendances, or 301,832 patients. The overall attendance rate was 4.22 attendances per 1,000 patient-years (95% confidence interval [CI], 4.21–4.23). The attendance rate increased over the study period. Almost one-third of patients ( n = 92,192, 30.54%) attended more than once over the study period, and 15.83% attended more than once within a 12-mo period. There were 20,103 referral codes that were associated with 8,183 patients, with over half these patients being referred more than once. Odds of receiving a referral were highest in females (odds ratio [OR], 1.23; 95% CI, 1.17–1.29), in those living in rural locations (OR, 1.17; 95% CI, 1.12–1.22), and in the least deprived quintile (OR, 1.39; 95% CI, 1.29–1.48). Odds also increased with increasing age (OR, 1.03; 95% CI, 1.03–1.03). The increasing attendance may be explained by the increasing incidence of POFP within the population. These patients can attend on a repeated basis, and very few are referred, but when they are, this may occur multiple times; therefore, current care pathways could be improved.

Direct posterior dental restorations are commonly provided following management of dental caries. Amalgam use has been phased down and the feasibility of a phase-out by 2030 is being explored. Alternative direct restorative materials differ in their outcomes and provision. This research aimed to elicit the UK population’s preferences for different attributes of restorations and their willingness to pay (WTP) for restorative services and outcomes. A discrete choice experiment (DCE) was designed with patient and public involvement and distributed to a representative sample of the UK general population using an online survey. Respondents answered 17 choice tasks between pairs of scenarios that varied in levels of 7 attributes (wait for filling, clinician type, filling color, length of procedure, likely discomfort after filling, average life span of filling, and cost). An opt-out (no treatment) was included. Mixed logit models were used for data analysis. Marginal WTP for attribute levels and relative attribute importance were calculated. In total, 1,002 respondents completed the DCE. Overall, respondents were willing to pay £39.52 to reduce a 6-wk wait for treatment to 2 wk, £13.55 to have treatment by a dentist rather than a therapist, £41.66 to change filling color from silvery/gray to white, £0.27 per minute of reduced treatment time, £116.52 to move from persistent to no postoperative pain, and £5.44 per year of increased restoration longevity. Ability to pay affected willingness to pay, with low-income respondents more likely to opt out of treatment and value restoration color (white) and increased longevity significantly lower than those with higher income. Clinicians should understand potential drivers of restoration choice, so they can be discussed with individual patients to obtain consent. It is important that policy makers consider general population preferences for restorative outcomes and services, with an awareness of how income affects these, when considering the potential phase-out of amalgam restorations.

Aim To investigate attitudes and approaches of UK primary care dentists to carrying out vital pulp treatment (VPT) after carious exposure and with additional signs and symptoms indicative of irreversible pulpitis. Methodology An electronic questionnaire was openly distributed via publicly funded (NHS) local dental committees, corporate dental service-providers, professional societies and social media. Principally NHS practitioners and those from mixed and private practice were targeted, in addition to community and military dental officers, and dental therapists. Participants were asked questions relating to several clinical scenarios, with responses analysed using descriptive statistics. chi(2) tests with sequential Bonferroni correction were used to explore variables including the method of remuneration, practitioner type (dentist/therapist), postgraduate qualification(s), place of graduation and years since qualification. Variables with a relationship p <= .2 were selected for backwards likelihood ratio logistic modelling. Results In total, 648 primary care practitioners were included for analysis. Calcium hydroxide (CH) was most frequently used for direct pulp caps (DPCs) (398/600; 66.3%) with calcium silicate cements (CSCs) less frequently used (119/600; 19.8%). Rubber dam was used by 222/599 (37.1%) practitioners. A definitive pulpotomy for the management of teeth with signs and symptoms indicative of irreversible pulpitis was selected by 65/613 (10.6%) dentists. The principal barrier for the provision of definitive pulpotomies was a lack of training (602/612; 98.4%). Regression analysis identified NHS practitioners as a good predictor for using CH for DPCs, having shorter emergency appointments, limited access to magnification and not using rubber dam. Non-UK graduates were more likely to select CSCs, appropriately control pulpal haemorrhage, undertake appropriate postoperative evaluation and use rubber dam. Conclusions Practitioners deviated from evidence-based guidelines in a number of aspects including material selection, asepsis and case selection. A number of other challenges exist in primary care in providing predictable VPTs, including lack of time and access to magnification. These were most evident in NHS practice, potentially exacerbating existing social health inequalities. Possible inconsistencies in the UK undergraduate curriculum were supported by a lack of association between years since qualification and technique employed as well as the fact that non-UK graduates and dentists with postgraduate qualifications adhered more to evidence-based VPT guidelines.

To investigate current approaches and attitudes towards the management of deep caries in primary dental care within the United Kingdom (UK). Open distribution of an electronic questionnaire survey was undertaken to primary care dental professionals working in publicly funded National Health Service [NHS], privately funded, military and community dental services. Demographic variables investigated included the following: place of qualification, method of remuneration, level of restorative training, materials available, years qualified, appointment length and clinician type. Management variables focussed on case-based scenarios. Univariate analyses of responses to questions were undertaken using χ 2 tests with sequential Bonferroni correction. Variables with a statistical relationship of p  ≤ .2 were selected for binary logistic regression modelling. A total of 657 responses were received. Practitioners with formal postgraduate qualifications (PGQ) were more likely (OR, 95%CI) to undertake further tests to aid diagnosis including: gaining a patient history (1.80, 1.01–3.20), periapical radiography (1.43, 1.01–2.03), cold pulp testing (2.079, 1.46–2.97) and electric pulp testing (1.65, 1.02–2.65). Rubber dam was infrequently used for deep caries management (29.2%). Non-NHS practitioners were much more likely to use rubber dam (3.40, 2.15–5.37), as were those that had completed PGQ (2.24, 1.48–3.38). Non-selective caries removal was used in deep caries by 41.4% of practitioners. Indirect pulp caps were carried out by 56.7% of practitioners. NHS practitioners were more likely to place calcium hydroxide (3.74, 1.97–7.15), whilst non-NHS practitioners were more likely to place calcium silicate cements (CSCs) (3.303, 1.71–6.38) as were non-UK graduates (5.63, 2.47–12.86) and those with PGQ (2.12, 1.17–3.87). This UK survey highlights significant variation in the management of deep caries. There is lack of consensus regarding the use of a standard systematic approach to diagnosing disease, with a reliance on history and tests with poor specificity. Non-selective caries removal for managing deep carious lesions remains common, with low rubber dam compliance underlining a lack of asepsis. Notably, a significant number of practitioners placed indirect pulp caps, but CSCs and GIC were not commonly used. At present, although clear guidelines are available this is not translating into consistent management approaches in practice, suggesting that better dissemination of current treatments is essential to undergraduate and postgraduate groups.

This is the first article in a series reviewing the current literature surrounding the management of deep caries in permanent teeth. Approaches to caries management are continuing to evolve, with more conservative management increasingly favoured. This philosophy has never been more important than in managing the deep carious lesion. Evidence is emerging that the use of selective caries removal to reduce the risk of pulp exposure, in conjunction with calcium silicate cements, can be successful in maintaining pulp vitality, delaying the restorative cycle and prolonging the lifespan of the tooth.

Vital pulp therapies (VPTs) aim to preserve the vitality of the pulp. The European Society of Endodontology have begun a campaign to raise awareness on the efficacy of VPTs following on from the publication of their 2019 position statement, aimed at both specialists and general dental practitioners. This review examines the current evidence surrounding VPTs and provides a rational approach to the management of the exposed pulp with the aid of case studies. Success lies in accurate diagnosis and case selection, along with well-executed treatment and appropriate follow-up protocols. The introduction of calcium silicate cements has made these treatments more predictable.

Aim To investigate current approaches and attitudes towards the management of deep caries in primary dental care within the United Kingdom (UK). Methodology Open distribution of an electronic questionnaire survey was undertaken to primary care dental professionals working in publicly funded National Health Service [NHS], privately funded, military and community dental services. Demographic variables investigated included the following: place of qualification, method of remuneration, level of restorative training, materials available, years qualified, appointment length and clinician type. Management variables focussed on case-based scenarios. Univariate analyses of responses to questions were undertaken using chi(2) tests with sequential Bonferroni correction. Variables with a statistical relationship of p <= .2 were selected for binary logistic regression modelling. Results A total of 657 responses were received. Practitioners with formal postgraduate qualifications (PGQ) were more likely (OR, 95%CI) to undertake further tests to aid diagnosis including: gaining a patient history (1.80, 1.01-3.20), periapical radiography (1.43, 1.01-2.03), cold pulp testing (2.079, 1.46-2.97) and electric pulp testing (1.65, 1.02-2.65). Rubber dam was infrequently used for deep caries management (29.2%). Non-NHS practitioners were much more likely to use rubber dam (3.40, 2.15-5.37), as were those that had completed PGQ (2.24, 1.48-3.38). Non-selective caries removal was used in deep caries by 41.4% of practitioners. Indirect pulp caps were carried out by 56.7% of practitioners. NHS practitioners were more likely to place calcium hydroxide (3.74, 1.97-7.15), whilst non-NHS practitioners were more likely to place calcium silicate cements (CSCs) (3.303, 1.71-6.38) as were non-UK graduates (5.63, 2.47-12.86) and those with PGQ (2.12, 1.17-3.87). Conclusions This UK survey highlights significant variation in the management of deep caries. There is lack of consensus regarding the use of a standard systematic approach to diagnosing disease, with a reliance on history and tests with poor specificity. Non-selective caries removal for managing deep carious lesions remains common, with low rubber dam compliance underlining a lack of asepsis. Notably, a significant number of practitioners placed indirect pulp caps, but CSCs and GIC were not commonly used. At present, although clear guidelines are available this is not translating into consistent management approaches in practice, suggesting that better dissemination of current treatments is essential to undergraduate and postgraduate groups.

Objectives: High-speed dental instruments produce aerosol and droplets. The objective of this study was to evaluate aerosol and droplet production from a novel electric micromotor handpiece (without compressed air coolant) in real world clinical settings. Methods: 10-minute upper incisor crown preparations were performed in triplicate in an open-plan clinic with mechanical ventilation providing 3.45 air changes per hour. A 1:5 ratio electric micromotor handpiece which allows water coolant without compressed air (Ti-Max Z95L, NSK) was used at three speeds: 60,000 (60K), 120,000 (120K), and 200,000 (200K) revolutions per minute. Coolant solutions contained fluorescein sodium as a tracer (2.65 mmol L−1). High-speed air-turbine positive control, and negative control conditions were conducted. Aerosol production was evaluated at 3 locations (0.5 m, 1.5 m and 1.7 m) using: (1) an optical particle counter (OPC; 3016-IAQ, Lighthouse) to detect all aerosol; and (2) a liquid cyclone air sampler (BioSampler, SKC Ltd.) to detect aerosolised fluorescein, which was quantified by spectrofluorometric analysis. Settled droplets were detected by spectrofluorometric analysis of filter papers placed onto a rig across the open-plan clinic.Results: Local (within treatment bay) settled droplet contamination was elevated above negative control for all conditions, with no difference between conditions. Settled droplet contamination was not detected above negative controls outside the treatment bay for any condition. Aerosol detection at 1.5 m and 1.7 m, was only increased for the air-turbine positive control condition. At 0.5 m, aerosol levels were highly elevated for the air-turbine, minimally elevated for 200K and 120K, and not elevated for 60K. Conclusions: Electric micromotor handpieces which use water-jet coolant alone without compressed air, produce localised (within treatment bay) droplet contamination but are unlikely to produce aerosol contamination beyond the immediate treatment area (1.5 m), allowing them to be used safely in most open-plan clinic settings.

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.

AbstractPain arising for the teeth and supporting structures is a very common complaint, affecting around 9% of adults in the UK, and it can sometimes be difficult to determine the exact cause. In this narrative review, we explore the underlying neurophysiology of odontogenic pain and describe the relevance of this to clinical practise. We discuss characteristic features of pain arising from the various dentoalveolar structures and common oral disorders, and consider that non‐odontogenic pain may occasionally present as toothache. As well as describing current approaches to reaching a reliable diagnosis, we also discuss some innovative techniques and potential future developments in this area.

Introduction: A European Union amalgam phase-down has recently been implemented. Publicly funded health care predominates in the United Kingdom with the system favoring amalgam use. The current use of amalgam and its alternatives has not been fully investigated in the United Kingdom. Objectives: The study aimed to identify direct posterior restorative techniques, material use, and reported postoperative complication incidence experienced by primary care clinicians and differences between clinician groups. Methods: A cross-sectional survey was distributed to primary care clinicians through British dentist and therapist associations (11,092 invitations). The questionnaire sought information on current provision of direct posterior restorations and perceived issues with the different materials. Descriptive statistical and hypothesis testing was performed. Results: Dentists' response rate was 14% and therapists' estimated minimum response rate was 6% (total N = 1,513). The most commonly used restorative material was amalgam in molar teeth and composite in premolars. When placing a direct posterior mesio-occluso-distal restoration, clinicians booked on average 45% more time and charged 45% more when placing composite compared to amalgam (P < 0.0001). The reported incidences of food packing and sensitivity following the placement of direct restorations were much higher with composite than amalgam (P < 0.0001). Widely recommended techniques, such as sectional metal matrix use for posterior composites, were associated with reduced food packing (P < 0.0001) but increased time booked (P = 0.002). Conclusion: Amalgam use is currently high in the publicly funded sector of UK primary care. Composite is the most used alternative, but it takes longer to place and is more costly. Composite also has a higher reported incidence of postoperative complications than amalgam, but time-consuming techniques, such as sectional matrix use, can mitigate against food packing, but their use is low. Therefore, major changes in health service structure and funding and posterior composite education are required in the United Kingdom and other countries where amalgam use is prevalent, as the amalgam phase-down continues. Knowledge Transfer Statement: This study presents data on the current provision of amalgam for posterior tooth restoration and its directly placed alternatives by primary care clinicians in the United Kingdom, where publicly funded health care with copayment provision predominates. The information is important to manage and plan the UK phase-down and proposed phase-out of amalgam and will be of interest to other, primarily developing countries where amalgam provision predominates in understanding some of the challenges faced.

Objectives: To provide a narrative review on vital dental whitening chemistry, toxicity and safety, vital dental whitening techniques, whitening systems, potential side effects of whitening and cyclic whitening using products with a range of concentrations and pH values. In addition, new developments and recommendations in the field of vital dental whitening will be presented to help clinicians understand the whitening process, its advantages, limitations, and the impact of whitening concentration and pH on enamel providing guidance in tailoring whitening treatments. Data: Data were gathered using the following keywords: dental whitening, roughness, hardness, sensitivity, hydrogen peroxide, whitening pH, whitening concentration, whitening chemistry, colour, and toxicity. Sources: An electronic search was performed using PubMed and Scopus databases. Bibliographic material from papers reviewed was then used to find other relevant publications. Conclusions: The effectiveness of vital dental whitening depends on many factors, such as the concentration/pH of the whitening agent, application duration, chemical additives, and re-mineralising agents used. Developing new whitening products and technologies such as nano-additives and alternative carrier systems is showing promising results, and might prove efficient in maximising whitening benefits by accelerating the whitening reaction and/or minimising expected reversible/irreversible enamel structural damage.