Evaluation of a New Undergraduate Paediatric Dental Assessment Clinic Referral Pathway

Early childhood caries is a strong predictor for caries experience in later years [1]. It is therefore pertinent to focus on the prevention of dental caries from an early age. Health visitors (HV) in the United Kingdom are health providers who have contact with children from birth. They are therefore well positioned to engage families in good oral health practices from a young age [2]. HV are also able to signpost families towards suitable care arrangements. It is widely acknowledged that access to an NHS general dental practitioner in the United Kingdom is a challenge [3]. The COVID-19 pandemic compounded this, due to the cessation of routine dental care and preventive services [4]. Despite a return to routine services in June 2020, there is still a significant backlog of patients seeking registration with a dentist [4]. Simultaneously, there is a lack of suitable patients in the undergraduate (UG) paediatric dental clinics in Dundee Dental Hospital and School (DDH). This negatively impacts students' opportunities to achieve sufficient experience in caring for children and, therefore, to graduate as safe and proficient clinicians. To improve both the access to care for patients and increase clinical experience for students, a new pathway was created for direct HV and self-referrals (SR) to the UG clinic. Referrals to the dental hospital can be submitted by any parent or guardian whose child does not have a dentist. HV were advised to refer children whose oral health was of concern and who were not registered with a dentist. All referrals are vetted by consultants, and appropriate patients are subsequently booked into the clinic. Since its introduction in September 2022, the pathway has not been formally reviewed and thus a service evaluation was designed. To formally assess utilisation of clinics receiving solely HV referrals and SR, and translation of that into clinical experience for students. After review of the results, potential areas of improvement were identified and implemented. To measure any improvement, a second evaluation was carried out using the same methodology. However, for expediency, only a 6-month time-period was evaluated. This was from 1 March 2024 to 31 July 2024. In the first evaluation, 95 patients utilising the new referral pathway were allocated a new patient assessment over a 12-month period, a mean of 7.9 patients per month. This increased to 68 patients allocated over a 6-month period, a mean of 11.3 patients per month in the second evaluation. The data collected from the assessment appointment in the first and second service evaluations are summarised in Table 1 and data collected relating to the outcomes after initial assessment are summarised in Table 2. 48 (50.5%) HV 47 (49.5%) SR 7 (10.3%) HV 61 (89.7%) SR Following a team discussion of the results, an action plan was developed. This included providing education for the clinical supervising team on the importance of clear communication with health visitors and/or families after the initial consultation. Regularly updated lists of NHS dental practices currently accepting new patient registrations were to be distributed. The use of the departmental ‘Was Not Brought’ (WNB) pathway was to be reinforced, and efforts were to be made to ensure the timely discharge of patients following the completion of one course of dental treatment. Cycle 1 revealed high rates of patients who WNB, and contrary to the WNB policy, were still rebooked a further appointment. This leads to poor clinic utilisation and a lack of patient experience for the students. The department's WNB policy was reiterated to supervising staff members. After this simple change, the results of the patients not being brought after the first WNB were reduced by just under half in the second evaluation. This was a significant improvement in the clinic utilisation. Unexpectedly, a large number of patients were retained in the service despite having no active disease or treatment needs. Agreement within the teaching staff was reached after the first evaluation that there would be timely discharge of patients after one course of treatment. However, surprisingly, more patients were retained after they WNB in the second evaluation. This could be due to several reasons, for example some children who received silver diamine fluoride (SDF) had ongoing preventive monitoring needs or patients without dentists would have had limited discharge options. Notable improvements were seen after the first evaluation; however, communication continues to require reinforcement. There was a decrease in necessary correspondence in the second evaluation, despite highlighting poor compliance in the first evaluation. This may be a result of UG clinicians' lack of experience writing to families directly; therefore, further training and sign posting to letter proformas is needed. The patients attending through this new referral pathway attended weekly clinics focused on new patient assessments, offering students more experience in examination and assessment skills. While students often focus on meeting treatment totals to progress through their programme, research shows competency does not always correlate with frequency [5]. Emphasis should be placed on all clinical experiences, including treatment planning and behaviour management [5]. The clinic aims to increase treatment opportunities to ensure all students gain sufficient treatment experience. In order to achieve this, patients need to follow through to receive treatment at treatment clinics. This evaluation did not collect this data, and a future evaluation should include data on the volume of treatments received and student and patient feedback to further assess the pathway's effectiveness. This evaluation demonstrated that the new paediatric assessment clinic improved access to dental care for children in the community. The pathway also increased opportunities for undergraduate students to gain experience in paediatric dentistry. Further evaluation to include feedback from patients, students and supervisors and assessment of treatments provided and treatment outcomes is required to ensure the clinic meets its objectives. Health visitors and oral health improvement team members in Tayside, Scotland. The authors declare no conflicts of interest.