Can we expect patients to RETURN if the problem is structural?

Abstract A Commentary on A Commentary on Harris et al. RETURN randomized controlled trial to increase adult routine dental visits. J Dent Res 2026; https://doi.org/10.1177/00220345261425929 . Design Two-arm, parallel-group, open-label, superiority randomised controlled trial evaluating whether RETURN (InteRvention to rEduce inequaliTies in the Uptake of Routine deNtal care) could increase routine dental attendance in adults attending for urgent care. The RETURN intervention involved a conversation with trained dental nurses using a set of booklets and videos to discuss participants’ perceived barriers to routine dental care and to support participants in setting a dental visiting goal and action plan. Case selection A total of 1176 adults attending urgent dental care at 13 dental practices, or Liverpool Dental Hospital in North-West England, were recruited, consented, and randomised. Of these, 591 were allocated to RETURN and 585 to standard care. Participants and those delivering the intervention and conducting follow-up were therefore aware of treatment allocation. Eligible participants had not attended a dentist for a non-emergency appointment for at least 2 years, did not have a dentist for routine care, had adequate English language skills and were responsible for arranging their own appointments. Data analysis The two primary outcomes were, (i) attendance at a routine NHS dental appointment within 12-months, measured using Business Services Authority administrative records, and (ii) oral health-related quality of life, measured using OHIP-14 scores at 12-months adjusted for baseline values. Secondary outcomes included follow-up at 6- and 18-month time points, hospital/private care use, self-reported attempts to obtain routine care, dental anxiety, urgent dental attendance, prescriptions, and treatment received. The analysis followed the intention-to-treat principle. Analyses were carried out using mixed-effects regression models adjusted for relevant design factors. Sensitivity analyses examined alternative approaches to administrative record matching, adjustment for baseline characteristics, and missing data. Results At 12 months, those in the intervention group saw a 21% increase in the odds of routine dental attendance (odds ratio [OR]: 1.21; 97.5% confidence interval [CI]: 0.86 to 1.70). Because the estimate was imprecise, the confidence interval was compatible with both a modest reduction and a substantial increase in attendance. Similarly, there was improvement in oral-health-related quality of life at 12 months (mean difference −1.12; 97.5% CI: −3.08 to 0.83). Whilst these results did not reach the threshold for “statistical significance”, it should always be remembered that “significance” is, at best, a crude threshold. In terms of secondary outcomes, at 18 months, participants in the intervention arm were substantially more likely to report attempting to make a routine dental appointment (OR: 3.39; 97.5% CI: 1.83 to 6.27). There was also evidence of a small reduction in dental anxiety at 18 months. Conclusions This study suggests that behavioural interventions delivered during urgent dental care may have a small effect on routine attendance and oral health-related quality of life, though the estimates were imprecise. The trial was conducted in a context of limited routine dental appointment availability, which may have constrained the extent to which increased attempts to obtain care translated into realised attendance. Importantly, the authors emphasised that behavioural interventions are a complement, not a replacement, for structural reforms to address accessibility.