The physical health needs of people with serious mental illness have been neglected for a long time (1), this has initiated the development of guidelines and recommendations from the British Society for Disability and Oral Health (BSDH) for the oral health care for people with serious mental illness (2). Guidelines recommend monitoring and advice and although they are well meaning, randomised controlled trial evidence to support the recommendations is missing (3, 4). Cochrane systematic reviews found no randomised controlled trials of oral health advice or monitoring for people with serious mental illness (5). A Cochrane systematic review of general physical health advice interventions for people with serious mental illness (6) found evidence to suggest such interventions could lead to people accessing more health services. For oral health there is some survey evidence to suggest regular dental check-ups have been found to be associated with better oral health (7), so if a monitoring and advice intervention can influence someone with serious mental illness to visit a dentist this may in turn improve their oral health. A systematic review of 55 studies examining the prevalence of poor oral health and hygiene practices, dental treatment needs, and dental attendance of people with serious mental illness, was conducted to assess the extent to which people with serious mental illness brush their teeth and attend dental appointments. The majority of participants did not practice good oral hygiene, and were more likely not to have seen a dentist for a longer period of time than the general population. Those with serious mental illness also had more decayed teeth, more missing teeth, but fewer filled teeth, than the general population. Most of those with mental illness required some form of dental treatment ranging from oral hygiene instruction to complex dental treatment for those with shallow pockets or deep pockets in their teeth. A narrative review of the knowledge and attitudes regarding oral health in populations with serious mental illness from service users, and mental health and dental professionals’ perspectives found that individuals with serious mental illness were more likely to have poor oral health due to neglecting their oral hygiene and because they did not attend regular dental appointments. Previous negative experiences at dental appointments or general dental anxiety prevented individuals with a mental illness from seeking help until they experienced a dental emergency. The majority of service users reported that support from mental health nurses was helpful, even though nurses tended to report feeling unconfident and inadequately trained to provide this care. A systematic review of randomised controlled trials of interventions for improving the oral health of people with serious mental illness identified four studies which all had such varied interventions and measured different outcomes that combining them in a meta-analysis was not possible. Providing toothbrushes appeared to improve the oral health of people with serious mental illness. Some of the interventions involved an education element which also significantly improved oral health. A pragmatic cluster randomised controlled trial of an oral health intervention for people with serious mental illness involved 1074 service users from the Early Intervention in Psychosis teams in the East Midlands of England being randomised either to receive a dental intervention or standard care. The dental intervention involved completing a checklist with their Care Co-ordinator concerning their oral health and oral hygiene behaviour and the standard care simply involved continuing with standard care for 12 months before then completing the checklist. At baseline only 271/550 service users randomised to the dental intervention group completed dental checklists. Only 98/271 (36.1%) of service users returned a completed dental checklist at the 12 month follow up and for those allocated to standard care 91/524 (17%) returned a completed dental checklist at the 12 month follow up. The checklist did not improve oral health behaviour in people with serious mental illness. The oral health of people with serious mental illness remains a vastly under researched area. Mental health professionals should receive training to improve their oral health care knowledge. Mental health professionals should also provide advice to their patients regarding their oral health, monitor oral health as part of standard care and support patients to attend regular dental check-ups. An effective intervention that can be used within standard care could significantly improve the quality of life for people with serious mental illness.

Sri Lanka is a developing South Asian country which provides free education and healthcare for all its citizens. This thesis presents a policy-oriented study, partly empirical and partly modelling, whose aim was to understand dental care provision and workforce planning, at a time where Sri Lanka‟s dental health policies appear to have failed to achieve their intended results, leading to a mismatch between supply and demand, i.e. “underemployment and unemployment” of trained dental surgeons, despite an increasing need for dental care within the population. The first section of this thesis describes a novel method of collecting primary data on Sri Lanka‟s dental health professionals, in a challenging setting where there was no existing database. The thesis also presents a methodology to convert need for dental care to demand for care, adapting an existing model developed by the World Health Organization and the Federation Dentaire Internationale to suit the Sri Lankan setting. Finally, this section of the thesis describes a survey to identify the “timings” taken for various dental treatment modalities in Sri Lanka. The second section of the thesis presents a System Dynamics model, which uses the data obtained from these empirical surveys, to address dental workforce planning issues in Sri Lanka. The model is then used to simulate various different scenarios, generating realistic, practical and insightful lessons for policy making. Based on the results of this model, in 2011 the Government of Sri Lanka took steps to deal with the “employment mismatch” issue by restricting the annual intake of dental students and by creating 400 new Government-funded posts over the following two years.

Background: The National Health Service (NHS) aims to achieve maximum health gains with its limited resources, while also ensuring that it provides services according to need, irrespective of factors such as socioeconomic position (SEP). Aim: The aim of this thesis is to explore the relationships between SEP and various aspects of the NHS orthodontic service, including need, demand, supply, and outcomes. Methods: Three main data sources were used: two population-based surveys (the 2003 United Kingdom (UK) Children’s Dental Health Survey (CDHS) and the 2008-2009 NHS Dental Epidemiology Programme for England Oral Health Survey (OHS) in the North West) and an administrative data set (containing 2008-2012 North West NHS orthodontic activity data). The data were used to investigate levels of need and willingness to have orthodontic treatment, treatment utilisation, assessment procedures, and treatment outcomes, and the costs associated with the service. Subsequently, regression analyses were carried out to explore the associations between SEP and the various orthodontic variables. Results: Over a third of 12-year-olds had normative need for orthodontic treatment and over half had patient-defined need. Those in the most deprived groups in the North West tended to have lower levels of treatment compared to those in the least deprived group (despite the fact that normative need was not shown to vary by SEP), and they were more likely to discontinue treatment and have residual post-treatment need (RPTN). There was a great deal of variation among practices/orthodontic clinicians in terms of the percentages of patients with repeated assessments, treatment discontinuations, and RPTN. The major sources of potential inefficiency costs in the NHS orthodontic service in the North West are treatments that result in discontinuations (which cost £2.4 million per year), RPTN (which cost £1.8 million per year), and unreported treatment outcomes (which cost £13.0 million per year). Discussion: The NHS is not delivering orthodontic care equitably between SEP groups in the North West, as those from more deprived groups are more likely to fail to receive treatment, and to have poor outcomes if they do receive treatment. In addition, the wide range of process and outcome indicators between practices/orthodontic clinicians raises issues about quality of the overall service. In particular, treatment outcomes are frequently unreported, which highlights the need to improve the outcome monitoring systems in the NHS orthodontic service.

Antimicrobial resistance is an international public health problem and is associated with increased morbidity, mortality, and healthcare costs. Antibiotic consumption, particularly indiscriminate use of these agents, is recognised as a major cause of resistance. Clinical guidelines recommend that in otherwise healthy individuals, antibiotics should not be used in the management of acute dental conditions, in the absence of spreading infection and systemic upset. Instead, a surgical intervention should be the first-line treatment for such problems. This thesis describes the use of antibiotics for acute dental conditions in primary care in the UK, and explores factors that influence prescribing for dental problems using a mixed methods approach.

Oral health promotion interventions (OHPI) seek to achieve sustainable oral health improvements through actions directed at the underlying determinants of oral health. Clinical trials often promise levels of effectiveness which are not actually achieved in general use, indicating problems with implementation. This study set out to identify an OHPI for which there was strong evidence of effectiveness and then aimed to explore issues that arose in the implementation of that intervention. Research methods A sequential portfolio design was utilised. The first phase involved systematic reviews of literature to identify existing community based OHPI and interventions shown to be effective in reducing dental caries. These were also examined to determine whether the existing evidence base was informative about the process of implementing best evidence. Systematic reviews were undertaken on effectiveness of: supervised toothbrushing with fluoridated toothpastes, supervised fluoridated mouthrinsing and promotion of dietary behaviours, all, in school children. MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, EMBASE and BNI electronic databases were searched for articles published between 1990 and 2013. In total, 47 studies were included in the reviews: 21 studies on supervised toothbrushing with fluoridated toothpastes, 12 on fluoridated mouthrinsing and 14 studies on healthy dietary behaviours towards caries prevention. The second phase was a qualitative research study, which was undertaken to explore the experiences, and perceptions of participants involved in decision-making, planning and delivery of one specific community based OHPI (supervised toothbrushing) in the North East of England. Nineteen participants (NHS and school staff) participated in the qualitative study. Knowledge translation in oral health promotion One-to-one interviews and focus groups interviews were conducted with the participants. Normalisation Process Theory constructs informed the development of the interview guides and was also used in data analysis. In the third phase of the study, an integration of the findings of the first and second phases of the study was conducted. Results In the systematic reviews of literature conducted, the various levels of clinical effectiveness identified were influenced by appropriate and regular fluoride use, involvement of OHP specialists, supervision by parents and the free provision and availability of materials. There was however a general lack of comprehensive information on all aspects of implementation of OHPI. In the second phase of the study, an exploration of barriers to implementation of an OHPI revealed the following: -inadequate utilisation of research evidence -gaps in leadership and management structures -non- investment in engagement and ownership of the intervention -challenges with partnership working and evaluation of implementation of OHPI. Conclusions Availability of evidence of effectiveness of an intervention does not imply that the intervention will be successful when rolled out. Published articles on evidence-based interventions do not have comprehensive information on the mechanisms and workability of the processes required for effective implementation of OHPI. Normalisation Process Theory (NPT) enabled the exploration of factors that could facilitate knowledge translation and successful implementation of OHPI. In previous studies, NPT was used to evaluate effectiveness of interventions; in this study it was used to explore the implementation process of an OHPI and has highlighted the need for Knowledge translation in oral health promotion oral health promotion strategy makers and commissioners to revisit the “sense-making” aspect of evidence implementation, to reflect on the need for investing in all members of the team, to encourage the ‘ownership’ of interventions being implemented. In addition, there is a need to review existing leadership and management structures and to re-examine and amend the processes by which OHPI are monitored and reported. These measures would enable maximised effectiveness and sustainability of clinically effective OHPI.

Dentists have traditionally been the sole gatekeepers to the delivery of primary care dental services. Direct Access, a measure that allows Dental Care Professionals to see patients without a referral from a Dentist, is a fundamental change to this long-standing principle. This thesis systematically explores the attitudes of stakeholders across the micro, meso and macro levels of dentistry towards Direct Access in two distinct health care systems, the Netherlands and the UK.Direct Access was introduced in the Netherlands in 2006 and subsequently introduced in the UK in 2013. This study uses a qualitative approach to explore the attitudes towards the introduction of Direct Access in both of these states. It presents the results of semi-structured interviews with 74 participants (individually or as part of a group) including Students, Dental Care Professionals and Dentists at the micro-level, representatives of Professional Associations, Insurers and Dental Schools at the meso-level and Policy Makers at the macro-level. The results of this study show a significant range of attitudes towards Direct Access, but reveal a degree of consensus within individual stakeholder groups towards the reform’s introduction and impact. Dental Care Professionals interpret the introduction of Direct Access as recognition of their capabilities and expect it to primarily benefit patients through access to care and expertise. Dentists were more likely to view the introduction of Direct Access in terms of competition or professional persecution, with the impacts considered from a professional or financial viewpoint. Policy Makers saw potential for Direct Access to realign dental workforces and services to contemporary care needs. Attitudes at the meso level demonstrated the greatest variety and were more influenced by the idiosyncrasies of their respective health care system. In comparing the attitudes towards Direct Access in the Netherlands and the UK there were several differences, such as in the support of the Direct Access by Principal Dentists, however many of these can be explained by differences in healthcare funding and the time difference between the two reforms. Despite these differences stakeholders in both states felt that while Direct Access had the potential to create significant impacts on a range of issues (including professional competition, patient access to care, the reduction of care costs to patients and the state, the redistribution of dental tasks and the remodelling of the dental workforce) it was unlikely to do so in either the Netherlands or the UK. Flaws in the Direct Access regulations, legal obstructions to crucial procedures and imbalances in street-level professional power were perceived to obstruct Direct Access. Rather than revolutionising dental services Direct Access has been implemented selectively in the interest of dental practices.