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Background: Dental schools are recognised to be highly demanding and stressful learning environments. Studies which have examined stress and psychological wellbeing of students within the dental undergraduate environment have, for the last four decades, focused on negative measures of psychological wellbeing. In addition, these studies have been exclusively targeted at dental students; and therefore, ignored the education of other dental professionals. Aims: The aim of this programme of studies was to explore our understanding of stress and positive psychological wellbeing of dental hygiene and therapy students from both a national and international perspective, and then to utilise this knowledge to implement a possible intervention. Participants and methods: The research involved a mixed-method approach using validated psychological tools, semi-structured interviews, and participation in an intervention workshop. Statistical analyses of quantitative data collected were handled with SPSSTM software. Thematic analyses of students' experiences of stress and wellbeing were undertaken using Braun and Clarke's six stages of thematic analysis. Results: Data showed that dental hygiene and therapy students reported similar sources of stress to that of dental students. However, at the same time, the participants also reported high levels of positive psychological wellbeing. The qualitative study showed that, for dental hygiene and therapy students, the significance of the meaning they attributed to their undergraduate training mitigated much of their stressful experiences. Scores from the intervention study showed that taking a positive approach to the education of stress and wellbeing within the dental hygiene and therapy curricula had a beneficial impact on the way participants understood their experience of stress. Conclusions: The results from this programme of studies has made a valuable contribution to our understanding of stress and wellbeing in dental hygiene and therapy undergraduate education. Within the limitations of these studies, stress was seen in a broader context. This research brought into question whether eliminating stress was necessary, or indeed relevant, and concluded that psychological wellbeing needs to be explored further. It highlighted the important role meaning held, and the relationship between meaning and stress. It is concluded the need to argue for psychological interventions/education to be included within the undergraduate curriculum for all dental professionals.

Background: In primary care dentistry, strategies to reconfigure the traditional boundaries of various professions by task sharing and role substitution have been encouraged in order to meet changing oral health needs. Training dental professionals as a team in order to encourage collaborative practice has been part of this agenda. The focus of the first part of this research is the study of patients and the care activities at the University of Portsmouth Dental Academy (UPDA) and its predecessor organisation. This is a primary care learning institution, where mid-level dental providers; hygiene-therapists (HTS) and dental nurses (DN), train together as a team with dental students on an outreach placement. UPDA was established in September 2010, as a joint venture between the University of Portsmouth’s School of Professionals Complementary to Dentistry (SPCD) and King’s College London Dental Institute (KCLDI), with the objective of improving team working. Aim: The aim of this research was to investigate the patient base, treatment activity and skill mix practice at a primary dental care team training centre prior to, and after, its establishment, and to model the potential for skill mix use in national primary dental care based on the undergraduate training experience in this centre. Methods: This research involved a case study and an operational research modelling exercise. The former was undertaken using cross-sectional electronic patient management data from UPDA, extracted in two phases: a pilot, which covered two years around the period of UPDA’s establishment [2009/10 and 2010/11], and the main data spanning a four-year period before and after UPDA was established [2008/09 and 2011/12]. The data were used to investigate the patient base, expressed treatment needs and skill mix practice using univariate, multivariate and multilevel regression analyses. An operational research model and five alternative scenarios to test the potential for skill mix use in primary care were developed, as informed by the model of care at UPDA, professional policy including scope of practice, and contemporary evidence based practice. The five scenarios included: ‘No skill mix’, ‘UPDA model nationwide’, ‘Direct access’, ‘More prevention’ and ‘Maximum delegation’. The scenario outputs were clinical time, workforce numbers and salary costs. Results: The pilot data findings from 4,343 patients suggest that there was a significant change in the patient base when the new services were initially instituted: the new patient base was older (on average 4.7 years older p=0.001); with more patients non-exempt from payment 56.8% (994) to 71.4% (1,853) (p=0.001) with lower deprivation scores; 24.5 (95%CI: 23.8, 25.2) cf to 22.3 (95%CI: 21.7, 22.8); however, there was an increased likelihood of attending in the post-expansion period for patients with a higher geographical barriers to services score, i.e. those further away from services were more likely to attend the new expanded service (0.7%; OR: 1.007 (95% CI: 1.002 to 1.012). From the main extract analysis 10,341 closed/completed treatment plans which were undertaken on 6,351 patients seen over the four-year study period showed an increase in the proportion of patients completing care plans who were in the age groups of 45-54 years and 55-64 years and adult non-exempt from NHS charges. Increasing age was associated with a higher volume of expressed treatment need in general. Logistic regression analysis showed statistically significant association p<0.05: between having received common treatments at least once in the four-year period. Payment exempt adult patients were more likely to receive all common treatments compared with the non-exempt: partial dentures (x2.6), tooth restorations (x2.1), instruction/advice (x2), tooth extraction (x1.8) and scale/polish (x1.7). The least deprived were 50% more likely to have scale and polish and 50% less likely to have tooth extractions than the most deprived. Smokers compared with non-smokers had a higher likelihood of receiving tooth restorations (57%), instruction/advice (x4), scale/polish (x1.7), tooth extractions (x2) and partial dentures (x2.6). Females patients were 20% less likely a tooth extraction or a restorations compared to male patients. Multilevel analysis indicated that the area of residence explained 7% of the variance in rate of instruction/advice, 3.8% in scale and polish and 2.8% of the variance in tooth extractions. From a sub-sample data of patients and treatments coded by provider of care n= 2,063, 55% of patients had been delegated to hygiene-therapy students at least once and 46% of coded treatments had been delegated. A significantly higher proportion of children were delegated compared with adults (85% cf 50%; p=0.001). Similarly adult smokers were delegated at a higher rate compared with non-smokers (p=0.01). The rate of delegation of different treatments also varied, with preventive treatments highly delegated (85-90%) and restorative work moderately delegated (60%). The operational research model suggested that the majority of clinical time in NHS primary care is spent on tasks that could be delegated to dental care professionals (DCP). While 45-54 year old patients received the most clinical time. Using estimated NHS clinical working patterns, the model suggested that NHS workforce numbers and salary costs to meet the dental demand in 2011/12 for each scenario were i] ‘no skill mix’ dentist only scenario would require only 81% of the dentists currently registered in England. Ii] The ‘UPDA nationwide’ scenario would lead to 29.5% of clinical time delegated to hygiene-therapists and a 357% increase in hygiene-therapists and only 57% of the dentists currently registered in England would be required and this would lead to a 19% salary cost saving cf. the ‘no skill mix’ model. iii] Minimal ‘direct access’ scenario where 70% of examinations were delegated and UPDA’s model of skill mix was practised would require 40% of registered dentists and eight times the number of hygiene-therapists’ registered; this would save 38% salary cost cf. ‘no skill mix’. iv] ‘More prevention’ i.e. increasing fluoride varnish from 13.1% to 50% and maintaining UPDAs model of skill mix, would require 4.7 times the number of hygiene-therapists’ and 57% of registered dentists. It would be a 1% salary cost saving cf. ‘no skill mix’. v] ‘Maximum delegation’ scenario with all care within hygiene-therapists’ jurisdiction delegated at 100% except restorations and radiographs (50%), showed that only 30% of registered dentists would be required and ten times the number of hygiene-therapists’ registered. This scenario could have a 52% salary cost saving cf. a ‘no skill mix’ scenario. Conclusion: The patient base in this primary care training facility represented a wide range of the societal spectrum as would be expected in general primary care practice. There was a significant change in patient base following introduction of new services and team training, to an older, more non-exempt and more geographically deprived patient population. The trend in care was associated with socio-demography and indicated increasing expressed treatment need from middle-aged patients, males and adults who would have normally had to pay for care. Over the four-year study period, routine treatments such as instruction/advice and tooth restorations, which can be undertaken by hygiene therapists, were common and patients were more likely to receive them with increasing adult age, smoking and being an adult exempt from payment. More advanced care such as tooth extraction was more common for the most deprived and smokers when compared with their counterparts. Children and adult smokers were more commonly delegated to hygiene-therapy students. Alternative scenarios based on wider predictors of expressed treatment need, changing regulations on the scope of practice and increased evidence-based practice, suggests that majority of care in primary dental practice can be delegated to hygiene-therapists and there is potential time and salary cost saving if the majority diagnostic tasks and prevention were delegated. However, this would require either more training or enhancing of roles of mid-level dental providers.

The aim of the study was to determine whether sub-clusters identified within A. oris and A. naeslundii by Multi locus sequence typing (MLST) of the concatenated sequences of 7 housekeeping genes should be classified as subspecies or distinct species. Determination of whole genome sequences of selected strains of A. oris and A. naeslundii, using Illumina Genome Analyzer IIxe and Roche 454 methods was initiated using paired-end sequencing and single reads respectively. The sequences obtained were aligned using CLC software and annotated using RAST. In preliminary gene-by-gene, analysis a putative Lacto-N-Biose [LNB] gene operon was identified which may mediate growth of A. oris on LNB generated in vivo from the degradation of salivary mucins. The operon were found in all A. oris strains (n=19) but in 18 A. naeslundii strains the operon was dysfunctional with extensive, varied gene loss apparent. Mutants of Actinomyces oris-MG1 were produced with the LNB phosphorylase gene inactivated. All A. oris strains grew on LNB (increase in OD= 0.213 + 0.07 and final pH= 4.99) while none of the A. naeslundii strains (increase in OD=0.09 + 0.05 and final pH=6.3; both p<0.01) or the A. oris mutant did not grow significantly in the presence of LNB. This finding indicated that A. oris strains possess a functional LNB operon and so are better able to utilize LNB generated by the degradation of salivary O-linked glycans. This is the first demonstration of LNB utilization by a member of the oral microbiome and may explain the greater prevalence of A. oris compared to A. naeslundii in oral biofilms. Further the Reverse Transcriptase-PCR (RT-PCR) was carried out to demonstrate the up-regulation of LNBP gene when A. oris-MG1 was grown in LNB. Apart from bio-chemical characterization, comparative genomic analysis was carried out on whole genomic sequences. Digital DNA-DNA homology (DDH) values were obtained using in-silico genome-to-genome comparison and this analysis delivered results consistent with previous traditional classification. Evolutionary analysis using ClonalFrame was also observed. The mutation and recombination events were compared using chi-square test among A. oris and A. naeslundii isolates. A. oris mutation and recombination event were significantly higher than A. naeslundii showing the diversity of A. oris strains in the oral cavity. Seven house keeping genes of publically available strains were included in previous MLST analysis and it was investigated that k20, MG1, c505, OT175 clustered in A. oris group of isolates while OT171, OT170 and A. johnsonii appeared as separate branches in MLST analysis and same was observed in core genome phylogenetic tree. These findings suggest that A. oris forms six distinct groups based on Neighbour-Joining tree analysis, core genome alignment and DDH analysis while A. naeslundii forms a single compact cluster.