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Approved electronically generated cover-page version 1.0 The Use of Electronic Medical Records To Facilitate Identification of Patients Presenting With Oro-facial Complaints To The General Medical Practitioners

A thesis submitted to the University of Manchester for the degree of Master of Philosophy in Oral and Maxillofacial Surgery in the Faculty of Medical and Human Sciences

2013

SZE SENG CHAN

SCHOOL OF DENTISTRY CONTENTS

Page I. Contents 2

II. List of Tables 6

III. List of Figures 7

IV. List of Abbreviations and Acronyms 8

V. Abstract 9

VI. Declaration 10

VII. Intellectual Property Statement 11

VIII. Acknowledgement 12

1. Introduction 13 1.1 Overview of Oral Healthcare in the United Kingdom 13 (UK) 1.2 Oral Healthcare Expenditure 13 1.3 Establishment of National Health Service (NHS) 15 1.4 Reformation of NHS 16 1.5 NHS Organization Since 2012 18 1.6 Primary Care 19 1.7 Secondary Care 21

2. Justification For The Study 24 2.1 Separation of Medicine from Dentistry 24 2.2 Economic Impact of Oro-facial and/or dental 24 complaints

2 2.3 Medical and Dental Trainings 25 2.4 Health Behaviour of Patients presenting with Oro- 26 facial and/or Dental complaints 2.5 The characteristics of Patients Presenting with Oro- 27 facial and/or Dental complaints 2.6 Types of Oro-facial and/or Dental Problems 29 2.7 Quality of Care and Service Provision 29 2.8 Purpose of the Study 31

3. Objective 35

4. Method 36 4.1 Study Design 36 4.2 Patient Selection 36 4.3 City of Salford 36 4.4 Healthcare Services in Salford City 39 4.5 North West e-Health (NWeH) 41 4.6 Electronic Medical Records (EMRs) 41 4.7 EMIS Database 42 4.8 Read Codes Clinical Classification (RCCC) 43 4.9 Advantages of Using Electronic Medical Records 45 (EMRs) 4.10 Data Anonymisation 46 4.11 Data Collection 47 4.12 Data Analysis 49 4.13 Types of Outcome Measures 49 4.14 Data Storage and Disposal 49 4.15 Ethical Considerations 50 4.16 Funding 50 4.17 Publication Policy 50

5. Results 52 5.1 Number of Patients and Number of Attendances 52

3 5.2 Types of Oro-facial or/and Dental Complaint 57 5.3 Attendance Pattern by Gender 58 5.4 Attendance Pattern by Medical Co-morbidities 58 5.5 Attendance Pattern by Days of the Week 60 5.6 Attendance Pattern by Age 61 5.7 Attendance Pattern by Other Demographic Factors 62 6. Discussion 70 6.1 Challenges 70 6.1.1 Data Security 70 6.1.2 Data Quality 71 6.1.3 Coding Behaviour of GMPs 73 6.2 Main Findings 75 6.2.1 Attendance Pattern 75 6.2.2 Oro-facial or/and Dental Complaints 76 According to Age, Gender, and Ethnicity 6.2.3 Oro-facial or/and Dental Complaints 77 According to Days of the Week 6.2.4 Roles of GMPs in Managing Oro-facial 77 or/and Dental Complaints

6.2.5 Dental Abscess 78

6.3 Future Research Potentials 79

6.3.1 Potentials and Benefits 79

6.3.2 Integration of EMRs and EDRs 80

6.3.3 Ideas For Author’s Next Research 81

7. Conclusions 83

8. References 85 9. Appendices 91 9.1 Appendix 1 General Medical Practitioners In City of 91 Salford

4 9.2 Appendix 2 General Dental Practitioners In City of 95 Salford

9.3 Appendix 3 Read Codes for History and Symptoms 96

9.4 Appendix 4 Read Codes for Diagnosis of Oro- facial 98 Malignant Neoplasm

9.5 Appendix 5 Read Codes for Oro-facial Diagnosis 99

9.6 Appendix 6 Read Codes for Diagnosis of Oro-facial 116 Fractures

9.7 Appendix 7 Data Sharing Agreement 117 9.8 Appendix 8 Approval Letter from Governance 128 Committee for NWeH Words: 24,770

5 LIST OF TABLES

Page Table 1 Read Codes for Diabetes Mellitus 44 Table 2 Entry of Read codes to EMRs for Diabetes Mellitus 45 Table 3 List of Important Read Codes for Oro-facial Complaints 48 Table 4 Number of Patients Presenting with Tooth Related Problems 53 and Number of Attendances in PMCs from 1st January 2009 to 15th December 2012

Table 5 Number of Patients with Non-tooth related problems and 53 Number of Attendances in PMCs from 1st January 2009 to 15th December 2012

Table 6 Number of Patients and Number of Attendance for All Oro- 54 facial Complaints in PMCs from 1st January 2009 to 15th December 2012

Table 7 The Read Codes Included in the Diagnostic Groups 56

Table 8 Attendance Pattern for Oro-facial or/and Dental Complaints 61 and Non-dental Complaints by Age

Table 9 Attendance Pattern by Ethnicity 64

Table 10 Attendance Pattern by Religion 66

Table 11 Attendance Pattern by Social Group 68

6 LIST OF FIGURES

Page Pie-Chart Fifteen most common oro-facial or/and dental complaints 57 presented to GMPs from 1st January 2009 to 15th December 2012 Graph 1 Attendance Pattern for Oro-facial or/and dental complaints 59 and non-dental complaints by the gender Graph 2 Attendance Pattern for Oro-facial or/and dental complaints 59 and non-dental complaint by medical co-morbidities Graph 3 Attendance Pattern for Oro-facial or/and dental complaints 60 and non-dental complaints by days of the week Graph 4 The Trend of Attendance for 15 Most Common Oro-facial 63 or/and dental Complaints

7 LIST OF ABBREVIATIONS AND ACRONYMS

A&E Accident and Emergency Department DCB Dental Corporate Bodies EDRs Electronic Dental Records EMRs Electronic Medical Records GDPs General Dental Practitioners GMPs General Medical Practitioners ICD International Classification of Diseases IGPs Information Governance Principles IT Information Technology NWeH North West Electronic Health Organisation NHS National Health Service PMCs Primary Medical Cares PCTs Primary Care Trusts RCCC Read Code Clinical Classification SHAs Strategy Health Authorities SIR Salford Integrated Records UK United Kingdom USA United State of America WHO World Health Organisation

8 ABSTRACT The University of Manchester SzeSeng Chan

Master of Philosophy in Oral and Maxillofacial Surgery

The Use of Electronic Medical Records to Facilitate Identification of Patients Presenting With Oro-facial Complaints To The General Medical Practitioners

January 2014

Aims : To study the pattern of attendance of patients who present to General Medical Practitioners (GMPs) with oro-facial or/and dental complaints.

Data Source : All the Primary Medical Cares (PMCs) in the North West e-health database (NWeH).

Population : All the patients of 54 PMCs in Salford who had registered themselves with GMPs from January 2009 to 15th December 2012.

Method : A secondary analysis is performed on electronic consultation data entered daily at PMCs. The medical events were recorded by using Read Codes Clinical Classification system (RCCC). An agreed list of codes was designed by the investigators to recognise patients presenting with oro-facial complaints. The data extracted was anonymised. A descriptive analysis is used to define the patients’ characteristics.

Result : There were 20,216 patients who visited their GMPs for at least one or more oro-facial or/and dental complaints by 2012. Of all the 908,062 medical attendance at PMCs, 10.4% were related to oro-facial or/and dental problems. This represents 9.39% of the patients (n =215,382) from population of Salford who have registered themselves with GMPs. Oral aphthous ulcer was the commonest oro-facial disease presented to GMPs.

Discussion : Major challenges faced included data ownership and security issues, incomplete data and inconsistent data; and variation of data quality due to differences of coding behaviour of GMPs. The attendances for oro-facial or/and dental complaints were 1.94 time higher during weekdays than at weekend. A small but gradual rise was noted in the number of attendance related to dental abscess. This development may be the result of spending cut in NHS dental service.

Conclusion : The attendance rate for oro-facial and/or dental complaints varied between PMCs in Salford, but was significant and may have far-reaching implications on dental care planning in the United Kingdom (UK).

9 DECLARATION

That no portion of the work referred to in the thesis has been submitted in support of an application for another degree or qualification of this or any other university or other institute of learning.

10 Copyright Statement

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II. Copies of this dissertation, either in full or in extracts and whether in hard or electronic copies, may be made only in accordance to the Copyright, Designs and Patents Act 1988 (as amended) and regulations issued under it or, where appropriate, in accordance with licensing agreements which the University has entered into. This page must form any part of any such copies made.

III. The ownership of certain Copyright, designs, patents, trademarks and other intellectual property (the “Intellectual Property”) and any reproductions of copyright work in the dissertation, for example graphs, and tables (“Reproductions”), which may described in this dissertation, may not be owned by the author and may be owned by a third party. Such Intellectual Property and Reproduction cannot and must not be made available for use without the prior permission of the owner(s) of the relevant Intellectual Property and/or Reproductions.

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11 ACKNOWLEDGEMENT

I would like to express gratitude to my supervisor, Prof Paul Coulthard, for the useful comments, remarks and support throughout the learning process of this master thesis. I have been fortunate to have a supervisor who has provided me the freedom to explore on this exciting journey. But, at the same time, he has also given cordial motivation, valuable information and guidance, which helped me to complete many tasks at various stages.

I am also thankful to Prof Coulthard for encouraging me to use the correct terms and consistent notation in my writings, for carefully reading, and for countless revisions of this dissertation.

My advisor, Prof Martin Tickle, has been always there to give tremendous support. I would like to take this opportunity to thank to him for helping me to sort out numerous technical details of my work. Otherwise, I am sure it would have been an uphill struggle during the difficult times.

Most importantly, none of this would have been possible without the love and patience of my family. My immediate family has been a constant source of love, patience and strength all these years. I would like to express my greatest appreciation to my family. Also, I would like to thank to all my course mates and the staff for their contribution; especially Prof Aneez Esmail, Prof Stephen Campbell, Ms Dawn Sheridan, Mr Mark Delderfield and Mr Edmund Bailey; who had been playing the vital roles for the success of this project.

Finally, I am indebted to all those individuals who have made this dissertation possible and because of whom my graduate experience has been one that I will treasure forever.

12 1. INTRODUCTION

1.1 Overview of Oral Healthcare in the United Kingdom (UK)

In recent years, there has been an increasing interest in attaining the optimum level of oral health for all in the United Kingdom (UK). Dental health service has continued and aspired to fulfil this noble mission. During the last 30 years since 1980s, much evidence indicates that oral health has improved significantly in the UK and other industrialised countries despite having considerable variations in the delivery system of dental healthcare and availability of resources to fund the effort (Tickle et al 2011).

However, dental diseases still remain as some of the most common chronic diseases in the UK population. The cost of dental health has risen steadily beyond the general inflation rate. These can largely be attributed to various reasons, such as the mechanism for distributing the healthcare resources, price of medication and dental materials, personnel wages, history of consumer need and demand, current government political philosophy, the aging population, the application of more sophisticated technology and the influence of market economy (Al-Haboubi et al 2013).

There is an increasing concern that many individuals are being deprived of their essential need for dental healthcare because the traditional consumption model which is dictated by disposable income and consumer choices has treated dental healthcare as a commodity. Furthermore, current economic climate has proved to be enormously challenging for the UK to get the dental healthcare provision reasonably right.

1.2 Oral Healthcare Expenditure

According to NHS Expenditure for General Dental Services and Personal Dental Services England, 1997/98 to 2005/06 (before the new dental contract was introduced on 1 April 2006), the total expenditure spent on NHS dental services increased from

13 £27 per head of the population in 1997/98 to £39 in 2005/06 (Burke & Kidd, 2009). Unfortunately, increased spending did not lead to the expected whole-population improvement of dental healthcare in the UK.

Health expenditure per capita (including dental healthcare) in the United States of America (USA) was estimated about $7,598 in 2009, which was 45% more than the amount allocated by Switzerland, the second highest spending country on healthcare (Pritchard & Wallace, 2011). Indeed, the similar disheartening development has also been observed in the USA although the USA spends about 90% more than the UK on healthcare.

In the UK, the healthcare issues have evolved to become an important component of the welfare structure of community. The failure to provide adequate access to healthcare is considered politically and ethically unacceptable. Organization of healthcare is not about finding an ideal panacea that will satisfy every need and want. But, a realistic compromise should be reached with uncomfortable choices to get the best of all worlds with the limited resources we have.

Both the public and the private sector have always played their parts for provision of oral healthcare in the UK. The public sector mainly consists of primary dental care and secondary dental care services (Holten 2013). The majority of remaining treatment is supplied through the private sector. The uptake of private- based dental services is frequently determined by consumer choices and affordability.

Payment of private dental healthcare is either based on a fee-for- items/treatment method (self-financed method), a weighted capitation plan, an insurance scheme (cash plan insurance, e.g. Boots; or indemnity insurance, e.g. Dentplan) or individualised dental payment plans (enable the patient to spread the total cost of expensive treatment, e.g. complex implant retained bridge work over time).

In addition to the individual dentists and traditional partnership, a sizable number of dental corporate bodies (‘companies’) (DCB) are mushrooming to provide 14 oral healthcare in the UK after the amendment of Dental Act 1984 in July 2005 (Holten 2013). The directors of most DCB are either the registered dentists or registered dental care professionals. The directors monitor the day-to-day management of the business of dentistry.

DBC are becoming popular among many dentists because of the advantage of quality branding, limited business liability, flexibility of ownership, and partnership taxation benefit. Laing and Buisson, a renowned market intelligence company, estimated that the total spend on dentistry of private sector to be equalled to around £2.5 billion for the UK in 2007/08 (Holmes et al 2011). Private dentistry is more responsive to the rapid changes in dental healthcare needs and offer quality treatment with the best possible price. Paradoxically, these can usually be attained at the expense of equality, equity, and fairness to the others.

In 1948, the central government realised that the welfare system could no longer meet the healthcare needs and had decided to gradually drawn in by taking over the local hospitals, church-led and other charity-based health service. Government intervention in healthcare could provide a safety net for those patients who were not affluent enough to purchase healthcare service out of their own pocket.

1.3 Establishment of National Health Service (NHS)

The inception of the National Health Service (NHS) was the first healthcare system to offer universal, equitable and free healthcare access. The provision of oral healthcare in the UK was soon transformed and shaped by the development in NHS. The funds for oral healthcare in NHS are derived from the public (through direct taxation or national insurance), and to lesser extent supplemented by the co-payment (Brunton et al 2008).

In the USA, individual patients buy a care plan from healthcare company and only receive dental healthcare from the contracted dentists (Cohen 2009). Dutch and Swedish dental healthcare are essentially private with the public paying the dentists’ 15 service directly according to an agreed scale of cost arranged between the dental profession and their government.

The primary dental care service has remained virtually unchanged for more than 50 years. At the earlier stage of NHS functioning, there was a huge gap between unmet dental treatment need and availability of dental workforces. Even with a major influx of resources and substantial assistance from general medical practitioners (GMPs), NHS primary care service which acted as a point of first contact still could not cope with the dental workload. Therefore, provision of dental healthcare by independent general dental practitioners (GDPs) on fee-for-items/treatment basis was introduced to speed up the clearance of backlog (Brunton et al 2008).

The GDPs are self-employed contractors, not obliged to register patients and could claim for treatments performed from a fee scale that embraced over 400 items. As there was no financial incentive to render the ordinary people to be free of dental diseases, many GDPs were only interested in pulling out teeth, making dentures and doing fillings (Tickle et al 2009). By the early 1990s, it was clear that the remuneration system encouraged over-treatment and did not provide continuing dental healthcare.

1.4 Reformation of NHS

In 1990, NHS dental services underwent its first ‘reform’. The GDPs were required to register their patients to promote on-going dental healthcare. By its nature of capitation based remuneration system, the GDPs were expected to deal with whatever dental problems faced by the patients (Tickle et al 2009). The new system had gained a wide acceptance from the public and within the profession.

However, the Dentists and Doctors Review body subsequently discovered that this had led to overspending in the dental budget because the government had underestimated the number of patients registered and the productivity of the GDPs. Consequently, the government slashed the fee scale by 23% in 1992 (Tickle et al 2009). Many GDPs were disappointed with the new contact and left NHS amid fears of 16 earning less for ever increasing volume of workload and associated rising operating cost.

Access to NHS services became more difficult. The disparities in the distribution of dental healthcare were exacerbated by geographical inequalities and reached its climax when the patients were queuing in their hundreds for hours to register with a new NHS dental practice opening in Scarborough, Yorkshire (Tickle et al 2009).

Following the devolution in 1998, England, Scotland, Wales and Northern Ireland have control over their own health policy respectively. Since then, dental health provision in these countries seems to be in a constant state of flux (Holden 2013, Tickle et al 2009). Due to much variations and diversities of current dental policy for the delivery of dental healthcare, the author will only focus the discussion solely on NHS dental services in England.

Today, dental caries and periodontal diseases still dominate the major burden of dental workforce. Nevertheless, the pattern of dental diseases has altered. Older generations who had been edentulous and wearing dentures are gradually being replaced by younger generations who retain their natural teeth and prefer to have their teeth restored rather than extracted (Batchelor & Brooks 2009). Hotly debated controversy about access to NHS dental service and the delivery of NHS care continues to make sensational headlines in the media despite much effort to increase the dental workforce through recruitment of more student dentists.

New generations desire outstanding standards of dental healthcare and more informed about their treatment options, poor clinical technique and paternalistic dentists who take little heed of their wishes are no longer tolerated (Batchelor & Brook 2009). The concept of self-care should also be emphasized. This can empower each individual in the society to take up the responsibility for their own concerns and priorities of dental health (Burke & Kidds 2009). In the light of these developments, the dental profession and the public soon recognise that reformation of previous system is not evitable to accommodate the ever-challenging dental health expectation.

17 In April 2006, NHS dental services in England had experienced one of the most dramatic yet courageous changes in history (Whittaker & Birch 2012, Tickle et al 2011). At present, NHS dental healthcare is only free-of-charge at the point of delivery for certain groups of population. These include all children aged 18 olds and below and in full education time, pregnant women, women who have given to a child within the previous year, patients who are staying in NHS hospitals, outpatients of NHS hospital dental service, prison inmates, and individuals who are receiving various type of low- income related support (Tickle et al 2011).

To contain the cost of dental healthcare in population with a lower prevalence of oral diseases, the dental remuneration system has evolved radically from an open- ended fee-for-items/treatment NHS dental contract to one with cash- limited and co- payment basis for all other individuals. The dental patients who are not eligible for free treatment pay a proportion of the cost of treatment to the GDPs directly and the government subsidises the balance. In 2012 alone, NHS is estimated to allocate approximately £2.25 billion for dentistry and the NHS patient will be expected to pay further £550 million to NHS dental services (source : The Health and Social Care Information Centre Annual Report and Accounts 2011/2012).

1.5 NHS Organization Since 2012

NHS is under the administration of Department of Health (DH). The head of DH is Secretary of the State for health who is obliged to report to Prime Minister. At the time of writing, a NHS primary care in England was commissioned by a primary care organisation, e.g. primary care trusts (PCTs) or local clinical commissioning groups. In turns, 152 NHS primary care trusts (PCTs) were overlooked by 10 regional Strategic Health Authorities (SHAs). Ultimately, DH was responsible for 10 SHAs which supervised all the NHS activities in England.

Nonetheless, most of the primary care professionals were independently contracted to NHS. They enjoyed significant freedom to organize their own premises of practice and employed their own staffs. Primary care also allowed the individual 18 healthcare professionals to decide for themselves with whom, where and how they would choose to work. This structure was reorganized systematically when Health and Social Care Act 2012 came into force.

Under the new law, all the PCTs and SHAs were abolished and be replaced by a new health planning body called Public Health England. Thereafter, Public Health England was established in April 2013. £60 to £80 billion of commissioning (healthcare funds) would be steered away from the abolished PCTs to a yet to clarified number of "clinical commissioning groups", partly run by GMPs’ and GDPs’ consortium (The NHS in England. [online] Available at: http://www.nhs.uk/NHSEngland/thenhs/about/Pages/nhsstructure.aspx [Accessed July 4, 2013]). The front liners (GMPs and GDPs) would be given the direct responsibility to overseer the NHS fund to influence the local healthcare provision.

Today, NHS is the largest government-funded health service in the world. The combined strength of NHS workforce (England, Scotland, Wales, and Northern Ireland) is 1.7 million people, with NHS England occupying more than 80% of the employment (1.4 million people) to serve a population of 52 million people (Whittaker& Birch 2012). About 50% of those are clinically qualified. These include GMPs, GDPs, pharmacists, allied healthcare professionals, nurses, ambulance staff, hospital and community health service (HCHS) and dental staff. In general, NHS consists of two important components: primary and secondary care.

1.6 Primary Care

Primary care provides the first contact for the public. A diverse range of healthcare professionals are serving in primary care, including GMPs, GDPs, pharmacists and optometrists (The NHS in England. [online] Available at: http://www.nhs.uk/NHSEngland/thenhs/about/Pages/nhsstructure.aspx [Accessed July 4, 2013]). Traditionally, they are generalists at the coalface to meet the common healthcare need of local community with their respective skills (general medicine, general dentistry, drug safety and dispensation, eye care and corrective lenses 19 prescription). The World Health Organization (WHO) has placed very high regards to primary care, particularly in developing countries, as an imperative component of financially pressed welfare system to render the healthcare provision more accessible and affordable.

A primary care professional must acquire mastery of a broad remit of essential knowledge. Primary care professionals provide a wide spectrum of services to patients of all ages from routine check-up and consultation to diagnosis and management of acute or chronic, physical, mental, dental and social health matters. They serve a large number of populations from all walks of life with assorted cultural, political, socioeconomic, and geographical background.

Continuity and prevention are key characteristics of primary care, as the healthcare professionals work together with the patients, government and non- government organizations to promote health through health education, health screening and building public health policy. Collaboration among providers is a desirable characteristic of primary care. If the medical problems are beyond their capabilities, these healthcare professionals will function as gatekeepers to coordinate and direct transfer of patients from primary care to secondary care.

Effective and efficient primary care allows smooth flow of patients to the right specialist doctors. This will result in better utilisation of limited resources by not using expensive secondary care to treat all illnesses, especially the trivial ones. In England, there is a distinctive demarcation between primary care and secondary care to improve quality of care and decrease the overall cost of healthcare provision. In contrast, many doctors in the USA play both roles as primary care providers and hospital specialists in certain medical branch, e.g. family medicine (Cohen et al 2009).

Unlike the situation in England, primary care in the USA becomes a special type branch of medicine (general practice medicine) in its own right and patients are free to go directly to their favourite specialist doctors if they wish. The workforces of primary care in USA also include general internal medicine, general paediatrics, and obstetricians and gynaecologists for women patients. Historically, these doctors are 20 being defined as those who do not complete a specialist residency (Cohen et al 2009). Besides the work roles as primary care providers that closely resemble that of GMPs in England, they also provide some inpatient hospital care and domiciliary home care.

1.7 Secondary Care

NHS has evolved to develop a unique system of healthcare specialization: secondary care. The healthcare professionals here are equipped with multi-facet expertise of relevance to treat particular types of complicated diseases (The NHS in England. [online] Available at: http://www.nhs.uk/NHSEngland/thenhs/about/Pages/nhsstructure.aspx [Accessed May 30, 2013]). Most of these healthcare professionals have acquired knowledge dedicated exclusively to a medical field through advanced level of hospital training or postgraduate education.

They tend to work collectively as a team in the hospitals rather than as individual healthcare professionals. These include the consultants, specialist doctors (physicians or surgeons), nurses, and other allied health workers (e.g. medical physicists, speech therapists, physiotherapists, dieticians, clinical radiographers).

There are 2 main types of secondary care: emergency care and elective care. Except in the emergencies, the patients can only access to secondary care through referrals from GMPs or other primary care professionals. A fairly robust referral mechanism exists in England to ascertain that the patients are guided to the appropriate specialists. On the other hand, elective care deals with planned specialist medical care or surgery. The boundary whether the elective care being private or entirely NHS has becoming increasingly blurred in some medical fields, e.g. ophthalmology which also provides service to private patients.

A small group of dental specialists, consultants and professionals complementary to dentistry (e.g. dental nurses, dental hygienists, dental therapists, dental technicians) also work in secondary care to provide hospital dental care (NHS 21 dental services. [online] Available at http://www.nhs.uk/NHSEngland/AboutNHSservices/dentists/Pages/find-an-NHS- dentist.aspx [Accessed September 1, 2013]).

Hospital dental care is responsible for: 1. the provision of consultant advice and treatment being referred by GMPs and GDPs because of the complexity of the cases. 2. the dental care of hospital in-patients. 3. the dental care of short-stay patients to meet their need as a part of comprehensive treatment for other non-dentally related conditions. 4. the emergency dental care for the relief of pain and swelling. 5. the dental care of patients with complex medical problems, who may require the support of recovery facilities, resuscitation equipment and intensive nursing care.

Only a handful of hospitals provide dental care to the general public. Some are linked to the universities for teaching purposes. Large number of the patients is recruited for undergraduate training, postgraduate specialisation and healthcare research. Hospital dental care is highly specialised. There are 4 main specialities covered by hospital dental services: 1. Oral and Maxillofacial Surgery 2. Orthodontics 3. Paediatric dentistry 4. Restorative dentistry Other specialties may be available in some hospitals, especially in the university linked dental hospitals, which include oral surgery, periodontics, special need dentistry, prosthodontics and endodontics. In general, the hospital dentists and specialists serve fewer patients than GDPs.

However, the nature of treatment offered is more complex and technically demanding. The patients seen are usually referred by GDPs, GMPs, other medical specialists and the allied healthcare workers. The dental care of a significant 22 proportion of them are complicated with inherent medical conditions, congenital abnormalities, and complex oro-facial diseases. In contrast to individual or partnership practices in GMPs or GDPs settings, hospital dentists and specialists tend to work together as a team. They also have a common access to the patient details using specialised facilities.

Most A&E departments of the major hospitals in the UK have on-site cover from oral and maxillofacial surgery team during working hours (Holmes et al 2011). In some hospitals, there are also on-call oral and maxillofacial staffs in A&E. Primary and secondary injuries to facial skeleton and the associated soft tissues are essentially managed by oral and maxillofacial staff. They work closely with neurosurgical, ophthalmological, and other A&E colleagues. These settings often provide better quality and more appropriate emergency maxillofacial treatment to the patients with shorter waiting time.

2. JUSTIFICATION FOR THE STUDY

23 The motivation of the study and the specifics pertaining to the challenges faced by patients presenting with oro-facial and dental complaints seeing their General Medical Practitioners (GMPs) are reviewed here. First, the challenges will be outlined before highlighting the clinical areas that requires attention. Next, the motivation behind this research is presented.

2.1 Separation of Dentistry from Medicine

The separation of dentistry from medicine has been practiced in many countries. General Medical Practitioners (GMPs) and General Dental Practitioners (GDPs) seldom communicate about issues relating to their patients’ oral health. This approach increases overhead and causes inefficiency in the delivery of oral healthcare service (Cohen et al 2011). The overall well-being can only be optimized if both the oral and general health can be improved at the same time by multidisciplinary involvement in the healthcare system.

Dentistry is a special domain of modern healthcare system. Dentistry concerns with the care for oral cavity, teeth and associated structures. It is delivered by the GDPs and other dental specialists; e.g. oral surgeons, periodontists, endodontists, orthodontists, prosthodontists, dental implantologists, restorative dentists etc. Meanwhile, medicine concerns with the care for systemic health and the rest of the body. It is delivered by GMPs, medical specialists and various other healthcare professionals; nurses, optometrists, physiotherapists, occupational therapists, dietitians, psychiatrists, speech and language therapists etc.

2.2 Economic Impact of Oro-facial and/or dental complaints

Oro-facial and dental problems lead to diminished quality of life, emotional distress and physical suffering. Both Cohen et al 2009 and Mcdonald et al 2012 agreed that dental problems had an adverse impact on economic productivity. Cohen 2009 reported that there was a loss of about 2,442,000 days of work and 52 million hours 24 from school as a result of the acute dental problems in 1996. In the UK, dental treatment cost about £2.25 billion to National Health Service (NHS) and £550 million to patients in 2012 (Healthcare report across the UK, a comparison of the NHS in England, Scotland, Wales and Northern Ireland 2012. [online] Available at http://www.nao.org.uk/wp-content/uploads/2012/06/1213192.pdf [Accessed May 18, 2013]).

Indeed, some authorities have implied that such loss could carry greater socio- economic impact than other common medical problems e.g. gastrointestinal disorders, ear infections, skin and eye conditions (Naidu et al 2008).

2.3 Medical and Dental Trainings

Historically, dentistry had developed independently as an autonomous part of healthcare system at its inception; to cope with the overwhelming oral healthcare need with limited workforce training. The separation of dentistry from other components of healthcare systems has worked well for many years to reduce the prevalence of oral disease. However, this leads to the assumption that oral healthcare delivery is simply a mechanical endeavor (‘engineering of teeth’) by layman; with little or no relationship exists between oral healthcare and systemic healthcare. Consequently, dental education has not been well-integrated into the basic curriculum of modern medical schools because of time and financial restraints.

Over the years, dentistry and dental education have become isolated organizationally and educationally from other healthcare professionals, especially the medicine. Despite that, there is substantial evidence to show that increasing number of patients (registered or unregistered with GDPs) are seeking dental treatment from GMPs, Community Pharmacists (CP) and Accident and Emergency Department (A&E) prior to attending their GDPs or hospital dentists (Cohen et al 2009). To optimize the delivery of oral healthcare, these front line services should work together as one; in order to be able to respond to whatever is thrown at it over the coming years.

25 Equally, however, the dentists need to demonstrate that they are in a position to take on some of the basic function of their medical counterparts. Perhaps, medical and dental schools are partly to blame in this matter. Whatever the reasons, the notion of diagnosing common medical conditions, e.g. diabetes mellitus, hypertension – once the shared responsibilities of all healthcare professionals – is starting to become an exclusive preserve of the physicians.

Checks on dentists’ performance in managing patients with medical co- morbidities is of critical importance to provide safe dental care. Dentists who fail to demonstrate their abilities to manage medically compromised patients must undergo revalidation and retraining. Yes, it is true that the dentists are being asked to do more and out of their comfort zone; but so are many other non-dental healthcare providers who are seeing patients with oro-facial and/or dental problems.

2.4 Health Behaviour of Patients Presenting with Oro-facial and/or Dental complaints

Most of the dental patients presenting to GMPs are often interested in requesting for temporary relief of oro-facial and dental problems. They can present to GMPs at primary care clinics or A&E. This trend of patient behavior is shared globally in both the developing and developed countries. Naidu et al 2008 reported that about two-third of the studied patient population in Trinidad and Tobago attended their physician for dental care because the access to primary dental care was scarce secondary to geographic, socioeconomic and organizational barriers. In contrast, Bell et al 2008 suggested that some patients preferred GMPs to GDPs as they perceived GMPs were more competent at managing their dental complaints.

Moreover, Anderson et al 1999 described that some patients felt more comfortable to visit their GMPs for the management of the oro-facial and/or dental problems because they have better rapport with their GMPs. However, Cohen et al 2009 found that financial constraint was the main hurdle for visiting physicians (GMPs) in primary care setting or hospital emergency department (A&E). Majority of patients were from low-income and minority ethnicity group. 26 Some researchers also pointed out that some patients present to A&E department for emergency care following actual failed attempt to visit their own GDPs or perceived lack of GDPs service during weekends (Anderson et al 1999, Pennycook et at 1993). In addition, a few studies discovered that the lack of access to dental care during opening hours of primary dental practices is complicated by subtle discrepancies in healthcare system, payment mechanisms, referral patterns, delivery standard, patient belief, government policies and associated political impacts, distribution of dental resources and assorted GDPs factors (knowledge, attitudes, culturally-based biases) (Cohen et al 2003, Davis et al 2007, Drum et al 1998, Lockhart et al 2000, Quinonez et al 2009).

Comparison of healthcare system performance based on uniform definitions, indicators and measure has been made at national and international level. Although it may not be entirely fair to compare different healthcare systems, but in effect, it could offer a rich source of information to assist health system planning decision and policymakers in monitoring the gap and implementation. Whilst the differences between the USA, the UK and other parts of world in healthcare resource allocation and utilization are striking, there are some noticeable parallels in the use of primary medical care and A&E department for dental-related problems.

2.5 The characteristics of Patients Presenting with Oro-facial and/or Dental complaints

The profile of patients visiting GMPs to address their oro-facial and dental problems exhibits diverse geographical, age and sex variations. Caution should be exercised when interpreting the evidence presented with limitations in mind. Most of the studies showed slight female predilection and wide age range. In 2001, 3.1% of 890 million visits (275,900,000 visits) were presented to GMPs for treatment and prevention of dental-related problems in the USA (Cohen et al 2006). 2.7% of these patients received care in A&E although 68.1% of them had registered themselves with GDPs. 27 In the USA, approximately 3% of the oro-facial and dental problems were handled by GMPs in 2001 (Cohen et al 2006). 43% of these patients were seen by GMPs in primary care setting and the remainder was managed in Emergency Department. In 2009, the number of dental related visits in Emergency Department soared up to 3,381 per 100,000 for American aged between 15 to 44 years (Niska et al 2010). The rate of dental-related visits climbed by almost 46% (4,935 patients per 100,000 populations) from 2001 to 2008; whereas asthma remained almost unchanged over the same time period. On average, 2% of these patients (around 35 patients per day) would need hospital admission.

A survey by Cohen et al 2010 demonstrated that the number of patients attending GMPs at physician offices were twice as prevalent as those who visited the A&E department. In general, adults of African Americans and the disadvantaged groups were shown to be more likely to seek dental care from A&E department than other population. Anderson et al 1999 discovered that the 0.3% of patient attendance to GMPs or 185 consultations per 10,000 persons in 30 PMCs of Wales was related to dental complaints. More than half of them ranged between the ages of 16 to 44 years.

On the other hand, the A&E attendance in England is growing at about 3% each year with a total spending of £2.22 billion in 2011. (Healthcare report across the UK, a comparison of the NHS in England, Scotland, Wales and Northern Ireland 2012. [online] Available at http://www.nao.org.uk/wp- content/uploads/2012/06/1213192.pdf [Accessed May 18, 2013]). Of these, there is about 37% of visit to A&E department is of minor and non-emergency nature (Curtis2012). However, little or no data has been available about the exact percentage of these visits which represent the non-emergency dental attendance. The key to problem is most if not all coding method used by A&E departments only classifies dental-related visits into “other medical conditions” category. For this reason, further research with more specific data collection is required to study the epidemiology of non-emergency dental attendance in England.

28 2.6 Types of Oro-facial and/or Dental Problems

A wide array of oro-facial and/or dental problems is encountered by GMPs. The type of oro-facial and/or dental complaints that prompted the patients to seek care from GMPs or A&E department include dental abscess (including cellulitis), toothache pain, dental trauma, broken teeth, bleeding gum, defective fillings, crown problems, denture problems, jaw/face pain, burning mouth, oral mucosal lesions and various other problems.

Surprisingly, dental abscess and toothache are the commonest oral problems seen by GMPs in primary care settings or the A&E departments. No dramatic difference in the presentation pattern of these problems is observed regardless of ethnicity, age, country and sex.

These findings were consistently supported by Cohen et al 2006, Cohen et al 2009, Bell et al 2005, Davis et al 2010, Drum et al 1998, Horton and Harris 2001, Naidu et al 2008 and Quinonez et al 2009. The pattern of dental-related complaints presented to GMPs is essentially similar to those presented to GDPs. Understandably; this means that most of these patients could have been equally or better managed by their GDPs (Pennycook et al 1993).

2.7 Quality of Care and Service Provision

It would appear that patients with non-emergency dental attendance could further saturate workforce of the already heavily loaded A&E department. Placing too much workload on the healthcare professionals in A&E will not only reduce the efficiency and increase the waiting-time for other emergency medical conditions, but also demoralizes them and thus affects the long-term sustainability of the whole healthcare system. Besides that, it can increase chances of making errors which could endanger patients’ safety during delivery of care.

29 Perhaps, the issue of enormous workload at A&E departments comes to a head recently; following national news stories of an elderly woman with suspected heart failure who had to wait 18 hours for a bed after she was admitted to A&E at Queen Mary Hospital, South London. The existing practice of “overuse” of access for non- emergency care in A&E (including non-emergency dental visits) may no longer be viable. It may be time for an exploration of new ways to provide a more balanced and comprehensive quality of care.

Referral of patients presenting with oro-facial symptoms from GMPs only takes place when the diagnosis cannot be reached. Most patients received no or little intervention (Quinovez et al 2009). The care and treatment provided by GMPs are usually empirical and differ vastly depending on the level of their training and experience. Patients are not given adequate explanation about their dental problems, treatment, and prevention (Cohen et al 2009). Cohen 2009 described that more than 80% of A&E visits for dental-related visits ended up with prescriptions of analgesia and antibiotics. Many of those who sought dental care from a physician’s office or hospital emergency department realized that they would need to visit their dentists for definitive care (Cohen et al 2009).

In addition, most of the patients are neither followed-up nor advised to go to the dentist for further management. Misdiagnosis and inaccurate management are not uncommon because GMPs are not specifically trained in managing oro-facial and/or dental problems. Interestingly, Lockhart et al 2000 highlighted that about one-third of practicing GMPs were not confident to perform adequate oral examination.

Delay in diagnosis and referral can bring about unnecessary morbidity. In a survey, Mathu‐Muju et al 2008 drew our attention to the confidence level of Early Head Start (EHS) staff regarding GMPs competence to manage dental-related problems. About 30.5% of them believed that GMPs were not able provide diagnosis and preventive treatment to toddlers and young children. The injudicious admission to hospital for management of non-traumatic dental problems will incur a heavy financial burden to the healthcare system.

30 Costing data from USA averaged that Medicaid claim for dental-related problems was US$5793 per hospital admission (Cohen et al 2010). More importantly, the total expenditure for dental-related hospital admission varied considerably from US$949 to US$43524 (Quinonez et al 2009). One imperative but unanticipated finding was that standard GDPs treatment for most preventable dental-related problem in the USA only cost half or less than the treatment provided in the Emergency Department (US$ 80 per extraction, US$ 300 per dental fillings). These figures clearly show that the funding could have been channeled more efficiently to alternative areas of public health and dental provision to promote other aspects of oral healthcare instead.

2.8 Purpose of the Study

There have been a number of valuable studies of dental-related visits to GMPs in the UK using a cross-sectional design (Anderson et al 1999, Bell et al 2008, Pennycook et al 1993). However, none of these studies provide a picture of the changes over a meaningful period of time or forecast the trends in utilization of GMPs service for the oro-facial and/or dental problems. All of which present insights on local demographic characteristics of a limited population with 4 months of observation being the longest.

New researches should focus on developing approaches to collect detailed data on a daily basis, so that we could detect the changes in primary care setting or A&E department resource utilization associated with dental-related problems. This will allow us to better appreciate the dynamic nature of dental-related visits to GMPs. The balance of cost-consciousness and acceptable quality of care can only be achieved through waste removal, evidence-based care, labour efficiency and reduction of unjustified variation throughout the system, but not merely healthcare service advancement via adoption of new techniques, equipment and medicine.

To address the areas alluded to earlier, it should be emphasized that the close collaboration between GMPs, GDPs, A&E department, healthcare policy makers and patients is crucial. Government and Private sector need to work together to ensure 31 universal and equitable access to dental healthcare, especially for the most vulnerable. Inconsistencies in the coverage of dental service must be identified and eliminated by strengthening and reforming healthcare policies (Cohen and Manski 2006, Cohen et al 2009, Drum et al 1998).

As we have seen, GDPs cannot stand alone to meet the constantly evolving needs of complex populations. Therefore, GMPs will have to play an imperative role in helping to fill the gap. Yet, many GMPs usually lack comprehensive dental training (Naidu et al 2008, Pennycook et al 1993). We cannot expect the incorporation of complete dentistry learning into the already hectic undergraduate medical education. As a start, however, one would recognize that better understanding of dental-related problems through continuing professional development is undoubtedly encouraging (Cohen et 2009, Pennycook et al 1993 Quinonez et al 2009).

Pennycook et al 1993 also stressed that public education is necessary to empower those who suffer urgent dental-related problems but have little knowledge and motivation to visit their GDPs. The patients will become better informed about their treatment options and weigh the cost versus the benefit of dental treatment. In addition, they begin to take responsibility of their own dental health, to adopt healthier lifestyle and to involve actively in prevention programmes.

To facilitate access of dental-related problems to A&E departments, guidelines and allocation systems (nurse triage) have been conceived (Cohen et al 2011, Davies et al 2010, Horton et al 2001). These approaches allow assignment of patients according to treatment priorities in order to receive appropriate care. Nonetheless, the benefit has been proven to be small and experiences methodological weaknesses.

If they remain unresolved, the access matter may only get worse when these waiting time redistribution-based mechanisms (“triaging” of A&E department) fail. Consequently, this could lead to longer queues and delays for all the patients (including non-dental-related problems). This may even further overstretch its staff and push the limits of its resources. The nature of this possibility is more or less not known at the time of writing and should be investigated in the future research. 32 To a certain extent, it appears that many underserved patients may depend on A&E department for providing temporary solution to their dental-related problems. In light of that, Cohen et al 2006 suggested that the addition of GDPs or GMPs with specialized training in A&E department to manage patients presenting with dental- related problems. But the current evidence based on cost-benefit analyses seems too strong to deny this expensive option. Cohen’s view has been criticized by Davies et al 2010 because the fundamental issue is not what services are available in A&E department, but how to provide optimum dental care access to these patients so that A&E department is not used for non-emergency dental problems.

Many will agree that the root of the problem is that the dental care supply is not meeting the demand. The indiscriminate use of GMPs service in primary care setting or A&E department is both costly and ineffective. Action rather than hypothesis oriented-solutions to dental access problems are needed. Perhaps, something radically new (e.g. to locate and book dental care appointments online through a centrally coordinated computer system and mobile device applications) need to be explored to uncover the hidden capacity of GDPs which may be difficult for the most vulnerable to find.

If not addressed properly, it is likely to grow over time before another queuing incidence for new dentist registration similar to that seen in 2004 at Scarborough, Yorkshire resurfaces. The discussion of presentation of oro-facial and/or dental related problems to GMPs raises many critical challenges and interesting questions for the health consumers, professionals and healthcare decision makers.

This is the first collaborative study involving Oral and Maxillofacial Department, School of Dentistry, University of Manchester; and Primary Care Research Group, School of Medicine, University of Manchester. Hopefully, this study will help to define the number and demographics of patients presenting with oro-facial complaints to General Medical Practitioners (GMPs). It is important to compare the patients with oro-facial complaints who attend their GMPs to those who attend their General Dental

33 Practitioners (GDPs) to assess healthcare service management and to ensure quality assurance.

34 3. OBJECTIVE

The objectives of this study were:

1. To identify the number of patients who have attended General Medical Practitioners (GMPs) for oro-facial or/and dental complaints.

2. To describe the demographics of those patients who have attended GMPs for oro-facial or/and dental complaints.

3. To identify the types of oro-facial or/and dental complaints that the patient presented in PMCs.

4. To investigate any association between type of oro-facial or/and dental complaints and demographics factors.

35 4. METHOD

4.1 Study Design

This research was carried out by the postgraduate research student, Chan Sze Seng (CSS) under the supervision of clinical research professor, Professor Paul Coulthard (PC) in the population of Salford City. The data was extracted from North West e-Health (NWeH) which holds the details of over 2 million patients in electronic medical records (EMRs). All GMPs in Salford who had been using electronic medical records for at least a year were included.

4.2 Patient Selection

The patients of this study were taken from the electronic medical records software developed by North West e-Health (NWeH). To minimise selection biases, especially the centripetal bias, all the patients in the 54 PMCs were included in this study.

4.3 City of Salford

City of Salford is a metropolitan borough of Greater Manchester in North West England. It has a resident population of 233,933 (Salford District: total population. Vision of Britain. [online] Available at http://www.neighbourhood.statistics.gov.uk/dissemination/LeadAreaSearch.do?a=7& r=1&i=1001&m=0&s=1401109576968&enc=1&areaSearchText=salford&areaSearchTy pe=13&extendedList=false&searchAreas=Statistics.gov.uk [Accessed April 27, 2014]).

Under the Local Government Act 1972, City of Salford became a local government district administered from Salford Civic Center in Swinton (Salford Metropolitan Borough key statistics [online] Available at http://www.neighbourhood.statistics.gov.uk/dissemination/LeadAreaSearch.do?a=7&

36 r=1&i=1001&m=0&s=1401109576968&enc=1&areaSearchText=salford&areaSearchTy pe=13&extendedList=false&searchAreas=Statistics.gov.uk [Accessed April 27, 2014]).

The climate of City of Salford is temperate, with 13.2 °C and 6.4°C being the average highest and lowest temperatures respectively. Geographically, it is bounded by River Irwell on the southeast, Wigan on the west, Bolton on the northwest and Bury on the north. City of Salford is closely related to Manchester because their historical interest and participation in economic activities. The part of the city located adjacent to west of Manchester are highly industrialised with denser population.

The rest of the city comprises a mix of suburban and rural areas, like most cities in the UK. For ease of administration and governance, City of Salford is divided into Central Salford and Salford West. There are 7 wards within Central Salford and they are: Broughton, Calremont, Irwell Riverside, Kersal, Ordsall, Langworthy and Weaste & Seedley. Salford West has 13 wards of more rural in nature, including Barton, Boothstown & Ellenbrook, Cadishead, Eccles, Irham, Little Hulton, Pendlebury, Swinton North, Swinton South, Walkden North, Walkden South, Winton and Worsley.

Salford was politically, economically and socially more important than its neighbour, Manchester. However, this scenario had changed after the Industrial Revolution in the late 18th century as a result of the economic decline of its textile industry. Until the 1990s, the city and its economies have constantly suffered much squeezing and grinding. Unemployment, crime, housing and social problems were common from 1960s. The number of vehicle offences, thefts of vehicles and sexual offences were all slightly higher than the averages for England, but lower than its neighbour, Manchester.

Today, redevelopment plans is ongoing to regenerate and modernise City of Salford. Parts of City of Salford have experienced marked urbanisation, especially Salford Quays and Middlewood Locks. MediaCity UK at Salford Quays houses BBC North and Granada Television since 2011 while Middlewood Locks has been redesigned as a contemporary residential settlement. Also, JCDecaux UK has established one of its main office in Metroplex Business Park, Salford.

37 Tourism, financial service, e-commerce, retail and construction are the main contributors of its economy. Notably, the purpose built Salford Quays has been described to be the new possible city centre for City of Salford. In addition, much attention has been given to redevelop University of Salford, which was founded in 1967. Being one of four universities in Greater Manchester, it has over 19,000 students with student satisfaction’s level reaching 69.7%. £150 million has been invested to set up new facilities, such the £10 million law school and the £22 million health and social care building (Salford Metropolitan Borough key statistics [online] Available at http://www.neighbourhood.statistics.gov.uk/dissemination/LeadAreaSearch.do?a=7& r=1&i=1001&m=0&s=1401109576968&enc=1&areaSearchText=salford&areaSearchTy pe=13&extendedList=false&searchAreas=Statistics.gov.uk [Accessed April 27, 2014])

According to the 2011 UK Census, the total population in City of Salford was 233,933. Majority of the residents was white, whilst Asian and Black comprise the minority groups with only 1.4% and 0.6% respectively (Salford Metropolitan Borough ethnic group data. [online] Available at http://www.neighbourhood.statistics.gov.uk/dissemination/LeadAreaSearch.do?a=7& r=1&i=1001&m=0&s=1401109576968&enc=1&areaSearchText=salford&areaSearchTy pe=13&extendedList=false&searchAreas=Statistics.gov.uk [Accessed April 27, 2014]).

There were 100 females for every 96.9 males. 44% were single and 36.7% were married. There were about 155,400 residents of working age living in City of Salford. Almost two fifth of which were working full time. Of those aged over 16 years of age, 15.9% had an academic qualifications while 35.5% of them had no first or higher degree. Both figures were comparatively not in line with the UK national trend. (20%, 28.9%) (Salford Metropolitan Borough household data. [online] Available at http://www.neighbourhood.statistics.gov.uk/dissemination/LeadAreaSearch.do?a=7& r=1&i=1001&m=0&s=1401109576968&enc=1&areaSearchText=salford&areaSearchTy pe=13&extendedList=false&searchAreas=Statistics.gov.uk [Accessed April 27, 2014]).

It may be argued that the population of City of Salford may not be a perfect representation of the UK population as a whole. For pragmatic reasons, the data could only be obtained from this population rather than the entire UK population as this was not accessible to the author for this study at the time of writing. Nonetheless, the 38 baseline characteristics of the sample of the patients were carefully described so that the generalizability of data could be easily deduced.

Furthermore, the population of patients in this study was large. A large sample would provide more reliable estimates and less likely to affect the precision of the result. Therefore, much information from this study could be applied to the UK population if used cleverly.

4.4 Healthcare Services in Salford City

Over the years, healthcare services in City of Salford have been subjected to continued reorganisation and modernisation. Demographics changes and the changing burden of disease are among the recognizable challenges faced in this city. At the time of writing, the responsibility to deliver health services in City of Salford was shared by NHS and private healthcare. NHS was publicly funded and private care was largely a private insurance-based healthcare system. In recent years, crossover between NHS and private care was becoming increasingly common in City of Salford.

In Salford City, there were commissioning trusts, e.g. Primary Care Trust and provider trusts in the NHS. Commissioning trusts were responsible for assessing the healthcare need and then finding the best healthcare providers (NHS or private providers) to deliver healthcare service to the local population. The services commissioned included general medical practitioner services, community nursing and mental health service. (Salford Clinical Commissioning Group. [online] Available at http://www.salfordccg.nhs.uk/ [Accessed April 27, 2014])

On the other hand, provider trusts were the direct healthcare deliverers. Most of the previously mentioned healthcare services were provided in primary care settings. Like other cities of the UK, a number of independent healthcare providers were involved, e.g. GMPs, GDPs, pharmacists and optometrists (Salford Clinical Commissioning Group. [online] Available at http://www.salfordccg.nhs.uk/ [Accessed

39 April 27, 2014]). They were usually contractors and acted as the first portals for most people in Salford City to access basic healthcare services.

In general, GMPs were either principals or partners in PMCs. The vast majority of them in City of Salford were self-employed, but they had contractual arrangement with NHS. Some of them worked in GP-led acute care units of NHS hospitals or perform locum works. Principals and partners in GP surgeries are self-employed. The vast majority of GMPs in Salford City derived most of their income from the National Health Service (NHS) (Salford Clinical Commissioning Group. [online] Available at http://www.salfordccg.nhs.uk/ [Accessed April 27, 2014]).

Medical visit to PMCs are free for all residents in City of Salford. But, most adults of working age who are not on benefits were required to pay prescription only medicine of £7.60 per item since April 2012. A change in the GMPs contract would start after April 2014 in line with NHS reformation. Under the new system, GMPs would not have to work unsociable hours, and only get paid according to the number of patients treated and the type of treatment given. At the time of writing, the author could identify 57 PMCs and 17 general dental practices in City of Salford. The details of these PMCs could be found in Appendix 1 and 2 (Local Authority, NHS England. [online] Available at http://http://www.england.nhs.uk/ourwork/sop/la-pcks/ [Accessed April 27, 2014]).

Secondary care could be either NHS or private providers. They provided elective and emergency care. Nonetheless, NHS owned hospitals still played a crucial part in handling the majority of secondary care. There were 3 NHS owned hospitals in Salford City, namely Salford Royal, Oakland hospital and Pendleton Gateway. Private hospitals in Salford City inclined to provide only routine surgeries due to the lack of level 3 critical care unit or intensive care unit, e.g. Priory Hospital (Salford Clinical Commissioning Group [online] Available at http://www.salfordccg.nhs.uk/ [Accessed April 27, 2014]).

40 From the beginning of the study, the author had taken an avid interest in studying the geographical location and distribution of 54 PMCs. But, the data extracted was anonymised and processed. This data was considered sensitive. Time and financial constraint had limited our ability to acquire more information on this matter as a separate ethical approval was needed. There was a meagre possibility that all of these 54 PMCs could have located closely together in the same topographical area. Yet, this concern might easily be dismissed when we scrutinise the PMCs and their addresses available in Appendix 1.

4.5 North West e-Health (NWeH)

North West e-Health (NWeH) is a non-profit organisation. It is a joint effort between the University of Manchester, Salford Primary Care Trust and Salford Clinical Commissioning Group (formerly known as Salford Royal Foundation Hospital Trust). The project started to develop in Salford in 2009. Based in University of Manchester and Salford Quay, it can provide research-ready health record data of over 2 million people across the North West of England. NWeH brings healthcare record data together for improving services in a secure environment, including EMIS. Therefore, the healthcare professionals and researchers can share information regardless of sites and disciplines more easily than the conventional healthcare intelligence.

4.6 Electronic Medical Records (EMRs)

Information technology has revolutionised industries after industries. Today, many GMPs record all the complaints and symptoms reported by the patients into the computer during consultations. Patient data is recorded using either coded or narrative approach. In a coded approach, the medical event (symptom or diagnosis) is recorded by selecting from a drop-down list or a customized template.

On the other hand, the entry of ‘free text’ can be used in narrative approach. Narrative approach allows greater freedom of expression, description of temporal 41 relationship and severity of a medical condition –it tells a story. Yet, coded approach is preferred by many GMPs as it can represent the medical event accurately in a more uniform manner. Often, coded data is produced by “pick from a list” software programme. As a result of careless selection and entry of codes by GMPs, over- documentation and duplication of research data may occur in this study.

Medical conditions are recorded using the Read Codes Clinical Classification (RCCC). The codes can be cross-referenced to the International Classification of Diseases; a medical coding system which is used by secondary care. This allows easy transfer of referrals and communication of patient care with the secondary care. Information from secondary care can be obtained by GMPs without having to be transcribed and entered into EMRs retrospectively themselves. This includes hospital admissions, specialists involved in the patient care, discharge medication and diagnosis, investigation and treatment outcomes.

Also, the GMPs prescriptions are computerised. A copy of prescription form can be printed for the patient to present at the pharmacy. Medicine prescribed can usually be linked with a medical event (symptom or diagnosis) recorded in EMRs. However, the link between a therapy record entry and an entry in the medical records in some cases may be less obvious. It is because prescriptions by the hospital doctors or other specialists will not appear in the computer system unless the treatment is to be continued by GMPs.

4.7 EMIS Database

EMIS has long enjoyed a good reputation as the electronic medical records software provider of PMCs in the UK. EMIS software helps PMCs to reduce paperwork, increase efficiency and improve healthcare outcomes. It has also played a strong role in implementing EMRs in the NHS.

EMIS database is run by EMIS Group Public Limited Company (EMIS Group PLC). The software company was set up in 1980s in Egton near Whitby in North Yorkshire. In 42 June 2012, EMIS Group PLC supplied the computer system to over half of all Primary Medical Cares (PMCs) and more than 195 clinical services in the UK. The automatic data collection software was conceived by Dr Peter Sowerby and co-author Dr David Stables.

EMIS tailors to suit the individual PMC’s need. It facilitates patient medical record keeping, patient referrals, treatments, communications between clinicians and arrangement of appointments into the electronic medical records (EMRs). In Salford, the data is collected weekly by EMIS from PMCs. All GMPs routinely check their EMIS data at desktops for at least twice daily.

4.8 Read Codes Clinical Classification (RCCC)

Read Codes Clinical Classification (RCCC) was developed by Dr James Read, a general medical practitioner from Loughborough, UK. Read codes consist of a set of clinical-terms (or concepts) matching codes. It has been used in NHS since 1985 to facilitate GMPs to record the everyday routine, patient findings and procedures in health and social care. At the time of writing, there are 2 versions of RCCC: Version 2 (V2) and Version 3 (V3). Version 3 has evolved from the earlier versions of Read Codes with the addition of new concepts and clinical terms (V3 has the full capacity of 656 million terms).

Read codes is composed of a maximum of 5 characters with a combination of letters and numbers. Hence, it is also referred to as the “5-bytes codes”. Each character or number may represent a category or chapter. There are 3 categories (diagnoses, processes of care, medication) and they are further subdivided into smaller chapters.

Read codes beginning with capital letters are used to describe diagnoses, e.g. J010. (dental caries), H33 (asthma). Reads codes beginning with numbers relate to the processes of care. These are used to record history, symptoms, examinations, investigations, test results and surgical procedures, e.g. 44P (serum cholesterol), 424 43 (full blood count). Read codes beginning with small case letters are recorded automatically into Electronic Medical Records (EMRs) when a medication or treatment is prescribed, e.g. bu25 (Aspirin 75mg tablets).

Read codes are organized in a unique hierarchy. Every chapters of Read code supports a different level of details (up to 5 levels exist). Longer Read codes with more characters (numbers, letters or a combination of letters and numbers) contain more specific information to be entered at the required level of details. To explain the hierarchy structure of Read codes, the example of diabetes mellitus is given in Table 1, as below:

Table 1 Read Codes for Diabetes Mellitus Read Code Diagnosis C Endocrine, Nutritional, Metabolic and Immunity Disorders C1 Other Endocrine Gland Diseases C10 Diabetes mellitus C10E Type 1 Diabetes mellitus C10E7 Type 1 Diabetes mellitus with retinopathy

For diabetes mellitus, each Read code begins with the capital letter C (the category). The pattern is repeated across smaller chapters (numbers, letters or a combination of letters and numbers) to add extra layers of explicit particulars to the diagnosis (can also be processes of care or medications as appropriate).

Read codes are precise because they are case-sensitive. Inaccurate entering of Read codes can change the clinical connotation entirely. For example, 8HTK is used to record the referral of a patient to stop smoking-clinic while referral to diabetic eye clinic is identified by 8HTk.

Read codes can be recorded by direct code entry, using keywords or templates. The clinicians may choose to enter Read code quickly in EMRs if the codes are known to them. By using keywords (full terms, letter prompts, or abbreviations), the medical

44 events (diagnoses, processes of care or medications) can be recorded from a drop- down list of Read codes. It is simpler and allows the most accurate Read codes for description of the medical event. Being more specific, the clinicians will be able to elicit the precise codes in a more concise list. To explain the entry of Read codes to EMRs using keyword approach, the example of diabetes mellitus is given in Table 2:

Table 2 Entry of Read codes to EMRs for Diabetes Mellitus Types of Keyword Examples Full term Diabetes Mellitus Letter prompts Diab, Diab Mel Abbreviation DM

Both approaches share common characteristics: they require the clinicians to have some knowledge of medical terminology and a sound understanding of the structure of Read code system.

The template (guidelines) approach facilitates multiple data entries quickly in a standardised manner with less clerical errors. This will ensure data entry is consistent across the practices for each individual patient to avoid redundancy and duplication. Nonetheless, template approach is seldom preferred by GMPs for non-routine data entry because it is limited by the availability of predefined Read codes in the default template. Moreover, any error occurs in the template will be reproduced whenever the template is being used in the future. Therefore, data extracted from template approach was not considered in this study.

4.9 Advantages of Using Electronic Medical Records (EMRs)

In this study, EMRs were chosen because they were comprehensive, easily available and offered systematic coverage of patient details. EMRs provided a non- interventional, retrospective database. Access to the data relevant to this study was secure and protected.

45 It could accommodate a wide range of study designs because it supports public health audit, case control, nested case control cohort, and cross over designs with good flexibility. NWeH includes a longitudinal database of over 2 million individuals since 2009 with long term follow-ups. Therefore, patient population of NWeH data was representative of the local patients who had registered themselves with GMPs under NHS (National Health Service) within the Salford community. It is continually being updated and thus allows specific, population-based capture of patients who attended GMPs for management of oro-facial complaints.

Hence, this increased the transparency, trustworthiness, statistical power and generalizability of this research. In addition, NWeH could be obtained quickly as it was encrypted and already processed systematically by a team of committed database analysts, statisticians, researchers and support staff. Moreover, NweH was less likely to be subjected to recall bias and interviewer variability which can lead to loss of data. Finally, the cost of data collection was considerably lower than the primary collection of unprocessed new data.

4.10 Data Anonymisation

Data extracted was anonymised by NWeH and the researchers could not identify any individual patients. Identifiers such as a PMC's name, first line of the address and postcode were removed. They were replaced with codes comprising unique combination of identifying numbers and letters.

Therefore, the author could only gain access to minimum data as appropriate for the research purpose. Sensitive information was never being released unless there was a legal basis for disclosure only after explicit patient consent (written consent form) has been gained. In this study, no data that could identify patients himself/herself was requested.

46 The researchers were highly committed to protecting sensitive information and had complied strictly with the guidelines set by established Information Governance Principles (IGPs) that had been approved by the National Information Governance Board, SIR Governance Board (Salford Integrated Records), the Medical Ethics Committees of the British Medical Association and the University of Manchester.

4.11 Data Collection

The researchers had collected anonymous patient data, including past history and prescriptions, which had already been recorded in the normal clinical routine. The mechanism of identifying confidential and sensitive information had never been accessible to the investigators because data collected was anonymised from the collection stage.

The data had been processed to give the investigators to access demographic, medical, and prescription information at an individual patient level. Additional information to provide longitudinal record for each patient who was organized in the related files, such as referral to specialists, diagnoses, laboratory results, health behavioral characteristics (only obtainable from a few PMCs), and other clinical measurements had also been used for future research purposes.

All patients who were registered with National Health Services (NHS) in Salford will have complete electronic medical record of the patient’s healthcare. Using the EMRs, those findings and events (including patient complaints, diagnoses, prescription) relevant to the patient’s oro-facial problems and associated management were collected. The patients who have historical data with EMRs, but have either left the GMPs practices or died, were not included in the study.

At the time of writing, there are 313,609 concepts and 336,187 clinical terms in RCCC version 3; 85,925 concepts and 98,158 clinical terms in RCCC version 2. Almost all Read codes for the diagnosis of oral cavity, salivary gland and jaw diseases began with the capital letter “J” and follow by the number “0” (J0…). Neoplastic diseases of oral 47 cavity, salivary gland and jaw were identified by the Read codes beginning with (B0…).Fractures of oro-facial region were represented by Read codes starting with (S0…).The oro-facial complaints of all the patients in NWeH were identified by referring to a list of Read codes agreed by CSS and PC for this study. For the full list of Read codes included in this study, the readers are advised to refer to a. Appendix 3 Read Codes for History and Symptoms b. Appendix 4 Read Codes for Diagnosis of Oro- facial Malignant Neoplasm c. Appendix 5 Read Codes for Oro-facial Diagnosis d. Appendix 6 Read Codes for Diagnosis of Oro-facial Fractures

Some of the more important Read codes for diagnosis of oro-facial complaint are presented in Table 3:

Table 3 List of Important Read Codes for Oro-facial or/and Dental Complaints

Read Code Oro-facial Complaints J010. Dental Caries J0250 Dental Abscess J03.. Gingival and periodontal disease J043C Impacted Wisdom Teeth J046. Temporomandibular Joint Disorders J05y. Other Specified Dental Disorder J06.. Diseases of the jaws

J064. Inflammatory jaw conditions

J065 Alveolitis of jaw J07.. Salivary gland Diseases J080. Stomatitis J082. Oral Aphthae J090. Glossitis B0... Malignant neoplasm of lip, oral cavity and pharynx B00.. Malignant neoplasm of lip

48 B01.. Malignant neoplasm of tongue B02.. Malignant neoplasm of major salivary glands

B04.. Malignant neoplasm of floor of mouth

S0... Fracture of skull

S028. Fracture of skull and facial bones

4.12 Data Analysis

The main focus of the study was to determine the number of the patients with oro-facial or/and dental complaints and their characteristics in Salford. A descriptive analysis was performed. The data was then summarized to represent the population of patients in Salford by using measure of central tendency and measure of variability. Subsequently, the summaries were presented in simple-to-understand tables, pie- chart and graphs using Microsoft® Office Excel and Microsoft® Office Access software. Analysis of associations was performed using IBM SPSS software version 20.

4.13 Types of Outcome Measures

The main outcomes to be analyzed are: 1. The number and demographics of patients who visited their GMPs for oro-facial or/and dental complaints. 2. The pattern and trend of attendance of patients who visited their GMPs for oro-facial or/dental complaints.

4.14 Data Storage and Disposal

The data was stored in the campus (School of Dentistry, University of Manchester). Hard copies of the data were kept in a locked cabinet in a locked room.

49 (PC’s room) However, the hard copies could be retrieved in response to a request for ethical review. Data stored electronically was saved and backed-up on a password protected hard drive (P-drive, University of Manchester). The data was stored for a maximum period of six months after the conclusion of the study. Following the storage period, hard copies of the data was shredded, while the electronic data files were deleted from all storage devices including any recycling bins.

4.15 Ethical Considerations

The patient data was never been used for any other purpose than the one in the study. This research was retrospective and data extracted was anonymised. Therefore, informed consent specifically for this research was not deemed necessary because no new patient data was acquired. The researchers had gained ethical approval from the Ethic Committee of NWeH and NHS Research Committee on 15th July 2013 (and SIR Governance Board on 11th October 2013). A copy of data sharing agreement between the researchers and Ethic Committee of NWeH can be found in Appendix 7 and Appendix 8.

4.16 Funding

This was a postgraduate research-based study. This study was not supported by any external funding sources. There was no conflict of interest because no person other than CSS and PC who were involved directly or indirectly, in the development of the project protocol, data analysis, data collection, data interpretation, manuscript preparation, and the decision to publish.

4.17 Publication Policy

All the corresponding investigators (CSS and PC) have full access to all the data and final responsibility for the decision to submit the findings of this research for 50 publication. The study results were primarily used by CSS for writing his MPhil dissertation. The main manuscript was prepared by CSS and be circulated to the other member for revision.

51 5. RESULTS

5.1 Number of Patients and Number of Attendances

Data for the purposes of this study was extracted from NWeH and dated between 1st January 2009 and 15th December 2012. For all the analyses, only patients with oro-facial or/and dental complaints were taken into account for most of the medical events. The total number of reported patients with oro-facial and/or dental complaints is shown in Table 4, Table 5 and Table 6. These tables provide an overall view of the number of cases, the number of patients, and the specific turnover rate. Table 7 shows an overview of all the Red Codes included in each diagnostic group.

By 2012, a total of 20,216 patients from 54 PMCs presented with oro-facial or/and dental complaints. This represents 9.39% of the patients (n =215,382) from population of Salford who have registered themselves with GMPs (Salford Metropolitan Borough key statistics. [online] Available at http://www.neighbourhood.statistics.gov.uk/dissemination/LeadAreaSearch.do?a=7& r=1&i=1001&m=0&s=1401109576968&enc=1&areaSearchText=salford&areaSearchTy pe=13&extendedList=false&searchAreas=Statistics.gov.uk [Accessed April 27, 2014]). The percentage of the patient population presenting oro-facial or/and dental complaints during this 4 year period varied from 0% (4 PMCs did not record any oro- facial or/and dental complaints related attendance) to 17.82% (n= 215,382) across Primary Medical Cares (PMCs).

By using the entry identification letters and numbers of PMCs (also known as journal ID), 94,548 attendances linked to oro-facial or/and dental complaints were revealed within 4 years (34,038 tooth related attendances, 60,510 non tooth-related attendances). 65,809 attendances were presented for at least one oro-facial or/and dental complaints with one or more unrelated medical complaints or pre-existing medical diagnoses (Table 4, Table 5, Table 6). Therefore, about 30.4% (28,739) of these attendances were not associated with any medical conditions at all.

52 Table 4 Number of Patients Presenting with Tooth Related Problems and Number of Attendances in PMCs from 1st January 2009 to 15th December 2012

Diagnosis Number of Patients Number of Attendances Teeth and dental hard tissue 5,647 26,303 diseases Gingival/periodontal diagnosis 709 4,822

Other dental diseases 787 2,903

Total 7,143 34,038

Table 5 Number of Patients with Non-tooth related Oro-facial problems and Number of Attendances in PMCs from 1st January 2009 to 15th December 2012

Diagnosis Number of Patients Number of Attendances

Oral soft tissue diseases 5,261 21,202

Salivary gland diseases 3,953 9,629

Diseases of the tongue 1,208 6,411

Diseases of the jaw 1,381 16,582

Dento-facial diseases 768 1,452 (including congenital dental deformities)

Other Tooth-related oro- 502 5,234 facial complaints

Total 13,073 60,510

Tooth-related attendances alone were about two times more likely in 2 PMCs – A70D71 and T2I00 (min = 630.33). Patients attending for non-tooth related oro-facial

53 problems were about twice as much as those who attended for tooth related complaints. Among the PMCs, 6 PMCs (A7D71, B5I81, T8S55, T2I00, T7D46, U0R53) had outnumbered the others by recording more than 2,000 non-tooth related oro- facial attendances in 4 years.

Table 6 Number of Patients and Number of Attendances in PMCs for All Oro-facial Complaints from 1st January 2009 to 15th December 2012

Number of Tooth Number of Non Tooth PMC Number of Patients Related Attendance Related Attendance A7D71 621 1096 2,336 A0T12 0 0 0 A4J41 254 653 895 A5Y34 312 550 719 A4X31 76 45 89 A0P36 533 892 1,510 A9L20 63 298 178 A3Q85 408 773 1,175 A4C74 493 887 1,002 B5I81 638 975 2,011 B0R00 23 66 142 B8D23 418 886 1,223 B7M12 345 509 1,190 B6B59 12 31 42 B4G26 452 845 1,345 B3Z56 502 883 1,739 B1U88 490 801 1,387 B0D76 457 838 1,293 G9F22 409 856 1,238 G5K51 398 781 855 G7D99 127 482 478 G3D72 486 823 987 G1O81 31 146 185 G2Z17 553 903 1,985 G0V02 480 883 1,463 G6N58 596 894 1,642 P5U30 0 0 0 P2X98 673 998 1,830 P8E57 462 980 1,541 P3H40 599 909 1,778 P7W33 683 360 1,928 54 P6P32 8 10 12 P1E52 58 158 138 P0B63 642 982 1,963 P9D27 0 0 0 T4T82 532 991 1,302 T9J72 93 90 194 T8S55 675 925 2,180 T0G78 12 10 45 T3Q92 248 590 572 T2I00 737 1237 3,123 T1F68 616 958 1,865 T6H25 401 802 1,086 T7D46 685 892 2,088 U5Q11 638 948 2,202 U0R53 625 995 2,237 U2Y27 509 882 1,568 U4B38 0 0 0 U6K90 273 747 588 U3M54 493 890 1,245 U7N20 553 954 1,665 U1H45 5 2 7 U8R71 317 527 952 U9E36 502 405 1292 Total 20,216 34,038 60,510

55 Table 7 The Read Codes Included in all the Diagnostic Groups

Diagnosis Read Codes Oral Tissue Diseases 1922. 1923. 1928. 192Z 194.. 1942. 1943. 1944. 194z. 1M3.. R0400 1475 A5312 B0… B00.. B03.. B04.. B05.. B06.. B07.. B08.. B0z.. J007. J08.. J080. J0800 J0801 J080z J081. J082. J0820 J0821 J0822 J0823 J0824 J0825 J082z J083. J0830 J0831 J0832 J0833 J0834 J0835 J0836 J083z J084. J0841 J0842 J0843 J0844 J084z J085. J0850 J0851 J0852 J0853 J0854 J0855 J0856 J0857 J0858 J0859 J085A J085D J085E J085F J085z J086. J0860 J0861 J0862 J0863 J0864 J086z J087. J0870 J0871 J0872 J0873 J0874 J087z J088. J08z. J08z0 J08z1 J08z2 J08z3 J08z4 J08z5 J08z6 J08z7 J08z8 J08z9 J08zA J08zB J08zC J08zD J08zE J08zF J08zz Salivary Gland Diseases 1925. 1926. 1927. 192B. B02.. J07.. J070. J0700 J0701 J0702 J0703 J0704 J0705 J0706 J0707 J0708 J0709 J0710 J0711 J0712 J071z J072. J0720 J0721 J0722 J0723 J0724 J0725 J0726 J0727 J072z J073. J0730 J0731 J0732 J073z J074. J0740 J0741 J0742 J074z J075. J0750 J0751 J0752 J0753 J0754 J0755 J0756 J075z J076. J0760 J0761 J0762 J0763 J0764 J076z J077. J0770 J0771 J0771 J077z J07y. J07y1 J07y2 J07y3 J07y4 J07y5 J07y6 J07y7 J07y8 J07y9 J07yz J07z. J08.. J080. J0800 J0801 J080z J081. Diseases of the tongue 1924. 1929. 192A. B01.. J09.. J090. J0900 J0901 J090z J091. J092. J093. J0930 J0931 J093z J094. J0940 J0941 J0942 J094z J095. J096. J09y. J09y0 J09y1 J09y2 J09y3 J09y4 J09y5 J09yz J09z. PA0.. PA1.. PA2.. Diseases of the jaw 193.. 193Z. J0250 J0251 J0270 J0271 J028.J04.. J040. J0400 J0401 J0402 J0403 J0404 J0405 J0406 J0407 J0408 J0409 J040A J040B J040z J041. J0410 J0411 J0412 J0413 J0414 J0415 J041z J042. J0420 J0421 J0422 J0423 J0424 J0425 J0426 J0427 J0428 J0429 J042A J042B J042C J042D J042E J042F J042G J042H J042I J042J J042K J042L J042M J042z J045. J0450 J0451 J0452 J0453 J0454 J0455 J045z J05.. J060. J0600 J0601 J0602 J0603 J060z J061. J0611 J0612 J0613 J061z J062. J0621 J0622 J062z J063. J064. J0640 J0641 J0642 J0643 J0644 J0645 J0646 J0647 J064z J065. J0650 J0651 J065z J06y. J06y1 J06y2 J06y3 J06y4 J06y5 J06y6 J06y7 J06y8 J06yz J06z. Dento-facial diseases (including 191.. 1912. 1913. 1914. P91.. P92.. P9z.. P9… P90.. J00.. J000. J0001 J0002 J0004 J0005 J000z J001. J0010 J0011 J0012 J0013 congenital dental deformities) J001z J004. J0043 J0046 J0047 J0048 J0049 J004z J005. J0050 J0051 J0052 J0053 J0054 J005z J006. J00y. J00y0 J00yz J00z. J04y. J04z. Other Tooth-related oro-facial J0… J0003 J002. J003. J0030 J0031 J003z J0040 J0041 J0042 J0044 J0045 J01.. J010. J0100 J0101 J0102 J0103 J0104 J0105 J0106 complaints J0107 J0108 J0109 J010A J010B J010z J011. J0110 J0111 J011z J012. J0121 J0122 J0123 J0124 J0125 J012z J013. J0130 J0131 J0133 J013z J0140 J0141 J014z J015. J016. J017. J0170 J0171J0172 J017z J017. J01y. J01z. J02.. J020. J0200 J0201 J0202 J0203 J0204 J0205 J0206 J020z J021. J0210 J0211J0211 J021z J022. J0220 J022z J023. J023z J024. J025. J025z J026. J0260 J0261 J026z J027. J027z J02z. J03.. J031. J0310 J0311 J0312 J0313 J0314 J031z J032. J0321 J0322 J0323 J032z J033. J0330 J0331 J0332 J0333 J033z J034. J035. J036. J0360 J0361 J0363 J0364 J036z J036z J03X. J03y. J03y1 J03y2 J03y3 J03y4 J03y5 J03y6 J03y7 J03y8 J03y9 J03yz J03z. J043. J0430 J0431 J0432 J0433 J0434 J0435 J0436 J0437 J0438 J0439 J043A J043B J043C J043D J043E J043F J043z J044. J046. J0460 J0461 J0462 J0463 J0464 J0465 J046z J050. J051. J0510 J0511 J0512 J051z J052. J053. J054. J05y. J05z. J06.. Oro-facial fractures S0... S00.. S022. S023. S024. S025. S026. S027. S028. S02A. S02B. S02C. S02x. S02y. S02z. S04.. S0z..

56 5.2 Type of Oro-facial or/and Dental Complaints

Among those who attended their GMPs for oro-facial or/and dental complaints, more than one-fifth (22.42%) of them were connected to the oro-facial soft tissues. The 15 most common oro-facials or/and dental complaints presented to GMPs over the 4 years period is depicted in pie chart:

Pie-chart Fifteen most common oro-facial or/and dental complaints from 1st January 2009 to 15th December 2012 (n= 94,548)

oral aphthous ulcer

bad breath

bad taste

tooth pain 13.64% 2.52% teething syndromes

33.31% difficulty in swallowing 5.60% lump in the gum 7.45% clicking jaw

limitation of mouth opening 11.98% 1.35% dental abscess 4.55% lump in the tongue 0.75% 6.37% 1.35% 2.23% 3.56% bleeding gum 1.81% 1.37% 2.16% pain under denture

pain after removal of teeth

pain under denture

Other oro-facial or/and or dental complaints

Diseases of teeth and oro-facial soft tissue diseases accounted for 58.43% of all the attendances with oro-facial or/and dental complaints to GMPs. (Table 4 and Table 5). This finding closely matches that of the studies by Anderson et al 1999, Cohen 2003, and Cohen et al 2009. In all age groups, dental abscesses, dental caries, oral aphthae, salivary gland swelling and temporomandibular joint disorders are among the commonest oro-facial diseases encountered in general medical practices. On the other hand, teething problems, feeding difficulties due to suspected dental pathology and 57 disorders of tooth development/eruption were the usual complaints in children under 6 years-old.

5.3 Attendance Pattern by Gender

There was a female predominance in attendance pattern for both oro-facial or/and dental complaints and non-dental related complaints. Females (11,341) were 12.7% more likely than males (8,785) to attend for oro-facial or/and dental complaints. However, the overall attendance for any medical reasons (with oro-facial or/and dental complaints being included) demonstrated only slight female predilection as shown in Graph 1.

5.4 Attendance Pattern by Medical Co-morbidities

The median number of attendances for patients with medical comorbidities presenting with oro-facial or/and dental complaints were 2.5 times higher than those who were without co-existing medical problems. Oro-facial or/and dental complaint related attenders visited their GMPs more frequently than attenders who never presented themselves for oro-facial or/and dental complaints (Graph 2). Patients with other oro-facial or/and dental complaints were 1.77 times (n= 20,216) more likely to visit their GMPs than those who were with only tooth related complaints.

58 Graph 1 Attendance Pattern for Oro-facial or/and dental complaints and non-dental complaints by gender

120000 110078 105304 100000

80000

60000 Females Males 40000

20000 11341 8,785

0 Oro-facial or/and dental All the patient complaints complaints

Graph 2 Attendance Pattern for Oro-facial or/and dental complaints and non-dental complaints by medical co-morbidities

1600 1,423 1,381 1,378 1400 1,325 1,308 1,266 1,168 1200 1,103

1000 Patients with at least one 842 856 834 778 781 801 799 813 pre-existing medical 800 problem

600 Patients with two or more 473 pre-existing medical 406 418 423 406 435 problems 400 354 345 Patients without any prior 200 medical diagnosis

0

59 5.5 Attendance Pattern by Days of the Week

The time of attendance for these patients is given in Graph 3. Date of attendance was used to separate the patients into 2 main groups: 1. week day and 2.weekend (Saturday and Sunday). The oro-facial or/and dental attendances occurred about twice as high (1.94, n= 94,548) during week day than at weekends in most primary medical practices included in this research. In general, the proportion of attendances to GMPs at weekends for non-dental related complaints was less frequent at weekends than during weekdays. Most PMCs usually worked from 9 am to 5 pm; and did not offer out-of-hours and weekend appointments. Hence, access and convenience to PMCs could probably be one of the many underlying reasons for these findings.

Graph 3 Attendance Pattern for Oro-facial or/and dental complaints and non-dental complaints by day of the week

42733 weekend (2012) 6786 2964 200116 weekday (2012) 9927 5764

39762 Non oro-facial or/dental weekend (2011) 5873 2871 complaints 194065 weekday (2011) 9942 5696 Other oro-facial 35792 complaints weekend (2010) 5345 2754 189807 Tooth related complaints weekday (2010) 9662 5619 30564 weekend (2009) 4981 2792 175223 weekday (2009) 7994 5578

0 100000 200000 300000

60 5.6 Attendance Pattern by Age

Most of the patients presented with oro-facial or/and dental complaints to GMPs were children under 6 years-old, and adult of age between 16 to 45 years-old. This displayed similar attendance pattern to other researches of various study designs (Anderson et al 1999, Cohen et al 2009). In contrast to patients of all other complaints not related oro-facial or/dental complaints, they were more likely to be in the younger age groups (patients were aged predominantly between 40 to 80 years-old for non dental-related medical complaints). The children under 5 years-old and adult of age ranged from 16 to 55 years-old accounted for almost half of the attendance for all reasons (41.12% for oro-facial or/and dental complaints, 39.99% for non-dental related medical complaints, n= 908,062)

Table 8 Attendance Pattern for Oro-facial or/and dental complaints and non-dental complaints by age

Age Tooth related Other Oro-facial Non oro-facial complaints complaints or/and dental complaints

Under 6 5327 6305 50227 6 to 15 years old 3308 7733 75748 16 to 25 years old 4721 9282 70481 26 to 35 years old 3928 8871 98910 36 to 45 years old 2914 3346 68665 46 to 55 years old 3785 5658 125159 56 to 65 years old 3074 7237 171434 66 to 75 years old 3129 6898 131244 75 years old and 3952 5180 115894 over

In this study, the number of dental attendance grew steadily annually between 0.05% to 0.09% (n= 94,548). Most patients who presented to GMPs for oro-facial 61 or/and dental complaints were mainly from the 0-4 year-old and 16-45 year-old age groups. In comparison, these age-groups also accounted for almost half of the number of all patients who attended GDPs for oro-facial and/or dental complaints in the primary dental practices of England (Healthcare report across the UK, a comparison of the NHS in England, Scotland, Wales and Northern Ireland 2012. [online] Available at http://www.nao.org.uk/wp-content/uploads/2012/06/1213192.pdf [Accessed May 18, 2013]).

Interestingly, these age groups (0-6 year-old and 16-45 year-old age groups) represented about 56.32% (n= 268,290) patients who attended their GMPs for tooth related complaints in 2012 alone. The pattern of some tooth related complaints was closely linked to age-distribution of the patients. For example, teething problem was almost observed exclusively in the 0-6 year-old age group while dry mouth and difficulties in swallowing were more prevalent in the patients above 65 years-old. The number of oral aphthous ulcer related attendance climbed by 0.07% to 1.53% (n= 908,262) yearly.

Graph 5 plots number of attendances for first half (from January to June) and second half (from July to December) over the 4 years. Unlike other studies, seasonal variation was not clearly shown for all the oro-facial or/dental complaints (Brunton et al 2012, Cohen et al 2011). Nevertheless, the number of dental abscess recorded a small but gradual increase. For other oro-facial and/or complaints, the trend was not notably well-defined.

5.7 Attendance Pattern by Other Demographic Factors

For other important studied variables, there was no significant correlation (P<0.05) with the social background of the patients (ethnicity, religion, social group), and the size of practices (based on the number of recorded patient attendances).

62 Graph 4 The Trend of Attendance for 15 Most Common Oro-facial or/and dental Complaints

4,500

oral aphthous ulcer 4,000 bad breath

3,500 bad taste

tooth pain 3,000

teething syndromes

2,500 difficulty in swallowing

lump in the gum 2,000

clicking jaw

1,500 limitation of mouth opening

1,000 dental abscess

lump in the tongue 500 bleeding gum

0 pain under denture

pain after removal of teeth

pain under denture

Other oro-facial or/and or dental complaints

63 Table 9 Number of Attendances by Ethnicity

PMC White Black Asian Others Foreign Total A7D71 2,012 456 278 291 395 3,432 A0T12 0 0 0 0 0 0 A4J41 1,134 131 53 56 174 1,548 A5Y34 826 189 57 62 135 1,269 A4X31 57 21 16 17 23 134 A0P36 1,252 389 243 311 207 2,402 A9L20 302 48 33 57 36 476 A3Q85 888 278 182 331 269 1,948 A4C74 962 210 165 287 265 1,889 B5181 1,334 528 266 455 403 2,986 B0R00 99 36 11 35 27 208 B8D23 1,004 401 293 226 185 2,109 B7M12 1,050 339 52 156 102 1,699 B6B59 30 21 5 8 9 73 B4G26 1,100 462 201 235 192 2,190 B3Z56 1,531 395 192 287 217 2,622 B1U88 1,075 476 198 254 185 2,188 B0D76 1,051 454 184 267 175 2,131 G9F22 870 518 283 247 176 2,094 G5K51 1,054 308 71 116 87 1,636 G7D99 490 258 50 94 68 960 G3D72 1,046 427 61 149 127 1,810 G1O81 202 51 15 28 35 331 G2Z17 1,785 565 102 223 213 2,888 G0V02 1,052 683 126 237 248 2,346 G6N58 1,438 468 115 279 236 2,536 P5U30 0 0 0 0 0 0 P2X98 1.807 456 98 256 211 2,828

64 P8E57 1,464 427 145 207 278 2,521 P3H40 1,706 415 81 253 232 2,687 P7W33 1,137 492 93 232 334 2,288 P6P32 8 5 0 6 3 22 P1E52 174 63 10 23 26 296 P0B63 1,775 487 112 215 356 2,945 P9D27 0 0 0 0 0 0 T4T82 1,149 483 87 246 328 2,293 T9J72 185 47 8 21 23 284 T8S55 1,772 464 178 275 416 3,105 T0G78 34 6 2 5 8 55 T3Q92 598 276 58 132 98 1,162 T2I00 2,713 643 125 347 532 4,360 T1F68 1,645 498 108 235 337 2,823 T6H25 1,017 426 145 162 138 1,888 T7D46 1,560 584 109 371 356 2,980 U5Q11 598 132 323 486 3,150 U0R53 1,745 545 97 493 302 3,182 U2Y27 1,065 617 115 276 377 2,450 U4B38 0 0 0 0 0 0 U6K90 684 328 73 112 138 1,335 U3M54 957 465 136 272 305 2,135 U7N20 1,317 432 115 398 357 2,619 U1H45 5 1 0 2 1 9 U8R71 759 396 45 192 87 1,479 U9E360 868 432 97 157 143 1,697

65 Table 10 Number of Attendances by Religion

PMC Christian Muslim Hindu Sikh Jewish Others Total A7D71 2,423 271 33 45 12 678 3,462 A0T12 0 0 0 0 0 0 0 A4J41 709 271 17 76 43 432 1,548 A5Y34 739 185 89 7 14 235 1,269 A4X31 51 8 5 3 4 63 134 A0P36 1,354 145 32 18 11 842 2,402 A9L20 207 43 27 13 7 179 476 A3Q85 903 102 18 43 15 867 1,948 A4C74 828 74 34 14 8 939 1,889 B5181 1,120 113 89 88 23 1,553 2.986 B0R00 86 7 3 0 0 112 208 B8D23 871 78 31 13 8 1,108 2,109 B7M12 734 67 22 5 4 867 1,699 B6B59 25 5 0 0 0 43 73 B4G26 718 168 15 2 0 1,287 2,190 B3Z56 832 98 13 3 0 1,676 2,622 B1U88 723 87 54 22 5 1297 2,188 B0D76 456 103 46 5 0 1,521 2,131 G9F22 101 0 0 0 0 1,993 2,094 G5K51 526 65 19 16 0 1,010 1,636 G7D99 179 86 14 0 0 681 960 G3D72 456 32 0 1 0 1,321 1,810 G1O81 88 4 1 0 0 238 331 G2Z17 617 136 56 8 0 2,071 2,888 G0V02 245 198 14 8 4 1,877 2,346 G6N58 533 126 43 31 1 1,802 2,536 P5U30 0 0 0 0 0 0 0 P2X98 707 23 45 32 0 2,021 2,828

66 P8E57 487 89 3 0 0 1,942 2,521 P3H40 542 78 20 2 0 2,045 2,687 P7W33 636 82 12 6 0 1,552 2,288 P6P32 5 0 0 0 0 17 22 P1E52 10 1 0 0 0 285 296 P0B63 303 9 1 0 0 2,632 2,945 P9D27 0 0 0 0 0 0 0 T4T82 578 110 0 0 0 1,605 2,293 T9J72 71 0 0 0 0 213 284 T8S55 546 34 14 6 0 2,505 3,105 T0G78 0 0 0 0 0 55 55 T3Q92 0 0 0 0 0 1,162 1,162 T2I00 677 183 9 3 0 3,488 4,360 T1F68 763 154 15 0 0 1,891 2,823 T6H25 642 110 3 0 0 1,133 1,888 T7D46 603 117 56 24 3 2,177 2,980 U5Q11 559 7 1 0 0 2,583 3,150 U0R53 832 78 33 2 0 2,287 3,232 U2Y27 568 98 54 62 2 1,666 2,450 U4B38 0 0 0 0 0 0 0 U6K90 384 67 35 8 0 841 1,335 U3M54 536 97 7 2 0 1,493 2,135 U7N20 658 186 67 5 0 1,703 2,619 U1H45 0 0 0 0 0 9 9 U8R71 428 58 2 0 0 990 1,479 U9E360 325 12 2 0 0 1,358 1,697

67 Table 11 Number of Attendances by Social Group PMC Professional Skilled Unskilled Not Total & Managerial Otherwise Specified A7D71 230 234 228 2,770 3,462 A0T12 0 0 0 0 0 A4J41 15 113 27 1,393 1,548 A5Y34 59 65 256 889 1,269 A4X31 0 0 0 134 134 A0P36 43 5 278 2,076 2,402 A9L20 0 0 0 476 476 A3Q85 34 71 322 1,521 1,948 A4C74 101 65 80 1,643 1,889 B5181 0 0 0 2,986 2,986 B0R00 0 0 0 208 208 B8D23 137 122 167 1,683 2,109 B7M12 23 79 68 1,529 1,699 B6B59 0 0 0 73 73 B4G26 67 163 98 1,862 2,190 B3Z56 45 154 116 2,307 2,622 B1U88 0 0 0 2,188 2,188 B0D76 15 107 155 1,854 2,131 G9F22 31 61 76 1,926 2,094 G5K51 25 69 110 1,432 1,636 G7D99 4 42 31 883 960 G3D72 64 129 78 1,539 1,810 G1O81 0 0 0 331 331 G2Z17 0 0 0 2,888 2,888 G0V02 83 162 107 1,994 2,346 G6N58 4 91 85 2,356 2,536 P5U30 0 0 0 0 0

68 P2X98 17 125 141 2,545 2,828 P8E57 45 174 84 2,218 2,521 P3H40 62 35 83 2,507 2,687 P7W33 0 0 0 2,288 2,288 P6P32 0 0 0 22 22 P1E52 3 32 25 236 296 P0B63 15 344 230 2,356 2,945 P9D27 0 0 0 0 0 T4T82 78 183 129 1,903 2,293 T9J72 7 16 34 227 284 T8S55 94 148 341 2,522 3,105 T0G78 0 0 0 55 55 T3Q92 26 125 105 906 1,162 T2I00 49 212 285 3,814 4,360 T1F68 133 143 289 2,258 2,823 T6H25 0 0 0 1,888 1,888 T7D46 113 62 272 2,533 2,980 U5Q11 54 146 193 2,457 3,150 U0R53 25 278 151 2,778 3,232 U2Y27 77 118 148 2,107 2,450 U4B38 0 0 0 0 0 U6K90 15 48 28 1,244 1,335 U3M54 55 83 129 1,868 2,135 U7N20 34 86 116 2,383 2,619 U1H45 0 0 0 9 9 U8R71 8 57 98 1,316 1,479 U9E360 0 0 0 1,697 1,697

69 6. DISCUSSION

6.1 CHALLENGES

6.1.1 Data Security

Electronic medical records (EMRs) offer an inexpensive and easy access to a large volume of data. This development has opened endless possibilities for researches in primary medical care (PMCs) on an unprecedented pace with improvement of data quality over the time. Nevertheless, my supervisor (PC) and I (CSS) were faced by many challenges when trying to capitalise on this opportunity for the very first time.

General medical practitioners (GMPs) collect data and share them with third parties (e.g. Department of Health, NHS, not-for-profit organisation, and insurance companies). Data ownership and security issue often invite controversy. To what extent, should third parties be placed in a position to grant approval for the researchers to access these data still remains hotly debated. Clearer definition and clarification are needed to protect sensitive (when the identities of patients are known to the researchers) and non-sensitive data.

Some argue that there is a minority of patients who have clear opinions about whom they wish their personal and sensitive information to be shared. Nonetheless, many patients are happy to see their data being contributed for useful researches. The author took about half a year to go through the application process of obtaining access to the non-sensitive database despite the project’s nature of being not controversial and straightforward. This is essential to protect the participants’ interest and privacy. New measures are being constantly studied and introduced to make it easier for the researchers by slashing red tapes and unnecessary rules.

70 6.1.2 Data Quality

One of the biggest challenges confronted by us in this project was to work with incomplete and inconsistent data. There was no information available from 4 PMCs regarding oro-facial or/and dental complaints. Unfortunately, the cause underlying for such missing data could not be determined. This is because the data was anonymised (the identities of patients and the PMCs were not known to the investigators from the outset) and the author lacked of tool to study the narrative records. A significant part of the data used to drive clinical decision-making was recorded by GMPs using unstructured narrative text.

Most GMPs have little training in the diagnosis of oro-facial or/and dental complaints. Also, there has been no agreed calibration on how to record a dental diagnosis in the same standardized manner by different GMPs (from the same or different PMCs). Not infrequently, the diagnosis of a medical event could not be established at the time of consultation and the gap may be filled-in by GMPs with the use of free narrative text.

The competency of GMPs at diagnosis of oro-facial or/and dental complaints has been difficult to be determined due to the nature of this study design. Some GMPs may use inclusive codes, e.g. salivary gland diseases, dental pain, soft tissue diseases to ‘catch all’ the possible suspected diagnoses in order to avoid missed diagnoses and misdiagnoses. The self-limiting but chronic nature of some oro-facial complaints, e.g. gum diseases, temporomandibular joint pain, oral aphthous ulcer may render under- reporting of these common diseases from many GMPs. In addition, the likelihood of unrecorded out-of-hour or telephone consultations by the nursing staffs or receptionists went unnoticed by GMPs could not be ruled out entirely.

The free text could not be automatically translated by the computer software into the related Read Codes. Narrative records would enable the researchers to make sense of the natural history of a disease and thus ascertained that all the studied patients who complained of oro-facial complaints had actually had the oro-facial diseases. In this preliminary study, the investigators also could not certain whether or 71 not GMPs did make a correct diagnosis. Some codes, e.g. “191Z., Tooth symptom NOS” ; “J010z, Dental caries NOS” may indicate suspicion rather than confirmation of a specific oro-facial disease and therefore must be construed with caution.

Accuracy of data recorded by the GMPs in the computer varied from one PMC to another. Different diagnoses can also be coded with the same Read codes when the same treatment or management is provided. Again, whether or not the GMPs did record data correctly was hard to be verified. However, inaccurate reporting and recording may be minimised by the data-linkage features of NWeH databases. Data linkage of computer systems allowed association of treatment or intervention to the relevant medical events (diagnoses or symptoms) in a chronological order (by studying the sequence of entry).

PMC has a huge potential to diagnose and relocate the delivery of care for oro- facial malignancy and facial trauma closer to patients’ homes. Lately, hospital is increasingly being used for managing patients with these conditions which cannot be provided more appropriately in other settings. New information and technologies such as life-streaming can support GMPs to deliver safe and high quality care to these patients from their PMCs while the hospital clinicians remote from PMCs responding to real-time diagnostic information.

It was the author’s hope to give some insight on this important area from the outset. Nonetheless, data on oro-facial malignancy and facial trauma was not sufficient for the analysis in this study. This is potentially problematic as late diagnosis and referral of patients with suspected oro-facial cancer has been a specific concern in the UK.

There are a few possible reasons. Lack of experience and confidence of GMPs in facial trauma, lesser GMPs’ emphasis on preventive oral cancer screening; and patients’ preference to be seen in the hospitals could perhaps explain this finding. Finally, the author could not distinguish whether this data was simply missing from the original source or failure of GMPs to record.

72 6.1.3 Coding Behaviour of GMPs

Using administrative/billing data as a surrogate for clinical data may be problematic. The coding behaviour of GMPs may be influenced by the payment practice. There may be an inclination for GMPs more likely to report certain medical events if they were to receive payments for the specific diagnoses, leading to false inference of certain oro-facial diseases (Ryan et al 2009). Some commercial computer softwares in the market also propel GMPs to select Read codes which maximize reimbursement. This “profit element” may drive up the frequency of certain code entries.

For example, it was possible that GMP would report Bonjela-treated oral ulcers rather than burning mouth syndromes which were usually managed by wait-and-see approach. In addition, data recording of oro-facial complaints could also be distorted by the medical certification for sickness absence and the patients with sickness- attention-seeking behaviour. Close watch and surveillance of traffic of the codes could provide some understanding on GMPs’ coding behaviour, but the tool to acquire this information (the locations of PMCs and software utilisation habit) was not at the investigators’ disposal (Still awaiting for NWeH’s approval at the time writing). Hence, the over/under-representation of some oro-facial diseases cannot be reliably ruled out in this study.

Detailed clinical researches are necessary to understand the health behaviour of the patients who see their GMPs for oro-facial complaints instead of their GDPs. The use of EMRs makes it easier for the researchers to infer from the data collected of the outcomes of GMPs care for oro-facial problems. However, this is only possible if the data collection has been supervised by the investigators for quality assurance in a small and selected number of primary care practices.

There has been a limited publication of research methods for studying oro- facial diseases by using EMRs. Choosing the acceptable research methods for analysing the data from primary medical care database can be very difficult. Making decisions on

73 which Read codes for oro-facial diseases, practices or other individual data items to be included or excluded in the study were never easy for the author.

Strict inclusion or exclusion criteria’s increase the risk of omitting the obvious but significant information. Nonetheless, the author tried to be as detailed as possible when describing the research methods to permit other researchers to replicate the processes involved in this study. Therefore, issues such as patient satisfaction, GMPs satisfaction, differences in treatment costs and duration of treatment time were not investigated here due to difficulties in data interpretation, nature of study design; and lack of complete data.

The author has always strived very hard for greater data availability to make this study as comprehensive and as complete as possible. Sadly, the data on some read codes was extremely little for meaningful analysis. In particular, there was no data available at all for oro-facial trauma, and dento-facial deformity. Perhaps, these oro- facial conditions are perceived as more serious oro-facial conditions. Additionally, many oro-facial trauma cases are actually very challenging and well beyond capability of GMPs who frequently work in solitary settings. These conditions are more often seen by colleagues in A&E or oral and maxillofacial units, and thus help to explain the information gap in this study.

There has never been a time in our mind to dismiss GMPs’ or other healthcare professionals’ input as irrelevant. Indeed, they could shine some light on preference, expectations, social, personal and home circumstances of the patients who visited them for oro-facial diseases. To involve all the GMPs from these 54 PMCs was next to impossible because the identities of PMCs were not known. Moreover, when we look a little closer at the design of this study, the reasons start to become clear. These important issues are expected to be dealt with in the subsequent studies with more appropriate designs.

74 6.2 MAIN FINDINGS

6.2.1 Attendance Pattern

NWeH is a large database, which holds EMRs of about 215,382 patients from 54 PMCs in Salford. To facilitate discussion, the oro-facial or/and dental complaints seen in PMCs are grouped into 3 main categories:

1. Oro-facial or/and dental complaints which should have been managed by GDPs (because GDPs would have greater level of training and experience than GMPs for them), e.g. dental abscess, dental trauma, salivary gland stone, temporomandibular joint pain dysfunction syndrome.

2. Oro-facial or/and dental complaints which would be perceived by many patients to be related to GDPs’ routine work (tooth-related complaints), e.g. dental caries, periodontitis, fracture of enamel, toothwear.

3. Oro-facial or/and dental complaints which GMPs would be expected to manage comfortably by themselves, e.g. bad breath, swallowing difficulties, oral aphthous ulcer, dry mouth.

The number of attendance for oro-facial or/and dental complaints presented to GMPs in Salford is significantly large (94,548 attendance from 2009 to 2012). The tooth related complaints consisted of 36% (n= 34,038) of oro-facial or/and dental complaints or 9.43%(n = 908,062) of attendances for all complaints in PMCs. About 20.15% (n= 34,038) of the tooth related problems were seen in patients with other non-tooth related medical problems. Many of these patients may not be aware that their complaints were of dental origin which should therefore have been managed by their GDPs. Also, some patients may not have even realise the presence of oro-facial or/and dental problems until they were consulted by their GMPs.

Unlike study by Anderson et al 1999, the attendance rate in this study for or- facial or/and dental complaints was comparatively higher. Although attendance 75 pattern varied among 54 PMCs, the yearly medical consultations (for all the complaints) averaged to 1,888 consultations per 10,000 patients per practices. This study was not able to show the correlation of number of PMCs available in a residential areas with the number of patients visited GMPs for oro-facial or/and dental complaints because the addresses of the PMCs were not available to the author.

In some areas where primary dental practices were geographically abundant in City of Salford (this information can be retrieved from Results for Dentists in Salford, NHS choices webpage), the attendance for oro-facial or/and dental complaints was higher than one would have expected. There could be many possible reasons for this observation. These probably included geographical location and popularity of these practices, prevalence and incidence of dental diseases, socioeconomic status, ethnic background; and variation in oral health related behaviour (Fayle 2013, McCormick et al 2008).

6.2.2 Oro-facial or/and Dental Complaints According to Age, Gender and Ethnicity

The pattern and age distribution of the attendance in this study were consistent with other studies (Anderson et al 1999 et al, Cohen et al 2009, Mathu- Muju et al 2008). The types of oro-facial or/and dental complaints were universal to the patients of all age group regardless of the sex, ethnicity and marital status. It has been shown that the differences in illness behaviour, eagerness on seeking medical assistance and beliefs about illness are influenced by cultural and religious background in the UK.

Unlike other medical conditions, e.g. ischemic heart diseases and diabetes and other studies (Cohen et al 2003, Drum et al 1998, Lockhart et al 2000), oro-facial or/and dental complaints related attendance did not show a specific predilection for certain ethnic minorities in this study. However, the failure to note such observation may relate to fact that these patients may be under-managed or under-reported by GMPs in Salford.

76 Females are more likely than males to report ill-health to their GMPs. Women tend to be more health conscious and readily to discuss their health matters with their GMPs (Cohen et al 2006). Cohen et al 2011 also conceded that females usually presented dental related problems to GMPs and GDPs earlier with less severe manifestations as a result of higher level of dental awareness. Although more female attended GMPs for oro-facial or/and dental complaints in this study, but the chi-square test did not show significant association between gender and the number of patient attendance (Chi-square X2= 1.47, P = 0.12). Further studies are needed to assess whether men are less likely to acknowledge oro-facial or/and dental problems to themselves or others in the UK. The reluctance to seek help can be alarmingly worrying. The delay may cause serious oro-facial infection, e.g. cellulitis; and oral cancer to become more advanced and harder to treat.

6.2.3 Oro-facial or/and Dental Complaints According to Days of the Week

The number of attendances in PMCs for oro-facial or/and dental complaints were notably higher during the weekdays. This attendance pattern could be the result of lack of dental access (actual and perceived) at weekends and in the evening (out-of working hours). Many patients may not know the way to find an emergency dental service. In the UK, the patients can call the 24 hours NHS Direct Helpline to obtain the help of an emergency dentist. Nevertheless, it is not a helpline dedicated only to emergency dental service and is determined by the availability of dentists to offer emergency dental service. Unregistered patients and expensive treatment cost to the patients further complicate the matter. Some of these differences can be explained by locations and distribution of dental services. But, even within the same geographical areas, the differences can sometimes be surprisingly marked (Cohen et al 2011).

6.2.4 Roles of GMPs in Managing Oro-facial or/and Dental Complaints

Arguably, GDPs are the best healthcare professionals to treat most if not all the oro-facial or/and dental complaints often seen in the PMCs. The patients who 77 attended their GMPs with oro-facial or/and dental complaints were those who also visited them for other non-dental related medical conditions (Anderson et al 1999, Bell et al 2008). The reasons underlying this findings may include closer patient rapport with GMPs, integration of dental management as a part of general healthcare, difficulties of getting an appointment at convenient office hours, and transportation barriers (especially for the very young and the elderly patients).

Patients’ preference towards management of non-tooth related oro-facial problems by GMPs, lack of key investigation tools (e.g. haematological, biochemical, immunological tests) and broader prescription privilege may also place GMPs in a more advantageous position for some non-dental oro-facial problems; e.g. oral ulcers, dry mouth, facial pain (Bell et al 2008). Despite competency being shown by GMPs in managing most oro-facial complaints, mismanagement of patients is not uncommon (Bater et al 2005, Holton et al 2001, Mathu-Muju et al 2008).

Numerous patients seek GMPs’ care for dental infection. Instead of helping patients to make an emergency dental appointment (in order to diagnose and remove dental source of infection), many GMPs attempt to improve patients’ temporarily with prolonged antibiotics and anti-inflammatory agents (Mathu-Muju et al 2008, Muirhead 2011). This could potentially lead to antibiotic resistance and harmful consequences to the patients. Effective referral system and better communication between GMPs and GDPs are needed to promote the practice of holistic patient care; through the recognition of the dentists’ role as ‘oral physicians’ in treating dental and non-dental related oro-facial diseases.

6.2.5 Dental Abscess

There is a small but steady overall increase in the rate of dental abscess related attendances in PMCs of Salford. In author’s opinion, this trend is predicted to continue as NHS dental services in England continue to suffer from substantial cut back since a few years ago. Consequently, many dentists who want to provide their patients the oral healthcare they entitled are now forced to give only basic standard of treatment. 78 A range of treatment options to fits individual’s budget is no longer becoming viable to many patients.

Obviously, the patients of the low socio-economic group are the most vulnerable to be come to harm by the dental diseases because they are the most affected by the poverty, social rejection and discrimination. The long-term strategy must aim to better target resources of NHS, shorten waiting time and not just to make hit-or-miss saving. Furthermore, it is extremely difficult to put a fixed price tag on the quality of life which good oral healthcare can improve. Further studies are required to ascertain exactly how many individuals from the most-at-risk populations would be losing out.

6.3 FUTURE RESEARCH POTENTIAL

6.3.1 Potentials and Benefits

Routinely collected data from electronic medical records (EMRs) are becoming increasingly important over the years. Technological development, the perceived need of clinicians to adopt information technology (IT), availability of training to meet changing demand of IT progress, public support of healthcare professionals’ attitude conducive to health, and strong political will have all contributed toward raising the data quality. Patient information can be pooled into large databases for conducting the audit, health service planning, epidemiological research studies.

Simple service data from EMRs is ideal for health resources utilisation or quality of oral healthcare related researches. This can be achieved by identifying and involving the people at risk from oro-facial diseases. The study results about a population’s oral health status and the effects of healthcare could then be made accessible to the public and healthcare professionals for service planning. The conclusion from dubious anecdote is no longer acceptable to be used as infallible evidence to fully inform decision on health economies.

79 The digital innovation allows us to harness in-depth insight into the oral health of population and reaffirms decision in reliable, transparent and precise ways. The impact of system planning and implementation can be easily assessed with EMRs as the relevant data is being continuously acquired by people with expert knowledge and strategic implementation skill. Nevertheless, the lack of completeness and accuracy of data from EMRs can adversely affect quality of research. Future research on inter- practitioners and inter-practices variation when recording the oro-facial complaints can produce a better understanding of the problem.

Coding enables the diagnosis of oro-facial problems or medical events to be recorded consistently and accurately into EMRs. Although the EMRs as the source of data is less complex than extracting data from hand-written clinical notes, but formal training is essential when involving more than one researcher in a large study. GMPs have long accustomed themselves to record medical events (diagnoses or patient complaints) using coded computerised system. But, GDPs usually record the management in the Electronic Dental Records (EDRs) and infer a diagnosis or problem from the management of their patients (e.g. dental caries from the placement of temporary fillings).

Thus, future researchers with dental background who are interested in this area should consider training in Read code classification system if the quality of the data is to be further enhanced. Following that, a more conducive research environment can perhaps be achieved with little concerns about standardisation of terminology choices and missing data even though the integration of EMRs and EDRs has proven to be difficult at present in the UK.

6.3.2 Integration of EMRs and EDRs

The linking of EMRs and EDRs is much anticipated in the UK to provide comprehensive knowledge of the patients who see GMPs for oro-facial complaints. Also, a large amount of data is required to assess the odds of less common yet serious diseases, e.g. oral cancer, trigeminal neuralgia by connecting the local databases to the 80 international research network. Mobilising such invaluable information will enable greater personalisation and localisation of oro-facial care by better targeting the healthcare resources. Future research can be designed to explore the challenges and barriers encountered when integrating EMRs and EDRs in the UK.

6.3.3 Ideas For Author’s Next Research

The collected data from this study was collected by North West e-Health (NWeH) by using only a single brand of computer software system (EMIS system). And assuming, only those GMPs who had undergone the requisite training of EMRs in the North West of the UK were included in this study. The exclusion of a subset of medical practices with poor or above a certain quality level can run the risk of either understating or overstating the data quality. At the time of writing, no research has been carried out to compare the different computer software systems.

The findings of this study can have a wide range of effects on local GMPs’ and GDPs’ emotion; some feeling of doubt, shock, fear and anger may be expected. The design of this study makes the exploration of their views an easier said than done effort. Certainly, some of the research data in this study may have uses unforeseen by the author. There are still many questions to answer about the patients’ behaviour and the reasons that lead to such behaviour. More significant findings could probably be uncovered by applying different techniques or integrating with other data sets.

To gather a better understanding of this social phenomenon in City of Salford, qualitative methodology may be the better research strategy. Data can be collected from GMPs or GDPs via well-structured interview instruments, case studies and videotapes. They will be able to have their say, evolve; and generate ideas and solutions. This will then allow us to focus on “why patients present to GMPs with oro- facial or/and dental complaints” rather than “who, where, when etc present to GMPs with oro-facial or/and dental complaints” as in this study.

81 However, there appears to be more ethical dilemmas and data validity concerns associated with qualitative than with quantitative research. Sampling bias, procedural bias, investigator bias, and measurement bias are commoner due to subjective nature of data collection and analysis. Also, some researchers may tend to conform to the conventions, rather than to produce original work to study the real causes of these group of patients with oro-facial and/or dental complaints.

It would be interesting to look into the advantages and disadvantages presented by each principal networks for research in the UK, e.g. General Practice Research Database (GPRD), Q-research when used to identify the patients who see GMPs for oro-facial problems (Hippisley-Cox J et al 2004). To date, comparison between databases and their validity of data for oro-facial diseases in the UK has yet to be studied in both the medical and dental settings.

Maybe, this effort will drive the development of a reliable unique identifier for most if not all the oro-facial diseases in the UK. This linkage of databases is particularly useful in researches related to oral health service performance and utilization for sharing healthcare intelligence with the policy makers to ensure oral healthcare equity.

82 7. CONCLUSIONS

The findings from this study show that the use of primary medical care service by patients with oro-facial or/and dental complaints is not uncommon in the UK. The use of electronic medical records (EMRs) appears to be gaining popularity worldwide. Many countries have ambitious plans to integrate clinical data from general medical practitioners (GMPs), general dental practitioners (GDPs) and other healthcare professionals to improve quality of care and provide data for researches. To improve data quality for research, incentives, well-established clinical guidelines and technical progress are important.

The progress of healthcare informatics over the year has been very encouraging. Better communication between the patients, General Medical Practitioners (GMPs), the dental professionals and other healthcare providers will certainly deliver a holistic oro-facial healthcare for all. Training of the current and next generation of medical and dental care providers in EMRs or EDRs is crucial to integration and improvement of oral healthcare information technology.

The concept of teamwork in oral healthcare is necessary to achieve cohesive oral healthcare because a significant proportion of patients see their GMPs for oro- facial complaints. The next generation of GMPs should be trained to be well versant in knowledge about oro-facial diseases and the related systemic implications. At the same time, the next generation of dentists should be comfortable to treat dental patients with systemic medical conditions. Proper delivery of oral healthcare can be delayed by lack of articulation between the dental and medical professionals.

This study affirms that many patients will visit their GMPs rather than GDPs for management of oro-facial or/and dental complaints. From 2009 to 2012, about 9.39% of 215,382 patients presented to GMPs in Salford for the management of oro-facial or/and dental problems. In 2011, it was estimated that £1,900 per person in England was spent on primary medical healthcare (Healthcare report across the UK, a comparison of the NHS in England, Scotland, Wales and Northern Ireland 2012. [online] Available at http://www.nao.org.uk/wp- 83 content/uploads/2012/06/1213192.pdf [Accessed May 18, 2013]). If each of these 20,224 patients visited GMPs solely for tooth-related problems (i.e. if they were all fit and well without any medical disease), one can imagine how great the cost and impact of dental attendances will have on the care provision in primary medical services.

Rising cases of dental abscess attended by GMPs is an apprehensive development. If untreated, it may lead to osteomyelitis, dental cysts, sinusitis, cavernous sinus thrombosis, mediastinitis or potentially life-threatening infection. GMPs should cooperate closely with GDPs to reduce the risk of dental abscess by treating the preventable cause timely – dental caries. Traumatised tooth are best managed promptly by the more experienced dentists.

As the UK government pushes ahead with plan to slash NHS spending in the budget, NHS dental service is one of the many healthcare sectors expected to hurt the most. In trying economic times, more elderly, people with learning disabilities and socially deprived individuals will be pushed out of the system as a result of increased dental fee and cost. Urgent actions must be taken to prioritise budget as fairly as we can. Prudent restrictions on recruitment of healthcare staff and judicious cut to unnecessary administration cost could probably be more sensible.

Despite GDPs having more training and experience, GMPs are envisaged to handle more and more patients presenting with dental problems for years to come. The underlying reasons for patients with oro-facial complaints seeking help from their GMPs are most likely to be multifactorial. Patient education, better dental access, cross-training and healthcare workforce integration could cultivate a shift towards more holistic treatment approaches.

To gain better understanding of why patients with oro-facial or/and dental complaints attend their GMPs instead of their GDPs, the author plans to set up a research with designs to accommodate and collect patient input in the near future.

84 8. REFERENCES

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Anderson, R., Richmond, S., & Thomas, D. W. (1999). Epidemiology: Patient presentation at medical practices with dental problems: an analysis of the 1996 General Practice Morbidity Database for Wales. British dental journal, 186(6), 297-300.

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90 9. APPENDICES

Appendix 1 General Medical Practitioners In City of Salford

1. J Dr Amin Lords Avenue, Salford, M5 5JR

2. Salford Medical Practice 194-198, Langworthy Rd, Salford, M6 5PP

3. Chapel Medical Centre 220, Liverpool Rd, Irlam, Manchester, M44 6FE

4. Salford Care Centres 451, Liverpool St, Salford, M6 5QQ

5. Clarendon Surgery Pendleton Gateway, 1, Broadwalk, Salford, M6 5FX

6. Dr I Jeet Energise Healthy Living Centre, 3, Douglas Green, Salford, M6 6ES

7. The Surgery 37, Orient Rd, Salford, M6 8LE

8. The Sorrel Group Practice The Surgery, 23, Bolton Rd, Salford, M6 7HL

9. The Sorrel Group Practice 9, Victoria Rd, Salford, M6 8FZ

10. Ordsall Health Surgery 118, Phoebe St, Salford, M5 3PH

11. Dr N.N Kassam 4-5, Mocha Parade, Salford, M7 1QE

12. Dr K Buch Lower Broughton Health Centre, Great Clowes St, Salford, M7 1RD

13. Doctors Surgery 10-12 Hodge Road, Walkden, Manchester, M28 3AT

14. Lower Broughton Health Centre Great Clowes St, Salford, M7 1RD

15. Blackfriars Medical Practice 138, Chapel St, Salford, M3 6AF

16. Lakes Medical Centre 21, Chorley Rd, Manchester, M27 4AF

17. Drs Larah D.G, Bacall L & Joseph S Higher Broughton Health Centre, Bevendon Square, Salford, M7 4TP

91 18. Dr Jaffe’s Surgery 3, Oakwell Drive, Salford, M7 4PY

19. The Poplars Medical Centre 202, Partington Lane, Manchester, M27 0NA

20. Dr D.L.J Freed 14, Marston Rd, Salford, M7 4ER

21. Dr S Levenson 8, Limefield Rd, Salford, M7 4LZ

22. Silverdale Medical Practice 659, Bolton Rd, Pendlebury, Manchester, M27 8HP

23. The Sides Medical Centre, Moorside Rd, Manchester, M27 0EW

24. Davis Dr W.S 53, Leicester Road, Salford, M7 4AS

25. Medical Surgery 23, Bolton Rd, Salford, M6 7HL

26. Jones, S B Surgery 26, Bolton Rd, Salford, M6 7HL

27. Salford Health Authority 1, Paddington Close, Salford, M6 5PL

28. Drs Randall McIinerney & Bhima 494, Liverpool, St Salford, M6 5QZ

29. R M Baishnab 195, Langworthy Road, Salford, M6 5PW

30. Baishnab, R M 3, Tootal Rd, Salford, M5 2HJ

31. Willow Surgery Lords Avenue, Salford, M5 2JR

32. Salford Medical Centre 94-198, Langworthy Rd, Salford, M6 5PP

33. Daruzzaman Care Centre 3, Derby Road, Salford, M5 2QZ

34. Clarendon Surgery Lance Burn Health Centre Churchill Way, Salford, M5 4BE

35. Singh, D P Surgery 29, Littleton Rd, Salford, M6 6ED

36. Haber Surgery 250, Langworthy Rd, Salford, M6 5WW

92 37. Claremont Medical Centre 91, Claremont Road, Salford, M6 7GP

38. Nestor Primecare Services Ltd. 25,Bolton Road, Salford, M6 7HL

39. Baqui, T Churchill Way, Salford, M6 5BN

40. S Sahay & D N das Churchill Way, Salford, M6 5QX

41. Baqui Dr T Churchill Way , Salford, M6 5QX

42. Orient Road Surgery 37, Orient Road, Salford, M6 8LE

43. Randall, S C The Surgery, 39 Orient Rd, Salford, M6 8LE

44. Salford Health Authority 169, Gerald Road, Salford, M6 6BL

45. Mohil, D S 2, Gerald Rd, Salford, M6 6BL

46. Allergist, M D 14, Marston Rd, Salford, M7 0ER

47. Ordsall District Centre Ordsall District Centre Belfort Drive, Salford, M5 3PP

48 .J.M Whiteley Surgery 249, Bolton Rd , Salford, M6 7HP

49. Drs Ramachandran Finegan Hall & Jones 9 Victoria Rd, Salford, M6 8FZ

50. Trinity Medical Centre 198-202 Chapel St, Salford, M3 6BY

51. Salford Health Matters Eccles Gateway, 28, Barton Lane, Eccles, Manchester, M30 0TU

52. St. Andrews Medical Centre 30, Russell St, Eccles, Manchester, M30 0NU

53. The Sides Medical Centre Moorside Rd, Swinton, Manchester, M27 0EW

54. Doctors Surgery 10-12, Hodge Road, Walkden, Manchester, M28 3AT

55. Longfield Lodge Surgery 276, Liverpool Rd, Cadishead, Manchester, M44 5DX

93 56. Doctors Surgery 7 Manchester Road, Walkden, Manchester, M28 3NS

57. Ellenbrook Medical Centre 14, Morston Close, Worsley, Manchester, M28 1PB

58. The Limes Medical Centre 8-12, Hodge Rd, Worsley, Manchester, M28 3AT

59. Gill Medical Centre 5, Harriet St, Walkden, Worsley, Manchester, M28 3DR

60. Dr M.T Khan 152a, Manchester Rd East, Little Hulton, Manchester, M38 9LQ

61. Dr A Ahuja 1a, Dearden Avenue, Little Hulton, Manchester, M38 9GH

62. Cleggs Lane Medical Centre 131, Cleggs Lane, Little Hulton, Manchester, M38 9RS

94 Appendix 2 General Dental Practitioners In City of Salford

1. The Height Dental Practice 371, Bolton Road, Salford, M6 7NJ

2. Hill & O'Reilly 483, Liverpool St, Salford, M6 5QQ

3. S Helm & A Holland B.D.S 192, Langworthy Rd, Salford, M6 5PP 4. Urban Dental 185, Langworthy Rd, Salford, M6 5PW 5. Dental Surgery 483 Liverpool Street, Salford, M6 5QQ 6. Simon Taylor 89, Bolton Rd, Salford, M6 7HN 7. Dental at Media City UK Broadway, Salford, M50 2TG 8. Windsor Dental Practice Belvedere Rd, Salford, M6 5EQ 9. Jeremy Cooper 11, Victoria Rd, Salford, M6 8FZ 10. The Height Dental Practice B.D.S 371, Bolton Rd, Salford, M6 7NJ 11. Dental Surgery 311, Littleton Rd, Salford, M7 3TA 12. R.A Mizon 342, Great Cheetham St East, Salford, M7 4UJ 13. Dobkin A.J & Wander P.A & Associates 1, Great Cheetham St West, Salford, M7 2JB 14. The Malt House Deva Centre, Trinity Way, Salford, M3 7BD 15. Alan Freedman 494, Great Cheetham St East, Salford, M7 4TW 16. S Woolf 35, Holden Rd, Salford, M7 4LR 17. Maggie Jackson Dental Hygiene Deva Centre, Trinity Way, Salford, M3 7BD

95 Appendix 3 Read Codes for History and Symptoms

132.. Social group

1321. Social group 1 – professional

1322. Social group 2 – managerial

1323. Social group 3 – skilled

1324. Social group 4 - semi-skilled

1325. Social group 5 – unskilled

132Z. Social group NOS

133.. Personal status

134.. Country of origin

135.. Religion

136.. Alcohol consumption

137.. Tobacco consumption

13C.. Mobility - social functioning

13E.. Inadequate housing

13F.. Housing dependency scale

13K.. Economic milestones

13L.. Family illness

14... Past medical history

191.. Tooth symptoms

1911. No tooth problem

1912. Toothache

1913. Bad teeth/caries

1914. Dental swelling

191Z. Tooth symptom NOS

1921. No mouth problem

1922. Sore mouth

1923. Sore gums

1924. Loss of taste

1925. Excessive salivation

96 1926. Dribbling from mouth

1927. Dry mouth

1928. Bleeding gums

1929. Tongue symptoms

192A. Bad taste in mouth

192B. Dribbling from one side of mouth

192Z. Mouth symptom NOS

193.. Chewing symptoms

1932. Difficulty chewing

193Z. Chewing symptom NOS

194.. Swallowing symptoms

1942. Difficulty swallowing solids

1943. Difficulty swallowing liquids

1944. Painful swallowing

194Z. Swallowing symptom NOS

1M3.. Pain in face

P91.. Cleft lip (harelip)

P92.. Cleft palate with cleft lip

P9z.. Cleft palate or cleft lip NOS

P9... Cleft palate and lip

P90.. Cleft palate

R0400 [D]Facial pain

1475. H/O: trigeminal neuralgia

A5312 Postherpetic trigeminal neuralgia

97 Appendix 4 Read Codes for Diagnosis of Oro- facial Malignant Neoplasm

B0... Malignant neoplasm of lip, oral cavity and pharynx

B00.. Malignant neoplasm of lip

B01.. Malignant neoplasm of tongue

B02.. Malignant neoplasm of major salivary glands

B03.. Malignant neoplasm of gum

B04.. Malignant neoplasm of floor of mouth

B05.. Malignant neoplasm of other and unspecified parts of mouth

B06.. Malignant neoplasm of oropharynx

B07.. Malignant neoplasm of nasopharynx

B08.. Malignant neoplasm of hypopharynx

B0z.. Malignant neoplasm of other and ill-defined sites within the lip, oral cavity and

pharynx

98 Appendix 5 Read Codes for Oro-facial Diagnosis

J0... Oral cavity, salivary glands and jaw diseases

J00.. Tooth development and eruption disorders

J000. Anodontia

J0000 Partial anodontia

J0001 Complete anodontia

J0002 Congenital anodontia

J0003 Senile anodontia

J0004 Hypodontia

J0005 Oligodontia

J000z Anodontia NOS

J001. Supernumerary teeth

J0010 Fourth molar

J0011 Mesiodens

J0012 Paramolar supernumerary tooth

J0013 Supplemental teeth

J001z Supernumerary teeth NOS

J002. Tooth size and form abnormality

J003. Mottled teeth

J0030 Dental fluorosis

J0031 Non-fluoride enamel opacities

J003z Mottled tooth NOS

J004. Disturbance of tooth formation

J0040 Aplasia of cementum

J0041 Hypoplasia of cementum

J0042 Dilaceration of tooth

J0043 Antenatal enamel hypoplasia

J0044 Neonatal enamel hypoplasia

J0045 Postnatal enamel hypoplasia

J0046 Horner's teeth

99 J0047 Hypocalcification of teeth

J0048 Regional odontodysplasia

J0049 Turner's tooth

J004z Tooth formation disturbance NOS

J005. Hereditary tooth structure disturbances NEC

J0050 Amelogenesis imperfect

J0051 Dentinogenesis imperfect

J0052 Odontogenesis imperfect

J0053 Dentinal dysplasia

J0054 Shell teeth

J005z Hereditary tooth structure disturbances NEC NOS

J006. Tooth eruption disturbances

J007. Teething syndrome

J00y. Other tooth development and eruption disturbances

J00y0 Pre-eruption tooth colour changes

J00yz Other tooth development and eruption disturbances NOS

J00z. Tooth development and eruption disorders NOS

J01.. Teeth hard tissue diseases

J010. Dental caries

J0100 Arrested dental caries

J0101 Cementum dental caries

J0102 Acute dentine dental caries

J0103 Chronic dentine dental caries

J0104 Dentine dental caries unspecified

J0105 Acute enamel dental caries

J0106 Chronic enamel dental caries

J0107 Incipient enamel dental caries

J0108 Enamel dental caries unspecified

J0109 Infantile melanodontia

J010A Odontoclasia

100 J010B White spot lesions of teeth

J010z Dental caries NOS

J011. Excessive attrition of teeth

J0110 Approximal tooth wear

J0111 Occlusal tooth wear

J011z Excessive tooth attrition NOS

J012. Abrasion of teeth

J0120 Dentifrice abrasion of teeth

J0121 Habitual abrasion of teeth

J0122 Occupational abrasion of teeth

J0123 Ritual abrasion of teeth

J0124 Traditional abrasion of teeth

J0125 Wedge defect of teeth NOS

J012z Abrasion of teeth NOS

J013. Erosion of teeth

J0130 Teeth erosion due to medicine

J0131 Teeth erosion due to vomiting

J0132 Idiopathic teeth erosion

J0133 Occupational teeth erosion

J013z Erosion of teeth NOS

J014. Pathological tooth resorption

J0140 External resorption of teeth

J0141 Internal resorption of teeth

J014z Pathological tooth resorption NOS

J015. Hypercementosis

J016. Ankylosis of teeth

J017. Posteruptive teeth staining

J0170 Teeth staining due to drugs

J0171 Teeth staining due to metals

J0172 Teeth staining due to pulpal bleeding

101 J017z Posteruptive teeth staining NOS

J01y. Other teeth hard tissue disease

J01z. Hard tissue teeth disease NOS

J02.. Pulp and periapical tissue disease

J020. Pulpitis

J0200 Pulpal abscess

J0201 Pulpal polyp

J0202 Acute pulpitis

J0203 Chronic hyperplastic pulpitis

J0204 Chronic ulcerative pulpitis

J0205 Chronic pulpitis unspecified

J0206 Suppurative pulpitis

J020z Pulpitis NOS

J021. Necrosis of the pulp

J0210 Pulp gangrene

J0211 Mummified pulp

J021z Necrosis of the pulp NOS

J022. Pulp degeneration

J0220 Pulp stones – denticles

J022z Pulp degeneration NOS

J023. Abnormal pulp hard tissue

J023z Abnormal pulp hard tissue NOS

J024. Acute apical periodontitis

J025. Periapical abscess without a sinus

J0250 Dental abscess

J0251 Dentoalveolar abscess

J025z Periapical abscess without a sinus NOS

J026. Chronic apical periodontitis

J0260 Apical granuloma

J0261 Periapical granuloma

102 J026z Chronic apical periodontitis NOS

J027. Periapical abscess with a sinus

J0270 Alveolar process fistula

J0271 Dental fistula

J027z Periapical abscess with a fistula NOS

J028. Radicular cyst

J02z. Pulp and periapical tissue disease NOS

J03.. Gingival and periodontal disease

J030. Acute gingivitis

J031. Chronic gingivitis

J0310 Simple marginal gingivitis

J0311 Ulcerative gingivitis

J0312 Desquamative gingivitis

J0313 Hyperplastic gingivitis

J0314 Gingivostomatitis

J031z Chronic gingivitis NOS

J032. Gingival recession

J0320 Generalised gingival recession

J0321 Localised gingival recession

J0322 Postinfective gingival recession

J0323 Postoperative gingival recession

J032z Gingival recession NOS

J033. Acute periodontitis

J0330 Acute pericementitis

J0331 Acute pericoronitis

J0332 Paradontal abscess

J0333 Periodontal abscess

J033z Acute periodontitis NOS

J034. Chronic periodontitis

J035. Periodontosis

103 J036. Accretions on teeth

J0360 Subgingival dental calculus

J0361 Supragingival dental calculus

J0362 Betel deposit on teeth

J0363 Plaque on teeth

J0364 Tobacco deposit on teeth

J036z Accretions on teeth NOS

J03X. Disorder of gingiva and edentulous alveolar ridge, unspecified

J03y. Other specified periodontal disease

J03y0 Giant cell epulis

J03y1 Giant cell peripheral granuloma

J03y2 Gingival cysts

J03y3 Gingival enlargement NOS

J03y4 Gingival fibromatosis

J03y5 Gingival polyp

J03y6 Periodontal lesions due to traumatic occlusion

J03y7 Gingival and edentulous alveolar ridge lesion associated with trauma

J03y8 Gingival hyperplasia

J03y9 Parulis

J03yz Other specified periodontal disease NOS

J03z. Gingival and periodontal disease NOS

J04.. Dentofacial anomalies

J040. Major jaw size anomalies

J0400 Mandibular hyperplasia

J0401 Mandibular hypoplasia

J0402 Mandibular macrognathism

J0403 Mandibular micrognathism

J0404 Mandibular size abnormality unspecified

J0405 Maxillary hyperplasia

J0406 Maxillary hypoplasia

104 J0407 Maxillary macrognathism

J0408 Maxillary micrognathism

J0409 Maxillary size abnormality unspecified

J040A Macrognathism unspecified

J040B Micrognathism unspecified

J040z Major jaw size anomaly NOS

J041. Jaw to cranial base anomaly

J0410 Asymmetry of jaw

J0411 Mandibular prognathism

J0412 Maxillary prognathism

J0413 Prognathism NOS

J0414 Mandibular retrognathism

J0415 Maxillary retrognathism

J041z Retrognathism NOS

J042. Dental arch relationship anomalies

J0420 Anterior crossbite

J0421 Posterior crossbite

J0422 Crossbite unspecified

J0424 Mesio-occlusion

J0425 Midline deviation

J0426 Anterior open-bite

J0427 Posterior open-bite

J0428 Open-bite unspecified

J0429 Excessive overbite

J042A Horizontal overbite

J042B Vertical overbite

J042C Overbite unspecified

J042D Excessive overjet

J042E Posterior lingual occlusion of mandibular teeth

J042F Soft tissue impingement

105 J042G Traumatic overbite

J042H Reverse overjet

J042J Malocclusion, Angle class I

J042K Malocclusion, Angle class II, division 1

J042L Malocclusion, Angle class II, division 2

J042M Malocclusion, Angle class III

J042z Dental arch relationship anomalies NOS

J043. Tooth position anomaly

J0430 Anterior imbrication of teeth

J0431 Posterior imbrication of teeth

J0432 Tooth crowding NOS

J0433 Anterior diastema

J0434 Posterior diastema

J0435 Abnormal tooth spacing NOS

J0436 Tooth rotation

J0437 Tooth transposition

J0438 Impacted incisors

J0439 Impacted canines

J043A Impacted premolars

J043B Impacted molars

J043C Impacted wisdom teeth

J043D Impacted and buried teeth NOS

J043E Embedded teeth

J043F Impacted teeth

J043z Tooth position anomaly NOS

J044. Malocclusion unspecified

J045. Dentofacial functional anomalies

J0450 Abnormal jaw closure

J0451 Malocclusion due to abnormal swallowing

J0452 Malocclusion due to mouth breathing

106 J0453 Malocclusion due to tongue habit

J0454 Malocclusion due to lip habit

J0455 Malocclusion due to finger habit

J045z Dentofacial functional anomalies NOS

J046. Temporomandibular joint disorders

J0460 Temporomandibular joint ankylosis

J0461 Costen's syndrome

J0462 Temporomandibular joint derangement

J0463 Snapping jaw

J0464 Temporomandibular joint-pain-dysfunction syndrome

J0465 Locked temporomandibular joint

J046z Temporomandibular joint disorder NOS

J04y. Other dentofacial anomalies

J04y. Other dentofacial anomalies

J04z. Dentofacial anomalies NOS

J05.. Other dental diseases and conditions of the teeth and supporting structures

J050. Teeth exfoliation due to systemic causes

J051. Acquired absence of teeth

J0510 Loss of teeth due to an accident

J0511 Loss of teeth due to extraction

J0512 Loss of teeth due to local periodontal disease

J051z Acquired absence of teeth NOS

J052. Edentulous alveolar ridge atrophy

J053. Retained dental root

J054. Orofacial sinus

J05y. Other specified dental disorder

J05z. Dental diseases and conditions NOS

J06.. Diseases of the jaws

J060. Developmental odontogenic cyst

J0600 Alveodental cyst

107 J0601 Dentigerous cyst

J0602 Eruption cyst

J0603 Primordial cyst

J060z Developmental odontogenic cysts NOS

J061. Fissural cysts of the jaw

J0610 Globulomaxillary cyst

J0611 Incisor canal cyst

J0612 Median anterior maxillary cyst

J0613 Median palatal cyst

J061z Fissural cysts of the jaw NOS

J062. Other cysts of jaw

J0620 Aneurysmal cyst of jaw

J0621 Haemorrhagic cyst of jaw

J0622 Traumatic cyst of jaw

J062z Cyst of jaw NOS

J063. Central giant cell granuloma

J064. Inflammatory jaw conditions

J0640 Abscess of jaw

J0641 Acute osteitis of jaw

J0642 Chronic osteitis of jaw

J0643 Residual osteitis

J0644 Acute osteomyelitis of jaw

J0645 Chronic osteomyelitis of jaw

J0646 Periostitis of jaw

J0647 Dental sequestrum

J064z Inflammatory jaw conditions NOS

J065. Alveolitis of jaw

J0650 Alveolar osteitis

J0651 Dry socket

J065z Alveolitis of jaw NOS

108 J06y. Other specified jaw diseases

J06y0 Torus mandibularis

J06y1 Exostosis of jaw unspecified

J06y2 Torus palatinus

J06y3 Cherubism

J06y4 Fibrous dysplasia of jaw

J06y5 Latent bone cyst of jaw

J06y6 Osteoradionecrosis of jaw

J06y7 Unilateral condylar mandibular hyperplasia

J06y8 Unilateral condylar mandibular hypoplasia

J06yz Other specified jaw diseases NOS

J06z. Jaw diseases NOS

J07.. Salivary gland diseases

J070. Atrophy of salivary gland

J0700 Atrophy of parotid gland

J0701 Atrophy of submandibular gland

J0702 Atrophy of sublingual gland

J070z Atrophy of salivary gland NOS

J071. Hypertrophy of salivary gland

J0710 Hypertrophy of parotid gland

J0711 Hypertrophy of submandibular gland

J0712 Hypertrophy of sublingual gland

J071z Salivary gland hypertrophy NOS

J072. Sialoadenitis

J0720 Allergic parotitis

J0721 Toxic parotitis

J0722 Parotitis NOS

J0723 Sialoadenitis of the submandibular gland

J0724 Sialoadenitis of the sublingual gland

J0725 Sialoangiitis

109 J0726 Sialodochitis

J0727 Infective sialoadenitis

J072z Sialoadenitis NOS

J073. Abscess of salivary gland

J0730 Abscess of parotid gland

J0731 Abscess of submandibular gland

J0732 Abscess of sublingual gland

J073z Abscess of salivary gland NOS

J074. Fistula of salivary gland

J0740 Fistula of parotid gland

J0741 Fistula of submandibular gland

J0742 Fistula of sublingual gland

J074z Fistula of salivary gland NOS

J075. Sialolithiasis

J0750 Parotid sialolithiasis

J0751 Submandibular sialolithiasis

J0752 Sublingual sialolithiasis

J0753 Parotid sialodocholithiasis

J0754 Submandibular sialodocholithiasis

J0755 Sublingual sialodocholithiasis

J0756 Sialodocholithiasis NOS

J075z Sialolithiasis NOS

J076. Mucocele of salivary gland

J0760 Mucocele of salivary gland unspecified

J0761 Extravasation cyst of salivary gland

J0762 Retention cyst of salivary gland

J0763 Ranula

J0764 Parotid cyst

J076z Salivary gland mucocele NOS

J077. Salivary secretion disturbance

110 J0770 Salivary hyposecretion

J0771 Sialorrhoea

J0772 Chronic sialosis of parotid gland

J077z Salivary secretion disturbance NOS

J07y. Other salivary gland diseases

J07y0 Benign lymphoepithelial salivary gland lesion

J07y1 Parotidsialectasia

J07y2 Submandibularsialectasia

J07y3 Sublingual sialectasia

J07y4 Sialectasia NOS

J07y5 Stenosis of parotid duct

J07y6 Stenosis of submandibular duct

J07y7 Stenosis of sublingual duct

J07y8 Stenosis of salivary duct NOS

J07y9 Necrotising sialometaplasia

J07yz Other salivary gland diseases NOS

J07z. Salivary gland disease NOS

J08.. Oral soft tissue disease

J080. Stomatitis

J0800 Ulcerative stomatitis

J0801 Vesicular stomatitis

J080z Stomatitis NOS

J081. Gangrenous stomatitis

J082. Oral aphthae

J0820 Minor aphthous ulceration

J0821 Major aphthous ulceration

J0822 Recurrent aphthous ulceration

J0823 Herpetic aphthous ulceration

J0824 Aphthous stomatitis

J0825 Periadenitis mucosa necrotica recurrens

111 J082z Oral aphthae NOS

J083. Oral cellulitis and abscess

J0830 Cellulitis of floor of mouth

J0831 Oral soft tissue cellulitis unspecified

J0832 Abscess of oral soft tissue unspecified

J0833 Ludwig's angina

J0834 Oral fistula

J0835 Oroantral fistula

J0836 Uvulitis

J083z Oral cellulitis and abscess NOS

J084. Cysts of oral soft tissue

J0840 Dermoid cyst of mouth

J0841 Epidermoid cyst of mouth

J0842 Epstein's pearls

J0843 Lymphoepithelial cyst of mouth

J0844 Nasolabial cyst of mouth

J084z Cysts of oral soft tissue NOS

J085. Diseases of lips

J0850 Abscess of lip

J0851 Cellulitis of lip

J0852 Fistula of lip

J0853 Hypertrophy of lip

J0854 Angular stomatitis and cheilitis

J0855 Cheilodynia

J0856 Ectropion of lip, acquired

J0857 Cheilitis

J0858 Lip ulcer

J0859 Factitious cheilitis

J085A Plasma cell cheilitis

J085D Exfoliative cheilitis

112 J085E Glandular cheilitis

J085F Granulomatous cheilitis

J085z Diseases of lips NOS

J086. Leukoplakia of oral mucosa

J0860 Leukoplakia of gingiva

J0861 Leukoplakia of lips

J0862 Leukoplakia of tongue

J0863 Leukoplakia of buccal mucosa

J0864 Hairy leukoplakia

J086z Oral mucosa leukoplakia NOS

J087. Other oral epithelium disturbances

J0870 Oral erythroplakia

J0871 Oral focal epithelial hyperplasia

J0872 Oral leukoedema

J0873 Leukokeratosisnicotinapalatini

J0874 Sublingual keratosis

J087z Oral epithelium disturbances NOS

J088. Oral submucosal fibrosis

J08z. Other and unspecified diseases of oral soft tissue

J08z0 Cheek biting

J08z1 Lip biting

J08z2 Denture stomatitis

J08z3 Melanoplakia

J08z4 Papillary hyperplasia of palate

J08z5 Eosinophilic granuloma of oral mucosa

J08z6 Irritative hyperplasia of oral mucosa

J08z7 Pyogenic granuloma of oral mucosa

J08z8 Traumatic ulcer of oral mucosa

J08z9 OrofacialCrohn's disease

J08zA Mouth polyp

113 J08zB Orofacialgranulomatosis

J08zC Burning mouth syndrome

J08zD Angina bullosahaemorrhagica

J08zE Mucositis following radiation therapy

J08zF Oral mucositis

J08zz Oral soft tissue diseases NOS

J09.. Diseases of tongue

J090. Glossitis

J0900 Abscess of tongue

J0901 Traumatic ulceration of tongue

J090z Glossitis NOS

J091. Geographictongue

J092. Medianrhomboidglossitis

J093. Hypertrophy of tonguepapillae

J0930 Black hairy tongue

J0931 Coated tongue

J093z Tongue papillaryhypertrophy NOS

J094. Atrophy of tongue papillae

J0940 Smooth atrophic tongue

J0941 Hunter's glossitis

J0942 Moeller's glossodyniaexfoliativa

J094z Tongue papillary atrophy NOS

J095. Plicated (scrotal) tongue

J096. Glossodynia

J09y. Other specified tongue conditions

J09y0 Atrophy of tongue

J09y1 Crenated tongue

J09y2 Hypertrophy of tongue

J09y3 Glossocele

J09y4 Glossoptosis

114 J09y5 Polyp of tongue

J09yz Other specified tongue conditions NOS

J09z. Tongue diseases NOS

PA0.. Tongue tie – ankyloglossia

PA1.. Othertongue anomalies

PA2.. Other specified mouth and pharynx anomalies

115 Appendix 6 Read Codes for Diagnosis of Oro-facial Fractures

S0... Fracture of skull

S00.. Fracture of vault of skull

S022. Fracture of mandible, closed

S023. Fracture of mandible, open

S024. Fracture of malar or maxillary bones, closed

S025. Fracture of malar or maxillary bones, open

S026. Closed orbital blow-out fracture

S027. Open orbital blow-out fracture

S028. Fracture of skull and facial bones

S02A. Le Fort I fracture maxilla

S02B. Le Fort II fracture maxilla

S02C. Le Fort III fracture maxilla

S02x. Closed fracture other facial bone

S02y. Open fracture other facial bone

S02z. Fracture of facial bone NOS

S04.. Multiple fractures involving skull or face with other bones

S0z.. Fracture of skull NOS

116 Appendix 7 Data Sharing Agreement

117 118 119 120 121 122 123 124 125 126 127 Appendix 8 Approval Letter from Governance Committee for NWeH

128