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University Dental School and Hospital, Wilton, Cork, Ireland
Correspondence: * corresponding author, f.burke{at}ucc.ie
KEY WORDS: Oral research • primary care
This paper serves as an introduction to a series of papers on oral research in primary care. Oral research in primary care is placed in the context of general oral research. Possible challenges to the execution of oral research in primary care are explored, together with suggestions for the enhancement of research in this sphere.
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Oral Research in Primary Care |
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Dr. McKay’s activity was an early example of research in primary dental care—research carried out in the primary care setting: the dental surgery (or office) or in the community. In the years that have passed since 1901, the contribution of primary care research to the overall body of oral research has been minimal. Questions arise as to how oral research in primary care can be developed.
Most oral research is institutionalized. Fundamental research in basic science ranges from molecular biology to materials science. By its nature, it requires specialized equipment, materials, and techniques. Much of this research is carried out by scientists who may have had little exposure to clinical dentistry. The potential exists for a considerable gulf to exist between basic science researchers and primary care researchers. Many commercial companies have their own Research and Development programs, with dedicated researchers to develop new products and refine existing ones, so that the optimum product is delivered to the consumer.
Applied clinical research is based mainly in the dental schools. Academics are encouraged to carry out research to advance scholarship, inform their teaching, and enhance their professional development. Closely intertwined with this is the mentoring of young researchers, especially graduate students, who undertake research as part of their post-graduate programs. Research is facilitated in dental schools, since this activity forms part of the job specification for academics and researchers.
A considerable amount of essential research is epidemiologically based, with populations studied at a point in time or over a discrete time period to determine levels of oral health, changes in oral health, responses in oral health to intervention(s), and predictors of oral health. Many of these studies involve participation of large cohorts of people over a prolonged period.
In many instances, there is considerable overlap and synergy between researchers in basic sciences, clinical researchers, population-based research, and industry. Research projects are often multi-centered and multi-skilled, and there is some common ground for the dissemination of research findings.
However, most of clinical dentistry is carried out in the primary care setting—whether general practice or in the community service. Primary oral health care providers are confronted with a variety of oral diseases, patterns of oral disease, patient attitudes and expectations, medical conditions, and systems of remuneration. These may affect the care provided for patients and the treatment outcomes. Elucidation of the clinical issues confronting primary care workers is difficult to determine. The primary care setting has advantages for research, in that it is grounded in the real world, and it has a large pool of patients. Given that the primary focus of primary care is the delivery of patient care, research may be further down the agenda, especially since many primary care workers exist in isolation, compared with other research cohorts. Some thought-provoking data are emerging. It is particularly noteworthy that a considerable proportion of repeat restorations are placed in clinical practice (Mjör, 2001; Burke et al., 2002). Is this due to material defects, patterns of disease, diagnostic criteria, or systems of payment? These may affect the care provided for patients and/or their outcome.
It would be beneficial to determine, from primary care workers, what barriers they perceive toward carrying out research. Possible barriers could include: a perceived lack of relevance of research to clinical care, funding, lack of training/expertise/confidence in research methodology, fear of losing patients from practice if subjected to experimental techniques, lack of recognition for research efforts, lack of time in clinical practice to carry out research, a lack of infrastructure and administrative support, and absence of outreach from research bodies to collaborate in research. Addressing these issues and especially providing support for and recognition of the efforts of primary care researchers may provide a pathway for encouraging more primary care researchers.
Given the paucity of primary care research relative to that carried out by research bodies, it is difficult to state conclusively that there are substantial differences between research outcomes in these two spheres. Comparison of research between primary care and controlled clinical trials has highlighted some differences in outcomes (Mjör, 2001).
One of the critical dilemmas is the application of new research findings and methodologies to primary care research. A particular concern is the volume of research, carried out in Basic Sciences, of which primary care workers and researchers are unaware. There is little communication of these research outcomes, since there is little common ground for attendance at scientific meetings, publication in journals, or even understanding of the technical language or concepts. Facilitation of this process presents a particular challenge. Caution should be exercised in the exact replication of institutionalized research methodologies in the primary care setting. The rationale for this caution is two-fold: It may not be feasible to replicate the methodologies exactly, and to do so may negate the uniqueness of primary care research outcomes. Different research methodologies may be more appropriate for the primary care setting.
Indeed differences between institutionally based experimental clinical trials and community-based trials have been highlighted to include differences in study aims, conditions, manpower, funding, study population, theoretical basis, and use of a negative control (O’Mullane, 1976). Specifically, institutionally based clinical trials for a therapeutic intervention may be conducted under conditions which give the intervention optimum conditions to show its effectiveness for a hypothetical, controlled population. A community- or primary-care-based clinical trial would be conducted to test the efficacy of an intervention on a fully representative real population.
Research in dental schools, hospitals, or research institutes is generally focused on the delivery of the research only. Consequently, the research is delivered in ideal conditions. There are few constraints on time, optimum support is delivered, and patient care is delivered in optimum circumstances. Much research in primary care is delivered in tandem with patient care. Patient care is the primary activity in primary care, and a reconfiguration of this may be needed to marry the twin aims of treatment and research. Moreover, the subjects involved in institutional research may be a specific cohort of patients and may not reflect the general population. Conversely, the population attending for primary care may also not reflect the general population but may be a population different from that which attends for institutional research.
Differences between research outcomes in the two spheres matter in several respects. Should differences in research outcomes occur, then the causality for these differences should be elucidated. This may lead to a greater understanding of the area being studied, especially with regard to the robustness of a particular methodology. It should always be borne in mind that, when comparing primary care research with institutional research, one is not comparing like with like. Otherwise, there is a danger of assuming that the research outcomes in one sphere are not valid, because they do not coincide with results from the other sphere.
Researchers in primary care work to a different set of priorities than those in academia. Delivery of patient care is their primary focus. However, because of this, in many respects their research is the most valuable that can be carried out. To develop research in primary care, options need to be considered to stimulate primary care researchers. Such stimuli would include not only research training and material benefits for carrying out research, but also the non-quantifiable rewards of peer validation and self-satisfaction. Developing these issues will help future generations of Dr. Frederick S. McKays in primary care research.
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References |
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Dean HT (1938). Endemic fluorosis and its relation to dental caries. Public Health Rep 53:1443–1452 [cited in Nutrition 6:435–445, 1990].
McKay FS (1916). An investigation of mottled teeth (I). Dent Cosmos 58:477–484.
Mjör IA (2001). The basis for everyday real-life operative dentistry. Oper Dent 26:521–524.[Medline]
O’Mullane DM (1976). Efficiency in clinical trials of caries preventive agents and methods. Community Dent Oral Epidemiol 4:190–194.[Medline]
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