Public policy and the market for dental services

Health policy and regulations in Seychelles - barriers and opportunities for oral health inclusion

BACKGROUND

Successful and inclusive policies that embrace oral health as part of the health agenda have the potential to alleviate the burden of oral diseases and to promote dental public health. This study aimed to understand the factors influencing the inclusion of oral health in health and public policy and regulations in the Seychelles. The barriers and opportunities for inclusion / non-inclusion as well as the impact thereof were explored.

METHODOLOGY

A qualitative approach was adopted using document analysis and interviews as data collection strategies to allow for a complete analysis of the research problem. Using a purposive sampling approach, individual face to face interviews were conducted with patients, dental staff and representatives of the upper management. Policy and related oral health statistical documents were reviewed to ascertain how oral health was located and implemented from a national to a district level. Thematic analysis and content analysis were used to analyse and interpret the qualitative data.

RESULTS

The study provided insight on how oral health is contextualised in the Seychelles and how public policy and strategic documents influences the oral health outcomes. There is fragmentation in how the health and oral health agendas are managed and it is coupled with a severe lack of involvement and commitment to address the latter.

CONCLUSION

Oral health needs to be integrated in all relevant policies and public health programmes as part of the broader national NCDs in Seychelles in order reduce the incidence of oral diseases in the population.

Dental service utilization and the COVID-19 pandemic, a micro-data analysis

BACKGROUND

Global crises and disease pandemics, such as COVID-19, negatively affect dental care utilization by several factors, such as infection anxiety, disrupted supply chains, economic contraction, and household income reduction. Exploring the pattern of this effect can help policy makers to be prepared for future crises. The present study aimed to investigate the financial impact of COVID-19 disruptions on dental service utilization.

METHODS

Data on the number of dental services offered in Dental School Clinics of Tehran University of Medical Sciences was collected over a period of two years, before and after the initial COVID-19 outbreak in Iran. School of Dentistry operates two clinics; one with competitive service fees and one with subsidies. Regression analyses were performed to determine the effect of the pandemic on the number of dental services divided by dental treatment groups and these clinics. The analyses were adjusted for seasonal patterns and the capacity of the clinics.

RESULTS

There was a significant drop in dental services offered in both clinics across all dental groups in the post-COVID period (on average, 77 (39.44%) fewer services per day). The majority of the procedure loss happened in the Private clinic. Adjusting for seasonal patterns and the service capacity, regression results documented 54% and 12% service loss in Private and Subsidized clinics following the pandemic, respectively. Difference-in-difference analysis documented that the Subsidized clinic performed 40% more treatments than the Private clinic in the post-COVID period.

CONCLUSIONS

Pandemic -reduction in dental care utilization could have long-term ramifications for the oral health of the population, and policymakers need to provide supportive packages to the affected segments of the economy to reverse this trend.

Maintenance of dental records and awareness of forensic odontology among pakistani dentists: a mixed-method study with implications for dental data repository

OBJECTIVE

Dental records and forensic odontology play an important role in both healthcare and the legal system, aiding in personalized patient care, human identification, and legal proceedings. This study aims to investigate dental record-keeping practices and assess the awareness of forensic odontology among Pakistani dentists over 12 months. This study aims to collect data from 500 dentists, identify areas for enhancement, and develop a strategic action plan to improve record-keeping quality and forensic odontology application, culminating in a comprehensive dental data repository to support legal and criminal investigations in Pakistan.

METHODOLOGY

This study employed a mixed-method approach conducted at Hamdard Dental College from January to March 2023. The quantitative phase involved distributing questionnaires to 463 dentists, chosen through stratified random sampling. Out of these, 413 responded, yielding an 86% response rate. These questionnaires focused on dental record-keeping practices and dentists' awareness of forensic odontology. Subsequently, based on the questionnaire results, face-to-face interviews were conducted with 20 purposively selected dentists to gain deeper insight into the challenges and potential solutions. Data from both phases were integrated and analyzed accordingly.

RESULTS

The study included 413 participants, mainly females (79%), with ages ranging from 27 to 65 years and an average age of 46.4 years. Most dentists had 5-20 years of work experience (53%), and most (87.4%) were practicing in private clinical settings. All the dentists generated medical and dental records, but the duration of their record-keeping varied, with some maintaining them for up to a year and others for two years or longer. Five themes were generated from the qualitative content analysis. These themes were dentists' perceptions, barriers and challenges, knowledge and awareness, and improvement strategies.

CONCLUSION

Our study revealed that local practitioners in Pakistan exhibit subpar practices in dental record-keeping and maintenance of patient history, irrespective of whether they use a digital or traditional file-based system. Even though dentists are cognizant of the importance of record-keeping, they do not actively maintain comprehensive records. This suggests the need for improved training and system improvements to address the gaps in record-keeping practices.

Is value-based healthcare a strategy to achieve universal health coverage that includes oral health? An Australian case study

The 2021 Resolution on Oral Health by the 74th World Health Assembly supports an important health policy direction: inclusion of oral health in universal health coverage. Many healthcare systems worldwide have not yet addressed oral diseases effectively. The adoption of value-based healthcare (VBHC) reorients health services towards outcomes. Evidence indicates that VBHC initiatives are improving health outcomes, client experiences of healthcare, and reducing costs to healthcare systems. No comprehensive VBHC approach has been applied to the oral health context. Dental Health Services Victoria (DHSV), an Australian state government entity, commenced a VBHC agenda in 2016 and is continuing its efforts in oral healthcare reform. This paper explores a VBHC case study showing promise for achieving universal health coverage that includes oral health. DHSV applied the VBHC due to its flexibility in scope, consideration of a health workforce with a mix of skills, and alternative funding models other than fee-for-service.

The effects of a sugar-sweetened beverage tax: moving beyond dental health outcomes and service utilisation

Despite considerable academic and policy interest in the taxation of sugar-sweetened beverages (SSBs), its extra-health implications remain largely unexplored. We investigated the impact of an SSB tax on school absenteeism due to improved dental health, in a framework that accounted for the distribution of the benefit. We designed a quantitative, decision-analytic model that synthesised existing evidence in the areas of dental epidemiology, public health and economics, and simulated causal mechanisms that lead to changes in school attendance in Australian children and adolescents aged 6-17, in a tax vs no tax scenarios. Introducing a 20% sales tax on SSBs would result in a 0.73% (95% confidence interval: 0.38; 1.10), or 4684 (2412; 7071) days per year nationwide, reduction in school absences attributable to dental health reasons. While positive impacts would be seen across the board, the distribution of benefit was favourable towards boys, older teens and those from lower socio-economic status. Our study highlights the need for, and the viability of, quantifying distributions of direct and indirect consequences of public health policy. Despite modest effect size, the equity profile of SSB tax, the long-lasting benefits of educational gains, and potential synergies with other interventions, make it an attractive option for policymakers to consider.

Exploring the contexts, mechanisms and outcomes of a torture, abuse and dental anxiety service in Norway: a realist evaluation

Background

Torture, abuse and dental anxiety (TADA) are often precursors to developing a pathological relationship with dental care due to elevated anxiety. Consequently, patients who suffer from one or more of these tend to avoid dental services. This could leave them with severe tooth decay, which could affect their general and psychosocial health. Norwegian dental services have implemented the TADA service to specifically alleviate dental anxiety and restore oral health for the TADA patient group. However, the service has not been evaluated, and there is a need to understand how and why this service works, for whom, under what circumstances. Therefore, this study aimed to develop theories on how the service’s structure alleviates dental anxiety and restores these patients’ oral health. Although developed in a Norwegian context, these theories may be applicable to other national and international contexts.

Methods

This realist evaluation comprised multiple sequential methods of service and policy documents (n = 13), followed by interviews with service developers (n = 12).

Results

The analysis suggests that, by subsidising the TADA service, the Norwegian state has removed financial barriers for patients. This has improved their access to the service and, hence, their service uptake. National guidelines on service delivery are perceived as open to interpretation, and can hereby meet the needs of a heterogeneous patient group. The services have become tailored according to the available regional resources and heterogeneous needs of the patient population. A perceived lack of explicit national leadership and cooperative practices has resulted in regional service teams becoming self-reliant and insular. While this has led to cohesion within each regional service, it is not conducive to interservice collaborations. Lastly, the complexity of migration processes and poor dissemination practices is presumed to be the cause of the lack of recruitment of torture survivors to the service.

Conclusions

Policy documents and service developers described the TADA service as a hybrid bottom-up/top-down service that allows teams to practise discretion and tailor their approach to meet individual needs. Being free of charge has improved access to the service by vulnerable groups, but the service still struggles to reach torture survivors.

'Toothless’—the absence of political priority for oral health: a case study of Ireland 1994–2021

Background

Calls are emerging for oral health system reform under the Universal Healthcare (UHC) domain, while internationally there is an absence of political priority for oral health. In the Republic of Ireland there is very limited coverage of oral healthcare for the whole population. ‘Smile agus Sláinte’ Ireland’s oral health policy published in 2019, represents the first change to national policy in over 25 years.

Methods

This research examined the key factors influencing oral health policy, development, and implementation in Ireland during the period 1994–2021. A case study approach was adopted with two strands of data collection: documentary analysis and semi-structured interviews with elite participants. Analysis was guided by Howlett’s five stream framework.

Results

Ireland shares the international experience of oral health having very low political priority. This has perpetuated unequal access to public dental services for children and special needs populations while austerity measures applied to adult schemes resulted in increased unmet need with no universal coverage for dental care. The only area where there is political interest in oral health is orthodontic care. This low political priority combined with a lack of actor power in national leadership positions in the Department of Health and Health Service Executive has contributed to successive non-implementation of oral health policy recommendations. This is most evident in the failure to publish the Draft National Oral Health Policy in 2009. The research finds a failure to adequately engage with key stakeholders, particularly the dental profession in the development of the 2019 policy. All these weaknesses have been exacerbated by the COVID-19 pandemic.

Conclusions

Ireland’s new oral health policy, ‘Smile agus Sláinte’, presents an opportunity for the provision of much needed public dental services. However, successful reform will require strong political will and collaboration with dental leadership to provide advocacy at national level. Global calls to incorporate oral health into the UHC agenda and an agreed political consensus for UHC in Ireland may provide an opportunity for change. Genuine engagement of all stakeholders to develop an implementation strategy is necessary to harness this potential window of opportunity for oral health system reform.

Food insecurity, home ownership and income-related equity in dental care use and access: the case of Canada

Background

It has been documented that income is a strong determinant of dental care use in Canada, mostly due to the lack of public coverage for dental care. We assess the contributions of food insecurity and home ownership to income-related equity in dental care use and access. We add to the literature by adding these two variables among other socio-economic determinants of equity in dental care use and access to dental care. Evidence on equity in access to and use of dental care in Canada can inform policymaking.

Methods

We estimate income-related horizontal inequity indexes for the probability of 1) receiving at least one dental visit in the last 12 months; and 2) lack of dental visits during the 3 years before the interview. We conduct the analyses using data from the 2013–2014 Canadian Community Health Survey (CCHS) at the national and regional level.

Results

There is pro-rich inequity in the probability of visiting a dentist or an orthodontist and in access to dental care in Ontario. Inequities vary across jurisdictions. Housing tenure and food insecurity contribute importantly to both use of and access to dental care, adding information not captured by standard socio-economic determinants.

Conclusions

Redistributing income may not be enough to reduce inequities. Careful monitoring of equity in dental care is needed together with interventions targeting fragile groups not only in terms of income but also in improving house and food security.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12760-6.

Access to denture restoration services under removable dentures subsidy program for adults aged 65 years and older in Taiwan- an interpretive approach

Background

Access is an important issue in health equality. Availability of dental services and cost subsidies is an important factor affecting access to denture restoration for the elderly. This study aims to explore access to denture restoration services in the elderly removable denture’s subsidy program of  Taiwan.

Methods

Access to the elderly removable dentures subsidy program was measured from two aspects, that is, availability of subsidies and payment for these services and the characteristics of patients and their treatment needs. The first aspect included reimbursements and the number and location of subsidy clinics, and the second aspect included the age and gender distribution of patients and denture types. Information on reimbursement regulations and the number and location of dental clinics providing subsidized services were obtained from the website of the Taoyuan City Public Health Bureau, Taoyuan Hospital, Department of Statistics and Ministry of Health and Welfare. Data on patient characteristics and denture type were obtained through a retrospective survey. We selected individuals who participated in the elderly removable denture’s subsidy program from 2015 to 2018 at the Geriatric Dentistry Department of Taoyuan Hospital. We conducted data analysis using an interpretive approach.

Results

This study found that reimbursement amounts are inadequate, and the availability of subsidized services is low. Moreover, the proportion of male applications is slightly higher than that of females. In addition, among the applicants, removable partial dentures for single or two arches are the most common.

Conclusions

Problems of insufficient numbers of contracted hospitals and low reimbursement amounts are observed in the subsidy program, which are the key factors affecting access to denture restoration services among the elderly. Policymakers should exclude wealthy individuals and offer subsidy only to low-income elderly individuals with missing teeth who are in dire need of financial support to improve their dental health.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07504-6.

Regular Dental Care Utilization: The Case of Immigrants in Ontario, Canada

Considering the critical role of oral health on people's well-being, access to regular dental care to improve oral health may be a useful medium for improving immigrant integration and settlement in Canada. Using the 2013-14 Canadian Community Health Survey, this study contributes to the literature and policy by examining if there are disparities in regular utilization of dental care among recent immigrants, established immigrants, and the native-born in Ontario, Canada. Adopting Andersen's behavioural model of health services use as a conceptual framework, we introduce three sets of variables in our statistical analysis including predisposing, need, and enabling factors. At the bivariate level, recent (OR = 0.42, p < 0.001) and established immigrants (OR = 0.81, p < 0.001) are less likely to use dental care at least once a year than their native-born counterparts. Once accounting for enabling characteristics, however, we observe that the direction of the association becomes positive for established immigrants (OR = 1.15, p < 0.05). The difference between recent immigrants and the native-born is partially attenuated when we control for enabling characteristics but remains statistically significant (OR = 0.73, p < 0.05). Based on these findings, we provide several implications for policymakers and future research.

First Nations and Metis peoples' access and equity challenges with early childhood oral health: a qualitative study

Background

Inequities in early childhood oral health are evident amongst Indigenous peoples and communities in Manitoba, Canada. Early childhood caries (ECC) is decay in primary dentition in children under 6 years of age. A severe form of the disease occurs at a higher rate in Indigenous populations compared to the general population. ECC has been strongly associated with social determinants of health.

Methods

Focus groups and sharing circles were conducted with four First Nations and Metis communities in urban and rural communities in Manitoba. There were eight groups in total of purposively sampled participants (n = 59). A grounded theory approach guided thematic analysis of audio recorded and transcribed data.

Results

Indigenous participants experienced challenges similar to those found in the general population, such as encouraging and motivating parents and caregivers to establish regular oral hygiene routines for their children. However other challenges reported, disproportionately affect Indigenous communities. These include poor access to dental care, specifically no dental offices within 1 h driving radius and not having transportation to get there. Not having evidence-based oral health information to support good oral hygiene practices, preventing parents from making the best choices of oral hygiene products and oral health behaviours for their children. Poverty and food insecurity resulting in poor nutritional choices and leading to ECC. For example, feeding children sugary foods and beverages because those are more readily avialble than healthy options. Confusing or difficult encounters with dental professionals, highlighted as a factor that can erode trust, reduce compliance and impact continued attendance at dental offices.

Conclusion

Closing existing early childhood oral health gaps for First Nations and Metis peoples and communities requires equity-oriented healthcare approaches to address specific problems and challenges faced by these populations. Family, community and systemic level interventions that directly implement community recommendations are needed.

Planning the oral health workforce: Time for innovation

The levels and types of oral health problems occurring in populations change over time, while advances in technology change the way oral health problems are addressed and the ways care is delivered. These rapid changes have major implications for the size and mix of the oral health workforce, yet the methods used to plan the oral health workforce have remained rigid and isolated from planning of oral healthcare services and healthcare expenditures. In this paper, we argue that the innovation culture that has driven major developments in content and delivery of oral health care must also be applied to planning the oral health workforce if we are to develop ‘fit for purpose’ healthcare systems that meet the needs of populations in the 21st century. An innovative framework for workforce planning is presented focussed on responding to changes in population needs, service developments for meeting those needs and optimal models of care delivery.

COVID-19 Has Clarified 2 Foundational Policy Questions in Dentistry

Before the COVID-19 pandemic, health policy debates about the importance of oral health and dental care were intensifying around the world. These debates were invariably complex and muddled by political, professional, and commercial interests. Although, in broad terms, 2 foundational questions have tended to undergird debates on how dental care should be addressed in health policy. These are: who should receive the support of governments, and what constitutes essential or medically necessary dental care? In our view, the COVID-19 pandemic has provided a stark social and policy context that has radically clarified both questions.

Knowledge Transfer Statement:

This commentary can be used by governments, regulators, professional groups, and other stakeholders in their considerations of what constitutes essential or medically necessary dental care and how to best allocate dental care resources.

Impact of changing provider remuneration on NHS general dental practitioner services in Northern Ireland: a mixed-methods study

Background

Policy-makers wanted to reform the NHS dental contract in Northern Ireland to contain costs, secure access and incentivise prevention and quality. A pilot project was undertaken to remunerate general dental practitioners using a capitation-based payment system rather than the existing fee-for-service system.

Objective

To investigate the impact of this change in remuneration.

Design

Mixed-methods design using a difference-in-difference evaluation of clinical activity levels, a questionnaire of patient-rated outcomes and qualitative assessment of general dental practitioners’ and patients’ views.

Setting

NHS dental practices in Northern Ireland.

Participants

General dental practitioners and patients in 11 intervention practices and 18 control practices.

Interventions

Change from fee for service to a capitation-based system for 1 year and then reversion back to fee for service.

Main outcome measures

Access to care, activity levels, service mix and financial impact, and patient-rated outcomes of care.

Results

The difference-in-difference analyses showed significant and rapid changes in the patterns of care provided by general dental practitioners to patients (compared with the control practices) when they moved from a fee-for-service system to a capitation-based remuneration system. The number of registered patients in the intervention practices compared with the control practices showed a small but statistically significant increase during the capitation period (p < 0.01), but this difference was small. There were statistically significant reductions in the volume of activity across all treatments in the intervention practices during the capitation period, compared with the control practices. This produced a concomitant reduction in patient charge revenue of £2403 per practice per month (p < 0.05). All outcome measures rapidly returned to baseline levels following reversion from the capitation-based system back to a fee-for-service system. The analysis of the questionnaires suggests that patients did not appear to notice very much change. Qualitative interviews showed variation in general dental practitioners’ behaviour in response to the intervention and how they managed the tension between professional ethics and maximising the profits of their business. Behaviours were also heavily influenced by local context. Practice principals preferred the capitation model as it freed up time and provided opportunities for private work, whereas capitation payments were seen by some principals as a ‘retainer fee’ for continuing to provide NHS care. Non-equity-owning associates perceived the capitation model as a financial risk.

Limitations

The active NHS pilot period was only 1 year, which may have limited the scope for meaningful change. The number of sites was restricted by the financial budget for the NHS pilot.

Conclusions

General dental practitioners respond rapidly and consistently to changes in remuneration, but differences were found in the extent of this change by practice and provider type. A move from a fee-for-service system to a capitation-based system had little impact on access but produced large reductions in clinical activity and patient charge income. Patients noticed little difference in the service that they received.

Future work

With changing population need and increasing financial pressure on the NHS, research is required on how to most efficiently meet the expectations of patients within an affordable cost envelope. Work is also needed to identify and evaluate interventions that can complement changes in remuneration to meet policy goals.

Trial registration

Current Controlled Trials ISRCTN29840057.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 6. See the NIHR Journals Library website for further project information.

Assessment of public oral healthcare services in Curitiba, Brazil: a cross-sectional study using the Primary Care Assessment Tool (PCATool)

OBJECTIVES

To compare two different models of public oral health in primary care services, a so-called family health strategy (FHS), as opposed to non-FHS services designated as 'conventional' healthcare (CHC), regarding the presence and extent of the attributes of 'good' primary healthcare (PHC). The null hypothesis of this study is that the attributes do not differ between the FHS and CHC.

DESIGN

Cross-sectional.

SETTING

Public PHC services in Curitiba, the state capital of Paraná.

PARTICIPANTS

PHC users of the public oral health network (n=900) and dentists active in this municipal network (n=203).

PRIMARY AND SECONDARY OUTCOME MEASURES

The Primary Care Assessment Tool (PCATool)-Dentists and PCATool-Users were used to analyse the primary outcomes ('essential' attributes) and secondary outcomes ('derived' attributes) in the PHC.

RESULTS

Overall, the primary care services in oral health were well evaluated, both by users and by dentists, with mean scores ascribed to PHC attributes mostly above the cut-off point (6.6). The exception for users were affiliation (6.36; 95% CI 6.11 to 6.60) and accessibility (5.83; 95% CI 5.78 to 5.89); and for dentists the accessibility (5.80; 95% CI 5.63 to 5.96). When comparing FHS and CHC, there was a superiority of the FHS model, which reached a general mean score of 7.53 (95% CI 7.48 to 7.58) among users and 7.56 (95% CI 7.45 to 7.67) among dentists; on the other hand, the CHC general mean score was of 6.61 (95% CI 6.49 to 6.73) and 6.68 (95% CI 6.56 to 6.80) respectively for users and dentists.

CONCLUSIONS

The results reveal a reasonable level of attainment of PHC attributes in the services investigated. Nevertheless, public health managers should make efforts to reduce the difficulties faced by users in accessing dental care. The more positive results achieved by FHS services indicate that the provision of oral healthcare under this strategy should be expanded.

Needs in Service Provision for Oral Health Care in Older People: A Comparison Between Greater Manchester (United Kingdom) and Utrecht (the Netherlands)

Retaining natural teeth for longer, together with increasing care dependency in the elderly, has the potential to hamper adequate oral self-care and service provision. The aim of this qualitative study was to compare and contrast views from a multi-stakeholder perspective on the future priorities for oral health care services of older people in the United Kingdom and the Netherlands. A participatory setting partnership was undertaken with 4 key stakeholder groups in the United Kingdom and the Netherlands. A final consensus group considered collective responses. The views of the different groups were recorded, transcribed verbatim, and analyzed thematically. Two main themes derived: “individual well-being” and “underlying principles of service provision.” Codes relating to principles of service provision focused on the importance of developing quality criteria, improving access, prevention and screening, awareness raising, education and training, together with multidisciplinary care. In both countries, oral health was seen as an important element of “individual well-being,” and a number of “principles of service provision” were suggested. This contrasts with the current lack of evidence-based treatments and quality criteria that are available for dependent older people.

Preventive dental visiting: a critical interpretive synthesis of theory explaining how inequalities arise

BACKGROUND

In many countries, those with lower socioeconomic status are disproportionately affected by poor oral health. This can be attributed, at least in part, to differences in preventive dental visiting. While several theories have been applied to the area, they generally fail to capture the recursive nature of dental visiting behaviour, and fall short of informing the design of complex interventions to tackle inequalities.

OBJECTIVE

To undertake a systematic review and synthesis of theory in order to provide an overview of the pathways which bring about socioeconomic inequalities in early dental visiting, and identify possible intervention points.

METHODS

Electronic searching identified 8947 titles and abstracts. Paper screening and citation snowballing left 77 included papers. Drawing on the tenets of Critical Interpretive Synthesis, data extraction involved capturing concepts and relationships and translating these sometimes into synthetic constructs.

RESULTS

We theorize that at the individual (micro-level), dental visiting behaviour is influenced by: the 'Importance of obtaining care', 'Emotional response' and 'Perceived control', which feed into a balancing of 'Competing Demands' against 'Internal resources' (coping, self-identity), although attendance is tempered by the effective 'Affordability and Availability of services'. Positive Care experiences are theorized to lower the demands and increase internal resources associated with dental visiting. We also outline meso-level factors 'Social norms and sanctions', 'Obligations, expectations and trust', 'Information channels', 'Social structures' and theorize how these can exert an overwhelming influence in deprived areas.

CONCLUSIONS

Socioeconomic inequalities in early dental visiting emerge from several stages in the care-seeking process. Dental visiting behaviour should be viewed not just as a one-off event, but extending over time and social space. Since there is recursivity in peoples' most recent dental experience any future visits we identify that interventions which make care a positive experience for low socioeconomic patients may be particularly beneficial in reducing inequalities.

Cost-effectiveness analysis of the single-implant mandibular overdenture versus conventional complete denture: study protocol for a randomized controlled trial

Background

Preliminary clinical studies on the single-implant mandibular overdenture (SIMO) have reported favorable results as an alternative to the conventional complete dentures for rehabilitation of the edentulous mandible. Clinical and patient-reported outcomes were assessed but no evidence is available with respect to the cost-effectiveness of this treatment, which is particularly important to test whether the incremental cost associated with the implant treatment is justified facing the benefits from the intervention. Thus, the aim of this study is to assess the cost-effectiveness of single-implant mandibular overdentures.

Methods/design

This randomized clinical trial will include edentulous individuals who meet eligibility criteria. Participants will be randomized into one of the treatment groups: a conventional complete denture group or a single-implant mandibular overdenture group. Direct costs related to therapies in both groups will be identified, measured and valuated for 1 year after treatment. Oral health-related quality of life and satisfaction with the dentures will be the primary outcome variables. Incremental cost-effectiveness ratios will be estimated and graphically presented on cost-effectiveness planes. A Markov decision tree will be constructed to set out the consequences of the competing alternatives. Sensitivity analysis on the most important assumptions will be performed in order to assess the robustness of the model.

Discussion

This is the first trial-based cost-effectiveness study on single-implant mandibular overdentures. Specific challenges in designing the protocol are considered. The expected results are of high clinical relevance and may contribute to the decision-making process when choosing between different alternatives for the rehabilitation of the edentulous mandible.

Trial registration

ClinicalTrials.gov Identifier: NCT02710357, registered on 11 March 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1646-0) contains supplementary material, which is available to authorized users.

Determining the optimal model for role substitution in NHS dental services in the UK: a mixed-methods study

Background

Maximising health gain for a given level and mix of resources is an ethical imperative for health-service planners. Approximately half of all patients who attend a regular NHS dental check-up do not require any further treatment, whereas many in the population do not regularly attend. Thus, the most expensive resource (the dentist) is seeing healthy patients at a time when many of those with disease do not access care. Role substitution in NHS dentistry, where other members of the dental team undertake the clinical tasks previously provided by dentists, has the potential to increase efficiency and the capacity to care and lower costs. However, no studies have empirically investigated the efficiency of NHS dental provision that makes use of role substitution.

Research questions

This programme of research sought to address three research questions: (1) what is the efficiency of NHS dental teams that make use of role substitution?; (2) what are the barriers to, and facilitators of, role substitution in NHS dental practices?; and (3) how do incentives in the remuneration systems influence the organisation of these inputs and production of outputs in the NHS?

Design

Data envelopment analysis was used to develop a productive efficiency frontier for participating NHS practices, which were then compared on a relative basis, after controlling for patient and practice characteristics. External validity was tested using stochastic frontier modelling, while semistructured interviews explored the views of participating dental teams and their patients to role substitution.

Setting

NHS ‘high-street’ general dental practices.

Participants

121 practices across the north of England.

Interventions

No active interventions were undertaken.

Main outcome measures

Relative efficiency of participating NHS practices, alongside a detailed narrative of their views about role substitution dentistry. Social acceptability for patients.

Results

The utilisation of non-dentist roles in NHS practices was relatively low, the most common role type being the dental hygienist. Increasing the number of non-dentist team members reduced efficiency. However, it was not possible to determine the relative efficiency of individual team members, as the NHS contracts only with dentists. Financial incentives in the NHS dental contract and the views of practice principals (i.e. senior staff members) were equally important. Bespoke payment and referral systems were required to make role substitution economically viable. Many non-dentist team members were not being used to their full scope of practice and constraints on their ability to prescribe reduced efficiency further. Many non-dentist team members experienced a precarious existence, commonly being employed at multiple practices. Patients had a low level of awareness of the different non-dentist roles in a dental team. Many exhibited an inherent trust in the professional ‘system’, but prior experience of role substitution was important for social acceptability.

Conclusions

Better alignment between the financial incentives within the NHS dental contract and the use of role substitution is required, although professional acceptability remains critical.

Study limitations

Output data collected did not reflect the quality of care provided by the dental team and the input data were self-reported.

Future work

Further work is required to improve the evidence base for the use of role substitution in NHS dentistry, exploring the effects and costs of provision.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Wealth-related versus income-related inequalities in dental care use under universal public coverage: a panel data analysis of the Japanese Study of Aging and Retirement

BACKGROUND

There is a substantial body of evidence of income-related inequalities in dental care use, attributed to the fact that dental care is often not covered by public health insurance. Wealth-related inequalities have also been shown to be greater than income-related inequalities. Japan is one of the exceptions, as the the universal pubic health insurance system has covered dental care. The aim of this study was therefore to compare wealth- and income-related inequalities in dental care use among middle-aged and older adults in Japan to infer the mechanisms of wealth-related inequalities in dental care use.

METHODS

Data were derived from the Japanese Study of Aging and Retirement, a survey of community-dwelling middle-aged and older adults living in five municipalities in eastern Japan. Of the participants in the second wave conducted in 2009, we analyzed 2581 residents. Dental care use was measured according to whether the participant had been seen by a dentist or a dental hygienist in the past year. The main explanatory variables were income and wealth (financial assets, real assets and total wealth). The need for dental care was measured using age, the use of dentures and chewing ability. The concentration indices for the distribution of actual and need-standardized dental care use were calculated.

RESULTS

Among the respondents, 47.9% had received dental care in the past year. The concentration index of actual dental care use (CI) showed a pro-rich inequality for both income and wealth. The CIs for all three wealth measures were larger than that for income. A broadly comparable pattern was seen after need-standardization (income: 0.020, financial assets: 0.035, real assets: 0.047, total wealth: 0.050).

CONCLUSIONS

The results showed that wealth-related inequalities in dental care use were greater than income-related inequalities in Japan, where most dental care is covered by the public health insurance system. This suggests that wealth-related inequalities in dental care use cannot be explained by economic budget constraints alone. Further studies should investigate the mechanisms of wealth-related inequalities in dental care use.

Oral health technicians in Brazilian primary health care: potentials and constraints

Different perspectives on the role of mid-level workers in health care might represent a constraint to health policies. This study aimed to investigate how different agents view the participation of oral health technicians in direct activities of oral healthcare with the goal of understanding the related symbolic dispositions. Theoretical assumptions related to inter-professional collaboration and conflicts in the field of healthcare were used for this analysis. A researcher conducted 24 in-depth interviews with general dental practitioners, oral health technicians and local managers. The concepts of Pierre Bourdieu supported the data interpretation. The results indicated inter-professional relations marked by collaboration and conflict that reflect an action space related to different perspectives of primary care delivery. They also unveiled the symbolic devices related to the participation of oral health technicians that represent a constraint to the implementation of oral health policy, thus reducing the potential of primary health care in Brazil.

Introducing high-cost health care to patients: dentists' accounts of offering dental implant treatment

OBJECTIVES

The decision-making process within health care has been widely researched, with shared decision-making, where both patients and clinicians share technical and personal information, often being cited as the ideal model. To date, much of this research has focused on systems where patients receive their care and treatment free at the point of contact (either in government-funded schemes or in insurance-based schemes). Oral health care often involves patients making direct payments for their care and treatment, and less is known about how this payment affects the decision-making process. It is clear that patient characteristics influence decision-making, but previous evidence suggests that clinicians may assume characteristics rather than eliciting them directly. The aim was to explore the influences on how dentists' engaged in the decision-making process surrounding a high-cost item of health care, dental implant treatments (DITs).

METHODS

A qualitative study using semi-structured interviews was undertaken using a purposive sample of primary care dentists (n = 25). Thematic analysis was undertaken to reveal emerging key themes.

RESULTS

There were differences in how dentists discussed and offered implants. Dentists made decisions about whether to offer implants based on business factors, professional and legal obligations and whether they perceived the patient to be motivated to have treatment and their ability to pay. There was evidence that assessment of these characteristics was often based on assumptions derived from elements such as the appearance of the patient, the state of the patient's mouth and demographic details. The data suggest that there is a conflict between three elements of acting as a healthcare professional: minimizing provision of unneeded treatment, trying to fully involve patients in shared decisions and acting as a business person with the potential for financial gain.

CONCLUSIONS

It might be expected that in the context of a high-cost healthcare intervention for which patients pay the bill themselves, that decision-making would be closer to an informed than a paternalistic model. Our research suggests that paternalistic decision-making is still practised and is influenced by assumptions about patient characteristics. Better tools and training may be required to support clinicians in this area of practice.

Socioeconomic inequalities in the use of dental care services in Europe: what is the role of public coverage?

OBJECTIVES

The aim of this study was to analyse inequalities in the use of dental care services according to socioeconomic position (SEP) in individuals aged ≥50 years in European countries in 2006, to examine the association between the degree of public coverage of dental services and the extent of inequalities, and specifically to determine whether countries with higher public health coverage show lower inequalities.

METHODS

We carried out a cross-sectional study of 12 364 men and 14 692 women aged ≥50 years from 11 European countries. Data were extracted from the second wave of the Survey of Health, Ageing and Retirement in Europe (SHARE 2006). The dependent variable was use of dental care services within the previous year, and the independent variables were education level as a measure of SEP, whether services were covered to some degree by the country's public health system, and chewing ability as a marker of individuals' need for dental services. Age-standardized prevalence of the use of dental care as a function of SEP was calculated, and age-adjusted indices of relative inequality (RII) were computed for each type of dental coverage, sex and chewing ability.

RESULTS

Socioeconomic inequalities in the use of dental care services were higher in countries where no public dental care cover was provided than in countries where there was some degree of public coverage. For example, men with chewing ability from countries with dental care coverage had a RII of 1.39 (95%CI: 1.29-1.51), while those from countries without coverage had a RII of 1.96 (95%CI: 1.72-2.23). Women without chewing ability from countries with dental care coverage had a RII of 2.15 (95%CI: 1.82-2.52), while those from countries without coverage had a RII of 3.02 (95%CI: 2.47-3.69).

CONCLUSIONS

Dental systems relying on public coverage seem to show lower inequalities in their use, thus confirming the potential benefits of such systems.

Oral health in Brazil: the challenges for dental health care models

This paper discusses adult oral health in Brazil according to three perspectives: 1) the available epidemiological evidence about the population's oral-health-related epidemiological situation, especially adults and the elderly population, in relation to two high prevalence oral injuries (dental caries and tooth loss), 2) the main health care models for dealing with this situation, by analyzing the related historical processes in order to reveal the likely social, political and epidemiological implications of the different models, and 3) lastly, the possible challenges to Brazilian dentistry or collective oral health in overcoming these obstacles. The main results of the study indicate that, from an epidemiological point of view, Brazil is undergoing a transition in dental caries and tooth loss, which is not yet reflected in the profile of the elderly, but which is tentatively evidenced in young adults. Tooth loss remains high. Certain aspects of society's economic and political superstructure have an important impact on oral health indicators and existing inequalities. Oral health care models have a relative importance and must not be neglected. Vestiges of ideological movements, like preventive medicine, may explain the current impasse in collective oral health practices, such as the preeminence of Finalized Treatment (FT) in clinics and of preventive care in schools fostered by community-based programs. It is therefore important to develop conceptual, theoretical reflections and to increase the objects of intervention, their purposes and their modus operandi. The practice of dentistry according to these alternative models is still being constructed. New studies related to the different formats of these new practices are recommended.

Is accessing dental care becoming more difficult? Evidence from Canada's middle-income population

Objective

To explore trends in access to dental care among middle-income Canadians.

Methods

A secondary data analysis of six Canadian surveys that collected information on dental insurance coverage, cost-barriers to dental care, and out-of-pocket expenditures for dental care was conducted for select years from 1978 to 2009. Descriptive analyses were used to outline and compare trends among middle-income Canadians with other levels of income as well as national averages.

Results

By 2009, middle-income Canadians had the lowest levels of dental insurance coverage (48.7%) compared to all other income groups. They reported the greatest increase in cost-barriers to dental care, from 12.6% in 1996 to 34.1% by 2009. Middle-income Canadians had the largest rise in out-of-pocket expenditures for dental care since 1978.

Conclusions

This study suggests that affordability issues in accessing dental care are no longer just a problem for the lowest income groups in Canada, but are now impacting middle-income earners as a consequence of their lack of, or decreased access to, comprehensive dental insurance.

Dental treatment needs in the Canadian population: analysis of a nationwide cross-sectional survey

BACKGROUND

Nationally representative clinical data on the oral health needs of Canadians has not been available since the 1970s. The purpose of this study was to determine the normative treatment needs of a nationally representative sample of Canadians and describe how these needs were distributed.

METHODS

A secondary analysis of data collected through the Canadian Health Measures Survey (CHMS) was undertaken. Sampling and bootstrap weights were applied to make the data nationally representative. Descriptive frequencies were used to examine the sample characteristics and to examine the treatment type(s) needed by the population. Bivariate logistic regressions were used to see if any characteristics were predictive of having an unmet dental treatment need, and of having specific treatment needs. Lastly, multivariate logistic regression was used to identify the strongest predictors of having an unmet dental treatment need.

RESULTS

Most of the population had no treatment needs and of the 34.2% who did, most needed restorative (20.4%) and preventive (13.7%) care. The strongest predictors of need were having poor oral health, reporting a self-perceived need for treatment and visiting the dentist infrequently.

CONCLUSIONS

It is estimated that roughly 12 million Canadians have at least one unmet dental treatment need. Policymakers now have information by which to assess if programs match the dental treatment needs of Canadians and of particular subgroups experiencing excess risk.

Government spending on dental care: is it a public priority?

OBJECTIVES

The majority of Canadians believe that the government should play some role in providing dental care within Canada's health care system. However, it is unclear whether Canadians consider this as a top public priority. This study determines whether dental care is a public priority among Canadian adults relative to other policy concerns and identifies factors predictive of a first priority ranking for dental care.

METHODS

Data were collected in 2008 from a national random sample of 1,005 Canadian adults through a telephone interview survey. Respondents were asked to rank five spending priorities (dental care, pharmacare, home care, vision care, and child care) in terms of preferences for new government spending. Simple descriptive analyses were undertaken based on sociodemographic characteristics. Logistic regression modeling was conducted to determine which factors are predictive of a first priority ranking for dental care.

RESULTS

Comparatively, dental care stands as the third choice among the other spending priority areas. Approximately 21 percent of adults consider dental care a first priority for spending. First priority ranking of dental care appears to be linked to socioeconomic factors: household income, educational attainment, and dental insurance coverage.

CONCLUSIONS

As a public priority, a moderate level of demand exists for more government spending on dental care in Canada, specifically among those of low income, low educational attainment, and who lack dental insurance coverage. A sustained effort should be made to push forward public dental care policies that target priority population subgroups.

Equity in dental care among Canadian households

BACKGROUND

Changes in third party financing, whether public or private, are linked to a household's ability to access dental care. By removing costs at point of purchase, changes in financing influence the need to reach into one's pocket, thus facilitating or limiting access. This study asks: How have historical changes in dental care financing influenced household out-of-pocket expenditures for dental care in Canada?

METHODS

This is a mixed methods study, comprised of an historical review of Canada's dental care market and an econometric analysis of household out-of-pocket expenditures for dental care.

RESULTS

We demonstrate that changes in financing have important implications for out-of-pocket expenditures: with more financing come drops in the amount a household has to spend, and with less financing come increases. Low- and middle-income households appear to be most sensitive to changes in financing.

CONCLUSIONS

Alleviating the price barrier to care is a fundamental part of improving equity in dental care in Canada. How people have historically spent money on dental care highlights important gaps in Canadian dental care policy.

The Monitor Practice Programme: is non-invasive management of dental caries in private practice cost-effective?

BACKGROUND

The objective of this research was to assess the efficacy and cost-effectiveness of a non-invasive approach to dental caries management in private dental practice.

METHODS

Private dental practices from a variety of locations in New South Wales were randomly allocated to either non-invasive management of caries, or continue with usual care. Patients were followed for three years and caries incidence assessed. A patient-level decision analytic model was constructed to assess the cost-effectiveness of the intervention at two years, three years, and hypothetical lifetime.

RESULTS

Twenty-two dental practices and 920 patients were recruited. Within the clinical trial there was a significant difference in caries increment favouring non-invasive therapy at both two and three years. Efficacy was independent of age, gender, medical concerns, fluoride history, or previous history of dental caries, in a population of patients attending for treatment in private dental practices, in a variety of locations both urban and rural. Cost per DMFT avoided estimate was A$1287.07 (two years), A$1148.91 (three years) decreasing to A$702.52 in (medium) and A$545.93 (high) risk patients (three years).

CONCLUSIONS

A joint preventive and non-invasive therapeutic approach appears to be cost-effective in patients at medium and high risk of developing dental caries when compared to the standard care provided by private dental practice.