What is health economics?

On the Pathogenicity of the Oral Biofilm: A Critical Review from a Biological, Evolutionary, and Nutritional Point of View

Plaque control is one of the most recommended approaches in the prevention and therapy of caries and periodontal diseases. However, although most individuals in industrialized countries already perform daily oral hygiene, caries and periodontal diseases still are the most common diseases of mankind. This raises the question of whether plaque control is really a causative and effective approach to the prevention of these diseases. From an evolutionary, biological, and nutritional perspective, dental biofilms have to be considered a natural phenomenon, whereas several changes in human lifestyle factors during modern evolution are not “natural”. These lifestyle factors include the modern “Western diet” (rich in sugar and saturated fats and low in micronutrients), smoking, sedentary behavior, and continuous stress. This review hypothesizes that not plaque itself but rather these modern, unnatural lifestyle factors are the real causes of the high prevalence of caries and periodontal diseases besides several other non-communicable diseases. Accordingly, applying evolutionary and lifestyle medicine in dentistry would offer a causative approach against oral and common diseases, which would not be possible with oral hygiene approaches used on their own.

Smoking Cessation therapy is a cost-effective intervention to avoid tooth loss in Brazilian subjects with periodontitis: an economic evaluation

Background

Smokers present a higher prevalence and severity of periodontitis and, consequently, higher prevalence of tooth loss. Smoking cessation improves the response to periodontal treatment and reduces tooth loss. So, the aim of this study was to evaluate the efficiency in resources allocation when implementing smoking cessation therapy vs. its non-implementation in smokers with periodontitis.

Methods

We adopted the Brazilian public system perspective to determine the incremental cost-effectiveness (cost per tooth loss avoided) and cost-utility (cost per oral-related quality-adjusted life-year ([QALY] gained) of implementing smoking cessation therapy. Base-case was defined as a 48 years-old male subject and horizon of 30 years. Effects and costs were combined in a decision analytic modeling framework to permit a quantitative approach aiming to estimate the value of the consequences of smoking cessation therapy adjusted for their probability of occurrence. Markov models were carried over annual cycles. Sensitivity analysis tested methodological assumptions.

Results

Implementing the therapy saved approximately US$ 100 over the time horizon accompanied by a slightly better effect, both in CEA and CUA. Considering uncertainties, the therapy could be cost-effective in the most part of simulated cases, even being cheaper and more effective in 35% of cases in which the oral-health related outcome is used as effect. Considering a willingness-to-pay of US$100 per health effect, smoking cessation therapy was cost-effective, respectively, in 72% and 99% of cases in cost-utility and cost-effectiveness analyses.

Conclusions

Implementation of smoking cessation therapy may be cost-effective, considering the avoidance of tooth loss and oral health-related consequences to patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-01932-2.

[Frugal dentistry-saving resources with a focus on core functions and patient needs]

Frugal dentistry is derived from the term "frugal" (meaning simple, economical, usable, suitable). It focuses on dental interventions, which on one hand leads to a cost reduction compared to treatment alternatives and on the other hand focuses on dental core functionalities taking into account the patient's needs. In 2020, the World Health Organization (WHO) highlighted the urgency to prioritize cost-effective and affordable interventions.Against this background, a classification and review of frugal dentistry is carried out in this article. To what extent its objectives can be substantiated is investigated. Based on literature sources and an exemplary clinical presentation, options for frugal dentistry are shown. In addition, examples of potential frugal interventions and innovations are named and explained for a number of subject fields in dentistry. There are serious deficits in the systematic development and implementation of frugal dentistry. Numerous efforts in research, teaching, and patient care are therefore still required.

CariesCare International adapted for the pandemic in children: Caries OUT multicentre single-group interventional study protocol

Background

Comprehensive caries care has shown effectiveness in controlling caries progression and improving health outcomes by controlling caries risk, preventing initial-caries lesions progression, and patient satisfaction. To date, the caries-progression control effectiveness of the patient-centred risk-based CariesCare International (CCI) system, derived from ICCMS™ for the practice (2019), remains unproven. With the onset of the COVID-19 pandemic a previously planned multi-centre RCT shifted to this “Caries OUT” study, aiming to assess in a single-intervention group in children, the caries-control effectiveness of CCI adapted for the pandemic with non-aerosols generating procedures (non-AGP) and reducing in-office time.

Methods

In this 1-year multi-centre single-group interventional trial the adapted-CCI effectiveness will be assessed in one single group in terms of tooth-surface level caries progression control, and secondarily, individual-level caries progression control, children’s oral-health behaviour change, parents’ and dentists’ process acceptability, and costs exploration. A sample size of 258 3–5 and 6–8 years old patients was calculated after removing half from the previous RCT, allowing for a 25% dropout, including generally health children (27 per centre). The single-group intervention will be the adapted-CCI 4D-cycle caries care, with non-AGP and reduced in-office appointments’ time. A trained examiner per centre will conduct examinations at baseline, at 5–5.5 months (3 months after basic management), 8.5 and 12 months, assessing the child’s CCI caries risk and oral-health behaviour, visually staging and assessing caries-lesions severity and activity without air-drying (ICDAS-merged Epi); fillings/sealants; missing/dental-sepsis teeth, and tooth symptoms, synthetizing together with parent and external-trained dental practitioner (DP) the patient- and tooth-surface level diagnoses and personalised care plan. DP will deliver the adapted-CCI caries care. Parents’ and dentists’ process acceptability will be assessed via Treatment-Evaluation-Inventory questionnaires, and costs in terms of number of appointments and activities. Twenty-one centres in 13 countries will participate.

Discussion

The results of Caries OUT adapted for the pandemic will provide clinical data that could help support shifting the caries care in children towards individualised oral-health behaviour improvement and tooth-preserving care, improving health outcomes, and explore if the caries progression can be controlled during the pandemic by conducting non-AGP and reducing in-office time.

Trial registration: Retrospectively-registered-ClinicalTrials.gov-NCT04666597-07/12/2020: https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S000AGM4&selectaction=Edit&uid=U00019IE&ts=2&cx=uwje3h. Protocol-version 2: 27/01/2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-01674-1.

Population-Based Prevalence of Oral Conditions as a Basis for Planning Community-Based Interventions: An Epidemiological Study From Rural Burkina Faso

Objectives: The purpose of the present study was to: (i) provide timely data on dental caries and periodontal conditions in rural Burkina Faso; (ii) identify the oral health practices carried out in this population, and (iii) to prioritize evidence-based interventions at the community level. Methods: Leaning on WHO recommendations for oral health epidemiological studies, clinical examinations and questionnaire-based surveys were conducted in two different age groups (adolescents: 15-19 years old; adults: 35-44 years old) in the health district of Nouna, Burkina Faso. Caries and tooth status were assessed according to the DMFT Index. The periodontal status was assessed by a modified Community Periodontal Index on all teeth present and measuring the level of attachment-loss of six index teeth. Questionnaire items specifically included utilization of oral health care and oral health behaviors. Results: The prevalence of untreated caries was 38% in adolescents and 73% in adults. In terms of periodontal health, 21% of adolescents and 61% of adults had an attachment loss ≥4 mm. Ninety seven percent of adolescents had not attended a dentist in the previous year and 78% of adults had never seen a dentist in their life. About one third of adolescents and adults cleaned their teeth less often than once per day with equal proportions of toothbrushes and traditional chewing sticks made of tree branches. Fluoride toothpaste was used by <10% of study participants. Almost half of the examined people reported to drink a sugar-sweetened beverage at least once a day. Conclusions: Dental caries and periodontitis are highly prevalent in rural Burkina Faso. These findings highlight the key relevance of epidemiological data for identifying people's oral health needs as basis for developing, testing, and implementing oral health interventions and programs. Special emphasis should be put on the design and evaluation of community-based interventions.

[Global oral health in the international health policy spotlight-challenges and new opportunities for sustainable improvement]

Orale Erkrankungen sind ein signifikantes globales Gesundheitsproblem über alle Länder und Bevölkerungsgruppen hinweg. Mit fast 3,5 Mrd. Erkrankungsfällen (2017) sind so viele Menschen betroffen wie von keiner anderen Krankheitsgruppe. Die Haupterkrankungen sind unbehandelte Karies der bleibenden oder der Milchzähne, fortgeschrittene Parodontopathien, Zahnlosigkeit sowie Karzinome der Mundhöhle und Lippen. Bei weitgehend unverändert hoher globaler Prävalenz erhöhen durch Bevölkerungswachstum bedingte stark steigende Fallzahlen den Druck auf schwache oder überlastete Gesundheitssysteme, insbesondere in Ländern der unteren und mittleren Einkommensgruppen.

Dennoch wird der Mundgesundheit in vielen Ländern nur unzureichende Priorität eingeräumt und sie erhält als wichtiges Thema im gesundheitspolitischen Diskurs der deutschen und globalen Akteure nach wie vor wenig Aufmerksamkeit. Eine der fundamentalen Herausforderungen ist dabei die Gewährleistung eines allgemeinen und fairen Zugangs zu adäquater universeller Basisgesundheitsversorgung für alle Menschen ohne Verursachung von finanziellen Härten (Universal Health Coverage).

Dieser Beitrag gibt einen einführenden Überblick über die globalen Trends der weltweiten Krankheitslast der oralen Haupterkrankungen, die von starken Ungleichheiten geprägt sind. Verbesserungsansätze aus der bevölkerungsweiten Risikoreduktion und Prävention, der Versorgungsplanung sowie gesundheitspolitische Lösungen werden kurz vorgestellt. Dabei werden die im internationalen Diskurs wichtigen Themen angesprochen und die im Rahmen einer Lancet-Artikelserie zur globalen Mundgesundheit aus dem Jahr 2019 entwickelten Reformbereiche besprochen. Schließlich werden neue Initiativen diskutiert sowie Empfehlungen für die deutsche und internationale gesundheitliche Entwicklungspolitik gegeben, die in den kommenden Jahren die Situation der globalen Mundgesundheit entscheidend verbessern könnten.

Reorienting Oral Health Services to Prevention: Economic Perspectives

Despite the recognized need to change the emphasis of health services by shifting the balance from treatment to prevention, limited progress has been made in many settings. This is true in oral health, where evidence for preventive interventions that work has not been systematically exploited in oral health services. While reorienting health services is complex and context specific, economics can bring a helpful perspective in understanding and predicting the impact of changes in resource allocation, provider remuneration systems, and patient payments. There is an increasing literature on the economics of different prevention approaches. However, much of this literature focuses on the costs and potential savings of alternative approaches and fails to take into account benefits. Even where benefits are taken into account, these tend to be narrowly focused on clinical outcomes using cost-effectiveness analysis, which may be of little relevance to the policy maker, patient, and the public. Some commonly used economic approaches (such as quality-adjusted life years and incremental cost-effectiveness ratios) may also not be appropriate to oral health. Using alternative techniques, including wider measures of benefit and employing priority setting and resource allocation tools, may provide more comprehensive information on economic impact to decision makers and stakeholders. In addition, it is important to consider the effects of provider remuneration in reorienting services. While there is some evidence about traditional models of remuneration (fee for service and capitation), less is known about pay for performance and blended systems. This article outlines areas in which economics can offer an insight into reorientation of health systems toward prevention, highlighting areas for further research and consideration.

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.

Forecasting future dental health expenditures: Development of a framework using data from 32 OECD countries

Objective

To (1) develop a framework for forecasting future dental expenditures, using currently available information, and (2) identify relevant research and data gaps such that dental expenditure predictions can continuously be improved in the future.

Methods

Our analyses focused on 32 OECD countries. Dependent on the number of predictors, we employed dynamic univariate and multivariate modelling approaches with various model specifications. For univariate modelling, an auto‐regressive (AR) dynamic model was employed to incorporate historical trends in dental expenditures. Multivariate modelling took account of historical trends, as well as of relationships between dental expenditures, dental morbidity, economic growth in terms of gross domestic product and demographic changes.

Results

Estimates of dental expenditures varied substantially across different model specifications. Models relying on dental morbidity as one of the predictors performed worst regardless of their specification. Using the best‐fitted model specification, that is the univariate second‐order autoregression [AR(2)], the forecasted dental expenditures across 32 OECD countries amounted to US$316bn (95% forecasted interval, FI: 258‐387) in 2020, US$434bn (95%FI: 354‐532) in 2030 and US$594bn (95%FI: 485‐728) in 2040. Per capita spending in 2040 was forecasted to be highest in Germany (US$889, 95%FI: 726‐1090) and lowest in Mexico (US$52, 95%FI: 42‐64).

Conclusions

The present study demonstrates the feasibility and challenges in predicting dental expenditures and can serve as a basis for improvement towards more sustainable and resilient health policy and resource planning. Within the limitations of available data sources, our findings suggest that dental expenditures in OECD countries could increase substantially over the next two decades and vary considerably across countries. For more accurate estimation and a better understanding of determinants of dental expenditures, more comprehensive data on dental spending and dental morbidity are urgently needed.

Healthcare Challenges and Future Solutions in Dental Practice: Assessing Oral Antibiotic Resistances by Contemporary Point-Of-Care Approaches

Antibiotic resistance poses a global threat, which is being acknowledged at several levels, including research, clinical implementation, regulation, as well as by the World Health Organization. In the field of oral health, however, the issue of antibiotic resistances, as well as of accurate diagnosis, is underrepresented. Oral diseases in general were ranked third in terms of expenditures among the EU-28 member states in 2015. Yet, the diagnosis and patient management of oral infections, in particular, still depend primarily on empiric means. On the contrary, on the global scale, the field of medical infections has more readily adopted the integration of molecular-based systems in the diagnostic, patient management, and antibiotic stewardship workflows. In this perspective review, we emphasize the clinical significance of supporting in the future antibiotic resistance screening in dental practice with novel integrated and point-of-care operating tools that can greatly support the rapid, accurate, and efficient administration of oral antibiotics.

Should Medicaid include adult coverage for preventive dental procedures? What evidence is needed?

BACKGROUND

Medicaid programs may have a salient financial incentive to provide adult coverage for cost-effective preventive dental procedures because they face responsibility for catastrophic costs of dental disease. Whether there is sufficient evidence to support adult Medicaid coverage of preventive dental services is unclear.

METHODS

Using an optimal insurance model, the author examines what evidence there is to support coverage of cost-effective preventive dental services in Medicaid and what evidence gaps remain.

RESULTS

There is insufficient evidence to support adult Medicaid coverage for preventive dental procedures.

CONCLUSIONS

More research is needed to identify preventive dental procedures that are cost-effective from a Medicaid perspective, quantify the impact dental prevention has on dental-related health care costs and overall health care costs, and quantify the impact patient-side and provider-side financial incentives have on take-up of specific preventive dental treatments.

PRACTICAL IMPLICATIONS

Although Medicaid programs may have an interest in preventing catastrophic costs of dental disease (that is, dental-related emergency department visits), there is insufficient evidence for Medicaid programs to provide coverage for preventive dental procedures.

Dutch oral health care quality measures: a modified Delphi study

Objectives: Quality measures offer opportunities for evaluation and improvement of the quality of oral health care. This study describes the development of a core set of oral health care quality measures for adults in the Netherlands, which can be used in dental practice. Materials and methods: A comprehensive two-stage approach was used, consisting of: (1) identification of an initial set of measures based on appraised literature; and (2) a four-round modified RAND/UCLA Appropriateness Method to establish measures that are relevant, appropriate and important to oral health care. Measures were rated anonymously on a nine-point Likert scale, ranging from 1 (lowest rating) to 9 (highest rating), followed by a group discussion to reach consensus. Multiple key stakeholder groups in the Dutch oral health care field were involved in the Delphi rounds, including dental professionals, scientists and representatives from Dutch oral health care organisations. Results: The study resulted in a core set of 13 oral health care quality measures. The measures cover domains related to oral disease outcomes, oral treatment and preventive services, patient experiences, patient safety, and organisational aspects of oral health care. In addition, the study led to the identification of 49 structural aspects of oral health care that are important to measure. Discussion: To our knowledge, this is the first study combining appraised literature from a systematic review and a rigorous multi-stage procedure with extensive stakeholder involvement to develop a core set of oral health care quality measures. In the next phase, the measures will be tested on feasibility, reliability, and will be piloted and implemented in practice.

Once bitten, twice shy? Lessons learned from an experiment to liberalize price regulations for dental care

In 2012, The Netherlands established the so-called "free market experiment", which allowed providers of dental care to set the prices for their dental services themselves. The introduction of market mechanisms is intended to improve the quality of care and to contribute to cost containment, but increasing health expenditures for citizens have been observed in this context. Using large-volume health insurance claims data and exploiting the 2012 experiment in Dutch dental care, we identified the effects of a liberalization of service prices. Using pooled regression with individual fixed effects, we analyzed changes in utilization patterns of prevention-oriented dental services in response to the experiment as well as the elasticities in demand in response to variations in out-of-pocket (OOP) prices. We found substantial increases in prices and patients' OOP contributions for dental services following the liberalization with differences in increases between types of services. In response to the experiment, the proportion of treatment sessions containing preventive-oriented services decreased significantly by 3.4% among adults and by 5.3% for children and adolescents. Estimates of short-run price elasticities of demand for different services point towards differences in price sensitivity. One potential explanation for the observed variations in prices and utilization could be different extents of asymmetric information for first-stage and follow-on services. Price liberalization seems to have affected the composition of treatment sessions towards a decreasing use of preventive services, suggesting a shift in the reason for seeing a dental care provider from a regular-preventive perspective to a symptom-based restorative approach.