Oral diseases: a global public health challenge.

Oral diseases are among the most prevalent diseases globally and have serious health and economic burdens, greatly reducing quality of life for those affected. The most prevalent and consequential oral diseases globally are dental caries (tooth decay), periodontal disease, tooth loss, and cancers of the lips and oral cavity. In this first of two papers in a Series on oral health, we describe the scope of the global oral disease epidemic, its origins in terms of social and commercial determinants, and its costs in terms of population wellbeing and societal impact. Although oral diseases are largely preventable, they persist with high prevalence, reflecting widespread social and economic inequalities and inadequate funding for prevention and treatment, particularly in low-income and middle-income countries (LMICs). As with most non-communicable diseases (NCDs), oral conditions are chronic and strongly socially patterned. Children living in poverty, socially marginalised groups, and older people are the most affected by oral diseases, and have poor access to dental care. In many LMICs, oral diseases remain largely untreated because the treatment costs exceed available resources. The personal consequences of chronic untreated oral diseases are often severe and can include unremitting pain, sepsis, reduced quality of life, lost school days, disruption to family life, and decreased work productivity. The costs of treating oral diseases impose large economic burdens to families and health-care systems. Oral diseases are undoubtedly a global public health problem, with particular concern over their rising prevalence in many LMICs linked to wider social, economic, and commercial changes. By describing the extent and consequences of oral diseases, their social and commercial determinants, and their ongoing neglect in global health policy, we aim to highlight the urgent need to address oral diseases among other NCDs as a global health priority.

[Lack of medical or dental care: Impact on health expenditures for people with chronic disease]. / L'effet du non-recours aux soins médicaux et dentaires sur les dépenses de santé des personnes ayant une maladie chronique.

BACKGROUND: People with chronic disease often have dental (especially periodontal) disorders. Nevertheless, people with chronic disease seek dental care less often than others. We wanted to know if there is a relationship between the consumption of medical care and the consumption of dental care, and if so if the relationship is especially strong for people with chronic disease. METHODS: We conducted a longitudinal study that combined two data-sets: consumption data from the French National Health Insurance Fund and health and socioeconomic welfare data collected with a dedicated national survey. We studied healthcare expenditure and analyzed the association between healthcare consumption, health status and healthcare expenditure over a four-year period (2010-2013). RESULTS: People who did not seek medical or dental care in 2010 exhibited irregular consumer behavior thereafter. This pattern was particularly evident among those with chronic disease whose healthcare expenditures did not stabilize during the study period compared with the rest of the study population. Among people who did not seek medical care in 2010, variation in average dental care expenditure was 91% in people with chronic disease versus 42% for those without chronic disease. Lack of medical care during the first year of the study was also associated with greater expenditure-delay in people with chronic disease (77%) compared with 15% in people without chronic disease. CONCLUSION: The lack of medical or dental care in 2010 for people with chronic disease did not lead to an increase in medical and dental consumption in the following years. The catch-up delay was longer than four years. This highlights a problem of monitoring and identifies a marginalized population within the healthcare system.

Economic and Practical Considerations in the Treatment of Oral Mucosal Chronic Graft-Versus-Host Disease.

Chronic graft-versus-host disease (cGVHD) frequently affects the oral mucosa and is generally responsive to topical immunomodulatory therapies. Clinicians may benefit from guidance in choosing the most appropriate therapy with respect to practicality and cost. To assess the economic considerations related to topical immunomodulatory treatments for management of oral mucosal cGVHD and their practical implications. Topical treatments used for management of oral cGVHD were obtained from the National Institutes of Health Consensus document for ancillary and supportive care. Cost data for a standard 1-month prescription was obtained from national databases for commercially available formulations and from compounding pharmacies for formulations requiring compounding. There are numerous topical preparations used for the management of oral cGVHD, many of which require compounding. The average wholesale price of the commercially available agents ranges from $5 to $277/month, and the cost of the compounded preparations ranges from $43 to $499/month. Costs can be influenced by drug-, patient-, and pharmacy-related factors. The costs associated with topical treatment of oral cGVHD are substantial, particularly because the disease is chronic and expenses accumulate over time. Rational prescribing according to a proposed algorithm, including de-escalation of therapy when indicated, can help to minimize associated costs. This has practical implications for patients, physicians, pharmacies, and insurance providers.

Economic models for prevention: making a system work for patients.

The purpose of this article is to describe alternative means of providing patient centered, preventive based, services using an alternative non-profit, economic model. Hard to reach, vulnerable groups, including children, adults and elders, often have difficulties accessing traditional dental services for a number of reasons, including economic barriers. By partnering with community organizations that serve these groups, collaborative services and new opportunities for access are provided. The concept of a dental home is well accepted as a means of providing care, and, for these groups, provision of such services within community settings provides a sustainable means of delivery. Dental homes provided through community partnerships can deliver evidence based dental care, focused on a preventive model to achieve and maintain oral health. By using a non-profit model, the entire dental team is provided with incentives to deliver measurable quality improvements in care, rather than a more traditional focus on volume of activity alone. Examples are provided that demonstrate how integrated oral health services can deliver improved health outcomes with the potential to reduce total costs while improving quality.

Skill-mix in preventive dental practice--will it help address need in the future?

BACKGROUND: Population health needs are changing. The levels of dental caries and periodontal disease across the population as a whole is falling. The proportion of adults with a functional dentition in many developed countries has increased substantially and edentulous rates have dropped to some of their lowest levels. Despite this, a pronounced social gradient still exists, many adults do not attend dental services regularly and disease in young children remains intransigent amongst the poorest. New challenges are emerging too as the growing number of older people, above sixty-five years of age, retain their teeth. METHODS: Ensuring "the right number of people with the right skills are in the right place at the right time to provide the right services to the right people" is critical for future dental service provision, both to meet the new challenges ahead and to ensure future services are cost-effective, efficient and reduce health-inequalities. Greater use of "skill-mix" models could have a substantial role in the future, as dentistry moves from a "cure" to a "care" culture. DISCUSSION: The provision of dental services in many countries currently adopts a "one-size-fits-all", where the dentist is the main care-giver and the emphasis is on intervention. As needs change in the future, the whole of the dental team should be utilised to deliver primary, secondary and tertiary prevention in an integrated model. Growing evidence suggests that other members of the dental team are effective in providing care, but introducing this paradigm shift is not without its challenges. The provision of incentives within funding systems and social acceptability are amongst the key determinants in producing a service that is responsive to need, improves access and delivers equity.

Prevention in practice--a summary.

BACKGROUND: This paper is a summary document of the Prevention in Practice Conference and Special Supplement of BMC Oral Health. It represents the consensus view of the presenters and captures the questions, comments and suggestions of the assembled audience. METHODS: Using the prepared manuscripts for the conference, collected materials from scribes during the conference and additional resources collated in advance of the meeting, authors agreed on the summary document. RESULTS: The Prevention in Practice conference aimed to collate information about which diseases could be prevented in practice, how diseases could be identified early enough to facilitate prevention, what evidence based therapies and treatments were available and how, given the collective evidence, could these be introduced in general dental practice within different reimbursement models. CONCLUSIONS: While examples of best practice were provided from both social care and insurance models it was clear that further work was required on both provider and payer side to ensure that evidence based prevention was both implemented properly but also reimbursed sufficiently. It is clear that savings can be made but these must not be overstated and that the use of effective skill mix would be key to realizing efficiencies. The evidence base for prevention of caries and periodontal disease has been available for many years, as have the tools and techniques to detect, diagnose and stage the diseases appropriately. Dentistry finds itself in a enviable position with respect to its ability to prevent, arrest and reverse much of the burden of disease, however, it is clear that the infrastructure within primary care must be changed, and practitioners and their teams appropriately supported to deliver this paradigm shift from a surgical to a medical model.

The platform for better oral health in Europe--report of a new initiative.

Public health practitioners are required to apply their competencies at a range of levels from governmental to small community groups. A recurring theme at BASCD conferences has been the need to influence policy at the highest level if improvements to oral health and better treatment of oral ill-health are to occur. This paper presents a clear example of such dental public health action at a European level. This report outlines the reasons why it is necessary to try to improve oral health within Europe, in general, and the European Union in particular. It goes on to describe how the newly formed Platform for Better Oral Health in Europe is trying to work at a macro level, and bring interested associations, groups and individuals together. Collectively they can then alert European institutions and national governments to oral health problems and promote policies to improve the current situation. It describes the current problems, their resource implications, the objectives of the Platform, its actions so far and its plans for the immediate future. It suggests that, if the problems are to be addressed, it will be necessary for all interested parties to work together at a European level to raise oral health issues higher on the E.U. agenda.

Networked remote area dental services: a viable, sustainable approach to oral health care in challenging environments.

OBJECTIVE: This study examines the cost effectiveness of a model of remote area oral health service. DESIGN: Retrospective financial analysis. SETTING: Rural and remote primary health services. PARTICIPANTS: Clinical activity data and associated cost data relating to the provision of a networked visiting oral health service by the Centre for Rural and Remote Oral Health formed the basis of the study data frameset. The cost-effectiveness of the Centre's model of service provision at five rural and remote sites in Western Australia during the calendar years 2006, 2008 and 2010 was examined in the study. MAIN OUTCOME MEASURED: Calculations of the service provision costs and value of care provided were made using data records and the Fee Schedule of Dental Services for Dentists. The ratio of service provision costs to the value of care provided was determined for each site and was benchmarked against the equivalent ratios applicable to large scale government sector models of service provision. RESULTS AND CONCLUSION: The use of networked models have been effective in other disciplines but this study is the first to show a networked hub and spoke approach of five spokes to one hub is cost efficient in remote oral health care. By excluding special cost-saving initiatives introduced by the Centre, the study examines easily translatable direct service provision costs against direct clinical care outcomes in some of Australia's most challenging locations. This study finds that networked hub and spoke models of care can be financially efficient arrangements in remote oral health care.

Disability days in Canada associated with dental problems: a pilot study.

OBJECTIVE: The aim of this study was to explore disability days, or bed days and cut-down days, associated with dental problems in Canada. METHODS: Data were collected through a national telephone interview survey of 1005 Canadians aged 18 years and over using random digit dialling. Participants were asked to enumerate the number of disability days associated with dental problems in the previous 2-week period. Descriptive and bivariate logistic regression analyses were undertaken. RESULTS: In the previous 2-week period, 33 people, or 3.3% of the sample, reported spending a day in bed because of a dental problem. Of these, 22 people also reported having to cut down on their normal activity because of the dental problem. It appears that younger age groups, those with the lowest incomes, college educations, no dental insurance, oral pain and a history of visiting a hospital emergency room for a dental problem, were all more likely to report a dental disability day. CONCLUSIONS: These data demonstrate the potential economic impacts of dental problems in Canada, yet they must be interpreted with caution because of the very low prevalence of the main outcome measure, the potential for selection bias and the relative inconsistency with existing historical estimates.

Functional and psychosocial impacts of oral disorders in Canadian adults: a national population survey.

BACKGROUND: In Canada, national health surveys do not usually include questions pertaining to self-perceived oral health. Those that do use ad hoc sets of questions rather than standardized and validated measures of the functional and psychosocial impacts of oral disorders. AIMS: To collect national data on the impacts of oral disorders from a representative sample of Canadian adults and to compare the results with similar national surveys conducted in the United Kingdom and Australia. METHODS: Data were collected from adults by means of a telephone interview survey based on random-digit dialing. Oral health was measured with the short-form Oral Health Impact Profile (also known as the OHIP-14 questionnaire), which asks about the frequency of 14 functional and psychosocial impacts that people have experienced in the previous year as a result of problems with their teeth, mouth or dentures. RESULTS: Of 3,033 interviews conducted, data were sufficient for analysis for 3,019 respondents. Just under one-fifth of the 3,019 respondents (19.5%) reported 1 or more of the 14 impacts "fairly often" or "very often" in the previous year. The prevalence was higher among edentulous respondents (30.7%) than among dentate respondents(18.6%), as were the extent and severity scores. The prevalence of impacts was lowest in Atlantic Canada (16.1%) and highest in the Prairies (23.3%), although the difference was not statistically significant. Prevalence rates and extent and severity scores were highest among those who wore dentures, recipients of public dental care and irregular dental visitors. Considerable income disparities were also observed, with 34.9% of those from the lowest-income households reporting impacts. The prevalence of effects and the extent and severity scores in Canada were similar to those reported from the United Kingdom and Australia. CONCLUSIONS: One in 5 Canadian adults experienced adverse impacts from oral disorders. Further work is needed to identify the material and psychological determinants of these impacts.

Cost implications for the treatment of five oral lesions commonly found in HIV/AIDS.

The objectives of this study were to determine the cost of a prescribed treatment plan; to compare the costs in an academic hospital cost with that of private pharmacy; and to determine the average treatment cost per visit. The descriptive, retrospective study that investigated the cost implications of the treatment of five oral lesions associated with HIV/AIDS: oral candidiasis, oral hairy leukoplakia, periodontal diseases, oral ulcers and Kaposi's sarcoma. One hundred and twenty four cases with oral HIV lesions were selected from the list of 181 HIV patients listed in the attendance registers of three hospitals in the selected study sites. A data capture sheet was used to obtain information related to diagnosis, investigations done, staging of the disease, treatment plan and treatment outcome. None of the patients were on antiretroviral therapy. The association between the number of hospital visits and the total cost of treatment was significant (p < 0.05). Also, there was a significant negative relationship between the outcome of treatment and the total hospital costs (p < 0.05). The lower the hospital treatment cost, the better the outcome. There was no significant association between staging of the disease and the hospital cost (p > 0.05), but the CD4 count significantly influenced the hospital cost (p<0.05). The average hospital treatment and private pharmacy cost was 207.06 and 357.85 rands respectively (16.21 euros and 28.02 euros respectively). There is a need to evaluate the current treatment protocols, as some treatments may be ineffective. Governments should endeavour to provide antiretroviral and other relevant drugs, at no cost, to HIV/AIDS patients.

Oral health of high-cost patients and evaluation of oral health measures as predictors for high-cost patients in South Korea: a population-based cohort study.

OBJECTIVE: To examine the oral health conditions and oral health behaviour of high-cost patients and evaluate oral health measures as predictors of future high-cost patients. DESIGN: A retrospective, population-based cohort study using administrative healthcare records. SETTING: The National Health Insurance Service (NHIS) medical check-up database (a.k.a. NHIS-national health screening cohort database) in South Korea. PARTICIPANTS: 131 549 individuals who received biennial health check-ups including dental check-ups in 2011 or 2012, aged 49-88. PRIMARY OUTCOME MEASURES: Current and subsequent year high-cost patient status. RESULTS: High-cost patients, on average, incur higher dental costs, suffer more from periodontal disease, brush their teeth less and use secondary oral hygiene products less. Some of the self-reported oral health behaviours and oral symptom variables show statistically significant associations with subsequent year high-cost patient indicators, even after adjusting for demographic, socioeconomic, medical conditions, and prior healthcare cost and utilisation. CONCLUSIONS: We demonstrate that oral health measures are associated with an increased risk of becoming a high-cost patient.

Building better oral health: a dental home for all Texans.

Poor oral health affects more than just the mouth. It can seriously compromise a person's general health, quality of life and life expectancy. Oral diseases can and do lead to systemic problems--damaging other parts of the body and resulting in the need for expensive emergency department visits, hospital stays and medications. The consequences of poor oral health, however, go far beyond damaging medical effects. Oral disease can also wreak economic havoc--keeping children out of school and adults home from work--not to mention lower productivity of workers in pain. Untreated oral diseases can also drive up health care costs in general. The good news is that with proper oral health care, both at home and in professional settings, many of the negative consequences associated with poor oral health can be prevented. The State of Texas has a unique and unprecedented opportunity to significantly increase access to oral health care for all Texans. Complying with the Frew agreement is a key priority. However, there are additional ways that Texas policymakers can improve the oral health of the state. In an effort to begin a constructive dialogue about improving the oral health of all Texans, the Texas Dental Association (TDA) with grant funding from the American Dental Association (ADA) commissioned an independent third-party report on the issue of access to oral health care in Texas modeled after the 2000 groundbreaking surgeon general's report, Oral Health in America. The TDA assembled a team of five nationally recognized dentists from both academia and private practice to oversee the project. The dentists (hereafter called the editorial review board or ERB) were asked to identify the state's most pressing issues, needs and challenges associated with improving the oral health of all Texans, with a special focus on the state's most vulnerable. The ERB looked carefully at the economic, medical and social consequences of untreated oral disease in Texas. It reviewed the current systems of oral health care delivery and payment throughout the state. The team also studied the oral health status of Texans in general and analyzed the oral health disparities that exist in the state. Finally, the ERB made specific and practical policy recommendations to expand access to oral health care in Texas, including: 1) Identifying a "dental home" for every Texan. 2) Strengthening the Texas Department of State Health Services (DSHS) Oral Health Program (OHP). 3) Creating new programs to encourage general dentists and specialists to practice in underserved areas and to treat underserved populations. 4) Developing a comprehensive oral health public awareness and education campaign. 5) Expanding access to oral health services for older Texans. As the face of Texas continues to change, the state must put in place a new, more aggressive strategy to improve access to oral health care. This challenge must be approached as a shared responsibility--among dentists, allied health professionals, primary care providers, policymakers, community-based organizations, parents and schools. The job is too big--and too important--for any one group to try to tackle alone. The time to act is now.

Systematic review and meta-analysis of randomised controlled trials on the effectiveness of school-based dental screening versus no screening on improving oral health in children.

OBJECTIVES: The current study aimed to evaluate the effectiveness of school-based dental screening versus no screening on improving oral health in children aged 3-18 years by a systematic review and meta-analysis of randomised controlled trials. SOURCES AND STUDY SELECTION: Three sets of independent reviewers searched MEDLINE, EMBASE, Web of Science and other sources through April 2016 to identify published and nonpublished studies without language restrictions and extracted data. DATA: Primary outcomes included prevalence and mean number of teeth with caries, incidence of dental attendance and harms of screening. Cochrane's criteria for risk of bias assessment were used. RESULTS: A total of five cluster RCTs (of unclear or high risk of bias), including 28,442 children, were meta-analysed. For an intracluster correlation coefficient of 0.030, there was no statistically significant difference in dental attendance between children who received dental screening and those who did not receive dental screening (RR 1.11, 95% 0.97, 1.27). The Chi-square test for heterogeneity and the Higgin's I2 value indicated a substantial heterogeneity. Only one study reported the prevalence and mean number of deciduous and permanent teeth with dental caries and found no significant differences between the screening and no screening groups. CONCLUSIONS: There is currently no evidence to support or refute the clinical benefits or harms of dental screening. Routine dental screening may not increase the dental attendance of school children, but there is a lot of uncertainty in this finding because of the quality of evidence. CLINICAL SIGNIFICANCE: Evidence from the reviewed trials suggests no clinical benefit from school-based screening in improving children's oral health. However, there is a lot of uncertainty in this finding because of the quality of evidence. There is a need to conduct a well-designed trial with an intensive follow-up arm and cost-effectiveness analysis. SYSTEMATIC REVIEW REGISTRATION NUMBER: CRD42016038828 (PROSPERO database).

Hospitalization of Western Australian children for oral health related conditions: a 5-8 year follow-up.

BACKGROUND: This study investigated in-patient oral health care provision for children under 18 years of age in Western Australia. METHODS: Hospitalizations of children for oral health conditions over a four-year period were analysed using data obtained from the Western Australian Hospital Morbidity Data System (HMDS). This study followed a previously published study examining similar data for 1995. RESULTS: Between 1999-2000 and 2002-2003, a total of 26 497 episodes of care were attributed to oral health conditions among children aged 0-17 years. The cost of this care exceeded $40 million. Embedded and impacted teeth accounted for 33.2 per cent of oral health episodes, dental caries 28.3 per cent, pulp and periapical tissue conditions 7.1 per cent and dentofacial anomalies 6.1 per cent. With the exception of the infant age group (0-1 years), non-Aboriginal children had higher admission rates than Aboriginal children. In the 13-17 year age group a non-Aboriginal child was 31 times more likely to be admitted to hospital for an oral condition than an Aboriginal child. CONCLUSIONS: This study confirms the impact of oral health related conditions among children in Western Australia. It is also clear that there are differences between age and population groups in terms of access to in-patient dental services and exposure to risk factors for specific oral conditions.