Prioritizing population oral health through public policy in Australia: the Victorian experience.

Dental caries, a non-communicable disease, is one of the most prevalent diseases globally and share common modifiable risk factors with obesity such as excess sugar intake. However, prioritization by governments to improve population oral health has been limited and is typically excluded from the discourse of public health policy development. Therefore, interventions that target dental caries can have other co-benefits including obesity prevention. In Victoria, Australia, local government authorities have a regulatory requirement to develop their Municipal Health and Wellbeing Plans. The aim of this paper is to identify whether prioritization for oral health by local government authorities in Victoria has changed through the subsequent renewal of the Victorian Public Health and Wellbeing Plans 2011-2015 and 2019-2023. Three desktop audits for all publicly available Municipal Health and Wellbeing Plans by local government authorities in Victoria were conducted between 2014 and 2022. Key terms related to oral health was searched within these policy documents and categorized into six indicators: (i) included oral health as a priority, (ii) linked healthy eating and oral health, (iii) supported the Achievement Program, (iv) included the Smiles 4 Miles program, (v) advocated for fluoridated drinking water, and (vi) included other strategies related to oral health. Overall, there was statistically significant reduction in five of the six indicators, with the exception for prioritization of other strategies related to oral health such as targeting excess sugar intake and smoking. A multi-sectoral approach, that includes oral health would be advantageous to address the growing burden of non-communicable diseases.

Dental Health Services Victoria value-based health care principles for oral health models of care.

BACKGROUND: Efforts to progress oral healthcare reform can be challenging with competing interests of governments and service providers to achieve the intended outcomes. The value-based health care approach has been adopted in many areas of healthcare but has had limited applications to oral healthcare systems. Dental Health Services Victoria, an Australian state government funded entity, commenced its journey to value-based health care in 2016, to shift away from traditional dental service models that reward activity and volume towards a stronger emphasis on value and outcomes. AIMS: To maintain the value-based health care agenda focus, Dental Health Services Victoria developed three key principles, which can be adopted by other organisations engaged in reforming oral healthcare, to improve the oral health for the population it serves. MATERIALS & METHODS: In 2018, Dental Health Services Victoria developed a value-based health care framework, which has informed strategic organisation priorities for action. In 2023, the following three key principles are identified as being essential to support the operationalisation and development of effective models of oral healthcare: Principle 1 - Care is co-designed with the person or population Principle 2 - Prevention and early intervention are prioritised. Principle 3 - Consistent measurement of health outcomes and costs are embedded. DISCUSSION: The exploration of the three key principles is an important communication tool to translate value-based health care into practice with key stakeholders. Further work is required to socialise them to within dental teams. CONCLUSION: Organisations looking to commence the value-based health care agenda can apply Dental Health Services Victoria's three key principles as a first step.

Modeled health economic and equity impact on dental caries and health outcomes from a 20% sugar sweetened beverages tax in Australia.

Dental caries is the most prevalent oral disease across the life course. This study modeled the population health and economic impact of a 20% sugar sweetened beverages tax (SSB) for preventing dental caries compared to no intervention (societal and healthcare perspective). A cost-effectiveness analysis according to quintiles of area-level socioeconomic disadvantage was performed for the 2020 Australian population (0-100 years old) using a closed cohort Markov model. A qualitative assessment of implementation considerations (e.g., acceptability, equity, sustainability) was undertaken. Health outcomes were modeled as decayed teeth prevented and disability-adjusted life years (DALYs) averted. The 10-year and lifetime scenarios were modeled with probabilistic sensitivity analysis (Monte Carlo simulation, 2000 cycles). The 10-year scenario from a societal perspective yielded cost-savings of AUD$63.5M, healthcare cost-savings of AUD$42.2M, 510,977 decayed teeth averted and 98.1 DALYs averted. The lifetime scenario resulted in societal cost savings of AUD$176.6M, healthcare cost-savings of AUD$122.5M, 1,309,211 decayed teeth averted and 254.9 DALYs averted. Modeling indicated 71.5% and 74.5% cost-effectiveness for the 10-year and lifetime scenarios, respectively. A three-fold health benefit for the least advantaged was found compared to the most advantaged. A 20% SSB tax in Australia is cost-effective and promotes health equity.

Is Australia's lack of national clinical leadership hampering efforts with the oral health policy agenda?

The landmark 2021 Resolution on Oral Health by the 74th World Health Assembly has elevated the importance of oral health into the global health policy agenda. This has led to the development and adoption of the World Health Organization (WHO) Global Strategy on Oral Health in 2022. It acknowledged the need to integrate oral health as part of universal health coverage (UHC), which is supported by national clinical leadership for oral health. Although Australia is a signatory WHO member state, it is yet to appoint a Commonwealth Chief Dental Officer to provide national clinical leadership. This commentary provides a background on the current issues on population oral health in Australia, an insight into the Australian oral healthcare system, and explores some of the challenges and learnings related to previous Commonwealth dental programs. This paper highlights why expertise in dental public health is required to steer national oral health policy that is focused on prevention and early intervention. A population oral health approach for UHC should be informed by evidence, prioritise and address oral health inequities, and be co-ordinated by national clinical leadership for oral health.

Economic Evaluations of Preventive Interventions for Dental Caries and Periodontitis: A Systematic Review.

OBJECTIVES: To critically examine the methods used for full economic evaluations of preventive interventions for dental caries and periodontitis. METHODS: Published literature post-2000 was searched to April 2021. Based on a developed intervention classification framework for dental caries and periodontitis, only universal, selective or indicated interventions were included in this review. The Drummond 10-point checklist was used for quality appraisal. RESULTS: Of 3,007 unique records screened for relevance, 73 studies were reviewed. Most model-based studies (61/73) used cost-effectiveness analysis (49%) or cost-benefit analysis (28%). Trial-based studies (16/73) commonly used cost-effectiveness analysis (59%). Four studies used both economic evaluation methods. Sixty-four papers (88%) were on dental caries, eight papers (11%) focused on periodontitis, and one paper (1%) included both oral diseases; 72% of model-based and 82% of trial-based studies were of good quality. The most frequently investigated dental caries preventive interventions were water fluoridation (universal intervention; cost-saving or cost-effective), fissure sealant and fluoride varnish (selective and indicated interventions; cost-effectiveness outcomes were inconsistent). Supportive periodontal therapy with oral health education (indicated intervention; cost-effective) was the most frequently evaluated preventive intervention for periodontitis. Thirty percent of studies with a time horizon > 1 year did not apply an appropriate discount rate and 26% did not comprehensively discuss other important considerations beyond the technical analysis. CONCLUSIONS: Generic health outcome measures should be incorporated for economic evaluations on preventive interventions for dental caries and periodontitis, and an increased focus to prevent periodontitis using economic evaluation methods is needed to inform resource allocation and policy decision-making.

Evaluation of an intervention to promote minimally invasive dentistry (MID) in an Australian community dental agency-A pilot study.

OBJECTIVES: To evaluate the impact of an intervention consisting of a 1-day continuing professional development (CPD) education programme on the International Caries Classification and Management System (ICCMS™ ), and monthly performance feedback, and to promote minimally invasive dentistry (MID) for children aged under 12 years in an Australian community dental agency. The a priori hypotheses assumed the intervention would increase preventive services, and treatment demand was met. METHODS: A quasi non-randomized controlled trial with convenience sampling method was adopted. Fourteen dental practitioners received the intervention. The prevalence of dental caries and gingivitis in Australian children was used to determine the treatment demand and used as the performance benchmark. Ten types of preventive and non-preventive dental services were examined. A Difference-in-Differences (DiD) of 12-month pre- (baseline) and post-intervention analysis was performed. RESULTS: The intervention group demonstrated increases in topical fluoride application and dietary analysis and advice services. The standard care group had increases in oral prophylaxis or scale and clean, topical fluoride application and oral hygiene instructions (p-value <0.05). The DiD analysis confirmed the above findings in the intervention group, while other preventive services declined. In the intervention group, the performance benchmark for oral prophylaxis or scale and clean and oral hygiene instructions was met at baseline and post-intervention. CONCLUSIONS: Only a few preventive services had already met the performance benchmark. The intervention was associated with varied changes to preventive and non-preventive dental services. More robust study design addressing the study limitations and validating the performance benchmark is required.

A Cost Analysis of an Outreach School-Based Dental Program: Teeth on Wheels.

BACKGROUND: This study evaluated an outreach mobile dental service called Teeth on Wheels (TOW). The dental program targeted Australian children from low household income, who are eligible for the Child Dental Benefits Scheme (CDBS) in Victoria, Australia. The program is complemented with a school-based oral health promotion element. METHODS: A retrospective cohort study was performed with a convenience sample. Children must have had at least three dental examinations during the 2016-2019 calendar years to be included in the study. Comparisons were made between the 2016-17 and 2018-19 calendar years. It was hypothesised that the program would result in reduced costs and the number of restorations and extractions in the latter period. RESULTS: A total of 414 children were included in the analysis. The total mean costs of the program per child reduced from AU$605.3 in 2016-17 to AU$531.1 in 2018-19. The results showed an overall mean reduction in all restorations and extractions performed, but only statistical significance was noted for reductions of restored deciduous teeth. CONCLUSIONS: This outreach program, which is focused on prevention and minimally invasive dentistry, can be a promising alternative model of delivery for dental services in young children.

A Validation and Cost-Analysis Study of a Targeted School-Based Dental Check-Up Intervention: Children's Dental Program.

BACKGROUND: Limited evidence exists to inform best practice approaches to implement school-based dental screening to address child retention via referral for dental services. This research tested the null hypothesis that a targeted school-based dental check-up program (intervention) has a 75% child retention rate for public dental care (H0 = 0.75). METHODS: A prospective non-randomised controlled trial was conducted with a convenience sampling approach in metropolitan Melbourne, Australia. Children in the intervention group were recruited from two preschools and two primary schools from a low socioeconomic area. Children in the standard care group were recruited from the local public dental service. Statistical analysis was performed using Stata IC Version 12. RESULTS: Children in the intervention (45%) were significantly less likely to have never had a dental check-up compared to standard care (20%) (p < 0.001). There was no significant difference for the child retention rate for the intervention group when compared against the null hypothesis (p = 0.954). The total society costs were AU$754.7 and AU$612.2 for the intervention and standard care groups, respectively (p = 0.049). CONCLUSIONS: This validation study provides evidence that a targeted school-based dental check-up program can achieve a 75% child retention rate and should be considered for program expansion.

A Markov cost-effective analysis of biannual fluoride varnish for preventing dental caries in permanent teeth over a 70-year time horizon.

ISSUE ADDRESSED: Biannual application of fluoride varnish is effective for dental caries prevention, but its cost-effectiveness using quality-adjusted life years (QALY) is unknown. This study performed a cost-effectiveness analysis, from the Australian health care system perspective of biannual application of fluoride varnish versus current practice (non-routine application) for an individual aged 15 years and older over a 70-year time horizon. METHODS: Health outcomes measured were the number of prevented decayed, missing, and filled teeth (prevented-DMFT) and QALY gained. The calculated incremental cost-effectiveness ratio (ICER) was compared against the reference cost-effectiveness ICER threshold of AUD$28 033 per QALY gained. A published Markov model capturing dental caries progression of eight permanent molars was used. This 6-monthly cycle model represented ten possible health states for an individual tooth. A 5% discount rate was applied with relevant sensitivity analysis. RESULTS: In the base-case scenario, the net cost for the intervention was $3600 compared to $2303 in the current practice arm. The intervention arm yielded 13.99 DMFT and 15.44 QALY gained, whereas the current practice arm yielded 15.52 DMFT and 14.74 QALY gained. The estimated ICER was $849 per prevented-DMFT and $1851 per QALY gained. Sensitivity analysis shows the ICER ranged from $424-$1807 per prevented-DMFT and $1851-$3941 per QALY gained. CONCLUSION: Biannual professional application of fluoride varnish appears to be a highly cost-effective strategy and should be considered for universal funding in Australia's health care system.

A dental workforce strategy to make Australian public dental services more efficient.

BACKGROUND: Dental services can be provided by the oral health therapy (OHT) workforce and dentists. This study aims to quantify the potential cost-savings of increased utilisation of the OHT workforce in providing dental services for children under the Child Dental Benefits Schedule (CDBS). The CDBS is an Australian federal government initiative to increase dental care access for children aged 2-17 years. METHODS: Dental services billed under the CDBS for the 2013-2014 financial year were used. Two OHT-to-dentist workforce mix ratios were tested: Model A National Workforce (1:4) and Model B Victorian Workforce (2:3). The 30% average salary difference between the two professions in the public sector was used to adjust the CDBS fee schedule for each type of service. The current 29% utilisation rate of the CDBS and the government target of 80% were modelled. RESULTS: The estimated cost-savings under the current CDBS utilisation rate was AUD 26.5M and AUD 61.7M, for Models A and B, respectively. For the government target CDBS utilisation rate, AUD 73.2M for Model A and AUD 170.2M for Model B could be saved. CONCLUSION: An increased utilisation of the OHT workforce to provide dental services under the CDBS would save costs on public dental service funding. The potential cost-savings can be reinvested in other dental initiatives such as outreach school-based dental check programmes or resource allocation to eliminate adult dental waiting lists in the public sector.

Neurosurgical Oncology in Vietnam.

BACKGROUND: In conjunction with Vietnam's unparalleled economic growth over the past 20 years, our scope of neurosurgical interventions has considerably diversified throughout this time period. METHODS: Although still appreciably limited, healthcare resources and infrastructure have expanded and shifted the focus within neurosurgery at Ho Chi Minh City's Cho Ray Hospital from head trauma (which remains highly prevalent) to an equal proportion of elective cases for vascular lesions, tumors, and degenerative spine disease. Arguably the most significant progress throughout the new millennium has been achieved in the realm of neurosurgical oncology. RESULTS: About 1000 craniotomies are performed annually for brain tumors at our institution, most of which are for lower-grade lesions that result in excellent surgical outcomes. We continue to strive to improve the standard of care for patients with malignant brain tumors, as the first multidisciplinary neuro-oncology care team was founded recently in 2016. CONCLUSIONS: This article is the first in the English neurosurgical literature to report on the current state and outcomes of neuro-oncology in Vietnam, as we highlight our experiences in caring for patients with brain tumors at Cho Ray Hospital.

Developing Professionalism in Dentistry: A Systematic Review.

This article was migrated. The article was marked as recommended. Background: Professionalism is a core competency and concern in all health professional education. Evidence from nursing and medicine suggests the evidence base for approaches to developing and assessing professionalism at undergraduate level is weak. In 2015, notifications, imposed sanctions, and in some cases de-registration against dental practitioners for reported incidences of breaches in infection control in New South Wales, Australia, have refreshed the essential need for dental practitioners to promote public safety and protection. Aim: To investigate the evidence for clinical education practice approaches to develop professionalism in dentistry. Methods: Relevant electronic databases were searched for full-text peer reviewed papers relating to dental practitioners published between 2000 and June 2016 in English. All research designs were included. Following initial and detailed screening, included papers were independently quality appraised and strength of evidence graded by two independent reviewers. Results: Removal of duplicates resulted in 195 unique papers; following screening 34 full text articles were assessed for eligibility resulting in 15 papers evaluated in this review. Eight different clinical education approaches were identified. Most studies were of low quality and reported low levels of educational outcomes based on Kirkpatrick's Hierarchy. There is a lack of good quality evidence to support any one approach to develop professionalism in dentistry. What evidence there is focuses on low level educational outcomes such as learners experience. Conclusions: Low level outcomes is common in educational research and therefore unsurprising. More disappointing was failure to adequately justify the methodology and the absence on the definition of dental professionalism. The research findings is consistent with the evidence across other health professions internationally. There is scope for an inter-professional approach to tackle the challenge developing and subsequently assessing professionalism.