Comparison of potential long-term costs for preventive dentistry treatment of post-orthodontic labial versus lingual enamel cavitations and esthetically relevant white-spot lesions: a simulation study with different scenarios.

BACKGROUND: Post-orthodontic white-spot lesions (WSL) in esthetically relevant incisor and canine areas impair dentofacial esthetics, and preventive dentistry treatment is definitely required in case of enamel cavitations. The incidence of lingual post-orthodontic WSL and cavitation following lingual MB treatment has been reported to be distinctively decreased compared to labial MB treatment. Moreover, lingual WSL do not impair dentofacial esthetics. It was the objective of this study to calculate consequential costs of preventive dental care necessary to recover labial or lingual post-orthodontic cavitations as well as esthetically relevant WSL following either labial or lingual MB interventions. METHODS: MB treatments (labial / lingual) were simulated in 1,000,000 patients between the ages of 12-18Y, with a median residual life time expectancy of 58Y based on local mortality tables. Range of MB Tx duration was 9-45 mo. Frequencies of post-orthodontic (labial / lingual) enamel damages were derived from large-scale WSL incidence studies. Anterior composite survival rates were based on a systematic review on the subject. Within the context of the German dental fee system (GOZ 2.3 and 3.5 fee increments), simulation of costs for enamel damage treatment and re-treatment (maximum: 5x) were based on single-surface composite restorations for lingual or labial cavitations and labial WSL treatment; and lingual WSL fluoridation. RESULTS: Overall mean total costs for Tx and re-Tx of both WSLs and cavitations may sum up to 1718.91 Eur in the high-cost (GOZ 3.5) scenario for conventional MB cases, versus 19.94 Eur for lingually treated cases, given that renewal of simulated single-surface restorations takes place at 15-year intervals. When focussing on patients diagnosed with least of one WSL, and/or cavitation, these mean costs increase up to 2332.35 Eur for conventionally treated MB patients, or 65.03 Eur for lingual MB patients. CONCLUSION: Costs for repeated treatment of post-orthodontic enamel damages produced by conventional vestibular fixed appliances may easily exceed the initially higher costs associated with lingual orthodontic treatment. Judged economically in the long term, lingual MB Tx may be considered as a more cost-effective solution for a correction of malocclusion.

[Opinions about oral care: an online questionnaire among readers of NTvT]. / Meningen over mondzorg: een online-onderzoek onder NTVT-lezers.

By means of a brief online questionnaire with 12 statements about the organisation, quality and impact of oral care in the Netherlands, the readers of the Netherlands Journal of Dentistry (NTVT) were asked to express their opinions on a number of important subjects concerning oral care in the Netherlands with respect to health economic matters. A total of 237 readers (61% men, 39% women) completed the online questionnaire. 70% of them were working as dentists and had been active in a practice for between 31 and 40 years. According to the study, a shift from curing to prevention was considered to be necessary. Most of the respondents also thought inequality in oral health in the Netherlands is increasing and people avoid going to the dentist due to the associated costs. In conclusion, most oral care providers appear to be reasonably positive about Dutch oral care. Attention for prevention, appreciation of oral health and the reduction of inequality in oral care continue to be necessary.

Distribution of Preventive Dental Care during Pregnancy in Rhode Island, 2012 to 2015.

AIMS: To examine the distribution of preventive dental care for pregnant women in Rhode Island. METHODS: The data used were obtained from the 2012 to 2015 Rhode Island Pregnancy Risk Assessment Monitoring System (RIPRAMS). Statistical analyses were conducted for respondents who had valid information for both preventive dental care receipt and race/ethnicity to examine population differences in the receipt of preventive dental care. RESULTS: Respondents who identified as Hispanic and had more than 12 years of education had higher odds for preventive dental care receipt in Rhode Island between 2012 to 2015 compared to non-Hispanic whites. Furthermore, respondents with lower household income were the least likely to have received preventive dental care. This was especially true for black and non-Hispanic women who reported being neither black nor white. CONCLUSION: Preventive dental care in Rhode Island between 2012 and 2015 did not meet the perinatal and Infant Oral Health Quality Improvement (PIOHQI) target of 60% in minority populations.

Estimating the Cost Savings of Preventive Dental Services Delivered to Medicaid-Enrolled Children in Six Southeastern States.

OBJECTIVE: To quantify the impact of multiyear utilization of preventive dental services on downstream dental care utilization and expenditures for children. DATA SOURCES/STUDY SETTING: We followed 0.93 million Medicaid-enrolled children who were 3-6 years old in 2005 from 2005 to 2011. We used Medicaid claims data of Alabama, Georgia, Mississippi, North Carolina, South Carolina, and Texas. STUDY DESIGN: We clustered each state's study population into four groups based on utilization of topical fluoride and dental sealants before caries-related treatment using machine learning algorithms. We evaluated utilization rates and expenditures across the four groups and quantified cost savings of preventive care for different levels of penetration. DATA EXTRACTION METHOD: We extracted all dental-related claims using CDT codes. PRINCIPAL FINDINGS: In all states, Medicaid expenditures were much lower for children who received topical fluoride and dental sealants before caries development than for all other children, with a per-member per-year difference ranging from $88 for Alabama to $156 for Mississippi. CONCLUSIONS: The cost savings from topical fluoride and sealants across the six states ranged from $1.1M/year in Mississippi to $12.9M/year in Texas at a 10 percent penetration level. Preventive dental care for children not only improves oral health outcomes but is also cost saving.

Socioeconomic inequality in the provision of specific preventive dental interventions among children in the UK: Children's Dental Health Survey 2003.

Aim To assess socioeconomic inequality regarding specific preventive interventions (fissure sealants or any treatment to prevent caries) and dental visits among UK children.Method Data were from the Children's Dental Health Survey 2003, which included participants from England, Wales, Scotland, and Northern Ireland. The number of children in the analysis was 2,286. Variables were sex, age, area of residency (for example, England), mother's education, family social class, and deprivation level. Descriptive and regression analyses were performed.Results There were no significant socioeconomic differences in the use of preventive services. Deprivation and family social class (for example, intermediate and manual) were significantly associated with less regular dental visits (odd ratio 0.41, 95% CI [0.28, 0.63]; odd ratio 0.53, 95% CI [0.31, 0.89]; odd ratio 0.37, 95% CI [0.24, 0.58], respectively). Regular dental visits were associated with reporting preventive care for caries (odds ratio 2.25, 95% CI [1.45, 3.49]) and with the number of sealed tooth surfaces (rate ratio 1.73, 95% CI [1.16, 2.60]).Conclusion Despite apparent socioeconomic inequalities in regular dental visits, there was no significant inequality in using specific preventive interventions by children in the UK. This finding should be interpreted with caution considering the relatively small subsample included in this analysis.

The cost-effectiveness of three interventions for providing preventive services to low-income children.

OBJECTIVE: We evaluated the impact of loan repayment programmes, revising Medicaid fee-for-service rates, and changing dental hygienist supervision requirements on access to preventive dental care for children in Georgia. METHODS: We estimated cost savings from the three interventions of preventive care for young children after netting out the intervention cost. We used a regression model to evaluate the impact of changing the Medicaid reimbursement rates. The impact of supervision was evaluated by comparing general and direct supervision in school-based dental sealant programmes. RESULTS: Federal loan repayments to dentists and school-based sealant programmes (SBSPs) had lower intervention costs (with higher potential cost savings) than raising the Medicaid reimbursement rate. General supervision had costs 56% lower than direct supervision of dental hygienists for implementing a SBSP. Raising the Medicaid reimbursement rate by 10 percentage points would improve utilization by <1% and cost over $38 million. Given one parameter set, SBSPs could serve over 27 000 children with an intervention cost between $500 000 and $1.3 million with a potential cost saving of $1.1 million. Loan repayment could serve almost 13 000 children for a cost of $400 000 and a potential cost saving of $176 000. CONCLUSIONS: The three interventions all improved met need for preventive dental care. Raising the reimbursement rate alone would marginally affect utilization of Medicaid services but would not substantially increase acceptance of Medicaid by providers. Both loan repayment programmes and amending supervision requirements are potentially cost-saving interventions. Loan repayment programmes provide complete care to targeted areas, while amending supervision requirements of dental hygienists could provide preventive care across the state.

Increased public reimbursement for prophylactic visits with dentists associated with increased receipt of preventive dental services in children.

OBJECTIVE: To determine whether higher reimbursement for children's preventive dentistry correlates with greater utilization of preventive dental care. METHODS: A cross-sectional analysis of National Survey of Children's Health 2011/2012 was conducted, combined with state Medicaid reimbursement rates for preventive dentistry. Analyses included prevalence, unadjusted odds ratios, and multivariable logistic regression for receipt of preventive dental services. RESULTS: Of all surveyed American children 1-17 years, almost 20 percent had not received preventive dental care in prior year; this percentage is even higher in those with public insurance. Each $10 increase in state reimbursement was associated with a 17 percent decrease in odds of children not receiving preventive services. CONCLUSIONS: Higher state reimbursement for preventive services may increase children's receipt of preventive dental care.

Provision of Preventive Dental Services in Children Enrolled in Medicaid by Nondental Providers.

OBJECTIVES: Aims of this study are to determine (1) the association of oral health services (OHS) provided by nontraditional providers with the percentage of Medicaid children 0 to 5 years of age who receive ≥1 preventive services from all provider types in the United States; and (2) characteristics of state Medicaid policies associated with provision of OHS. METHODS: We conducted a time-series cross-sectional study of preventive services provided by nontraditional (OHS) and dental (PDS) providers for Medicaid-enrolled children from birth to 5 years of age in all states during 2010 to 2013 (204 observations). We applied panel data multiple regression analysis techniques to exploit year and state variation in aggregate data available in Centers for Medicare and Medicaid Services reports (form CMS-416). Total preventive dental services (TPDS =OHS + PDS) was predicted by months since state enactment of a policy to reimburse medical providers for OHS. RESULTS: The 44 states with a policy reported 4.3% of children per state per year with any OHS. For all states, an average of 30.1% received PDS and 34.5% TPDS. The delivery of OHS was associated with a small increase in percentage with TPDS. One year of Medicaid OHS availability was associated with an increase of 1.5% in the percentage of children with TPDS per state per year. CONCLUSIONS: Implementation of policies by Medicaid programs to support integration of OHS into primary care is associated with increases in overallTPDS use, but efforts are needed to improve implementation in practice to achieve national impact on access.

Economic Models of Preventive Dentistry for Australian Children and Adolescents: A Systematic Review.

PURPOSE: To identify economic evaluation models and parameters that could be replicated or adapted to construct a generic model to assess cost-effectiveness of and prioritise a wide range of community-based oral disease prevention programmes in an Australian context. METHODS: The literature search was conducted using MEDLINE, ERIC, PsycINFO, CINHAL (EBSCOhost), EMBASE (Ovid), CRD, DARE, NHSEED, HTA, all databases in the Cochrane library, Scopus and ScienceDirect databases from their inception to November 2012. RESULTS: Thirty-three articles met the criteria for inclusion in this review (7 were Australian studies, 26 articles were international). Existing models focused primarily on dental caries. Periodontal disease, another common oral health problem, was lacking. Among caries prevention studies, there was an absence of clear evidence showing continuous benefits from primary through to permanent dentition and the long-term effects of oral health promotion. CONCLUSION: No generic model was identified from previous studies that could be immediately adopted or adapted for our purposes of simulating and prioritising a diverse range of oral health interventions for Australian children and adolescents. Nevertheless, data sources specified in the existing Australian-based models will be useful for developing a generic model for such purposes.

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.

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.

Paying for prevention in clinical practice: Aligning provider remuneration with system objectives.

Evidence on the efficacy of preventive procedures in oral health care has not been matched by uptake of prevention in clinical practice. Reducing oral disease in the population reduces the size of the future market for treatment. Hence a provider's intention to adopt prevention in clinical practice may be offset by the financial implications of such behaviour. Effective prevention may therefore depend upon prevention-friendly methods of remuneration if providers are to be rewarded appropriately for doing what the system expects them to do. This paper considers whether changing the way providers are paid for delivering care can be expected to change the utilisation of preventive care in the population in terms of the proportion of the population receiving preventive care, the distribution of preventive care in the population and the pattern of preventive care received. A conceptual framework is presented that identifies the determinants of rewards under different approaches to provider remuneration. The framework is applied to develop recommendations for paying for prevention in clinical practice. Literature on provider payment in dental care is reviewed to assess the evidence base for the effects of changing payment methods, identify gaps in the evidence-base and inform the design of future research on dental remuneration.

Cost-Benefit Analysis of the Age One Dental Visit for the Privately Insured.

PURPOSE: The purpose of this study was to perform a cost-benefit analysis of the age one dental visit for privately insured patients. METHODS: A major insurance company provided claims from various states submitted between 2006-2012. Data provided included numbers of procedures and respective costs from the first visit until age six years. Data was organized into five groups based on age, for which the first D0145/D0150 code was submitted [(1) age younger than one year old; (2) age one or older but younger than two years old; (3) age two or older but younger than three years old; (4) age three or older but younger than four years old; and (5) age four or older but younger than five years old]. The ratio of procedures per child and average costs per child were calculated. RESULTS: Claims for 94,574 children were analyzed; only one percent of these children had their first dental visit by age one. The annual cost for children who had their first dental visit by age one was significantly less than for children who waited until an older age. CONCLUSION: There is an annual cost benefit in establishing a dental home by age one for privately insured patients.

Relative cost-effectiveness of home visits and telephone contacts in preventing early childhood caries.

OBJECTIVES: To evaluate the cost-effectiveness of a home-visit intervention conducted by oral health therapists relative to a telephone-based alternative and no intervention. METHODS: A Markov model was built to combine data on dental caries incidence, dental treatments, quality of life and costs for a cohort of children from age 6 months to 6 years. The probabilities of developing caries and subsequent treatments were derived primarily from the key intervention study. The outcome measures were costs (US dollars), quality-adjusted life years (QALYs) and the number of carious teeth prevented. One-way and probabilistic sensitivity analyses were used to test the stability of the model. RESULTS: For every group of 100 children, the model predicted that having the home-visit intervention would save $167 032 and telephone contacts $144 709 over 5½ years relative to no intervention (usual care). The home visits and telephone intervention would prevent 113 and 100 carious teeth (per 100 children) relative to no intervention in a period of 5½ years. Sensitivity analysis showed that a lower rate of caries reduced the intervention's cost-effectiveness primarily through reducing general anaesthesia costs. The home visits and telephone interventions resulted in 7 and 6 QALYs, respectively, gained over the usual care group for the 100 children over 5½ years. Both interventions were 'dominant,' as they saved costs and produced health benefits over usual care. CONCLUSIONS: Both the home visits and telephone-based community interventions conducted by oral health therapists were highly cost-effective than no intervention in preventing early childhood caries.

Business Barriers and Opportunities for Transforming to Preventive Care to Treat Early Childhood Caries.

Primary, secondary, and tertiary preventive dental services have the potential for achieving the triple aim of better health outcomes for populations, better patient experience of care, and lower per capita costs. Yet, maximization of preventive services has not occurred in dental practice nor been promoted by dental plans. While the lack of such things as diagnostic codes, caries classification systems, and validated risk assessment tools are barriers to increasing preventive care, they may not be the primary barriers that need to be addressed. The purpose of this paper was to focus on three issues: (1) the dental care business model based on a value proposition of surgical care rather than preventive care; (2) the benefit plan design that undervalues or does not cover effective primary, secondary, and tertiary preventive services; and (3) the current financial crisis in health care. It is the business model of dental practice and the benefit design of payers that are the biggest barriers that will have to change to transform dental care into a more effective and efficient means of achieving and maintaining health.

A new dental insurance scheme--effects on the treatment provided and costs.

The aim of this study was to investigate whether the revenues cover the costs in a pilot capitation plan, a dental insurance scheme, and to compare this capitation plan (CP) with the original fee-for-service system (FFS), in terms of the amount and type of dental care provided. Data was collected longitudinally over a period of three years from 1,650 CP patients in five risk groups at a test clinic, and from 1,609 (from the test clinic) and 3,434 (from a matched control clinic) FFS patients, in Göteborg, Sweden. The care investigated was the number of total treatments provided and the number of examinations by dentists and dental hygienists, together with preventive, restorative and emergency treatments. The economic outcome was positive from the administrator's perspective, in all risk groups for the three-year period. The amount and type of care provided differed between the payment models, as CP patients received more preventive treatments, less restorative treatments, and more examinations by dental hygienists than the FFS patients. Emergency treatment was performed more often on CP patients, and the difference was due to a higher frequency of such treatments among women in the CP group. The difference between clinics concerning certain treatment measures was sometimes greater than the difference between payment models. The results from this study indicate a net positive economic outcome for the pilot CP system over three years. The payment model and the clinic affiliation had impact on what type and amount of dental care the patients received. This might suggest that the risk of skewed selection and its consequences as well as the influence of clinic-specific practice need further investigation, to ensure economic sustainability in a longer perspective.

Extending oral health care services to underserved children through a school-based collaboration: Part 3--A cost analysis.

PURPOSE: The purpose of this manuscript was to conduct a cost analysis of the Miles of Smiles Program, a collaboration between the University of Missouri-Kansas City School of Dentistry and the Olathe School District in Kansas. This preventive program was implemented to improve the access to oral health care for low income children within the school district. METHODS: An inventory list and de-identified patient records were used to determine the costs associated with operating the program to serve 339 elementary school students during the 2008 to 2009 school term. Costs related to equipment, supplies and personnel were included. The costs were then compared to the amount of Medicaid reimbursement obtained for the services provided. Additionally, the cost of operating a similar program, if staffed by dental professionals rather than supervised dental hygiene students, was estimated. RESULTS: The cost of operating the program during the 2008 to 2009 school term was $107,515.74. The program received Medicaid reimbursement for approximately 1.5% of the total operating cost of and approximately 6.3% of the total billable services, however, challenges with submitting and billing Medicaid claims for the first time contributed to this low rate of reimbursement. If a similar program that utilized dental professionals was implemented and treated the same number of patients, the cost would be approximately $37,529.65 more due to higher expenses associated with personnel and supplies. CONCLUSION: The program is not self-sustainable based on Medicaid government-funded insurance reimbursement alone, and therefore continuous external sources of funding or a change in the program design would be necessary for long-term sustainability of the program.