Dental Policy Lab 2 - towards paying for health in dentistry.

The first Alliance for a Cavity-Free Future (ACFF)/King's College London Dental Policy Lab, held in 2017, identified the need for a review of dental payment systems in order to see progress towards achieving improvements in caries and cavities. The lack of incentivisation for preventive intervention and care has long been a barrier to progress. The second Dental Policy Lab, held in July 2018, focused on this issue with the overarching question: 'How can we create and implement acceptable prevention-based dental payment systems to achieve and maintain health outcomes?' Using a design approach and participatory research, 29 participants from five stakeholder categories developed a blueprint report that aims to serve as a framework to adapt or create remuneration systems that are compatible with evidence-based dentistry with a focus on preventive care. Aimed at policymakers and policy entrepreneurs, this blueprint provides guidance and potential solutions using several international examples. The report and accompanying infographic explored in this paper have been well received and have helped to frame discussions in several country settings, with a direct implementation which is being trialled in France in 2021.

Dental Policy Lab 1 - towards a cavity-free future.

Although many dental professionals argue that prevention of oral diseases, including dental caries, will benefit both the patient and public finances, a paradigm shift has yet to happen in most countries. The literature has demonstrated that caries prevention and control is possible, but authorities have yet to implement health systems that allow patients to stay in a good health state. 'Policy Labs' are an innovative policy-making initiative that allow a positive collaboration between the many stakeholders around a given policy issue. In July 2017, 24 international experts, including representatives of both international and European Chief Dental Officers associations, were gathered for the first Alliance for a Cavity-Free Future/King's College London Dental Policy Lab to identify the main barriers for a change, and concrete actions to facilitate a policy shift towards increased resource allocation in prevention. A comprehensive report and well-received infographic summarising the key recommendations (explored in this paper) were produced to explain the situation and highlight the value of a cavity-free world to policymakers, demonstrating where change is needed. The first Dental Policy Lab proved to be an efficient way to generate new ideas and concrete ways to implement them, and has led to several subsequent initiatives worldwide.

From 'ICDAS' to 'CariesCare International': the 20-year journey building international consensus to take caries evidence into clinical practice.

This paper charts the 20-year collaborative journey made by international teams of dental researchers, educators and practitioners. Following the initial development of the International Caries Detection and Assessment System (ICDAS) in 2002, the International Caries Classification and Management System (ICCMS) was collaboratively developed between 2010-2017 with several dental research and practice organisations, and influenced by best evidence judged via SIGN methodology, the UNEP Minamata Treaty (and linked phasing down of dental amalgam), three Dental Policy Labs and an international movement in operative dentistry to move towards minimally invasive dentistry. The FDI World Dental Federation publicised and advocated the ICCMS in 2019, when the 'CariesCare International' Consensus Guide and 4D caries management system was published to aid the delivery of ICCMS into practice. This system, which is designed to help practitioners deliver optimal caries care for patients, is now being adapted internationally for post-pandemic use in the 'Caries OUT' study. It is also being used as a vehicle for implementing the updated Delivering better oral health guidance on caries, as part of the minimum intervention oral healthcare delivery framework in the UK.

Application of recommended preventive measures against COVID-19 could help mitigate the risk of SARS-CoV-2 infection during dental practice: Results from a follow-up survey of French dentists.

BACKGROUND: During the first-wave of the COVID-19 pandemic, dentists were considered at high-risk of infection. In France, to stop the spread of SARS-CoV-2, a nationwide lockdown was enforced, during which dentists suspended their routine clinical activities, working solely on dental emergencies. This measure has had an indisputable mitigating effect on the pandemic. To continue protecting dentists after suspension of nationwide lockdown, implementation of preventive measures was recommended, including adequate personal protective equipment (PPE) and room aeration between patients. No study has explored whether implementation of such preventive measures since the end of the first-wave has had an impact on the contamination of dentists. METHODS: An online survey was conducted within a French dentist population between July and September 2020. To explore risk factors associated with COVID-19, univariate and multivariate logistic regression analyses were performed. RESULTS: The results showed that COVID-19 prevalence among the 3497 respondents was 3.6%. Wearing surgical masks during non-aerosol generating procedures was a risk factor of COVID-19, whereas reducing the number of patients was a protective factor. CONCLUSIONS: Considering the similar COVID-19 prevalence between dentists and the general population, such data suggest that dentists are not overexposed in their work environment when adequate preventive measures are applied. IMPACT: Dentists should wear specific PPE (FFP2, FFP3 or (K)N95 masks) including during non-aerosol generating procedures and reduce the number of patients to allow proper implementation of disinfection and aeration procedures. Considering the similarities between COVID-19 and other viral respiratory infections, such preventive measures may also be of interest to limit emerging variants spread as well as seasonal viral outbreaks.

Prevalence and risk indicators of first-wave COVID-19 among oral health-care workers: A French epidemiological survey.

BACKGROUND: Previous studies have highlighted the increased risk of contracting the COVID-19 for health-care workers and suggest that oral health-care workers may carry the greatest risk. Considering the transmission route of the SARS-CoV-2 infection, a similar increased risk can be hypothesized for other respiratory infections. However, no study has specifically assessed the risk of contracting COVID-19 within the dental profession. METHODS: An online survey was conducted within a population of French dental professionals between April 1 and April 29, 2020. Univariable and multivariable logistic regression analyses were performed to explore risk indicators associated with laboratory-confirmed COVID-19 and COVID-19-related clinical phenotypes (i.e. phenotypes present in 15% or more of SARS-CoV-2-positive cases). RESULTS: 4172 dentists and 1868 dental assistants responded to the survey, representing approximately 10% of French oral health-care workers. The prevalence of laboratory-confirmed COVID-19 was 1.9% for dentists and 0.8% for dental assistants. Higher prevalence was found for COVID-19-related clinical phenotypes both in dentists (15.0%) and dental assistants (11.8%). Chronic kidney disease and obesity were associated with increased odds of laboratory-confirmed COVID-19, whereas working in a practice limited to endodontics was associated with decreased odds. Chronic obstructive pulmonary disease, use of public transportation and having a practice limited to periodontology were associated with increased odds of presenting a COVID-19-related clinical phenotype. Moreover, changes in work rhythm or clinical practice were associated with decreased odds of both outcomes. CONCLUSIONS: Although oral health-care professionals were surprisingly not at higher risk of COVID-19 than the general population, specific risk indicators could exist, notably among high aerosol-generating dental subspecialties such as periodontology. Considering the similarities between COVID-19-related clinical phenotypes other viral respiratory infections, lessons can be learned from the COVID-19 pandemic regarding the usefulness of equipping and protecting oral health-care workers, notably during seasonal viral outbreaks, to limit infection spread. IMPACT: Results from this study may provide important insights for relevant health authorities regarding the overall infection status of oral health-care workers in the current pandemic and draw attention to particular at-risk groups, as illustrated in the present study. Protecting oral health-care workers could be an interesting public health strategy to prevent the resurgence of COVID-19 and/or the emergence of new pandemics.

2018 French dental contracts: On the road to achieving universal dental health coverage?

Following the failure of earlier negotiations, the new French Government decided not to go ahead with a unilateral decision to define fees in the dental contracts, and to reopen the negotiations. This in a bid to satisfy the providers' requests, as well as to negotiate Emmanuel Macron's presidential campaign promise of no out-of-pocket expenses on dental prosthetics. The three stakeholders, the National Health Insurance System, Dental Trade Unions and Complementary Health Insurers, started another round of negotiations which lead to an agreement. This new convention, which will be phased in from the 1 st of April 2019, will exclude 90 % of dental procedures from out-of pocket payments for patients. Though economic models were controversial between the stakeholders, this reform is likely to engage France in a system where the dental medical divide is narrowing, quasi-universal dental coverage is achieved and policy making processes are adaptable to the evolution of evidence-based medicine and economic realities. This reform, supported by more than 95 % of the French population, is likely to serve as an example for its impact on: political campaigns; the role of comprehensive data collection systems; economic models; and adaptive policies in order to overcome barriers to reforms.

The highly controversial payment reform of dentists in France: Seeking a new compromise after the 2017 strike.

France possesses a mixed public-private oral health system with no out of pocket payments for most routine dental treatments. The "Convention" regulates tariffs between the elected dental trade unions, the National Health Insurance and Complimentary Health Insurers. It is periodically revised and negotiated by the three parties in order to introduce new procedures, improve the access to dental care of the population and to adjust procedure costs for inflation. At the beginning of the last negotiations in September 2016 health minister Marisol Touraine introduced a new legal procedure, the Arbitrary Judgment, which came into force if the Dentists failed to agree to the NHI's propositions. These propositions included setting caps on most of the previously unregulated dental prosthetics and a global price ceiling on the whole dental market. This sparked a nationwide strike of the profession, a blockade of all 16 Dental Schools and several national protests. This movement raised nationwide debates regarding the access to dental treatments, preventive care and out of pocket payments for patients. The political tensions generated between the stakeholders, as well as the lack of both robust epidemiological and economic data challenges the ability of this policy making process to produce comprehensive, evidence based and economically sustainable reforms.