Cost-effectiveness of non-surgical periodontal therapy for patients with type 2 diabetes in the UK.

AIM: Periodontal therapy has been shown to reduce glycated haemoglobin in patients with diabetes, although considerable uncertainty remains regarding the sustainability of such changes. We evaluate the cost-effectiveness of non-surgical periodontal therapy and rigorous maintenance treatment in patients with type 2 diabetes and periodontitis from a provider perspective in the UK. METHOD: Lifetime costs relating to periodontal treatment were modelled for a cohort of patients with type 2 diabetes. The projected lifetime impact of changes in glycated haemoglobin on diabetes treatment costs and quality adjusted life expectancy were estimated from a published simulation model. Costs and outcomes were combined to estimate the Incremental Cost-Effectiveness Ratio for periodontal therapy in patients with type 2 diabetes. RESULTS: The Incremental Cost-Effectiveness Ratio was £28,000 per Quality Adjusted Life-Year for a man aged 58 with glycated haemoglobin of 7%-7.9%. The results were particularly sensitive to assumptions on the impact of periodontal therapy on glycated haemoglobin, the proportion of patients who comply with maintenance therapy and the proportion of compliant patients who respond to treatment. CONCLUSION: Assuming improvements in glycated haemoglobin can be maintained, periodontal therapy may be cost-effective for patients with type 2 diabetes at acceptable cost-per-Quality Adjusted Life-Year thresholds in the UK.

Social disparities in dental insurance and annual dental visits among medically insured patients with diabetes: the Diabetes Study of Northern California (DISTANCE) Survey.

INTRODUCTION: People with diabetes are at increased risk of periodontal disease and tooth loss. Healthy People 2010 set a goal that 71% or more of people with diabetes should have an annual dental exam. METHODS: We assessed dental insurance and annual dental visits among dentate respondents from the Diabetes Study of Northern California (DISTANCE) Survey cohort (N = 20,188), an ethnically stratified, random sample of patients with diabetes aged 30 to 75 years receiving medical care from Kaiser Permanente Northern California. We calculated predicted probabilities for an annual dental visit (PPADV) by using regression models that incorporated age, sex, education level, annual household income, and self-reported race/ethnicity, stratified by whether the respondent had dental insurance. RESULTS: Among 12,405 dentate patients, 9,257 (75%) had dental insurance. Annual dental visits were reported by 7,557 (82%) patients with dental insurance and 1,935 (61%) patients without dental insurance. The age-sex adjusted odds ratio for an annual dental visit was 2.66 (95% confidence interval, 2.33-3.03) for patients with dental insurance compared to those without dental insurance. For patients with dental insurance, the PPADV was 71% or more for all except those with the lowest household income. In contrast, for those without dental insurance, the PPADV was less than 71% for all except those with the most education or the highest income. We found some racial/ethnic subgroups were more likely than others to take advantage of dental insurance to have an annual dental visit. CONCLUSION: Patients with diabetes in this managed care population who lacked dental insurance failed to meet the Healthy People 2010 goal for an annual dental visit. An increased effort should be made to promote oral health among people with diabetes.

Dental economics and the aging population.

In 2011, the oldest segment of the baby boom generation will be 65 years of age, marking the beginning of an important demographic shift for dentistry. As seniors, boomers will continue to need dental care, more than previous cohorts of seniors. However, many may lack the means to fully finance their dental care. With the associations between oral and systemic health becoming clearer, dental practitioners will become increasingly involved in promoting their patients' overall health. This article reviews recent trends and projections in dental spending and how an aging population may impact clinical practice and dental business operations.

Special Care Dentistry Association consensus statement on sedation, anesthesia, and alternative techniques for people with special needs.

Many people with special needs (PSN) have difficulty having good oral health or accessing oral health services because of a disability or medical condition. The number of people with these conditions living in community settings and needing oral health services is increasing dramatically due to advances in medical care, deinstitutionalization, and changing societal values. Many of these individuals require additional supports beyond local anesthesia in order to receive dental treatment services. The purpose of this consensus statement is to focus on the decision-making process for choosing a method of treatment or a combination of methods for facilitating dental treatment for these individuals. These guidelines are intended to assist oral health professionals and other interested parties in planning and carrying out oral health treatment for PSN. Considerations for planning treatment and considerations for each of several alternative modalities are listed. Also discussed are considerations for the use of combinations of modalities and considerations for the repeated or frequent use of these modalities. Finally, the need to advocate for adequate education and reimbursement for the full range of support alternatives is addressed. The Special Care Dentistry Association (SCDA) is dedicated to improving oral health and well being of PSN. The SCDA hopes that these guidelines can help oral health professionals and other interested individuals and groups to work together to ensure that PSN can achieve a "lifetime of oral health."

A review of guidelines for sedation, anesthesia,and alternative interventions for people with special needs.

There are significant numbers of people in our society with disabilities or other special needs. Their number and percentage are growing, in some cases, dramatically. Many of these individuals need special support in order to receive dental treatment. Modalities that can be used to provide dental treatment include pharmacological approaches to produce various levels of sedation or anesthesia. In addition to the use of medications, there are also techniques that employ behavioral or psychological interventions. In some circumstances, physical support or protective stabilization is used. There are also social supports and prevention strategies that can impact the individual's preparation for and need for dental treatment. This review of the numerous guidelines, which have been published for the use of sedation and anesthesia to facilitate the delivery of dental treatment, indicates that there are fewer guidelines for the inclusion of behavioral or psychological interventions or for the incorporation of social supports or prevention strategies. In addition, most published guidelines do not include considerations for people with special needs. There is a need for increased research and documentation of combined treatment modalities, and these combined approaches need to be incorporated into guidelines for patient care for people with special needs. There is also a need to advocate for reimbursement systems that support all appropriate treatment options so that practitioners can be free to recommend treatment options based on the efficacy and safety of each option.

Provision of dental services in a dedicated clinic for HIV infected people in Greece.

OBJECTIVES: An observational study was carried out in order to describe the experience gained from the establishment of a dedicated dental clinic for HIV-infected people in Athens, Greece. METHODS: Data were collected retrospectively from the files of HIV-seropositive individuals attending the dedicated clinic for a period of seven years (1997-2003) and included the following variables: demographic characteristics, transmission route of HIV disease, oral lesions, general health concerns, dental visiting behavior before and after HIV-disclosure and dental procedures, carried out during the study period. RESULTS: The study patients comprised 426 HIV-seropositive individuals; 355 male (83%), 71 female (17%), mean age 40 years (range 17-76). The predominant mode of acquisition of HIV infection was sexual contact (88.5%), followed by intravenous drug abuse (3.8%), blood transfusion (2.5%) and vertical transmission (0.3%). Most of the patients attended the dedicated clinic because of direct/indirect denial of treatment by their dentist (29.1%), fear of attending their dentist (20.6%), financial constraints (17.5%), or because they were seeking specialized services (2.4%). Nearly half of the patients (46%), after they have been informed about their HIV-seropositivity, either did not attend their dentist, or did not disclose their HIV-status when they did attend. The type of 4688 dental procedures carried out during the study period, were the same as those performed in any general dental practice, without exhibiting increased risk of post-treatment complications. Finally, a relatively low overall incidence (41%) of oral lesions was observed, due to the effect of the highly active anti-retroviral therapy (HAART). CONCLUSIONS: Dedicated dental clinics can play a supplementary, but substantial role in the overall management of people whose HIV-status, or HIV-related clinical problems may prevent them from obtaining treatment from general dental practitioners within Greece.

Improving oral health for individuals with special health care needs.

The purpose of this paper was to highlight information and issues raised in a keynote address for the American Academy of Pediatric Dentistry's Symposium on Lifetime Oral Health Care for Patients with Special Needs held in November, 2006. Topics include: (1) relevant statistics and definitions; (2) the prevalence and impact of common oral diseases in individuals with special health care needs (ISHCN); (3) an overview of oral health care delivery for ISHCN; (4) key delivery system and policy issues; and (5) a synopsis of major contextual initiatives related to ISHCN. In light of the Academy's primary interest in infants, children, and adolescents--including children with special health care needs--the major focus is on children. Significant oral health and oral health care issues for adults with special needs, however, generally parallel those for children and are of interest to the Academy, particularly as they relate to the transition from pediatric care to adult care, a critical period for extending the level of oral health and health trajectory established during childhood.

Congenital diseases and a New York State regulation. Help is here.

Knowledge of a little known New York State regulation and its insurance implications can be used to provide dental benefits to people who have congenital diseases or anomalies. An explanation of the regulation is provided, and some of the more common congenital diseases that may affect the dentition, such as amelogenesis imperfecta, dentinogenesis imperfecta, ectodermal dysplasia, cleft lip/palate and trisomy 21, are reviewed.

A comparison of costs in providing dental care for special needs patients under sedation or general anaesthesia in the North East of England.

OBJECTIVE: To compare the costs of providing dental treatment under general anaesthesia or sedation for special needs patients. METHODS: After a Delphi exercise, a questionnaire was designed, piloted and then sent to nine NHS Trust dental service managers, within the Salaried Dental Services in the North East of England, to obtain information on the costs incurred during the treatment of special needs patients using sedation or general anaesthesia. The questionnaire related to the average number of such patients treated per session, staff costs, depreciation cost for buildings and equipment, and overhead costs including consumables and drugs. RESULTS: All nine dental service managers returned completed questionnaires. The all-inclusive cost for treatment per patient under general anaesthesia ranged from 203.65-479.50 pounds (mean cost: 285.79 pounds) and for sedation from 57.60-153.50 pounds (mean cost: 90.81 pounds). On average three special needs patients were treated per session. The greatest variation in the costs for general anaesthesia was due to staffing costs, which ranged from 1064.10 to 350.00 pounds per session across the Trusts. CONCLUSIONS: In the small number of centres sampled, the cost of delivering dental care under sedation or general anaesthesia was shown to vary widely. Overall, the mean cost of sedation was one-third that of general anaesthesia. However, the cost of both was substantial and cognisance needs to be taken of the costs of such services.

Use of dental care by HIV-infected medical patients.

Although increasing attention has been paid to the use of dental care by HIV patients, the existing studies do not use probability samples, and no accurate population estimates of use can be made from this work. The intent of the present study was to establish accurate population estimates of the use of dental services by patients under medical care. The study, part of the HIV Cost and Services Utilization Study (HCSUS), created a representative national probability sample, the first of its kind, of HIV-infected adults in medical care. Both bivariate and logistic regressions were conducted, with use of dental care in the preceding 6 months as the dependent variable and demographic, social, behavioral, and disease characteristics as independent variables. Forty-two percent of the sample had seen a dental health professional in the preceding 6 months. The bivariate logits for use of dental care show that African-Americans, those whose exposure to HIV was caused by hemophilia or blood transfusions, persons with less education, and those who were employed were less likely to use dental care (p < 0.05). Sixty-five percent of those with a usual source of care had used dental care in the preceding 6 months. Use was greatest among those obtaining dental care from an AIDS clinic (74%) and lowest among those without a usual source of dental care (12%). We conclude that, in spite of the high rate of oral disease in persons with HIV, many do not use dental care regularly, and that use varies by patient characteristics and availability of a regular source of dental care.

State of the evidence base for medically necessary oral health care.

OBJECTIVE: The purpose of this article was to highlight the recent call for an evidence-based approach to public policy decision making with respect to funding dental services and the need this creates for enhanced clinical research activities. STUDY DESIGN: Systematic reviews on topics of importance to oral health care practitioners are being conducted and published by various national and international groups. Recent activities to assess evidence to support medically necessary dental services were reviewed. RESULTS: An Institute of Medicine Committee on Medicare Coverage Extensions found little published scientific evidence that directly assessed the effectiveness of dental services in preventing or managing systemic health outcomes for patients with head and neck cancer, lymphoma, leukemia, organ transplantation, and heart valve repair or replacement. CONCLUSIONS: The scientific community must strive to meet the challenge of conducting well-designed randomized, controlled trials that test the impact of dental treatment interventions on systemic health to meet the growing need for evidence to support or refute widely accepted dental treatment protocols for medically complex patients.

Extending Medicare coverage to medically necessary dental care.

BACKGROUND: Periodically, Congress considers expanding Medicare coverage to include some currently excluded health care services. In 1999 and 2000, an Institute of Medicine committee studied the issues related to coverage for certain services, including "medically necessary dental services." METHODS: The committee conducted a literature search for dental care studies in five areas: head and neck cancer, leukemia, lymphoma, organ transplantation, and heart valve repair or replacement. The committee examined evidence to support Medicare coverage for dental services related to these conditions and estimated the cost to Medicare of such coverage. RESULTS: Evidence supported Medicare coverage for preventive dental care before jaw radiation therapy for head or neck cancer and coverage for treatment to prevent or eliminate acute oral infections for patients with leukemia before chemotherapy. Insufficient evidence supported dental coverage for patients with lymphoma or organ transplants and for patients who had undergone heart valve repair or replacement. CONCLUSIONS: The committee suggested that Congress update statutory language to permit Medicare coverage of effective dental services needed in conjunction with surgery, chemotherapy, radiation therapy or pharmacological treatment for life-threatening medical conditions. PRACTICE IMPLICATIONS: Dental care is important for members of all age groups. More direct, research-based evidence on the efficacy of medically necessary dental care is needed both to guide treatment and to support Medicare payment policy.

Delivering dental care to nursing home and homebound patients.

The growing life expectancy has created a number of challenges for society and for the dental profession. One of these challenges is the increasing number of people, particularly those over age 85, who are considered frail and functionally impaired, who no longer can live independently or participate in the community. If the impairment is severe enough, the older adult may become home-bound or unable to leave the home without assistive aids or, less commonly, institutionalized in a nursing home. The characteristics of the homebound and nursing home resident represent a dramatic contrast from those who are the same age and living in the community: They are older, predominantly female, and have more physical and mental disabilities. In addition, there are differences in oral health characteristics, of which dentists and other health professionals need to be aware. Although there are a number of obstacles and barriers that make providing dental care more difficult for these patients, federal mandates and a growing professional response to develop initiatives for outreach and access are beginning to have an effect. Still the challenge for providing dental care to these groups remains great, and it will take a tremendous effort from many oral health professionals before significant change is evident. There are many professional and personal rewards for providing this care, and we as dental professionals must be committed to seeing that the oral health needs are met for all underserved populations in our society.

A qualitative exploration of dental practitioners' knowledge, attitudes and practices towards HIV+ and patients with other 'high risk' groups.

This paper expands upon a previous quantitative study which measured dentists' knowledge, attitudes and practices towards patients carrying blood-borne viruses in order to identify potential barriers to the provision of adequate dental treatment. Although some useful findings were obtained in that study, it was suggested that further qualitative work needed to be conducted in order to provide the opportunity for dental practitioners' to expand, reflect and justify their opinions and beliefs in more detail. The aim of this study is to present the results of such a qualitative investigation.

Specialist practitioner' in surgical dentistry: preliminary report on a pilot scheme at East Surrey Hospital, Redhill, UK.

This continuing pilot scheme was designed to assess whether minor oral operations could be done by a 'specialist practitioner' in surgical dentistry in hospital. The preliminary results indicate that patients benefit from the improved facilities and expertise that are available in the hospital, that the provision of treatment within the hospital is at a sufficiently 'local' level to meet their requirements, and that this increased quality of service can be provided at no greater cost to the NHS than treating them in a dental surgery. A large amount of the dentoalveolar surgery done (such as removal of third molars) is regarded as routine, but 'routine' is often mistakenly thought to mean 'simple' or 'easy'. Dentoalveolar surgery not only demands the highest quality of care and expertise but it also requires the necessary immediate support if medical or surgical complications arise.

Perceived barriers and facilitators to dental treatment among female caregivers of children with and without HIV and their health care providers.

PURPOSE: This study sought to identify barriers and facilitators to dental care among families of predominately low socioeconomic status having children with and without HIV. METHODS: Twelve focus group sessions with African-American and Hispanic caregivers and 18 individual semistructured interviews with key informant health care providers were held at two sites: a hospital-based program (HBP) and a dental school-based program (DSBP), that provide pediatric dental services. SPSS Textsmart software was used to analyze qualitative data within and across group types and sites. RESULTS: Focus group participants (n = 72, averaging 6 women per group) included: HIV-seropositive biological mothers of HIV-seropositive children (4 groups); HIV-seronegative caregivers of HIV-seropositive children (4 groups); and Medicaid-eligible, HIV-seronegative caregivers of HIV-seronegative children (4 groups). The most commonly expressed barrier to dental care across groups was poor interpersonal communication between dental staff and caregiver/child. HIV-seronegative groups cited health care delivery system factors as barriers to receiving dental care more frequently than HIV-seropositive caregivers who cited shame/anger and family illness as being more important. Common facilitators were positive communication and transportation assistance. Unique facilitators for HIV-seropositive groups were coordination of the dental visits with medical appointments at the HBP. Key informants acknowledged high stress in families having children with HIV/AIDS, cited dental fear among caregivers as a barrier to dental treatment adherence and reported that dental care seemed to be a low priority among many of these families. CONCLUSIONS: Facilitators and barriers to care included factors in the family, dental care and health care delivery systems as well as interpersonal communication between the dental providers and the families.

Dental-care experiences of people living with HIV/AIDS in Aotearoa New Zealand.

Previous surveys of people living with HIV/AIDS suggest that such persons may have difficulty in securing dental care and that some dentists would prefer to refer such individuals. This study aimed to assess the experiences of people living with HIV/AIDS in Aotearoa New Zealand in obtaining and undergoing dental treatment. Survey forms were distributed through organisations working with people with HIV/AIDS. Fifty-seven questionnaires were analysed. The majority of respondents were gay white males. Seventy-five percent of participants felt that dental care was important, or very important, and 37 percent had increased the frequency of visits to the dentist since being diagnosed as HIV-positive. Forty-two (74 percent) participants had disclosed their HIV status to their dentists. Of this group, the majority had experienced either supportive or sympathetic reactions. Of those who concealed their status, 31 percent feared rejection by the dental practitioner, and 31 percent felt the dentist was taking adequate precautions and that there was no need to volunteer information on HIV status. Only three people reported denial of treatment on the grounds of their HIV status. An additional two people were immediately referred on by their practitioner after disclosure. Almost half the participants had changed dentists after they were diagnosed as HIV-positive. The main reasons stated included cost of treatment, fear of breach of confidentiality, or shifting to a new centre. Even though 33 percent received dental care in a hospital environment, 63 percent suffered systemic manifestations of HIV-infection, and 51 percent had oral manifestations.(ABSTRACT TRUNCATED AT 250 WORDS)

The costs and consequences of neglected medically necessary oral care.

Oral diseases and conditions may adversely affect general health, and certain medical conditions may have a negative effect on oral health. However, little attention has been given to assessing the economic costs and consequences associated with care that is a direct result of, or has a direct impact on, an underlying medical condition and/or its resulting therapy. The costs can be significant for patients; their families; third-party payers such as insurance companies, Medicare, and Medicaid; and society. The health consequences of such conditions may dramatically affect function, morbidity, quality of life, and survival. This paper reviews one possible approach for identifying and measuring the costs and consequences associated with medically necessary oral health care and presents a framework for evaluating medically necessary oral health care. The paper also describes the cost components of care and the dimensions of health consequences. Finally, an example illustrates this approach. The summary information presented here is meant to offer concepts and ideas important in assessing the costs and health consequences associated with medically necessary oral health care. Individuals interested in a more detailed discussion of economic evaluation of health care programs and outcomes assessment are referred elsewhere. 10-23

Treating unique patient populations and practice growth.

Developing a dental practice niche for patients with specific medical conditions can provide a tremendous benefit to this patient population while enhancing practice productivity and profits. Capitalizing on this opportunity requires development of comprehensive, customized patient management systems. To remain profitable, practice fees must be adjusted to account for the additional time and effort invested in serving these unique patients.

Why not Medicaid dentistry?

Charitable dental services and Medicaid dentistry are two components of services provided to patients with limited financial resources. An approach to making the case for improvements in Medicaid dentistry may best be made by increasing the public's awareness of the charitable services provided by individual dentists.