Prevention of dental disease versus surgical treatment.

The members of the Minnesota legislature have debated methods by which access to dental care and treatment of dental disease can be improved at a cost lower than that of present delivery systems. This review sheds light on some significant aspects of what the dental profession has learned over the last century that has proven significantly beneficial to the overall health of the American populace. Recommendations are made in the use of cost-effective dental public health interventions that could be used to provide better access and improved dental health at lower cost.

Cost-effectiveness models for dental caries prevention programmes among Chilean schoolchildren.

AIM: This study aims to estimate the cost-effectiveness from a societal perspective of seven dental caries prevention programmes among schoolchildren in Chile: three community-based programmes: water-fluoridation, salt-fluoridation and dental sealants; and four school-based programmes: milk-fluoridation; fluoridated mouthrinses (FMR); APF-Gel, and supervised toothbrushing with fluoride toothpaste. METHODS: Standard cost-effectiveness analysis methods were used. The costs associated with implementing and operating each programme, using a societal perspective, were identified and estimated. The comparator was non-intervention. Health outcomes were measured as dental caries averted over a 6-year period. Costs were estimated as direct treatment costs, programmes costs and costs of productivity losses as a result of each dental caries prevention programme. Incremental cost-effectiveness ratios were calculated for each programme. Sensitivity analyses were conducted over key parameters. RESULTS: Primary cost-effectiveness analysis (discounted) indicated that four programmes showed net social savings by the DMFT averted. These savings encompassed a range of values per diseased tooth averted; US$16.21 (salt-fluoridation), US$14.89 (community water fluoridation); US$14.78 (milk fluoridation); and US$8.63 (FMR). Individual programmes using an APF-Gel application, dental sealants, and supervised tooth brushing using fluoridated toothpaste, represent costs for the society per diseased tooth averted of US$21.30, US$11.56 and US$8.55, respectively. CONCLUSION: Based on cost required to prevent one carious tooth among schoolchildren, salt fluoridation was the most cost-effective, with APF-Gel ranking as least cost-effective. Findings confirm that most community/school-based dental caries interventions are cost-effective uses of society's financial resources. The models used are conservative and likely to underestimate the real benefits of each intervention.

Advanced dental education programs: status and implications for access to care in California.

Primary care residencies in dentistry include general practice residency and advanced education in general dentistry--collectively known as postdoctoral general--dentistry and pediatric dentistry. These primary care programs are the most likely to serve underserved populations during the training experience. An expansion of primary care dental residency positions in California has the potential to positively impact access to care in California. However, there are significant political and financial barriers to realizing this potential.

Access to dental care and the capacity of the California dental care system.

The authors estimated the following levels of technical efficiency for three types of dental practices in California where technical efficiency is defined as the maximum output that can be produced from a given set of inputs: generalists (including pediatric dentists), 96.5 percent; specialists, 77.1 percent; community dental clinics, 83.6 percent. Combining this with information on access, it is estimated that the California dental care system in 2009-10 could serve approximately 74 percent of the population.

Community dental service--four years on.

In July 2000, the first group of graduates entered compulsory community dental service. The aim of this study was to document the experiences of the community dentists four years on. A cross-sectional, descriptive study was carried out among 232 community dentists. A structured questionnaire divided into nine sections: demography, the allocation process, accommodation & living conditions, dental clinic facilities - equipment and materials, work environment, income, sense of achievement, intellectual fulfillment. Forty five per cent of the sample (n = 105) responded, 51% were male and the mean age of the sample was 24.8 years. Of the responadents 47% could speak the local language; nearly a quarter (24%) felt that the allocation process was not handled efficiently and 30% said that they needed more information about their placement posting. Sixty per cent were placed within 20km of the nearest town; 11% did not have access to telephone or fax and 47% were provided with accommodation. Thirty five per cent described the condition of the clinics operating as poor. A fifth of the respondents (21%) indicated that they did not have full sets of instruments. Eight per cent did not have an autoclave and 7% a high-speed hand piece. Fifty one per cent did not have oxygen and nearly two thirds (58%) of the clinics did not have any emergency equipment. Seventy one per cent reported that the equipment broke down often and 65% that it was not fixed promptly. Nearly all (90%) indicated that they would welcome a short course that might assist them to repair broken down equipment. Eighty five per cent reported that they enjoyed their work environment. Seventy per cent had no supervision, but more than a third felt confident enough to work without it. Although 80% felt that their professional competence had improved, an equal number indicated that they have lost some of their clinical competence in one or other area. Despite the fact that 65% reported that there were many opportunities to improve their clinical skills, more than half felt that they were over-skilled for the job. Eighty per cent of the respondents indicated the year was fulfilling and worthwhile. Problem areas centred on the adequacy of the information provided prior to allocation, high cost of accommodation, break down of equipment and lack of basic restorative materials. It is gratifying to note that there have been many improvements since the initial intake of community dentists in 2000, but there remains a few areas that still need to be addressed.

Bridging the gap: a dental access initiative for Northland children.

This paper describes a dental access initiative in Northland, New Zealand, to investigate the feasibility and benefits of engaging a mobile community dentist to accept referrals of children who required treatment beyond the scope of practice of dental therapists. The pilot programme aimed to provide equitable and timely access to the services of a publicly funded dentist, for children living in the more economically-deprived and rural areas of Northland.

The origins and design of the Dental Pipeline program.

Funded by The Robert Wood Johnson Foundation and the California Endowment and with student financial aid from the W.K. Kellogg Foundation, the primary goal of the Pipeline, Profession, and Practice: Community-Based Dental Education program is to reduce disparities in access to dental care. In a national competition, fifteen dental schools were selected to participate. By the final year (2007) of the five-year project, the schools are expected to achieve three objectives: 1) increase the time (sixty days/year) that senior students and residents spend in patient-centered community clinics and practices treating underserved populations; 2) provide didactic and clinical courses for students and residents that prepare them for their community experiences; and 3) recruit more underrepresented minority and low-income students. The national program office that directs the project is located at Columbia University, and a national advisory committee oversees the program for the sponsoring organizations. The challenge is to demonstrate that the Pipeline objectives are achievable and that the program is sustainable without external support.

Technical and cost efficiency of oral health care provision in Finnish health centres.

In this study we measured the productive efficiency of public dental health provision across Finland. The analysis was based on data envelopment analysis (DEA) using linear programming. In addition, we investigated various factors explaining the technical and cost efficiency of public dental care using a parametric Tobit model. These analyses revealed substantial variation in productive efficiency between health centres in different municipalities. The level of cost inefficiency was generally between 20% and 30%. Good dental health of the population, high rates of unemployment and high per capita expenditure on primary care in the municipality were associated with technical and cost inefficiency. According to the results, cost efficiency would not be improved by shifting input allocation towards more auxiliary manpower in health centres. Individual efficiency scores were clearly sensitive to the choice of output specification. Changing the unit of output measurement from visit- to patient-based measures affected markedly the ranking of dental health centres. However, the set of exogenous correlates associated to inefficiency was strikingly similar for both types of output specification. More resources are needed if the coverage of public dental care is extended to all age groups. The health centre specific efficiency scores obtained in this study can be used locally to evaluate, design and implement structural changes in the production processes.

The efficiency of the community dental service in England: a data envelopment analysis.

OBJECTIVES: To assess the efficiency with which health authorities' Community Dental Services provide dental care in England. METHODS: A data envelopment analysis of inputs (hours worked by dental officers, therapists, hygienists and others) and outputs (screening, treatment, prevention) of the Community Dental Service (CDS) was conducted. Relative efficiency ratings of the CDS by health authority were further analysed in order to identify external factors which effect efficiency and are outside the control of the Community Dental Service. RESULTS: The relative efficiency of the CDS varies widely in England--on average the CDS is operating at 75% of efficient levels compared to best-practice services. This could not be explained by plausible factors outside the CDS's control, such as differences in deprivation and urban-rural differences between health authorities. CONCLUSIONS: These results, if validated by further studies, should be disturbing since many Community Dental Services services appear to be under-performing. However, this data-driven study could not uncover the detailed context of an individual service's performance. A useful next step would be detailed case-studies of several "star" and under-performing services to search for deeper reasons underpinning relative performance levels.

Economic evaluation of community programs for the prevention of dental caries in Catalonia, Spain.

The purpose of the present study was to estimate the cost-effectiveness of three alternative community programs to prevent dental caries among Catalonia's schoolchildren. The programs were: fluoridation of the public water supply, fort-nightly 0.2% NaF mouthrinses administered in schools, and supervised toothbrushing with a fluoride toothpaste in schools. Caries prevalence data for Catalan children are given and the methodology for the study is described. The estimated cost of saving 1 DMFS with each program was: 53.40 Pts (US$ 0.39) with fluoridation of the water supply; 305.20 Pts (US$ 2.26) with fluoride mouthrinses; and 1498 Pts (US$ 11.09) with supervised toothbrushing. The feasibility of the programs in Catalonia and their educational values for the target population are considered.

The cost of upgrading cross-infection control in twelve community dental service surgeries, 1988-1989.

A retrospective survey was established in 1989 to cost the upgrading of cross-infection control methods in twelve community dental service surgeries. The capital and maintenance expenditure averaged 3244.85 pounds per surgery, indicating that the costs might be less than currently projected.

Resource costs of capitation maintenance care in Britain.

The aims of this study were to examine variations in the resource cost of maintenance care for children under capitation by the area in which the dentist worked, the gender of the dentist, the number of years that the dentist had been qualified and the social class mix of the practice locality. Data were analysed from those collected during a clinical trial of capitation and fee-for-service payment systems that took place between 1986 and 1989. The costs of restorative/surgical treatment were over twice as high in Grampian than in Bromley. The costs of all treatment provided were 46 per cent higher in Salford than in Bromley. The date of qualification of the dentist was the only factor significantly associated with the cost of preventive treatment provided, with more recent graduates offering more preventive care than older dentists. The difficulties of using uniform national capitation rates are discussed.

Nationwide survey of dentist recruitment and salaries in community health centers.

Recruitment of dentists continues to be a problem in community health center (CHC) dental practices. This study was carried out to quantify the scope of the problem and to determine CHC dentist salaries and benefits. Community health center executive directors nationwide were surveyed regarding dentist vacancies, recruiting issues, and salary and benefit information. Of 345 surveys mailed, 159 responses were received (46.1%). Slightly fewer than half of the responding executive directors (47.8%) reported one vacant dentist position. An additional 11.9% of executive directors reported a second vacancy. The overall vacancy rate was 17.6%. Median salaries ranged from 78,000 dollars for entry-level dentists to 90,000 dollars for dentists with 10 or more years of experience, not including benefits. There are difficulties in recruiting dentists to CHC dental practices. Mean salaries in CHCs are slightly higher than in academic positions, but less than in private practice employment or ownership. Caution should be used when comparing salaried positions with substantial benefits to self-employment or sole proprietorships.

Theoretical considerations in applying benefit-cost and cost-effectiveness analyses to preventive dental programs.

Benefit-cost analysis and cost-effectiveness analysis can be used to evaluate preventive regimens and aid policy-makers in making resource-allocation decisions. This paper demonstrates the application of benefit-cost and cost-effectiveness analyses to preventive dental programs. The two analyses are defined and described, and the purpose of each technic is compared. For a hypothetical community, four dental preventive programs are described: community water fluoridation, school water fluoridation, weekly school-based mouthrinses, and school-based sealants. Benefit-cost ratios and cost-effectiveness ratios are calculated for each program first assuming steady-state conditions, i.e., maximum caries reduction, and then for a 20-year period. Both explicit and implicit costs are included. Underlying assumptions and limitations, as well as the effects of changes in caries rates, differential attack rates, and discount rates on the outcome, are discussed. The analysis reveals that community water fluoridation yields the greatest net benefits and most favorable B/C and C/E ratios. School water fluoridation and mouthrinsing programs are the next most cost-effective, with similar B/C and C/E ratios when the implicit cost of teachers' time is omitted from the calculations. The school-based sealant program yields negative net benefits.

A community-based dental program for older adults.

The planning and implementation of a community-based outreach program for older adults is described. Objectives of the program were to provide dental health education to older persons at their place of residence, to improve access to dental care for that population, and to increase the number of older adults treated at a dental facility administered by the Department of Community Dentistry, University of Michigan. Data collected during encounters with participants are reported to supplement the description of the program. In the first year, 98 older adults (mean age 71.3 years) participated in the outreach program which was directed by a dental hygienist. Of those persons whose initial encounter was with the outreach program, 47 percent eventually contacted the dental care facility and 36 percent completed treatment. Persons who elected to seek treatment average 3.9 encounters with the hygienist during the program; persons who did not seek treatment averaged 2.2 encounters. Strengths and weaknesses of the program are discussed.

Community-based sealant programs in the United States: results of a survey.

The appropriate use of pit and fissure sealants could reduce substantially the majority of occlusal caries among US school-aged children. The 1986-87 national oral health survey conducted by the NIDR showed that less than 8 percent of the children 5-17 years of age had sealants on their teeth. The purpose of this national study was to document the current status of community-based sealant programs and to identify general program characteristics. Data were gathered through a mail survey to all state dental directors and site visits to four selected comprehensive community-based programs. Twenty-nine states were currently conducting sealant programs. The vast majority of these programs had formal quality assurance systems and companion health education components. Eight states indicated that sealant programs had been terminated within the last two years. Medicaid reimbursement for sealants was available in 42 states, with a mean reimbursement rate of $10.71 per sealant. Reimbursement rates ranged from $3.00-$20.00 per sealant. State practice acts almost uniformly permitted the placement of sealants by dental hygienists (n = 48), but less frequently by dental assistants (n = 15). Approximately 43 percent of state practice acts did not require a dentist to be present physically when auxiliaries place sealants in public/community sealant programs. All respondents indicated that there was a need for additional programs in their state. No structural factors--for example, level of Medicaid reimbursement for sealants or state practice act requirements for auxiliary supervision--were found to be associated with the presence of community-based sealant programs. Nationally, only a small percentage of children appeared to be receiving sealants in community programs.

A community collaboration: the dental emergency assistance program.

The Dental Emergency Assistance Program is a collaboration between Michigan dentists and a United Way agency. The program's goal is to provide timely, accessible dental care to underserved people in a large metropolitan area. The authors analyzed the program's 1993 activities to determine sources of patient referrals, patients' demographic characteristics, and the types and value of services provided by participating dentists. The evaluation indicated that the Dental Emergency Assistance Program was successfully addressing the emergency dental needs of an underserved portion of the community.

Investigating the potential for students to provide dental services in community settings.

Some dental educational institutions in North America have incorporated community-oriented programs into their curriculum. The purpose of this study was to investigate the potential for the clinical placement of Ontario's dental and dental hygiene students in community-based settings. Key informant interviews were used to collect data. The study group consisted of 15 key informants from 9 potential placement sites and 4 educational institutions in Toronto and London, Ontario. The textual data were analyzed qualitatively to identify important issues regarding a clinical placement program. Results showed that there is strong support for the placement of students in community-based clinics; however, the degree to which health centres can accommodate students varies. The majority would not set any limit on the types of dental services that students could provide as long as the services were within the students' competencies. Funding was identified as a barrier to the implementation of such a program, with most of the organizations not able to contribute financially. None would be able to provide sufficient supervision without additional funding. These results indicate that a clinical placement program would be a welcome addition to the training of dental and dental hygiene students, but that external funding for supervision and operational expenses must be available before a program can be instituted.

Community orthodontic services: a local review.

A review is presented of orthodontic treatment and working conditions in one area of the Community Dental Service over a typical period of one year (1984). Treatment totals, case load, working facilities and schedules are discussed, drawing comparisons with the hospital service and specialist practice and with previously published surveys of orthodontics in the community service. An estimate of the size of school population likely to support a full-time community orthodontist is made together with the number of referring practitioners. Comments are also made on the range of treatment provided, patients' attitudes, cooperation and such problems as missed appointments. A short section is devoted to actual timings of specific procedures in orthodontics, followed by discussion of the hospital attachment for community orthodontists, with some recommendations on working conditions and comments on career structure.

Management information failings and future requirements for dental commissioning groups.

OBJECTIVE: To examine existing secondary care management information systems for dental specialities, and to determine their completeness and suitability for supporting effective primary care led purchasing decisions. DESIGN: An observational cross-sectional study of current information systems in selected secondary care provider units and the applicability of their data for contracting dental services. A comparative study of two information systems in two settings (primary and secondary care) and the utility of the data gathered for contracting for dental services. SUBJECTS: Secondary care activity data was sought from the key secondary dental care providers (hospitals) in two dental total purchasing localities. Referral data were also collected directly from general dental practitioners. MAIN OUTCOME MEASURES: The integrity, quality and accuracy of current secondary care activity data in dental specialities, in comparison to data supplied from primary dental care. RESULTS: The secondary care activity data was found to be incomplete, inadequate and inaccurate. It was found that due to data retrieval insufficiency, indicative budgets for secondary providers may be reduced to less than half of their actual entitlement. The data inflated individual dental outpatient attendance by 3.3 times between 1995/6 and by 2.5 times between 1996/7. CONCLUSION: Existing management information systems within secondary care providers are not structured in a way which will adequately inform future commissioning by the dental profession. Communication between primary and secondary care must be increased and data inputting methods in secondary care provider units must be substantially improved.