Use of programme budgeting and marginal analysis to set priorities for local NHS dental services: learning from the north east of England.

Background: Priority setting is necessary where competing demands exceed the finite resources available. The aim of the study was to develop and test a prioritization framework based upon programme budgeting and marginal analysis (PBMA) as a tool to assist National Health Service (NHS) commissioners in their management of resources for local NHS dental services. Methods: Twenty-seven stakeholders (5 dentists, 8 commissioners and 14 patients) participated in a case-study based in a former NHS commissioning organization in the north of England. Stakeholders modified local decision-making criteria and applied them to a number of different scenarios. Results: The majority of financial resources for NHS dental services in the commissioning organization studied were allocated to primary care dental practitioners' contracts in perpetuity, potentially constraining commissioners' abilities to shift resources. Compiling the programme budget was successful, but organizational flux and difficulties engaging local NHS commissioners significantly impacted upon the marginal analysis phase. Conclusions: NHS dental practitioners' contracts resemble budget-silos which do not facilitate local resource reallocation. 'Context-specific' factors significantly challenged the successful implementation and impact of PBMA. A local PBMA champion embedded within commissioning organizations should be considered. Participants found visual depiction of the cost-value ratio helpful during their initial priority setting deliberations.

Self-management programmes in temporomandibular disorders: results from an international Delphi process.

Self-management (SM) programmes are commonly used for initial treatment of patients with temporomandibular disorders (TMD). The programmes described in the literature, however, vary widely with no consistency in terminology used, components of care or their definitions. The aims of this study were therefore to construct an operationalised definition of self-management appropriate for the treatment of patients with TMD, identify the components of that self-management currently being used and create sufficiently clear and non-overlapping standardised definitions for each of those components. A four-round Delphi process with eleven international experts in the field of TMD was conducted to achieve these aims. In the first round, the participants agreed upon six principal concepts of self-management. In the remaining three rounds, consensus was achieved upon the definition and the six components of self-management. The main components identified and agreed upon by the participants to constitute the core of a SM programme for TMD were as follows: education; jaw exercises; massage; thermal therapy; dietary advice and nutrition; and parafunctional behaviour identification, monitoring and avoidance. This Delphi process has established the principal concepts of self-management, and a standardised definition has been agreed with the following components for use in clinical practice: education; self-exercise; self-massage; thermal therapy; dietary advice and nutrition; and parafunctional behaviour identification, monitoring and avoidance. The consensus-derived concepts, definitions and components of SM offer a starting point for further research to advance the evidence base for, and clinical utility of, TMD SM.

Factors affecting direction and strength of patient preferences for treatment of molar teeth with nonvital pulps.

AIM: To elicit the factors affecting willingness to pay (WTP) values for the preferred options of participants for dealing with a molar tooth with a nonvital pulp, a common but difficult problem. METHODOLOGY: A total of 503 patients were recruited from dental practices in the North East of England and interviewed. Their preferred treatment option for a molar tooth with a nonvital pulp (endodontics, extraction and various prosthetic restorative options) and WTP for this preferred option were elicited. Factors affecting preferred option and WTP were analysed using econometric modelling. RESULTS: Overall, 53% of the sample wished to save the tooth with a mean WTP of £373. The variance in WTP was high. Of those opting for extraction, the majority chose to leave a gap or have an implant. The preferred option was influenced by previous treatment experience. WTP was only influenced by having a low income. CONCLUSIONS: The high level of variance in WTP and its relatively unpredictable nature pose difficult questions for policy makers trying to ensure the delivery of an equitable service. For dentists, it is important not to make assumptions about patient preference and strength of preference when making decisions. Ideally, WTP values should be considered alongside effectiveness data, and those on costs, in policy making.

DEEP Study: does EQ-5D-5L measure the impacts of persistent oro-facial pain?

The EQ-5D-5L is a generic quality of life (QOL) measure widely used throughout the world, which has the advantage that it allows health-state preferences to be elicited. The aim of this study was to examine whether: a) variation in the standardised reference period for EQ-5D-5L from 'today' to 'the last month' had a minimal clinically meaningful difference; (b) EQ-5D-5L had convergent validity with a multidimensional pain measure in quantifying the impacts of pain. As part of a larger study into the effectiveness and efficiency of care pathways for persistent orofacial pain (POFP) (http://research.ncl.ac.uk/deepstudy), participants with POFP (n = 100) completed two versions of the EQ-5D-5L at the same time with different reference periods ('today' vs. 'last month'). Participants also completed the first section of the West Haven-Yale Multidimensional Pain Inventory (v3) to assess convergent validity. Two-tailed nonparametric inferential statistics, intra-class correlation coefficients (ICC), and within-subject change scores were used to compare the two EQ-5D-5L versions. Convergent validity was assessed using Spearman's rho correlation coefficients. Health-state valuations were significantly different (P < 0.01), and there was good similarity between the two versions' ICC 0.86 (95% CI 0.79-0.91). The within-subject mean change was 0.03 (95% CI 0.01-0.06). For convergent validity, all relationships were significant (P < 0.05) and in the expected directions. EQ-5D-5L demonstrates sufficient convergent validity to be used with POFP, and a change in the standard reference period may be unnecessary if a multidimensional pain measure is also used.

What constitutes an ideal dental restorative material?

Intense environmental concerns recently have prompted dentistry to evaluate the performance and environmental impact of existing restoration materials. Doing so entices us to explore the 'what if?' innovation in materials science to create more ideal restorative materials. Articulating a specification for our design and evaluation methods is proving to be more complicated than originally anticipated. Challenges exist not only in specifying how the material should be manipulated and perform clinically but also in understanding and incorporating implications of the skill of the operator placing the restoration, economic considerations, expectations patients have for their investment, cost-effectiveness, influences of the health care system on how and for whom restorations are to be placed, and global challenges that limit the types of materials available in different areas of the world. The quandary is to find ways to actively engage multiple stakeholders to agree on priorities and future actions to focus future directions on the creation of more ideal restorative materials that can be available throughout the world.

Creating a patient-based condition-specific outcome measure for Temporomandibular Disorders (TMDs): Oral Health Impact Profile for TMDs (OHIP-TMDs).

The aim of this study was to generate a putative patient-based outcome measure specifically for Temporomandibular Disorders (TMDs) using a mixed-method approach. A combined quantitative-qualitative methodology was used to identify the most relevant items in the Oral Health Impact Profile (OHIP-49) for TMDs. The quantitative study involved 110 patients with TMDs diagnosed using the Research Diagnostic Criteria for TMDs (RDC/TMD) and 110 age- and sex-matched controls. All subjects completed the OHIP-49. The qualitative study involved semi-structured interviews with a separate sample of patients with TMDs (n = 29). The two resultant data sets were analysed blinded and separately. Each data set used predetermined rules to select candidate items for the putative OHIP for TMDs. The two sets of selected items were then compared using a priori rules to make a final item selection for OHIP TMDs. Eighteen pre-existing items were selected through the quantitative process and fourteen by the qualitative process. On comparison of the two selections all but two of the items selected by the qualitative process had also been selected by the quantitative process. Two new candidate items emerged from the qualitative data that were not covered by OHIP-49. A 22 item putative OHIP-TMDs outcome measure emerged from the final selection process. A putative OHIP-TMDs outcome measure has been generated which requires further testing especially in relation to its responsiveness to change.

Randomised cross-over study of oral appliances for snoring.

OBJECTIVES: To compare a mandibular advancement splint to a control bite raising appliance in the treatment of snoring with or without mild obstructive sleep apnoea syndrome. DESIGN: A prospective two-treatment randomised cross-over clinical trial. SETTING: Single centre secondary care Dental Hospital. PARTICIPANTS: Fifty-two subjects (36 men, 16 women) diagnosed with non-apnoeic snoring or mild obstructive sleep apnoea syndrome (apnoea/hypopnoea index < or =15 events/h), were recruited from Departments of Respiratory Medicine and ENT surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust. MAIN OUTCOME MEASURES: The Snoring Symptoms Inventory questionnaire (SSI) and the Epworth Sleepiness Score (ESS) were used to evaluate changes in symptoms. Patient reported outcomes (compliance, adverse events, splint preference) were recorded by questionnaire. Subjects attended for five study visits and used a mandibular advancement splint and a bite raising appliance at home each for 4 weeks, with a 3-week washout period between devices. RESULTS AND CONCLUSIONS: Thirty-eight subjects completed the study. Both the mandibular advancement splint and bite raising appliance significantly reduced the SSI compared to the baseline scores: mandibular advancement splint 5.5, P = 0.013; bite raising appliance 3.1, P = 0.005. No statistically significant difference between the two treatment periods was detected (P > 0.05). The reduction in the Epworth Sleepiness Score was: mandibular advancement splint 1.0, P = 0.02; bite raising appliance 0.3, P = 0.4. The change in the Epworth Sleepiness Score was not statistically significantly different between the mandibular advancement splint and bite raising appliance treatment periods (P > 0.05). CONCLUSIONS: In this cohort of patients diagnosed with snoring +/- mild OSA: 1 both the mandibular advancement splint and bite raising appliance designs of splint appeared to reduce the symptoms of snoring; 2 no difference in the magnitude of this effect was detected in favour of one design of splint.

Evaluation of the cost-effectiveness of root canal treatment using conventional approaches versus replacement with an implant.

AIM: To evaluate the cost-effectiveness of root canal treatment for a maxillary incisor tooth with a pulp infection, in comparison with extraction and replacement with a bridge, denture or implant supported restoration. METHODOLOGY: A Markov model was built to simulate the lifetime path of restorations placed on the maxillary incisor following the initial treatment decision. It was assumed that the goal of treatment was the preservation of a fixed platform support for a crown without involving the adjacent teeth. Consequently, the model estimates the lifetime costs and the total longevity of tooth and implant supported crowns at the maxillary incisor site. The model considers the initial treatment decisions, and the various subsequent treatment decisions that might be taken if initial restorations fail. RESULTS: Root canal treatment extended the life of the tooth at an additional cost of pound5-8 per year of tooth life. Provision of orthograde re-treatment, if the root canal treatment fails returns further extension of the expected life of the tooth at a cost of pound12-15 per year. Surgical re-treatment is not cost-effective; it is cheaper, per year, to extend the life of the crown by replacement with a single implant restoration if orthograde endodontic treatment fails. CONCLUSION: Modelling the available clinical and cost data indicates that, root canal treatment is highly cost-effective as a first line intervention. Orthograde re-treatment is also cost-effective, if a root treatment subsequently fails, but surgical re-treatment is not. Implants may have a role as a third line intervention if re-treatment fails.

Overview and quality assurance for the oral health component of the National Health and Nutrition Examination Survey (NHANES), 2003-04.

The 2003-04 National Health and Nutrition Examination Survey (NHANES) was a collaborative effort involving 28 federal funding partners with the National Center for Health Statistics. The collaborators for the 2003-04 NHANES oral health component included the National Institute of Dental and Craniofacial Research and the National Center for Chronic Disease Prevention and Health Promotion, Division of Oral Health. Oral health data are available on 8272 persons aged 2 years or older. This report provides an overview of the 2003-04 oral health component including content descriptions and procedures for oral health assessments conducted for the first time in a national survey in the United States. These assessments include posterior functional contacts, tooth wear, and oral health-related quality of life. This report also provides evaluations of data quality in terms of examiner reliability statistics (percent agreements, kappas, and correlation coefficients) for various NHANES 2003-04 oral health examination components and analytical recommendations for producing 6-year estimates using the previous two NHANES data collection components (1999-2000 and 2001-02).

Depression as a risk factor for denture dissatisfaction.

Depression is associated with impaired health outcomes. This study investigated whether there is a significant association between depression and dissatisfaction with dentures in older adults. In a population-based study (1180 adults aged 65-74 yrs), depression was measured by an abbreviated Geriatric Depression Scale. Denture dissatisfaction was assessed with a five-point Likert-type question ("very dissatisfied" to "very satisfied"). The depression-denture dissatisfaction association was analyzed with simple (dissatisfied vs. not dissatisfied outcome) and ordinal logistic regression (based on outcome's full range). For each unit increase on the 15-point depression scale, the probability of denture dissatisfaction increased by 24% [95% confidence interval, 15-34%, P < 0.001 (simple logistic regression)] and the probability for higher levels on the five-point dissatisfaction scale increased by 16% [95% CI, 11-22%, P < 0.001 (ordinal logistic regression)], adjusted for potential confounding variables. The likely causal association in older adults has major implications for the evaluation of treatment effects and the demand for prosthodontic therapy.

Life-course epidemiology: concepts and theoretical models and its relevance to chronic oral conditions.

Etiological models that predominantly emphasize current adult life styles, such as smoking, diet and lack of exercise have recently been seriously challenged by a growing body of evidence that disturbed early growth and development, childhood infection, poor nutrition, and social and psychosocial disadvantage across the life-course affect chronic disease risk, including chronic oral disease. This relatively new area of research is called life-course epidemiology. The life-course framework for investigating the aetiology and natural history of chronic disease proposes that advantages and disadvantages are accumulated throughout life generating differentials in health along the life-course, but most importantly later in life. Furthermore, its dynamic framework brings together the effects of intrinsic factors (individual resources) with extrinsic factors (environmental factors). The aim of this paper is to give an overview of this new epidemiological approach and to discuss how the life-course framework has been applied to chronic oral conditions.

How do factors at different stages of the lifecourse contribute to oral-health-related quality of life in middle age for men and women?

The relative contributions of factors operating in fetal life, childhood, and adulthood to the risk of disease in middle age have become important research issues, but self-perceived oral health has rarely been considered in this context. This study investigated the impact of risk factors operating throughout life on self-perceived oral health, according to the Oral Health Impact Profile (OHIP), at age 50 yrs in 305 individuals from the Newcastle Thousand Families cohort. Factors from early and adult life contributed to the OHIP scores, but in men, self-perceived oral health was mostly explained by factors operating early in life. In women, the number of teeth retained in adulthood had a more prominent impact. Lifecourse influences on oral-health-related quality of life appear different for men and women, which may have implications for the effectiveness of public health interventions and health promotion.

An empirically derived population-response model of the short form of the Oral Health Impact Profile.

OBJECTIVE: The aim of this paper was to model the consequences of dental conditions from an empirical basis and to test the model's ability to predict response combinations. METHODS: The model was derived from responses to the short-form Oral Health Impact Profile (OHIP14) obtained from a UK population sample of 5281 dentate adults. This model was then used to predict OHIP14 response combinations obtained from a sample of 3973 dentate and edentulous adults in Australia. FINDINGS: The empirically derived population-response model accounted for over 98% of response combinations of Australian dentate adults. CONCLUSIONS: The empirically derived model followed a similar hierarchical pattern to the base model underlying the long-form version of the measure (thereby supporting the validity of the OHIP14 measure) and was strongly predictive of the pattern of responses obtained from Australian adults.

Onset of neoplastic phenotype in an epithelial cell strain from adult BALB/c mouse lung alveolus.

Prolonged culture of NAL1A in 1 microM dexamethasone (CAS: 50-02-2) at low passage numbers resulted in the emergence of a morphologically altered and malignant cell strain, NAL1AM. (NAL1A was derived from lungs of normal adult female inbred BALB/c mice and exhibits several characteristics of epithelial cells.) A clone of NAL1A, B5, was shown to undergo a spontaneous morphologic alteration during culture in normal medium to resemble NAL1AM and cells of NUL1, a strain cultured directly from urethane (CAS: 51-79-6)-induced adenomas of mouse lung. Whereas NAL1A did not form colonies in soft agar, the clone B5 of NAL1A as well as NAL1AM and NUL1 showed quite high anchorage-independent growth (colony-forming efficiency, 6.3-7.8%). Compared with NAL1A cells, clone B5, NAL1AM, and NUL1 each exhibited a ninefold-reduced level of cellular binding of epidermal growth factor.

Characteristics of four new human cell lines derived from squamous cell carcinomas of the head and neck.

Four human cell lines were established from biopsy specimens of squamous cell carcinomas of the larynx (TR131 and TR138), tongue (TR126), and buccal mucosa that had infiltrated a lymph node (TR146). All 4 lines readily formed colonies on a plastic substratum, but they were virtually incapable of forming colonies in an anchorage-independent semisolid support system of soft agar (cloning efficiencies, less than 0.02%). The proliferation of this group of tumor-derived cell lines, therefore, appeared to be highly anchorage dependent. Keratin filaments could be visualized in each line by indirect immunofluorescence with the use of polyclonal or monoclonal antibodies to keratins; staining with monospecific antibodies indicated that 3 of the 4 lines expressed simple epithelial keratins 8 and 18, whereas 1 of the 4 also expressed keratin 19. A panel of lectins revealed characteristic localization patterns distinct from those observed on other epithelial cell lines. Cells from 3 lines (TR131, TR138, and TR146) inoculated into nude mice (nu/nu) produced cystic nodules or unequivocal tumors having a histology indicating a squamous cell origin for the injected cells. Electron microscopy demonstrated that the cell lines covered a spectrum of differentiation capability ranging from the undifferentiated monolayer cultures of TR126 to the rather well differentiated, stratified cultures of TR131.

The reported impact of oral condition on children in the United Kingdom, 2003.

BACKGROUND: The 2003 Children's Dental Health Survey is the fourth in a series of decennial national children's dental health surveys of the United Kingdom. AIMS: This paper is concerned with how children are reported to have been affected by their oral condition during the 12 month period immediately preceding the survey and how this relates to the children's experience of caries, their dental attendance behaviour and their social class. METHOD: The information was gathered by self-completion questionnaire distributed to the parents of half of the sample who were clinically examined in the dental survey. RESULTS: Some form of impact was reported by the parents of 22% of five-year-olds, 26% of eight-year-olds, 34% of 12-year-olds and 28% of 15-year-olds. The pattern of responses to the eight impact questions was broadly similar across age groups. The most frequently reported type of impact was pain in all age groups. Impacts on oral function, self-confidence, orally related activity and on the child's emotions were experienced by 4-10% of children of all ages. Fewer children (1-2%) were reported to have experienced more far reaching impacts affecting their social functioning, general health and life overall. CONCLUSIONS: Most children were reported not to have experienced any of the problems covered by the questionnaire. Of those who did, most reported a single problem and for most this was pain. Nevertheless there was a group of children for whom oral function, self-confidence, orally related activity, emotions, social functioning, their health or their life in general were reported to have been affected by their oral condition. The nature of dental care which is appropriate for such children needs to be determined.

Oral health habits amongst children in the United Kingdom in 2003.

BACKGROUND: The 2003 Children's Dental Health Survey is the fourth in a series of decennial national children's dental health surveys. AIMS: This paper presents data on parental attitudes towards the care of children's teeth and gums, reported oral hygiene behaviours and clinical measures of hygiene and periodontal health in 2003 and highlights trends since previous surveys. METHOD: A total of 10,381 children were examined in schools by trained and calibrated examiners. Four measures of hygiene and periodontal health were recorded as part of the clinical examination. In addition, 3,342 questionnaires were completed by parents of a sub-sample of these children. The questionnaire enabled information to be collected about reported oral health behaviours and parental attitudes. RESULTS: About three quarters of children across all age groups are reported to brush their teeth twice daily. A range of oral health products was reported as being used in addition to toothbrushes and toothpaste. There is a trend in parental preferences towards restoration of teeth rather than extractions and towards a better understanding of dental caries prevention. Although overall a higher proportion of children in this survey appeared to have gingival inflammation, plaque and calculus than 10 and 20 years ago, there was no change in the proportion of older children with gingivitis. CONCLUSIONS: Dental practitioners have a role to play in reinforcing these positive attitudes and encouraging appropriate and effective oral hygiene behaviours in their child patients.

The dentinal caries experience of children in the United Kingdom, 2003.

BACKGROUND: The 2003 Children's Dental Health Survey is the fourth in a series of decennial national children's dental health surveys. AIMS: This paper reports the survey-derived estimates of dentinal caries experience of children aged five, eight, 12 and 15 years, considering the trends over recent decades and the position in 2003 following changes in disease presentation and the use of additional criteria. METHODOLOGY: A representative UK sample of children in the four specified age groups were invited to participate in a clinical dental examination in school. A total of 12,698 children were sampled and 10,381 were examined (82%). Examinations were undertaken in school by trained and calibrated examining teams using reclining chairs and portable lights, the criteria were visual, limited to dentine caries and no diagnostic aids were employed. In order to compare trend data with 1993 and earlier surveys the criteria allowed the re-classification of the full 2003a results (those including cavities and visual dentine caries - D(3cv)MFT/d(3cv)mft) according to the previous criteria to produce results labelled 2003b (those restricted to dentinal cavities--D(3c)MFT/d(3c)mft). RESULTS AND CONCLUSIONS: The experience of obvious dentinal caries in children within the UK has continued to change over the last decade and patterns are different for the two dentitions. While continuing overall improvements are evident for permanent teeth across the UK (D(3c) for 15-year-old children falling from 42% in 1983, via 30% in 1993 to 13% in 2003 for example), trends amongst those experiencing dentinal caries are more concerning and there have been no statistically significant improvements for primary teeth (the mean number of teeth with obvious dentine decay (d(3c)) at age five years being 1.3 in 1983 and 1.4 in both 1993 and 2003). The inclusion in the criteria of visual dentinal caries resulted in higher estimates of mean caries and mean caries experience in the permanent dentition (at age 15 years D(3) increasing from 0.2 to 0.8, D(3)MFT increasing from 1.6 to 2.0 for example) but not the primary dentition (where the estimates for % d(3)mft at age five years were identical at 43%). Geographic variations also persist across the UK (% with D(3cv)MFT at 12 years being 41% for England, 54% Wales, 73% Northern Ireland and 43% for the UK; % with d(3cv)mft at age 5 years: 41% for England, 52% Wales, 61% Northern Ireland and 43% for the UK). These survey results have implications for planning and for daily practice, but must be interpreted carefully acknowledging the specific survey conditions and diagnostic criteria employed.

The orthodontic condition of children in the United Kingdom, 2003.

BACKGROUND: The 2003 Children's Dental Health Survey is the fourth in a series of decennial national children's dental health surveys in the United Kingdom. AIMS: This paper reports on the orthodontic condition of children aged 12 and 15 years. METHODOLOGY: A representative sample of children across the UK were invited to participate in a clinical dental examination in school. Two thousand, five hundred and ninety-five 12-year-olds and 2,142 15-year-olds were examined. Current and past orthodontic treatment and type of appliance worn were recorded. Orthodontic treatment need was assessed by the Modified IOTN in those not undergoing treatment. A postal questionnaire sought parents' views on the orthodontic condition of their children and perceived need for treatment. RESULTS: At age 12, 35% were judged to have an orthodontic treatment need, 57% had no need and 8% were wearing an appliance. The corresponding figures at age 15 were, 21% (need), 65% (no need) and 14% (wearing appliance). A higher proportion of girls (p < 0.05) were wearing an appliance than boys. A greater proportion of 15-year-olds were undergoing treatment than in the 1993 and 1983 surveys and the use of fixed appliances had increased. CONCLUSIONS: In this representative sample of UK children, one in five were still judged as having an orthodontic treatment need at age 15 years, as determined by the modified index of orthodontic treatment need. However, considerable variation was observed between professional and lay perceptions of need.