Public Valuation of Direct Restorations: A Discrete Choice Experiment.

Direct posterior dental restorations are commonly provided following management of dental caries. Amalgam use has been phased down and the feasibility of a phase-out by 2030 is being explored. Alternative direct restorative materials differ in their outcomes and provision. This research aimed to elicit the UK population's preferences for different attributes of restorations and their willingness to pay (WTP) for restorative services and outcomes. A discrete choice experiment (DCE) was designed with patient and public involvement and distributed to a representative sample of the UK general population using an online survey. Respondents answered 17 choice tasks between pairs of scenarios that varied in levels of 7 attributes (wait for filling, clinician type, filling color, length of procedure, likely discomfort after filling, average life span of filling, and cost). An opt-out (no treatment) was included. Mixed logit models were used for data analysis. Marginal WTP for attribute levels and relative attribute importance were calculated. In total, 1,002 respondents completed the DCE. Overall, respondents were willing to pay £39.52 to reduce a 6-wk wait for treatment to 2 wk, £13.55 to have treatment by a dentist rather than a therapist, £41.66 to change filling color from silvery/gray to white, £0.27 per minute of reduced treatment time, £116.52 to move from persistent to no postoperative pain, and £5.44 per year of increased restoration longevity. Ability to pay affected willingness to pay, with low-income respondents more likely to opt out of treatment and value restoration color (white) and increased longevity significantly lower than those with higher income. Clinicians should understand potential drivers of restoration choice, so they can be discussed with individual patients to obtain consent. It is important that policy makers consider general population preferences for restorative outcomes and services, with an awareness of how income affects these, when considering the potential phase-out of amalgam restorations.

Amalgam Phase-Down Part 1: UK-Based Posterior Restorative Material and Technique Use.

INTRODUCTION: A European Union amalgam phase-down has recently been implemented. Publicly funded health care predominates in the United Kingdom with the system favoring amalgam use. The current use of amalgam and its alternatives has not been fully investigated in the United Kingdom. OBJECTIVES: The study aimed to identify direct posterior restorative techniques, material use, and reported postoperative complication incidence experienced by primary care clinicians and differences between clinician groups. METHODS: A cross-sectional survey was distributed to primary care clinicians through British dentist and therapist associations (11,092 invitations). The questionnaire sought information on current provision of direct posterior restorations and perceived issues with the different materials. Descriptive statistical and hypothesis testing was performed. RESULTS: Dentists' response rate was 14% and therapists' estimated minimum response rate was 6% (total N = 1,513). The most commonly used restorative material was amalgam in molar teeth and composite in premolars. When placing a direct posterior mesio-occluso-distal restoration, clinicians booked on average 45% more time and charged 45% more when placing composite compared to amalgam (P < 0.0001). The reported incidences of food packing and sensitivity following the placement of direct restorations were much higher with composite than amalgam (P < 0.0001). Widely recommended techniques, such as sectional metal matrix use for posterior composites, were associated with reduced food packing (P < 0.0001) but increased time booked (P = 0.002). CONCLUSION: Amalgam use is currently high in the publicly funded sector of UK primary care. Composite is the most used alternative, but it takes longer to place and is more costly. Composite also has a higher reported incidence of postoperative complications than amalgam, but time-consuming techniques, such as sectional matrix use, can mitigate against food packing, but their use is low. Therefore, major changes in health service structure and funding and posterior composite education are required in the United Kingdom and other countries where amalgam use is prevalent, as the amalgam phase-down continues. KNOWLEDGE TRANSFER STATEMENT: This study presents data on the current provision of amalgam for posterior tooth restoration and its directly placed alternatives by primary care clinicians in the United Kingdom, where publicly funded health care with copayment provision predominates. The information is important to manage and plan the UK phase-down and proposed phase-out of amalgam and will be of interest to other, primarily developing countries where amalgam provision predominates in understanding some of the challenges faced.

Amalgam Phase-Down Part 2: UK-Based Knowledge, Opinions, and Confidence in the Alternatives.

INTRODUCTION: Amalgam use has recently been phased down, and the potential for a phase-out is being investigated. OBJECTIVES: The study aimed to identify knowledge of the phase-down and opinions of a potential phase-out of amalgam by UK primary care clinicians and assess their confidence in using different materials in different situations. METHODS: An anonymized, prepiloted cross-sectional e-survey was used to assess primary care clinicians' knowledge and opinions of the amalgam phase-down and potential phase-out and their confidence in using amalgam and the alternatives in different situations. In total, 11,902 invitations were distributed through British dentist and therapist associations. Prior hypotheses were tested alongside descriptive statistics. RESULTS: Response rate was 13% (n = 1,513). Knowledge of the amalgam phase-down was low, with just 3% clinicians correctly identifying all patient groups in whom amalgam use should be avoided in the United Kingdom. Postgraduate education on posterior composite placement was high (88%), but a large majority had personal and patient-centered concerns over the suitability of the alternatives and lacked confidence when placing composite in comparison to amalgam in difficult situations (P < 0.0001). Logistic regressions revealed that the best predictors of high confidence in placing mesio-occluso-distal composites and composites in difficult situations were being a private general dentist or being primarily a composite user. CONCLUSION: Primary care clinicians have major personal and patient-centered concerns regarding the amalgam phase-down (of which they have limited knowledge) and potential phase-out. Many lack confidence in using the alternative, composite, to restore posterior teeth in difficult situations, whereas confidence in using amalgam in similar situations is high. Effective education of clinicians and understanding patients' needs, alongside policy changes, are required to enable a successful amalgam phase-down and potential phase-out. KNOWLEDGE TRANSFER STATEMENT: This study shows that UK primary care clinicians are worried about the phase-down of amalgam for themselves and their patients. Many lack confidence in the alternative, composite, when used in difficult situations, which is in stark contrast to amalgam. Knowledge of the phase-down is limited. There is a need for more effective education of clinicians, an understanding of patients' values, and policy changes to ensure the success of the phase-down and potential phase-out of amalgam.

Eliciting Preferences for Adult Orthodontic Treatment: A Discrete Choice Experiment.

INTRODUCTION: There has been little research to explore how adults financially value private orthodontic treatment and whether they have preferences for different attributes of treatment. This study used a discrete choice experiment and aimed to determine whether the recognized skill level of the dental professional and the type of orthodontic appliance influence the values that the public places on private adult orthodontic treatment. METHODS: In total, 206 adult patients or the parents/guardians of children attending general dental practices in the northeast of England were recruited to complete a discrete choice experiment. Three attributes were included: the type of dental professional providing treatment, the type of orthodontic appliance, and cost. Also collected were demographic and orthodontic history characteristics. Results were analyzed with conditional logistic regression and elicited marginal willingness to pay (MWTP). RESULTS: Participants value the training and expertise of the dental professional providing private orthodontic treatment greater than the type of orthodontic appliance. MWTP for orthodontic treatment increased in conjunction with the recognized skill level of the dental professional. Participants were willing to pay more for aesthetic appliances over a fixed metal appliance. CONCLUSIONS: Participants value the training and expertise of the dental professional providing private adult orthodontic treatment greater than the type of orthodontic appliance. These preferences concur with other discrete choice experiments undertaken in medical specialties that included attributes focusing on the qualification, skill, or expertise of the health care professional. MWTP for orthodontic treatment increased in conjunction with the recognized skill level of the dental professional. Participants were willing to pay more for aesthetic appliances than metal fixed appliances. The cost of orthodontics is significant, and adults appreciate the importance of having options and making choices.Knowledge Transfer Statement: The results of this study suggest that patients are willing to pay more for orthodontic services provided by clinicians with higher levels of formal training. In a competitive market where the public appears to prefer the provider over treatment modality, there is an incentive for clinicians to optimize their knowledge and skills to deliver the high-quality orthodontic treatment that patients are demanding. Orthodontic clinicians should be mindful of the demand for the different adult orthodontic appliances and tailor their skill sets accordingly.

Resource Allocation in a National Dental Service Using Program Budgeting Marginal Analysis.

INTRODUCTION: In any health system, choices must be made about the allocation of resources (budget), which are often scarce. Economics has defined frameworks to aid resource allocation, and program budgeting marginal analysis (PBMA) is one such framework. In principle, patient and public values can be incorporated into these frameworks, using techniques such as willingness to pay (WTP). However, this has not been done before, and few formal resource allocation processes have been undertaken in dentistry. This study aimed to undertake a PBMA with embedded WTP values in a national dental setting. METHODS: The PBMA process was undertaken by a panel of participant-researchers representing commissioners, dentists, dental public health staff, and academics. The panel reviewed current allocations and generated a set of weighted criteria to evaluate services against. Services to be considered for removal and investment were determined by the panel and wider discussion and then scored against the criteria. Values from a nationally representative WTP survey of the public contributed to the scores for interventions. Final decisions on removal and investment were taken after panel discussion using individual anonymous electronic voting. RESULTS: The PBMA process resulted in recommendations to invest in new program components to improve access to general dentists, care home dentistry, and extra support for dental public health input into local government decisions. Disinvestments were recommended in orthodontics and to remove routine scaling and polishing of teeth. DISCUSSION: The PBMA process was successful in raising awareness of resource allocation issues. Implementation of findings will depend on the ability of decision makers to find ways of operationalizing the decisions. The process illustrates practical aspects of the process that future dental PBMAs could learn from. KNOWLEDGE TRANSFER STATEMENT: This study illustrates a framework for resource allocation in dental health services and will aid decision makers in implementing their own resource allocation systems.

Editorial - Community Water fluoridation.

Since the discovery of the caries preventive benefits of fluoride, it has been the cornerstone of preventive programs for children and adults. Water fluoridation, the controlled addition of a precise amount of fluoride to community water systems to the level beneficial for dental health, is one of the most effective and safe means to deliver fluoride (McDonagh et al., 2000; National Health and Medical Research Council, 2017). In 1999, the US Centers for Disease Control and Prevention (CDC) named fluoridation of drinking water as one of ten great public health achievements in the 20th Century, alongside vaccination, control of infectious diseases, a decline in death from coronary heart disease and other accomplishments (CDC, 2011). This is a remarkable recognition of the impact of dental conditions and the importance of a dental preventive program.

Reorienting Oral Health Services to Prevention: Economic Perspectives.

Despite the recognized need to change the emphasis of health services by shifting the balance from treatment to prevention, limited progress has been made in many settings. This is true in oral health, where evidence for preventive interventions that work has not been systematically exploited in oral health services. While reorienting health services is complex and context specific, economics can bring a helpful perspective in understanding and predicting the impact of changes in resource allocation, provider remuneration systems, and patient payments. There is an increasing literature on the economics of different prevention approaches. However, much of this literature focuses on the costs and potential savings of alternative approaches and fails to take into account benefits. Even where benefits are taken into account, these tend to be narrowly focused on clinical outcomes using cost-effectiveness analysis, which may be of little relevance to the policy maker, patient, and the public. Some commonly used economic approaches (such as quality-adjusted life years and incremental cost-effectiveness ratios) may also not be appropriate to oral health. Using alternative techniques, including wider measures of benefit and employing priority setting and resource allocation tools, may provide more comprehensive information on economic impact to decision makers and stakeholders. In addition, it is important to consider the effects of provider remuneration in reorienting services. While there is some evidence about traditional models of remuneration (fee for service and capitation), less is known about pay for performance and blended systems. This article outlines areas in which economics can offer an insight into reorientation of health systems toward prevention, highlighting areas for further research and consideration.

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.

Can intravenous conscious sedation with midazolam be effective at facilitating surgical dentistry in adolescent orthodontic patients? A service evaluation.

Background Surgical dentistry during orthodontic care often occurs in adolescence and may involve surgical removal or exposure of teeth. The invasive nature of treatment, combined with dental anxiety, means care can often be provided under general anaesthesia (GA). Best-practice guidelines however endorse conscious sedation as an alternative, where appropriate. Although a limited number of studies have shown safe and effective use of intravenous conscious sedation (IVCS) with midazolam in this cohort, robust evidence to support routine use is lacking. Aim To assess whether IVCS with midazolam can effectively facilitate surgical dentistry in adolescent orthodontic patients in primary care.Method A retrospective service evaluation was undertaken reviewing clinical records of adolescents (aged 12-15 years) undergoing surgical exposure and/or surgical removal of teeth under IVCS with midazolam.Results A total of 174 adolescents (mean age 14.2 years) attended for treatment between 2009 and 2015. Of these adolescents, 98.9% (N = 172) allowed cannulation, with all surgical dentistry completed during a single visit. Midazolam dose ranged from 2-7 mg with 79.1% of patients having good or excellent cooperation and three minor adverse events occurring.Conclusion This service evaluation shows IVCS with midazolam can effectively facilitate surgical orthodontics in carefully selected adolescents. There is however a distinct need to further explore potential for this technique to provide a viable alternative to GA.

The orthodontic condition of children in England, Wales and Northern Ireland 2013.

Background The 2013 Children's Dental Health Survey is the fifth in a series of national surveys.Aims This paper reports the orthodontic condition of 12- and 15-year-olds and how they and their parents feel about the appearance of their teeth.Methodology A representative sample of children (5y, 8y, 12y, 15y) in England, Wales and Northern Ireland were invited to participate in dental examinations. A modified Index of Orthodontic Treatment Need (IOTN) was used as a measure of orthodontic treatment need for 12- and 15-year-olds. Children and parents were invited to complete a questionnaire about oral health behaviour and attitudes.Results Nine percent of 12-year-olds and 18% of 15-year-olds were undergoing orthodontic treatment at the time of the survey. Forty-four percent of 12-year-olds and 29% of 15-year-olds expressed a desire for straighter teeth, however over half of this group would not qualify for NHS treatment. Unmet treatment need was higher in children eligible for free school meals (P <0.05 at 15y).Conclusions Provision of and demand for orthodontic treatment is increasing, with a significant proportion of children who desire orthodontic care not eligible to receive it. Children from deprived backgrounds have greater unmet orthodontic treatment need.

Caries experience, the caries burden and associated factors in children in England, Wales and Northern Ireland 2013.

Background The 2013 Children's Dental Health Survey is the fifth in a series of national surveys.Aims To describe caries prevalence and severity and factors affecting these, in children in England, Wales and Northern Ireland in 2013.Methodology A representative sample of children (aged 5, 8, 12 and 15 years) in England, Wales and Northern Ireland were invited to participate in dental examinations. Caries was measured at both the dentine ('obvious caries') and dentine plus enamel ('clinical caries') levels and analysis included identifying those with indicators of significant burden of caries and identifying predictive factors.Results In 5-year-olds, 40% had obvious caries experience increasing to 56% when enamel lesions were included. In 15-year-olds, the respective figures were 46% and 63%. Fourteen percent of 5-year-olds and 15% of 15-year-olds had a least one indicator of significant levels of caries and those from deprived backgrounds were more likely to fall into this group.Conclusions Overall, the prevalence of caries in children is continuing to decrease, but the rate is slowing. The level of disease for those with disease is much higher than the average values might suggest and there remain a sizeable minority with a significant burden of caries, associated with deprivation. This complex picture poses significant clinical and public health challenges.

Forty years of national surveys: An overview of children's dental health from 1973-2013.

INTRODUCTION: The first national survey of children's dental health in England and Wales was carried out in 1973. Subsequent surveys, in 1983, 1993 and 2003, included all United Kingdom health departments. The 2013 survey involved England, Wales and Northern Ireland. AIM: To consider all five surveys, from 1973 to 2013, so as to summarise trends in the dental health of children in the UK over the last 40 years. MATERIALS AND METHOD: The 2013 survey was commissioned by the Health &Social Care Information Centre and all surveys used data collected during dental examinations conducted in schools on a random sample of children by NHS dentists, together with a questionnaire to parents of those children. In 2013, a pupil questionnaire for 12- and 15-year-olds was introduced, to complement information received from parents and carers. RESULTS: A total of 69,318 children, aged 5-15 years, were involved, from 1973-2013. Caries prevalence has reduced from 72% to 41% in 5-year-olds, and from 97% to 46% in 15-year-olds in 40 years. Changes in periodontal disease, orthodontic treatment, accidental damage to anterior teeth, tooth surface loss and enamel defects, are also summarised. Behavioural and attitudinal characteristics observed in the 2013 report are listed. CONCLUSIONS: Caries is now concentrated in a minority of children. The prevalence of gingivitis has not changed a great deal in 40 years. About half of those children assessed 'in orthodontic need' receive treatment.

What are dental non-attenders' preferences for anxiety management techniques? A cross-sectional study based at a dental access centre.

OBJECTIVE: Dental anxiety is a barrier to attendance. Dental non-attenders may seek emergency care and may prefer to receive anxiety management measures for treatment required. Little is known about the preferences of these dental non-attenders for different anxiety management techniques. Understanding such preferences may inform management pathways, improve experiences, alleviate anxieties and encourage a more regular attendance pattern. As such, the aim of this study was to gain a greater understanding of the dental anxiety of patients attending a dental access centre for emergency dental treatment and to ascertain preferences for different anxiety management techniques. DESIGN: Cross-sectional study involving self-completed questionnaires and clinical observation. SETTING: NHS Dental Access Centre, York, UK. SUBJECTS AND METHODS: Two hundred participants not registered with a general dental practitioner, aged 18 years or over, experiencing pain and self-referred were recruited on a consecutive sampling basis. Participants completed a questionnaire eliciting demographic and dental history details, dental anxiety and preferences for dental anxiety management options. MAIN OUTCOME MEASURES: Correlation of the modified dental anxiety scale with preference for different dental anxiety management techniques. RESULTS: No significant predictive factors were found that explained preferring local anaesthetic to sedation, or general anaesthesia for restorations or extractions. Those highly anxious were less likely to consider tell-show-do techniques (p=0.001) or watching explanatory videos (p=0.004) to be helpful for overcoming their anxieties than the low or moderate anxiety groups. CONCLUSIONS: People attending access centres may represent a group who are unwilling to explore non-pharmacological methods to overcome their anxieties. This supports the need for sedation to provide treatment. Future work may include exploring in more depth the thoughts and opinions of this group of patients to improve understanding of their complex dental attitudes. From this, more effective strategies may be developed to encourage regular dental attendance.

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.

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.