A quality appraisal of economic evaluations of community water fluoridation: A systematic review.

OBJECTIVES: To critically appraise the methodological conduct and reporting quality of economic evaluations (EE) of community water fluoridation (CWF). METHODS: A systematic literature search was conducted in general databases and specialist directories of the economic literature. The Consensus on Health Economic Criteria list (CHEC) appraised the methodological quality while the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) assessed the reporting quality of included studies. RESULTS: A total of 1,138 records were identified, of which 18 met the inclusion criteria. Cost analysis emerged as the most prevalent type of EE, though a growing trend towards conducting full EEs is observed. CHEC revealed the items most frequently unfulfilled were the study design, measurement and valuation of costs and outcomes, while CHEERS also identified reporting deficiencies in these aspects. Furthermore, the review highlights subtleties in methodological aspects that may not be discerned by CHEC, such as the estimation of the impact of fluoridation and the inclusion of treatment savings within cost estimates. CONCLUSIONS: While numerous studies were conducted before publication of these assessment instruments, this review reveals that a noteworthy subset of studies exhibited good methodological conduct and reporting quality. There has been a steady improvement in the methodological and reporting quality over time, with recently published EEs largely adhering to best practice guidelines. The evidence presented will assist policymakers in leveraging the available evidence effectively to inform resource allocation decisions. It may also serve as a resource for researchers to enhance the methodological and reporting standards of future EEs of CWF.

Dental Extractions under General Anesthesia: New Insights from Process Mining.

INTRODUCTION: Tooth extraction under general anesthetic (GA) is a global health problem. It is expensive, high risk, and resource intensive, and its prevalence and burden should be reduced where possible. Recent innovation in data analysis techniques now makes it possible to assess the impact of GA policy decisions on public health outcomes. This article describes results from one such technique called process mining, which was applied to dental electronic health record (EHR) data. Treatment pathways preceding extractions under general anesthetic were mined to yield useful insights into waiting times, number of dental visits, treatments, and prescribing behaviors associated with this undesirable outcome. METHOD: Anonymized data were extracted from a dental EHR covering a population of 231,760 patients aged 0 to 16 y, treated in the Irish public health care system between 2000 and 2014. The data were profiled, assessed for quality, and preprocessed in preparation for analysis. Existing process mining methods were adapted to execute process mining in the context of assessing dental EHR data. RESULTS: Process models of dental treatment preceding extractions under general anesthetic were generated from the EHR data using process mining tools. A total of 5,563 patients who had 26,115 GA were identified. Of these, 9% received a tooth dressing before extraction with an average lag time of 6 mo between dressing and extraction. In total, 11,867 emergency appointments were attended by the cohort with 2,668 X-rays, 4,370 prescriptions, and over 800 restorations and other treatments carried out prior to tooth extraction. DISCUSSION AND CONCLUSIONS: Process models generated useful insights, identifying metrics and issues around extractions under general anesthetic and revealing the complexity of dental treatment pathways. The pathways showed high levels of emergency appointments, prescriptions, and additional tooth restorations ultimately unsuccessful in preventing extractions. Supporting earlier publications, the study suggested earlier screening, preventive initiatives, guideline development, and alternative treatments deserve consideration. KNOWLEDGE TRANSFER STATEMENT: This study generates insights into tooth extractions under general anesthetic using process mining technologies and methods, revealing levels of extraction and associated high levels of prescriptions, emergency appointments, and restorative treatments. These insights can inform dental planners assessing policy decisions for tooth extractions under general anesthetic. The methods used can be combined with costs and patient outcomes to contribute to more effective decision-making.

Impact of Reducing Water Fluoride on Dental Caries and Fluorosis.

Guidance intended to reduce fluoride toothpaste ingestion in early childhood was introduced in Ireland in 2002. In 2007, water fluoride concentration was adjusted from 0.8-1.0 to 0.6-0.8 ppm. The objective of this study was to determine the difference in caries and fluorosis levels following introduction of these 2 policy measures. A before-and-after study compared caries and fluorosis in random samples of 8-y-olds in Dublin (n = 707) and Cork-Kerry (n = 1148) in 2017 with 8-y-olds in Dublin (n = 679) and Cork-Kerry (n = 565) in 2002. Dentinal caries experience (primary teeth, d3vcmft(cde)) and fluorosis (permanent teeth, Dean's index of very mild or higher) were clinically measured. Lifetime exposure to community water fluoridation (CWF) was classified as "full CWF"/"no CWF." Effect of examination year on caries prevalence and severity and fluorosis prevalence was assessed using multivariate regression adjusting for other explanatory variables. There was little change in commencement of fluoride toothpaste use at ≤24 mo following introduction of toothbrushing guidance. Among children with full CWF, there was no statistically significant difference in caries prevalence or severity between 2017 and 2002. In 2017, caries prevalence was 55% in Dublin (full CWF) and 56% in Cork-Kerry (full CWF), and mean d3vcmft(cde) among children with caries was 3.4 and 3.7, respectively. Caries severity was less in 2017 (mean 4.2) than 2002 (mean 4.9) among children with no CWF (P = 0.039). The difference in caries severity between children with full CWF and no CWF was less in 2017 than in 2002 (interaction P = 0.013), suggesting a reduced benefit for CWF in 2017. In 2017, fluorosis prevalence was 18% in Dublin (full CWF) and 12% in Cork-Kerry (full CWF). Fluorosis was predominantly "very mild" with no statistically significant difference between 2017 and 2002. CWF at 0.6 to 0.8 ppm is an effective caries-preventive measure. Results suggested low uptake of toothbrushing guidance, a reduced caries-preventive effect for CWF in primary teeth, and no reduction in fluorosis following introduction of the policy measures.

Fluoride Revolution and Dental Caries: Evolution of Policies for Global Use.

Epidemiological studies over 70 y ago provided the basis for the use of fluoride in caries prevention. They revealed the clear relation between water fluoride concentration, and therefore fluoride exposure, and prevalence and severity of dental fluorosis and dental caries. After successful trials, programs for water fluoridation were introduced, and industry developed effective fluoride-containing toothpastes and other fluoride vehicles. Reductions in caries experience were recorded in many countries, attributable to the widespread use of fluoride. This is a considerable success story; oral health for many was radically improved. While previously, water had been the only significant source of fluoride, now there are many, and this led to an increase in the occurrence of dental fluorosis. Risks identified for dental fluorosis were ingestion of fluoride-containing toothpaste, water fluoridation, fluoride tablets (which were sometimes ingested in areas with water fluoridation), and infant formula feeds. Policies were introduced to reduce excessive fluoride exposure during the period of tooth development, and these were successful in reducing dental fluorosis without compromising caries prevention. There is now a much better understanding of the public perception of dental fluorosis, with mild fluorosis being of no aesthetic concern. The advantages of water fluoridation are that it provides substantial lifelong caries prevention, is economic, and reduces health inequalities: it reaches a substantial number of people worldwide. Fluoride-containing toothpastes are by far the most important way of delivering the beneficial effect of fluoride worldwide. The preventive effects of conjoint exposure (e.g., use of fluoride toothpaste in a fluoridated area) are additive. The World Health Organization has informed member states of the benefits of the appropriate use of fluoride. Many countries have policies to maximize the benefits of fluoride, but many have yet to do so.

Improving oral healthcare using academic detailing - design of the ADVOCATE Field Studies.

Background: Academic detailing (AD) is a defined form of educational outreach that can be deployed to intrinsically motivate practitioners towards improving quality of care. This paper describes the design of the ADVOCATE Field Studies. This proof of concept study aims to evaluate the feasibility, acceptability and usefulness of AD, reinforced with feedback information to promote prevention-oriented, patient-centred and evidence-based oral healthcare delivery by general dental practitioners (GDPs). Methods: Six groups of GDPs will be recruited; two groups of six to eight GDPs in each of three countries - the Netherlands, Germany and Denmark. GDPs will meet for four Academic Detailing Group (ADG) meetings for open discussions using comparative feedback data to stimulate debate about their dental practice performance and care delivery. Group meetings will be moderated using the AD methodology. Qualitative data will be collected through focus group interviews, an online discussion forum, field notes and debriefs of ADG meetings and analysed by conventional content analysis using MaxQDA software. Discussion: The results of the study will provide novel information on the feasibility, perceived acceptability and usefulness of AD and feedback data for GDPs to improve oral healthcare delivery.

Barriers and facilitators for prevention in Danish dental care.

Objective: To explore barriers and facilitators to oral disease prevention in Danish dental care from a multi-stakeholder perspective. Methods: Eleven semi-structured focus groups and interviews about Danish oral healthcare were conducted with 27 stakeholders (general public, dental teams, dental policy makers) in Copenhagen. Transcripts were analyzed using deductive thematic analysis independently by KR and HL, supervised by JC and KVC. Results: Seven broad themes were identified, including both barriers and facilitators: Knowledge and attitudes, Education and training, Regulation, Incentivization, Multidisciplinary approach, Access to care and the Dental professional-patient relationship. Whilst all themes were relevant to each group of stakeholders, the salient driver within each theme was different for each group. Conclusions: Stakeholder perspectives on the Danish Oral health care system suggest the following are important features for a preventively focused system: (a) Involving all stakeholders in oral healthcare planning. (b) Securing sufficient and ongoing briefing regarding disease prevention for all stakeholders. (c) Regulatory support and creation of incentives to promote and facilitate implementation of disease prevention. (d) Appropriate prevention for disadvantaged groups within society which may be possible to a higher degree by means of multidisciplinary collaboration. (e) Personal relations between the patient and the professional based on mutual trust.

Toward More Patient-Centered and Prevention-Oriented Oral Health Care: The ADVOCATE Project.

ADVOCATE (Added Value for Oral Care) is a project funded by the European Commission's Horizon 2020 program, which aims to develop strategies for a system transition toward more patient-centered and prevention-oriented oral health care delivery within health care systems. This system should balance the restorative and preventive approaches in dental and oral health care. ADVOCATE is a partnership among 6 European Union member states, which involves collaboration among universities, state-funded health care providers, and private insurance companies in Denmark, Germany, Hungary, Ireland, the Netherlands, the United Kingdom, and Aridhia, a biomedical informatics company based in Scotland. There are 6 interrelated work packages, which aim to address the following objectives: 1) in-depth evaluation of oral health care systems in European Union member states to identify best system designs for oral disease prevention, 2) development of a set of measures to provide information on oral care delivery and oral health outcomes, 3) evaluation of a feedback approach in dental practice that aims to facilitate a change toward preventive oral health care delivery, and 4) economic evaluation of strategies to promote preventive oral health care and development of policy recommendations for oral health care systems. The project is novel in its use of data that are routinely collected by health insurance organizations, as well as the engagement of key stakeholders from dental teams, insurers, patients, and policy makers in guiding the development and progress of the project. This article outlines in detail the objectives and research methodology of the ADVOCATE project and its anticipated impact. Knowledge Transfer Statement: This commentary describes the development of policy options to promote a greater focus on disease prevention in general dental practice. The approach builds on identifying the comparative effectiveness of alternative incentive schemes, as well as methods to monitor clinical and patient-derived measures of success in creating health for patients. The article describes the development and application of the measures and the evaluation of their success in orienting clinical practice more toward disease prevention.

Fluoride and Oral Health.

The discovery during the first half of the 20th century of the link between natural fluoride, adjusted fluoride levels in drinking water and reduced dental caries prevalence proved to be a stimulus for worldwide on-going research into the role of fluoride in improving oral health. Epidemiological studies of fluoridation programmes have confirmed their safety and their effectiveness in controlling dental caries. Major advances in our knowledge of how fluoride impacts the caries process have led to the development, assessment of effectiveness and promotion of other fluoride vehicles including salt, milk, tablets, toothpaste, gels and varnishes. In 1993, the World Health Organization convened an Expert Committee to provide authoritative information on the role of fluorides in the promotion of oral health throughout the world (WHO TRS 846, 1994). This present publication is a revision of the original 1994 document, again using the expertise of researchers from the extensive fields of knowledge required to successfully implement complex interventions such as the use of fluorides to improve dental and oral health. Financial support for research into the development of these new fluoride strategies has come from many sources including government health departments as well as international and national grant agencies. In addition, the unique role which industry has played in the development, formulation, assessment of effectiveness and promotion of the various fluoride vehicles and strategies is noteworthy. This updated version of 'Fluoride and Oral Health' has adopted an evidence-based approach to its commentary on the different fluoride vehicles and strategies and also to its recommendations. In this regard, full account is taken of the many recent systematic reviews published in peer reviewed literature.

Critique of the review of 'Water fluoridation for the prevention of dental caries' published by the Cochrane Collaboration in 2015.

The Cochrane Review on water fluoridation for the prevention of dental caries was published in 2015 and attracted considerable interest and comment, especially in countries with extensive water fluoridation programmes. The Review had two objectives: (i) to evaluate the effects of water fluoridation (artificial or natural) on the prevention of dental caries, and (ii) to evaluate the effects of water fluoridation (artificial or natural) on dental fluorosis. The authors concluded, inter alia, that there was very little contemporary evidence, meeting the Review's inclusion criteria, that evaluated the effectiveness of water fluoridation for the prevention of dental caries. The purpose of this critique is to examine the conduct of the above Review, and to put it into context in the wider body of evidence regarding the effectiveness of water fluoridation. While the overall conclusion that water fluoridation is effective in caries prevention agrees with previous reviews, many important public health questions could not be answered by the Review because of the restrictive criteria used to judge adequacy of study design and risk of bias. The potential benefits of using wider criteria in order to achieve a fuller understanding of the effectiveness of water fluoridation are discussed.

Analysis of a payments database reveals trends in dental treatment provision.

Use of fluoride has led to dramatic improvements in oral health; however, the impact of these improvements on the volume and mix of treatment provided in dental systems is largely unknown. The use of administrative data to analyze trends in treatment provision gives 'real-life' insight into the impact of changing levels of oral health on oral health services. The first aim of this study was to determine the extent to which useful data on temporal treatment patterns could be extracted from a public insurance database. The second aim, contingent on the first, was to investigate whether increased tooth retention and decreases in caries were reflected in the volume and types of treatment provided to adults within a public social insurance scheme between 1997 and 2008. Data were retrieved from the Dental Treatment Benefit Scheme databases, and new datasets were generated to analyze the distribution of treatments and mean treatments provided to 1,271,937 adults over the 12-year period. Provision of restorations, extractions, and dentures decreased, and the ratio of preventive/diagnostic to invasive treatments per dentist increased, which supports reported improvements in oral health. In conclusion, this paper illustrates the decline in invasive treatments, and increase in preventive treatments that accompanied improvements in oral health.

Milestones in oral health services in the Republic of Ireland.

With the many changes occurring in Ireland it would seem an opportune time to review the body of research conducted and policy enacted in the Republic of Ireland on oral health services and oral health. The dental health of the nation prior to water fluoridation, the legislation and policy decisions impacting on oral health up to budgetary changes, and the production of evidence-based guidelines will be discussed. The first national survey of dental health was conducted in Ireland in 1952 - 'Dental Caries in Ireland'. In the intervening 60 years, further surveys of the oral health of people in Ireland have been carried out. Legislation, surveys and policy documents that have shaped dentistry and the oral health of the population are set out in Tables 1 and 2. A more comprehensive description of the policies can be found in the thesis submitted in fulfilment of Masters in Dental Public Health (MDPH) by the lead author.

A new index to measure tooth wear--methodolgy and practical advice.

A new tooth wear index, designed to measure stages of tooth wear in enamel and dentine is presented. The index measures the lateral spread of wear in enamel and the depth of tooth wear in dentine. The index scores enamel loss at 5 levels and 6 levels in dentine and provides a more sensitive index for monitoring the progression of wear than older indices. The protocols and methods of the index are described and incorporate refinements based on the combined experiences of two independent studies conducted on adults and children. The findings of both studies are summarised and recommendations are made for future studies which investigate the prevalence of tooth wear in adults or children.

Non-biological factors associated with tooth retention in Irish adults.

OBJECTIVES: To identify non-biological factors associated with retention of natural teeth and sound untreated natural teeth among adults in Ireland. DESIGN: Data were collected in the 2000/'02 epidemiological survey of the oral health of Irish adults. CLINICAL SETTING: Participants underwent a clinical oral examination in health board dental clinics and a detailed interview pertaining to oral and general health. PARTICIPANTS: The analysis is based on a random sample of adults aged 16-24 years (n = 1,196), 35-44 years (n = 978), and 65 years and older (n = 714). MAIN OUTCOME MEASURES: Dependent variables were number of natural teeth present (NT), number of sound untreated natural teeth (SUNT), likelihood of being dentate, having 21 or more NT (21+NT), 28 or more NT (28+NT), and 18 or more SUNT (18+SUNT). Socioeconomic status (SES) was based on being disadvantaged, occupation status and educational attainment. Behavioural factors included smoking, snacking, brushing frequency and dental visiting patterns. Bivariate and multivariate regression analyses were performed. RESULTS: Tooth retention decreased with increasing age group. Level of education, disadvantage status, being in employment, frequent brushing and visiting the dentist for a check-up (instead of when in need or pain) were associated with tooth retention. Attending for a check-up moderated the impact of disadvantage on tooth retention among 35-44 year-olds. CONCLUSIONS: The results of this study indicate that several non-biological determinants are important for dental health in this adult population.

Development of gold standard ion-selective electrode-based methods for fluoride analysis.

BACKGROUND/AIMS: Currently available techniques for fluoride analysis are not standardized. Therefore, this study was designed to develop standardized methods for analyzing fluoride in biological and nonbiological samples used for dental research. METHODS: A group of nine laboratories analyzed a set of standardized samples for fluoride concentration using their own methods. The group then reviewed existing analytical techniques for fluoride analysis, identified inconsistencies in the use of these techniques and conducted testing to resolve differences. Based on the results of the testing undertaken to define the best approaches for the analysis, the group developed recommendations for direct and microdiffusion methods using the fluoride ion-selective electrode. RESULTS: Initial results demonstrated that there was no consensus regarding the choice of analytical techniques for different types of samples. Although for several types of samples, the results of the fluoride analyses were similar among some laboratories, greater differences were observed for saliva, food and beverage samples. In spite of these initial differences, precise and true values of fluoride concentration, as well as smaller differences between laboratories, were obtained once the standardized methodologies were used. Intraclass correlation coefficients ranged from 0.90 to 0.93, for the analysis of a certified reference material, using the standardized methodologies. CONCLUSION: The results of this study demonstrate that the development and use of standardized protocols for F analysis significantly decreased differences among laboratories and resulted in more precise and true values.

Is the shortened dental arch an underused treatment strategy in the Republic of Ireland?

OBJECTIVES: To determine the proportion of Republic of Ireland 35-44 and 65+ year-olds currently satisfying the criteria for a classic shortened dental arch (SDA) of 20 anterior teeth. RESEARCH DESIGN: Secondary analysis of data collected in the 2000/02 epidemiological survey of the oral health of Irish adults. CLINICAL SETTING: Participants underwent a clinical oral examination in health board dental clinics and completed a detailed interview pertaining to dental and general health. PARTICIPANTS: The analysis is based on a random sample of adults, aged 35 to 44 years (n = 978), and 65 years and older (n = 714). MAIN OUTCOME MEASURES: The SDA was measured as 20 teeth in the mouth in the positions normally described as from the left second premolar to the right second premolar in each arch. RESULTS: Only one of the 35-44 year-olds and none of the 65+ year-olds had teeth in their mouths in positions normally described as a classic SDA. However, of the 35-44 year old age group only five patients who had at least a premolar dentition of 20 contiguous teeth had been provided with a removable denture compared to one patient from the 65+ years group. CONCLUSIONS: Very few older patients in the Republic of Ireland have a SDA based on the measure used. However, very few have been provided with removable dentures where they already possess at least a premolar dentition of 20 contiguous teeth. Suggested reasons for this may include limitations of the data recorded, patient preferences and economic factors.

Predictors of utilisation of dental care services in a nationally representative sample of adults.

OBJECTIVE: The objective of this study was to identify the predictors of utilisation of dental care services in Ireland. PARTICIPANTS: The 2007 Irish Survey of Lifestyle, Attitudes and Nutrition is a cross-sectional study, conducted in 2006/2007 (n = 10,364), by interviews at home to a representative sample of adults aged 18 years or over. MAIN OUTCOME MEASURES: Multivariate logistic regression was used to investigate the influence of socioeconomic, predisposing and enabling factors on the odds of males and females having a dental visit in the past year. RESULTS: The significant predictors of visiting the dentist in the past year were for males: having 3rd level education, employment status, earning 50,000 euros or more, location of residence, use of a car, brushing frequently, and dentition status. For females, the predictors were being between 25-34 or 55-64 years-old, education level, earning 50,000 euros or more, location of residence, use of a car, brushing frequently and dentition status. CONCLUSIONS: Predictors of the use of dental services vary by gender. Predictors common to both genders were education level, higher income, location of residence, use of a car, brushing frequently and dentition status. Many of the predictors of dental visiting in the past year are also related to social inequalities in health. These predictors may be useful markers of impact for policies designed to address inequalities in access to oral health services.

The caries-preventive effect of chlorhexidine varnish in children and adolescents: a systematic review.

AIMS: Our purpose was to systematically review the literature on the effectiveness of chlorhexidine varnish for preventing dental caries in children and adolescents and to determine its effectiveness compared to fluoride varnish. METHODS: MEDLINE, EMBASE and the Cochrane Library were searched through December 2009 to identify relevant randomised trials with blind outcome assessment and a minimum duration of 1 year. The search was later updated in MEDLINE and the Cochrane Library to March 19th, 2010. Risk of bias of the included trials was assessed. The primary outcome was the caries increment. RESULTS: Twelve trials met the inclusion criteria for the review. There was considerable variation between trials in the concentration and frequency of application of the chlorhexidine varnish, in baseline caries levels and in background exposure to fluoride. Six parallel-group trials reported no statistically significant difference in caries increment in permanent teeth with the application of chlorhexidine varnish compared to placebo or no treatment. The results of 4 split-mouth trials were conflicting: 2 trials found no significant difference in caries increment and 2 reported statistically significant results in favour of chlorhexidine varnish. One trial of the effect of chlorhexidine varnish in primary teeth demonstrated a statistically significant reduction in caries increment. The results of 1 trial comparing chlorhexidine varnish with fluoride varnish for preventing caries in adolescents were equivocal. CONCLUSION: Evidence regarding the effectiveness of chlorhexidine varnish for preventing caries is inconclusive. Further well-conducted randomised trials are required before chlorhexidine varnish can be recommended for caries prevention.

Fluoridation and tooth wear in Irish adults.

The aim of this study was to determine the prevalence of tooth wear in adults in Ireland and its relationship with water fluoridation. The National Survey of Adult Oral Health was conducted in 2000/2001. Tooth wear was determined using a partial mouth examination assessing the upper and lower anterior teeth. A total of 2456 subjects were examined. In this survey, increasing levels and severity of tooth wear were associated with ageing. Men were more affected by tooth wear and were more likely to be affected by severe tooth wear than women. It was found that age, and gender were significant predictors of tooth wear (P < 0.01). Overall, there was no significant relationship between fluoridation and tooth wear in this study.