Deliberative Improvement of Oral Care Quality: The Horizon Europe DELIVER Project.

KNOWLEDGE TRANSFER STATEMENT: The EU DELIVER project aims to enhance the quality of oral health care through codevelopment and coproduction of solutions together with citizens/patients, providers, and policymakers. The unique multicountry nature of the project will facilitate fast-track prototype development and testing of innovative QI approaches in select countries. Reflective learning regarding the transferability of findings between different countries and settings offers unique opportunities to drive progress toward context-specific implementation of innovative oral health care QI approaches. The collective knowledge gained from the 7 European countries involved in DELIVER can also generate knowhow for improving the quality of oral health care in other countries around the globe.

Prioritization, Incentives, and Resource Use for Sustainable Dentistry: The EU PRUDENT Project.

KNOWLEDGE TRANSFER STATEMENT: The EU PRUDENT project aims to enhance the financing of oral health systems through novel evidence and implementation of better financing solutions together with citizens, patients, providers, and policy makers. The multicountry nature of the project offers unique windows of opportunity for rapid learning and improving within and across various contexts. PRUDENT is anticipated to strengthen capacities for better oral care financing in the EU and worldwide.

Modelling a Consultant Workforce for the United Kingdom: needs-based planning for Dental Public Health.

OBJECTIVE: To develop a needs-based workforce planning model to explore specialist workforce capacity and capability for the effective, efficient, and safe provision of services in the United Kingdom (UK); and test the model using Dental Public Health (DPH). BASIC RESEARCH DESIGN: Data from a national workforce survey, national audit, and specialty workshops in 2020 and 2021 set the parameters for a safe effective DPH workforce. A working group drawing on external expertise, developed a conceptual workforce model which informed the mathematical modelling, taking a Markovian approach. The latter enabled the consideration of possible scenarios relating to workforce development. It involved exploration of capacity within each career stage in DPH across a time horizon of 15 years. Workforce capacity requirements were calculated, informed by past principles. RESULTS: Currently an estimated 100 whole time equivalent (WTE) specialists are required to provide a realistic basic capacity nationally for DPH across the UK given the range of organisations, population growth, complexity and diversity of specialty roles. In February 2022 the specialty had 53.55 WTE academic/service consultants, thus a significant gap. The modelling evidence suggests a reduction in DPH specialist capacity towards a steady state in line with the current rate of training, recruitment and retention. The scenario involving increasing training numbers and drawing on other sources of public health trained dentists whilst retaining expertise within DPH has the potential to build workforce capacity. CONCLUSIONS: Current capacity is below basic requirements and approaching 'steady state'. Retention and innovative capacity building are required to secure and safeguard the provision of specialist DPH services to meet the needs of the UK health and care systems.

Evidence-Informed Oral Health Policy Making: Opportunities and Challenges.

Despite a clear need for improvement in oral health systems, progress in oral health systems transformation has been slow. Substantial gaps persist in leveraging evidence and stakeholder values for collective problem solving. To truly enable evidence-informed oral health policy making, substantial "know-how" and "know-do" gaps still need to be overcome. However, there is a unique opportunity for the oral health community to learn and evolve from previous successes and failures in evidence-informed health policy making. As stated by the Global Commission on Evidence to Address Societal Challenges, COVID-19 has created a once-in-a-generation focus on evidence, which has fast-tracked collaboration among decision makers, researchers, and evidence intermediaries. In addition, this has led to a growing recognition of the need to formalize and strengthen evidence-support systems. This article provides an overview of recent advancements in evidence-informed health policy making, including normative goals and a health systems taxonomy, the role of evidence-support and evidence-implementation systems to improve context-specific decision-making processes, the evolution of learning health systems, and the important role of citizen deliberations. The article also highlights opportunities for evidence-informed policy making to drive change in oral health systems. All in all, strengthening capacities for evidence-informed health policy making is critical to enable and enact improvements in oral health systems.

OPERATIONALIZING ORAL HEALTH OUTCOME MEASURES TO IMPROVE THE ORAL HEALTH OF PERSONS WITH INTELLECTUAL DISABILITIES.

Individuals with intellectual disability (ID) face significant challenges in preventing oral diseases. They also lack access to high-quality oral health care in professional settings. To understand the effects of oral conditions on their lives and health, it is necessary to assess their oral health outcome measures. For those with mild ID, who possess adequate linguistic and cognitive abilities, accessibility features should be incorporated in the dental patient reported outcome (dPRO) measures. But many other individuals often lack the linguistic and cognitive ability to self-report through dPRO measures. While self-reported measures are preferable, requiring dPROs in this population would result in a high amount of missing data and the inability to assess interventions for improving their dental health. Thus, there is a need to use proxy-reported outcome (ProxRO) measures, observer reported outcome (ObsRO) measures, and clinician reported outcome (ClinRO) measures among those with ID. This is also a common approach taken by other specialties that work closely with those with ID, where the measures for activities of daily living and adaptive behavior measures use reporting by caregivers. ProxRO measures in dentistry that were created for infants and young children provide a structure for appropriate adaptations and the creation of relevant outcome measures. Including input from the intensely multidisciplinary teams that provide supports for those with ID is key to creating high-quality measures and oral health interventions for those with ID.

Causal Effect of Tooth Loss on Cardiovascular Diseases.

Many studies suggest associations between oral health and cardiovascular diseases, but there is a lack of causal evidence. Exploiting exogenous variation in tooth loss in US adults due to differential childhood exposure to fluoridated water, this study investigated the causal effect of tooth loss on cardiovascular diseases. A total of 722,519 participants in the Behavioral Risk Factor Surveillance System (BRFSS) waves 2006, 2008, or 2010 (birth years 1940-1978) were included in the analytical sample. To identify the effect of tooth loss on having a history of coronary heart disease (CHD) or stroke, instrumental variable analysis exploited childhood exposure to drinking water fluoride as an instrument. The weighted prevalence of CHD and stroke histories was 5.1% and 2.1%, respectively. First-stage regression indicated that childhood exposure to drinking water fluoride was a strong instrument for the number of lost teeth in adulthood (coefficient -0.61; 95% confidence interval [CI] -0.80, -0.41; F = 37.47). The probability of CHD was significantly higher by 1.04 percentage points (95% CI 0.57, 1.50) per lost tooth. The effect of tooth loss on stroke was significant only for people aged ≥60 y (coefficient 0.93 percentage points; 95% CI 0.14, 1.71). These findings are supportive of a causal effect of tooth loss on cardiovascular diseases among US adults, particularly in older age.

Causal Inference: Onward and Upward!

When announcing the Sveriges Riksbank Prize in Economic Sciences in Memory of Alfred Nobel 2021, the Royal Swedish Academy emphasized how conclusions about cause and effect can be drawn from natural experiments. But what can dental research learn from this? The economist's toolbox provides a number of methods for causal inference from observational data such as instrumental variables, regression discontinuity designs, or difference-in-differences analyses. Although the relevance of improving causal inference in dental research has repeatedly been highlighted in recent years, dental research still seems to reveal major room for improvement in the application of such methods. First, there seems to be an absence of causal literature on key essential research questions for oral health. Second, the diversity and diffusion of causal inferential methods in the dental literature seem very limited so far. Third, while dental research has widely been promoting the use of directed acyclic graphs (DAGs) to help conceptualize causal thinking, comparably little attention seems to have been paid to choosing and applying appropriate data-analytic approaches for causal inference. Fourth, similar to other fields of medicine, confusion seems to persist within the dental research community as to the use of causal language. If dental research is to secure a robust evidence base for promoting effective oral health interventions, we argue that dental research needs to move beyond its current methodological echo chamber and embrace a radically different approach to causal inference. We call for editors, reviewers, and authors to embrace a much more critically reflective approach to causal inference.

Social Mobility and Tooth Loss: A Systematic Review and Meta-analysis.

This study systematically reviews the evidence of the association between life course social mobility and tooth loss among middle-aged and older people. PubMed, Scopus, Embase, and Web of Science were systematically searched in addition to gray literature and contact with the authors. Data on tooth loss were collated for a 4-category social mobility variable (persistently high, upward or downward mobility, and persistently low) for studies with data on socioeconomic status (SES) before age 12 y and after age 30 y. Several study characteristics were extracted to investigate heterogeneity in a random effect meta-analysis. A total of 1,384 studies were identified and assessed for eligibility by reading titles and abstracts; 21 original articles were included, of which 18 provided sufficient data for a meta-analysis with 40 analytical data sets from 26 countries. In comparison with individuals with persistently high social mobility, the pooled odds ratios (ORs) for the other categories were as follows: upwardly mobile, OR = 1.73 (95% CI, 1.53 to 1.95); downwardly mobile, OR = 2.52 (95% CI, 2.19 to 2.90); and persistently low, OR = 3.96 (95% CI, 3.13 to 5.03). A high degree of heterogeneity was found(I2 > 78%), and subgroup analysis was performed with 17 study-level characteristics; however, none could explain heterogeneity consistently in these 3 social mobility categories. SES in childhood and adulthood is associated with tooth loss, but the high degree of heterogeneity prevented us from forming a robust conclusion on whether upwardly or downwardly mobile SES may be more detrimental. The large variability in effect size among the studies suggests that contextual factors may play an important role in explaining the difference in the effects of low SES in different life stages (PROSPERO CRD42018092427).

[Do the additional costs of mandibular implant-retained overdentures even out the improved quality of life?] / Wegen de meerkosten van een implantaatgedragen mandibulaire gebitsprothese op tegen de verbeterde kwaliteit van leven?

In publications, implant retained overdentures have frequently been suggested to be a cost-efficient treatment alternative to conventional dentures. But whether the additional health benefits of implant retained overdentures even out the higher costs is not answered unequivocally. The qualification of the improved quality of life and the valuation of costs are strongly determined by the decision maker (insurance and/or patient). Future research must be encouraged to further elucidate patient willingness to pay for implant retained overdentures and the societal return on investment herein more generally.

[The effect of periodontal treatment on diabetes-related healthcare costs. A retrospective study]. / Effect van parodontale behandeling op diabetesgerelateerde zorgkosten. Een retrospectief onderzoek.

Periodontitis has been considered the sixth complication of diabetes. The aim of this study was to assess the impact of periodontal treatment on diabetes-related healthcare costs in patients with diabetes. Data on 41,598 adults (45.7% female) with at least 1 insurance claim in 2012 for diabetes-related treatment were included in the analysis. The impact of periodontal treatment on diabetes-related healthcare costs was analysed by means of fixed effect models for panel data. The median diabetes-related healthcare costs per patient in 2012, including costs for diagnosis, treatment, medication, and hospitalisation, were €38.45 per quarter (interquartile range €11.52 - €263.14). The fixed effects models showed a reduced expenditure on diabetes-related costs of €12.03 [95%CI €-15.77; €-8.29] per quarter following periodontal treatment. These results support the relevance and necessity of good periodontal care for patients with diabetes.

[Good oral care deserves to be better integrated into primary care]. / Goede mondzorg verdient een betere integratie in de eerstelijnszorg.

Oral and general health are inextricable. In primary care, the fields of care by general practioners, youth healthcare, healthcare for older people and oral care are all distinctly separated. Healthcare professionals are increasingly confronted with the complexity and increase in Noncommunicable diseases (NCD's) and an aging population. The aetiology of NCD's in primary care concern the professional fields of all healthcare professionals mentioned, meaning that lifestyle-related risks might be prevented more effectively through collaboration. In primary care, the number of medically compromised people is on the rise and healthcare professionals encounter each other's patients, whose risks remain invisible to them. Through collaboration such problems could be faced more effectively. Better integration of oral care into primary care can also contribute to the quality of care and safety of care receivers, and reduce further inequality. In order to better design this integration with the help of innovation, more practicebased research and implementation is needed.

Effectiveness and Policy Determinants of Sugar-Sweetened Beverage Taxes.

Sugar consumption is on the rise globally with detrimental (oral) health effects. There is ample evidence that sugar-sweetened beverage (SSB) taxes can efficiently reduce sugar consumption. However, evidence alone is seldom enough to implement a policy. In this article, we present a narrative synthesis of evidence, based on real-world SSB tax evaluations, and we combine this with lessons from policy development case studies. This article is structured according to the Health Policy Analysis Triangle, which identifies a policy's content and process and important contextual factors. SSB tax policy content needs to be coupled to existing problems and public sentiment, which depend on more aspects than aspects related to (oral) health alone. Whether or not to include artificially sweetened beverages, therefore, is not solely a matter of showing the evidence of their oral health impact but also dependent on the stated aim of a tax and public sentiment toward tax policies in general. SSB taxes also need to be in line with existing tax and decision-making rules. Earmarking revenue for specific (health promotion) purposes may therefore be less straightforward as it might appear. The policy process of creating context-sensitive SSB tax policy content is not easy either. Advocacy coalitions need to be formed early in the process, and stamina, expertise, and flexibility are required to get a SSB tax adopted in a specific community. This requires a meticulously considered SSB tax structure implementation process. Oral health professionals who want to lead the way in advocating for SSB taxes should realize that evidence-based arguments on potential effectiveness alone will not be enough to realize change. The oral health community can learn important lessons from other "doctor-activists" such as pulmonologists, who have successfully advocated for higher tobacco taxes by being visible in the public debate with clear messaging and robust policy proposals.

Causal effect of tooth loss on depression: evidence from a population-wide natural experiment in the USA.

AIMS: Depression severely affects people's health and well-being. Oral diseases have been suggested to be associated with depression, but so far, there is no causal evidence. This study aimed to identify the causal effect of tooth loss on depression among US adults in a natural experiment study. METHODS: Instrumental variable analysis was conducted using data from 169 061 respondents born in 1940-1978 who participated in the 2006, 2008 or 2010 waves of the Behavioral Risk Factor Surveillance System (BRFSS). Random variation in tooth loss due to differential childhood exposure to drinking water fluoride was exploited as an instrument. RESULTS: US adults who were exposed to drinking water fluoride in childhood had more remaining teeth, therefore providing a robust instrument (F = 73.4). For each additional tooth loss, depressive symptoms according to the eight-item Patient Health Questionnaire depression (PHQ-8) score increased by 0.146 (95% CI 0.008-0.284), and the probability of having clinical depression (PHQ ⩾10) increased by 0.81 percentage points (95% CI -0.12 to 1.73). CONCLUSIONS: Tooth loss causally increased depression among US adults. Losing ten or more teeth had an impact comparable to adults with major depressive disorder not receiving antidepressant drugs.

Front-of-Package Food Labeling to Reduce Caries: Economic Evaluation.

Front-of-package food labeling (FoPFL) is increasingly advocated as an effective intervention to facilitate behavior changes toward healthier food purchasing and consumption, particularly in relation to products with added sugar. The present study assessed the potential caries-related impacts of FoPFL, using Germany as an example. The outcomes of interest were caries lesions prevented, dental treatment costs avoided, productivity loss reductions, and disability-adjusted life years (DALYs) averted. The baseline consumption of added sugar was derived from the German National Nutrition Survey. The reduction in sugar intake due to FoPFL was modeled according to estimates from a recent meta-analysis. Microsimulations were performed for 500,000 individuals and over a time horizon of 10 y. Deterministic and probabilistic sensitivity analyses were performed to check the robustness of results. For the period from 2017 to 2027, FoPFL was identified to prevent 2,370,715 (95% confidence interval [CI], 2,062,730-2,678,700) caries lesions and avert 677.62 (95% CI, 589.59-765.65) DALYs. Treatment cost savings amounted to €175.67 million (95% CI, €152.85-€198.49), and productivity losses reduced by €27.33 million (95% CI, €23.78-€30.88). Sensitivity analyses showed that the magnitude of the effects is highly dependent on consumers' response to FoPFL. Our findings suggest that FoPFL has the potential to substantially reduce caries increment, caries-related morbidity, and economic burden. In addition, our study allows for the inclusion of oral health estimates in overall health estimates for sugar-related food labeling. Before prioritizing a strategy to tackle sugar consumption, decision makers should carefully consider all relevant context-specific factors and implementation costs.

Usage and Scientific Properties of the ADVOCATE Oral Health Care Measures.

BACKGROUND: Feedback information about the quality of oral health care is important for reflective learning by oral health care professionals and the wider health system. To this end, a list of 48 topics describing oral health and oral health care was recently agreed as part of the EU H2020 ADVOCATE project. OBJECTIVE: This article reports on the formulation of measures based on the ADVOCATE topics and provides information on usage, reporting, validity, and reliability of the measures. METHODS: The AIRE instrument was used to guide the methodological approach adopted. The appropriateness of the measures was tested among 39 general dental practitioners (GDPs) in Denmark, Germany, and the Netherlands. Data were collected from a convenience sample of patients via a questionnaire deployed in an online application in their practice. Feasibility, acceptability, and usefulness of the measures were evaluated through focus group interviews with GDPs. Face validity and test-retest reliability of the measures were assessed. RESULTS: For 46 of the 48 topics, a measure could be defined by constructing a definition and a numerator and denominator. Data collection for all 46 measures was feasible and acceptable for patients using the online questionnaire. The practicalities of using claims data for the purpose of giving feedback to individual and groups of GDPs proved to be challenging in terms of timely access of such data, the granularity of the data, and matching the content of the data with the consented items on quality of oral health care. Face validity was considered appropriate, as the patients found the questionnaire easy to understand. Test-retest reliability was found to be acceptable for 36 of 46 measures. CONCLUSION: The broad range of the ADVOCATE oral health care measures could make a useful contribution to a more transparent, evidence-based, and patient-centered oral health care system. KNOWLEDGE TRANSFER STATEMENT: This study shows the usage, reliability, and validity of 46 oral health care measures. The measures, which include patient experience and health behaviors, were found to be useful to stimulate discussions about clinical practice. The measures can provide essential information for quality improvement strategies and useful and relevant feedback information for GDPs.

An International Working Definition for Quality of Oral Healthcare.

To assess and improve the quality of oral healthcare, we must first agree on what constitutes good care. Currently there is no internationally accepted definition for quality of oral healthcare. Therefore, the purpose of the study was to establish a working definition for quality of oral healthcare that would help to advance further improvements in the field of quality improvement in oral healthcare. The development of the working definition included a 3-step approach: 1) literature screening; 2) expert-based compilation of an initial list of topics, leaning on the National Academy of Medicine framework for quality of care; and 3) a World Café with voting, which took place during the annual general meeting of the International Association for Dental Research in 2018. Following this approach, the collective intelligence of involved participants yielded a comprehensive list of items, prioritized by relevance. The resulting working definition comprises 7 domains­patient safety, effectiveness, efficiency, patient-centeredness, equitability, timeliness, access to care­and 30 items, which together characterize quality of oral healthcare. This aspirational working definition provides the potential to facilitate further conversations and activities aiming at quality improvement in oral healthcare. KNOWLEDGE TRANSFER STATEMENT: This special communication describes the development of a working definition for quality of oral healthcare. The findings of this study are intended to raise awareness of the relevance of quality improvement initiatives in oral healthcare. The working definition described here has the potential to facilitate further conversations and activities aiming at quality improvement in oral healthcare.

[Research agenda oral care for older people in the Netherlands and Flanders (Belgium)]. / Wetenschapsagenda 'Mondzorg voor ouderen' in Nederland en Vlaanderen.

Oral care for older people is an underexposed topic in dentistry as well as in general healthcare, while oral care professionals are increasingly confronted with frail and multimorbid older people with complex care needs. The research agenda 'Oral care for the elderly' was developed to encourage the collaboration of researchers in the Netherlands and Flanders (Belgium) to do more research in this area and in this way, to achieve an expansion and implementation of knowledge. This will make possible the provision of a socially responsible and robust basis for sustainable oral care for frail older people. The focus of the agenda is on 3 themes, namely oral health and oral function for older people; multi/interdisciplinary collaboration within primary care and the costs, benefits and long-term effect(s) of oral care throughout the entire course of life. This article provides an overview of this research agenda and the way in which it has been established.

What is health economics?

OBJECTIVES: This paper describes the principles of economics and their application to the promotion, protection and restoration of oral health in populations and the planning, management and delivery of oral health care. After illustrating the economic determinants of oral health, the demand for oral health care is discussed with particular reference to asymmetric information between patient and provider. The reasons for the market failure in (oral) health care and their implications for efficiency and equity are explained. We go on to describe how economic evaluation contributes to policies aimed at maximising oral health gains where resources are constrained. The behavioural aspects of patients´ demand for and dental professionals´ provision of oral health services are discussed. Finally, we outline methods for planning the dental workforce in ways that reflect system goals.

The caries-related cost and effects of a tax on sugar-sweetened beverages.

OBJECTIVES: While taxes on sugar-sweetened beverages (SSBs) have frequently been proposed to reduce non-communicable diseases like obesity and type 2 diabetes, relatively little is known about the caries-related impacts of SSB taxation. We assessed the effect of a 20% ad valorem tax on SSBs on dental caries and related treatment costs, specifically taking into account that consumers may switch from SSBs to other (non-taxed) sugar-containing drinks. STUDY DESIGN: Cost-effectiveness analysis. METHODS: A tooth-level Markov model was developed to evaluate the cost and effects of SSB taxation. Tax-related changes in sugar consumption were calculated using available evidence on SSBs price and cross-price elasticities, thereby taking changes in drinks consumption behaviors into account. The model was used to establish lifetime disease-free tooth years, caries lesions prevented, caries-related treatment costs avoided, tax revenues, and administrative costs (reference case: the Netherlands). Deterministic and probabilistic sensitivity analyses were performed to address uncertainties. RESULTS: A 20% SSB taxation would result in an average of 2.13 (95% uncertainty interval [UI] 2.12-2.13) caries-free tooth years per person and, on population level, prevention of 1,030,163 (95% UI 1,027,903-1,032,423) caries lesions. The intervention was found to save an aggregate total of € 159.01 (95% UI 158.67-159.35) million in terms of dental care expenditures. The estimated lifetime tax revenues (€3.49billion) were larger than the administrative costs for taxation (€37.3 million). CONCLUSIONS: Our results show that SSB taxation may substantially improve oral health and reduce the caries-related economic burden. Benefits would be the greatest for younger age groups.