Professional competencies and work-related support in relation to periodontal therapy and work satisfaction: A questionnaire study among Swedish Dental Hygienists.

OBJECTIVES: To analyse dental hygienists' (DHs) views on professional competencies and behavioural interventions in the treatment of periodontitis patients, perceived work-related support and work satisfaction. METHODS: A Web-based questionnaire was distributed to all DHs employed at the public dental service in the county of Västra Götaland, Sweden. 302 (83%) responded to the questionnaire; 291 of these DHs stated that they on regular basis treated periodontitis patients and thus constituted the sample for analyses. Based on initial correlation and bivariate analyses of the questionnaire data, multiple logistic regression models were formulated to estimate perceived competencies to treat patients with periodontitis and work satisfaction. RESULTS: The multiple analyses revealed that DHs who worked with specific methods for behavioural intervention, like motivational interviewing, were more likely to rate themselves as "definitely possessing the competencies required to treat patients with periodontitis" (OR 4.0). Likewise, this group of DHs did not consider it more difficult to charge their patients the financial costs for such a behavioural intervention than for scaling therapy (OR 3.1). The perception that one's professional competencies were utilized well in daily practice was associated with high work satisfaction (OR 4.1). More years in the profession (OR 1.03) and a good support by colleagues (OR 1.9) had also a positive impact on work satisfaction. CONCLUSIONS: Dental hygienists' considered that competencies in the treatment of periodontitis patients were related to the practice of behavioural interventions as part of therapy. A stimulating and supportive work environment, with opportunities for professional development, is important for work satisfaction.

Factors Influencing Dental Students' Interest in Advanced Periodontal Education: Perspectives of Department Chairs.

The number of graduates of U.S. dental schools enrolled in U.S. postdoctoral programs in periodontics has been decreasing. The aims of this study were to determine the perspectives of periodontics department chairs regarding 1) features of a school's predoctoral curriculum that promote student interest in advanced periodontal education and 2) characteristics of a periodontal residency program that make it more attractive to dental students over other specialty programs. In 2015, a 14-question survey was designed and sent to chairs of periodontics departments at all 65 U.S. dental schools at the time. Questions addressed number of instructional hours; specialty clinic rotations; elective courses; number of applicants to periodontal residency; existence of a residency program; length of the residency program; and externships, fellowships, and financial stipends offered. The survey response rate was 73.8%. The results showed that departments offering more than seven clinical credit hours in periodontics to predoctoral students had the greatest number of residency applicants. Most of the applicants were from institutions that offered specialty clinic rotations, elective courses, and residency programs in periodontics. The number of applicants did not change significantly if a stipend or fellowship was offered. However, the availability of an externship was significantly associated with a greater number of applicants (p=0.042). These results suggest that offering periodontal clinical rotations, elective courses, and especially externships in periodontics during predoctoral education may encourage more graduating students to pursue postdoctoral periodontal education.

Background, training experiences, and career plans of U.S. periodontal residents: report of a web-based survey.

The purpose of this cross-sectional study was to survey the backgrounds and perspectives of U.S. periodontal residents in 2012. A 64-item web-based survey was distributed to all periodontal residents in the United States (544 residents enrolled in 54 graduate programs) via email in March 2012. Data on the residents' demographics, experiences during graduate periodontal training, and goals were collected and analyzed, and percentages were calculated. The survey had a 19.1% response rate. Most of the respondents (74%) had graduated from international dental schools, and 81.7% were in combined programs (clinical training combined with a Master's degree, PhD, or other doctoral degree). Almost one-fourth of the responding residents (24%) reported a total debt of more than $300,000 after graduation. More than 60% of the respondents planned to practice in a private setting as an associate, partner, or solo practice owner. The responding residents reported having chosen their graduate programs based mainly on the programs' clinical education and reputation (72% and 48%, respectively). Future studies will determine educational trends and outcomes for periodontal residents in the longer term.

Cost analysis of periodontitis management in public sector specialist dental clinics.

BACKGROUND: The objective of this paper is to quantify the cost of periodontitis management at public sector specialist periodontal clinic settings and analyse the distribution of cost components. METHODS: Five specialist periodontal clinics in the Ministry of Health represented the public sector in providing clinical and cost data for this study. Newly-diagnosed periodontitis patients (N = 165) were recruited and followed up for one year of specialist periodontal care. Direct and indirect costs from the societal viewpoint were included in the cost analysis. They were measured in 2012 Ringgit Malaysia (MYR) and estimated from the societal perspective using activity-based and step-down costing methods, and substantiated by clinical pathways. Cost of dental equipment, consumables and labour (average treatment time) for each procedure was measured using activity-based costing method. Meanwhile, unit cost calculations for clinic administration, utilities and maintenance used step-down approach. Patient expenditures and absence from work were recorded via diary entries. The conversion from MYR to Euro was based on the 2012 rate (1€ = MYR4). RESULTS: A total of 2900 procedures were provided, with an average cost of MYR 2820 (€705) per patient for the study year, and MYR 376 (€94) per outpatient visit. Out of this, 90% was contributed by provider cost and 10% by patient cost; 94% for direct cost and 4% for lost productivity. Treatment of aggressive periodontitis was significantly higher than for chronic periodontitis (t-test, P = 0.003). Higher costs were expended as disease severity increased (ANOVA, P = 0.022) and for patients requiring surgeries (ANOVA, P < 0.001). Providers generally spent most on consumables while patients spent most on transportation. CONCLUSIONS: Cost of providing dental treatment for periodontitis patients at public sector specialist settings were substantial and comparable with some non-communicable diseases. These findings provide basis for identifying potential cost-reducing strategies, estimating economic burden of periodontitis management and performing economic evaluation of the specialist periodontal programme.

Economics of periodontal care: market trends, competitive forces and incentives.

The adoption of new technologies for the treatment of periodontitis and the replacement of teeth has changed the delivery of periodontal care. The objective of this review was to conduct an economic analysis of a mature periodontal service market with a well-developed workforce, including general dentists, dental hygienists and periodontists. Publicly available information about the delivery of periodontal care in the USA was used. A strong trend toward increased utilization of nonsurgical therapy and decreased utilization of surgical periodontal therapy was observed. Although periodontal surgery remained the domain of periodontists, general dentists had taken over most of the nonsurgical periodontal care. The decline in surgical periodontal therapy was associated with an increased utilization of implant-supported prosthesis. Approximately equal numbers of implants were surgically placed by periodontists, oral and maxillofacial surgeons, and general dentists. Porter's framework of the forces driving industry competition was used to analyze the role of patients, dental insurances, general dentists, competitors, entrants, substitutes and suppliers in the periodontal service market. Estimates of out-of-pocket payments of self-pay and insured patients, reimbursement by dental insurances and providers' earnings for various periodontal procedures and alternative treatments were calculated. Economic incentives for providers may explain some of the observed shifts in the periodontal service market. Given the inherent uncertainty about treatment outcomes in dentistry, which makes clinical judgment critical, providers may yield to economic incentives without jeopardizing their ethical standards and professional norms. Although the economic analysis pertains to the USA, some considerations may also apply to other periodontal service markets.

The lifetime direct cost of periodontal treatment: a case study from a Norwegian specialist practice.

BACKGROUND: Successful periodontal treatment requires a commitment to regular lifelong maintenance and may be perceived by patients to be costly. This study calculates the total lifetime cost of periodontal treatment in the setting of a specialist periodontal practice and investigates the cost implications of choosing not to proceed with such treatment. METHODS: Data from patients treated in a specialist practice in Norway were used to calculate the total lifetime cost of periodontal treatment that included baseline periodontal treatment, regular maintenance, retreatment, and replacing teeth lost during maintenance. Incremental costs for alternative strategies based on opting to forego periodontal treatment or maintenance and to replace any teeth lost with either bridgework or implants were calculated. RESULTS: Patients who completed baseline periodontal treatment but did not have any additional maintenance or retreatment could replace only three teeth with bridgework or two teeth with implants before the cost of replacing additional teeth would exceed the cost of lifetime periodontal treatment. Patients who did not have any periodontal treatment could replace ≤ 4 teeth with bridgework or implants before a replacement strategy became more expensive. CONCLUSIONS: Within the limits of the assumptions made, periodontal treatment in a Norwegian specialist periodontal practice is cost-effective when compared to an approach that relies on opting to replace teeth lost as a result of progressive periodontitis with fixed restorations. In particular, patients who have initial comprehensive periodontal treatment but do not subsequently comply with maintenance could, on average, replace ≤ 3 teeth with bridgework or two teeth with implants before this approach would exceed the direct cost of lifetime periodontal treatment in the setting of the specialist practice studied.

The cost-effectiveness of supportive periodontal care: a global perspective.

AIM: To evaluate the cost-effectiveness of supportive periodontal care (SPC) provided in generalist and periodontal specialist practices under publicly subsidized or private dental care. MATERIAL AND METHODS: SPC cost data and the costs of replacing teeth were synthesized with estimates of the effectiveness of SPC in preventing attachment and tooth loss and adjusted for differences in clinician's time. Incremental cost-effectiveness ratios were calculated for both outcomes assuming a time horizon of 30 years. RESULTS: SPC in specialist periodontal practice provides improved outcomes but at higher costs than SPC provided by publicly subsidized or private systems. SPC in specialist periodontal practice is usually more cost-effective than in private dental practice. For private dental practices in Spain, United Kingdom and Australia, specialist SPC is cost-effective at modest values of attachment loss averted. Variation in the threshold arises primarily from clinician's time. CONCLUSION: SPC in specialist periodontal practice represents good value for money for patients (publicly subsidized or private) in the United Kingdom and Australia and in Spain if they place relatively modest values on avoiding attachment loss. For patients in Ireland, Germany, Japan and the United State, a higher valuation on avoiding attachment loss is needed to justify SPC in private or specialist practices.

Cost-effectiveness of endodontic molar retreatment compared with fixed partial dentures and single-tooth implant alternatives.

INTRODUCTION: One of the most challenging situations in dentistry is a failed root canal treatment case. Should a failed root canal-treated tooth be retreated nonsurgically or surgically, or should the tooth be extracted and replaced with an implant-supported restoration or fixed partial denture? These four treatment alternatives were compared from the perspective of cost-effectiveness on the basis of the current best available evidence. METHODS: The costs of the four major treatment modalities were calculated using the national fee averages from the 2009 American Dental Association survey of dental fees. The outcome data of all treatment modalities were retrieved from meta-analyses after electronic and manual searches were undertaken in the database from MEDLINE, Cochrane, ISI Web of Knowledge, and Scopus up to April 2010. The treatment strategy model was built and run with TreeAge decision analysis software (TreeAge Software, Inc, Williamstown, MA). RESULTS: Endodontic microsurgery was the most cost-effective approach followed by nonsurgical retreatment and crown, then extraction and fixed partial denture, and finally extraction and single implant-supported restoration. CONCLUSIONS: The cost-effectiveness analysis showed that endodontic microsurgery was the most cost-effective among all the treatment modalities for a failed endodontically treated first molar. A single implant-supported restoration, despite its high survival rate, was shown to be the least cost-effective treatment option based on current fees.

Update on the changing numbers and distribution of periodontists.

A review of the 2006 and past American Dental Association (ADA) studies on the distribution of dentists provides information on the evolving number of periodontists. Despite an overall increase in the number of periodontists, major differences continue in practitioner/population ratios in different geographic areas. As in past reviews, suggestions are offered for efforts by the ADA and/or the American Academy of Periodontology to draw attention to the limited numbers of periodontists in particular regions and states; to increase efforts to educate the public on the need and value of periodontal services; and to increase the profession's awareness of the growing diversity in the nation's population and the need to modify and adjust its efforts to attract underserved populations with different familial, cultural, and educational backgrounds.

The cost-effectiveness of supportive periodontal care for patients with chronic periodontitis.

OBJECTIVE: To systematically evaluate the evidence for effectiveness of supportive periodontal care (SPC) provided in specialist care and general practice for patients with chronic periodontitis; to construct a model for the cost effectiveness of SPC. SEARCH STRATEGY: Electronic database searches of MEDLINE, EMBASE and SCOPUS were performed with hand searching of relevant journals and Workshops of Periodontology. SELECTION CRITERIA: SPC for patients with chronic periodontitis, at least 12 months follow-up and clinical attachment level as a primary outcome. RESULTS: Three articles addressed the question (Nyman et al. 1975, Axelsson & Lindhe 1981, Cortellini et al. 1994): Deltas CAL for patients undergoing "specialist" SPC were 0.1 mm (2 years), 0.2 mm (6 years) and -0.01 mm (3 years) respectively. In generalist care the Deltas CAL during SPC were -2.2, -1.8 and -2.8 mm. Differences between specialist and generalist SPC were an extra 20.59 tooth years and 3.95 mm attachment loss for generalist SPC. Incremental cost-effectiveness ratios were an extra 288 euros for one tooth year or an extra 1503 euros/1 mm reduction in loss of attachment for SPC delivered in specialist care. CONCLUSION: SPC delivered in specialist as compared with general practice will result in greater stability of clinical attachment but this will be achieved at relatively greater cost.

Attitudes regarding specialist referrals in periodontics.

OBJECTIVE: To examine the attitudes of dental practitioners towards specialist periodontal referral in the North East of England. SUBJECTS AND METHODS: Semi-structured interviews were conducted with a purposive sample of 10 practitioners. Interviews continued until data saturation occurred. The data were organised using a framework and analysed by two researchers working independently. RESULTS: Perceptions of periodontal disease and treatment appear to be heavily influenced by the NHS remuneration system. Treatment in general practice was limited to simple scaling and there was an apparent reluctance to treat advanced periodontitis. Such cases were commonly referred to specialists, confirming the demand for a referral service in periodontics. The perceived potential for medico-legal consequences was a strong driver of referrals. Distance to the referral centre and the perceived costs of treatment were significant barriers to referral. Dentists valued the specialist's personal reputation and clinical skills more highly than academic status. Deficiencies in communication between primary and secondary care were highlighted. CONCLUSIONS: Increased resources are required to manage periodontal diseases within the NHS. There is a need for a periodontal referral service in the North East of England to improve accessibility to specialist care. This would appear to be most appropriately delivered by increased numbers of specialist practitioners.

Success rates in periodontal treatment as related to choice of evaluation criteria. Presentation of an evaluation criteria staircase for cost-benefit use.

BACKGROUND, AIMS: The aim of the present investigation was to determine the success rates of treatment of 36 patients with moderate to advanced periodontal disease as related to different clinical and radiographic criteria. METHOD: The treatment comprised oral hygiene education, subgingival scaling and root planing, and when judged indicated, periodontal surgery. An "evaluation criteria staircase" comprising 5 levels was introduced to be utilized for evaluation of the treatment results in 4 proximal sites (1 in each quadrant) which were followed for 3 years. The highest level of the staircase (level 1) is the most challenging and comprises the traditonal criteria for "perfect" periodontal health, while the lower levels are gradually less demanding. RESULTS: At the follow-up examination 3 years after active treatment, 52.1% of the experimental sites fulfilled the criteria for successful treatment according to level 1. On the lowest level (level 5) which only required no further loss of alveolar bone for treatment to be considered "successful", the number of such treated sites reached 95.1%. The present data showed that even if level 5 was accepted as the evaluation criterion for "success", resulting in very few failed sites (4.9%), these sites may demand considerable extra clinical time and costs for retreatment because of their distribution among many individuals (13.2%). This clinical time increases substantially if higher levels of success are desired. From a cost-benefit point of view, it is therefore of utmost importance that not only patient compliance but also disease resistance and the value of the affected tooth for the dentition are taken into consideration when the indications for retreatment are weighed. This is especially important since many sites were found to be non-progressive for a long time, even though they did not exhibit perfect periodontal health. CONCLUSIONS: It is suggested that the "evaluation criteria staircase" presented in this paper might be a helpful clinical instrument for decision-making in individually designed and site-related retreatments of patients with periodontal disease.

[Insurability of periodontal care in 1999]. / Verzekerbaarheid van parodontale zorg in 1999.

In this study an overview of dental insurance in the Netherlands for periodontal care is presented. Since the dental insurance reform in 1995, dental care is no longer part of the collective health care system. Patients are therefore obliged to enter the market for private dental insurance. Of the 118 available insurance packages 86 (73%) contain dental care. Sixty eight of these packages (58%) include periodontal care. A minority of the companies (4) include periodontal care in all packages. Fifty two percent of the companies apply additional terms, which reduces the scope of the claims. In this paper it is concluded that a sufficient amount and diversity of insurance packages is present. Since patients may not know about the diversity, insufficient coverage of treatment costs may result. It is concluded that market elements are successful integrated in the field of dental insurance. It has to be shown in the future if this success will lead to an increase of dental and periodontal health of the patients.

Cost-effective design for dental randomized clinical trials with longitudinal observations.

In general, randomized clinical trials (RCT) in dentistry involve longitudinal observations. In such studies, the total cost is a function of the number of study subjects and visits, the study duration, and the type and number of examinations at each visit. In this paper, we derived the minimum cost design for longitudinal RCTs with 2 treatment arms and multiple visits. We optimized the number of subjects, visits and repeated measurements under the constraints of the requirements for statistical significance, power and minimum total study cost. A SAS macro was written and made available on the World Wide Web, so interested clinical investigators can easily find optimal designs. The application of the program is illustrated using an example.