Planning the future of oral health care workforce: Moving beyond demographic change.

The adoption of Universal Health Coverage for oral health care will not be sufficient to ensure that health care resources are accessible in accordance with needs for care. Government intervention in planning and allocating resources will be required to replace traditional market forces if market failure is not to be replaced by government failure. In this paper we explore the limitations of current 'fixed in time' approaches to planning the oral health care workforce and present an enhanced dynamic model for workforce planning that responds directly to changes in population, evidence-based best practice and new models of care.

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.

Who are the 10%? Characteristics of the populations and communities receiving fluoridated water in England.

OBJECTIVES: In England, around 10% of the population receive optimally fluoridated water. This coverage has evolved through a combination of historical local decision-making and natural geography, rather than being strategically targeted at the national level. It is important to understand if the current distribution is equitable according to indicators of oral health need and to identify any population-level differences in socio-demographic characteristics that could introduce bias to studies evaluating the effectiveness of water fluoridation. BASIC RESEARCH DESIGN: Descriptive analysis comparing the census characteristics of populations that received optimally fluoridated (=/⟩ 0.7 mg F/L) and non-fluoridated water (⟨0.7 mg F/L) between 2009 and 2020. RESULTS: Populations receiving fluoridated water between 2009-2020 were on average slightly younger, more urban, more deprived, with lower education levels, higher unemployment and lower car and home ownership than the populations who received non-fluoridated water. They are more ethnically diverse, with a higher proportion of Asian ethnicity and a lower proportion of White ethnicity, compared to the non-fluoridated population. DISCUSSION: This descriptive analysis provides evidence that water fluoridation coverage within England is targeted reasonably equitably in relation to population-level indicators of need. It also confirms the need to consider the impact of underlying differences in age, deprivation, rurality, and ethnicity when evaluating the impact of water fluoridation on health outcomes in England.

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.

Protocol for a Randomised controlled trial to Evaluate the effectiveness and cost benefit of prescribing high dose FLuoride toothpaste in preventing and treating dEntal Caries in high-risk older adulTs (reflect trial).

BACKGROUND: Dental caries in the expanding elderly, predominantly-dentate population is an emerging public health concern. Elderly individuals with heavily restored dentitions represent a clinical challenge and significant financial burden for healthcare systems, especially when their physical and cognitive abilities are in decline. Prescription of higher concentration fluoride toothpaste to prevent caries in older populations is expanding in the UK, significantly increasing costs for the National Health Services (NHS) but the effectiveness and cost benefit of this intervention are uncertain. The Reflect trial will evaluate the effectiveness and cost benefit of General Dental Practitioner (GDP) prescribing of 5000 ppm fluoride toothpaste and usual care compared to usual care alone in individuals 50 years and over with high-risk of caries. METHODS/DESIGN: A pragmatic, open-label, randomised controlled trial involving adults aged 50 years and above attending NHS dental practices identified by their dentist as having high risk of dental caries. Participants will be randomised to prescription of 5000 ppm fluoride toothpaste (frequency, amount and duration decided by GDP) and usual care only. 1200 participants will be recruited from approximately 60 dental practices in England, Scotland and Northern Ireland and followed up for 3 years. The primary outcome will be the proportion of participants receiving any dental treatment due to caries. Secondary outcomes will include coronal and root caries increments measured by independent, blinded examiners, patient reported quality of life measures, and economic outcomes; NHS and patient perspective costs, willingness to pay, net benefit (analysed over the trial follow-up period and modelled lifetime horizon). A parallel qualitative study will investigate GDPs' practises of and beliefs about prescribing the toothpaste and patients' beliefs and experiences of the toothpaste and perceived impacts on their oral health-related behaviours. DISCUSSION: The Reflect trial will provide valuable information to patients, policy makers and clinicians on the costs and benefits of an expensive, but evidence-deficient caries prevention intervention delivered to older adults in general dental practice. TRIAL REGISTRATION: ISRCTN: 2017-002402-13 registered 02/06/2017, first participant recruited 03/05/2018. Ethics Reference No: 17/NE/0329/233335. Funding Body: Health Technology Assessment funding stream of National Institute for Health Research. Funder number: HTA project 16/23/01. Trial Sponsor: Manchester University NHS Foundation Trust, Oxford Road, Manchester, M13 9WL. The Trial was prospectively registered.

Productive efficiency and its determinants in the Community Dental Service in the north-west of England.

OBJECTIVES: To assess the efficiency of service provision in the Community Dental Services and its determinants in the North-West of England. SETTING AND SAMPLE: 40 Community Dental Services sites operating across the North-West of England. BASIC RESEARCH DESIGN: A data envelopment analysis was undertaken of inputs (number of surgeries, hours worked by dental officers, therapists, hygienists and others) and outputs (treatments delivered, number of courses of treatment and patients seen) of the Community Dental Services to produce relative efficiency ratings by health authority. These were further analyzed in order to identify which inputs (determined within the Community Dental Services) or external factors outside the control of the Community Dental Services are associated with efficiency. MAIN OUTCOME MEASURE: Relative efficiency rankings in Community Dental Services production of dental healthcare. RESULTS: Using the quantity of treatments delivered as the measure of output, on average the Community Dental Services in England is operating at a relative efficiency of 85% (95% confidence interval 77%- 99%) compared to the best performing services. Average efficiency is lower when courses of treatment and unique patients seen are used as output measures, 82% and 68% respectively. Neither the input mix nor the patient case mix explained variations in the efficiency across Community Dental Services. CONCLUSIONS: Although large variations in performance exist across Community Dental Services, the data available was not able to explain these variations. A useful next step would be to undertake detailed case studies of several best and under-performing services to explore the factors that influence relative performance levels.

Variations in survival time for amalgam and resin composite restorations: a population based cohort analysis.

OBJECTIVE: To estimate the association between the restorative material used and time to further treatment across population cohorts with universal coverage for dental treatment. BASIC RESEARCH DESIGN: Cohort study of variation in survival time for tooth restorations over time and by restoration material used based on an Accelerated Failure Time model. CLINICAL SETTING: Primary dental care clinics. PARTICIPANTS: Members of Canada's First Nations and Inuit population covered by the Non-Insured Health Benefits program of Health Canada for the period April 1, 1999 to March 31, 2012. INTERVENTION: Tooth restorations using resin composite or amalgam material. MAIN OUTCOME: Survival time of restoration to further treatment. RESULTS: Median survival time for resin composite was 51 days longer than amalgam, for restorations placed in 1999-2000. This difference was not statistically significant (p⟩0.05). Median survival times were lower for females, older subjects. Those visiting the dentist annually, and decreased monotonically over time from 11.2 and 11.3 years for resin composite and amalgam restorations respectively placed in 1999-2000 to 6.9 and 7.0 years for those placed in 2009-10. CONCLUSIONS: Resin composite restorations performed no better than amalgams over the study period, but cost considerably more. With the combination of the overall decrease in survival times for both resin composite and amalgam restorations and the increase in use of resin composite, the costs of serving Health Canada's Non-Insured Health Benefits population will rise considerably, even without any increase in the incidence of caries.

Expression of E6AP and PML predicts for prostate cancer progression and cancer-specific death.

BACKGROUND: The promyelocytic leukemia (PML) tumor suppressor plays an important role in the response to a variety of cellular stressors and its expression is downregulated or lost in a range of human tumors. We have previously shown that the E3 ligase E6-associated protein (E6AP) is an important regulator of PML protein stability but the relationship and clinical impact of PML and E6AP expression in prostatic carcinoma is unknown. METHODS: E6AP and PML expression was assessed in tissue microarrays from a phase I discovery cohort of 170 patients treated by radical prostatectomy for localized prostate cancer (PC). Correlation analysis was carried out between PML and E6AP expression and clinicopathological variates including PSA as a surrogate of disease recurrence. The results were confirmed in a phase II validation cohort of 318 patients with associated clinical recurrence and survival data. RESULTS: Survival analysis of the phase I cohort revealed that patients whose tumors showed reduced PML and high E6AP expression had reduced time to PSA relapse (P = 0.012). This was confirmed in the phase II validation cohort where the expression profile of high E6AP/low PML was significantly associated with reduced time to PSA relapse (P < 0.001), clinical relapse (P = 0.016) and PC-specific death (P = 0.014). In multivariate analysis, this expression profile was an independent prognostic indicator of PSA relapse and clinical relapse independent of clinicopathologic factors predicting recurrence. CONCLUSION: This study identifies E6AP and PML as potential prognostic markers in localized prostate carcinoma and supports a role for E6AP in driving the downregulation or loss of PML expression in prostate carcinomas.

Perioperative management of a parturient with VACTERL association for a caesarean section.

A parturient with VACTERL association (vertebral defects, anal atresia, cardiac defects, trachea-oesophageal fistula, renal abnormalities and limb abnormalities) was listed for an elective caesarean section. She had a short neck with reduced cervical extension and flexion. Magnetic resonance imaging of her whole spine was performed which showed failure of cervical spine segmentation and cervical stenosis. Neuraxial blockade could have resulted in unpredictable spread of local anaesthetic due to the low volume of the spinal canal, and could have caused myelopathic changes within the spinal cord due to cerebrospinal fluid pressure changes. A general anaesthetic using a rapid sequence induction was also predicted to be challenging due to her fixed, unstable neck and severe cervical spine stenosis. After a multidisciplinary discussion Including neurosurgeons, we planned for awake tracheal intubation followed by general anaesthesia. However, before the date of her planned delivery, she required an urgent caesarean section due to severe preeclampsia. This was performed under general anaesthesia following uncomplicated awake tracheal intubation.

Natural Heterobilharzia americana infection in horses in Texas.

The schistosome Heterobilharzia americana infects dogs, raccoons, and other mammals in the southeastern United States. Migration of eggs into the liver results in parasitic granulomas with varying degrees of fibrosis and inflammation. Recently, hepatic parasitic granulomas in horses were shown to be caused by H. americana infection. In the present study, samples of liver from 11 of 12 horses with hepatic granulomas identified at necropsy (n = 11) or surgical biopsy (n = 1) were used for DNA extraction, polymerase chain reaction amplification and sequencing using primers specific for a portion of the H. americana small subunit ribosomal RNA gene. A polymerase chain reaction amplicon of the correct size was produced from the extracted DNA in 8 of the 11 horses. Amplicons from 5 of the 8 positive horses were sequenced and had 100% identity with H. americana. In all but 2 of the 12 horses, Heterobilharzia was not responsible for the primary clinical disease, and the hepatic granulomas were considered an incidental finding.

Workforce Planning Models for Oral Health Care: A Scoping Review.

BACKGROUND: For health care services to address the health care needs of populations and respond to changes in needs over time, workforces must be planned. This requires quantitative models to estimate future workforce requirements that take account of population size, oral health needs, evidence-based approaches to addressing needs, and methods of service provision that maximize productivity. The aim of this scoping review was to assess whether and how these 4 elements contribute to existing models of oral health workforce planning. METHODS: A scoping review was conducted. MEDLINE, Embase, HMIC, and EconLit were searched, all via OVID. Additionally, gray literature databases were searched and key bodies and policy makers contacted. Workforce planning models were included if they projected workforce numbers and were specific to oral health. No limits were placed on country. A single reviewer completed initial screening of abstracts; 2 independent reviewers completed secondary screening and data extraction. A narrative synthesis was conducted. RESULTS: A total of 4,009 records were screened, resulting in 42 included articles detailing 47 models. The workforce planning models varied significantly in their use of data on oral health needs, evidence-based services, and provider productivity, with most models relying on observed levels of service utilization and demand. CONCLUSIONS: This review has identified quantitative workforce planning models that aim to estimate future workforce requirements. Approaches to planning the oral health workforce are not always based on deriving workforce requirements from population oral health needs. In many cases, requirements are not linked to population needs, while in models where needs are included, they are constrained by the existence and availability of the required data. It is critical that information systems be developed to effectively capture data necessary to plan future oral health care workforces in ways that relate directly to the needs of the populations being served. KNOWLEDGE TRANSFER STATEMENT: Policy makers can use the results of this study when making decisions about the planning of oral health care workforces and about the data to routinely collect within health services. Collection of suitable data will allow for the continual improvement of workforce planning, leading to a responsive health service and likely future cost savings.

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.

Preferences for surveillance strategies for women treated for high-grade precancerous cervical lesions.

OBJECTIVES: Data are lacking on how women view alternative approaches to surveillance for cervical cancer after treatment of high-grade cervical intraepithelial neoplasia. We measured and compared patient preferences (utilities) for scenarios with varying surveillance strategies and outcomes to inform guidelines and cost-effectiveness analyses of post-treatment surveillance options. METHODS: English- or Spanish-speaking women who had received an abnormal Pap test result within the past 2 years were recruited from general gynecology and colposcopy clinics and newspaper and online advertisements in 2007 and 2008. Participation consisted of one face-to-face interview, during which utilities for 11 different surveillance scenarios and their associated outcomes were elicited using the time tradeoff metric. A sociodemographic questionnaire also was administered. RESULTS: 65 women agreed to participate and successfully completed the preference elicitation exercises. Mean utilities ranged from 0.989 (undergoing only a Pap test, receiving normal results) to 0.666 (invasive cervical cancer treated with radical hysterectomy or radiation and chemotherapy). Undergoing both Pap and HPV tests and receiving normal/negative results had a lower mean utility (0.953) then undergoing only a Pap test and receiving normal results (0.989). Having both tests and receiving normal Pap but positive HPV results was assigned an even lower mean utility (0.909). 15.9% of the respondents gave higher utility scores to the Pap plus HPV testing scenario (with normal/negative results) than to the "Pap test alone" scenario (with normal results), while 17.5% gave the Pap test alone scenario a higher utility score. CONCLUSIONS: Preferences for outcomes ending with normal results but involving alternative surveillance processes differ substantially. The observed differences in utilities have important implications for clinical guidelines and cost-effectiveness analyses.

Willingness to Pay for Mandibular Overdentures: A Societal Perspective.

OBJECTIVES: Dental services in many countries are funded out-of-pocket by patients whose acceptance of a dental treatment depends on their valuation of it. Using a willingness-to-pay (WTP) strategy, this study aimed to determine how people who do not wear dentures value the benefits of dentures retained by implants and what factors explain variations in WTP among subjects. METHODS: Telephone numbers of a representative Canadian sample were obtained from a consumer database provider. Respondents completed either an internet-based or telephone survey with 3 payment scenarios: paying oneself (out-of-pocket), coverage with private health insurance, and publicly financed through additional taxes. Personal information data (e.g., age, income) were used as independent variables in regression models to assess the determinants of WTP amounts. RESULTS: Among 1,096 respondents, 317 participated in the survey (response rate, 28.9%). The mean WTP of participants (mean ± SD age: 41.2 ± 0.6 y; 54.3% male) who were dentate/partially edentate was $5,347 for implant overdentures. Considering a 1 in 5 chance of becoming edentate, they were willing to pay $26.93 as monthly payments for private insurance. They were also willing to pay an additional yearly tax of $103.63 to support a public program. WTP private payments increased substantially with increase in household income and dental needs. CONCLUSION: This preference study provides information to dentists, insurance companies, and policy makers on what dentate people are willing to pay for implant overdentures, whether directly or with insurance/government coverage. KNOWLEDGE TRANSFER STATEMENT: This study provides results of interest to many stakeholders. For clinicians, the results reveal what people are willing to pay for implant overdentures for themselves. It also provides information to employers and insurance companies on how people value having coverage for this kind of service. Furthermore, it provides public policy makers the value that people place on public funding of such treatments and how they would support a decision to publicly fund such a treatment.

A Global Geomorphologic Map of Saturn's Moon Titan.

Titan has an active methane-based hydrologic cycle1 that has shaped a complex geologic landscape2, making its surface one of most geologically diverse in the solar system. Despite the different materials, temperatures, and gravity fields between Earth and Titan, many surface features are similar between the two worlds and can be interpreted as products of the same geologic processes3. However, Titan's thick and hazy atmosphere has hindered the identification of geologic features at visible wavelengths and the study of surface composition4. Here we identify and map the major geologic units on Titan's surface using radar and infrared data from the Cassini orbiter spacecraft. Correlations between datasets enabled us to produce a global map even where data sets were incomplete. The spatial and superposition relations between major geologic units reveals the likely temporal evolution of the landscape and gives insight into the interacting processes driving its evolution. We extract the relative dating of the various geological units by observing their spatial superposition in order to get information on the temporal evolution of the landscape. Dunes and lakes are relatively young, while hummocky/mountainous terrains are the oldest on Titan. Our results also show that Titan's surface is dominated by sedimentary/depositional processes with significant latitudinal variation, with dunes at the equator, plains at mid-latitudes and labyrinth terrains and lakes at the poles.

Murine leukemia viruses: antigenic studies by quantitative complement fixation.

The murine leukemia viruses of Rauscher and Friend, derived from plasnma of infected Balb/c mice, was purified. Their antigenic relationship was studied by quantitative complement-fixation reactions with the virion antigen and homologous antiserums. The complement-fixation curves observed in cross-reactions indicated close antigenic similarity between these two leukemia viruses. Highly purified viral preparations contained detectable amounts of host antigens.

A pictorial view of the three-dimensional representation and comparative two-dimensional image orientation derived from computed tomography angiography in a dog with a patent ductus arteriosus.

Patent ductus arteriosus (PDA) occlusion is one of the more common cardiovascular procedures performed in dogs. Two-dimensional imaging has been the primary method of visualizing the PDA and is the basis of its morphologic description. Transesophageal echocardiographic imaging has further characterized the three-dimensional (3D) variation in ductal morphology and shape (circle, oval). An accurate assessment of the shape and dimensions of a PDA in an individual dog is important when making decisions about definitive closure. Ductal measurements from angiography and echocardiography have not been found to be interchangeable, likely related in part to the static two-dimensional measurement of a 3D structure. We describe the use of computed tomography angiography (CTA) images imported into three software programs as a tool to provide 3D information about PDA anatomy including a comparison to images obtained from classic two-dimensional imaging modalities. These images provide an example of thorax and heart position related to transducer position and the orientation of image acquisition to demonstrate why measurements do not always compare. Additionally, 3D images are useful as a training tool and in the development of devices and training opportunities. Multidimensional imaging provides a unique representation of the 3D anatomical structure of the ductus arteriosus as displayed in these images from a dog with a PDA.

Exposures and reported symptoms associated with occupational deployment to the Buncefield fuel depot fire, England 2005.

OBJECTIVES: An explosion at the Buncefield fuel depot outside London occurred on 11 December 2005. We conducted a retrospective cohort study of airborne exposures and health status for workers deployed. METHODS: Deployed individuals were identified through their occupational health departments. We sent a self-completion questionnaire asking about health symptoms during the burn and post-burn phases. The prevalence of health symptoms in workers was compared to symptoms in local residents not under the smoke plume. RESULTS: Of 1949 eligible individuals, 815 returned questionnaires (response rate 44%). Respiratory protection was used by 39%. Symptoms were reported by 41% of individuals during the burn phase compared with 26% in the post-burn phase. In a final multivariable model, reporting of any symptoms was associated with deployment inside the inner fire cordon during the burn phase (OR 2.07, 95% CI 1.24 to 3.47) and wearing a face mask (OR 2.33, 95% CI 1.67 to 3.26). Compared with the general public, eye irritation (prevalence ratio (PR) 2.1, 95% CI 1.5 to 3.0), coughing (PR 1.3, 95% CI 1.0 to 1.8) and headaches (PR 1.7, 95% CI 1.2 to 2.5) were more common in workers deployed during the burn phase but not the post-burn phase. CONCLUSIONS: Increased reporting of symptoms close to the fire during the burn phase was consistent with increased exposure to products of combustion, although no major acute illness was reported. That only a minority of individuals used face masks, which were not protective for symptoms, raises questions about the availability of adequate respiratory protection for such incidents.

Public policy and the market for dental services.

Social inequality in access to oral health care is a feature of countries with predominantly privately funded markets for dental services. Private markets for health care have inherent inefficiencies whereby sick and poor people have restricted access compared to their healthy and more affluent compatriots. In the future, access to dental care may worsen as trends in demography, disease and development come to bear on national oral healthcare systems. However, increasing public subsidies for the poor may not increase their access unless availability issues are resolved. Further, increasing public funding runs counter to policies that feature less government involvement in the economy, tax policy on private insurance premiums, tax reductions and, in some instances, free-trade agreements. We discuss these issues and provide international examples to illustrate the consequences of the differing public policies in oral health care. Subsidization of the poor by inclusion of dental care in social health insurance models appears to offer the most potential for equitable access. We further suggest that nations need to develop national systems capable of the surveillance of disease and human resources, and of the monitoring of appropriateness and efficiency of their oral healthcare delivery systems.