Identifying children with dental care needs: evaluation of a targeted school-based dental screening program

OBJECTIVES: It has been suggested that changes in the distribution of dental caries mean that targeting high-risk groups can maximize the cost effectiveness of dental health programs. This study aimed to assess the effectiveness of a targeted school-based dental screening program in terms of the proportion of children with dental care needs it identified. METHODS: The target population was all children in junior and senior kindergarten and grades 2, 4, 6, and 8 who attended schools in four Ontario communities. The study was conducted in a random sample of 38 schools stratified according to caries risk. Universal screening was implemented in these schools. The parents of all children identified as having dental care needs were sent a short questionnaire to document the sociodemographic and family characteristics of these children. Children with needs were divided into two groups: those who would and who would not have been identified had the targeted program been implemented. The characteristics of the two groups were compared. RESULTS: Overall, 21.0 percent of the target population were identified as needing dental care, with 7.4 percent needing urgent care. The targeted program would have identified 43.5 percent of those with dental care needs and 58.0 percent of those with urgent needs. There were substantial differences across the four communities in the proportions identified by the targeted program. Identification rates were lowest when the difference in prevalence of need between the high- and low-risk groups was small and where the low-risk group was large in relation to the high-risk group. The targeted program was more effective at identifying children from disadvantaged backgrounds. Of those with needs who lived in households receiving government income support, 59.0 percent of those with needs and 80.1 percent of those with urgent needs would be identified. CONCLUSIONS: The targeted program was most effective at identifying children with dental care needs from disadvantaged backgrounds. However, any improvements in cost effectiveness achieved by targeting must be balanced against inequities in access to public health care resources.     

Cost‐effectiveness of an experimental caries‐control regimen in a 3.4‐yr randomized clinical trial among 11–12‐yr‐old Finnish schoolchildren

The aim of this study was to assess the cost‐effectiveness of an experimental caries‐control regimen in a randomized clinical trial (RCT) conducted in Pori, Finland, in 2001–2005. Children (n = 497) who were 11–12 yr of age and had at least one active initial caries lesion at baseline were studied. The children in the experimental group (n = 250) were offered an individually designed patient‐centered regimen for caries control. The children in the control group (n = 247) received standard dental care. Furthermore, the whole population was exposed to continuous community‐level oral health promotion. Individual costs of treatment procedures and outcomes (DMFS increment score) for the follow‐up period of 3.4 yr were calculated for each child in both groups. The incremental cost‐effectiveness ratio was €34.07 per averted DMF surface. The experimental regimen was more effective, and also more costly. However, the total costs decreased year after year, and for the last 2 yr the experimental regimen was less expensive than the standard dental care. The experimental regimen would probably have been more cost‐effective than standard dental care if the follow‐up period had been longer, the regimen less comprehensive, and/or if dental nurses had conducted the preventive procedures.     

Racial and socioeconomic disparities in health from population-based research to practice-based research: the example of oral health

Oral health serves as an excellent model for understanding social disparities in health. Associations among race, socioeconomic status, oral health, and dental care are strong. Multiple points along the dental care process allow investigation of disparities and mechanisms; and there are multiple types of treatment services (ranging from those that all patients and clinicians would likely agree on, to multiple treatment options, to discretionary treatments). Florida Dental Care Study (FDCS) data are used to provide examples of these concepts. Without regard to whether the dental care system was ultimately entered, the FDCS found substantive social differences in 1) incidence of need; 2) responsiveness to this need; and 3) propensity to seek preventive services. Once the dental care system had been accessed, substantive social differences were still evident with regard to 1) clinical condition; 2) awareness of treatment options; and 3) treatment discussions and recommendations. Once differences in clinical condition were taken into account, and once analysis was limited to persons who had entered the dental care system, social differences in receipt of care were still evident. Findings suggested that although dental care was effective at treating and preventing certain oral conditions, social differences in treatment effectiveness were evident.     

Usefulness of a Statewide Referral Directory of Dentists Found Willing to Treat Disabled Persons

Referral directories of dentists willing to treat disabled individuals have been used as an expeditious means of improving access to care for this group. The purpose of this survey was to assess the usefulness of one such statewide referral directory. Agencies, individual field workers, and organizations to which the directory had been sent 18 months earlier were surveyed to determine the usefulness of the directory. Of the 77 groups and individuals surveyed, 46 (59.7 percent) reported that they had received the directory. The directory was considered "useful" or "very useful" by 58.7 percent of the acknowledged recipients. An additional 19.6 percent considered it to be "marginally useful." The directory was estimated to be used at least once per month by 59.1 percent of the recipients. Referral directories address only one aspect of access to dental care for disabled individuals; the effectiveness of such directories depends on their appropriate use by referring agencies.     

Adequacy and effectiveness of a public dental care program for old-age pensioners

The purpose of the present work was to assess the adequacy and effectiveness of a public dental program for old-age pensioners. The dental care program offered free consultation and treatment at reduced prices to all pensioners (3072) in a municipality near Oslo in 1979. To study treatment need and access to dental care, a random sample of 430 pensioners was drawn from the total population of old-age pensioners; 371 persons were clinically examined. Of the 3072 old-age pensioners 23.7% responded positively and indicated that they were interested in the program, whereas 19.8% accepted, and 14.6% had the treatment carried out. The program adequacy was low and became lower when more restricted criteria for access to dental services were used. The program effectiveness was 18% or 16%, depending on which criteria were used for access. Acceptance of the program was highest among people who were aware of it, had natural teeth, had a dental problem, did not have their own dentist, had limited education, or were among the young pensioners.     

A retrospective longitudinal study of caries prevalence during and 7 years after free dental care at school in Finland

ABSTRACT The objective of the study was to evaluate the benefit left from free dental care at public school after an average time interval of 7 years (mean: 7.03 years). The school dental service given to 66 Army recruits was extracted from their respective school dental care records, and then compared with the caries situation at the time of their military service. The results showed that the average number of 10.42 filled and extracted tooth surfaces at the end of school dental care had increased to a score of 36.72 DMFS 7 years later. The increase was significantly higher than expected on the basis of the average caries development between ages 7 and 15 years. Of the teeth filled during school dental care, only 26% were in no need of additional treatment, 15% had been properly retreated afterwards and the rest were either decayed (35%), retreated and redecayed (13%) or extracted (11%). Of the teeth that had been given root canal treatment at school, 27% had been extracted within the following 7 years. The caries situation was worst in the group of recruits who had had free dental care for the longest period of time. It was concluded that constant free repair of the teeth does not seem to give long term relief from the caries problem.     

Effectiveness of oral health care--some Danish experiences.

The paper presents an overview of the oral health situation in Denmark with consideration to the effectiveness of dental health care services to children, adolescents, and adults. According to the Act on Dental Health consolidated in 1986, the Municipal Dental Service provides systematic preventive and curative care free of charge to the child population and adolescents. The adults are responsible for a substantial part of the payments at the private dental practitioners but some of the payments, in particular the curative services, are covered by the National Health Insurance Scheme. The Municipal Dental Service is attended by nearly 100%. In order to plan and evaluate the service, a standardized recording system has been established. Thereby, national oral epidemiological data have been provided since 1972. Partly due to the preventive approach, a general decrease over-time in the prevalence of dental caries has been documented for children and adolescents. For example, in 1972 children in first class had a mean caries experience of 12.4 def-s against 3.9 def-s in 1990. Moreover, the distribution of dental caries has become even more skewed which means that an increasing number of the children are free of caries while a limited number of the children still show a significant caries experience. According to interview data from 1987, 72% of the adult population 16 years of age and above reported regular dental visits at least once a year. The proportion of regular dental visitors were high in 16-24-years-old (92%) but lower in the age group 65-74 (35%). In 1982, clinical epidemiological data were collected as part of a national oral health survey. The results indicated that the amount of untreated dental caries and the number of missing teeth were significantly lower among regular dental visitors than irregulars. As to periodontal health, treatment needs were also prominent among regular dental visitors. In a longitudinal survey, over-time changes in the occurrence of denture wearers have been observed. In 1976, 30% of the 35-44-year-olds were denture wearers against 11% in 1986. One important finding from this survey was that social inequality in oral health seems to be reduced in younger adults. Finally, experiences from implementation of health education and preventive dental care in industrial settings are discussed, and the health outcome of a comprehensive public dental health care programme for old-age pensioners is reviewed.     

Stimulating dental attendance in the Netherlands: comparison of three conceptual frameworks

A field-experiment was done to study the differential effectiveness of three conceptual approaches to stimulate the demand for dental care. Persuasive messages were based on Ajzen & Fishbein's theory of reasoned action, on the health-belief model, and on the notion that knowledge of rights and obligations is a prerequisite for seeking dental care. All messages included an application form and a return envelope. Subjects were 269 members of Amsterdam health insurance companies. They had not received regular dental treatment and/or a certificate of dental fitness for at least 21/2 yr. Subjects received one of the three messages, an application form only (with a return envelope), or no message at all. Applying for treatment and acquiring a dental certificate were the behavioral measures. In all, 47.4% of insured who received message and/or application form applied for treatment. No control subjects applied. Fifteen months later 70% of the applicants had obtained a dental certificate. A differential effectiveness of the three messages was absent. Contrary to our expectations the condition of no message, application form only proved as effective as the message conditions. Results furthermore indicate that the main reason for not applying concerns fear of dental treatment. Whether or not the subject applied did not correlate with his knowledge of rights and obligations, sex, age, level of education, and occupational status.     

Orthodontic treatment outcomes in the long term: findings from a longitudinal study of New Zealanders

The aim of this study was to use a health services research (HSR) approach to examine the longer-term outcomes of orthodontic treatment. Participants in a longstanding population-based New Zealand cohort study (the Dunedin Multidisciplinary Health and Development Study) were allocated to one of four malocclusion severity categories on the basis of orthodontic data collected at age 12. The outcome of that care by age 26 was evaluated using the key indicators of equity (was it fair?); efficacy (did it work?); effectiveness (did it work in the longer term?); and safety (was it associated with a greater subsequent experience of caries, periodontal disease, or tooth loss?). Data were available for 452 Study members, of whom 56.2% were in the minor/none category, 29.0% were in the definite category, 10.2% were in the severe category, and 4.6% were in the handicapping treatment-need category. No clear differences in treatment uptake by socioeconomic status were apparent, and the proportion treated increased across the malocclusion severity categories, as did the proportion that showed an improvement following treatment. By age 26 a difference between those who had and those who had not been treated was evident, with the percentage of those rating their dental appearance as above average increasing with increasing severity of the age-12 orthodontic treatment need. This was also true for the percentage that considered their orthodontic treatment to have been successful. There were no significant differences in caries experience, periodontal disease occurrence, or tooth loss between those who had and had not been treated by age 26. This study has found the equity, efficacy, effectiveness, and safety of orthodontic treatment in the Dunedin cohort to be acceptable.     

The impact of income on children's and adolescents' preventive dental visits.

INTRODUCTION: Limited information is available on the effect of income level on whether people visit a dentist for preventive care, whereas more has been written regarding the effect of income on "any" dental visits--which may include emergencies. Also, little is known of the effects of "near-poor" income (101 to 200 percent of the U.S. federal poverty level) on dental visits and preventive dental visits. The authors examined the impact of income at the "poor" and "near-poor" poverty levels on preventive dental visits made by children and adolescents. METHODS: The authors used data from the 1996 Medical Expenditure Panel Survey for children and adolescents younger than 19 years of age to estimate the percentage of this group who had had preventive dental visits. They performed a multiple logistic regression analysis to adjust poverty levels by race and ethnicity, age and sex. RESULTS: The distribution of preventive dental visits for those who were poor was similar to that for those who were near-poor, but the percentage distribution of preventive visits for children and adolescents with higher income was significantly different from that for those in the lower income groups. This was true across all the variables considered. CONCLUSIONS: It is important to evaluate and monitor preventive care utilization trends for U.S. children and adolescents in the poor and near-poor categories separately, particularly in states that do not provide similar levels of access under the State Children's Health Insurance Program, or SCHIP. Enrollment of eligible children in Medicaid and SCHIP via oral health promotion outreach efforts, access to care and utilization of dental primary and secondary care services must be increased.     

Oral Health Care Reform in Finland – aiming to reduce inequity in care provision

Background  

In Finland, dental services are provided by a public (PDS) and a private sector. In the past, children, young adults and special needs groups were entitled to care and treatment from the public dental services (PDS). A major reform in 2001 – 2002 opened the PDS and extended subsidies for private dental services to all adults. It aimed to increase equity by improving adults' access to oral health care and reducing cost barriers. The aim of this study was to assess the impacts of the reform on the utilization of publicly funded and private dental services, numbers and distribution of personnel and costs in 2000 and in 2004, before and after the oral health care reform. An evaluation was made of how the health political goals of the reform: integrating oral health care into general health care, improving adults' access to care and lowering cost barriers had been fulfilled during the study period.     

Frequency of dental visits in Sweden during 1974–77

Abstract A longitudinal study of the frequency of dental visits has been conducted on a sample of 1302 individuals aged 20–60 years. These individuals had previously been interviewed regarding their dental care habits. They had also (subsequent to the interview) been clinically examined by a dentist. The results presented are based on the official dental care consumption statistics if, Sweden, and thus differ from the information obtained from the interviews. In all age groups women had a higher frequency of dental visits than men. The average number of courses of treatment carried out over a 4-year period was 2.0. Only 23% of the individuals received treatment once a year or more often, whereas 79% received treatment at least once during a period of 4 years. These figures were lower than those reported in the interviews. Individuals with a higher number of courses of treatment had also had a higher frequency of dental visits before, had been called in by their dentist for check-ups, had a higher income and knew more about teeth and their care, used oral hygiene aids daily and were living in metropolitan areas. Younger people with many remaining teeth and those with many decayed teeth had had a higher frequency of courses of treatment.     

A dental health education programme, including home visits, for nursery school children.

The aim of this study was to measure the effectiveness of three preventive programmes by measuring changes in oral hygiene, gingivitis and the uptake of dental care of nursery school and young primary school children living in areas of urban deprivation. The oral hygiene and gingivitis of a group of children who brushed their teeth daily at school improved during the study, but deteriorated during the summer holiday. A second group of children also brushed their teeth at school, and in addition their parents were given dental health education by a dental hygienist at home. Parents of a third group of children were given dental health education only at home. The oral hygiene and gingivitis of both the second and third groups improved and was maintained during the school holiday. The preventive programmes had little effect on the uptake of dental care in any of the study groups.     

Advertising in dentistry

Due to a rapid increase of unemployment among dentists in many countries, the interest in advertising as a means of stimulating the demand for dental care is increasing. In some countries (i.e. USA, Canada, Finland and Holland) campaigns have been organized and the results have been published. In order to give as complete a picture as possible of all promotional activities in the field of dentistry, the member organizations of the FDI have been asked to answer the following questions: (1) Are individual dentists in your country allowed to solicit new patients by means of advertisements? (2) Do you, as an organization, have guidelines for your members in this respect? (3) Have there been any joint promotional activities by dentists in your country aimed at increasing the demand for dental care? (a) If so, in what form (e.g. advertisements, television or radio commercials)? (b) How much money was invested in such activities? (c) What were the results achieved? The results are presented. The effectiveness of specific methods used in stimulating the demand for dental care are analysed. Moreover, a comparison is made between studies on the attitudes of dentists toward advertising in Holland and the United States.     

Acceptance of dental care following early extractions under rectal sedation with diazepam in preschool children

The aim of the study was to evaluate the effect of amnesia in preschool children on their later acceptance of dental care. Forty-six 4-6-year-old children, who between 2 and 4 years previously had had primary incisors extracted because of trauma, were reexamined for dental health and acceptance of dental care. The extractions had been performed under rectal sedation with diazepam (0.7 mg/kg body weight). Information about dental treatment and degree of cooperation during the intervening period was obtained from records at the referring clinic. The parents were interviewed about their child's experience of amnesia concerning the extractions, background variables, and experiences of dental care before the follow-up examination. Amnesia concerning the extractions was reported in 85% of the children. Twenty-nine percent had on some occasion exhibited behavior management problems (BMP) during the intervening period. Lack of amnesia was significantly associated with BMP (P < 0.002). Children without amnesia concerning the extractions tended to accept dental care less well at the reexamination. Parents were able to predict their child's acceptance of dental care at the follow-up with a significant degree of success (P = 0.02). In conclusion, amnesia in preschool children concerning extractions seems to be essential to facilitate positive acceptance of future dental care.     

Gender-based differences in factors related to non-utilization of dental care in young Norwegians. A longitudinal study

The present study had the following aims: (i): to evaluate the utilization of dental care among young adults during the age period from 18 to 23 yr; and (ii) to explore possible characteristics at the age of 18 yr that may predict non-utilization of dental care at the age of 23 yr. Respondents from a random sample of adolescents that had been surveyed at the age of 18 yr (n = 968) were surveyed again at the age of 23 yr. The data were based on (1) baseline data collected at the age 18 yr, and (2) a questionnaire mailed to the same subjects at the age of 23 yr. The response rate was 69%. The time since the last dental appointment at the age of 23 yr was longer for men than for women. Of the 2% that had not been to the dentist for the last 5 yr or more, the majority were men (69%). Multivariate logistic regression analyses showed that the following characteristics at the age of 18 yr were predictive of being included in a non-utilization group (n = 45) at the age of 23 yr: multiple fears (odds ratio (OR) = 3.0), treatment at the age of 18 yr not completed (OR = 2.5), and high dental anxiety (OR = 2.0 for women and OR = 1.2 for men). These gender differences may influence future strategies for prevention of dropout from care and possible interventions aimed at bringing adolescents back to regular dental care.     

The future of preventive programs in countries with different systems for dental care

From 1990 onward the decline of caries has leveled off in economically developed countries and the effectiveness of preventive programs seems to have diminished. The aim of this paper is to consider the future of caries prevention in the light of the studies conducted during the past decade. A shift from population-based prevention to a high-risk strategy has been promoted in countries where caries is strongly polarized. In Finland, however, an intensive preventive program targeted to high-risk individuals had little effect on caries increment, which suggests that the utility of a high-risk strategy is questionable. The relative effects of population-based methods have also decreased during the last decades. Although discontinuation of water fluoridation had no effect on caries in Kuopio, Finland, water fluoridation is still effective in countries with a lower level of basic prevention and a less homogenous social structure. From the standpoint of cost-effectiveness, the use of professionally applied fluoride gels has been questioned in children with a low caries rate, and the same is probably true for fluoride varnishes. In countries with a high caries rate, a low level of basic prevention, and an unorganized dental care system any preventive program seems to be effective. The importance of fluoride toothpastes as a cost-effective and feasible method of fluoride delivery is indisputable and will be so in all countries irrespective of the caries level and dental care systems. Population-based dental health education continues to be important, also in the countries where the caries rate has so far been low.     

Effects of an oral health program on the occurrence of oral candidosis in a long-term care facility

OBJECTIVES: The aim was to evaluate the effectiveness of a preventive oral health program on the prevalence of oral candidosis in 237 frail or dependent residents in a long-term care facility. Half of the residents were included in an experimental group which benefited from a preventive oral hygiene program including instruction of the carers and implementation of a recall program for professional oral hygiene care. METHODS: Intraoral examinations and yeast cultures from the oral mucosa and the fitting denture surface were carried out at baseline and 18 months later. The outgrowth of yeast was estimated on Oricult-N dip slides using the scale: no growth; 1-20 colonies; 21-100 colonies; >100 colonies. RESULTS: At baseline (n = 237) and at 18 months (n = 159) the experimental and the control groups were similar with regard to the residents' distribution by age, sex, dental and prosthetic status and prevalence of denture stomatitis. The 78 residents lost had the same baseline characteristics as the survivors, except for being older. In the experimental group the severity of the inflammation of the palate decreased (P = 0.005) as well as the prevalence of glossitis (P = 0.005). At baseline high yeast scores from the mucosa (>20) were observed in about 50% of the residents in the experimental as well as the control group. At 18 months this figure was 23.4% for the experimental and 48.7% for the control group (P = 0.001). There was also a reduction of the number of residents with positive cultures and the denture yeast scores at 18 months in the experimental group (P = 0.05). CONCLUSIONS: This study has shown that the preventive program was effective in reducing the colonization of the oral mucosa and dentures by Candida and thereby improving the health of the oral mucosa.     

A model for extending the reach of the traditional dental practice: the ForsythKids program

BACKGROUND: The authors describe and evaluate the short-term effectiveness of a community-based program for dental caries prevention in children. METHODS: The authors enrolled pupils in the ForsythKids program after receiving informed consent. They targeted children at six Massachusetts elementary schools, grades 1 through 3, with pupil populations at high risk of developing caries. The children underwent examination by dentists using calibrated technique and received comprehensive preventive care from dental hygienists. The authors determined effectiveness by means of comparing results of the initial examination with those of a second examination performed six months later. RESULTS: At baseline, 70 percent of the 1,196 participating children had decayed or filled teeth. More troublingly, 42.1 percent of the primary teeth and 31.1 percent of the permanent teeth had untreated decay. Six months after preventive intervention, the proportion of teeth with new decay was reduced 52 percent in primary teeth and 39 percent in permanent teeth. Furthermore, the percentage of children with newly decayed or restored primary and permanent teeth was reduced by 25.4 percent and 53.2 percent, respectively. CONCLUSIONS: These results indicate that this care model relatively quickly can overcome multiple barriers to care and improve children's oral health. CLINICAL IMPLICATIONS: If widely implemented, comprehensive caries prevention programs such as ForsythKids could accomplish national health goals and reduce the need for new care providers and clinics.     

Effectiveness of primary school-based oral health education in West Java,Indonesia

A study in West Java has indicated that involvement of primary health care personnel and schoolteachers in oral health education (OHE) at primary schools is a feasible approach that is sustainable. AIM: The present study aims to assess the effects of that school-based OHE programme on pupils who had completed the programme one and a half years ago. METHODS: Eight experimental and six control primary schools in the same area participated in the study. Out of each school 10 children, aged 8-12-years old, were randomly selected. RESULTS: ANOVA with age and gender as co-variables showed statistically significantly lower (21%) habitual plaque scores among children from experimental schools as compared to those from control schools. Tooth brushing effectiveness had significantly improved among experimental children and they took longer for tooth brushing when supervised. The dmft/dmfs values were comparable but the DMFT/DMFS values of children from experimental schools tended to be lower (not statistically significant) than of those from control schools. Differences in oral health knowledge were apparent but self-reported habits pertaining to oral health were comparable between children from experimental and control schools. CONCLUSION: This school-based OHE programme had a moderate positive effect on oral health knowledge and on habitual plaque levels and on the effectiveness of tooth brushing. The effects on caries levels and on self-reported behaviour were inconclusive.