A functional natural dentition for all – and for life? The oral healthcare system needs revision

The cost of dental care adds to the costs of the already overburdened health sector. Do we – as patients and as society –receive oral health care that is both aligned with the actual disease experience and also, critically based on up‐to‐date scientific knowledge about the major oral diseases? In many places, the practice of dentistry reflects a response to disease patterns that once existed and is based on diagnostic and therapeutic approaches that are no longer valid. Instead, a new cadre of dental professionals is needed, one that is capable of meeting the actual health needs of our populations. This cadre should ensure that patients maintain a functioning dentition from cradle to grave based on cost‐effective disease control principles. There is an urgent need to: (i) reconsider the roles of the different oral health cadres involved in the provision of oral health care; (ii) integrate oral health into general healthcare services; and (iii) restructure the training of oral health personnel. We advocate a radical reform of the oral healthcare system involving the training of two new types of professionals integrated with the general healthcare system: The oral healthcare provider – a highly skilled professional specialised in the diagnosis and control of oral diseases and with a profound understanding of oral health as part of general health – and the oral clinical specialist – whose role is the provision of advanced oral rehabilitation, able also to treat people with complex chronic diseases and multiple medications.     

Developing primary health clinical teams for public oral health services in Tasmania

This paper reviews the problem of socio-economic health inequalities and highlights the relevance of these issues for the delivery of public oral health services in the Australian island State of Tasmania. It contends that unless there is reform of existing public oral health systems, inequities in oral health care linked to socio-economic factors and geographic location will remain. The challenge is, firstly, to understand the current situation and why it has occurred. Secondly, we need to ensure that this understanding is shared across educational and professional sectors for the development of innovative approaches to the problem. Thirdly, we must carry out preliminary research and evaluation for any reforms. Using a combination of approaches, i.e., primary health care, a 'common risk' approach and increasing workforce numbers has been identified as a method showing the most potential to improve access to equitable oral health care. An outline of a current research project evaluating the impact of the integration of primary oral health care clinical teams into public oral health services is provided. The clinical teams combine the skills of the dentist and an expanded role for dual trained dental therapists/dental hygienists. The teams focus on the development of innovative clinical practice in the management and prevention of common oral diseases that take into account the broader determinants of oral health inequality. This project will be conducted in Tasmania, where the dominance of small rural and remote communities, adverse socio-economic factors and shortage of oral health professionals are key issues to consider in planning public oral health services and programmes. The results of the evaluation of the Tasmanian pilot model will contribute to the evidence base that will support the introduction of new approaches to public oral health care.     

Influence of patient,visit, and oral health factors on dental service provision

OBJECTIVES: Service provision should reflect the oral health of the patient. However, patient and visit factors may influence service patterns and the appropriateness of care delivered. The aim of this study was to examine factors associated with variation in dental services and to assess whether variation by patient and visit characteristics persisted after controlling for oral health status. METHODS: A random sample of Australian dentists was surveyed during 1997-98 (response rate = 60.3%). Private general practitioners (n = 345) provided data on service provision, as well as patient, visit and oral health variables from a log of a typical clinical day (n = 4,115 patients). Multivariate Poisson regression models were run for eight service areas (e.g., diagnostic, preventive, and restorative). RESULTS: Significant effects (P < .05) were observed for oral health factors in all eight models, visit factors in all eight models, patient demographics in four models, dental knowledge/behavior in one model, and area-based socioeconomic status in one model. CONCLUSIONS: After controlling for oral health, visit characteristics persisted as significant predictors of services, with nonemergency visits, insurance, and capital city location associated with more favorable service mix patterns. Higher socioeconomic status areas and payment scale ratings also were associated with a better service pattern in particular service areas. These findings show that a wide range of factors, in addition to oral health, contribute to variation in service provision.     

Institutional barriers to providing oral health services for underserved populations in New York City

Objectives : We sought to explore institutional barriers to the provision of oral health services for the underserved among inner-city health centers. Methods : Mail-based survey of Medicaid-approved health centers in New York City without oral health services. The importance of four barrier categories was rated: resource issues, dental provider difficulties, referral problems, and low priority of dental care. Results : 36 health centers completed the survey. The most important barriers were resource issues (66.7% agreed), dental provider difficulties (29.4%), referral problems (24.2%), and low priority (15.2%). Top individual barriers were lack of start-up funds (88%), lack of physical space (74%), lack of available funding sources (71%), and low reimbursement rates for dental services (69%). Most centers (78%) identified a need for dental services for their patients. Conclusions : Access to oral health care remains a large problem for the underserved. Institutional barriers will need to be addressed to close the gap.     

Ethnic disparities in the prevalence of dental caries and restorative dental treatment in Brazilian children

Aim : This study assesses disparities in the oral health status of Brazilian black and white children. Participants : 11‐and 12‐year‐old schoolchildren living in 131 cities of the State of São Paulo, Brazil. Methods : Spatial data analysis of city‐level indexes of oral health, socio‐economic status and provision of dental services. Main outcome measures : Ethnic ratios of the DMFT and the care index. Results : White children had higher indexes of caries in permanent teeth than their black counterparts, concurrent with a higher utilisation of dental attendance. The gap of caries prevalence between black and white children was reduced in cities with a better profile of socio‐economic status. Cities with higher per‐capita yearly budget, expenditure in health, and provision of public dental services presented reduced indications of ethnic inequality in dental care. Conclusion : The knowledge of conditions associated with a lower ethnic discrepancy in the risk of caries and in the incorporation of dental services can be used to design socially appropriate dental services. An improved community dental service, higher public expenditure in health and per‐capita municipal yearly budget contribute effectively to reducing inequities in oral health by allowing an incorporation of restorative dental treatment more equitably distributed between black and white children.     

Systems for the provision of oral health care in the Black Sea countries. Part 11: Serbia

This paper gives an overview of the provision of health care in the Republic of Serbia. It then gives details of the system for the provision of oral health care, the education of dentists and dental staff, epidemiological data, and costs. It includes details of the state (public) and private sectors of health and dental care in Serbia. Private health and oral health care is based mainly on a number of practices that provide medical and dental care to the population. The state sector has a wider range of types of provision, including complex health care institutions. The number of employees in the private health and dental sector is much smaller than the number of employees in the public sector. Far fewer patients seek private medical and dental care than visit a doctor and dentist in the state sector, which still provides the bedrock for the health system in Serbia.     

Access to care – what can the United States learn from other countries?*

This paper briefly describes the US system for dental care services; asserts that there is much to be learned by considering the experience of other countries; identifies a few lessons that may be learned from comparisons with England, Australia, and other nations; and encourages the monitoring of outcomes associated with innovations in financing and delivery of services elsewhere. Oral health is affected by more factors than access to dental care. Because so many factors at the individual, environmental, and delivery system levels affect oral health, interpreting the findings from international studies is difficult. Furthermore, the findings of these international studies are confounded by significant intra-country variation in outcomes and expectations. While public funding and the public provision of services (such as programs in schools or community health centers) can be powerful instruments of change, they have their limitations. Examination of all types of public subsidization of dental care may reveal inadvertent distributions that may increase disparities. The discovery of best practices and lessons learned in the financing and organization of dental care may begin by comparing US experiences with those of other countries.     

The dental therapist movement in the United States: A critique of current trends

Dental therapists are members of the oral health workforce in over 50 countries in the world typically caring for children in publically funded school‐based programs. A movement has developed in the United States to introduce dental therapists to the oral health workforce in an attempt to improve access to care and to reduce disparities in oral health. This article critiques trends in the United States movement in the context of the history and success of dental therapists practicing internationally. While supporting the dental therapist movement, we challenge: a) the use of dental therapists treating adults, versus focusing on children; b) the use of dental therapists in the private versus the public/not‐for‐profit sector; and c) requirements that a dental therapist must also be credentialed as a dental hygienist.     

Comprehensive dental services for an underserved and medically compromised population provided through a community partnership and service learning

The University of the Pacific, Arthur A. Dugoni School of Dentistry in San Francisco established a comprehensive dental care program at Laguna Honda Hospital, a public, skilled nursing facility. The program had three goals: (1) to provide dental students and residents an opportunity to provide oral health care for adults who were frail and medically compromised who could not come into the clinics, (2) to increase students’ access to patients who needed removable prosthodontics, and (3) to fulfill Pacific's commitment to public service. Laguna Honda and Pacific pooled their resources to bring comprehensive dental care to patients who were not able to access the dental school clinics. The long‐term goals are to restore and maintain the oral health of those who reside in the facility, and to educate future dentists to provide oral health care for similar populations.     

口腔卫生师的职业与职责

口腔卫生师(hygienist)是口腔医疗卫生保健的特殊职业,是口腔卫生保健的专业人才,是口腔疾病预防的主力,作为口腔医学的重要组成部分,组成了口腔医疗的基本结构单元.口腔卫生师有明确的职业特征和社会属性,在大众的口腔医疗卫生保健中发挥独特的重要作用.口腔卫生师通过口腔卫生宣教,提高大众的口腔健康素质和修养;通过口腔照...     

The building blocks of precision oral health in early childhood: the ZOE 2.0 study

Improving children's oral health is a long-standing area of priority and sustained efforts by many stakeholders. Despite these efforts, dental caries, particularly early childhood caries (ECC), persists as a clinical and dental public health problem with multilevel consequences. Despite recent successes in the non-restorative management of dental caries, remarkably little has been done in the domain of ECC prevention. There is promise and expectation that meaningful improvements in early childhood oral health and ECC prevention can be made via the advent of precision medicine in the oral health domain. We posit that precision dentistry, including genomic influences, may be best examined in the context of well-characterized communities (versus convenience clinical samples) and the impact of contextual factors including geography and social disadvantage may be explainable via mechanistic (i.e., biological) research. This notion is aligned with the population approach in precision medicine, which calls for the latter to be predictive, preventive, personalized, and participatory. The article highlights research directions that must be developed for precision dentistry and precision dental public health to be realized. In this context, we describe the rationale, activities, and early insights gained from the ZOE 2.0 study – a large-scale, community-based, genetic epidemiologic study of early childhood oral health. We anticipate that this long-term research program will illuminate foundational domains for the advancement of precision dentistry and precision dental public health. Ultimately, this new knowledge can help catalyze the development of effective preventive and therapeutic modalities via actions at the policy, community, family, and person level.     

Community‐specific,preventive oral health policies: preventive measures on dental caries

In all health fields, limited infrastructure and resources hinder the provision of basic services to low‐income populations. Subsequently, oral health is often neglected, as over 90% of caries remains untreated in developing communities. In order to deliver the most cost‐effective prevention methods, public health officials must assess each available strategy on an individual community basis. In this paper, examples from oral health will demonstrate the importance of community‐specific determinants in the formation of preventive public health policies. These determinants include economical, cultural, social, and political elements that can assist policy makers in generating effective functional public health policies.     

Doctor,my tooth hurts: the costs of incomplete dental care in the emergency room

Objectives: This study aims to examine the charges and frequency of return visits for treating dental health problems in hospital emergency rooms (ERs) in order to provide a basis for policy discussion concerning cost‐effective and appropriate treatment for those without access to private dental services. Methods: Records were abstracted from hospital administrative data systems for dental‐related ER visits from five major hospital systems in the Minneapolis‐St. Paul metropolitan area during a 1‐year period. Data on the number of visits and charges were analyzed by age and type of payor (public or private). Similar data were obtained from records for a commercially insured population from a single large employer. Results: There were over 10,000 visits to ERs for dental‐related problems with total charges reaching nearly $5 million in 1 year, mainly charged to public programs and reimbursed at about 50 percent. The frequency of repeat visits suggests that while acute pain and infection were treated by the ER physicians, the underlying dental problem often was not resolved. In contrast, a population with commercial dental insurance rarely used hospital ERs for dental problems. Conclusions: Access to preventive and restorative dental care is a critical public health problem in the United States, particularly for those without insurance and those covered by public programs. Public health policy initiatives such as the use of dental therapists should be expanded to improve access and to provide alternatives that offer more complete and less costly care for oral health problems than do hospital ERs.     

Integration of medicine and basic science in dentistry: the role of oral and maxillofacial surgery in the pre‐doctoral dental curriculum

It is the premise of this paper that the need for medical and basic science instruction in dentistry will increase over time. However, student and faculty appreciation of the relevance and significance of medicine and basic science to clinical dentistry has been elusive, largely due to difficulties linking biomedical science instruction and clinical dental instruction. The scope of traditional procedure based oral surgery instruction can be expanded in an attempt to bridge the medical science‐clinical gap. Topics such as health status evaluation, medical risk assessment, and a variety of other biomedical issues can be presented to students in a way which imparts specific dental meaning to basic medical science in real‐life clinical situations. Using didactic and chair side instruction in an oral surgery clinical environment, students are confronted with the need to understand these issues and how they relate to the patients they encounter who present for dental care.     

Variations in Australian dental therapy practice by practitioner and workplace characteristics

Introduction: Understanding dental therapy practice across clinical settings is useful for education and service planning. This study assessed if dental therapy service provision varied according to practitioner and workplace characteristics. Methods: Members of professional associations representing dental therapists (DT) and oral health therapists (OHT) were posted a self-complete survey collecting practitioner and workplace characteristics, together with clinical activity on a self-selected typical day of practice. Differences in service provision according to characteristics were assessed by comparing mean services per patient visit. Negative binomial regression models estimated adjusted ratios (R) of mean services per patient. Results: The response rate was 60.6%. Of practitioners registered as an OHT or a DT, 80.0% (n = 500) were employed in general clinical practice. Nearly one-third of OHT and nearly two-thirds of DT worked in public sector dental services. Patterns of service provision varied significantly according to practice sector and other characteristics. After adjusting for characteristics, relative to private sector, public sector practitioners had higher provision rates of fissure sealants (R = 3.79, 95% confidence interval [95% CI]: 2.84–5.06), restorations (R = 3.78, 95% CI: 2.94–4.86) and deciduous tooth extractions (R = 3.58, 95% CI: 2.60–4.93) per patient visit, and lower provision rates of oral health instruction (R = 0.86, 95% CI: 0.76–0.98), fluoride applications (R = 0.43, 95% CI: 0.33–0.56), scale and cleans (R = 0.39, 95% CI: 0.34–0.45) and periodontal services (R = 0.20, 95% CI: 0.14–0.28) per patient visit. Conclusion: Differences in service provision according to sector indicate that OHT and DT adapt to differing patient groups and models of care. Variations may also indicate that barriers to utilising the full scope of practice exist in some settings.Key words: dental therapists, oral health therapists, dental practice, dental practitioners, mid-level dental providers, dental practice management     

Patient dental values and their relationship to oral health status, dentist perceptions and quality of care

In this study, 1287 patients completed a questionnaire assessing knowledge of home care procedures, adherence to home care instructions, obstacles presented to the dentist in delivering care, and ability to pay for optimal care. Ninety-seven dentists that provided treatment for these patients completed a parallel questionnaire. Measures of oral health and the quality of restorative care were based on clinical examinations. It was found that though patient values and dental perceptions were associated, dentist perceptions did not closely match patient dental values. Analysis of variance indicated that patient dental values were related positively to both oral health measures and the quality of restorations. Patient-reported compliance with home care recommendations showed the strongest relationship to both oral health and quality of restorations.     

Issues in Financing Dental Care for the Elderly

The elderly make up an increasingly larger segment of the patient population in dental practices. This article reviews recent epidemiologic, demographic, and health services research, and concludes that significant segments of the elderly are at high risk for oral disease and/or limited access to dental treatment, and consequently warrant classification as high-risk groups for policy considerations. It then proposes policy options to the dental community and public decision makers. Oral care can be viewed as having three components. Two basic components are the primary care component--which includes diagnostic, preventive restorative, and periodontal care--and the acute care component--i.e., the treatment of oral pain, trauma, and infection. The third, rehabilitative component, has to do with the restoration of oral function, including prosthodontics and cosmetic dentistry. Viewing dental care in this perspective may help link funding for dental primary care services with that for other primary health services, and link restoration of function and improvement of quality of life with similar health services, like hearing, vision, and social services. In addition, approaching dental care policy makers on several levels--i.e., federal, state, and local--will contribute to our ability as a profession, in the decades ahead, to meet the oral health needs of more elders: including the frail, those at high risk for oral disease, and those with limited access to care.     

More attention to public health in the European Union — implications for dentistry?

At present the European Union is developing its competence on health and new important issues will be taken on board in European health policy. Increasing mobility of people and integration of the applicant countries puts pressure on the current health care provision systems. A mandate for an open co-ordination process in public health is expected to be given by the European Council. The process will start by exchange of information and best practice models. The next step will be the presentation of common targets between member countries, followed by national action programmes and indicators. It is likely that a lot of emphasis will be put on access to health services, comparisons of costs of health care and benchmarking the costs of items of care. In the long run this will mean convergence of the health care systems. If oral health is to be considered an integral part of general health dental professionals need to be aware of and be able to influence the actions to be taken.     

Evaluation of a Dental Public Health Program for Old-age Pensioners in Denmark

A high priority is given to improvements in the oral health of the elderly in Scandinavia. In 1987 a Danish municipality established a dental public health care program for old-age pensioners. All 67-year-old citizens were offered school-based preventive and curative care using guidelines and principles established by the Danish Municipal Dental Service for children. Care was provided free of charge. Citizens not wishing to obtain care through the public system could do so from private dental practitioners. Reimbursement for care obtained from the private system was provided by the National Health Insurance and the municipality. The purpose of this study was to evaluate the outcome of the program after three years of operation. A follow-up design was used and data were collected by interviews and clinical registrations. At baseline and follow-up 216 (71%) and 235 (77%) pensioners, respectively, were interviewed about their self-assessments of dental health, dental knowledge, attitudes, and behavior. Clinical data were collected only for the elderly who participated in the public program, and included 194 persons at baseline and 187 at follow-up. These data included information on tooth loss, dental caries, periodontal health, and presence and function of removable dentures. At the follow-up, 86 percent of all respondents had regular dental visits of at least once a year compared to 46 percent at baseline; 75 percent participated in the public program and 11 percent obtained care from private practitioners. At the end of the intervention period, fewer elderly reported symptoms of poor oral health or impaired function of dentures. Moreover, improvements in self-care, knowledge, and attitudes in oral health were found. The clinical data showed a reduction in unmet need for dental treatment. More preventive care services were given to attenders of the public program than the private one. The present evaluation of systematic public dental care demonstrates positive results in improvment of the oral health and life-quality among the elderly.     

Public Health Implications of Recent Research in Periodontal Diseases

Knowledge of the epidemiology, natural history, and bacterial etiology of the periodontal diseases has advanced considerably as a result of research conducted through the 1980s. Prevention and control of these conditions, however, remains mechanical, cumbersome, and often impractical, based as it is on bacterially nonspecific plaque removal for an indeterminate period. This research has not yet changed the content of public health programs, but it does affect the way the programs are applied. Because sever, generalized disease seems to be less prevalent than previously thought, the need of regular, routine professional care for everybody is questioned. Professional care in a public health context is likely to be more efficient when targeted toward those with severe disease. Dental health education for personal oral hygiene is still supported by scientific studies, though a targeted approach and careful assessment of educational content is needed. Until predictive screening methods for identifying susceptible individuals are developed, selection of priority groups for education and treatment should be guided by epidemiologic data.