National Health Care: Whither Goeth Dentistry?*

National health insurance is reemerging as an important issue on the national health policy scene. The continuing escalation of health care costs in the US and increasing numbers of individuals without access to health services are stimulating a variety of proposals to redesign the structure and financing of the American health care system. Some change in the current system toward a more national approach to health care is inevitable in the years ahead. While dental care is subject to pressures similar to other health care services, little attention is being accorded dental services in the various national health care proposals that are being advanced. This may be due largely to organized dentistry's reluctance to define a role for itself. If dentistry is to be included in such a plan, it is essential that concerted efforts start soon and that the various public and private sectors of dentistry work collaboratively to develop the dental component to such a plan. The future oral health of the public and the future health of dentistry as a profession depend on it.     

Implementation of public health genomics and applications to public health dentistry

National and state public health genomics efforts exist to effectively and responsibly translate genome-based knowledge to improve population health and reduce health disparities. Over the past two decades, public health genomics efforts have utilized the core public health functions of assessment, policy development, and assurance. Current evidence for a small number of genomic applications suggests that many lives could be saved if these were implemented in recommended populations. With the drastic increase in new genetic tests and technologies, multidisciplinary public health genomics efforts that should include public health dentistry are of greater importance. There is a need to integrate public health dentistry in efforts to increase use of evidence-based genomic tests and services to improve health outcomes. Additionally, public health genomic efforts also are utilized to promote awareness about the insufficient evidence of the validity, utility and ethical, legal, and social implications for the vast majority of genomic tests. This is demonstrated by a recent genetic testing policy statement and educational resources from the American Dental Association. These organizational efforts should be considered in other realms of public health genomics to ensure that only genetic tests and preventive services with sufficient evidence for use are being implemented in clinical and public health.     

Dental public health: new opportunities--new responsibilities

Major changes affecting oral health in the United States have provided new leadership challenges for public health dentistry. Two new roles for dental public health are proposed: leadership in the incorporation of expanded public health skills into the education of every clinical dentist; and a broadening of the specialty in a manner similar to that of preventive medicine, involving the creation of subspecialties in public health dentistry, occupational environmental dentistry, and management policy dentistry. The current status of community dentistry departments in dental schools and programs of public health education for dental personnel in schools of public health are reviewed. Content is suggested for the incorporation of expanded public health skills into the education of every clinical dentist.     

Geriatric oral health issues in Australia

Aim : To identify and discuss geriatric oral health issues in Australia. Methods : A discussion of the demographic trends, oral health trends, and barriers to dental care for older Australians is presented, together with a review of Australian public and private sector geriatric dental services, geriatric dental research, and geriatric dental education. Conclusions : Key geriatric oral health issues for Australia include: edentulism is decreasing and older Australians are retaining more natural teeth; coronal and root caries are significant problems, especially as older adults become more functionally dependent, cognitively impaired, and medically compromised; the oral health status of institutionalised older Australians is poor; the onset of severe oral diseases appears to occur in many older Australians prior to their institutionalisation, when they are homebound and dependent upon carers; carers of older adults do not have access to practical education about dental care; the majority of older Australians are eligible to use public‐funded dental services, but barriers limit their access to these services; few Australian public or private dental services are designed with a geriatric focus; geriatric dental education does not have a high profile in Australian dental schools; no specialty exists in Australia for geriatric dentistry, nor is there a national geriatric dentistry association.     

Changing patterns of oral health and implications for oral health manpower. Responsibility to the public

This paper examines organized dentistry's responsibility for informing the public about changing patterns of oral disease. The public is divided into two groups: governments and other organizations that are responsible for allocating funds for dental treatment, education and research, and the general population that is eligible to use dental services. Some governments in industrialized countries apparently believe that with the decline in caries, monies for dentistry can be reduced without affecting the oral health of the population. This assumption can be challenged, since oral disease levels in lower socioeconomic class groups and the elderly continue to be very high. Further, the goals of the dental care system should be raised to eliminate edentulousness. Dentistry needs to make the public aware that adequate care for the poor and elderly and eliminating edentulousness will require increased support for dentistry. At the patient level, regular users of care who are healthy should be informed that more frequent visits and complex services may have little effect on oral health. In contrast, infrequent users of dental care should be made aware that dentistry has the technology to prevent disease and the loss of teeth. One phase in the history of dentistry is coming to an end but another is beginning. In the new era the dental profession can make even greater contributions to the quality of life of individuals and society.     

Dental hygiene's interdisciplinary relationship with dental public health: a position paper

Dental hygienists' collaboration with social institutions, health-care workers and organisations, educational institutions, and dentistry can prevent oral diseases. Dental hygienists working in these organisations can reach an unprecedented number of people, thereby increasing preventive oral care to many undeserved. Working within a dental public health career increases choices and opportunities for the dental hygienist and benefits the public.     

A framework for oral health care value-based payment approaches

Background

Dental practice has remained relatively insulated from payment upheavals in the broader health care system. The prevailing value-based payment (VBP) models in health care are largely absent in oral health care. The authors present an oral health care value-based payment framework for dentistry.

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.     

荷兰的牙科教育、医疗及健康保障体系

荷兰位于西欧,其牙科教育和医疗水平在欧洲居领先地位。荷兰目前有3所牙学院,每年共招生约300名本科学生,每年仅培养5～7名牙科矫正医师和3～5名牙科外科医师。目前全荷兰有7623名职业牙医,283名牙科矫正医师和203名牙科外科医师,约8500名牙科助手和2000名牙科洁治医师。在荷兰,牙科行医必须符合《个人卫生健康职业法令》,只有先行注册,才可被称为“牙医”。牙医这一职业由于导致很大的职业压力,近年来备受西方国家关注。本文总结了该方面的主要研究成果,并介绍了荷兰近年在医疗保障体制上的改革现况,可资我国医改借鉴。     

Using big data to promote precision oral health in the context of a learning healthcare system

There has been a call for evidence-based oral healthcare guidelines, to improve precision dentistry and oral healthcare delivery. The main challenges to this goal are the current lack of up-to-date evidence, the limited integrative analytical data sets, and the slow translations to routine care delivery. Overcoming these issues requires knowledge discovery pipelines based on big data and health analytics, intelligent integrative informatics approaches, and learning health systems. This article examines how this can be accomplished by utilizing big data. These data can be gathered from four major streams: patients, clinical data, biological data, and normative data sets. All these must then be uniformly combined for analysis and modelling and the meaningful findings can be implemented clinically. By executing data capture cycles and integrating the subsequent findings, practitioners are able to improve public oral health and care delivery.     

Oral health in the context of primary care in Brazil

This article presents an integrative literature review that analyses the advances and challenges in oral health care of the Brazilian primary health care system, based on a political agenda that envisages re‐organising the unified health system (SistemaÚnico de Saúde – SUS). It is presumed that the actions suggested by the Alma‐Ata Conference of 1978 are still up‐to‐date and relevant when adapted to the situation in Brazil. Several studies and policies are reviewed, including works demonstrating the importance of primary care as an organising platform in an integrated health‐care network, Brazil's strategy for reorganising the primary care network known as the Family Health Strategy, and the National Oral Health Policy. This review discusses results obtained over the last twenty years, with special attention paid to changes in oral health‐care practices, as well as the funding of action programmes and assistance cover. The conclusion is that oral healthcare in the Brazilian primary health care system has advanced over the past decades; however, serious obstacles have been experienced, especially with regard to the guarantee of universal access to services and funding. The continuous efforts of public managers and society should focus on the goal of achieving universal coverage for all Brazilians.     

Potential to improve oral health care through evidence, protocols, and payment models

Evidence-based health care aims to utilize the best available evidence from scientific methods and apply this evidence to clinical and public health practice. Evidence of the benefits and risks of treatment is derived from randomized controlled clinical trials, systematic reviews, and expert panels. Evidence-based clinical parameters and guidelines should foster the best health outcomes for individuals or populations at reduced costs. By incorporating evidence-based guidelines into payment models, the payers - private or public - have the capacity to improve oral health care and ultimately oral health outcomes. This paper uses examples from pediatric dentistry to show how adoption of caries risk factors, clinical management protocols, and a reimbursement system based on evidence-based guidelines may allow for better quality of care to more individuals and at a lower cost.     

Assessment of dental health state utilities

The term "health state utility" implies the assigning of a numerical value to a state of health. Assessment of the success of health care procedures, using health state utilities, enables evaluation of available treatments and procedures in terms of differing health outcomes and therefore facilitates cost-benefit analyses. Although measurement of general health state utilities has become increasingly common in medicine using a variety of techniques, few attempts have as yet been made in dentistry to place valuations on different dental health states. The absence of tried and tested methods for measuring tooth quality make the benefits gained from preventive and restorative dental programmes difficult to quantify. The aim of this study was to assess the average utility values, held by a group of dentists and a group of members of the general public, for four different tooth states which it was hypothesised would have different values. These were 1) a decayed and painful posterior tooth; 2) a decayed and non-painful posterior tooth; 3) a posterior tooth which had been restored and would need further restorative treatment and 4) a permanently restored posterior tooth. A standard gamble questionnaire was used to elicit the utility values which were then substituted as "weightings" in a modified version of the "T-health" index (1). The results show that it is possible to assess dental health state utility values using the standard gamble method and that the average utility values of the dentists in the study were consistently higher than those of the general public.(ABSTRACT TRUNCATED AT 250 WORDS)     

Priorities for future public health research in orofacial clefts.

The National Center on Birth Defects and Developmental Disabilities at the Centers for Disease Control and Prevention conducted a workshop in January 2006, entitled "Prioritizing a Research Agenda for Orofacial Clefts." The goals of the meeting were to review existing research on orofacial clefts (OFCs), identify gaps in knowledge that need additional public health research, and develop a prioritized research agenda that can help guide future public health research. Experts in the field of epidemiology, public health, genetics, psychology, speech pathology, dentistry, and health economics participated to create the research agenda. Research gaps identified by the participants for additional public health research included: the roles of maternal nutrition, obesity, and diabetes in the etiology of OFCs; psychosocial outcomes for children with OFCs; the quality of life for families and children with OFCs; and the health care costs of OFCs. To create the research agenda, the participants prioritized the research gaps by public health importance, feasibility, and outcomes of interest. This report summarizes the workshop.     

Oral health in Uganda: the need for a change in focus

This paper reviews the oral health care system of delivery in Uganda as accurately as possible given the limited research base. The paper looks into the evolution of dentistry in Uganda as well as the havoc wrecked on health care in general by two decades of civil strife in an effort to find explanations for the poor performance of the oral health system. Alternative methods of service delivery are suggested drawing from the rich experiences of countries like Sri Lanka and Tanzania. The alternative model highlights the need for a Primary Health Care approach to oral health service delivery implemented in a systematic manner. The paper concludes with a call to all Ugandan oral health workers to take personal and collective responsibility for the improvement of oral health outcomes of 24 million Ugandans through research, advocacy, adherence to professional ethics and continued education.     

Dentistry and health policy

Views expressed from several quarters of the health care system suggest that a reexamination of health policy concerning how health care is organized is likely in the next few years. The last time that a reorganization of health care occurred in the United States, dentistry was not included in a major component (Medicare). A review of the profession's stand at that time, and changes in demography of the elderly population since then, suggests that the position of the profession arrived at in the 1960's needs to be reexamined. The time to discuss what the position of dentistry should be in a new policy debate is now. Alternative approaches responding to economic considerations in the oral health care of the elderly are presented to stimulate discussion about the role of dentistry in health advocacy, both for the elderly and the population at large.     

Should dentists become 'oral physicians'? No, dentistry must remain dentistry

Dentistry is not an allied health profession. It is not a paramedical profession. It is time that dentistry be recognized as the profession that offers patients some of the most complex surgery performed on the human body--namely, restorative dentistry and rehabilitation of the masticatory system. Dentistry is the only anatomically focused health care profession that is university-based and for which primary care responsibility is maintained by the profession. An inferiority complex about what it means to be a dentist has served only to confuse the public and bring us further from our goal of improving the health of all our patients. This inferiority complex is driven by the public and the medical profession, neither of which understands how dentistry fits into overall health care. It is essential that every academic health center have oral health education as an integrated part of health care education for dentists, physicians, nurses, allied dental personel, physical therapists, psychologists and all who receive university-based health care education. In this way, all the health professions and the public will see dentistry and oral health as essential to patients' overall health. The idea of emulating those who do not have the strength of basic-science education, practice complexity, surgical skills or community status by seizing a new title will not elevate the profession for the future. The public knows what a dentist is. It is our task to inform the public about the capabilities of dentists and the value of oral health and our profession. We can accomplish this best by assuring that our profession's name, "dentistry," is understood to represent one of the world's most accomplished surgical endeavors, one that is thoroughly integrated into the fabric of health care. Thus, good oral health will be thoroughly integrated into what it means to be healthy.     

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.     

Expanding Health Insurance Coverage and the Implications for Dentistry

Numerous proposals have been suggested for expanding health insurance coverage to the over 30 million Americans without health insurance. These proposals range from establishing a program of national health insurance modeled after the Canadian system to establishing statewide risk pools. Many of these proposals could have an impact on financial access to dental care for the approximately 120 million people without dental insurance. Dental insurance coverage has been shown to increase access to dental services and improve oral health status. Oral health professionals could facilitate discussions concerning health insurance expansion by informing policymakers about important preventive benefits to be gained by improving access to dental services. Dental public health professionals can serve as a bridge between organized dentistry and health policymakers by providing information to help formulate the priorities and characteristics of a dental health insurance program. This visibility and influence in the health policy arena would be beneficial to dentistry and could ultimately result in greater access to dental services and improved oral health for the uninsured.