Evidence summary: what is the effectiveness of alternative approaches for increasing dental attendance by poor families or families from deprived areas?

A Cost Analysis of an Outreach School-Based Dental Program: Teeth on Wheels

BACKGROUND

This study evaluated an outreach mobile dental service called Teeth on Wheels (TOW). The dental program targeted Australian children from low household income, who are eligible for the Child Dental Benefits Scheme (CDBS) in Victoria, Australia. The program is complemented with a school-based oral health promotion element.

METHODS

A retrospective cohort study was performed with a convenience sample. Children must have had at least three dental examinations during the 2016-2019 calendar years to be included in the study. Comparisons were made between the 2016-17 and 2018-19 calendar years. It was hypothesised that the program would result in reduced costs and the number of restorations and extractions in the latter period.

RESULTS

A total of 414 children were included in the analysis. The total mean costs of the program per child reduced from AU$605.3 in 2016-17 to AU$531.1 in 2018-19. The results showed an overall mean reduction in all restorations and extractions performed, but only statistical significance was noted for reductions of restored deciduous teeth.

CONCLUSIONS

This outreach program, which is focused on prevention and minimally invasive dentistry, can be a promising alternative model of delivery for dental services in young children.

Disentangling a web of causation: An ethnographic study of interlinked patient barriers to planned dental visiting, and strategies to overcome them

OBJECTIVE

To explore barriers to planned dental visiting, investigating how barriers interlink, how they accumulate and change, and how individuals envisage overcoming their combination of barriers through personal strategies.

METHODS

An ethnographic study was conducted of adult urgent dental care attenders who did not have a dentist, including 155 hours of nonparticipant observations, 97 interviews and 19 follow-up interviews in six urgent dental care settings. Data were analysed using constant comparison, first identifying barriers and personal strategies to overcome them, and subsequently analysing interlinks between barriers and personal strategies.

RESULTS

Accounts of barriers to planned dental visiting encompassed multiple barriers, which related to socioeconomic circumstances as well as experiences of oral health care. Barriers were multi-layered and more difficult to overcome when occurring together. Personal strategies to overcome diverse barriers often hinged on increasing importance of oral health to individuals, yet this was not always sufficient. The combination of barriers participants experience was dynamic, changing due to personal, family, or employment circumstances, and with increasing severity of barriers over time. Over time, this could lead to higher cost, and additional barriers, particularly embarrassment.

CONCLUSION

Barriers to planned dental visiting are complex, multi-layered and change over time, constituting a 'web of causation'. This adds a novel perspective to the literature on barriers to dental visiting, and requires that researchers, dental practitioners and policy makers remain open to barriers' interlinked effects, changes in primacy among individual patients' barriers, and their accumulation over time to better support uptake of planned dental visiting.

Investigating the relationship between multimorbidity and dental attendance: a cross-sectional study of UK adults

Introduction

Regular dental attendance is related to better oral health. However, long-standing health conditions (LSHCs) may be related to dental attendance and this relationship may vary by socioeconomic status.

Method

Data were collected from wave two (2013–2015) of the Yorkshire Health Study (n= 7,654). Data included dental attendance, LSHC, age, gender, education-level, smoking, body mass index, and area-level deprivation. Logistic regression (attend or not) was used to analyse associations with LSHC and multimorbidity.

Results

Overall, 63.1% (n = 4,826) of individuals attended the dentist. Of these, 37.8% (n =2894) had no LSHC, 26.0% (n = 1987) had one LSHC and 36.4% (n = 2784) had two or more LSHC. The presence of a singular LSHC was not associated with dental attendance(OR = 0.91 [0.81, 1.04]), however, those with two or more LSHCs were more likely to attend the dentist (OR = 0.81 [95% CI 0.72, 0.92]). Interactions between individual-level education, as a marker of socioeconomic status, and LSHC revealed few associations with dental attendance.

Conclusion

Multimorbidity was associated with dental attendance such that those with multimorbidity were more likely to attend. These important findings highlight the increasing challenge of multimorbidity for global healthcare systems.

Economic Evaluation of a Pilot School–Based Dental Checkup Program

The objectives of this study were to perform an economic evaluation of a targeted school-based dental checkup program in northern metropolitan Melbourne, Victoria. A 12-mo retrospective case-control cohort analysis using the decision tree method evaluated the incremental cost-utility and cost-effectiveness ratio (ICUR/ICER) for passive standard care dental services and an outreach pilot intervention completed in 2013. A societal perspective was adopted. A total of 273 children ( n = 273) aged between 3 and 12 y met the inclusion/exclusion criteria: 128 in the standard care group and 145 in the intervention group. The total society costs included health sector costs, patient/family costs, and productivity losses in 2014 Australian dollars. Outcome measures were evaluated using quality-adjusted tooth years (QATY) and the combined deciduous and permanent decayed, missing, and filled teeth prevented (DMFT-prevented). A generic outcome variable was created to determine the impact of the intervention to reach underserved populations based on government concession eligibility (cardholder status). Uncertainties were incorporated using 95% confidence intervals. The mean total society cost per child is $463 and $291 ( P = 0.002), QATY utility difference is 0.283 and 0.293 ( P = 0.937), effectiveness difference is 0.16 and 0.10 ( P = 0.756), and cardholder status is 50.0% and 66.2% ( P = 0.007), respectively, for the standard care and intervention groups. On average per child, there was a cost saving of $172 and improvement of 0.01 QATY, with an additional proportion of 16.2% of cardholder children reached. The calculated ICER was $3,252 per DMFT-prevented. The intervention dominates standard care for QATY and per 1% cardholder reached outcome measures. Our study found the pilot checkup program was largely less costly and more effective compared with the current standard care. Further research is needed to quantify the value of outreach interventions to prevent dental caries development and progression in populations from low socioeconomic status.

Knowledge Transfer Statement: The findings of this research demonstrated that an outreach dental program can be less costly and more effective than standard models of dental care. It showed that a school-based dental checkup program is beneficial despite other opinions that dental screening is ineffective as a method to improve public dental health. There is fiscal economic evidence to support broader expansion of similar programs locally and internationally to reduce dental caries for children from low-income families.