Optimizing the mix of basic dental services for Southern Thai schoolchildren based on resource consumption, service needs and parental preference

Safety and effectiveness of an innosvative SS-suction device to control moisture in dental procedures

Control of moisture is critical for retention of sealants, which can reduce the incidence of caries in high-risk groups.

OBJECTIVES

We investigated the safety and efficacy of the novel SS-suction device in the laboratory and a small clinical trial in children aged 6 to 8-years-old.

METHODS

First, a laboratory test of 52 SS-suction devices was conducted to determine the pressure generated by the chin plate to maintain suction at different intervals and to determine the pressure resistance of the spring to maintain suction in a child's mouth. Second, 12 healthy children with sound lower molars participated in a clinical trial of the use of SS-suction during sealant application.

RESULTS

The laboratory test showed that when pressed to the maximum distance of 25 mm, the chin plate produced a pressure of 247.5 ± 116.6 mmHg. At this pressure, the SS-suction could be used safely for up to 120 min without damaging the soft tissues. In the clinical study, the dentists inserted and removed the SS-suction in 7.80 ± 2.48 s. The range by which the chin plate was pressed down varied between 0 and 13 mm. The highest pressure on the skin was 120 mmHg (at 13 mm) and the device effectively maintained suction and effectively removed water and saliva. The time required to apply sealant was 7.01 ± 2.26 min.

CONCLUSIONS

The SS-suction is a safe, effective device for two-handed application of sealants in children, with no negative side effects.

CLINICAL SIGNIFICANCE

We demonstrate the unique SS-suction device can quickly drain water and saliva to help dentists treat young patients using a two-handed approach; this device provides good control of moisture during sealant application. The device prevents the tongue and cheeks from interfering with the operation area, reduces tension, and does not require a dental assistant.

A Cluster Randomized Controlled Trial of the Dental Sealants Quality in Rural Schoolchildren Using Innovative Suction without Dental Assistance

This study examined whether the moisture control innovation (tongue and cheek retractors and saliva contamination (SS-suction)) used without dental assistance could improve the quality of dental sealant in rural Thai school children compared to a standard treatment, i.e., high power suction with dental assistance. A single blind, cluster randomized controlled trial was conducted. Participants were 15 dental nurses working in sub-district health promoting hospitals and 482 children. All dental nurses attended workshops of SS-suction and revised dental sealant procedures. Children with sound lower first permanent molar teeth were simple-randomly assigned to either an intervention or control group. The children in the intervention group were sealed with SS-suction, and the children in the control group were sealed with high power suction and dental assistance. There were 244 children in the intervention group and 238 children in the control group. Dental nurses' satisfaction on SS-suction was record by visual analogue scale (VAS) for each tooth during treatment. After 15-18 months, caries on sealed surfaces were examined. The results showed that the median satisfaction score of SS-suction was 9 out of 10, and 17-18% children experienced uncomfortable sensation during insertion or removal. The uncomfortable feeling disappeared once the suction was in place. Caries on sealed surfaces did not differ significantly between the intervention and control groups. Caries on the occlusal surface was present in 26.7% and 27.5%, and caries on the buccal surface was present in 35.2% and 36.4% of cases in the intervention and control groups, respectively. In conclusion, dental nurses were satisfied with SS-suction in terms of both function and safety. The effectiveness of SS-suction was compatible with the standard procedure after 15-18 months.

Economic evaluations in paediatric dentistry clinical trials

Economic evaluations play an important role in identifying the cost-effectiveness of alternative healthcare programmes, informing decisions surrounding funding and the allocation of resources. This paper outlines the basic principles of economic evaluation and how it can be conducted alongside a clinical trial. Furthermore, it considers the ways in which evidence from these studies can be used, and the challenges researchers are faced with when conducting economic evaluations in the field of children's oral health.

Minimizing Health-Compromising Behaviors via School-Based Programs: An Optimization Approach

School health programs are united by their desire to promote health and health-related outcomes among youth. They are also united by the fact that their expected effects are contingent on successful program implementation, which is often impeded by a multitude of real-world barriers. Techniques used in management science may help optimize school-based programs by accounting for implementation barriers. In this exploratory study, we present a detailed example of the first known application of linear programming (LP), which is an optimization technique, to Positive Action (PA). PA is a social emotional and character development program that includes a six-unit, teacher-delivered, classroom curriculum. We specify how we used LP to calculate the optimal levels of program implementation needed to minimize substance use, subject to known levels of implementation barriers (e.g., disruptive behavior, teacher education, teacher attitudes towards character development, school resources, and school safety). We found that LP is a technique that can be applied to data from a school health program. Specifically, we were able to develop a model that calculated the number of lessons that should be taught to minimize a specific health-compromising behavior, given expected levels of predetermined implementation barriers. Our findings from this exploratory study support the utility of applying LP during the program planning and implementation processes of school health programs.

On value frameworks and opportunity costs in health technology assessment

OBJECTIVES

Proceeding from a basic concept underpinning economic evaluation, opportunity cost, this study aims to explain how different approaches to economics diverge quite dramatically in their ideas of what constitutes appropriate valuation, both in principle and practice. Because the concept of opportunity cost does not inherently specify how valuation should be undertaken or specify how appropriate any economic value framework (EVF) might be, the three main economics-based approaches to providing evidence about value for health technology assessment are described.

METHODS

This paper describes how the three main EVFs-namely, the extra-welfarist, welfarist, and classical-are most typically understood, applied, and promoted. It then provides clarification and assessment of related concepts and terminology.

RESULTS

Although EVFs differ, certain underlying characteristics of valuation were identified as fundamental to all approaches to economic evaluation in practice. The study also suggests that some of the rhetoric and terms employed in relation to the extra-welfarist approach are not wholly justified and, further, that only the welfarist approach ensures adherence to welfare-economic principles. Finally, deliberative analysis, especially when connected with a classical economic approach, can serve as a useful supplement to other analytical approaches.

CONCLUSIONS

All three approaches to economic evaluation have something to offer assessment processes, but they all display limitations too. Therefore, the author concludes that the language of economic evaluation should be used with sufficient humility to prevent overselling of EVFs, especially with regard to the qualities of evidence they provide for priority setting processes.

A dynamic, multi-professional, needs-based simulation model to inform human resources for health planning

BACKGROUND

As population health needs become more complex, addressing those needs increasingly requires the knowledge, skills, and judgment of multiple types of human resources for health (HRH) working interdependently. A growing emphasis on team-delivered health care is evident in several jurisdictions, including those in Canada. However, the most commonly used HRH planning models across Canada and other countries lack the capacity to plan for more than one type of HRH in an integrated manner. The purpose of this paper is to present a dynamic, multi-professional, needs-based simulation model to inform HRH planning and demonstrate the importance of two of its parameters-division of work and clinical focus-which have received comparatively little attention in HRH research to date.

METHODS

The model estimates HRH requirements by combining features of two previously published needs-based approaches to HRH planning-a dynamic approach designed to plan for a single type of HRH at a time and a multi-professional approach designed to compare HRH supply with requirements at a single point in time. The supplies of different types of HRH are estimated using a stock-and-flow approach.

RESULTS

The model makes explicit two planning parameters-the division of work across different types of HRH, and the degree of clinical focus among individual types of HRH-which have previously received little attention in the HRH literature. Examples of the impacts of these parameters on HRH planning scenarios are provided to illustrate how failure to account for them may over- or under-estimate the size of any gaps between the supply of and requirements for HRH.

CONCLUSION

This paper presents a dynamic, multi-professional, needs-based simulation model which can be used to inform HRH planning in different contexts. To facilitate its application by readers, this includes the definition of each parameter and specification of the mathematical relationships between them.

Critical review of willingness to pay for clinical oral health interventions

OBJECTIVES

This critical review aimed to identify, consolidate and evaluate the quality of Willingness to Pay (WTP) studies applied to clinical contexts in the field of dentistry.

METHODS

PubMed and Web of Science databases were systematically searched for relevant publications. Screening and data extraction was then performed. Primary literature in English-language were included to assess the WTP for oral health interventions, when the valuations were applied to a clinical measure. Twenty-six publications met the inclusion criteria.

RESULTS

WTP was elicited mainly via face-to-face interviews (13 publications) and questionnaires (12 publications). The majority (24) of publications selected an out-of-pocket payment vehicle. Eleven publications adopted a bidding method, nine publications adopted an open-ended format, and the remaining six studies adopted a payment card or choice method. Pre-testing was reported in only nine publications, and few studies accounted for starting point bias. Eight of 11 publications found that higher incomes were associated with higher WTP values. The female gender, a younger age and higher education levels were associated with a higher WTP in select studies.

CONCLUSIONS

Only a small minority of the studies used strategies to avoid well documented biases related to WTP elicitation. Cost versus benefit of many clinical scenarios remain uninvestigated.

CLINICAL SIGNIFICANCE

WTP studies in dentistry may benefit from pre-testing and the inclusion of a script to minimise hypothetical bias. They may also be better conducted face-to-face and via a shuffled payment card method. Income levels, and potentially education levels, gender and age, should be assessed for their influence on WTP values.

An Integrated Needs-Based Approach to Health Service and Health Workforce Planning: Applications for Pandemic Influenza

Healthcare systems must be responsive to the healthcare needs of the populations they serve. However, typically neither health services nor health workforce planning account for populations' needs for care, resulting in substantial and unnecessary unmet needs. These are further exacerbated during unexpected surges in need, such as pandemics or natural disasters. To illustrate the potential of improved methods to help planning for these types of events, we applied an integrated, needs-based approach to health service and workforce planning in the context of a potential influenza pandemic at the provincial level in Canada. This application provides evidence on the province's capacity to respond to surges in need for healthcare and identifies specific services which may be in short supply in such scenarios. This type of approach can be implemented by planners to address a variety of health issues in different contexts.

Simulating future supply of and requirements for human resources for health in high-income OECD countries

BACKGROUND

As part of efforts to inform the development of a global human resources for health (HRH) strategy, a comprehensive methodology for estimating HRH supply and requirements was described in a companion paper. The purpose of this paper is to demonstrate the application of that methodology, using data publicly available online, to simulate the supply of and requirements for midwives, nurses, and physicians in the 32 high-income member countries of the Organisation for Economic Co-operation and Development (OECD) up to 2030.

METHODS

A model combining a stock-and-flow approach to simulate the future supply of each profession in each country-adjusted according to levels of HRH participation and activity-and a needs-based approach to simulate future HRH requirements was used. Most of the data to populate the model were obtained from the OECD's online indicator database. Other data were obtained from targeted internet searches and documents gathered as part of the companion paper.

RESULTS

Relevant recent measures for each model parameter were found for at least one of the included countries. In total, 35% of the desired current data elements were found; assumed values were used for the other current data elements. Multiple scenarios were used to demonstrate the sensitivity of the simulations to different assumed future values of model parameters. Depending on the assumed future values of each model parameter, the simulated HRH gaps across the included countries could range from shortfalls of 74 000 midwives, 3.2 million nurses, and 1.2 million physicians to surpluses of 67 000 midwives, 2.9 million nurses, and 1.0 million physicians by 2030.

CONCLUSIONS

Despite important gaps in the data publicly available online and the short time available to implement it, this paper demonstrates the basic feasibility of a more comprehensive, population needs-based approach to estimating HRH supply and requirements than most of those currently being used. HRH planners in individual countries, working with their respective stakeholder groups, would have more direct access to data on the relevant planning parameters and would thus be in an even better position to implement such an approach.

On the margins of health economics: a response to 'resolving NICE'S nasty dilemma'

In a 2011 article published in this journal, Baker et al. set out to resolve a nasty dilemma for NICE by reconciling two approaches for determining whether adopting a new intervention would increase total health gains produced from available resources and hence increase system efficiency. In this response we show how the proposed reconciliation, as well as the two approaches on which it is based, fail to inform decision makers about the efficiency of a new intervention. We show how this arises from the misuse of incremental costs and effects of between-intervention comparisons as measures of changes in costs and effects associated with marginal adjustments to the scale of an intervention. Ironically, incremental data represent the choices faced by decision makers and we illustrate a method for determining unambiguously whether a new intervention represents an improvement in efficiency.

Cost-efficiency of indigenously fabricated mobile-portable dental unit in delivery of primary healthcare in rural India

AIM

Innovation in primary oral healthcare delivery is a potential yet relatively unexplored area in Dental literature. AIM of the present study was to assess the economic gains that can be made by designing and operating an indigenously fabricated portable dental unit in rural areas.

MATERIALS AND METHODS

Cost-efficiency was determined by comparing total revenue (number of patients treated) with total costs (direct - capital cost of fabrication; and indirect - dental materials, disposables, transport, miscellaneous) over a period of seven years (2005 to 2012). Operational efficiency of portable dental units was also compared with dental vans on various categories of performance indicators. Data analysis was based on institutional records of Rajasthan Dental College (RDC), Jaipur, India.

RESULTS

RESULTS show that a total of 52,900 patients who attended 223 camps during this period were provided various primary oral healthcare services using four such portable dental units that were developed @ Rs. 24,000 ($ 417) per unit. Based on a cost-efficiency of Rs 35.53 ($ 0.65) per person, which is among the lowest reported from any part of the world, the authors conclude that indigenously fabricated portable dental units provide a cost-efficient service. The other aspects most relevant to portable equipment were ease of transportation and feasibility in domiciliary care provision.

CONCLUSION

The Limitations of productivity due to time spent in setting up the unit and need for additional space/equipment was their main drawbacks vis-à-vis dental vans.

Mobile and portable dental services catering to the basic oral health needs of the underserved population in developing countries: a proposed model

India is the second most populous country in the world with an extensive rural population (68.8%). Children less than 18 years constitute about 40% of the population. Approximately, 23.5% of the urban population resides in urban slums. The extensive rural population, school children and the urban slum dwellers are denied of even the basic dental services though there is continuous advancement in the field of dentistry. The dentist to population ratio has dramatically improved in the last one to two decades with no significant improvement in the oral health status of the general population. The various studies have revealed an increasing trend in oral diseases in the recent times especially among this underserved population. Alternate strategies have to be thought about rather than the traditional oral health-care delivery through private dentists on fee for service basis. Mobile and portable dental services are a viable option to take the sophisticated oral health services to the doorsteps of the underserved population. The databases were searched for publications from 1900 to the present (2013) using terms such as Mobile dental services, Portable dental services and Mobile and portable dental services with key articles obtained primarily from MEDLINE. This paper reviews the published and unpublished literature from different sources on the various mobile dental service programs successfully implemented in some developed and developing countries. Though the mobile and portable systems have some practical difficulties like financial considerations, they still seem to be the only way to reach every section of the community in the absence of national oral health policy and organized school dental health programs in India. The material for the present review was obtained mainly by searching the biomedical databases for primary research material using the search engine with key words such as mobile and/or portable dental services in developed and developing countries (adding each of these terms in a sequential order). Based on the review of the programs successfully implemented in developed countries, we propose a model to cater to the basic oral health needs of an extensive underserved population in India that may be pilot tested. The increasing dental manpower can best be utilized for the promotion of oral health through mobile and portable dental services. The professional dental organizations should have a strong motive to translate this into reality.

Putting your money where your mouth is: parents' valuation of good oral health of their children

The aim of this study was to investigate the parental willingness to invest in good oral health for their child in terms of money and time and to relate this to oral health related knowledge and behavioral aspects. 290 parents of 6-year-old children, participating in a RCT on caries preventive strategies in The Netherlands were asked to provide information on education, oral health habits, dietary habits, knowledge on dental topics, willingness to pay and perceived resistance against investing in preventive oral health actions for their children. Despite the fact that parents overall valued oral health for their child highly, still 12% of the parents were unwilling to spend any money, nor to invest any time by brushing their children's teeth to maintain good oral health for their child. Additionally, they indicated that they were unwilling to visit the dentist for preventive measures more than once a year. These children may certainly be considered at higher risk of developing oral diseases because worse oral hygiene habits and dietary habits were found in this group. Given the results, it may be necessary to differentiate in allocating caries prevention programmes to target parents or (school-based) children directly.