Introducing high-cost health care to patients: dentists' accounts of offering dental implant treatment

OBJECTIVES

The decision-making process within health care has been widely researched, with shared decision-making, where both patients and clinicians share technical and personal information, often being cited as the ideal model. To date, much of this research has focused on systems where patients receive their care and treatment free at the point of contact (either in government-funded schemes or in insurance-based schemes). Oral health care often involves patients making direct payments for their care and treatment, and less is known about how this payment affects the decision-making process. It is clear that patient characteristics influence decision-making, but previous evidence suggests that clinicians may assume characteristics rather than eliciting them directly. The aim was to explore the influences on how dentists' engaged in the decision-making process surrounding a high-cost item of health care, dental implant treatments (DITs).

METHODS

A qualitative study using semi-structured interviews was undertaken using a purposive sample of primary care dentists (n = 25). Thematic analysis was undertaken to reveal emerging key themes.

RESULTS

There were differences in how dentists discussed and offered implants. Dentists made decisions about whether to offer implants based on business factors, professional and legal obligations and whether they perceived the patient to be motivated to have treatment and their ability to pay. There was evidence that assessment of these characteristics was often based on assumptions derived from elements such as the appearance of the patient, the state of the patient's mouth and demographic details. The data suggest that there is a conflict between three elements of acting as a healthcare professional: minimizing provision of unneeded treatment, trying to fully involve patients in shared decisions and acting as a business person with the potential for financial gain.

CONCLUSIONS

It might be expected that in the context of a high-cost healthcare intervention for which patients pay the bill themselves, that decision-making would be closer to an informed than a paternalistic model. Our research suggests that paternalistic decision-making is still practised and is influenced by assumptions about patient characteristics. Better tools and training may be required to support clinicians in this area of practice.

The influence of economic incentives on treatment patterns in a third-party funded dental service

OBJECTIVE

To investigate the response of dental practitioners to administration and remuneration adjustments to the Dental Treatment Services Scheme (DTSS) in the Republic of Ireland.

DESIGN

Following the introduction of a series of administration and fee adjustments by a third party payments system in December 1999 the pattern of extractions and restorations are examined to determine whether the adjustments had influenced provider behaviour, in particular whether a substitution effect from extractions to restorations would result from a relative fee increase of 62% for amalgam fillings.

DATA AND METHODS

Data on patient and provider characteristics from June 1996 to April 2005, collected by the Health Service Executive (HSE) National Shared Services Primary Care Reimbursement Service to facilitate remuneration to dentists providing services in the DTSS, was used in this analysis. A graphical analysis of the data revealed a structural break in the time-series and an apparent substitution to amalgam fillings following the introduction of the fee increases. To test the statistical significance of this break, the ratio of amalgams to restorations was regressed on the trend, growth and level dummy variables, using Ordinary Least Squares (OLS) regression. The diagnostics of the model were assessed using the Jarque-Bera normality test and the LM to test for serial correlation.

RESULTS

The initial results showed no evidence of a structural break. However on further investigation, when a pulse dummy was included to account for the immediate impact of the fee adjustment the results suggest a unit root process with a structural break in December 1999. This implies that the amalgam fee increase of December 1999 influenced the behaviour patterns of providers.

CONCLUSIONS

System changes can be used to change the emphasis from a scheme that was principally exodontia/emergency based to a scheme that is more conservative and based on restoration/prevention.

Estimating determinants of dentist productivity: new evidence

OBJECTIVE

Productivity (output per unit of input) is a major driver of dental service capacity. This study uses 2006-2007 data to update available knowledge on dentist productivity.

METHODS

In 2006-2007, the authors surveyed 1,604 Oregon general dentists regarding-hours worked, practice size, payment and patient mix, prices, dentist visits, and dentist characteristics. Effects of practice inputs and other independent variables on productivity were estimated by multiple regression and path analysis.

RESULTS

The survey response rate was 55.2 percent. Dentists responding to the productivity-related questions were similar to dentists in the overall sampling frame and nationwide. Visits per week are significantly positively related to dentist hours worked, number of assistants, hygienists, and number of operatories. Dentist ownership status, years of experience, and percentage of Medicaid patients are significantly positively related to practice output. The contributions of dentist chairside time and assistants to additional output are smaller for owners, but the number of additional dentist visits enabled by more hygienists is larger for owners.

CONCLUSION

As in earlier studies of dental productivity, the key determinant of dentist output is the dentist's own chairside time. The incremental contributions of dentist time, auxiliaries, and operatories to production of dentist visits have not changed substantially over the past three decades. Future studies should focus on ultimate measures of output--oral health--and should develop more precise measures of the practice's actual utilization of auxiliaries and their skill and use of technology.

Occlusal tooth surface treatment plans and their possible effects on oral health care costs

PURPOSE

The aim of this study was to evaluate decision making with regard to detection and treatment of carious lesions on occlusal tooth surfaces and to evaluate the possible costs related to the different treatment plans of a group of clinicians in private practice.

MATERIALS AND METHODS

Forty extracted permanent teeth with no fillings or macroscopic carious cavitations were selected and radiographed, using a standard method similar to bitewing and then mounted in two models. A sample of 130 clinicians in private practice in Piracicaba, Brazil were asked to carry out combined visual-radiographic caries examination of the occlusal surfaces and to recommend possible treatment plans for each surface. Teeth were sectioned bucco-lingually and caries was assessed using a stereomicroscope and classified as either enamel or dentine lesions. The costs of treatments suggested by each examiner were calculated, using a fee scale reported by the Brazilian Federal Council of Dentistry.

RESULTS

Most teeth (53.7%) that were found to be sound on histological examination were considered to have enamel lesions. In 85.7% of these cases, the clinicians recommended restorative treatments. There was about 14-fold difference among clinicians concerning the costs related to decision making.

CONCLUSION

Not only did the clinicians overestimate the presence and depth of carious lesions, but they also tended to treat enamel lesions using invasive therapeutic procedures. Great disparities were observed with regard to treatment costs related to decision making. Assuming an in vivo situation, the clinicians may be performing overtreatments and consequently interfering in the quality of patients' oral health.

Clinical inertia in dentistry: a review of the phenomenon

AIM

Dentistry has been slow to adopt innovations in dental practice even when they are recommended by national organizations and supported by evidence-based guidelines. The objective of this review is to describe clinical inertia, a concept described frequently in the medical literature, and to use findings from tobacco cessation and dental sealant studies as evidence of its existence.

METHODS AND MATERIALS

A review of the literature published during the past 30 years was conducted to determine the state of affairs of two very different areas of dental practice, tobacco cessation intervention and application of sealants, to demonstrate the concept of clinical inertia in dental practice. Factors such as over estimating services provided, unfounded reasons not to act, lack of adequate training, and competing demands that account for the inertia were examined.

DISCUSSION

Clinical inertia is a complex concept that needs more attention in dentistry. A variety of strategies will be required to overcome it in order to provide the best care for the public.

CONCLUSION

Clinical inertia is a useful paradigm for explaining delays in the incorporation of new knowledge into clinical practice. It offers a model against which the broader dental community can develop and test strategies to reduce the delays in translating best practices into daily practices.

CLINICAL SIGNIFICANCE

The path to providing state-of-the-art care for the public is to engage in the discovery, dissemination, and acquisition of new knowledge then transform it into evidence-based best practices to be used in daily clinical practice.

Economic impact of regulating the use of amalgam restorations

OBJECTIVE

This article estimates the financial impact of a ban on amalgam restorations for selected population groups: the entire population, children, and children and women of childbearing age.

METHODS

Using claim and enrollment data from Delta Dental of Michigan, Ohio, and Indiana and the American Dental Association Survey of Dental Services Rendered, we estimated the per capita use and annual rate of change in amalgam restorations for each age, gender, and socioeconomic subgroup. We used population projections to obtain national estimates of amalgam use, and the dental component of the Consumer Price Index to estimate the annual rate of change in fees. We then calculated the number of dental amalgams affected by the regulation, and the fees for each of the years 2005 to 2020.

RESULTS

If amalgam restorations are banned for the entire population, the average price of restorations before 2005 and after the ban would increase $52 from $278 to $330, and total expenditures for restorations would increase from $46.2 billion to $49.7 billion. As the price of restorations increases, there would be 15,444,021 fewer restorations inserted per year. The estimated first-year impact of banning dental amalgams in the entire population is an increase in expenditures of $8.2 billion.

CONCLUSIONS

An amalgam ban would have a substantial short- and long-term impact on increasing expenditures for dental care, decreasing utilization, and increasing untreated disease. Based on the available evidence, we believe that state legislatures should seriously consider these effects when contemplating possible restrictions on the use of amalgam restorations.

Digital radiography: a survey of dentists in Hawai'i

PURPOSE

The purpose of this study was to determine the prevalence of digital radiography among dentists in Hawai'i and report their experiences using it.

METHODS

A 20-question survey was developed and used to interview dentists in Hawai'i. Approximately 500 dentists were contacted. The survey asked whether or not the dentist uses digital radiography. For those not using digital equipment, reasons were given as well as proposed future use. For users of digital equipment, further information was requested: group or solo practice, length of time with digital equipment, length of time to decide, brand of dental software, brand and type of digital equipment, how many different systems, satisfaction, would they do it again, financially worth it, advantages, disadvantages, diagnostic or not, use of special features, sensor replacement and maintenance costs, and any other comments about digital radiography.

RESULTS

102 dentists responded to the survey. 36 percent utilize digital radiography. Only 40 percent of nonusers have any inclination of converting to digital, cost being the most common reason not to convert. Average length of time with digital was 3.4 years and about 2 years to make the decision. Dentrix was the most popular software and Dexis the most popular equipment. The overwhelming majority are satisfied with systems, feel they are financially worth it, feel it is diagnostic, and would purchase them again. Advantages included things such as speed, no use of chemicals, and lower radiation. Disadvantages included cost, sensor-related issues, and computer issues. Digital users find special features helpful and utilize them regularly. Maintenance costs include annual software upgrades, sensor replacement, and barriers and bitetabs.

CONCLUSIONS

Digital radiography is becoming more prevalent in Hawai'i. The big obstacle seems to be cost for most dentists, although users believe it is a good financial investment.

Medicaid participation by private dentists in Alabama

OBJECTIVE

The objective of this study was to examine the relationship between private dentists' attitudes toward Medicaid and Medicaid patients and their extent of Medicaid participation.

METHODS

A survey was mailed to all Medicaid dentists in Alabama in 2003 (N = 518). Descriptive statistics were calculated, and multiple regression models were tested. The "dentists' extent of participation" was a measure of the percentage of Medicaid patients seen in one month. Independent variables included dentists' personal and practice characteristics; market area characteristics; and dentists' attitudes toward Medicaid and Medicaid patients.

RESULTS

A total of 277 (54%) surveys was returned. Non-Caucasian dentists in group practice had a higher mean of extent of Medicaid participation than Caucasian dentists in solo practice. Moreover, compared to privately insured families, dentists had significantly higher mean of extent of Medicaid participation if they perceived Medicaid reimbursement as generous; payments being processed faster; and families as not acceptable to non-Medicaid families in the practice.

CONCLUSIONS

Dentists' perceptions of Medicaid policies, such as generosity of payment and speed of processing payment, are important to ensure continued provider participation in Medicaid. Strategies to improve dentists' participation in Medicaid must be multifaceted to increase access to dental services for Medicaid children.

Attitudes and practice in the provision of removable partial dentures

OBJECTIVE

To identify the factors shaping the pattern of removable partial denture (RPD) provision by dentists in England. Design Cross sectional survey of general dental practitioners.

METHODS

Details of current practice and provision, influences, attitudes and demographic details were collected using a self-completion questionnaire mailed to general dental practitioners identified through the Dental Practice Board register.

RESULTS

Three hundred and eighty-five questionnaires were returned by general dental practitioners from 62 health authorities throughout England. The most important factor reported as influencing both the GDP's decision to provide a partial denture and its subsequent success was patient desire to have a partial denture. Constructing the denture from cobalt chrome, advising the patient on aftercare, making time available to make minor adjustments and being responsible for design were all factors dentists associated with success of a RPD. However, for a number of dentists there was a reported divergence between knowledge and practice.

CONCLUSION

Overall it is clear that provision of partial dentures continues to be patient led. However, the decision making process is also influenced by a number of factors including time, cost and the NHS fee structure.

Dental insurance: will it help or hinder adoption of caries management practices?

Whether public or private dental insurance will provide benefits for caries management practices is a business decision. The foundation for this decision is multifactorial and continually changing as the values of the purchasers and health care consumers evolve. Understanding the dynamics involved in allocating finite health care resources will help those who advocate for caries management inform decision makers about the potential benefits of these strategies.

Changes and factors associated with dentists' willingness to treat patients with severe disabilities

OBJECTIVE

This study investigated changes in dentists' willingness to treat severely disabled patients and to understand dentists' opinions on reimbursements after the implementation of a dental care financial reward program in Taiwan.

METHODS

Three hundred dentists from 29 teaching hospitals were randomly selected to answer a structured questionnaire, and 184 structured questionnaires were returned. Multiple regression analysis was used to examine the factors associated with dentists' willingness to treat severely disabled patients.

RESULTS

Approximately 60% of the dentists said reimbursements for treatment of severely disabled patients were reasonable. 50.4% of dentists were willing or very willing to treat disabled patients. Seventy-nine percent dentists affected by the program had a higher willingness but 83.7% dentists said this program did not make a significant difference to their income. 52.8% of dentists agreed the program would increase the quality of dental care. The factors significantly affecting dentists' willingness included dentist's age, specialty field, perception of the program in promoting the quality of dental services, and perception of the ability to provide adequate treatments for severely disabled patients.

CONCLUSIONS

The rewards program significantly increased the willingness of most hospital-base dentists to treat the severely disabled patients although the effect of incentive to their income was limited.

A comparison of costs in providing dental care for special needs patients under sedation or general anaesthesia in the North East of England

OBJECTIVE

To compare the costs of providing dental treatment under general anaesthesia or sedation for special needs patients.

METHODS

After a Delphi exercise, a questionnaire was designed, piloted and then sent to nine NHS Trust dental service managers, within the Salaried Dental Services in the North East of England, to obtain information on the costs incurred during the treatment of special needs patients using sedation or general anaesthesia. The questionnaire related to the average number of such patients treated per session, staff costs, depreciation cost for buildings and equipment, and overhead costs including consumables and drugs.

RESULTS

All nine dental service managers returned completed questionnaires. The all-inclusive cost for treatment per patient under general anaesthesia ranged from 203.65-479.50 pounds (mean cost: 285.79 pounds) and for sedation from 57.60-153.50 pounds (mean cost: 90.81 pounds). On average three special needs patients were treated per session. The greatest variation in the costs for general anaesthesia was due to staffing costs, which ranged from 1064.10 to 350.00 pounds per session across the Trusts.

CONCLUSIONS

In the small number of centres sampled, the cost of delivering dental care under sedation or general anaesthesia was shown to vary widely. Overall, the mean cost of sedation was one-third that of general anaesthesia. However, the cost of both was substantial and cognisance needs to be taken of the costs of such services.

Dentist preferences for patients: dimensions and associations with provider, practice, and service characteristics

Provider-patient relations may influence the nature of care provided. The aim of this study was to examine dentist preferences for patients, relate these to characteristics of dentists and practices, and to services provided. A random sample of Australian dentists completed mailed questionnaires (response = 60.3%). Four factor-based subscales and an overall scale (Selectivity) were derived from a 37-item battery. The 4 subscales comprised treatment adherence (behavior relevant to the treatment situation), personal adaptability (willingness to cooperate when expected to do so), social interactiveness (positive affect, communicativeness, and appreciativeness), and enabling characteristics (willing and able to pay, and good dental knowledge). Reliability was adequate (Cronbach's alpha = 0.71-0.90). Treatment adherence was associated with higher orthodontic rates, but a lower extraction rate; social interactiveness was associated with higher extraction and denture rates; personal adaptability was associated with higher orthodontic rates, but lower general/miscellaneous service rates; enabling characteristics was associated with higher endodontic and crown and bridge rates; selectivity was associated with higher rates of diagnostic, preventive, and total services per visit. The associations with service rates indicated that provider preferences were related to treatment behavior that could affect the mix of services, indicating that the nature of care provided may be influenced by the provider-patient relation.

Availability of dental appointments for young children in King County, Washington: implications for access to care

PURPOSE

The purpose of this study was to determine the proportion of dental offices in King County willing to provide a new appointment to young children and young children on Medicaid.

METHODS

A simulated parent phone call was made to 508 randomly chosen dental offices in King County. Of these, 291 offices provided preventive dental care to children. Data were collected on: (1) youngest age seen (options ranged from less than 1 to older than 5 years); (2) whether Medicaid was accepted; and (3) time to first available appointment.

RESULTS

In King County, more than 99% of dental offices providing care to children would see new patients 5 years of age or older, but only 15% of these offices would accept 5-year-olds on Medicaid. Nine percent of dental offices accepted patients younger than 1 for a new preventive visit, but just 3% accepted Medicaid-insured children in this age group.

CONCLUSIONS

Adhering to recommendations for early initiation of dental care is difficult, given the limited availability of dental appointments for young and Medicaid-insured children.

Management of dental trauma in primary care: a postal survey of general dental practitioners

OBJECTIVES

To determine the self-perceived knowledge and attitudes of general dental practitioners (GDPs) concerning management of dental trauma in primary care. To identify potential barriers to the management of dental trauma in primary care.

DESIGN AND SETTING

A self-completion postal questionnaire survey of 417 GDPs in six local health authority districts in northeast England.

MAIN OUTCOME MEASURES

Likert scale responses to 20 statements designed to test self-perceived knowledge and attitudes. Following descriptive statistical analysis. Factor analysis with principle components analysis was undertaken to identify areas of correlation in questionnaire responses, followed by Chi squared test, Spearman's Rank Correlation and analysis of variance (ANOVA) to measure association between variables.

RESULTS

The response rate was 74%. Enamel and dentine fractures were the most common injury, with 45% of GDPs responding seeing more than 10 cases of dental trauma in the preceding year and 53% of respondents seeing one to three cases of complicated crown fracture. Seventy-eight per cent believed that NHS remuneration was inadequate, but only 8% would refer patients with dental trauma to secondary care for this reason. Half of the GDPs believed that trauma could be treated more effectively in practice if NHS payments were greater. GDPs were significantly more likely to agree with this statement if they had previously undertaken a postgraduate course in the treatment of dental trauma (p=0.002). Single handed GDPs were statistically significantly more likely to agree with the statements 'I would not treat dental trauma cases at my practice because the NHS payment is inadequate' (p=0.008) and 'Treating dental trauma at my practice requires too much of my clinical time to be worthwhile' (p=0.002). Ninety-six per cent of GDPs disagreed that treatment of dental trauma rested solely within secondary care. Ninety-six per cent of GDPs agreed that they had a responsibility to provide initial emergency treatment for trauma patients prior to referral. Eighty-eight per cent of GDPs felt that aids to management would be useful.

CONCLUSIONS

Although GDPs believed that financial remuneration was inadequate, this did not prevent them treating trauma cases. They strongly agreed that they had responsibility for the management of dental trauma in primary care and that they believed trauma could be treated more effectively in practice if payment was greater. Time constraints were perceived as a barrier to long-term management of complex trauma cases in primary care. GDPs would welcome the use of management aids.

Categorisation of dental care provided in the Netherlands

OBJECTIVE

To describe the dental care provided in the Netherlands and investigate to what extent variations can be explained in accordance with certain general characteristics of patients.

METHOD

Besides the more usual classification of treatment into groups of dental procedures, in this study it is done using constructed categorisation of dental care based on characteristics such as 'preventive', 'curative', 'new', 'time-consuming', 'complicated' and 'lucrative' treatment. The data were collected from various groups of dentists. Two smaller groups of dentists-informants were asked to categorise dental procedures: 16 out of 55 (29%) and 57 out of 150 (38%). Finally this resulted in six type-scores for each procedure. From another larger group of dentists (n = 607) data were collected about the procedures they performed on a 25% random sample of their patients. Categorisations of dental care per patient were calculated by combining the data on the factual procedures performed with the six 'type-scores' for the procedures concerned. Furthermore, the financial returns dentists generated per patient were calculated from the care they provided.

RESULTS

Multilevel analysis shows that considerable variation exists in the categorisations of dental care provided according to age, gender, insurance situation and income level of patients. In youths, for example, relatively more 'preventive' and less 'curative', 'complicated' and 'lucrative' treatment is done and 'older' adults receive relatively less 'preventive' and more 'curative', 'time-consuming' and 'complicated' treatment.

CONCLUSIONS

By classifying the dental care provided in certain categories, a general view is obtained of the variations between patients in the care provided. The age of patients appears to be the most critical factor, but there are differences among dentists in the way the age of patients influences their conduct in the provision of dental care.

The relationship between children's dental caries experience and the prescription of general anaesthetics. an evaluation of the effectiveness of a Personal Dental Service Pilot

OBJECTIVES

To determine if there was a high correlation between the prescription of a general anaesthetic for dental treatment in young children by a Personal Dental Services (PDS) general anaesthetic pilot and the dental health of children at a ward level.

BASIC RESEARCH DESIGN

Postcode data from an audit of the single dental general anaesthetic provider in an area was extracted and mapped to individual wards. A proxy for the oral health population was obtained by using the results of a large-scale dental prevalence study of five-year-olds. The wards were ranked into quintiles by dmft and a mean dmft calculated for each. There were 1,406 patients who had a general anaesthetic, 74% were aged 11 years or less.

SETTING

A personal dental service dental general anaesthetic pilot in the north of England providing services for a population of approximately 300,000 residents in a non-fluoridated area. RESULTS There was a positive correlation between increasing levels of dental decay in the population and increasing intervention ratios for dental treatment under general anaesthesia (r2 = 0.90).

CONCLUSIONS

The PDS pilot provided dental care under general anaesthesia for more patients from wards with poor dental health than from wards with better dental health.

Blood pressure monitoring amongst Fijian general dental practitioners

This study was designed to gauge the attitude and practice towards monitoring of blood pressure among dentists in Fiji and to assess whether they were willing to participate in a national health campaign to screen blood pressure of dental patient without remuneration. Sixty-two questionnaires were mailed out to all General Dental Practitioners in the Republic of the Fiji Islands. Responses were obtained from 49 (79 %) dentists following a second reminder letter. The majority of the practitioners (85 %) had been taught to measure blood pressure as undergraduates and approximately two-third of them stated that blood pressure screening in dental office was very important. Only about one-third of the respondents reported measuring blood pressure routinely, however this figure rose dramatically to 92 % when assessing patients with known high blood pressure. Approximately two-thirds of the practitioners were willing to participate in a national health campaign to screen blood pressure of dental patients without remuneration. Most of the dental practitioners in Fiji acknowledged that blood pressure monitoring in dental office was very important. They also stated that additional training in blood pressure monitoring was of necessary. Therefore, it is essential for stakeholders such as the Fiji Dental Association and the Ministry of Health to assist in providing guidelines and training in blood pressure monitoring for dental professionals in Fiji as well as to assist in conducting national health campaigns to screen for blood pressure.

[25 years of INAMI data in dentistry]

The author presents 25 years of social security data about expenses and the number of medical acts in dentistry using lists and diagrams. By relating these expenses per year to the number of dentists per year, the average expenses per dentist are compared to the evolution of the index of consumption. In the same manner the average number of medical acts per dentist are calculated. By this method the author emphasizes the changes in average dental practice profile over 25 years.

Factors influencing choice of dental treatment by private general practitioners

Service rate variations have focused attention on treatment decisions. The aims of this study were to examine factors considered in choosing treatments, to classify dentists in terms of clinical decision making, and to investigate the association of decision making with services provided. From a random sample of dentists (response rate 60.3%) treatment constraints (15.0%), periodontal status (12.1%), tooth status (11.3%), mouth status (10.1%), and patient factors (9.8%) were considered important factors across six alternative treatment pair choice scenarios. Cluster analysis of the treatment choice scenarios produced one cluster that reflected patient preferences, another that reflected treatment constraints such as cost, and a third that reflected oral health factors. Compared with the oral health cluster, dentists in the constraints cluster had higher rates (p < .05) of extractions (rate ratio [RR] = 1.49), bridge work (RR = 1.77), and dentures (RR = 1.32), whereas dentists in the patient cluster had higher restoration rates for two-surface ionomers (RR = 2.45) and resins on three or more surfaces (RR = 1.50) and other preventive services (RR = 1.78) such as oral hygiene instruction. Although a range of factors influenced treatment choice, a limited set accounted for the majority of responses, with cost a major determinant, ahead of oral health status and patient preference. Decision-making style was associated with service provision.

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.

Changing patterns and the need for quality

This series of articles is aimed at anybody who places crowns and other extra-coronal restorations (ie veneers and shims) on individual teeth. We hope that everyone from experienced practitioners to undergraduate students may find something of value. Whoever reads them, we would ask to do so with an open mind. We have tried not to be dogmatic, and the techniques and materials described are not the only ones available, but are the ones which accord with the principles we describe.

Management of caries in the child three years of age and younger: a survey of post-doctoral pediatric dentistry program directors

PURPOSE

The purpose of this study was to report the results of a survey of pediatric dentistry post-doctoral program directors regarding education of post-doctoral students about management of caries in children 3 years-of-age or younger.

METHODS

Fifty-two pediatric dentistry advanced education program directors were sent questionnaires inquiring about payer sources in their programs, distribution of caries in children 3 years of age or younger within the payer sources, the methods they teach and use to treat the caries, and the effectiveness of treatment and outcome data about the success of their treatment.

RESULTS

Twenty-nine programs responded (56%). On average, two-thirds (66%) of the patients in post-doctoral pediatric dentistry programs are Medicaid patients. Program directors are fairly uniform in how they define methods of caries management, and they rate definitive therapy as the most effective method to manage all types of caries. Literature/textbooks were most frequently cited as the major source of scientific evidence to support treatment decisions. Fewer than 20% of program directors have outcome data on the effectiveness of their methods of treatment.

CONCLUSIONS

Medicaid is the major payer source for patients in post-doctoral programs and definitive therapy is considered by program directors to be the most effective approach to managing caries in this patient population. Program directors rely on the literature and textbooks and few have outcome data.

How and why politics affect dentistry

Dental practices are under scrutiny every day. The dynamics of the public, the media, the lawmakers, the regulators, and other special-interest groups create endless possibilities for influence over a practice and continue to challenge a dentist's ability to provide quality dental care to patients. This article describes examples of laws and regulations affecting dentistry and the impetus for them, whether real or perceived.

The ability to successfully include primary dental care practitioners in commissioning groups

OBJECTIVES

To evaluate two total purchasing (TP) sites and ascertain whether general dental practitioners (GDPs) could be successfully included in the total purchasing model of health care commissioning. Another objective was to examine the role GDPs may play in future primary care commissioning groups and trusts.

DESIGN

An observational cross-sectional study of two dental purchasing pilots in the North West Region.

SUBJECTS

Two TP sites were studied, one in South Cheshire, the other East Lancashire. Each TP organisation had a dental subgroup which had a formal structure and was given an active role in dental healthcare service decision making.

MAIN OUTCOME MEASURES

General dental practitioners' ability to manage dental health care provision in the selected sites and the suitability and effectiveness of the services managed by them.

RESULTS

GDPs were willing and able to form cohesive primary care commissioning organisations but attitudes in secondary care prevented the implementation of their decisions.

CONCLUSIONS

Structural, organisational and psychological changes would be necessary if GDP led purchasing were to be successfully implemented. Such changes are vital if GDPs and the dental profession are to have an effective role in the newly formed primary care groups and trusts.

Personal Dental Services--a practitioner's point of view

NHS dentistry has seen many changes recently. The latest has been the introduction of Personal Dental Services. This article describes the experiences of two general dental practitioners in their practice who entered as a first wave pilot. The article explains the steps involved in generating a proposal and preparing a practice to run as a pilot. The authors have highlighted areas of particular concern for others to consider before embarking on a similar journey.

The cost, effectiveness and cost effectiveness of removal and retention of asymptomatic, disease free third molars

PURPOSE OF INVESTIGATION

The study was undertaken to identify the least costly, most effective and most cost-effective management strategy for asymptomatic, disease free mandibular third molars.

METHODS AND PATIENTS

A decision tree model of the outcomes of mandibular third molar retention and removal was constructed. Probability data for possible outcomes were obtained from a comprehensive literature review and entered into the decision tree. The cost to the NHS in treating each outcome was calculated. 100 patients attending the oral surgery clinics, University of Wales Dental Hospital rated the effect of each outcome on their own life. The cost and effectiveness data for each outcome were entered into the decision tree and the analyses were conducted by 'folding back' the decision tree based on the probabilities.

MAIN FINDINGS

Mandibular third molar retention was less costly (170 Pounds), more effective (69.5 effectiveness units on a 100 point scale) and more cost-effective (2.43 Pounds per unit of effectiveness) than removal (226 Pounds, 63.3 and 3.57 Pounds respectively). These findings were sensitive to changes in the probability of pericoronitis, periodontal disease and caries.

PRINCIPAL CONCLUSIONS

Mandibular third molar retention is less costly to the NHS, more effective for the patient and more cost-effective to both parties than removal. However, should the likelihood of developing pericoronitis, periodontal disease and caries increase substantially then removal becomes the more cost-effective strategy.

A survey of the attitudes of members of the European Prosthodontic Association towards the shortened dental arch concept

A survey of members of the European Prosthodontic Association was undertaken to assess their attitudes to the shortened dental arch concept, and to evaluate their experience with the approach. Data were collected using questionnaires. From an overall response of 42%, 96% of respondents agreed that the approach was acceptable in clinical practice. Almost all respondents had applied the shortened dental arch concept with 72% of respondents having treated less than 50 patients in this way over the previous 5 years. In terms of comfort and function, treatment outcome was satisfactory. However, 42% of respondents indicated that prosthetic extension of shortened dental arches was occasionally required.