Oral Health Care Delivery System Research Articles

Oral health disparities and the workforce: a framework to guide innovation

Oral health disparities currently exist in the United States, and workforce innovations have been proposed as one strategy to address these disparities. A framework is needed to logically assess the possible role of workforce as a contributor to and to analyze workforce strategies addressing the issue of oral health disparities. Using an existing framework, A Strategic Framework for Improving Racial/Ethnic Minority Health and Eliminating Racial/Ethnic Health Disparities, workforce was sequentially applied across individual, environmental/community, and system levels to identify long-term problems, contributing factors, strategies/innovation, measurable outcomes/impacts, and long-term goals. Examples of current workforce innovations were applied to the framework. Contributing factors to oral health disparities included lack of racial/ethnic diversity of the workforce, lack of appropriate training, provider distribution, and a nonuser-centered system. The framework was applied to selected workforce innovation models delineating the potential impact on contributing factors across the individual, environmental/community, and system levels. The framework helps to define expected outcomes from workforce models that would contribute to the goal of reducing oral health disparities and examine impacts across multiple levels. However, the contributing factors to oral health disparities cannot be addressed by workforce innovation alone. The Strategic Framework is a logical approach to guide workforce innovation, solutions, and identification of other aspects of the oral healthcare delivery system that need innovation in order to reduce oral health disparities.

Global Theme Issue: Poverty and Human Development The effect of poverty on access to oral health care in Nigeria

Nigeria is a country with a population of over 140 million people (1). Over 60% of Nigerians live in rural areas. Poverty is especially severe in rural areas where social services and infrastructure are limited or non existent. Africa is the continent where the poorest people in the world live. Nigeria is the most populous black African country where about 70% of the population live under one dollar per day (2). Nigeria has been classified as a poor nation. In Nigeria, majority of those living in rural areas are poor and depend on agriculture for food and income. Small scale farmers who cultivate tiny plots of land and depend on rainfall rather than irrigation system produce about 90% of the country\'s food. Women play a major role in the production, processing and marketing of food crops. The poorest group go on subsistence living but are often short of food, particularly during the pre-harvest period. Many poor Nigerians suffer from malnutrition and other diseases related to poor nutrition such as acute necrotizing ulcerative gingivitis (ANUG) and cancrum oris (3-6). The HIV/AIDS pandemic has also taken a heavy toll on the rural population and could be considered an emerging public health problem. The extremes of poverty in Nigeria are outrageous. The outrage is not just that avoidable deprivation, suffering and death are intolerable; it is also that these situations coexist with affluence. Corruption is endemic in Nigeria and this has impoverished the nation. Intergenerational poverty exists in the country. Fight against poverty is necessary to reduce intergenerational transfer of poverty in Nigeria because most Nigerian children are born into poverty. The oral health status of underprivileged Nigerians is generally poor. Many Nigerians suffer from oral diseases such as caries, fracture teeth, gingivitis, periodontitis, acute necrotizing ulcerative gingivitis, cancrum oris, malocclusion, tumours and other dental problems (7-15). Non availability of National data on the prevalence of common oral diseases among Nigerians is a major problem and poses a great challenge to the Nigerian Dental Association whose members are major stakeholders regarding oral health care delivery system in the country. Lack of national data has affected planning meaningful oral health care for Nigerians. This paper identified the barriers to access oral health care and stress the various strategies by which the Nigerian Dental Association and all stakeholders could assist the Federal Government of Nigeria to overcome these barriers and formulate policies that will prevent oral disease and move the nation forward to achieve the millennium development goal. Nigerian Dental Journal Vol. 16 (1) 2008: pp. 40-42

Public policy and the market for dental services

Social inequality in access to oral health care is a feature of countries with predominantly privately funded markets for dental services. Private markets for health care have inherent inefficiencies whereby sick and poor people have restricted access compared to their healthy and more affluent compatriots. In the future, access to dental care may worsen as trends in demography, disease and development come to bear on national oral healthcare systems. However, increasing public subsidies for the poor may not increase their access unless availability issues are resolved. Further, increasing public funding runs counter to policies that feature less government involvement in the economy, tax policy on private insurance premiums, tax reductions and, in some instances, free-trade agreements. We discuss these issues and provide international examples to illustrate the consequences of the differing public policies in oral health care. Subsidization of the poor by inclusion of dental care in social health insurance models appears to offer the most potential for equitable access. We further suggest that nations need to develop national systems capable of the surveillance of disease and human resources, and of the monitoring of appropriateness and efficiency of their oral healthcare delivery systems.

A Qualitative Study of Limited Access Permit Dental Hygienists in Oregon

Many states have adopted alternative oral health care delivery systems that include expanded roles for dental hygienists. This qualitative study was designed to evaluate the impact of the Limited Access Permit (LAP) legislation in Oregon and to understand the relationship between dental hygienists and dentists within this delivery system. The snowball sampling technique was used to identify LAP dental hygienists and collaborating dentists. The snowball sampling technique begins with the identification of a known expert in the field who serves as the initial "sampling unit." Subsequent individuals are then recommended, or nominated, to the investigator by the initial study participant and are selected based upon the need to fill in or extend information. The final sample consisted of seven LAP dental hygienists and two collaborating dentists. Interviews, field observations, and document analysis were utilized for data collection. Factors that led to the creation of LAP dental hygiene practice, current LAP practice, personal characteristics, relationships between LAP dental hygienists and dentists, and the impact that LAP dental hygienists have had on access to oral health care were explored. Data revealed that the Oregon legislature twice expanded the LAP scope of practice to increase access to oral health care services. LAP dental hygienists practice in community and school-based settings. Common characteristics of LAP dental hygienists include entrepreneurship, lifelong learning, and a commitment to underserved populations. The findings from this study indicate that LAP dental hygienists and collaborating dentists have positive relationships. No evidence of lower quality of care in unsupervised dental hygiene practices was found. However, the impact of the LAP legislation is still unknown due to the limited numbers of LAP dental hygienists and the early nature of the LAP practice.

A global perspective on changes in the burden of caries and periodontitis: implications for dentistry*

The structure and contents of most oral health care systems and the contents of dental curricula reflect a deep-rooted tradition for attempting to cure oral diseases by refined technological means. However, better oral health conditions for the world's populations necessitate the application of up-to-date scientific knowledge to control the major oral diseases. This review points out that not only should the structure and contents of oral health care delivery systems be based on state-of-the-art knowledge about the biology of the oral diseases; they must also take into account the trends for change in caries and periodontal diseases within and between populations, and acknowledge the impact of changes in treatment philosophies for these trends. The oral disease profiles for populations in low- and high-income countries are briefly described, and it is concluded that the rapidly changing disease profiles observed in high-income countries necessitate re-thinking of the future role and organization of dentistry in such countries. The priorities for low- and middle-income countries must be to avoid repeating the mistakes made in the high-income countries. Instead, these societies might take advantage of setting priorities based on a population-based common risk factor approach. If such an approach is adopted, the training of personnel with oral health care competence must be rethought. The authors suggest three different cadres of dental care providers to be considered for an approach that allows health care planners in different populations around the world to prioritize appropriate oral health care with due respect for the socio-economic conditions prevailing.

Oral healthcare in transition in Eastern Europe.

Big changes have occurred in the oral healthcare delivery systems of most Eastern European countries since the fall of the Berlin wall in 1989 and the demise of communism in the former USSR in 1991. In the new situation it was necessary to reform the political and social systems including healthcare. Reforms were started to improve the economy and, in comparison with Western Europe, the generally lower living standards. It is difficult to obtain comprehensive data on oral healthcare in Eastern European countries but this paper reports data from nine countries and provides a 'macro' view of the current situation in these countries. Many countries seem to have adopted a Bismarckian model for the provision of oral healthcare based on a sickness insurance system.

Research Issues Related to Optimal Oral Health Outcomes

Patient outcomes form one part of the classic triad used to define quality of care: structure, process, and outcome. Outcomes research in dentistry should focus on global questions such as: What difference does dental care make to a patient? Do patients derive perceptible benefits from their dental care? What dental treatments work the best? Like programs or other courses of action, treatment outcomes are considered on three levels: the policy level, which asks, "Are we doing the right things for our target population, given our resources?" program evaluation, in which specific program objectives are set in terms of achievement or maintenance of certain rates and measures; and the individual patient level, in which specific physiologic, psychological, and sociological measures are used to determine individual treatment outcomes. Each level of evaluation can use treatment outcomes or oral health status measures as evaluation criteria. Clinicians routinely face the challenge of providing "appropriate" care to older veterans--a concept that considers the accuracy of risk assessment and diagnosis as well as treatment outcomes (such as the relative effectiveness and cost-effectiveness of alternative treatment strategies, together with the short- and longer-term physiologic and psychological results). Outcomes research is even more challenging when considering its application in older populations whose physical, social, and psychological health are increasingly interrelated and variable with age. Thus, outcomes research, and particularly research on the appropriateness of care, must consider the values and preferences (utility) of those outcomes for older veterans and their families. Optimal oral health outcomes can be achieved through invigorated oral health services research to better understand patients' preferences related to dental treatment decisions, to define oral health outcomes incorporating these preferences, and to assess the effectiveness of the current dental delivery system and its various components, including the appropriate mix of dental providers and allied health personnel, emerging technologies, and innovative prevention and health promotion strategies. An administrative structure and incentives should be established to support dental health services and outcomes research within the Department of Veterans Affairs (VA). A dental service network with an oversight board could be established to evaluate issues related to treatment outcomes. Alternatively, a Geriatric Research Education and Clinical Center devoted to the improvement of the quality of VA dental care and the oral health care delivery system could be established.

Social, Economic, and Professional Dimensions of the Oral Health Care Delivery System

Abstract This article reviews issues which serve as the basis for future research in the area of the oral health care delivery system. The review is presented within the context of the larger health care and social environment and includes assessments of structure and organization, participants, access and utilization, professional training, and science transfer. The major trends in the sociodemographics of the U.S. population, changes in oral health status, and abilities to alter disease processes through prevention and treatment strategies are among the challenges addressed. The conclusions of the review illustrate the complexity of the oral health care delivery system as a research opportunity for behavioral and social scientists.

Oral health care delivery in Denmark: a system of private enterprise and public accountability.

The Danish oral health care delivery system is a publicly funded, predominantly school based system of care for children and adolescents and a private practice copayment national health insurance mode for adults. Study of this dualistic system can provide useful information to dental public health practitioners. Interviews with experts in the Danish oral health care system and a selected review of the literature demonstrate that improvement trends are occurring in the oral health status of both adults and children. These improvement trends can be directly related to a combination of treatment and preventive measures undertaken by the country as a whole, and to specific interventions for certain subpopulation groups, such as preschoolers. Four key variables can be defined which have contributed to the success of the Danish oral health care delivery system (DOHCDS). These include 1) the role of private sector input into the development of the DOHCDS, 2) demography, 3) the Danish value system, and 4) the structure of the DOHCDS.

Review of training and evaluation studies in expanded functions for dental auxiliaries

A review of the literature on research in expanded functions for dental auxiliaries is presented. Summaries of each of the training and evaluation studies sponsored by both private and government agencies are given. Wide variation in research methods of these studies and the failure to report important details make it difficult to interpret and use the research findings. Results from all studies indicate that dental auxiliaries can, with the proper training, perform selected reversible and irreversible dental procedures at an acceptable level of quality. Future research should be conducted in private practice settings and in new oral health care delivery systems with various configurations of expanded function dental auxiliaries.