The Economics of a Cavity-Free World

powerof numbers

28th-29th June 2017

Policy Lab

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The Alliance for a Cavity-Free Future (ACFF)

The ACFF is a Global not-for-profit organisation which launched in September 2010.• The ACFF seeks to promote integrated clinical and public health action to confront the

disease burden of caries, fight caries initiation and progression, and, along with a global community of supporters, progress towards a Cavity-Free Future for all age groups.

• The ACFF was established in collaboration with a worldwide panel of experts in dentistry and public health who share a fervent belief in joining together across professional, geographic, and stakeholder lines, to create a unified global movement committed to combating caries in communities around the world.

• ACFF has 26 Chapters around the world who drive local action to meet the Goals.

ACFF Stretch Goal: Every Child born in 2026 and thereafter should stay Cavity-Free during their lifetime

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What does ‘Cavity-Free’ Mean: The Caries Continuum

Sound, Initial-Moderate Caries & CavitiesSound & Initial-Stage Caries=

Cavity-Free

This Policy Lab will focus on achieving a Cavity-Freeworld (but note that arrested initial-stage caries may still exist)

Dental Caries (tooth decay) “is a biofilm-mediated, sugar-driven, multifactorial, dynamic disease that results in the phasic demineralization and remineralization of dental hard tissues”. If preventive and/or non-operative interventions are not put into place in the early stages, dental caries can progress to lesions involving macroscopic loss of the tooth’s surface integrity (cavities).

ICDAS Caries Stages

PittsNB,ZeroD,MarshP,Ekstrand K,WeintraubJ,Ramos-GomezJ,Tagami J,Twetman S,Tsakos GandIsmailA.Dentalcaries.Nat.Rev.Dis.Primers3,17030(2017).

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See recent full review paper for further evidence overviews PittsNB,ZeroD,MarshP,Ekstrand K,WeintraubJ,Ramos-GomezJ,Tagami J,Twetman S,Tsakos GandIsmailA.Dentalcaries.Nat.Rev.Dis.Primers3,17030(2017).

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Structure of this briefing pack

• Background and overarching question

• Information and frameworks to inform the Policy Lab

• Aims and agenda of the Policy Lab

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Situation

Caries can be associated with other diseases• Caries shares risk factors with other NCDs (non communicable diseases e.g. obesity,

diabetes, metabolic syndrome), particularly via diet. By decreasing the prevalence of caries and its associated risk factors, we can also make a move to improve general health.

Prevention is possible• There is widespread acceptance that we have the scientific evidence to be able to maintain

teeth at a good level of health (either with sound surfaces, or contained at stages before the disease progresses to cavitated decay requiring restoration).

• With a focus on keeping teeth sound or using initial-stage caries prevention, a shift would be seen in dental practice towards risk-based direct prevention-based interventions (e.g. topical fluoride) and behaviour-based ‘treatment’ (e.g. advice on diet and dental hygiene).

Current Payment Systems do not support Prevention• The majority of oral health systems for dentists have been built around providing later

stage treatment (such as dealing with cavities by filling). They are mainly on a ‘Fee For Service’ model, paying per treatment offered.

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Complications

Little is being done to prioritise prevention• Despite International agreement over decades from dental and other professional

organisations that caries prevention should be a priority, little has been done globally to prioritise caries prevention and control for those inside or outside the dental access net.

Difficulty gaining platform• Often, agencies, governments and even patients do not like disease-specific advocacy,

particularly for a disease which is often viewed less serious compared to diseases such cancer and other more prominent healthcare issues.

Dentists are not currently paid to do prevention• There is currently no significant financial incentive for dentists to focus on prevention, as in

most health systems this currently would significantly reduce their incomes.

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Questions

How do we accelerate a policy shift towards increased resource allocation for caries prevention and control?

• What economic data is required to be presented within the discussion?• How do we tackle the building of a payment system to enable ‘payment for prevention’?• Who are the right policy and practice stakeholders to advocate for this shift?• How can we ensure that this will work for different parts of the population and different types of

countries?

THE POLICY LAB WILL HELP US ADDRESS THESE QUESTIONS

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Aims of the Policy Lab

The workshop will bring together a group of global thought leaders on dental and public health, chief dental officer representatives and heads of public health organisations to consider the economic prospects for achieving a cavity-free world.

The overarching question for the Policy Lab to address is:

How do we accelerate a policy shift towards increased resource allocation for caries prevention and control?

Our aim is to think as broadly as possible about the issues, the various ‘ingredients’ that can help accelerate progress and how these elements can be assured to work together successfully across different population sub-groups and different countries.

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Agenda for the Policy Lab

DAY 1 - Wednesday 28th June

16:00 Welcome and introductions A review of the progress so far and identification of the main outstanding challenges.Two talks to motivate, inform and inspire fresh thinking.Group work: Initial ideas for possible actions to accelerate progress by addressing stakeholder interests.

19:10 Drinks & Dinner (continued conversations and discussions)

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Agenda for the Policy Lab

DAY 2 - Thursday 29th June

08:45 Welcome back and introduction to Day 2Segmenting the population to help understand how to achieve change.Group work: A ‘deep dive’ into the obstacles and barriers and how progress can

be accelerated.Group work: Developing tailored ‘models of change’ for different types of country.

12:30 Lunch

13:15 Group work: A challenge to achieve the maximum impact in 12-months.Pulling it all together into a holistic and effective plan of action for the short, medium and longer term.

16:00 Close

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Information and Frameworks to Inform Policy Lab

Background information which will be considered further at the Policy Lab

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Win6 Cube: What Stakeholder Groups are involved?

To try and effectively work

with this complex issue, we need to

both recognise and consider the 6 key stakeholder groups who can influence progress/lack of

progress towards a Cavity-Free Future

(CFF)CFF EconomicallyViable

andAttractiveto:Dental/OralHealth

Industries

CFF EconomicallyViableandAttractiveto:Payers/Insurers

CFF EconomicallyViableandAttractiveto:Dentists/DentalTeams/Providers

CFF viaoptimalPreventive/MIcareforIndividuals&Populations

ProfessionalGuidance

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Dental Caries: Modelling to inform Policy and Targets

The futures study of dental decay employed modelling of caries epidemiology and prevention data to estimate the health gain achievable if key public health and clinical preventive interventions were optimised over a reasonable period.

This informed the setting of caries prevention targets for 2026 by the European Chief Dental Officers and the Alliance for a Cavity Free Future (www.AllianceforaCavityFreeFuture.org)

Reforming Dental Services in England: Policy Options. Health Education Journal Vol 64 (4) December 2005 (Supplement) ISSN 0017 8969

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Dental Caries: Global Burden Study - Prevalence of Oral Conditions

Marcenes,W.etal.Globalburdenoforalconditionsin1990–2010:asystematicanalysis.J.Dent.Res.92,592–597(2013)22

Dental Caries: Recent Global Estimates of Prevalence…(but be cautious...)

(Decay detected at Cavity level only)

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Current Caries Epidemiology: The lack of reliable data

‘Despite the widespread nature of tooth decay, reliable, standardized global data are limited. This is largely because oral health data are not integrated in national disease surveillance, particularly in low- and middle- income countries. Separate national oral health surveys are complex and costly to conduct, and hence not prioritized. This lack of up-to-date epidemiologic information constrains the development of appropriate approaches to reduce the disease burden.’

FDI Oral Health Atlas 2015The Challenge of Oral Disease: A Call for Global Action. The Oral Health

Atlas. Geneva: FDI World Dental Federation; 2015. 16-17.

(Decay detected at Cavity level only)

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Current trends in Caries: Scotland and “Childsmile” as an example

Key Results • More than two thirds (69%) of P1 children had no obvious decay experience in their primary teeth in 2016. This

is a large improvement since ISD started recording this information in 2003 (45%). • Note no obvious decay experience means there are no obvious decayed (no Cavities), missing or filled teeth.

• The average number of P1 children’s teeth affected by obvious decay experience in 2016 is 1.21. This is less than half of the average number of teeth affected in 2003 (2.76).

• HOWEVER - Inequalities remain, with only 55% of P1 children having no obvious decay experience in the most deprived areas compared with 82% in the least deprived areas.

Trends in the percentage of P1 (5-yr-old) children with no obvious decay experience in Scotland; 1988-2016

Scottish National Dental Inspection Programme (NDIP) 2016

Report of the 2016 Detailed National Dental Inspection Programme of Primary 1 children and the Basic Inspection of Primary 1 and Primary 7 children

Publication date – 25 October 2016 - ISD NHS Scotland

(Decay detected at Cavity level only)

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Dental Caries Classification: The Iceberg Metaphor

+ clinically detectable "cavities" limited to enamel

+ clinically detectable enamel lesions with “intact” surfaces

+ lesions detectable only with traditional diagnostic aids

+ sub-clinical initial lesions in a dynamic state of progression/regression

Mis-labelled "caries free" at the D threshold

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+ clinically detectable

lesions in dentine

lesions into pulp

D3 + enamel=

D3

D1

N B Pitts © 2016

Diagnostic threshold

determines what is recorded as “diseased” or

“sound”

The “iceberg of dental caries” (1994>)Diagnostic thresholds in surveys, research & practice

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Dental Caries Classification: Recommended for Dental Practice

Conventional Epidemiology EXCLUDESall initial &

most Moderate caries and

Radiographs!!

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Dental Caries Epidemiology: Impact of detection thresholds, 1 to 5 yrs

20.0%30.0%

36.2%

68.8%8.3%

14.2%

9.0%

11.8%

23.3%

21.7%

17.0%

7.4%

52.9%

36.7%

21.7%22.0%

9.0%

Prevalence of caries x ICDAS codes (Severity)Peru

ICDAS 2-6

ICDAS 3-6

ICDAS 4-6

ICDAS 5-6

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%1y 2y 3y 4y 5y

LatAm-Region IADR

B

C

AICDAS2-6

ICDAS3-6ICDAS4-6

ICDAS5-6

When – in Epidemiological assessments - initial (A) & moderate (B) caries lesions are included in caries counts, a very different picture of disease is seen – particularly for very young children

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Dental Caries Epidemiology: Impact of detection thresholds, 15 yr olds

[Data on 15 year-old children from 2013 National Child Dental Health Survey (CDHS) of England, Wales & NI]

•Traditional estimates of dental caries have been made recording only cavitated dentine caries. • Inclusion of (ICDAS 4) dentine lesions and cavitated enamel lesions (ICDAS 3) detects more of the lesions present in a population. • But the % dramatically increases when non-cavitatedenamel lesions (ICDAS 1&2) are recorded

PittsNB,ZeroD,MarshP,Ekstrand K,WeintraubJ,Ramos-GomezJ,Tagami J,Twetman S,Tsakos GandIsmailA.Dentalcaries.Nat.Rev.Dis.Primers3,17030(2017).)

The prevalence of initial stage-caries across populations is high

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Dental Caries in Adults: Natural History and Caries Trajectories (Dunedin Study)

Broadbent, Thomson and Poulton. Trajectory Patterns of Dental Caries Experience in the Permanent Dentition to the Fourth Decade of Life. J Dent Res. 2008; 87: 69–72.

Globally we have little Adult data – but the rate of new caries continues throughout Adulthood

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Dental Caries: Historical & Current Perspective of Restorative Model

Controlling the Caries ProcessPRIOR to filling is the key to breaking the repair cycle and improving care for patients

Elderton R J. Clinical studies concerning re-restoration of teeth. Advances in Dental Research 1990 4, 4-9.

Restoration Longevity: Effectiveness Matters Bulletin. York: NHS Centre for Reviews and Dissemination. 1999.

A long-term perspective of the international evidence

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Dental Caries: Emerging International Consensus- PreservativeManagement

We need new payment systems that fit this approach[Dentistry needs to accelerate moves away from the restorative-only model

which fails: economically; clinically; and for patients]

• Better understanding of the disease

• Holistic view of caries risk management

• Improved focus on early detection

• More unified caries classification systems

• Continuing promotion of “prevention”

• Awareness of limitations of restorations

• More Minimally-Invasive treatments

• Patient-centred approaches to reducing anxiety and fear of the dentist

PittsNB,ZeroD,MarshP,Ekstrand K,WeintraubJ,Ramos-GomezJ,Tagami J,Twetman S,Tsakos GandIsmailA.Dentalcaries.Nat.Rev.Dis.Primers3,17030(2017).

The Caries Balance

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Economic System: this challenge is a complex, inter-related system

Systems thinking on the Paradigm Shift- an overview looking at direct and indirect costs

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Proposed Integrated Solution: Three-Tiered Preventive Caries Care

Primary Prevention

SecondaryPrevention

TertiaryPrevention

Current Situation Preventively Focused Solution

Prevention of disease (in the absence of disease) carried out to variable extents by separate public health groups often not aligned to others involved with caries care. Not remunerated or incentivised.

Incentivised system for remuneration to allow for prevention of disease in the absence of disease, both upstream and downstream to clinical care

Prompt detection of early stage disease in order to provide effective arrest and or regression prior to the Cavity stage)- not remunerated or incentivised so is often not practiced appropriately (either no assessment or preventive interventions delivered, or premature and inappropriate tertiary stage restorative treatment is delivered instead)

Incentivised and remunerated system for prompt detection of early stage disease in order to provide effective arrest and or regression prior to the Cavity stage is delivered in BOTH public health and clinical care.

Restorative care is often provided when not yet needed according to contemporary guidance - (tooth structure destroying invasive surgical care provided, but often without any control of the aetiological or risk factors to prevent recurrence of caries). Currently dentists are mostly paid per restorative treatment administered.

Restorative care provided only where it is unequivocally needed - (tooth preserving minimally invasive surgical care combined with control of the aetiological and risk factors to prevent recurrence of caries). Incentivised to keep invasive care to a minimum.

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Population Segments: Splits Within Countries - USA as an example

Text, photo and statistics taken from:http://www.washingtonpost.com/sf/national/2017/05/13/the-painful-truth-about-teeth

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Population Groups: How do we segment our population groups

Access to care

Mot

ivat

ion

to c

ompl

y

B A

C

D

Individuals can sit anywhere on this spectrum, but could also be broadly grouped:

Group A: Highly motivated, with lots of access to care (but is this the right care?)

Group B: Highly motivated but not much access to care (i.e. system does not support those in their position, socioeconomic status, etc.)

Group C: Not motivated, not much access to care (seriously disadvantaged)

Group D: Not motivated, but with access to care

What economic measures need to be taken for each group?How can we build a cost effective, sustainable system which works for the whole population? 36

Application: How do we ensure that our approach is ‘Glocal’?

[‘Glocal’ = Based on Global evidence but adapted for local implementation]

Health systems around the world are so varied that any system we develop requires the ability to adapt to the parameters and situations faced within the country (or population) it relates to- it needs to be ‘Glocal’. One size definitely does not fit all! However, we can come up with the framework into which a country’s requirements are entered to see a ‘suggested’ level of required action and a broad cross section of country ‘types’.

The main points of information which we believe are needed to characterise the country context in which dental care operates are:• Gross Domestic Product (GDP) per capita• Public Spending on Dental Health• Public ‘out of pocket’ for dental health care• Access to care• Public Health Programmes• Public Dental Services Offered• Patient Compliance and Education• Nutrition (eg. sugar consumption)• Oral Health Indicators

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Example Framework of “Country Types”

CountryTypeA

SimilartoDenmark /Sweden

CountryTypeB

SimilartotheU.S.

CountryTypeC

SimilartoFrance,U.K.,Germany

CountryTypeD

Developingcountry

GDPpercapita High High Average Low

DentistryExpenditure(%GDP)

Aboveaverage Aboveaverage Average Low

PublicSpending High Low/Inexistent 1/3oftheexpenditure None(otherpriorities)

OutofPocketMoney/Insurance

Noneforsometargetedpopulationsoragegroups,Highforothers

HighAlotofpeoplewithoutinsurance,withoutaccess.

NoneforChildren,1/3Insurance1/3OOM

High

Accesstocare(demographics)

Veryaccessible,organisedforchildren

Veryaccessible Correctonnationalbasis,someterritorialinequalities

Complicated,lowworkforce

PublicHealthProgrammes Wellorganised Weak Variable Limited

PublicDentalService Totalforsomeagegroups

Very limited Variable Limited

Patientcomplianceandeducation

Aboveaverage Average Average Belowaverage

Nutrition ModerateinSugar Highinsugar ModerateinSugar Increasinglyhighinsugar

Oralhealthindicators Defined Notdefined Notdefined Notdefined

As an example, we might want to look at differential points in order to contrast Country Types.

Discussions can then be centered around ensuring that any measures suggested would work effectively within each Country Type.

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