There’s long been an argument about the merits or risks of shifting the ‘less complex’ patient workload from GPs to other professionals.
In this latest instalment of the ‘Talking Teeth‘ series, Winthrop Professor Marc Tennant and co-authors Estie Kruger and Yev Dudko discuss UK research that makes the same case for dental checkups.
Marc Tennant, Estie Kruger and Yev Dudko write
In 2015 the world’s leading dental scientific publication, the Journal of Dental Research quietly published a paper that has the potential to send shockwaves through the traditional models of dental care.
A group of the global leaders in dental public health have put the “dental check-up” up for debate, calling into question the model of dental care that we have known for 100 years.
So what did their lovely piece of work actually question? Very simply they asked: could a mid-level dental provider (for example, dental hygienists/therapists) do a check-up for dental decay and gum disease at an accuracy level equivalent to a fully-fledged dentist?
Why would this be a controversial question? Well, check-ups (or routine dental examinations) are completed by dentists and correspond to a substantial amount of time spent by these expensive and highly skilled clinicians (see more detail below).
The argument is that if a mid-level provider can do the same (or nearly the same) check-ups as a high cost, highly trained provider, then we have a way to move forward to a more cost-efficient model of care.
The study was conducted in the United Kingdom but is relevant in Australia, where both dentists and mid-level providers (therapists and hygienists) have equivalent training levels as in the UK. Dental decay and gum disease is no different to diagnose in different countries and cost remains a major issue for the community, as well as the State provided care models.
The study involved nearly 1,900 patients from 10 practices and ran over about 12 months. Each patient was examined by the dentist and the mid-level provider separately, with each taking about the same time (5 minutes) to do the routine examination. This was a “real life” test of the idea, not something done under perfect laboratory conditions.
Under the study, there was little difference in diagnosis between the dentist and the mid-level providers. The difference was worth noting but not alarming.
First, the study found that mid-level providers recommended eight more patients out of every 100 for care on the basis of a false positive diagnosis of decay.
On first glance, those numbers appear high, but remember at the end of the day these patients would be seen again by the dentist who was going to do the end-point care and who would have re-checked and not embarked on the filling if it was not needed.
So this is not so significant.
More interestingly, there was decay detected by dentists in 35 of each 100 patients, but seven were missed by the mid-level providers. This, for experts, is a sensitivity and specificity of 0.81 and 0.87. The gum disease check-up followed the same pattern. Those seven people with decay are important but the authors remind us that (like many diagnostic procedures in health) screening even by dentists alone is not 100 per cent perfect every-time and dental screening is something that is repeated regularly and this remains a key protection in systematic health care.
Implications for dental practice and health systems
So what does this mean for our health systems? Mid-level providers could allow our health system to reduce costs (in particular in the government sector) and thus extend access and reduce wait times for routine care. It is quite imaginable that this paper could lead governments to start thinking about mid-level providers being the check-up team that monitors a population’s oral health and refers to more expert providers. Now, clearly there is more to check-ups than just dental decay and gum disease but the paper starts the discussion of a new structural foundation to the design of dental health systems.
As the authors report, in the UK about a half of all NHS care is taken with up with routine examinations. This is some 13 million routine adult dental examinations – of which, they estimate, about a quarter are for high risk patients. Even eliminating the high risk patients (who must be seen by a dentist) a new model that puts mid-level providers at the core of the check-up system could see some 10 million routine adult dental examinations provided at a significantly lower cost every year. We are now talking big savings and the release of resources to address more pressing issues that require higher-level skills.
Of the dental public health papers of 2015, you can see why this one stands out as having the potential to re-design dental care. Making a dental system more effective and efficient is a vital part of society’s protection against one of its most pervasive disease burdens, and something that in Australia alone costs $10 billion per annum to treat.
Opportunity for change is here, particularly in the context of an election campaign where new policies are abounding. Making a fair and just system, with robust evidence-based science underpinning the decisions, is vital to our future.
Marc Tennant, Estie Kruger and Yev Dudko are part of the International Research Collaborative – Oral Health and Equity at the Department of Anatomy Physiology and Human Biology, The University of Western Australia.