Limited resources Implicit rationing Explicit priority setting
f
Political processes Technical methodologiesLay Professional Equity Efficiency
participation paternalism
Source: Coast J et al (eds) : Priority setting: The health care debate. 1996: Wiley & Sons, Chichester.
Under this model of health care planning, the proposed dental treatment need approach, which comprises integrated factors related to equity and effectiveness of treatment from the perspective of professional and lay people, should provide a useful guide for dental care planning.
9.7 Summary and conclusions
To improve the restricted traditional approach o f dental treatment need estimation, a new theoretical model o f treatment needs composed of ‘Normative’, ‘Impact-Related’, ‘Effective’ and ‘Accessible’ Treatment Needs, is proposed. A concise indicator ‘Oral Impacts on Daily Performances’ (OIDP) was developed, based on measuring impacts on eight physical, psychological and social aspects o f daily activities.
The main conclusion from the research is that:
The indicator ‘Oral Impacts on Daily Performances’ (OIDP) was tested as a valid and reliable indicator of oral outcomes. The process o f integrating the OIDP into normative need to generate ‘Impact- Related Treatment N eed’ and exploratory procedures in developing ‘Effective Treatment N eed’ was demonstrated. The new approach can improve dental treatment need estimations by modifying the extent of normative need, primarily by reducing the need for oral conditions with low impact on daily living and with low effectiveness treatment in people who had a low behavioural propensity.
In addition to the main conclusion, summary and conclusions based on the findings are made according to the four objectives o f the present study:
Objective 1
To develop a socio-dental indicator to measure perceived oral impacts with the suitable qualification fo r the integrating process and to test its
psychometric properties.
A new composite socio-dental indicator which measures the outcomes o f oral conditions was developed to facilitate the socio-dental approach in dental treatment need planning. The indicator, Oral Impacts on Daily Performances (OIDP), was designed to be a concise measure with a final single score, focusing on measuring the endpoint outcomes o f oral conditions on daily livings. Nine physical, psychological and social aspects o f daily activities representing major variables from various social indicators were chosen for their content validity. Scores were calculated by multiplying the frequency by the severity scores o f each performance. Then scores for all performances were summated. To increase the usefulness o f the OIDP for assessing specific treatment needs, questions were asked about the perceived causal symptoms and impairments of any impact on performance.
The indicator was piloted and then tested in the study population. This low caries people had as high an incidence o f oral impacts as industrialized, high dental disease populations. 73.6% o f all subjects had at least one daily performance affected by an oral impact. The highest incidence o f performances affected were Eating (49.7%), Emotional stability (46.5%) and Smiling (26.1%). Frequency and severity presented the paradoxical effect on different performances and should both be taken into account for overall estimation o f impacts. Eating, Emotional stability and Cleaning teeth performances had a high frequency or long duration o f impacts, but a low severity. The low frequency performances; Physical activities. Major role activity and Sleeping were rated as high severity. Pain and discomfort were mainly perceived as the causes of impacts (40.1%) for almost every
performance except Smiling. Toothache was the major causal oral condition (32.7%) o f almost all aspects o f performance.
The OIDP score was tested for reliability and validity. One o f the performance measures, Physical activities, was considered to be redundant and excluded, so the final version o f OIDP consists o f eight daily performances. It was concluded that the OIDP is a valid and reliable alternative indicator of oral outcomes which has potential to be appropriately used in the study population for dental care planning and evaluation o f outcomes.
Objective 2
2.6.2 To collect data on oral health status, normative treatment need, the perceived impact o f oral conditions, and the health and illness behaviour on
a group o f 35-44 year-old rural Thais.
79.8% o f sample o f 35-44 year old rural Thais had 28 sound teeth or more. Only 1.6 % had less than 20 sound teeth. 27.7% o f the sample were caries free. The mean DMFT was only 2.7 (sd 3.1) of which 1.6 were missing teeth and only 0.03 were filled. 21.5% and 90.2% had deep and shallow periodontal pockets respectively. Protheses wearing was found very rare (1.4%).
Normative treatment needs were generally high for periodontal treatments: 98.4%, 69.8% and 21.4% in scaling, root planing and deep pockets treatment respectively. Need for prostheses was found in one-third o f the
samples. Need for extraction, filling and pulp treatment were 28.3%, 26.7% and 2.4% respectively. Orthodontic need for moderate to severe malocclusion was 1 2 %.
62.1 % of subjects brushed their teeth twice daily. 21.4 % were current smokers. Dental service utilization o f the sample was generally very low. 57.9% reported never visiting a dentists in their lives. Only one fourth had their last dental visit during the past two years.
Objective 3
To generate the dental treatment need which included perceived oral impacts from people with clinical judgements and compare this kind o f treatment need, namely ‘Tmpact-Related Treatment Need", to the normative treatment need in the study population.
The part o f causal impairment in the OIDP measure was used to established the Condition-Specific OIDP scores (CS-OIDP), which is the impact score from only a relevant causal impairment o f a specific assessed treatment need. The combination o f normative needs and CS-OIDP scores generated the Impact-Related Treatment Need for various dental treatments.
As expected, the percentage o f people with need was decreased from normative need, when Impact-Related Treatment Need was applied. The differences were large in needs for prostheses, orthodontics and periodontal treatment (ranging from 21.7% to 40.2% o f normative need); moderate for restorations (64%); and low for pulp care and extractions (81.7%-91.7%).
A similar pattern o f need reduction was obtained when increasing cut-off points o f CS-OIDP scores.
The Impact-Related Treatment Need has a major advantage in planning dental services by reducing high normative treatment needs in proportion to the extent o f their impacts on daily living. In comparison among different dental treatments, ranking o f percentages o f people who need treatments changed. Ranking o f needs for scaling, root planing, prostheses and orthodontics decreased steadily when CS-OIDP scores using cut-off points 0, 5, 10, were integrated. While ranking o f needs for extraction, filling, treatm ent for deep periodontal pockets and pulp care were increased. The revised treatment needs were more realistic for dental care planning when compared to the actual services in the district and North-Eastern Region o f Thailand.
Objective 4
To explore the preliminary approach to assess the behavioural propensity o f periodontal treatment and integrate it into the ‘'Impact-Related Treatment N e e d ’' fo r periodontal treatment.
The appropriate behavioural propensity for effective periodontal treatment need was defined from the association between periodontal conditions and behavioural-related risk factors in the study population, in combination to that found in the available literature. The people who were non-smokers with plaque indices o f 0.80 or lower was appropriate to be defined as having acceptable behavioural propensity for periodontal treatment. These criteria were used in an integrating process to generate the exploratory