The Economics of a Cavity-Free World

The Economics of a Cavity-Free World Policy Lab 28th-29th June 2017 power of numbers 1

2 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

3 What does Cavity-Free Mean: The Caries Continuum 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 Pitts NB, Zero D, Marsh P, Ekstrand K, Weintraub J, Ramos-Gomez J, Tagami J, Twetman S, Tsakos G and Ismail A. Dental caries. Nat. Rev. Dis. Primers 3, 17030 (2017). Sound & Initial-Stage Caries = Cavity-Free This Policy Lab will focus on achieving a Cavity-Free world (but note that arrested initial-stage caries may still exist) Sound, Initial-Moderate Caries & Cavities

4 See recent full review paper for further evidence overviews Pitts NB, Zero D, Marsh P, Ekstrand K, Weintraub J, Ramos-Gomez J, Tagami J, Twetman S, Tsakos G and Ismail A. Dental caries. Nat. Rev. Dis. Primers 3, 17030 (2017).

5 Structure of this briefing pack Background and overarching question Aims and agenda of the Policy Lab Information and frameworks to inform the Policy Lab

8 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.

9 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.

11 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

13 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.

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) 16

17 Agenda for the Policy Lab DAY 2 - Thursday 29th June 08:45 Welcome back and introduction to Day 2 Segmenting the population to help understand how to achieve change. Group work: A deep dive into the obstacles and barriers and how progress be accelerated. Group work: Developing tailored models of change for different types of country. can 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

19 Information and Frameworks to Inform Policy Lab Background information which will be considered further at the Policy Lab

20 Win 6 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 Economically Viable and Attractive to: Dentists / Dental Teams / Providers CFF Economically Viable and Attractive to: Payers / Insurers CFF via optimal Preventive/MI care for Individuals & Populations Professional Guidance CFF Economically Viable and Attractive to: Dental / Oral Health Industries

21 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

Dental Caries: Global Burden Study - Prevalence of Oral Conditions Marcenes, W. et al. Global burden of oral conditions in 1990 2010: a systematic analysis. J. Dent. Res.92, 592 597 (2013)22

23 Dental Caries: Recent Global Estimates of Prevalence (but be cautious...) (Decay detected at Cavity level only)

Current Caries Epidemiology: The lack of reliable data (Decay detected at Cavity level only) 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 2015 The Challenge of Oral Disease: A Call for Global Action. The Oral Health Atlas. Geneva: FDI World Dental Federation; 2015. 16-17. 24

Current trends in Caries: Scotland and Childsmile as an example Trends in the percentage of P1 (5-yr-old) children with no obvious decay experience in Scotland; 1988-2016 (Decay detected at Cavity level only) 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 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. 25

26 Dental Caries Classification: The Iceberg Metaphor The iceberg of dental caries (1994>) Diagnostic thresholds in surveys, research & practice Diagnostic threshold determines what is recorded as diseased or sound + lesions into pulp clinically detectable lesions in dentine D3 Mislabelled "caries free" at the D 3 threshold + clinically detectable "cavities" limited to enamel + clinically detectable enamel lesions with intact surfaces + lesions detectable only with traditional diagnostic aids D3 + enamel= D1 + sub-clinical initial lesions in a dynamic state of progression/regression N B Pitts 2016

27 Dental Caries Classification: Recommended for Dental Practice Conventional Epidemiology EXCLUDES all initial & most Moderate caries and Radiographs!!

Dental Caries Epidemiology: Impact of detection thresholds, 1 to 5 yrs 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 100% 90% 80% 70% 60% Prevalence of caries x ICDAS codes (Severity) Peru 36.7% 21.7% 22.0% 17.0% 9.0% 7.4% 9.0% ICDAS 2-6 ICDAS 3-6 ICDAS 4-6 A B ICDAS 5-6 C ICDAS 2-6 50% 40% 30% 52.9% 23.3% 21.7% 8.3% 14.2% 68.8% ICDAS 3-6 ICDAS 4-6 ICDAS 5-6 20% 10% 0% 36.2% 30.0% 20.0% 11.8% 1y 2y 3y 4y 5y LatAm-Region IADR 28

Dental Caries Epidemiology: Impact of detection thresholds, 15 yr olds The prevalence of initial stage-caries across populations is high 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-cavitated enamel lesions (ICDAS 1&2) are recorded Pitts NB, Zero D, Marsh P, Ekstrand K, Weintraub J, Ramos-Gomez J, Tagami J, Twetman S, Tsakos G and Ismail A. Dental caries. Nat. Rev. Dis. Primers 3, 17030 (2017).) [Data on 15 year-old children from 2013 National Child Dental Health Survey (CDHS) of England, Wales & NI] 29

Dental Caries in Adults: Natural History and Caries Trajectories (Dunedin Study) Globally we have little Adult data but the rate of new caries continues throughout Adulthood 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. 30

Dental Caries: Historical & Current Perspective of Restorative Model A long-term perspective of the international evidence Controlling the Caries Process PRIOR 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. 31

Dental Caries: Emerging International Consensus- Preservative Management Better understanding of the disease The Caries Balance 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 Pitts NB, Zero D, Marsh P, Ekstrand K, Weintraub J, Ramos-Gomez J, Tagami J, Twetman S, Tsakos G and Ismail A. Dental caries. Nat. Rev. Dis. Primers 3, 17030 (2017). Patient-centred approaches to reducing anxiety and fear of the dentist 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] 32

33 Economic System: this challenge is a complex, inter-related system Systems thinking on the Paradigm Shift- an overview looking at direct and indirect costs

34 Proposed Integrated Solution: Three-Tiered Preventive Caries Care Primary Prevention Current Situation 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. Preventively Focused Solution Incentivised system for remuneration to allow for prevention of disease in the absence of disease, both upstream and downstream to clinical care Secondary Prevention Tertiary Prevention 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) 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. 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 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.

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 35

Population Groups: How do we segment our population groups B A Individuals can sit anywhere on this spectrum, but could also be broadly grouped: Motivation to comply C D 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) Access to care 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

37 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

Example Framework of Country Types 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. Country Type A Similar to Denmark / Sweden Country Type B Similar to the U.S. Country Type C Similar to France, U.K., Germany GDP per capita High High Average Low Dentistry Expenditure (% GDP) Above average Above average Average Low Country Type D Developing country Public Spending High Low / Inexistent 1/3 of the expenditure None (other priorities) Out of Pocket Money / Insurance Access to care (demographics) None for some targeted populations or age groups, High for others Very accessible, organised for children High A lot of people without insurance, without access. Very accessible None for Children, 1/3 Insurance 1 /3 OOM Correct on national basis, some territorial inequalities Public Health Programmes Well organised Weak Variable Limited Public Dental Service Patient compliance and education Total for some age groups High Very limited Variable Limited Complicated, low workforce Above average Average Average Below average Nutrition Moderate in Sugar High in sugar Moderate in Sugar Increasingly high in sugar Oral health indicators Defined Not defined Not defined Not defined 38