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This executive summary for Section 4 of the "Advancing Dental Education in the 21 st Century" project examines the projected oral health care delivery system in 2040 and the likely impact of system changes on dental education. Dental care is at an early stage of major changes with the decline in solo practice and increase in large group practices. These groups are not consolidated at the state level, but further consolidation is expected as they try to increase their negotiating leverage with dental insurers. At this time, there is limited integration of medical and dental care in terms of financing, regulation, education, and delivery. This pattern may change as health maintenance organizations and integrated medical systems begin to offer dental care to their members. By 2040, it is expected that many dentists will be employed in large group practices and working with allied dental staff with expanded duties and other health professionals, and more dental graduates will seek formal postdoctoral training to obtain better positions in group practices.

The major barriers to the collection of primary population-based dental services data are: (1) Dentists do not use standard record systems; (2) few dentists use electronic records; and (3) it is costly to abstract paper dental records. The value of secondary data from paid insurance claims is limited, because dentists code only services delivered and not diagnoses, and it is difficult to obtain and merge claims from multiple insurance carriers. In a national demonstration project on the impact of community-based dental education programs on the care provided to underserved populations, we have developed a simplified dental visit encounter system. Senior students and residents from 15 dental schools (approximately 200 to 300 community delivery sites) will use computers or scannable paper forms to collect basic patient demographic and service data on several hundred thousand patient visits. Within the next 10 years, more dentists will use electronic records. To be of value to researchers, these data need to be collected according to a standardized record format and to be available regionally from public or private insurers.

The length of time amalgam restorations last before replacement was investigated for use as an intermediate outcome measure in utilization review and quality assurance studies. Based on record data from 37 general dental practices, a determination was made of the average percentage of two- or three-surface amalgams receiving another service at 6, 12, and 24 months from the date of insertion. After 2 years, approximately 13 per cent of the amalgams were replaced, and the estimated median life time for amalgams was between 10 and 14 years. The variation in replacement rates among practices was substantial but was not explained by the technical quality of restorations or several practice characteristics.

Using data from the Rand Health Insurance Experiment, the effects of cost-sharing plans on the health of the primary teeth in 264 children aged 3 to 5 years were investigated. From six areas in the United States, families were assigned at random to different dental and medical insurance plans. The plans varied in the amount of required cost sharing. Families participated in the study for 3 (70%) or 5 (30%) years. Children covered by the plan (requiring no cost sharing) had significantly fewer decayed teeth and deft (decayed, extracted, and filled teeth) at the end of the study than did children covered by the cost-sharing plans. No differences existed among plans in the number of extracted and restored teeth. Children of middle- and low-income families benefited most from having access to free dental care.

Methods for controlling dental care expenditures are taking on greater importance with the rapid increase in prepaid dental plans. The use of regulatory systems to monitor provider performance are necessary to prevent gross over-utilization but are unlikely to result in net savings of more than five per cent of total gross premiums. Theoretically, prepaid group dental practice (PGDP) may reduce expenditures by changing the mix of services patients receive. The modest estimated savings and the small number of PGDPs presently in operation limit the importance of this alternative for the next five to ten years. If substantial reductions in dental expenditures are to be obtained, it will be necessary to limit dental insurance plans to cover only those services which have demonstrated cost-effectiveness in improving health for the majority of people. The concept that richer benefit plans may have small marginal effects on improving oral health may not be easy for the public to accept but, until they do, expenditures for dental care will be difficult to control.

Using data from a randomized trial in health insurance, this paper examines the effect of cost sharing on use of dental services. The data come from a sample of the nonaged, noninstitutionalized civilian population of six urban and rural sites. We find that: reducing the level of cost sharing increases demand for dental services; and dental expenses rise 46% when the coinsurance rate falls from 95% to 0%, subject to a catastrophic limit on out-of-pocket expenses. Of this increase, two-thirds is attributable to an increase in the likelihood of visiting a dentist during the year. Moreover, there is a substantial surge in demand during the first year of more generous coverage. The first-year response to cost sharing is nearly twice the second-year response.

This paper analyzes the relationship among presence of fluoride in the drinking water, oral health and dental expenditures in four towns in Finland. A two-stage least-squares model is used to determine the effect of fluoridated water and other independent variables on the number of missing teeth and per capita annual dental service expenditures for 555 adults. The results show that regularity of dental visits is the only significant factor explaining per capita expenditures. In contrast, many factors affect the number of missing teeth; most importantly, the number of dentists per capita, level of fluoride, age, education, use of services and smoking habits. These findings suggest that fluoride significantly improves oral health status but does not reduce adult per capita dental expenditures.

This paper examines the application of information and principles derived from social science research to increasing the effectiveness and efficiency of the dental care delivery system. Four major delivery system attributes are considered: the availability, accessibility, appropriateness and acceptability of care. The dentist to population ratio is a major determinant of the availability of dental care and many factors have to be considered in deciding on the appropriate number of dentists needed in a population. Optimum size of dental practices is another aspect of availability. The evidence suggests that practices with 2 or 3 dentists are more efficient than solo practices. However, large group practices appear only to be of equal or even less efficiency than small group practices. The accessibility of dental care is influenced by the geographical location of practices, the convenience of obtaining care during non-working hours, the reduction and dissemination of information on dental fees and, most importantly, the beliefs of people concerning their oral health status. The appropriateness of care concerns the impact of different services on improving oral health. Relatively little clinical research has been published on the costs and benefits of different dental services. The acceptability of dental care concerns both patients who visit the dentist and the larger society. Studies show that patients who visit the dentist are generally satisfied with the care they receive. Societal attitudes about the dental care system have not received much attention. Although social science research on the dental care delivery system is at an early stage of development, some data exist which are relevant to optimizing the practice of dentistry.

This study examines the amount and sources of variation in dental practice profiles. Three years of insurance claims data on 227 general dental practices were used to generate practice-specific utilization rates for 16 treatment service categories. The results indicated considerable heterogeneity among and within practices in the distribution of service utilization rates such that most distributions could not be described by conventional parametric probability models. Basic standardization methods were used to examine sources of variation among practices. Of the patient and insurance characteristics investigated, only patient age had a major effect on utilization rates. However, there was considerable stability in utilization rates within practices over four consecutive six-month time intervals. The implications of these findings for profile-based utilization review and quality-assurance systems are discussed.

This article considers some fundamental considerations in developing criteria and standards for use in a formal quality assurance program. These include the purpose of the review system, the types of problems being addressed, the availability of data, and the time and money that can be devoted to improving clinical performance.