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QUESTION
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Many of my patients report that my dental care has made them feel good about their oral health. In my practice, I have focused on detecting the clinical signs of success and have never thought of the non-clinical outcomes that seem to be what my patients value. Please explain the outcomes that dentists should assess to document the full range of benefits of dental care.
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ANSWER
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This question is timely, given the ongoing debate on the quality of, and access to, health care services. Many of the dilemmas that health professionals face in their decisions about health care for patients may be rooted in the differing values assigned by patients, payers and dentists to the various outcomes of dental treatments. Provision of dental care can be viewed primarily as a means of improving patients’ health-related quality of life, or HRQoL.1,2 HRQoL is defined as the "degree to which persons perceive themselves to be able to function physically, emotionally and socially."2 Achieving a high HRQoL depends partly on meeting the perceived expectations of patients. Clinical outcomes may contribute to improving the quality of life and lead to results that are valued by patients. Unfortunately, the dental community has not thoroughly evaluated the nonclinical benefits or outcomes of dental care.
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OUTCOMES OF DENTAL CARE
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Outcomes of dental care can be classified into four dimensions: clinical, biological, psychosocial and economical.3 Clinical outcomes are the physical results of the health services that a patient receives. For example, when a tooth is restored, clinical outcomes of interest might include the removal of caries, the mechanical quality of the restoration and improved chewing ability. When scaling and root planing is performed to treat inflamed periodontal tissues with pockets, the outcomes might be the removal of plaque, reduction in gingival bleeding and other signs of inflammation, and maintenance or reduction of pocket depth. These clinical outcomes are the results of treatment on which dental practitioners, educators and dental researchers have focused.
The biological outcomes of dental care include measures such as the reduction in cariogenic bacteria,4 change in salivary function,5 reduction in inflammatory mediators of periodontal disease,6 reduced levels of glucated hemoglobins7 in diabetics with periodontal disease, and reduced pain in patients with temporomandibular disorders.8 These and other biological outcomes are used to evaluate indirectly the effectiveness of a dental treatment.
The psychosocial outcomes of dental care have received limited attention in dentistry. All dentists appreciate that the success of their practices depends largely on the satisfaction of patients. However, we have limited information on the factors that determine patient and societal satisfaction with dental care.9 Reifel and colleagues10 have shown that successful direct communication with patients is an important factor in determining satisfaction with outcomes of care. In our opinion, satisfaction with dental care is an important determinant of why patients seek care and of their perception of the quality of dental care. Unfortunately, the dental community has not yet studied the determinants of patient satisfaction. We contend that patients with a high HRQoL place a high value on oral health as an integral part of a healthy lifestyle and are more likely to visit dentists and follow oral health advice than are patients who have a low HRQoL.
Another area that has received limited attention is the assessment of patients’ preferences (that is, their values or utilities) in regard to the different outcomes of dental care. Patients vary in the way they rate the benefits, harm, cost and convenience associated with different treatment options.11 Patients who place a high value on preserving oral and dental tissue are more likely to seek preventive treatment (such as sealants and fluoride application for early carious lesions) than restorative interventions. To measure preferences, the dental professional must present all of the treatment options, the methods of administering the treatments and the probabilities of success and failure during the life of a patient.12,13 After they present all the treatment options and the uncertainty in outcomes, dentists should ask patients to rank outcomes of the different interventions based on their order of preference. This information would help dentists to identify the relative value patients place on each option before considering the cost of treatment. The art of clinical practice is to balance patients’ preferences with their financial capabilities to achieve their desired outcomes.
There are only a few measures of psychosocial outcomes in dentistry. This area, however, is receiving more attention from the academic community and funding agencies. During the last 10 years, several indexes have been developed to measure oral HRQoL.14 The Oral Health Impact Profile,15 for example, measures functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability and handicaps. Another index, the General Oral Health Assessment Index (also known as the Geriatric Oral Health Assessment Index),16 assesses the psychosocial impact associated with oral diseases. In addition, other questionnaires have been designed to measure subjective oral health status indicators such as ability to chew foods and to speak, oral and facial pain, and impact of oral health status on daily living and social relations.17 Dentists may administer these questions to assess selected dimensions of patients’ HRQoL. Such information would be helpful in treatment planning as well as in assessing the outcomes of dental care.
Economic outcomes of dental care represent both the direct costs (out-of-pocket or premiums) of treatment as well as indirect costs (such as loss of wages, time away from work and ancillary expenses). The perspective used in an economic analysis influences the scope and interpretation of the economic impact and value of dental interventions. For example, from the perspective of a director of a public health program, sealing all first permanent molars in an area with low caries prevalence may not be cost-effective.18 The parents of a child may have another perspective. In their opinion, taxpayer dollars should be used to benefit their child, even if he or she faces a low risk of ever developing dental caries. Failure to understand these perspectives usually leads to conflicts among patients, policy makers and dentists. We contend that understanding the different perspectives is necessary to create informed policies and to reconcile differences among the parties in the dental care system. Dentists should be cognizant of the values and concerns that the population-at-large holds. Access to care, inequalities in health status between different groups in society, and cost of health care are three of the many issues that Americans are concerned about today.
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ASSESSING CLINICAL AND NONCLINICAL OUTCOMES
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The assessment of clinical and nonclinical outcomes of dental care is an area that should receive more attention from the dental profession, dental educators and the research community. Once we have tools to assess the public’s and patients’ oral HRQoL, we may discover that dental care has many hidden and beneficial outcomes beyond the prevention of disease and repair of damaged dental tissues.
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