SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
February, 2017 - SUPPORT Summary of a systematic review | print this article | download PDF
Access to dental care and dentists is difficult around the world, particularly in low- income countries. Consequently, many nations have employed alternative non dentist midlevel providers to conduct diagnostic, treatment planning, or irreversible surgical dental procedures.
People deciding whether to introduce dental auxiliaries into practice
Wright JT, Graham F, Hayes C, et al. A systematic review of oral health outcomes produced by dental teams incorporating midlevel providers. J Am Dent Assoc 2013; 144:75-91.
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
Dental caries are the most common chronic disease in children and adults. In low income countries they disproportionately affect those of lower socioeconomic status. It is precisely in these countries where access to dental care and dentists is more limited. As training of dentists is long and expensive, alternative oral healthcare providers have been developed. They perform some of the reversible and irreversible procedures traditionally performed by dentists. Both the names (dental assistant, dental auxiliary, dental nurse, dental hygienist, dental technician, dental therapist) and the range of duties they perform vary widely from country to country. They are often referred to as professions complementary to dentistry or midlevel providers.
| Review objectives: To determine the effect of a model of provision of dental care that utilizes midlevel providers compared to no care or care by dentists. | ||
| Type of | What the review authors searched for | What the review authors found |
|---|---|---|
| Study designs & interventions | Experimental, observational and descriptive studies evaluating the provision of irreversible and surgical procedures by midlevel providers | 18 retrospective or cross-sectional studies |
| Participants | People of any age | School children (15), Indian communities (2), military servicemen (1) |
| Settings | Urban or rural | The studies were conducted in Aus-tralia (6), Canada (3), Hong Kong (3), New Zealand (5) and the United States (3). |
| Outcomes | Dental disease incidence, prevalence, or severity; un-treated disease; and cost-effectiveness |
Caries, diagnostic procedures, treat-ment planning, irreversible or surgical pro-cedures
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| Date of most recent search: February 2012 | ||
| Limitations: This is a well-conducted systematic review with only minor limitations. | ||
Wright JT, Graham F, Hayes C, et al. A systematic review of oral health outcomes produced by dental teams incorporating midlevel providers. J Am Dent Assoc 2013; 144:75-91.
To compare DOT with self-administration of treatment or different DOT options for people requiring treatment for clinically active tuberculosis or prevention of active disease.
Wright JT, Graham F, Hayes C, et al. A systematic review of oral health outcomes produced by dental teams incorporating midlevel providers. J Am Dent Assoc 2013; 144:75-91.
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
Eighteen studies were included, involving 6042 participants, receiving irreversible dental treatment from teams that included midlevel providers.
Seven studies reporting caries outcomes showed a consistent trend of reduction in caries severity across time. Twelve studies that compared populations treated by dental therapists with private dental care or no care had inconsistent results.
Five studies reporting on untreated caries found a consistent trend of reduction in caries severity over time. Thirteen studies comparing populations treated by dental therapists with private dental care or no care found inconsistent results.
Dental care by midlevel providers |
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| People: Children from 9 to 16 years that received irreversible dental treatment Settings: Mostly schools in urban or rural areas Intervention: Dental care by midlevel providers (dental therapists or school dental service known to employ dental therapists) Comparison: Private dental care by dentists or not having received care recently |
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| Outcomes | Impact | Certainty of the evidence (GRADE) |
Comments | |
| Caries severity scores across time |
Reductions from 6% to 79% |
Very low |
Based on data from 7 uncontrolled before-after studies | |
| Caries increment and severity scores |
Reductions of 27% to increments of 38% compared to dentists and reductions from 0% to 21% compared to no dental care |
Very low |
Based on data from 9 observational studies with private care by dentists as the comparison and 3 studies with no dental care as the comparison | |
| Mean levels of untreated caries across time | Reductions from 17% to 79% |
Very low |
Based on data from 5 uncontrolled before-after studies | |
| Mean levels of untreated caries | From reductions of 78% to increments of 70% compared to dentists and reductions from 1% to 83% compared to no dental care |
Very low |
Based on data from 10 observational studies with private care by dentists as the comparison and 3 studies with no dental care as the comparison | |
| GRADE: GRADE Working Group grades of evidence (see above and last page) | ||||
| Findings | Interpretation* |
|---|---|
| APPLICABILITY | |
| Most studies evaluated school children from urban or rural areas in high-income countries. |
The provision of oral healthcare requires a complicated infrastructure, including appropriate supervision, dental offices, and a financing system. Therefore, the findings may not be directly applicable to low-income countries. |
| EQUITY | |
| Few studies included disadvantaged populations and populations without dental care. | The benefits of dental care by midlevel providers are potentially larger and more consistent for underserved populations, and therefore could reduce inequities. |
| ECONOMIC CONSIDERATIONS | |
| The systematic review did not address economic considerations. |
Scaling up midlevel providers requires re-sources, but probably less resources than scaling up dental care by dentists. |
| MONITORING & EVALUATION | |
| Good quality data from experimental studies is lacking. |
New workforce models incorporating midlevel providers should be launched with robust evaluation plans. Ideally cluster randomised trials or quasi-experimental studies should be used to determine the effectiveness and cost-effectiveness of these interventions. In addition to health outcomes, intermediate outcomes (such as wait times, travel distance, and retention of personnel who are trained and employed) should be measured. |
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*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: http://www.support-collaboration.org/summaries/methods.htm |
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Rodriguez TE, Galka AL, Lacy ES, et al. Can midlevel dental providers be a benefit to the American public? J Health Care Poor Underserved 2013; 24:892-906.
Phillips E, Shaefer HL. Dental therapists: evidence of technical competence. J Dent Res 2013; 92(7 Suppl):11S-5S.
Nash DA, Friedman JW, Mathu-Muju KR, et al. A Review of the global literature on dental therapists: In the context of the movement to add dental therapists to the oral health workforce in the United States. Oral Health Science Faculty Publications. 7. 2014. http://uknowledge.uky.edu/cgi/viewcontent.cgi?article=1009&context=ohs_facpub
Agustín Ciapponi, Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Ar-gentina
None declared. For details, see: www.supportsummaries.org/coi
This summary has been peer reviewed by: Timothy Wright and Tom Dyer.
Wright JT, Graham F, Hayes C, et al. A systematic review of oral health outcomes produced by dental teams incorporating midlevel providers. J Am Dent Assoc 2013; 144:75-91.
Ciapponi A. Do midlevel dental providers improve oral health? A SUPPORT Sum-mary of a systematic review. February 2017. www.supportsummaries.org
All Summaries:
evidence-informed health policy, evidence-based, systematic review, health sys-tems research, health care, low and middle-income countries, developing coun-tries, primary health care, clinical competence, delivery, dental auxiliaries, oral health
