IQuaD: Improving the Quality of Dentistry: a randomised controlled trial comparing oral hygiene advice and periodontal instrumentation for the prevention and management of periodontal disease in dentate adults attending dental primary care
Periodontal disease is the most common oral disease affecting adults. This disease is preventable, yet it remains the major cause of poor oral health worldwide and is the primary cause of tooth loss in older adults. There is a lack of strong evidence to inform clinicians and policy makers of the relative effectiveness (if any) and cost-effectiveness of different types of oral hygiene advice (OHA). The economic evaluation conducted as part of this cluster randomised controlled trial elicited the costs of dental care to both the NHS and patients and equated the data with benefits to patients. Benefits to patients were estimated using a discrete choice experiment administered to a sample of the general population to provide a scoring algorithm with which to weight the outcomes for the patient participants in the trial.
Outcome and Translation
63 dental practices and 1877 participants were recruited. Under Intention To Treat (ITT) analysis there was no evidence of a difference in gingival inflammation/bleeding (the primary clinical effectiveness outcome measure) across any of the randomised groups. There was no clinical benefit from scheduling 6-monthly or 12-monthly scale and polish over not scheduling these treatments unless desired or recommended. Furthermore, there was no clinical benefit of personalised over routine oral hygiene advice in either gingival inflammation/bleeding or patient centred outcomes (including oral health related quality of life).
Compared to standard care, no scale and polish with personalised advice had the greatest NHS: -£15 (-£34 to +£4) and participant: -£64 (-£112 to -£16) cost savings. The DCE shows that the general population value these services greatly and were willing to pay for both scale and polish and personalised advice. WTP for scale and polish was higher than personalised advice. Overall, Personalised OHA with 6-monthly PI had the greatest incremental net benefit to society: +£48 (+£22 to +£74). Sensitivity analyses did not change conclusions. The results of the study provide a dilemma for NHS dental policy makers who must consider whether or not to fund services that are not clinically beneficial but are highly valued by the general population.
External collaborators: J Clarkson, D Bonetti, N Pitts (University of Dundee); C Ramsay (HSRU, University of Aberdeen); J Burr (University of St. Andrews); H Worthington, C Jones, M Tickle (University of Manchester Dental Hospital); P Heasman, J Steele (University of Newcastle); L Young, I Madden, W McCombes (NHS Education for Scotland); P Hodge (University of Glasgow Dental School); M Ross (University of Edinburgh); D Ricketts, A Hall (Dundee Dental Care Hospital & School) and P Averley (Queensway Dental Practice)
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Clarkson, J. E., Ramsay, C. R., Averely, P., Bonetti, D., Boyers, D., Campbell, L., Chadwick, G. R., Duncan, A., Elders, A., Gouick, J., Hall, A. F., Heasman, L., Heasman, P. A., Hodge, P. J., Jones, C., Laird, M., Lamont, T. J., Lovelock, L. A., Madden, I., McCombes, W., McCracken, G. I., McDonald, A. M., McPherson, G., Macpherson, L. E., Mitchell, F. E., Norrie, J. D., Pitts, N. B., Pol, M. van der, Ricketts, D. N., Ross, M. K., Steele, J. G., Swan, M., Tickle, M., Watt, P. D., Worthington, H. V. and Young, L. (2013) 'IQuaD dental trial; improving the quality of dentistry: a multicentre randomised controlled trial comparing oral hygiene advice and periodontal instrumentation for the prevention and management of periodontal disease in dentate adults attending dental primary care [protocol]', BMC Oral Health, 13(1), 58.
Ramsay, C., Clarkson, J., Duncan, A., Lamont, T., Heasman, P., Boyers, D., Goulao, B., Bonetti, D., Bruce, R., Gouick, J., Heasman, L., Lovelock, L., MacPherson, L., McCracken, G., McDonald, A., Mitchell, F., Norrie, J., Pol, M. van der, Sharp, A., Steele, J., Watt, G., Worthington, H. and Young, L. (2017) Improving the Quality of Dentistry (IQuaD): a cluster factorial randomized controlled trial comparing the effectiveness and cost benefit of oral hygiene advice and/or periodontal instrumentation to routine care for the prevention and management of periodontal disease in dentate adults attending dental primary care. Final project report to NIHR (Project Number 09/01/45).
Ramsay, C.R., Clarkson, J.E., Duncan, A., Lamont, T.J., Heasman, P.A., Boyers, D., Goulao, B., Bonetti, D., Bruce, R., Gouick, J., Heasman, L., Lovelock-Hempleman, L.A., Macpherson, L.E., McCracken, G.I., McDonald, A.M., McLaren-Neil, F., Mitchell, F.E., Norrie, J.D., Pol, M. van der, Sim, K., Steele, J.G., Sharp, A., Watt, G., Worthington, H.V. and Young, L. (2018) 'Improving the Quality of Dentistry (IQuaD): a cluster factorial randomised controlled trial comparing the effectiveness and cost-benefit of oral hygiene advice and/or periodontal instrumentation with routine care for the prevention and management of periodontal disease in dentate adults attending dental primary care', Health Technology Assessment, 22(38).
Guolao, B., Ramsay, C., Lamont, T., Boyers, D. and Clarkson, J. (2017) 'Challenges of evaluating an efficient use of resources in dentistry: the IQuaD study' [poster], 5th Annual Research Symposium: Evidence for Sustainability, COSLA Conference Centre, Edinburgh, 16 March 2017.
Clarkson, J., Lamont, T., Duncan, A., Goulao, B., Boyers, D., Heasman, P. and Ramsay, C. (2017) 'Scale or oral hygiene advice? Results from a randomised trial', International Association for Dental Research (IADR) General Session, San Francisco, USA, 22-25 March 2017.
Boyers, D. and Pol, M. van der (2017) 'Health economic results from the Improving Quality of Dentistry (IQuaD) study', Scaling the Heights and Probing the Depths in the 21st Century, NHS Education for Scotland Dental Clinical Effectiveness Symposium 2017, Edinburgh International Conference Centre, Edinburgh, 1 December 2017.
Boyers, D. (2018) 'Improving the predictive validity of dental care DCEs, an application to the Improving Quality of Dentistry (IQuaD) study', Keynote lecture to the Centre for Oral Health Research (COHR), Newcastle University, Newcastle, England, 18 January 2018.
Boyers, D., Clarkson, J., Duncan, A., Goulao, B., Lamont, T., Ramsay, C. and Pol, M. van der (2018) 'Should we skip the dentist? Economic evaluation of scale and polish', 12th European Conference on Health Economics (EuHEA), Maastricht, The Netherlands, 11-14 July 2018.
Ord, F. and Boyers, D. (2018) 'Presentation of dental concerns at non-dental health providers' [poster], British Society for Dental Hygiene and Therapy - Oral Health Conference and Exhibition 2018, International Centre, Telford, England, 23-24 November 2018.