Oral care prevention

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Featured in half-yearly report: Health Policy Developments 9

Abstract

In 1997, major French health insurance funds introduced a prevention scheme for improving access to dental care for teenagers. It involved offering a free annual visit with 100% coverage for any subsequent treatment to those aged between 15 and 18 years. The evaluation of this scheme demonstrates that more than half of the teenagers who took part in this program needed treatment. But the participation rate was quite low, especially amongst the most deprived.

Purpose of health policy or idea

In 1997, the major health insurance schemes (for employees, self-employed workers and agricultural workers) and dentists' unions decided, in a conventional agreement [1], to put in place a national oral screening and prevention programme that would be known as BBD (Bilan Bucco-Dentaire - oral check-up). This programme marks a turning point in so far as, for the first time, prevention came within the scope of a conventional agreement. Moreover, the BBD is the first oral prevention programme proposed on a national scale. It involves "putting in place and developing incentive actions for oral prevention and screening to fight against late recourse to treatment". The BBD targets adolescents aged between 15 and 18 who appear to pay the least importance to a good oral hygiene. In France, preventive actions in the school environment are provided up to the age of 12. Adolescents are invited to take part in the BBD by means of a letter, sent every year to their home by the health insurance body, from their 15th to their 18th birthday. The oral check-up comprises two stages : a preventive exam where teenagers' oral health status is assessed and oral hygiene advices are given. This check-up is free and must be carried out in the three months following the teenager's birthday. It can be performed by any contracted dentist. If necessary, the dentist prescribes conservative or surgical treatments. These must be carried out in the 6 months following the preventive exam. These treatments (excluding prosthetics and orthodontics) are fully refunded by the health insurance funds (including the part normally covered by supplementary insurance schemes). Note that in France, normally about 70% of the consultation cost is covered by the compulsory insurance.

Main points

Main objectives

The main objective was to increase the number of regular visits to dentists by teenagers. It is also aimed to make an overall assessment of teenagers' dental health status and improve sensibility for prevention in dental care.

Type of incentives

The visit to the dentist within the framework of the BBD is free. Consecutive treatments, apart from prosthetic treatments and orthodontic appliances, are fully refunded by health insurance funds. This measure is designed to remove financial obstacles that may prevent young people from modest-income families from taking part, especially if they do not benefit from a supplementary health coverage.

All the targeted young people received a letter inviting them to take part in the BBD. Advertising campaigns used for promoting the BBD: TV, radio commercials especially on radio stations aimed at young people, leaflets in dental surgeries, junior and high schools, etc.

Groups affected

At the beginning, the scheme concerned young people aged between 15 and 18. In 2003, it was expanded to include 13-18 year-olds. Since January 2007, it became compulsory for the children aged 6 and 12, and reimbursed for 9, 15 and 18 year-olds, The health insurance funds pilot the programme and finance it, Unions of dentists, independent dentists and health centres carry out the BBD on the ground.

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral

Political and economic background

Since the 1980s, changes in lifestyle, oral prevention and health education campaigns, and the spread of the use of fluorinated products have improved the oral health of the French significantly, in particular of children. According to figures from the UFSBD (French Union for Oral Health), the average DMF index (Decayed-missing-filled) for children aged 12 has dropped from 4.2 in 1987 to 1.9 in 1998. However, at the end of the 1990s, major social inequalities were observed in terms of dental caries. In 1998, the DMF index was lower than 1.5 for children of senior executives and nearly 2.5 for the children of blue-collar workers. The average French index of 1.9 in 1998 could be compared with Great Britain's index of 1.1 and the WHO's target for 2010, which is 1. According to the Health, Health Care and Insurance (ESPS) survey of IRDES, in the mid-1990s almost one French person in five renounced treatment for financial reasons in the past 12 months and almost half of these concerned oral health. The renounciation rate is extremely unevenly distributed across population groups.  

In 1997, there was no oral care prevention programme in France on a national scale, despite the fact that dental care is one of the rare fields where the effectiveness of prevention and regular care is uncontested. The main stakeholders in the oral health area thus joined forces to reinforce preventive efforts aimed at young people and to better coordinate the existing schemes in order to limit a deterioration in oral health during adolescence which often implies costly treatment afterwards.

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Origins of health policy idea

The idea for the oral/dental check-up came from the health insurance fund, which observed in its consumption files that very few young people have used dental care services. Only 35% of 15-18 year-olds, an age bracket in which there is a high risk of cavities, visit a dentist in a given year, whereas the recommendation is to have a visit at least once a year for a check-up.

The BBD was implemented in a contractual framework grouping together the three main health insurance schemes (Cnamts, Canam, Msa) and the two leading unions of dental surgeons (UJCD and CNSD). The national agreement for dental surgeons is designed to govern relations between dentists and health insurance funds. It was the first time that a scheme of this kind has been put in place in France with regard to oral health. It marks an awareness of the need to promote prevention in order to improve the oral health status of the population. The modalities take their inspiration from other prevention programmes, for example the breast cancer prevention programme: an invitation by letter and a free examination.

 

 

Initiators of idea/main actors

• Providers: The unions of dental surgeons (dentists) signed the agreement on prevention (BBD) within the framework of contractual negotiations with the health insurance funds. However, a large number of dentists have declined to play the game by refusing to see teenagers as part of the BBD or by not following the instructions (not providing the messages of prevention, not marking BBD on the reimbursement forms, which has made it impossible to assess actual participation in BBD, etc.). This reticence on the part of professionals can be explained by an excess of administrative papers to be filled in as part of the BBD, by delays in the payment of the consultations (free for the insured persons) by health insurance funds, and perhaps also in part by negligence. The Union Française pour la santé bucco-dentaire (UFSBD – French union for oral health), a non-profit organisation created in 1966 to promote dental health and the independent dental profession, is not directly involved in the BBD, but it strongly supports it, in particular through the involvement of its dentists grouped together in 100 local committees.

• Payers: The three main health insurance schemes (Cnamts, Canam, Msa) for the salaried, self employed and the farmers. They finance the whole programme.

Stakeholder positions

All of the oral health players are agreed on the necessity of developing prevention schemes to continue to improve the dental health of the population and try to reduce inequalities.

Actors and positions

Providers
Unions of dental surgeons	very supportive		strongly opposed
French union for dental health	very supportive		strongly opposed
Payers
French health insurance	very supportive		strongly opposed

Influences in policy making and legislation

In August 2004, the French parliament adopted an act relating to public health policy. The 7th objective of this act is "A reduction in health inequalities, by promoting good health and improving access to treatment and diagnosis across the whole country". With regard to oral health, the aim is to reduce the average mixed DMF index by 30% by 2008 at the age of 6 (from 1.7 to 1.2) and at the age of 12 (from 1.94 to 1.4).[2].

Therefore a new more extensive preventive scheme, the EBD (oral exam), was introduced in the framework of an oral prevention programme launched in November 2005 by the Minister of Health. The EBD is largely inspired by the BBD. It entered into effect on 1st January 2007. The principles of these two schemes are identical. The EBD is compulsory for 6 and 9 years olds; it must be noted in their healthcare record. The health insurance funds extend this scheme by offering a oral examination every 3 years up to the age of 18.

Actors and influence

Providers
Unions of dental surgeons	very strong		none
French union for dental health	very strong		none
Payers
French health insurance	very strong		none

Positions and Influences at a glance

Monitoring and evaluation

Two main evaluations were carried out on the BBD: a medical evaluation under the responsibility of the major health insurance fund and a sociological study entrusted to Irdes. The medical evaluation aimed to describe the treatment needs and the treatments carried out on those participating in the scheme. It based on the monitoring of 12,000 teenagers who took part in the scheme. The evaluation looked at the changes in the DMF index over the course of successive years of screening and in the consumption of treatments following the preventive examination. A number of national and regional medical evaluations of this policy for salaried employees and for self-employed workers has been partially carried out [5, 4] [6]. The second evaluation (by IRDES) aimed to determine whether the BBD had reached its targets, in particular in terms of the participation of teenagers belonging to underprivileged families who do not usually have regular dental care.

Results of evaluation

The "medical" and "social" evaluations of the BBD reach different conclusions on the effectiveness of the BBD, which may appear contradictory. The medical evaluations observe that over half of the participants in the BBD needed treatment for tooth decay [4,5] and the same proportion had not consulted a dentist over the past twelve months [5,6]. They thus conclude that the BBD meets a real public health need. These same evaluations note that between one teenager in five and one in three has not had the subsequent treatment prescribed by the dental surgeon and that more than 40% of the treatment forms did not carry the letters EXP, which was required by the health insurance funds to ensure that subsequent treatments were fully covered. This reveals the lack of commitment on the part of the dental profession to the scheme.   Irdes' study [7] points the low number of teenagers participating in the BBD, the rate of participation consistently remained below 20% of those targeted (15 to 18 years old) between 1998 and 2005. The study of the insurance fund for self-employed people [4] notes that only 0.7% of the young people concerned took part in the three successive annual screenings (1998-1999-2000). Moreover, Irdes demonstrates that the rate of participation in the BBD is much lower among teenagers who do not go to a dental surgeon on a regular basis and who do not have a dentist near their home. It exceeds 20% among teenagers who say that they have an annual check-up and have a dentist less than 10 minutes from their home. It is less than 5% for whom the first dentist is more than 10 minutes from their home. However, Irdes also shows that the BBD was of primary benefit to modest-income households and the households of blue-collar workers or employees. The financial incentive thus played its role in part. At the same time, the rate of participation is very low among the most underprivileged households, for example those in which one or both parents are unemployed.

In conclusion, it can be said that while the Oral Check-up provided a good opportunity for teenagers from modest-income households who had not been to the dentist recently, it seems to fail for those populations who have the least access to treatment and who are the most underprivileged, for whom this type of invitation (by letter) is probably not adapted.

Expected outcome

The general aims of the oral check-up were to encourage regular oral care (once a year) among 15-18 year-olds, to assess their oral health status, to carry out the necessary treatment and to deliver messages of prevention to those who have the least access. There was an operational objective, which was to increase the annual proportion of young people consulting a dentist by 10% in the first year, from 35% to 45%. We have not found any figures from the health insurance body concerning this objective, but the low participation in the BBD (less than 20%) leaves no doubt that this objective was not met. No study has been carried out to measure the impact of the BBD on health status, the fairness of the system and the ultimate cost-effectiveness of the scheme. What we can say today [4, 5, 6] is that more than half of teenagers who took part in the BBD needed treatment. According to the evaluations, between 65% and 80% had this treatment. The BBD has thus been of of use for this group, more than half of whom had not been to a dentist in the previous year, even though the IRDES study shows that BBD did not work for the most deprived ones. 

We have not found any information on the overall cost of the BBD (insurance coverage of the visit and the treatment, communication, administration). The reticence of part of the dental profession regarding the BBD must also be noted, clearly to assure the success of any programme of this type it is essential to have the support of the profession by improving the dialog or reducing the extra paper work on their side. Despite all this, the BBD played a pivotal role in oral prevention among young people with the creation of compulsory Oral Exam (EBD) providing free treatment following the exam. Another new feature is that this exam will be entered in the healthcare record and will be accompanied in schools by a one-hour general information course given by a dentist from UFSBD (Union Française pour la Santé Bucco-Dentaire). Local stakeholders (DRASS, CAF, associations, social players, National Education, etc.) will be called upon to raise awareness regarding dental prevention among the most underprivileged populations. The health insurance funds extended this scheme by offering a check-up every three years up to the age of 18. The information, invitation and communication operations have been improved. At the moment, it is difficult to know if these measures will improve participation of the most deprived populations and reduce inequalities in this area.

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high

There is no information available on the cost efficiency. Its impact on equity seems to be marginal.

References

Sources of Information

[1] National agreement for surgeons published in JO no. 140 of 18 June 2006 (page 9167, text no. 7).

[2] Public Health Policy Act (no. 2004-806 of 9 August 2004) published in JO no. 185 of 11 August 2004.

[3] National agreement for dental surgeons published in JO no. 125 of 31 May 1997 (pages 8478-8491).

[4] Guillaud M., Prat H., Dematons MN., Blum-Boisgard C. (2004), Evaluation de la réalisation du bilan bucco-dentaire (BBD) conventionnel [Evaluation of the implementation of the contractual oral/dental check-up (BBD)], Revue d'Epidémiologie et de Santé Publique; 52:39-51.

[5] Chabert R., Matysiak M., Gradelet J., Chamodot MF. (2003), Le bilan bucco-dentaire : suivi prospectif d'adolescents en France. Etat de santé bucco-dentaire des adolescents de 15 ans en 1999. [The oral/dental check-up: prospective care for adolescents in France. Oral/dental health status of adolescents aged 15 in 1999.] Revue médicale de l'assurance maladie 2003; 34, 1:15-21.

[6] Urcam des Pays de la Loire, Dispositif conventionnel de prévention bucco-dentaire - Evaluation médicale (2000) [Contractual oral/dental prevention scheme - Medical evaluation (2000)], Urcam, 21 pages.

[7] Banchereau C., Doussin A., Rochereau T., Sermet C. (2002), L'évaluation du bilan bucco-dentaire : le BBD a-t-il atteint sa cible ? [Evaluation of the oral/dental check-up: has the BBD reached its target?], Credes, no. 1396, 140 pages (+ QES no. 57).

Author/s and/or contributors to this survey

Thierry Rochereau (Irdes), Sylvie Azogui (Paris VII)

Suggested citation for this online article

Thierry Rochereau (Irdes), Sylvie Azogui (Paris VII). "Oral care prevention". Health Policy Monitor, March 2007. Available at http://www.hpm.org/survey/fr/a9/3