Introduction

Many modern healthcare systems are faced with the challenge of increasing patient expectations, advances in healthcare and an ageing population set within a context of limitations on resources.1 Although the financial cost required to deliver the most appropriate care should not influence its uptake or its provision, this maybe unavoidable.2 In an attempt to utilise resources appropriately, the UK government in 1998 introduced the principle of clinical governance to the NHS.3 An important cornerstone of this concept is to improve the quality of services by delivering effective and efficient care based on agreed best practice and sound research. With this objective clinicians need to ensure that any intervention is associated with a high probability of benefit. However, achieving this aim can be difficult, particularly where the effectiveness and efficiency of care can be measured in a variety of ways. Additional factors may also influence decision making such as the healthcare setting, experience and expertise of the clinician and sources of funding.4,5,6 Such a position can frequently occur in restorative dentistry where there is often a range of options available for any specific condition and the 'best' quality of evidence may not be available.7

In addition, the importance of the biological cost of any care is becoming an increasingly significant consideration for the profession and can be particularly important when taking into account the long term implications of treatment.8 This can lead to difficulties when patient expectations and demands are high or possibly in conflict with the views of the clinician.9

This paper aims to review a number of current challenges in the provision of restorative dental care and illustrate possible contemporary methods in their management. The issues highlighted may, however, be equally applicable to other dental specialities.

The delivery of restorative dental care

The breadth of restorative dentistry results in a dynamic where care can be provided by a range of dental professionals working in primary and secondary care utilising different techniques and materials. The complexity of treatment can vary and multi-phase plans between different clinicians through the pathway is considered an efficient mode of delivery.10 For this reason, the aim of a modern restorative service must be to do 'the right thing, at the right time, for the right patient, in the right place and with the right staff'.11

Many cases requiring routine restorative dentistry can be managed in primary care without the need for secondary care input. Such a framework encourages cost effectiveness and ease of access for most patients. Equally, however, the reverse is also true, inappropriate care provided by inexperienced operators may ultimately require resources additional to that which would have been necessary if the care had been delivered by an appropriately trained and supported clinician from the outset.

Unfortunately, current restorative specialist care within the NHS and a hospital setting is limited. In 2006 an initiative by the Department of Health to develop dentists with special interests in the specialities of endodontics and periodontology had limited national impact.12 However, current proposals to restructure general dental service (GDS) contracts offers an opportunity for the concept of 'dentists with additional skills' to be initiated. The scope for increased skill mix among primary care practitioners may be greater in the future with a net increase in dentists from the European Union and greater numbers of undergraduates.13 Dentists may feel obliged to create niche interests and this can be applied within restorative dentistry. The recent recognition of the specialty of special care dentistry based primarily in the community also offers an opportunity to develop integrated care pathways for patients who require specialist restorative input.

Implementing skill mix programmes can also be applied to dental care professionals (DCPs). Despite the opportunities that dental therapists, hygienists and nurses with extended duties can provide in terms of prevention and restorative treatment there seems to be barriers in their utilisation.6 Indeed Brocklehurst and Tickle highlighted the differences between medicine and dentistry when considering care provision by dental care professionals.6 Cultural attitudes towards the utilisation of dental therapists in the delivery of invasive conservative treatment also need to be conquered.14 Allowing the workload of the dental team to be shared with dentists overseeing work by other members, while transferring care from one clinician to another as and when required can improve efficiency of care.6

It is important that developments are not seen in isolation, rather they are part of managed clinical networks (MCN) involving other local consultants and specialists, with agreed and monitored standards for eligibility and the standard of care provided. This self-supporting group of clinicians are a strong mechanism for ensuring that patients receive the care that they need in a timely fashion by the most suitable clinician in the area.15 Members of a MCN would also need to continue professional development within their field. This would require postgraduate deanery involvement so that appropriate educational support is in place to reflect the demands on local service.16

Primary/secondary care interface

Primary care practitioners acting as gatekeepers to secondary care are recognised as an efficient use of resources in medicine.17 The reasons for involvement of secondary care services include the need for diagnosis and treatment planning, complexity of treatment required and medico-legal concerns.18

The interface between primary and secondary care has also been examined and ideal characteristics such as equity, seamlessness and effectiveness have been identified.17,19,20 Primary care practitioners have also been shown to prefer input from a hospital-based consultant in comparison to specialist practitioners, providing access is acceptable.21,22,23 Recent evidence also suggests that specialists in restorative dentistry may have a greater balance between treatment options when planning complex cases in comparison to more focused specialties.4 Indeed patients referred to specialists in restorative dentistry for a specific issue may routinely present with a wide range of problems that may not have been readily apparent before attending secondary care.24 This is an important factor in the optimum use of resources since failure to consider all aspects of a patient's needs from the outset can lead to a compromised outcome and waste of resources.

However, the rate at which new patients are being referred for a restorative dentistry opinion has risen considerably since the specialties inception in 1973 and the deficit between the need for restorative specialist advice and the capacity and resource for its provision has been outlined.23,25,26,27

The cause of this increase in need is multi-factorial. Population increase and ageing in combination with patients' desire to retain compromised teeth and changes to demographics of primary care practitioners are probably key factors, and are unlikely to lessen. However, the scheme of remuneration in the GDS as well as clinical experience and expertise may also have contributed to this increased demand, but not necessarily need.13,27,28 In addition, the number of primary care practitioners is likely to have outstripped growth of secondary care support and input, which places added pressures on the specialist services.

The result of this is longer waiting times for initial consultation and any subsequent treatment required. More recently referral to treatment time targets have been initiated, which require patients to be seen and treatment started within 18 weeks.29 Although such initiatives invariably mean less waiting time for an initial consultation, the resultant pressure on treatment waiting lists can lead to a distortion of priorities and case acceptance for specialist care.

For this reason, good communication between primary and secondary care is essential to ensure that from the beginning patients are treated in the correct environment and by the most appropriate clinician. As such, the criteria for acceptance for care in each part of the service should be clear, agreed and sensitive to local need. They should also be consistently applied and continually monitored to reflect the changing needs of the local population and priority of resources.

The development of restorative care pathways, managed clinical networks and the concept of 'shared care' could all potentially add to the effectiveness and efficiency of care delivery, as could the delivery of specialist/consultant services closer to the highest population need. Expansion in the restorative dentistry speciality workforce will also provide the service with individuals with a broad base of knowledge to manage the needs of a local population in a cost effective manner both in service delivery and training.

Contemporary methods in streamlining care pathways include the accessibility of patient investigations allowing information sharing for a particular problem.30 In the advent of the digital age this can take the form of digitised records such as periodontal chartings, digital photographs and radiographs.31 This information can provide a more informed retrospective view of the problem, while possibly minimising the need for further interventions and thus costs. This information can also be utilised at the validation process when allocating to multi-disciplinary or single specialty clinics.32 The referral process from primary to secondary care could be made more efficient by utilisation of e-mail-based correspondence as opposed to paper-based.33 A pilot undertaken by Forth Valley NHS trust showed that on average a paper-based referral took 3 days and 27 minutes to be received and processed as opposed to 8 minutes utilising the e-mail format.33 Other advantages outlined included a reduced chance of referrals going missing, the ability to attach investigations such as radiographs and a pathway that was altogether more auditable.33

Funding

Despite evidence for demand, there is still a perceived disparity in funding for hospital-based restorative dentistry in England in comparison to other hospital-based specialties.34 The current funding situation in England can often be paradoxical. For example those patients with severe hypodontia or cleft lip and palate are considered the highest priority for orthodontic care in the NHS and are funded to reflect this position.35 However, these patients often require significant support from restorative dentistry which can vary from the provision of resin bonded bridges to extensive implant-based rehabilitation. This service commitment can be life-long with restorative maintenance being carried out in both primary and secondary care. However, current funding for this care is often grossly insufficient. This can lead to pressure on the services from commissioners as the needs of these and other patient groups requiring specialist restorative care is not fully understood.36

Funding levels ideally should be related to the effect that treatment provision has on quality of life, patient-centred outcome measures and relative health gain.37,38 This principle has been reflected in the recent review of GDS in England and work should be undertaken with the UK and devolved governments as well as the profession to develop this concept.39

Treatment planning in restorative dentistry

Biological and financial cost beneficence

The primary aim of restorative dentistry is the restoration and rehabilitation of oral and dental tissues lost as a result of congenital or acquired diseases while maintaining or improving function and aesthetics.40 However, potentially the provision of restorations may not always coincide with positive health gain, especially where treatment is elective and involves the removal of healthy tooth tissue (Figs 1a and b).41,42,43 Indeed a recent study described a decrease in quality of life subsequent to a course of elective treatment to improve the aesthetics of anterior teeth.44 This of course is also compounded by the high likelihood of the financial cost to the patient and possibly wider society to resolve any inappropriate care.45,46

Figure 1a
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Patient presenting with moderate tooth surface loss localised to the upper anteriors

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Figure 1b: Patient post preparation for all ceramic crown restorations.
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While temporised the 12 presented with acute pulpal symptoms and required extirpation

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Many groups that are a high priority for restorative dentistry require both functional and aesthetic rehabilitation. Often an option available to achieve this goal involves utilising a combination of minimally invasive procedures that can be predictable, delivered with ease and minimise the long-term adverse consequences (Figs 2a and b).47,48 This position is well illustrated with the change in management of advanced tooth surface loss in recent years. Historically, the management of such cases involved the provision of full arch extra-coronal restorations.49 This option may be appropriate for patients with heavily restored dentitions where parafunctional activity is the major cause of tooth surface loss. However, such procedures on teeth with limited extra-coronal tooth tissue, particularly in young patients, will invariably result in pulpal complications in addition to expediting teeth on the 'restorative failure cycle'.50,51,52 Patients value involvement in the decision making process and have been shown to favour positive health gain over aesthetics.53 Indeed recent data from Dental Protection shows that the cause for claims relating to porcelain veneer provision was often associated with poor communication.46

Figure 2a
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Patient presenting with moderate to severe tooth surface loss

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Figure 2b
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Patient restored with direct composite to restore aesthetics and protect underlying tooth tissue

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During the 1990s these issues were realised, particularly where young patients with 'erosive' tooth surface loss required care. This led to the development of direct adhesive techniques as a concept to provide optimal function and aesthetics in these patient groups but preserving the natural tooth tissue.54,55 The provision of direct adhesive materials can often be a more effective and efficient use of resources, particularly when the long-term consequence of traditional techniques are taken into consideration.56,57 However, adopting such a minimally invasive treatment approach is often not readily considered by clinicians. Such techniques may be more technically demanding than conventional techniques and this may be one of the obstacles to their acceptance as a viable option.

Greater emphasis on minimally invasive restorative techniques where tissue is consolidated and the pulp protected should be considered the contemporary approach to tooth restoration.46

Endodontic need

In the recent adult dental health survey, 7% of dentate adults had one or more clinical signs of endodontic infection.58 This is likely to be an underestimation of the true prevalence of periapical disease (Fig. 3).52 Despite the psychological, functional and aesthetic advantages of tooth retention by way of root canal treatment, there seems to be clear barriers to its provision within the GDS despite often high levels of predictability and cost effectiveness.59,60,61

Figure 3: Long cone periapical radiograph of 25, 26 and 27.
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Both the 25 and 26 were asymptomatic at presentation but presented with the need for primary and secondary root canal treatment respectively.

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The reasons for this possible reticence may include the perception that there is a need for further training and a perceived mismatch between remuneration and the clinical resources required to deliver an optimal result.5,59 An additional implication of this position is an increase in endodontic referrals to the hospital-based services.23,62

The introduction of implants has resulted in questionable debate when compared to endodontic therapy.63 Clinicians with limited skill and experience of providing endodontic procedures may see the success rate quoted for implants as the more attractive option to root canal therapy. However, a recent prospective qualitative study compared two cohorts of patients who were provided with either an implant or root canal treatment within a postgraduate institute.61 Although both cohorts illustrated similar oral health impact profile scores and satisfaction with treatment, all patients expressed a clear message that maintenance of the natural dentition should be instigated wherever possible.61 This opinion carries greater weight when considering the unknown long-term longevity of implants when compared to the accepted prognosis of optimally restored endodontically treated teeth. Indeed, if an implant is placed in a patient in their twenties, longevity of the restoration for the following 80 years is not entirely known. This longevity may be effected by peri-implant disease processes, the optimal management of which is yet to be realised.64 Such a perspective on long-term planning may allow clinicians to reconsider endodontics more readily before deciding on extraction and prosthetic replacement.

With increasing demand and significant untreated disease already in the population it would seem a priority to address the demands for endodontic care both in the GDS and specialist services.

Tooth replacement in the restored dentition

The negative effects of tooth loss can result in patients seeking a prosthetic replacement.65 There is now a wide range of options for the replacement of teeth, which vary in ease of provision, cost and morbidity.65 Ideally tooth replacement should be independent of abutment teeth or minimally invasive at best.66 An additional consideration is patient preferences, which evidence suggests is for fixed prostheses and restorations that require minimal healthy tissue removal.67

Unfortunately, current clinical practice may not fully reflect this position. For example a cohort of NHS dentists were shown to favour the provision of acrylic dentures when compared to fixed treatment options such as resin bonded bridges, conventional bridges and implants.68 However, partial acrylic dentures have been shown to increase plaque accumulation both in the denture bearing and opposing arch unless oral hygiene is excellent and denture wear is limited (Fig. 4).69 These findings are probably a reflection of the current NHS remuneration system, the overheads that are related to the different options as well as clinical experience.68

Figure 4: Acrylic denture restoring space 22.
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The patient preferred a fixed restoration. Gingivitis was detected on the majority of abutment teeth

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With respect to clinical experience, many practitioners may not consider resin bonded bridges (RBB) as a predictable mode of tooth replacement primarily due to historical high debond rates associated with their introduction in the UK.70 These historical problems could have been associated with bridge design, awareness of material sensitivity and case selection, the understanding of which has improved due to accumulated experience and extensive research (Fig. 5).71 Resin bonded bridges can be provided without mechanical preparation of the tooth structure and have shown good longevity and cost effectiveness especially when provided for the replacement of anterior teeth.72,73 Where dentitions are heavily restored, such as those in older patients, conventional bridgework may still be a sensible consideration.74

Figure 5
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Despite wear faceting this 20-year-old resin bonded bridge had no history of debonds or complications

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Where bridgework may not be indicated, alternative options such as implants may be a consideration but the option of conventional or adhesive bridgework should not be ignored in favour of implant availability. Although a balance is required when choosing treatment options, there have been recent suggestions that implants are less costly, more efficient and more cost effective than conventional bridgework.75

One obvious difference between implants and other restorative options is that in the GDS implants are not available and are therefore provided on a private basis, which could potentially influence the clinician's decision making process. Traditionally implant provision within secondary care is largely reserved for those patients falling within priority groups such as hypodontia, cleft palate, oral cancer and trauma. Despite this prioritisation, provision of implants in the hospital dental service (HDS) is often difficult to fund and clinically achieve.36,76,77 A recent study showed that, although the majority of patients qualified for implant treatment under RCS guidelines, depending on primary care trust funding treatment was not always provided.36

However, there are a growing number of individuals who do not fall into these traditional priority groups but whose clinical need is best served in the long term by the provision of implant retained prostheses. This is reflected in the recent York consensus published by the British Society of Prosthodontics which recommends the provision of implant supported restorations as the minimum standard of care when compared to traditional removable prostheses.78 This was based on patient centred outcomes and, in particular, quality of life reflected in the earlier Canadian McGill Consensus.79 Although the initial cost of implant-based restorations is relatively high, the authors argued that in the long term implant provision costs could be kept at a minimum while significantly improving quality of life.

Equally, acrylic removable prostheses can be a cost effective option where multiple spaces require restoration or as a transitional prostheses during a longitudinal treatment plan. Indeed a UK study illustrated that cobalt chromium dentures were more likely to be provided in a private setting, whereas partial acrylic dentures were more likely to be provided within the NHS.80 This may be a reflection of the relative overheads of the two prostheses and the training required for metal-based denture designs.80 Recent NHS statistics shows that the majority of complex courses of treatment (such as crowns, bridges and dentures) during 2010/2011 were provided for non-paying adults.58 One reason for this may be the lower standard of dental health among this patient cohort. One other possibility is the economic theory of moral hazard where treatment is readily provided to non-paying parties due to absence of monetary implications to the patient but financial gain to the provider.81

The financial pressures and skill mix issues could result in the provision of prostheses in situations where the alternative option would be more biologically sound and possibly require less future maintenance. Addressing these issues in the long-term strategy of prosthodontic care provision may prevent morbidities that would otherwise result from more invasive options.

Prevention of plaque related diseases

In the recent Adult dental health survey 83% of patients showed signs of periodontal diseases (Fig. 6).58 Although some patients are susceptible, periodontal disease is largely preventable with good patient education playing a key role.82 However, the time taken for the delivery of effective patient education may be significant. For example, a study examining the process of motivational interviewing and oral hygiene instruction concluded that 72 minutes of chairside time would be required to reach an optimal level of oral hygiene.83 Positive reinforcement over many visits has also been shown to improve hygiene levels.84 Indeed health promotion initiatives have been shown to be effective in improving oral health but there is limited evidence showing the cost effectiveness for periodontal disease prevention. The latter observation is more likely to be associated with the barriers in answering the research question as opposed to lack of cost effectiveness of prevention of plaque-induced diseases.

Figure 6
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Due to misplaced fears of bleeding during tooth brushing this patient presented with marked gingivitis, calculus and plaque accumulation

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Prevention against plaque-related diseases and the population studies suggests that there is still a need to appropriately fund, manage and monitor this area of patient care.58 Indeed the delivery of appropriate nationwide periodontal prevention strategies could be achieved by integrated workforce planning including increasing the proportion of hygienists/therapists while also investing and encouraging the development of dental nurses with extended skills such as delivery of oral hygiene instruction. This change could be achieved within a managed clinical network, which would include DCPs and dentists in both primary and secondary care.15 The role of DCPs could also extend into the areas of smoking cessation.85

One tool that could be utilised in educating, informing and directing patients in optimal hygiene measures is media technology.86 Indeed patient awareness on preventive strategies has increased subsequent to the digital age where information may be more readily available.86 These new mediums could be exploited to decrease costs in delivery of preventive strategies.

Management of the ageing dentition

The UK population is living longer and as a result the need for ongoing supportive care will increase.87 In contrast the incidence of edentulousness has been shown to be decreasing.58 These changes in life expectancy and tooth retention has implications for restorative maintenance.87 For example, age-related pathology such as toothwear, root canal sclerosis and root caries can be further complicated by general medical issues such as oral side effects of medications and the ability to perform daily hygiene practices.87

Although there has been a decrease in the proportion of the population who are edentulous, the number now equates to approximately 2.7 million, all of which will require the provision of prosthesis and maintenance for the foreseeable future.58 However, in contrast there appears to be a decrease in prioritisation of complete denture teaching by UK dental schools.88 This may result in newly qualified dentists lacking the necessary skills or confidence in complete denture provision and greater dependency on the secondary care sector. This is supported by evidence from studies which have shown that complete denture referrals are a significant number of those received in the HDS.24,26 One suggestion in dealing with this potential service deficit could be to expand the development of clinical technologists.89 This relatively small cohort of technician colleagues undergo further training in the clinical aspects of complete denture provision. As teaching in complete denture provision is in decline, this group may be able to supplement areas of need in complete denture provision. Their skill set in both technical and clinical aspects could result in significant improvements where access is limited.

There is a considerable body of work detailing edentulousness and the effect on oral health quality of life and in particular the improvements that can be gained from implant retained mandibular overdentures.90 Indeed implant retained mandibular overdentures and conventional complete dentures have been compared in terms of cost and oral health impact profiles by a Canadian group.91 The post operative oral health impact profile of implant retained mandibular overdentures was 33% better than conventional dentures.91 This significant improvement in oral health impact profile (OHIP) score came at a cost of approximately 1,600 Canadian dollars. This was largely attributed to the cost of the implants and their placement, although in the long term this initial outlay may be comparable to the repeated remake of a conventional prosthesis. The favourable patient related outcome measures for implant provision could provide a strong indication for healthcare providers to consider developing implant services, especially when considering patient related outcomes. However, this position may not be reflected in the funding provided to the hospital dental service. This is highlighted in the Andrews et al. study (2010) where 37% of edentulous patients suffering with denture intolerance did not receive funding for implant-based rehabilitation.36

Future work force planning arrangements will need to take into account the ageing population who will have significant dental needs. This may create further opportunities for joint team planning between restorative and other specialties, such as oral surgery and special care.

Priority groups for hospital care

The increasing demand on specialist hospital service means that traditional high priority groups may become disadvantaged. For example, patients with congenital defects (such as hypodontia and cleft lip palate) are a priority for NHS funded treatment.92 Due to their inherent complexity these patients are best treatment planned and managed in a multidisciplinary team, which may include primary and secondary care members.32,93,94 The input of restorative dentistry in treatment of cleft patients has been highlighted recently (Figs 7a and b).94 In contrast to the accepted multidisciplinary pathway there is a lack of recognition of restorative dentistry specialists in primary treatment and future maintenance. This has a significant impact on this cohort's ability to access dental care after the age of 18 years and the funding and resources required for their treatment. Indeed as patients enter adulthood the scope for further surgical or orthodontic intervention can diminish and ongoing treatment routinely falls on restorative secondary care services. This patient cohort can be difficult to treat where a combination of failed surgical and orthodontic treatment may present in patients who inherently have an increased incidence of periodontal disease and structural tooth defects.95,96

Figure 7a
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Middle aged cleft palate patient with failing restorations on the 24 and 25 in addition the patient had long standing difficulties associated with wearing a conventional overdenture prosthesis.

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Figure 7b: Both 24 and 25 required extraction.
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The patient was rehabilitated with an implant-supported prosthesis. Due to inherent lack of bone due to the cleft and resorption post-extraction implants were placed in the 13, 11, 21 and 25 regions

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In contrast, patients who present with head and neck cancer can present with both acute and chronic problems which require restorative management. Before formal radiotherapy a thorough assessment and any required treatment needs to be delivered to prevent untoward sequelae. Due to the urgency of cancer management, pressure is placed on both primary and secondary care services to make patients dentally fit in a short time span.97 Once formal cancer treatment is concluded the rehabilitation of these patients is often difficult due to radical changes in post surgery oral anatomy, reduced oral opening and changes to oral physiology subsequent to radiotherapy.98,99 Although there is an obvious need for restorative input for these patients, recent evidence has shown that this is currently less than national guidelines have outlined.100

Conclusion

Within a changing economic and demographic environment the provision of restorative dentistry needs to maintain efficiency while optimising resources. Utilisation of contemporary clinical methods while creating a diverse and adaptable environment for its provision could help in improving accessibility, oral health and the effective use of resources. Restorative dentistry appears well placed to respond to the current challenges and should embrace this as an opportunity to further develop the speciality for the benefit of patients. However, many of the potential developments are equally applicable to other specialities.