The Journal of EVIDENCE-BASED DENTAL PRACTICE

REVIEW ARTICLE

VALUE-BASED ORAL HEALTH CARE:

MOVING FORWARD WITH DENTAL
PATIENT-REPORTED OUTCOMES

STEFAN LISTL, Dr med dent, Dr rer pola,b

a
Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Dentistry - Quality and Safety of Oral Healthcare, Nijmegen,
the Netherlands
b
Section for Translational Health Economics, Department of Conservative Dentistry, Heidelberg University Hospital, Heidelberg, Germany

ABSTRACT CORRESPONDING AUTHOR:

Value-based oral health care is about improving people’s oral health outcomes Stefan Listl, Radboud University
divided by the costs involved. This article addresses five questions (the “5 W’s”) Medical Center, Department of
pertaining to the measurement of oral health outcomes: why oral health outcomes Dentistry - Quality and Safety of Oral
should be measured, what should be measured, by whom, when, and where. Healthcare, Philips van Leydenlaan
Therefore, dental patient-reported outcome measures offer great potential for 25, 6525 EX Nijmegen, the
driving improvements in oral health care. For illustration, a tentative set of seven key Netherlands.
relevant items is presented, which comprises the four dimensions of oral health– E-mail: Stefan.Listl@radboudumc.nl
related quality of life and the three dental conditions with the highest burden of
disease. Through promoting the ample use of oral health outcome measures, it is KEYWORDS
hoped that this article can contribute to expedite value-based oral health care. Value-based health care,
Patient-reported outcomes,
WHAT IS VALUE-BASED ORAL HEALTH CARE? Patient-reported outcome measures,
Oral health–related quality of life,
I n the context of value-based health care, value has been described as “patient
health outcomes achieved per dollar spent.”1 Along these lines, value-based oral
health care (VBOHC) is about improving people’s oral health outcomes divided by
Self-reported oral health,
Perceived oral health
the costs involved. Therefore, the objective of achieving good “value for money”
intertwines with principles of health economics and quality of care.2,3 Value-based
health care has been evolving as an approach to address the shortcomings of
existing health care setups which have failed to produce good value. Patient choice
and competition for patients are emphasized as core principles to encourage Conflict of Interest: The author has
continuous improvement in health care.4 Opportunities for improvement of oral no actual or potential conflicts of
health care through VBOHC could include more transparency about oral health interest.
outcomes versus costs in dental practice settings, better integration of dental Source of Funding: Not reported.
services in the wider health care system, provider payments that put more
emphasis on keeping people in good oral health instead of incentivizing
restorative dental treatment, reorienting oral health prevention more toward
public health as compared with chairside clinical approaches, and dental service
planning to be more responsive to population oral health needs. When J Evid Base Dent Pract 2019: [255-259]
navigating toward VBOHC, key relevant questions revolve around how to 1532-3382/$36.00
measure oral health outcomes that matter to people. The costs associated with ª 2019 The Author. Published by
oral health interventions are arguably more straightforward to determine. Elsevier Inc. This is an open access
article under the CC BY-NC-ND
THE 5 W’S OF MEASURING OUTCOMES: WHY, WHAT, BY license (http://
WHOM, WHEN, AND WHERE creativecommons.org/licenses/by-
nc-nd/4.0/).
The first question to be asked is why measure oral health outcomes? This is doi: https://doi.org/10.1016/
important because the definition of an exact use case (5 purpose) helps j.jebdp.2019.101344

September 2019 255

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 The Journal of EVIDENCE-BASED DENTAL PRACTICE

Figure 1. Use cases for the measurement of (oral) health outcomes.

narrowing down the subsequent decisions regarding
what should be measured by whom, where, and when.
Figure 1 schematically illustrates the range of use cases for
the measurement of (oral) health outcomes. Thereby,
outcomes can be measured either on the level of
individual persons or on the population level. Upon further
processing by various stakeholders (dentists, physicians,
payers, policy makers), they can be useful for (1) dental
care improvement, (2) medical-dental integration, (3)
value-based payments, (4) public health programming, or (5)
monitoring and needs-based planning.
For further illustration, use cases could include, inter alia,
the following:
 Dental care improvement: reflective learning by dental
care teams based on continuous feedback information
about patient outcomes before and after treatment.
The assessment can, for example, take place in the
format of an electronic survey implemented via a mo-
bile application. The feedback information can be
provided to dental care teams as infographics in, for
example, an electronic dashboard and serve for stra-
tegic choices regarding prioritization of interventions
with good value for money. For example, a mobile
application to retrieve patient-reported information and
an electronic dashboard system to provide feedback to
dental practitioners were recently developed within the
EU-Horizon 2020 project Added Value for Oral Care
(ADVOCATE);5–7
 Medical-dental integration: in addition to screening for
and monitoring of noncommunicable diseases which
share risk factors in common with oral diseases,
assessment of patient outcomes in primary care settings
provides opportunities for early detection of oral dis-
eases. Reversely, assessment of patient outcomes in
dental settings provides opportunities for early detec-
tion of noncommunicable diseases (eg, diabetes,
cardiovascular diseases). For example, the Dent@Pre-
vent consortium (www.oralsystemicintegration.com) has
been prototyping an electronic decision support
system for enhancement of medical-dental integration.
Thereby, patient outcomes—including self-reports
collected via a mobile application—serve as a central
information source to facilitate better alignment of care
processes between medical and dental care providers;8
 Value-based payments: health care payers (health
maintenance organizations or other types of dental

256 Volume 19, Number 3

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Table 1. A tentative set of seven key relevant items to assess oral health outcomes.
Measurement
object
Perceived oral health Oral function
Orofacial pain
Orofacial appearance
Psychosocial impact
Physical oral health Tooth loss
(b) Clinical assessment
Dental caries
Periodontitis
insurers) can selectively contract with dentists on the
basis of patient outcomes achieved and costs incurred
during previous years. In addition, contracted dentists
can be rewarded relative to the extent to which the
dentist’s patient population has been maintained in
good oral health. A framework including various
methods for oral health care value-based payments has
recently been described;9
 Public health programs: for example, identify the oral
health–related cost-effectiveness of various food label-
ing approaches on basis of population-representative
data;
 Monitoring: for example, cross-country comparison of
dental care systems performance by intergovernmental
organizations;
 Needs-based planning: for example, by a country’s
department of health. This is intended to ensure de-
livery of the right care, in the right place, at the right
time, by the right number of people, to those most in
need. Incorporating people’s oral health needs in
dental workforce planning is essential to ensure safe,
efficient, and sustainable oral health care.3
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The Journal of EVIDENCE-BASED DENTAL PRACTICE
Measurement
Assessment method item
Self-reported “Have you had difficulty chewing any
foods because of problems with your
teeth, mouth, dentures or jaw?”17
“Have you had painful aching in your
mouth?”17
“Have you felt uncomfortable about the
appearance of your teeth, mouth
dentures or jaws?”17
“Have you had difficulty doing your usual
jobs because of problems with your
teeth, mouth, dentures or jaws?”17
(a) Self-reported (a) Number of lost teeth (self-report)19
(b) Number of lost teeth (clinical)
Clinical assessment Number of teeth with untreated caries
(eg, moderate/extensive decay)20
Number of teeth with periodontal
pocketing (for example, stage III & IV)21
After having specified the concrete use case, the following
questions are what should be measured by whom? When
seeking to measure oral health, it is important to acknowl-
edge its multifaceted nature and attributes.10 Establishing a
well-thought-out set of measures that encompasses all
relevant oral health outcomes involves several layers of
complexity. First, the perspectives of all relevant stakeholder
groups need to be incorporated, but the main emphasis
should be placed on what matters to patients. In relation to
this, the potential of assessing dental patient-reported
outcomes (dPROs) by means of dental patient-reported
outcome measures (dPROMs) should be highlighted.11 For
several dental disciplines, for example, prosthodontics12
and orthodontics,13 the use of dPROs has been advocated
for evidence-informed clinical decision-making and reduc-
tion of avoidable waste related to research question/
outcome selection, aiming for an increased value of dental
research and interventions. Second, oral health is multifac-
eted, but—dependent on context—detailed incorporation
of all the various relevant dimensions may be challenging on
account of scarcity of time or other resources needed for
assessing oral health outcomes. Third, oral health outcome
measures should be fit for purpose, yet various use cases
may require specific outcome measures and their validity
may not have been empirically tested so far.
September 2019 257
 The Journal of EVIDENCE-BASED DENTAL PRACTICE
Broadly, it can be distinguished between two types of oral
health outcomes which both matter to patients and partly
intertwine: (1) perceived oral health in terms of oral health–
related quality of life (OHRQoL) and (2) physical oral health
in terms of dental conditions such as dental caries, peri-
odontitis, and tooth loss. The concept of OHRQoL ad-
dresses perceived oral health and has four dimensions: oral
function, orofacial pain, orofacial appearance, and psycho-
social impact.14,15 The validity of OHRQoL instruments such
as the 5-item Oral Health Impact Profile has been shown
previously,16,17 but even a set consisting of four items may
suffice to capture perceived oral health. Note that OHRQoL
instruments represent an important type of dPROMs. In
terms of physical oral health, a set of three items could be
prioritized, corresponding to the three dental conditions
with the highest burden of disease: dental caries, peri-
odontitis, and tooth loss.18 While it seems sensible that the
assessment of dental caries and periodontitis requires
diagnostic information from a health professional, self-
reports can provide a valid alternative for clinical assess-
ment of tooth loss.19
For illustration, Table 1 presents a tentative set of seven key
relevant items to assess oral health outcomes, including
both perceived and physical oral health. This set includes
items for the four OHRQoL dimensions and the three
dental conditions with the highest burden of disease.
Dependent on measurement constraints such as limited
time or budget, such a set may also provide a menu from
which to select individual items that are deemed feasible
and relevant for the respective VBOHC activity. For
example, if interview time to assess oral health outcomes
within a large multicountry survey such as the Survey of
Health, Ageing and Retirement (SHARE) is scarce,
information on self-reported tooth loss can already pro-
vide valid and relevant information for cross-country com-
parisons of dental health systems performance.19,22
In the future, cocreative review and updating (together with
all relevant stakeholders) of such and similar sets of measures
should be targeted at fruition of increasingly harmonized and
fit-for-purpose assessments of oral health outcomes.
Finally, to round off with the questions of when and where
measurement should take place, it is sensible to consider
the following additional criteria:
 the frequency with which measurement items can be
expected to change over time: for example, orofacial
pain will likely be more fluctuating than tooth loss;
 logistical circumstances: for example, standardized
measurement by calibrated study personnel within a
specific epidemiological study may require measure-
ment to be carried out in a specific study center;
 data privacy regulations.
258 Volume 19, Number 3
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WHEN THE RUBBER MEETS THE ROAD
Despite enormous dental expenditures, dental care systems
around the world still keep falling short of preventing many
people from suffering avoidable consequences of dental
diseases.23–25 The necessity for major reforms has recently
been urged.26,27 Yet in the spirit of Martin Luther King Jr.,
“Change does not roll in on the wheels of inevitability, but
comes through continuous struggle.” Hence, on the journey
of implementing dPROMs for VBOHC, be aware of “bumpy
roads” such as limitations in information technology
infrastructure or vested interests. It is all the more important
to emphasize the measures and data should be used in a
safe and responsible manner and the pitfalls of paternalis-
tically misguided normative approaches should be avoi-
ded.28,29 It is hoped that the “5 W’s” described previously,
emphasizing dPROs as an essential component of health
outcome assessment, will be helpful to shift up a gear with
VBOHC.
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