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Dental sealant knowledge, opinion, values and practice of Spanish dentists
© Martin et al; licensee BioMed Central Ltd. 2013
Received: 29 August 2012
Accepted: 28 January 2013
Published: 8 February 2013
Multiple guidelines and systematic reviews recommend sealant use to reduce caries risk. Yet, multiple reports also indicate that sealants are significantly underutilized. This study examined the knowledge, opinions, values, and practice (KOVP) of dentists concerning sealant use in the southwest region of Andalusia, Spain. This is a prelude to the generation of a regional plan for improving children’s oral health in Andalusia.
The survey’s target population was dentists working in western Andalusia, equally distributed in the provinces of Seville, Cadiz, and Huelva (N=2,047). A convenience sample of meeting participants and meeting participant email lists (N=400) were solicited from the annual course on Community and Pediatric Dentistry. This course is required for all public health sector dentists, and is open to all private sector dentists. Information on the dentist’s KOVP of sealants was collected using four-part questionnaire with 31, 5-point Likert-scaled questions.
The survey population demographics included 190 men (48%) and 206 women (52%) with an average clinical experience of 10.6 (± 8.4) years and 9.3 (± 7.5) years, respectively. A significant sex difference was observed in the distribution of place of work (urban/suburb) (p=0.001), but no sex differences between working sector (public/private). The mean ± SD values for each of the four KOVP sections for pit and fissure sealants were: knowledge = 3.57 ± 0.47; opinion = 2.48 ± 0.47; value = 2.74 ± 0.52; and practice = 3.48 ± 0.50. No sex differences were found in KOVP (all p >0.4). Independent of sex: knowledge statistically differed by years of experience and place of work; opinion statistically differed by years of experience and sector; and practice statistically differed by years of experience and sector. Less experienced dentists tended to have slightly higher scores (~0.25 on a Likert 1–5 scale). Statistically significant correlations were found between knowledge and practice (r=0.44, p=0.00) and between opinion and value (r=0.35, p=0.00).
The results suggest that, similar to other countries, Andalusian dentists know that sealants are effective, have neutral to positive attitudes toward sealants; though, based on epidemiological studies, underuse sealants. Therefore, methods other than classical behavior change (eg: financial or legal mechanisms) will be required to change practice patterns aimed at improving children's oral health.
Dental caries is among the most common of preventable childhood infections , and methods are currently available to cost effectively reduce caries . The most effective method to reduce occlusal caries are pit and fissure sealants, and over the last four years more than 11 guidelines and systematic reviews have recommended pit and fissure sealant use for at-risk populations [3–13]. However, studies from U.S. [14–16], Greece , Sweden , and Scotland [19, 20] all indicate that sealants are underutilized.
In Spain, recent surveys indicate a 56% caries prevalence among 15–16 year olds, while only 17% have sealants [21, 22]. Other Spanish studies demonstrate that occlusal sealants can reduce both occlusal and smooth surface decay by 87% and 68%, respectively, over a two year period . Over a nine year period sealants can reduce occlusal decay by 65% .
Thus there are effective methods for caries prevention, but they are underutilized. The theoretical frame for behavior change is an assessment of knowledge and attitudes affecting practice. However, neither theories of behavior change nor knowledge nor attitudes predict clinical practice . Instead, both indicate that values are better predictors [20, 26]. Therefore, we examined knowledge combined with opinions and values, as a first step toward initiating comprehensive caries prevention program in Spain. More particularly we assessed dentists in the western province of Andalusia regarding to the use of pit and fissure sealants.
To identify the current best evidence on pit and fissure sealants we queried MEDLINE using the following search strategy
(dental sealants) OR (tooth sealants) OR (fissure sealants) OR (pit and fissure sealants)
(meta-analysis) OR (systematic review)
1 AND 2
3 AND 4
Relevant = 11
To identify the current best evidence on knowledge, attitudes and practice regarding pit and fissure sealants we queried MEDLINE using the following search strategy
(dental sealants) OR (tooth sealants) OR (fissure sealants) OR (pit and fissure sealants)
(Health care quality, access, evaluation) OR (patient care management) OR (behavior and behavior mechanisms)
1 AND 2
3 AND 4
Relevant = 7
Information from the studies identified in the MEDLINE searches were used to generate the 31 survey questions in four groups: knowledge, opinion, values and practice. Each question was reviewed for pertinence and clarity by 8 full and part-time faculty who teach prevention (N=5), pediatric dentistry (N=2), or are program directors for community dentistry (N=1) in Andalusia. A Likert 1–5 scale survey (1 = strongly disagree; 5 = strongly agree), and narrative commentary were used to evaluate the survey. The questions were edited as suggested by the initial survey panel. The survey was then sent to 20 dentists twice, one week apart, to determine test/retest validity.
The survey’s target population was dentists working in 3 of the 4 western provinces of Andalusia: Seville, Cadiz, and Huelva (N=2,047). Raosoft was used to generate a power calculation (http://www.raosoft.com/samplesize.html). For a 5% margin of error, a 95% confidence level, a population of 2,047, and a response distribution of 50%, the minimum recommended survey size is 324.
We solicited a convenience sample of participants from the annual Community and Pediatric Dentistry course. This is a required course for all public health sector dentists, and is open to all private sector dentists. It is attended by dentists with an interest in pediatric dentistry. Direct solicitation of meeting participants and solicitation from participant email lists were used to recruit a convenience sample of 400 dentists, equally distributed between the three provinces. Meeting participants were surveyed at the meeting, in person, and accounted for approximately 46% of the responses. The meeting participants provided email addresses during registration. From this email list we selected individuals who did not respond in person. From this email list we identified individuals from three geographic regions. We then emailed the identified number of individuals in each region asking them if they would complete the survey. We iteratively continued this until we filled the quota determined by the power calculation. The total number of professionals attending the meeting who responded to our survey was 184. The remaining 216 participants were recruited by email.
Survey respondents were identified by 4 metrics: sex, years in practice (≤ 3, 4–15, ≥ 16), practice location (urban, suburban), and type of practice (public, private, both).
For each of the 31 survey items and for each of the four assessment domains (knowledge, opinions, values, and practice) a frequency distribution of the Likert scale was determined as well as the mean. These were evaluated individually using the Wilcoxon matched-pairs signed-ranks test, the Friedman nonparametric repeated measures ANOVA, or Spearman’s correlation.
Distribution and mean ± standard deviation of scores for the questions
*Mean ± SD
I think that the effectiveness of fissure sealants is supported by strong scientific evidence.
There is scientific evidence for the restorative use of dental sealants.
I am familiar with the technique of placing dental sealants.
I believe that fissure sealants should be reviewed after placement.
I understand the instructions for placing sealants.
I think that sealants should only be used on newly erupted teeth
I think that sealants wear out easily.
I believe that you must perform a caries risk assessment to prevent overtreatment.
Pit and fissure sealants have adverse effects.
I believe the technique of applying a sealant is the most important aspect to the success of the treatment.
I agree that resin sealants are more effective than glass ionomer sealant.
The most important factor for adhesion to occur in sealant placement is proper acid etching.
I think this technique takes time to do correctly.
The materials that are used for the placement of sealants are very expensive.
I do not use sealants very often as a preventive method because its effect is short lived.
Fissure sealants are used less than they should be.
The dental staff at my clinic communicate importance of using sealants to the patients.
It is difficult to explain to patients what dental sealants are.
It is difficult to justify the cost of sealants to parents
I think my patients understand the benefits of using sealants.
It is necessary to promote the use of sealants amongst dentists and dental educators.
I apply sealants because the oral public health community instructs me to.
I use dental sealant in the oral public sector because it is easy to apply and patients find it comfortable.
Since working in the oral health public community, I have greater belief in the effectiveness of sealants.
I sometimes avoid dental sealants for the possibility of sealing over caries.
I think sealants, besides being a preventive method, can also have a restorative effect and can be used on incipient caries.
This sealing technique, when used alongside fluoride application, may reduce the rate of decay more significantly.
In the case of partial or total loss of sealant, I would recommend reapplication.
The most important factor for adhesion to occur in sealant placement is proper insolation.
The most important factor for adhesion to occur in sealant placement is proper acid etching.
The benefits of using sealants should be considered with regard to the patient’s risk of caries and clinicians should follow specific guidelines
Mean ± SD
Mean ± SD
Years of experience
Place of work
Summary table for knowledge, values, opinion, practice
Knowledge (Q 1–12)
Value (Q 13–17)
Opinion (Q 18–24)
Practice (Q 25–31)
Total (Q 1–31)
Years of Experience
Place of Work
As indicated in Table 5, of the 16 assessments, 5 demonstrated statistically significant differences: Knowledge differed by years of experience (p=0.00), and place of work (p = 0.00); Opinion differed by years of experience (p=0.03) and sector (p=0.00). Similarly, practice about sealants differed by years of experience (p=0.00). Conversely, values around sealant placement did not statistically differ by sex, years of experience, practice sector or place of work.
Relationship between mean knowledge, values, opinions and practice
These primary findings indicate that dentists in western Andalusia have neutral to favorable knowledge, opinion, values, and practice attitudes about sealants (Table 3). The more detailed statistical findings for KOVP in relationship to demographics (Tables 5 and 6) need to be interpreted with caution. First, some are, and some are not significant. Yet, for those that are significant, the absolute differences between the highest and lowest values in each category for KOVP are modest. Second, these are secondary outcomes of association, and should be viewed as hypothesis generating. The study was powered for the primary outcome variables, not the secondary outcome variables. Therefore, the analyses in Tables 5 and 6 are vulnerable to type 1 or type 2 errors. In sum, the findings reported here: (1) adds Spain to a list of other countries in what appears to be a growing global phenomenon of under-utilization of the preventive sealants [14–19, 27]; and (2) expands the list of behavioral metrics around dental sealant knowledge and attitudes to include opinions and values that do not appear to adequately relate practice behavior. The survey did not, however: (1) determine the relationship of KOVP to actual sealant use; or (2) determine the relationship of traditional KAP with KOVP.
A troubling overall finding is the recognition of a clinical problem (caries), the availability of a cost-effective preventive solution (sealants), a neutral to positive KOVP, and the reluctance of the professional community to implement sealants in practice. This suggests that behavioral phenomena other than or in addition to KOVP may be driving clinical practice.
One hypothesis is that the theoretical KOVP imparted during dental school training differs from clinical training. For example, over the last 100 years dentists have successfully treated caries with surgery and repair using silver amalgam, plastic, gold or stainless steel. Dental schools therefore focus on providing training to instill basic knowledge of anatomy, anesthesia, material science, and clinical skill to facilitate surgical expertise in repairing the cavitated lesion. In parallel, compensation systems have evolved to reward clinicians for providing surgical care. This system therefore rewards treatment over prevention.
However, for more than 50 years, the oral health community has recognized that caries is a preventable infection, and developed methods to reduce the probability of initiation and progression of the infection. The most effective preventive method for occlusal caries is the application of pit and fissure sealants to the occlusal surfaces [3–13], which can reduce dental decay by up to 80%. Yet, globally, the epidemic of caries continues unabated [1, 2].
From a global oral health perspective, effecting systematic change in clinical care delivery to support prevention is challenging [14–19, 27]. This is also true historically across the health spectrum, ranging from the use of vitamin C to prevent scurvy (250 years before routine implementation) , to hand washing (100 years before routine implementation) , to a host of interventions and diagnostics that over treat, undertreat or mistreat patients (more than 15 years for routine implementation) .
From a behavioral viewpoint, multiple models have been suggested to effect behavior change. [31, 32]. Pioneering work by Bonetti and colleagues [20, 27, 33] examined six theoretical models for behavior change around sealant use. They include: action planning, common sense self-regulation model, operant learning theory, the precaution adoption process, social cognitive theory, and the theory of planned behavior. Their examination included knowledge as an additional predictor. Using multiple regression analysis, they found that these models for behavior accounted for only 38% in the variation in care. This again suggests that the current models for effecting clinical practice behavior change do not go far enough in identifying significant levers for change. Their work does suggest, however, that economic and legal mechanisms may be more effective in altering clinical practice.
In Spain, the National Health System provides care for all children, independent of parental income. State or regional programs can supplement this care. In Andalusia, two frameworks for oral care are available: public and private. Private dentists receive 36 euros for providing care. In contrast, dentists working in the public sector are on salary and remuneration is independent of the type of care they provide. This compensation system for the private sector may be a significant factor impacting the selection of care delivered. Similarly, the cost of materials (fluoride varnish, glass ionomer, composite, and amalgam) can impact the selection of care in the public sector since funds for purchasing are limited. Thus, economics, not KOVP, may be the practice drivers in Spain. Interestingly, Clarkson et al. examined the economic/education/values hypothesis. They found that only economics altered practice behavior by dentists . The current findings that KOVP are not predictive of practice, combined with the findings of Clarkson et al., suggest that alternate approaches to practice change and improving children’s oral health are needed.
Work at the Harvard Business School suggests that focusing on values may be the key driver for health improvement [34–36]. This group postulates and provides examples of systems that focus on rewarding value (defined as outcomes/costs for the care cycle). These systems increase access to care, improve health, and reduce the costs of care. The systems the Harvard team examined who use a values approach have: increased access to care, improved health, and reduced the costs of care. The Commonwealth Fund, in an extensively documented report, supports a value-based approach to care improvement . Further support for this concept, as it applies to oral health improvement in the U.S. comes from the Pew Trust report . The Pew Trust found that sealants are underused, resulting from two significant barriers to care: legal and economic.
In sum, the improvement of oral health, through the increased use of sealants, does not appear to be related to improving knowledge, attitudes, opinion or values of the dental community. Rather, economic and legal variables appear to provide more leverage. The oral health community must now consider if, when, and how we might begin to test these new hypothesis.
The results reported here suggest that, similar to other countries, Andalusian dentists know that sealants are effective, have neutral to positive attitudes toward sealants; though, based on epidemiological studies, underuse sealants. Therefore, methods other than classical behavior change (eg: financial or legal mechanisms) will be required to change practice patterns aimed at improving children's oral health.
The authors would like to thank the Vicerrectorado de Investigacion of the University of Seville, Harvard School of Dental Medicine, and the Forsyth Institute. We would also like to thank the following clinicians who participated in the validation of the survey: Drs. Anibal Gonzalez, Rafael Llamas, Maria del Aguila Cordero, David Ribas, Emilio Lledo, Manuel Poyato, Antonio Fernandez. We acknowledge the following sources for invaluable financial support NIMHD 1 R34 DE022272 (NIH2385) and NIDCR 1 U24 MD006964. We are grateful to Dr. Javier Gil for assistance with the statistical analysis.
- Benzian H, Hobdell M, Holmgren C, Yee R, Monse B, Barnard JT, van Palenstein HW: Political priority of global oral health: an analysis of reasons for international neglect. Int Dent J. 2011, 61 (3): 124-30. 10.1111/j.1875-595X.2011.00028.x.View ArticlePubMedGoogle Scholar
- Pitts N, Amaechi B, Niederman R, Acevedo AM, Vianna R, Ganss C, Ismail A, Honkala E: Global oral health inequalities: dental caries task group—research, agenda. Adv Dent Res. 2011, 23 (2): 211-20. 10.1177/0022034511402016.View ArticlePubMedPubMed CentralGoogle Scholar
- Mickenautsch S, Yengopal V: Caries-preventive effect of glass ionomer and resin-based fissure sealants on permanent teeth: An update of systematic review evidence. BMC Res Notes. 2011, 4 (1): 22-10.1186/1756-0500-4-22. PubMed PMID: 21276215; PubMedCentral PMCID: PMC3041989View ArticlePubMedPubMed CentralGoogle Scholar
- Hiiri A, Ahovuo-Saloranta A, Nordblad A, Mäkelä M: Pit and fissure sealants versus fluoride varnishes for preventing dental decay in children and adolescents. Cochrane Database Syst Rev. 2010, 17 (3): CD003067-Review. PubMed PMID: 20238319Google Scholar
- Yengopal V, Mickenautsch S: Resin-modified glass-ionomer cements versus resin-based materials as fissure sealants: a meta-analysis of clinical trials. Eur Arch Paediatr Dent. 2010, 11 (1): 18-25. 10.1007/BF03262705. Review. PubMed PMID: 20129029View ArticlePubMedGoogle Scholar
- Gooch BF, Griffin SO, Gray SK, Kohn WG, Rozier RG, Siegal M, Centers for Disease Control and Prevention: Preventing dental caries through school-based sealant programs: updated recommendations and reviews of evidence. J Am Dent Assoc. 2009, 140 (11): 1356-65. Review. PubMed PMID: 19884392View ArticlePubMedGoogle Scholar
- Yengopal V, Mickenautsch S, Bezerra AC, Leal SC: Caries-preventive effect of glass ionomer and resin-based fissure sealants on permanent teeth: a meta analysis. J Oral Sci. 2009, 51 (3): 373-82. 10.2334/josnusd.51.373. Review. PubMed PMID: 19776504View ArticlePubMedGoogle Scholar
- Marinho VC: Marinhozed trials of fluoride therapies for preventing dental caries. Eur Arch Paediatr Dent. 2009, 10 (3): 183-91. 10.1007/BF03262681. Review. PubMed PMID: 19772849View ArticlePubMedGoogle Scholar
- Griffin SO, Gray SK, Malvitz DM, Gooch BF: Caries risk in formerly sealed teeth. J Am Dent Assoc. 2009, 140 (4): 415-23. Review. PubMed PMID: 19339530View ArticlePubMedGoogle Scholar
- Ahovuo-Saloranta A, Hiiri A, Nordblad A, Mäkelä M, Worthington HV: Pit and fissure sealants for preventing dental decay in the permanent teeth of children and adolescents. Cochrane Database Syst Rev. 2008, 8 (4): CD001830-Review. PubMed PMID: 18843625Google Scholar
- Azarpazhooh A, Main PA: Pit and fissure sealants in the prevention of dental caries in children and adolescents: a systematic review. J Can Dent Assoc. 2008, 74 (2): 171-7. Review. PubMed PMID: 18353204PubMedGoogle Scholar
- Beauchamp J, Caufield PW, Crall JJ, Donly K, Feigal R, Gooch B, American Dental Association Council on Scientific Affairs: Evidence-based clinical recommendations for the use of pit-and-fissure sealants: a report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc. 2008, 139 (3): 257-68. Review. PubMed PMID: 18310730View ArticlePubMedGoogle Scholar
- Griffin SO, Oong E, Kohn W, Vidakovic B, Gooch BF, Bader J, Clarkson J, Fontana MR, Meyer DM, Rozier RG, Weintraub JA, Zero DT, CDC Dental Sealant Systematic Review Work Group: The effectiveness of sealants in managing caries lesions. J Dent Res. 2008, 87 (2): 169-74. 10.1177/154405910808700211. PubMed PMID: 18218845View ArticlePubMedGoogle Scholar
- Tellez M, Gray SL, Gray S, Lim S, Ismail AI: Sealants and dental caries: dentists' perspectives on evidence-based recommendations. J Am Dent Assoc. 2011, 142 (9): 1033-40.View ArticlePubMedGoogle Scholar
- Riley JL, Richman JS, Rindal DB, Fellows JL, Qvist V, Gilbert GH, Gordan VV, Dental PBRN Collaborative Group: Use of caries-preventive agents in children: findings from the dental practice-based research network. Oral Health Prev Dent. 2010, 8 (4): 351-9. PubMed PMID: 21180672; PubMed Central PMCID: PMC3074637PubMedPubMed CentralGoogle Scholar
- Ferracane J, Hilton T, Korpak A, Gillette J, McIntyre PS, Berg J, PRECEDENT Northwest: Use of caries prevention services in the Northwest PRECEDENT dental network. Community Dent Oral Epidemiol. 2011, 39 (1): 69-78. 10.1111/j.1600-0528.2010.00570.x. Epub 2010 Nov 29. PubMed PMID: 21114514; PubMed Central PMCID: PMC3031425.View ArticlePubMedGoogle Scholar
- Michalaki M, Sifakaki M, Oulis CJ, Lygidakis NA: Attitudes, knowledge and utilization of fissure sealants among Greek dentists: a national survey. Eur Arch Paediatr Dent. 2010, 11 (6): 287-93. 10.1007/BF03262765.View ArticlePubMedGoogle Scholar
- Oulis CJ, Berdouses ED, Mamai-Homata E, Polychronopoulou A: Prevalence of sealants in relation to dental caries on the permanent molars of 12 and 15-year-old Greek adolescents. A national pathfinder survey”. BMC Public Health. 2011, 11: 100-10.1186/1471-2458-11-100.View ArticlePubMedPubMed CentralGoogle Scholar
- Sarmadi R, Gahnberg L, Gabre P: Clinicians' preventive strategies for children and adolescents identified as at high risk of developing caries. Int J Paediatr Dent. 2011, 21 (3): 167-74. 10.1111/j.1365-263X.2010.01103.x. Epub 2010 Oct 21.View ArticlePubMedGoogle Scholar
- Clarkson JE, Turner S, Grimshaw JM, Ramsay CR, Johnston M, Scott A, Bonetti D, Tilley CJ, Maclennan G, Ibbetson R, Macpherson LM, Pitts NB: Changing clinicians' behavior: a randomized controlled trial of fees and education. J Dent Res. 2008, 87 (7): 640-4. 10.1177/154405910808700701.View ArticlePubMedGoogle Scholar
- Almerich Silla JM, Montiel Company JM: Oral health survey of the child population in the Valencia Region of Spain (2004). Med Oral Patol Oral Cir Bucal. 2006, 11 (4): E369-81. 1PubMedGoogle Scholar
- Llodra Calvo JC: Encuesta de salud oral en España 2010. RCOE. 2012, 17 (1): 13-46.Google Scholar
- Bravo M, Baca P, Llodra JC, Osorio E: A 24-month study comparing sealant and fluoride varnish in caries reduction on different permanent first molar surfaces. J Public Health Dent. 1997, 57 (3): 184-6. 10.1111/j.1752-7325.1997.tb02972.x.View ArticlePubMedGoogle Scholar
- Bravo M, Montero J, Bravo JJ, Baca P, Llodra JC: Sealant and fluoride varnish in caries: a randomized trial. J Dent Res. 2005, 84 (12): 1138-43. 10.1177/154405910508401209.View ArticlePubMedGoogle Scholar
- Martino S: Oral health behavioral and social intervention research concepts and methods. J Public Health Dent. 2011, 71 (Suppl 1): S2-6.View ArticlePubMedPubMed CentralGoogle Scholar
- Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O: Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q. 2004, 82 (4): 581-629. 10.1111/j.0887-378X.2004.00325.x.View ArticlePubMedPubMed CentralGoogle Scholar
- Bonetti D, Johnston M, Clarkson J, Turner S: Applying multiple models to predict clinicians' behavioural intention and objective behaviour when managing children's teeth. Psychol Health. 2009, 24 (7): 843-60. 10.1080/08870440802108918.View ArticlePubMedGoogle Scholar
- Magiorkinis E, Beloukas A, Diamantis A: Scurvy: past, present and future. Eur J Intern Med. 2011, 22 (2): 147-52. 10.1016/j.ejim.2010.10.006. Epub 2010 Nov 16View ArticlePubMedGoogle Scholar
- Chou DT, Achan P, Ramachandran M: The World Health Organization '5 moments of hand hygiene': the scientific foundation. J Bone Joint Surg Br. 2012, 94 (4): 441-5. 10.1302/0301-620X.94B4.27772. ReviewView ArticlePubMedGoogle Scholar
- Green BL, Li L, Morris JF, Gluzman R, Davis JL, Wang MQ, Katz RV: Detailed knowledge of the Tuskegee syphilis study: who knows what? A framework for health promotion strategies. Health Educ Behav. 2011, 38 (6): 629-36. 10.1177/1090198110391529. Epub 2011 Apr 11View ArticlePubMedPubMed CentralGoogle Scholar
- San Martin L: Análisis sobre el uso de selladores de hoyos, surcos y fisuras por los profesionales Andaluces. [tesis doctoral]. 2012, Sevilla: Sevilla UniversityGoogle Scholar
- Niederman R, Richards D, Brands W: The changing standard of care. J Am Dent Assoc. 2012, 143 (5): 434-7.View ArticlePubMedGoogle Scholar
- Bonetti D, Johnston M, Pitts NB, Deery C, Ricketts I, Tilley C, Clarkson JE: Knowledge may not be the best target for strategies to influence evidence-based practice: using psychological models to understand RCT effects. Int J Behav Med. 2009, 16 (3): 287-93. 10.1007/s12529-008-9017-1.View ArticlePubMedGoogle Scholar
- Porter ME, Teisberg EO: Redefining health care: creating value-based competition on results. 2006, Cambridge MA: Harvard Business School PressGoogle Scholar
- Porter ME: What is value in health care?. N Engl J Med. 2010, 363 (26): 2477-81. 10.1056/NEJMp1011024.View ArticlePubMedGoogle Scholar
- Kaplan RS, Porter ME: How to solve the cost crisis in health care. Harv Bus Rev. 2011, 89 (9): 46-52. 54, 56–61PubMedGoogle Scholar
- Schoen C, Guterman S, Zezza M, Abrams M: Confronting Costs. Stabilizing U.S. health spending while moving toward a high performance health care system. 2013, NY: The Commonwealth Fund Commission on a High Performance Health SystemGoogle Scholar
- Pew Center on the States: Falling Short. Most states lag on dental sealants. 2013, Washington DC: The Pew Charitable TrustsGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6831/13/12/prepub
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