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Dental implants, Thailand
Institute of Dentistry

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Complete tooth loss is a serious issue for the elderly in Thailand and also for the elderly across the globe. Teeth are used for chewing and grinding so food becomes smaller and easier for the stomach and intestine to digest efficiently. If there are no teeth to bite and chew food into small pieces beforehand, the digestive system will be overworked, causing nutrient deficiencies from eating less and suffering from dyspepsia, flatulence and stomachache. People who lose their teeth cannot chew properly so they tend to eat less fiber for an easier digestion. However, less fiber causes constipation in which the body reabsorbs all the waste back which leads to other diseases. Furthermore, toothless faces always look older which can take away self-confidence, make the person become more introvert and unhappy with his/her daily life. This will cause negative effects both physically and mentally so it is necessary for the patients to have a full replacement of false teeth. According to the National Dental Health Survey in the elderly by the Dental Health Office, Department of Public Health, 7.2% of 60-80 years old Thais suffer with complete tooth-loss and 2.5% of them need full replacement which equals 245,000 people. Even though the dentist gives the patient a full replacement, there will still be some problems with the lower denture that tend to be loose and slip off while chewing or talking. This is due to the alveolar ridge will commonly decrease in volume and change morphologically, causing less efficiency of the denture. The problem can be fixed by planting two implants on the ridge of the mandible to hold the lower denture firmly. Moreover, implants can preserve the alveolar bone as a healthy base for dentures as well. Before 2007, dental implants was a high level medical technology that must be provided by expert dentists, at that time, the Thailand dental educational system was yet able to provide any implant training courses. The dentists who would be able to provide implantation had to spend a lot of money on expensive classes from private education centers that had established only one to two places in Bangkok. Most dentists in the Public Health Service barely had the opportunity to study anything to be able to provide implants. Knowledge about implants was not well-known and can only be done in some private hospitals. Thailand was not able to produce implants domestically, so they must be imported from abroad with high costs and the price can reach 50,000-100,000 Thai Baht per unit (1,500-3,500 USD). While Thailand's per capita income is only 180,000 baht per year (about 5,779 USD), so it was impossible for any inferior or underprivileged individuals who need implants to access the service.

B. Strategic Approach

 2. What was the solution?
The major barrier for elderly and underprivileged patients to access to the service was due to very high cost of implant. According to His Majesty the King's idea of having Thai people a chance to use implants initiated a project of implant that are produced in the country for patients who experienced a complete tooth loss. It started with a primary research project of the National Science and Technology Development Office, the Ministry of Science and Technology. It was supposed to be developed continually to make the domestic production possible and help reduce the price of dental implants. It would establish equality among Thai people to have access to implants and a better quality of life, most importantly, to be able to rely on our own dental implant technology. The founding of the Advance Dental Technology Center (ADTEC) aims to manage the high level of dental technological research. The ADTEC together with the National Metal and Materials Technology Center (MTEC) of the Ministry of Science and Technology and three Faculties of Dentistry cooperated in the research about an appropriate implant design that meets international standards and have the ability to compete with imported ones. After registering a patent of invention, then expand to the commercial industry by producing and selling both domestically and internationally at a much lower price that Thailand used to import. The Institute of Dentistry, a state agency of the Department of Medical Services, Ministry of Public Health, has the duty of studying, analyzing, researching, developing knowledge and transferring dental technology and providing tertiary dental services. The institute took the responsibility of the implant project, celebrating the 80th anniversary of His Majesty the King in 2007, offers 10,000 patients two implants on the mandible to retain the lower denture, emphasizing on the elderly who experienced complete tooth loss. Significantly, its duty is to manage and coordinate all relevant agencies, including hospitals of the Ministry of Public Health, Ministry of Interior, Ministry of Defense, The Faculty of Dentistry from Chiang Mai University, Khonkaen University, Prince of Songkla University, and the Thai Red Cross Society Hospital. These agencies participate in a network of implant services that would be distributed thoroughly in every region of the country. The experts in dental implantation from universities and hospitals of the Ministry of Health were persuaded to train the dental staff to be able to provide implant services. Because of the familiarity of dental implants in Thailand, most people who needed treatment still did not know about the implant. It was necessary to publicize dental implants through different kinds of media and increase the chances for these patients to access care. In order to distribute the information to the patient thoroughly, we must work together with representatives of state and local agency volunteers.
 3. How did the initiative solve the problem and improve people’s lives?
Previously, there was no implant produced in the country. A few dentist can provide the implant service, there was no Implantoloty teaching in any University of Thailand. Almost the patient could not access the implant service because imported implants are expensive. The innovation of this project was to produce implants in our own country in order to lower prices and reduce imports of implants. Another innovation was training courses for dentists to offer quality service nationwide. In Asia, the countries that are capable of producing implants are South Korea and Thailand. The design and development of dental implants finally has been patented invention. The production reached the global standard and achieved the National Science and Technological Development Office's patent of invention. Training the staff for providing dental implants was a collaboration of highly skilled and qualified dentists in the country. We educated, encouraged and ensured all relevant staff and also published a handbook for dental personnel. A service network was set up by agencies nationwide, such as the Ministry of Public Health, Ministry of Education, Ministry of Interior and Ministry of Defense, so that people could get the implant services anywhere in the country with the same standards.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
This implant project was established to celebrate His Majesty the King's 80th Birthday Anniversary, 5 December 2007. The implementation plan for the first project was from 2007 to 2011 and served 10,000 patients with 2 implants in the lower jaw in order to retain their dentures. The implant technology was completely invented and transferred for manufacturing and many dental implant experts were invited to join the project, as well as academic committees and lecturers. Dental personals in the country were persuaded to join the training to be able to provide the implant services. The Dental Implant Board in this project consists of the Executive Board of Committee, the Academic Development committee and the Service Development committee. The dentists and the patients were prepared to be ready for providing the implants. Tools and equipment were supported. The monitoring system was designed in a software program called DENTIIS and visiting tours in the areas were planned. The second project is running from 2012 to 2016 to cover more 8,400 patients to celebrate The King’s 84thbirthday anniversary. Various strategies have been used to make the project successful. They are as follows: First, research and manufacture of dental implants by the Advance Dental Technology Center and the National Metal and Materials Technology Center, a joint research, designed dental implants appropriate for Thai people and produced implants in their own country. Research and manufacturing processes have met international standards and the products have been certified to be used and sold in the EU, such as GMP, ISO9001:2000, CEO197, ISO13485:2003, ISO10451, ISO5832, ISO14801, ISO7405 and ISO10993. Second, the training of dental personnel in service was one of the most important strategies. Expert instructors from various universities joined together as a teaching team. They trained the dental staff from basic to advanced levels, including training for instructors. Personnel in government hospitals will be trained to develop their abilities. The project management team has provided consulting, forum for sharing and learning as well as to supervise the operation closely. The trained dentists, dental assistants and dental technicians could create a team to provide services efficiently. They also raised funds to facilitate the poor patients as well. Thirdly, proactive public relation would set a positive attitude towards dental implant through television, community radio, and community agencies to the people for understanding the benefits of dental implants and not being afraid of having the surgery. In addition, patients could share their experiences about their own better quality of life after having a complete denture with implants to the other patients.
 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The main stakeholders involved in the implementation were the Ministry of Science and Technology and the Ministry of Public Health. Cooperation between the two ministries was to develop new knowledge in order to design implants, dental team training and database development. The Ministry of Science and Technology was responsible for the production and development of dental implants. After comprehensive research process, a private company was authorized to be the manufacturer of the implant. The Ministry of Public Health was responsible for managing services accessible to the public. The Institute of Dentistry, Department of Medical Services in Ministry of Public Health was the main agency for the management of patient services. Cooperation of agencies in Ministry of Public Health is comprised of several units in the central, provincial and village health volunteers. Besides the two main agencies, there are also other partners, including the Ministry of Education, Ministry of Interior and Ministry of Defense.
 6. How was the strategy implemented and what resources were mobilized?
The project's essential resources were; -Financial Resources: The budget which was approved by the Cabinet was divided into two parts. The first part was for the research and development of implants made by the Ministry of Science and Technology. Another was for the dental implant by the Ministry of Public Health. The Ministry of Public Health budget was distributed to support hospitals, such as equipment supplying, training and incentives for the service team and also the cost of travel of poor patients. -Technical Resources: The program supports all essential tools and equipment such as surgical, prosthodontic and implant-maintenance tools. It also provided the other tools required for service. The standard protocol guidebook for staff and guidebooks for patients were published. -Human resources: the program consists of the Dental Implant Board of Committee, implant research team, staff of Institute of Dentistry, expert team, provincial agencies, hospital staff, and health volunteers.
 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
The project had succeeded and benefited each and every part from household to national level. The quality of life of the elderly and underprivileged people had been improved six times more than with conventional dentures. They can eat properly and taste better which made them much healthier and happier. The false teeth did not slip off while chewing and made their meals much more enjoyable. It is easier for Thai people to access dental implants because of the increased number of dentists and professionals. Besides, dental implants in the country are ten times cheaper than imported ones. Thailand is now able to manufacture dental implants with high quality. The product has also reached the global standard and has been exported to Europe. The people’s knowledge about dental implants has increase more and more so they can accept the implant procedures. Some patients decided to pay their own money for the single implant of partial tooth loss, and as a result their quality of life has increased. Highly educated dental staff and the number of skillful staff in dental implants have increased all over the country in a relatively short period of time.
 8. What were the most successful outputs and why was the initiative effective?
The Institute of Dentistry with responsibility as the project manager will report the progress to the Dental Implant Board of Committee and The Ministry of Public Health regularly. Supervising activities was very important to ensure that they were on-schedule in meeting the objectives and performance targets. The information system had developed a web-based software application called the DENTIIS. It was a program used for collecting the patients' data in each service unit. The system consists of a main function including Administrator Management System, Project Monitoring System, and Report Progress System. The users were divided into four levels depending on the user’s authorization−system administrators, project directors, dentists, procurement officers and accountants. The outcome of this was a web-based project monitoring system which monitors, updates progress in projects, and tracks the progress and status of the projects. It was also used for observing a situation for any changes which might occur over time and provided a database for continuous maintenance. Other than the information system, tracking supervision in the service areas would create an opportunity to know the real problems and the supervisors might provide solutions to solve their problems. It also creates a better relationship between the project manager and service teams to ensure the achievement of the goals of the project and the development of the network of continuous service. Furthermore, there were home visits to collect the results of dental implants in the sample group. The patients were interviewed to enquire about the dentures and dental implant care, and were given appropriate instructions about them.
 9. What were the main obstacles encountered and how were they overcome?
The problems and obstacles during the project were; 1. Knowledge of the dental implants was not widespread. And the implementing the results of the research into the manufacture of the implant was very new. In the initial stage, dentists did not have confidence in the product therefore it could not be acceptable to serve the patients. So the management team needed to accelerate training the dentists and communicate with them more. And also seeking for the champion as an example was a starting point. The fact that the implants produced in their own country, which got the international standards, had been pronounced to gain more confidence. 2. Lack of implant experts was essential. Earlier, the local dentists who could provide implant services were only a few dozen. In addition to this, in Thailand there was no training course at any university. The goal was to deliver the implants for 10,000 people in the country within three years. It was necessary to increase the intensive implant training courses for dental personnel. 3. Previously, most of the people, especially tentative patients, still had a negative attitude towards implant surgery. They were still afraid of the surgery, so we needed to use media to create collective understanding. People who were experienced might share the implant's benefits direct to other patients or through documents and videos. Later we found that the use of community radio as a better way to bring information to the elderly than other media channels: television or newspapers.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
After the project completion 10,000 patients received the implant services, relevant agencies, dental personnel and individuals have got a lot of benefits. 1. The elderly and low-income people had been delivered 10,000 of dental services with advanced technology and free of charge. Those who had been implanted had a better quality of life. In 2010, local researchers found that elderly people who received the implants were up to 6 times happier than before. The patients who received the implant to stabilize the dentures can eat more with satisfaction. Although the implants can restore happiness to them, self care and professional care are very important for the implant surviving. Implants were attached to the patient for the rest of their lives, so continuous care is needed. The project management team have set a long-term care plan for these patients . 2. Among 10,000 patients everyone had been delivered 2 implants which the dental services would budget to cost 1,000 million baht. The total budget of the project was 134.5 million baht. Reducing the existing budget from avoiding implant importing is estimated at 400 million baht. 3. Other people groups had greater access to dental implants because there were more dental professionals providing this technology than in the past. Meanwhile, the price of dental implants in Thailand compared with the international standard, was5-10 times lower than for imported products. 4. Knowledge of dental implants occurs rapidly. There are enough manuals and textbooks suitable for dental implants for Thailand and knowledge development also was continued until the present. Knowledge of Advanced Dentistry increased across the country compared to the same period of time. Dental assistants were trained to be an assistant for the implant services and also the dental technicians. 5. Collaboration between the public sector and the private sector was critical to the success of the project. The Institute of Dentistry was the administrative center of the public service providing. The public relations and public service were the cooperation of public health personnel including civil society, village health volunteers and elderly clubs in each area. 6. There was a change in the work culture of dental personnel. Formerly, dentists often worked alone. Their role was the specialist who waited for their patients to come in for services. They became more open because the project required the coordination with other agencies and close contact with the patients. IT utilization has improved among the dental staffs because the report of the project must have been send through the Web-Based program, DENTIIS. 7. Dental health personnel had more pride in their work than ever. The previous dental health personnel rarely recognized the satisfaction of the clients. They had been listening to the appreciation of the elderly who were happier with the implants. 8. The positive impact of the elderly effected their families and society. Seniors were stronger and healthier because they could eat healthy food. The poor but healthy elderly could do their routine life by themselves and also contributed to society. Families did not have to devote their time in taking care of the sick and elderly. Eventually, happiness in the family was increased.
 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
The implant project caused a better quality of life for seniors and their families and also a sustained partnership between organizations and dental personnel to develop knowledge and dental technology. 1. Coordination in this project results in the dental implant network of more than 100 hospitals across the country. This is an opportunity to continue the development of other dental network such as a network in Geriatric Dentistry in Thailand. In 2011 the Institute of Dentistry, Department of Public Health together with Dental Innovation Foundation under Royal Patronage and private companies collaborated in the project of the 999 single-tooth implants for those who have lost some of their teeth. Thirty-five hospitals have developed the knowledge and skills to do a variety of types of implants, such as the implants for overdenture and implants for single teeth. They gained more experience to be an expert in dental implantation. Knowledge of implant dentistry and quality care for patients in Thailand has progressed. Due to the accumulated knowledge from experience, the problem solving for a lot of patients, knowledge of dental implants can step up to a higher level. 2. The power of human resources of dentists and dental assistants across the country increased. Dental groups have developed the ability to serve more patients and transfer their knowledge to other dental personnel; for example, the Nakhon-Chai-Bu-rin Group, which consist of 4 provinces: Nakhon Ratchasima, Chaiyaphum, Buriram, and Surin. Currently, dental implant providers have become qualified lecturers at local and regional levels. Now we have established implant centers in 77 provinces across the country. Nearly 200 hospitals nationwide can provide implants as a regular service in their hospitals. 3. Utilization of knowledge from research will be critical in creating a sustainable national economy. Technology was transferred to private firms to produce implant for the domestic industry with the lower price at the world standard level. In addition, the implant manufacturers may produce implants to be exported with CE Mark. The government plans for implant development must be proceeding. Finally, Thailand will have a positive reputation for technological innovation and manufacturing excellence. 4. Sustainability of public health services will lead good health to all people in the country. If seniors could chew effectively they would have good health. Their health has a strong positive impact on society, because they were not a burden of the family, are able to take care of themselves, earn their own living and also generate benefits to the community and society. The implant service is still not widely available for all patients especially the poor and the disadvantaged. The National Health Authority should establish sustainable services of dental implant that are essential to the quality of the patient’s life. Analysis of medical cost was done by the committee of International Health Policy Program, Thailand. It demonstrated the cost-effectiveness of the implant treatment is appropriated. So the agency responsible for national policy making should introduce the implant into the core package of Thai universal health coverage plan for all people.
 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
The lessons learned from the project of providing dental implant to people all over the country are very valuable. Collaboration is a key component to success. To foster cooperation among all stakeholders, the project management team should support constant and open communication, multi channel input to solve the problem as it occurs. Shared vision is essential in any team project. The delays in the project were mostly due to non-technical issues. Establishing a familiarity to an innovation technology by the public was difficult and need a period of time. Management systems must be effective and build up friendly cooperation. The management teams should be set up in a well-designed structure to plan, execute and manage the project. The focal point and the Project Management Office are important. Delegate responsibility to the group of committees for the project is necessary. The project management team must work seamlessly between management teams, public agencies and private sector. The coordination must be seriously committed to resolving all problems. The team should not be discouraged and open to accept criticism and seek agreements that all parties can accept. The team must be committed to continuous development of a knowledge sharing network, to strengthen and sustain the service system. The managing and monitoring system should be highly efficient in communicating and reporting the problems between the members in this project. So those issues can be managed properly. The service in implant technology required new skills. But there was no implant-training course in the university at that time. It took time to educate and improve the skills readily to provide services. At first, the service started slowly and the number of patients was very low due to the learning curve of dentists and staff. The training plan had been set with workshops and live demonstrations. The numbers of dental implant providers significantly increased within a relatively short period of time. Attitudes of stakeholders are critical to the cooperation. The service providers need to know and understand the profit of dental implants in order to make a sensible decision for the patients. Project management team should find a way to increase the confidence of the dentist and reduce resistance from the opposition. To communicate with the people, the proactive public broadcasting must be used in channels that the target groups prefer such as community radio stations. Even the minor risk factors should be captured. Service for elderly and underprivileged patients must consider all details; accessibility convenience and transportation costs might be supported. IT technology used as tools in recording the service information, keeping track of personnel, efficiency of management and budgets is beneficial. The system should be carefully designed to be user friendly and tested for a perfect performance. The program developer should be highly experienced for communicating and reporting the problem to the managing team in time. Some circumstances in the project were not anticipated, the tactic in problem solving may be used besides the systemic and technical resolutions.

Contact Information

Institution Name:   Institute of Dentistry
Institution Type:   Government Agency  
Contact Person:   chaweewan pakdethanakul
Title:   Director  
Telephone/ Fax:   668 172 19003
Institution's / Project's Website:  
E-mail:   dtchaweewan@gmail.com  
Address:   Institute of Dentistry, Tiwanon Rd.,Muaeng District,
Postal Code:   11000
City:   Pakkred
State/Province:   Nonthaburi
Country:  

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