Abstract: Two cluster-RCTs, with data from 503 dental practices, representing 821 dentists and 4771 patients, met the selection criteria. We judged the risk of bias to be high for both studies and the overall quality of the evidence was low/very low for all outcomes, as assessed using the GRADE approach. One study used a factorial design to investigate the impact of fee-for-service and an educational intervention on the placement of fissure sealants in permanent molar teeth. The authors reported a statistically significant increase in clinical activity in the arm that was incentivised with a fee-for-service payment. However, the study was conducted in the four most deprived areas of Scotland, so the applicability of the findings to other settings may be limited. The study did not report data on measures of health service utilisation or measures of patient outcomes. The second study used a parallel group design undertaken over a three-year period to compare the impact of capitation payments with fee-for-service payments on primary care dentists’ clinical activity. The study reported on measures of clinical activity (mean percentage of children receiving active preventive advice, health service utilisation (mean number of visits), patient outcomes (mean number of filled teeth, mean percentage of children having one or more teeth extracted and the mean number of decayed teeth) and healthcare costs (mean expenditure). Teeth were restored at a later stage in the disease process in the capitation system and the clinicians tended to see their patients less frequently and tended to carry out fewer fillings and extractions, but also tended to give more preventive advice. There was insufficient information regarding the cost-effectiveness of the different remuneration methods. Financial incentives within remuneration systems may produce changes to clinical activity undertaken by primary care dentists. However, the number of included studies is limited and the quality of the evidence from the two included studies was low/very low for all outcomes. Further experimental research in this area is highly recommended given the potential impact of financial incentives on clinical activity, and particular attention should be paid to the impact this has on patient outcomes.

Plain-language summary: Our review identified two studies examining the effects of different methods of remuneration on the behaviour of 821 dentists from 503 dental practices, involving 4771 patients. Both were conducted in the United Kingdom. One study investigated the impact of a fee-for-service payment and an educational intervention on the placement of fissure sealants in permanent molar teeth. The second study compared the impact of capitation payments and fee-for-service payments on primary care dentists’ clinical activity and the levels of dental decay that were experienced across the two payment systems. The first study found an increase in clinical activity related to fee-for-service payments. In the second study, dentists working under capitation arrangements restored carious teeth at a later stage in the disease process than fee-for-service controls. In the capitation arm, the dentists tended to see their patients less frequently and tended to carry out fewer fillings and extractions, but tended to give more preventive advice. There was insufficient information regarding cost-effectiveness of the different remuneration methods. Financial incentives within remuneration systems may produce changes to clinical activity undertaken by primary care dentists. However, the number of included studies is limited and the quality of the evidence is low/very low for all outcomes.