The impact of payment methods on oral health promotion and prevention programmes: scoping review

Abstract

Objectives

To explore and assess the effect of payment schemes on oral health promotion and prevention programmes.

Methods

A scoping review was conducted using the Arksey & O’Malley framework. MEDLINE (via PubMed), Embase (via Scopus), and The Cochrane Library were searched. Unpublished literature was also collected. Searching and screening were conducted until 31 July 2025. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews. All studies comparing payment methods for oral health prevention and promotion were included. A conceptual framework linking payment mechanism to provider incentive, service delivery behaviour, and preventive care outcomes was used to guide synthesis, with findings classified across three outcome levels: utilisation (Level 1), quality of preventive care processes (Level 2), and clinical oral health outcomes (Level 3). The studies were grouped according to the payment system, their impact on the service provider and receiver, and their advantages and disadvantages. After summarising the results, the data were analysed by consulting experts and compared with existing policies. Quality assessment was carried out using Joanna Brigg’s Institute’s Quality appraisal tools.

Results

Out of the 30 studies included, the review found that payment systems have various forms, with four main payment systems being Pay for performance (n = 3), Fee for service (n = 15), Capitation (n = 10), and Global Budget (n = 2). Other payment systems such as salary, treatment vouchers, or direct payment by the employer were also identified, and have been shown to increase preventive dental services and oral health promotion activities.

Conclusions

Fee-for-service payment is consistently associated with higher treatment volumes but lower rates of preventive care delivery, while capitation incentivises prevention but carries risks of patient selection and service reduction without adequate risk adjustment. Pay-for-performance and value-based payment approaches show promise for improving preventive care quality, though evidence remains limited. No single payment model reliably promotes oral health prevention across all contexts. A mixed payment model combining the activity incentives of fee-for-service, the cost-sharing principles of capitation, and the quality orientation of value-based payment offers the most promising framework for advancing oral health promotion. Policymakers should consider hybrid financing structures supported by quality monitoring, and further research is needed to evaluate their long-term effects on clinical oral health outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-026-08433-0.

Introduction

Oral diseases remain among the most prevalent chronic conditions worldwide, affecting nearly 3.5 billion people globally [1]. Despite being largely preventable, conditions such as dental caries and periodontal disease continue to impose substantial health and economic burdens, particularly among disadvantaged populations. Oral health promotion (OHP) and preventive dental care — including fluoride application, fissure sealants, oral hygiene instruction, and routine check-ups — are widely recognised as important strategies for reducing oral disease burden at the population level. However, preventive services remain underutilised in many dental care systems, with the majority of resources directed toward curative treatment of existing disease rather than its prevention [2, 3].

Several factors contribute to the gap between the evidence for prevention and its delivery in practice. Dental personnel are commonly required to focus on addressing existing oral diseases due to high service demand, leaving preventive activities underemphasised. Among the structural factors that shape this imbalance, the way dental services are financed and reimbursed has been identified as an important determinant of whether preventive care is prioritised or neglected [2, 4, 5]. Payment mechanisms create financial incentives that influence provider behaviour, clinical decision-making, and the balance between treatment-oriented and prevention-oriented care delivery [2, 6].

Under fee-for-service (FFS) models — the most common payment arrangement in dental care globally — providers are reimbursed per item of service, creating incentives to increase treatment volume but offering limited financial reward for time-intensive preventive activities such as oral health education or behavioural counselling [7–9]. Evidence suggests that FFS systems tend to be associated with higher levels of restorative and procedural services, while preventive care may receive comparatively less emphasis [8, 10]. In contrast, capitation — where providers receive a fixed payment per enrolled patient regardless of services provided — may align incentives with prevention by encouraging providers to maintain patient health rather than treat disease. However, capitation has also been associated with potential risks such as reduced service provision or selective enrolment if not appropriately designed and monitored [11–14]. Emerging payment approaches, including pay-for-performance (P4P), value-based payment (VBP), and hybrid models combining elements of multiple systems, have been proposed as mechanisms to better align financial incentives with preventive care objectives [15–19]. However, the extent to which these models improve preventive dental service delivery remains unclear.

Addressing this gap requires a multisectoral perspective, involving dental professionals, insurers, governmental bodies, and service recipients, as the interaction between payment design and preventive care delivery is shaped by the broader health system structure in each country [2, 10, 12]. Previous reviews have examined payment systems in dentistry from a general economic perspective [2, 10], but no comprehensive synthesis has specifically focused on how different payment mechanisms influence the delivery of oral health promotion and preventive dental services across diverse contexts and populations. The heterogeneity of payment models, study designs, and outcome measures across the existing literature makes direct comparison challenging; a scoping review is therefore appropriate to map the range of available evidence, characterise the relationship between payment mechanisms and preventive care delivery, and identify gaps in knowledge to inform future research and policy.

This scoping review aims to explore and assess the effect of payment mechanisms on oral health promotion and prevention programmes. Specifically, this review sought to: (1) identify and categorise the range of dental payment systems studied in relation to preventive care, (2) synthesise evidence on how different payment models influence utilisation, quality, and clinical outcomes of preventive dental services, and (3) provide evidence-informed guidance for dental financing policy aimed at strengthening prevention.

Methods

This scoping review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) [20] and Updated Arksey and O’Malley methodology by Levac and colleagues [21] carried out since July 2021 and updated in July 2025.

Search strategy

Electronic database which included MEDLINE (via PubMed), Embase (via Scopus), and The Cochrane Library were searched from July 2021 until July 2025.Grey literature, websites, and national documents were identified through targeted searches of relevant organisational and governmental websites, as well as manual searching of reference lists from included studies. Additional sources were retrieved through bibliography screening to ensure comprehensive coverage of relevant evidence. All non–peer-reviewed sources were screened using the same eligibility criteria as applied to peer-reviewed studies, including relevance to both payment methods and oral health promotion or prevention. The search terms used were as follows:

The following search strategy was applied in MEDLINE (via PubMed), combining MeSH controlled vocabulary with free-text keywords across two concept blocks:

• Concept 1 – Oral health promotion/prevention:

  • (“Oral Health“[MeSH] OR “oral health promotion“[tiab] OR “oral health prevention“[tiab] OR “Dental Prophylaxis“[MeSH] OR “Preventive Dentistry“[MeSH] OR “Preventive Health Services“[MeSH] OR “health promotion“[MeSH] OR “dental care“[tiab] OR “dental service*“[tiab])

• AND

• Concept 2 – Payment/financing/reimbursement:

  • (“Reimbursement Mechanisms“[MeSH] OR “Insurance, Dental“[MeSH] OR “Financing, Health“[MeSH] OR “Fee-for-Service Plans“[MeSH] OR “Capitation Fee“[MeSH] OR payment*[tiab] OR reimburs*[tiab] OR financ*[tiab] OR remunerat*[tiab] OR incentiv*[tiab] OR capitation[tiab] OR “fee-for-service“[tiab] OR “pay for performance“[tiab] OR “global budget“[tiab] OR “value-based“[tiab] OR salary[tiab] OR salaries[tiab])

The full search strategies for all three databases — including Embase (via Scopus) using Emtree controlled vocabulary and The Cochrane Library — are provided in Supplementary File 2. This scoping review was registered on the Open Science Framework (OSF): Registration DOI: 10.17605/OSF.IO/6A7XE.

Study selection

Prevention and promotion oral healthcare services as well as the reimbursement for dental professions were the concept of interest. The context was data from dental services in any country from any type of intervention or epidemiological study. Studies were included if they: (1) Human study, (2) Included information on “Payment methods” and “Oral health promotion and prevention”, and (3) written in English or Thai language. The oral health promotion is defined as strategies aimed at improving oral health by enabling individuals to increase control over their oral health behaviours, such as oral health education and behaviour change interventions. Oral health prevention refers to measures intended to prevent the onset or progression of oral diseases, including chairside clinical interventions such as fluoride application, sealants, and routine prophylactic care.

Protocols, abstracts, preprints, conference proceedings, thesis, grey literature, and any other non-peer-reviewed articles were reviewed if the content were related. However, the studies which not reported data on dental service and payment methods would be excluded.

Data charting, assessment of relevance and synthesis

According to Levac [21], title and abstract screening was performed independently by two reviewers (PG and NC), with a third reviewer (TT) resolving any disagreements. A pilot calibration exercise was conducted with five articles, in which all three reviewers independently assessed each article to establish consistency in inclusion decisions. Full-text screening was subsequently conducted independently by two reviewers (PG and TT), with discrepancies resolved through discussion among all three reviewers. Records were labelled as “included”, “maybe”, or “irrelevant”; all records marked as “included” or “maybe” proceeded to full-text review. Where disagreements could not be resolved through discussion, a consensus decision was made by the review team. All full texts were included in the data extraction stage.

Data extraction was completed by all reviewers who were calibrated and trained with key paper for extraction. Data extraction was completed through the structured data extraction sheet included: Design detail, Population and setting included Country, Mode for reimbursements, Oral health promotion and prevention programme, and findings or outcomes of the study. Expert consultation was conducted after completion of data extraction through a structured expert meeting (non-Delphi) following preliminary synthesis. The purpose of this consultation was to critically appraise, contextualise and validate the interpretation of findings through consensus-based discussion, particularly in relation to different payment mechanisms. The meeting did not involve formal Delphi procedures or contribute primary data to the review. Expert input was used to support the discussion and interpretation of results.

A narrative synthesis was conducted following the focus on the reimbursement for dental professions on oral health promotion or prevention programmes. As the limited of included studies as well as diverse design of study, the quantitative synthesis could not be processed. A synthesis of contents was done according to the reimbursement modes. WS provided methodological guidance and supported the interpretation of the synthesised findings to ensure coherence and clarity. Each study was assessed using the Joanna Briggs Institute (JBI) quality assessment tool for its study design [22]; however, consistent with scoping review methodology, no studies were excluded solely on the basis of methodological quality. Risk of bias at the individual study level was therefore descriptive rather than used to weight findings. As this review aimed to broadly map available evidence rather than synthesise effect estimates, formal statistical assessment of publication bias (e.g., funnel plots) was not applicable. To minimise the risk of publication bias, the search incorporated multiple electronic databases alongside grey literature, organisational websites, and manual reference list screening.

To guide the synthesis, this review adopts a conceptual framework in which payment mechanisms shape provider financial incentives, which in turn influence clinical behaviour and service delivery patterns, ultimately affecting oral health promotion and prevention uptake and downstream population-level oral health outcomes. This pathway — payment mechanism → provider incentive → service delivery behaviour → preventive care uptake → clinical outcome — was used to organise and interpret findings across each payment model examined. Three levels of outcomes were considered: Level 1 (utilisation of preventive services), Level 2 (quality of prevention and care processes), and Level 3 (clinical oral health outcomes such as caries reduction or changes in DMFT scores). This framework reflects the logic model commonly applied in health financing research [21] and was used to assess not only what is known about each payment model, but under what conditions each model supports or inhibits preventive oral healthcare.

This study had been exempted for ethical approval by The Research Ethics Committee (MHESI 78.0319/Ethics 532).

Results

The PRISMA-ScR diagram outlining the study selection process is presented in Fig. 1. Database searching identified 10,719 records (MEDLINE via PubMed: 5,874; Embase via Scopus: 3,701; The Cochrane Library: 1,144), with a further 5 records identified through other sources (websites and organisations), giving a total of 10,724 records. After removal of 2,028 duplicates, 8,698 records were screened at title and abstract level, of which 8,617 were excluded as irrelevant. Seventy-five full-text reports were sought from database searching; 10 could not be retrieved, leaving 65 reports assessed for eligibility. A further 5 reports were sought from other sources, of which 2 could not be retrieved, leaving 3 assessed for eligibility; giving 68 full-text reports assessed in total. Of the 65 database reports assessed, 36 were excluded: 20 because the outcome was not of interest, 12 because the intervention was not of interest, and 4 due to language restrictions. Of the 3 other-source reports assessed, 2 were excluded due to insufficient information. In total, 30 studies met all inclusion criteria.

Fig. 1.

Review process according to PRISMA Extension for Scoping Reviews [20]

Quality appraisal

Quality appraisal was conducted using the appropriate JBI tool for each study design [22], and was undertaken to contextualise the strength of evidence rather than to exclude studies, consistent with scoping review methodology. Appraisal results revealed considerable variability across the 30 included studies (full results in Appendix 1). The two RCTs [23, 24] and quasi-experimental studies employing difference-in-differences or interrupted time series analyses [4, 7] represented the highest level of internal validity and causal inference in the dataset. The four cohort studies and five cross-sectional studies were generally of moderate quality; findings from these designs support association between payment models and preventive service utilisation but cannot establish causality. The ten review and expert opinion papers were variable in methodological rigour; whilst informative for understanding conceptual frameworks and policy context, they carry a higher risk of author bias and should not be interpreted as primary evidence. The three qualitative studies and two mixed-methods studies provided contextual insights into provider and patient behaviour that quantitative designs could not capture. Overall, the evidence base is dominated by observational and opinion-based studies, with only a small number of experimental designs. This profile means that conclusions drawn from this review should be interpreted as evidence-informed policy directions rather than definitive causal findings.

Summary characteristics of the identified studies

The majority of studies were review and expert opinions (n = 10), observational studies (9 articles: 4 Cohort studies, 5 Cross-sectional), while only 6 experimental studies (2 RCTs, 4 NRCT) 3 qualitative studies, and 2 mixed method studies.

The findings were summarised by the content in Table 1. Modes of reimbursement for oral health promotion and prevention programmes could be summarised into 5 payment methods following:

Table 1.

Summary of studies on dental payment and reimbursement models

FFS Fee-for-service, GBS Global Budget System, P4P Pay-for-Performance, VBP/VBC Value-Based Payment/Care, PDS Public Dental Service, NHI National Health Insurance, DMFT Decayed, Missing, Filled Teeth, OHI Oral Hygiene Instruction, DiD Difference-in-Differences, ITS Interrupted Time Series, OOPE Out-of-pocket expenditure, UDA Unit Dental Activity

Outcome level classification: Level 1 — Utilisation (whether/how many preventive services were used), Level 2 — Quality of prevention (how well preventive services were delivered), Level 3 — Clinical outcomes (patient disease measures: DMFT, caries incidence)

Fee-for-service

The fee-for-service (FFS) payment model is the most common form of healthcare payment. It involves paying for healthcare services based on the actual services provided, making it an FFS budgeting approach. The utilisation of this payment system for purchasing dental services in the primary health insurance system can encourage service providers to offer more services. FFS incentivises service providers to increase the volume of services rendered, which tends to favour curative over preventive activities. However, it may lead to unequal access among individuals with similar needs and a tendency to allocate a higher budget for service purchases [3, 8].

The advantages of FFS lead dentists to develop new and additional services, such as oral prophylaxis, fillings, and extractions, to earn compensation. However, this may result in a reduction in preventive services, and there might be a lack of cost control in treatment or the provision of preventive dental services. A case study from the USA showed limitations on the quantity of service users through Medicaid due to low reimbursement and attempts to develop the model and service provision may lead to higher service prices. If the number of dentists is restricted, it may result in higher prices for preventive dental services purchased through insurance [3]. The FFS model is used, but there is a problem with insufficient emphasis on preventive care. Additionally, some countries have developed modified FFS models to better support preventive care, such as voucher-based dental programmes in Portugal [25]. In France, a check-up incentive scheme for children similarly demonstrated that financial incentives alone were insufficient to achieve target preventive service uptake [26].” In Taiwan, a modified FFS model operating under a global budget cap has been implemented to manage dental expenditure while encouraging preventive service delivery [27].

Across the identified FFS studies, evidence mainly reflects utilisation-level outcomes — such as service volume, procedure mix, and access patterns — with limited evidence on the quality of preventive care delivered or on patient clinical outcomes such as caries incidence.

Capitation

Paying compensation on a capitation basis is a method of reimbursing based on the number of individuals for whom the service provider is responsible, without considering the number of visits or details of the treatment received. The purchaser knows a specific budget for a certain population over a period, making it easy to control and manage the budget. However, a limitation is that service providers may choose populations with lower treatment needs to maximise profits, potentially resulting in underserved populations and a lack of focus on preventive services. This model is most suitable for areas with a suitable population density and size [2].

In Sweden, paying a capitation fee based on their risk of developing oral diseases. The risk assessment considers the oral health status at the time, as well as the oral health and medical history. Individuals with lower risk may choose to register under capitation since their expected treatment costs are lower and more predictable, making it financially advantageous compared with FFS for this group [13, 14]. Studies have found that individuals under the capitation model receive more preventive dental services compared to those under FFS models [13, 14]. A 12-year longitudinal study found that patients in the capitation group had significantly fewer decayed teeth than the FFS group, though this may partly reflect selection bias from lower-risk individuals opting into capitation [11].

In Northern Ireland, Brocklehurst et al. [7] examined the impact of shifting from FFS to capitation using difference-in-differences and interrupted time series analyses. The study found a statistically significant reduction in total treatment items (DiD = − 174.78, p < 0.01) following the transition to capitation. Fissure sealant also declined significantly (DiD = − 9.34, p = 0.01). Patients did not perceive significant differences in treatment quality but reported longer waiting times [7].

The capitation payment for dental services can lead to service limitations, particularly in preventive care [3]. Some studies have raised concerns that capitation may reduce overall service volume, with patients receiving fillings only when decay was already present and requiring fewer prescriptions [6]. However, this should be read alongside evidence from Sweden showing that capitation patients received significantly more preventive interventions including oral hygiene instruction and fluoride application compared with FFS patients [14].

Among the included capitation studies, evidence spans from utilisation level to outcomes such as visit rates, treatment volumes, and fissure sealant application rates as well as the quality of preventive care delivery, including oral hygiene instruction and fluoride application rates [7, 9, 10, 14]. One 12-year longitudinal study extended this to clinical outcomes, reporting significantly lower caries prevalence in the capitation group compared with FFS [11].

Global budget system

The Global Budget System (GBS) involves allocating a fixed budget at the regional or provincial level, with a predetermined spending cap designed primarily to contain total healthcare costs. The key objective of GBS is to limit healthcare expenditure within a defined period, with the budget cap negotiated between the responsible purchasing agency and healthcare provider associations [27].

GBS has been applied in several countries, including Germany and the United Kingdom, though evidence specific to dental services is most developed in Taiwan [27–29]. The difference lies in Taiwan’s single-payer system with a centralised health fund, managing budgets at the regional level. While GBS allows for effective cost control, it may create unintended incentives affecting the quality of care. The countries using this payment system for dental services, with Taiwan as an interesting case, may face challenges related to access and quality of care. In Taiwan, the NHI dental GBS operates through a floating-point value system: providers submit claims in points, and if total claims across a region exceed the budget cap, the monetary value of each point is reduced proportionally. This creates an incentive for dentists to increase service volume to compensate for the lower point value, contributing to the procedure mix shifts described above [27–29]. A GBS with a cap on spending alongside the FFS model was used under the National Health Insurance Act of Taiwan. Negotiations between the fund and healthcare providers involved a committee, the association of healthcare providers, labour unions, and employer groups to discuss the budget to be used for services in the following year, after which the allocated budget is distributed to the six health regions in Taiwan based on population proportions, with the dental budget capped according to the previously allocated amount.

Evidence from both included GBS studies operate at the utilisation level — reporting changes in dental visit rates, access to services, and procedure mix following budget implementation [27–29]. No included study measured the quality of preventive care delivery or clinical health outcomes under a dental global budget system, representing an important gap in the evidence base.

Pay for performance

The pay-for-performance (P4P) model compensates providers based on the achievement of predefined quality, safety, or outcome metrics — rather than on the volume of services provided [15, 16]. This distinguishes P4P from FFS, where payment is tied to service quantity regardless of outcome [2]. P4P aims to enhance the quality and efficiency of care by aligning financial incentives with measurable performance goals set prior to the service period [18]. The goals are set before undertaking operations, and the payment structure acts as a policy tool to drive work in line with the predefined objectives [15]. However, a limitation of the P4P model is that the set goals or outcomes may not be accurate indicators or comprehensive representations of overall job performance and service provision [16].

Implementing this system requires skilled personnel, considering various environmental factors and impacts. These include the sustainability and payment capabilities of the organisation, satisfaction and efficiency of personnel, and competition in the market or service providers. In this context, compensation serves as an additional motivational reward beyond the basic remuneration, such as regular salaries. The fairness of P4P compensation relies on equitable distribution, ensuring that individuals performing the same tasks receive equal compensation [15]. Conversely, those handling more tasks or more challenging work should receive higher compensation than those performing fewer or less demanding tasks [17].

Among the included P4P studies, evidence predominantly reflects utilisation-level outcomes, such as rates of sealant delivery and preventive service uptake [15]. One review suggested P4P has theoretical potential to improve the quality of care delivery but noted that this depends heavily on the accuracy and appropriateness of the performance metrics selected [16]. No included study measured clinical outcomes such as caries incidence under a dental P4P model.

Value-based payment (VBP)

The concept of Value-Based Healthcare (VBHC) is an extension of the principles of healthcare services emphasizing value, health outcomes, and cost control. This concept builds upon the teachings of Professor Michael E. Porter [30]. In this context, the value of healthcare services refers to the health outcomes that patients receive, comparing them to the amount of money or resources expended to achieve those outcomes, commonly known as the “costs of delivering the outcomes.”

It is important to distinguish three related, but distinct concepts used in this section. Value-Based Payment (VBP) refers to the overarching financing framework that ties reimbursement to the value of care delivered rather than its volume [24]. Pay-for-performance (P4P) is one specific mechanism within VBP, providing financial incentives linked to measurable quality or outcome metrics [15]. Value-Based Care (VBC) describes the broader care delivery philosophy of how providers organise and deliver services to maximise patient outcomes relative to cost, encompassing process of care, access to care, and oral health outcomes as distinct evaluative dimensions [31]. These three concepts operate at different levels: VBP shapes how money flows, P4P creates specific incentives within that flow, and VBC describes what happens at the point of care delivery. Primary care services and health promotion and disease prevention are crucial factors in achieving these goals. VBP often involves alternative payment models or P4P approaches [24, 30, 31]. In the United States, there are efforts to develop VBP systems in dentistry. The integrating VBP as a supplement to the existing FFS model is being used to improve oral health outcomes for the population. However, the implementation of value-based care (VBC) assessments in dentistry faces challenges in linking the performance of public health dentistry personnel to patient health outcomes. The model for evaluating VBC in dentistry within the context of Medicaid uses preventive services, such as sealants, as a model. The evaluative criteria considered four key points [24]: (1) Data for Evaluation, (2) Social determinants of health control, (3) Definition of “quality“, (4) Quality Measurement: The PREDICT (Population-centered Risk- and Evidence-based Dental Interprofessional Care Team) program acknowledges that social determinants of health influence patient outcomes but lie largely beyond the control of individual dental providers; accordingly, social determinants are incorporated as a control variable in outcome evaluations to avoid unfairly penalising providers for patient-level factors outside their influence [24]. Concerning the definition of “quality,” Institution of Medicine’s defined as the degree to which health services increase the likelihood of desired health outcomes for both individual patients and populations. These services must adhere to current professional knowledge standards. Using this framework, the PREDICT program adopts indicators for assessing the value of dental sealant services, the results of VBP model indicate a slight increase in the utilisation of sealants. This suggests an enhancement in preventive dentistry services and an increase in the diagnosis of conditions with modifiable risk factors [24].

The outcomes reported under value-based payment models operate primarily at Level 2 (quality of prevention and care processes), with some programmes extending to Level 3 (clinical outcomes such as caries reduction), reflecting the model’s explicit aim to link reimbursement to measurable health improvement.

Cross-model synthesis: patterns in the evidence

Across the four payment models examined, a consistent pattern emerges regarding prevention orientation: the alignment between financial incentives and preventive care delivery varies substantially, and no single model uniformly supports oral health promotion across all contexts. FFS is the model most consistently associated with lower rates of preventive service delivery. Its volume-based incentive structure rewards treatment activity over prevention, and no included study demonstrated FFS superior to an alternative model in preventive dental care delivery. By contrast, capitation provides the strongest and most consistent evidence for supporting preventive care: Swedish studies reported significantly higher rates of preventive interventions and lower caries prevalence in capitation patients compared to FFS patients [11, 14]. However, the Northern Ireland experience offers an important counterpoint: transition from FFS to capitation paradoxically reduced preventive interventions, including fissure sealants [7]. This divergence suggests that capitation’s effect on prevention is context-dependent and contingent on system design, monitoring mechanisms, and baseline provider behaviour. P4P and VBP models orient financial incentives explicitly toward measurable quality or outcome metrics, making them theoretically well-suited to promoting prevention; however, evidence in the dental context remains limited and operates predominantly at quality of prevention and care processes (Level 2).

Regarding cost control, GBS is the most effective mechanism for constraining total dental expenditure. Evidence from Taiwan [28, 29] confirms its success in limiting aggregate dental spending; however, the mechanism through which cost containment is achieved — progressive floating-point value dilution and consequent procedure mix shifts toward simpler, lower-value services — creates perverse incentives that may disadvantage complex preventive care. Capitation similarly provides budget predictability through fixed per-capita payments, offering effective cost control for the purchaser. FFS, in contrast, provides the least cost control, with evidence from multiple settings indicating that uncapped FFS systems generate high treatment volumes and expenditure growth driven by provider supply rather than patient need. P4P and VBP have limited evidence of cost control effects in dentistry, though their design intent is to improve the value not merely the volume of care.

Equity, access, and under-treatment concerns manifest through distinct mechanisms across models. Under FFS, access disparities are most pronounced among low-income and uninsured populations: in US Medicaid contexts; low reimbursement rates constrain provider participation, limiting access to preventive dental care for those most at risk [3, 8]. Under capitation, the primary equity concern is adverse selection and cream-skimming: without adequate risk adjustment, providers have a financial incentive to preferentially enrol healthier, lower-risk patients, potentially disadvantaging those with greater oral health needs [10, 11, 14]. Risk-adjusted capitation, as demonstrated in Sweden [14], can mitigate this problem by directing resources toward higher-need populations. GBS raises concerns about service dilution and reduced access as budgets approach their caps, while P4P and VBP offer the most explicit equity frameworks which were designed to incorporate social determinants of health as control variables, as in the PREDICT programme [24]; though implementation challenges in equitable metric design remain.

A striking pattern across all four models is the dominance of Level 1 (utilisation) outcomes and the relative scarcity of evidence at Level 2 (quality of preventive care processes) and Level 3 (clinical oral health outcomes). Only one included study measured clinical outcomes — caries prevalence — over a 12-year follow-up directly comparing capitation with FFS [11]. No included study reported clinical outcomes for GBS or P4P. This fundamental evidence gap means that, while utilisation patterns across payment models are relatively well-characterised, the downstream effect of payment model choice on actual population oral health — the ultimate objective of any payment reform — remains poorly understood and represents a priority area for future primary research.

Discussion

This scoping review reveals that payment models for oral healthcare services have distinguished characteristics and outcomes. Unlike previous reports, this scoping review focuses specifically on studies related to dental services, especially in preventive services. The findings indicate that the outcomes of various payment models for purchasing dental services do not significantly differ from the results of payment systems for other health services. The outcomes of payment systems for service delivery seem reasonably predictable. This is because dental services, while diverse, do not exhibit significant variations in terms of the impact of payment models [19].

In each payment model, there are both advantages and limitations. Regarding dental services, a summary comparison of the strengths and weaknesses of FFS, P4P, capitation and GBS payments can be made. It can be observed that FFS and P4P payment models can stimulate more service provision compared to capitation models [18]. There is a tendency for patients to receive treatment when dental issues become more severe, but there is also a risk of unnecessary treatments. Studies comparing FFS to other models consistently find that FFS is associated with lower rates of preventive service delivery. For example, patients in FFS plans receive fewer preventive visits and screenings compared to those in capitated systems, where incentives are better aligned with prevention [11, 14]. This showed a significant concern for policymakers as it may lead to increased budgetary burdens for service provision. Both capitation and GBS models are effective in controlling overall expenditure, though this may come at the cost of reduced preventive service delivery. Additionally, they may limit access for the population due to service constraints. The choice between models has budgetary implications and impacts service accessibility [10]. Many countries utilise multiple payment models for dental services to compensate for the shortcomings of each model. This depends on the structure of the health insurance system, context, and the management of oral health services in each country [32]. In addition, incorporating value-based payment (VBP) concepts can motivate providers to consider the quality and health outcomes of oral health services for patients. However, this conclusion is based on theoretical reasoning and limited utilisation-level evidence; no included study demonstrated causal improvement in clinical oral health outcomes attributable to VBP alone. Allocating budgets based on population risk can enhance efficiency and fairness in the oral health service system. The equity implications of payment models represent a critical but underexplored dimension of this review. FFS models have been associated with socioeconomic disparities in access: Telford et al. (2012) found significant variation in NHS fee-for-service (FFS) dental care provision according to deprivation level, with adolescents from more deprived areas receiving fewer preventive services [8]. Capitation models, in theory, support greater equity by providing a per-patient allocation regardless of service volume; however, without adequate risk adjustment, providers under capitation may selectively enrol lower-risk, higher-income patients, leaving high-need populations underserved. Petersson and Twetman (2017) noted that in the Swedish Public Dental Service, risk-adjusted capitation improved equity by directing resources to patients with higher caries risk [14]. Value-based payment approaches targeting Medicaid populations — such as the PREDICT programme evaluated by Conrad et al. (2021) — showed that VBP can improve sealant uptake in low-income children when designed with equity as an explicit goal [24]. Global budget systems, while effective in controlling overall expenditure, risk exacerbating geographic inequity: Hsueh et al. (2004) found that the Taiwanese NHI dental global budget reduced dental visits per person but did not resolve the maldistribution of dentists, with rural populations remaining underserved [28]. These findings suggest that no payment model is inherently equitable; equity outcomes depend critically on how models are designed, how risk is adjusted, and what governance mechanisms accompany implementation.

Risk adjustment is a critical but often neglected component of payment model design, particularly in capitation and value-based payment systems. In capitation, providers receive a fixed payment per enrolled patient; without case-mix or risk adjustment, this creates an incentive to enrol healthier, lower-risk patients and avoid high-need individuals — a phenomenon known as ‘cream-skimming’ or adverse selection. Petersson and Twetman (2017) demonstrated that risk-adjusted capitation in the Swedish Public Dental Service directed resources more appropriately toward patients with higher caries risk, mitigating this effect [14]. Without such adjustment, capitation payments fail to reflect the true cost of care for vulnerable populations, leading to under-provision of preventive services for those who need them most. In value-based payment systems, inadequate risk adjustment can distort performance metrics: providers serving disadvantaged populations with greater baseline disease burden may appear to underperform against outcome targets that do not account for patient complexity, creating a disincentive to serve high-need groups. Conrad et al. (2021) highlighted that the PREDICT VBP model succeeded in part because it was designed specifically for a Medicaid context, where the patient population and its risk profile were explicitly considered in target-setting [24]. These findings underscore that the success of both capitation and value-based models in promoting oral health prevention depends not only on the payment structure itself, but on whether risk adjustment mechanisms adequately reflect the health needs and social circumstances of the enrolled population.

Regarding preventive and health promotion services, studies suggest that population-based payment models, including both capitation and GBS, tend to encourage the delivery of these services. However, effective management systems, such as those in Taiwan with a regional health committee overseeing budget allocation and service rate regulation, play a crucial role in achieving desired outcomes. Furthermore, transitioning from FFS or P4P to VBP or gradually implementing changes is essential to ensure a smooth transformation [24].

This review also highlights the need to balance treatment-oriented and prevention-oriented care. FFS or P4P systems tend to encourage reactive care and higher service volumes, while capitation theoretically incentivises prevention by transferring financial risk to providers — who benefit from maintaining patient health — empirical evidence suggests a more complex picture. Brocklehurst et al. (2020) found that capitation was associated with significant reductions in both treatment items and fissure sealant delivery in the United Kingdom, suggesting that providers may respond to capitation by reducing activity broadly rather than shifting toward prevention specifically [7]. This discrepancy between theoretical expectation and observed behaviour warrants caution when interpreting capitation as inherently pro-preventive. Given these limitations, blended models, supported by quality monitoring and outcome-based incentives, may provide a more balanced approach. However, that no included study evaluated a fully implemented mixed payment model in dentistry; this recommendation is therefore an inferential policy proposition derived from the complementary incentive logic of each model, not a direct empirical finding of this review. Broader systemic factors including social determinants of health, oral health literacy, provider workforce distribution, and the integration of dentistry with primary care, also strongly shape oral health outcomes [2]. Payment reforms must therefore be embedded within comprehensive oral health strategies that combine financing with prevention programs, education, and monitoring of service quality [19].

The findings align with the WHO Global Oral Health Action Plan 2023–2030, which calls for integrating oral health into universal health coverage (UHC) and ensuring that financing mechanisms support prevention and equitable access [1, 33].This review suggests that payment model design is one structural lever for advancing these goals. However, payment reform alone is insufficient; governance, risk adjustment, and integration with primary care are equally essential. Policymakers reforming dental payment systems should consider alignment with UHC principles alongside cost control and preventive incentive goals. These findings apply most directly to the high-income settings represented in the evidence base; applicability to other contexts requires careful adaptation. The above synthesis should, however, be interpreted in the context of the strength and limitations of the available evidence.

This review has several limitations. Although multiple databases and grey literature sources were searched to minimise publication bias, studies reporting null or negative findings for payment interventions may be less likely to be published or indexed, potentially leading to an overestimation of the benefits of specific payment models. In addition, the inclusion to studies published in English or Thai may have introduced language bias, as relevant evidence from countries where oral health payment systems are studied in other languages—such as German, French, Japanese, or Chinese—may not have been captured.

Strength of evidence and causal uncertainty

The studies included in this review varied in design, ranging from randomised controlled trials and quasi-experimental studies to cross-sectional analyses and policy evaluations. This heterogeneity limits direct comparisons across payment models. Most evidence derives from observational data, which precludes causal inference; changes in utilisation or clinical outcomes may reflect confounding factors such as patient socioeconomic status, provider characteristics, or concurrent policy changes rather than the payment model itself. The scoping review methodology adopted here — following Arksey and O’Malley [34]as updated by Levac et al. [21] — does not require formal quality appraisal, and findings should therefore be interpreted as a mapping of available evidence rather than a definitive assessment of effectiveness.

Several key evidence gaps must be addressed before large-scale payment reform in oral health can be confidently implemented. First, there is a lack of long-term outcome data: most included studies report short-term utilisation measures rather than sustained clinical outcomes such as caries incidence or DMFT trajectories over five or more years. Second, evidence from low- and middle-income countries is almost entirely absent from this review; findings from high-income health systems (UK, Sweden, USA, Taiwan) may not transfer directly to contexts with different workforce structures, insurance coverage, or oral health burdens. Third, no included study evaluated a fully implemented blended or mixed payment model in dentistry; the evidence base for the recommended mixed-model approach therefore remains theoretical rather than empirical. Fourth, the mechanisms through which payment models influence provider behaviour and patient outcomes — the intermediate steps of the conceptual framework adopted in this review — are rarely measured directly, limiting causal interpretation. Fifth, studies examining the differential impact of payment models on specific vulnerable subgroups (children, elderly, rural populations, ethnic minorities) are sparse. Addressing these gaps through prospective studies, natural experiments, and cross-system comparative research is essential before broad payment reform recommendations can be translated into policy. Overall, the current evidence suggests potential associations between payment mechanisms and oral health promotion and prevention practices; however, there remains uncertainty regarding causal pathways. Future research should employ more specific study designs, including experimental and quasi-experimental approaches to strengthen causal inference and inform policy and financing decisions in dental health systems.

Conclusions

This scoping review demonstrates that no single payment model consistently promotes oral health prevention and promotion across all contexts. Each model carries inherent trade-offs between cost control, service volume, preventive incentives, and equity of access. Fee-for-service payment stimulates higher treatment volumes but is consistently associated with lower rates of preventive service delivery. Capitation models theoretically incentivise prevention through risk transfer; however, empirical evidence suggests that providers may respond by reducing overall activity rather than shifting meaningfully toward preventive care. Global budget systems are effective in controlling expenditure but may constrain service delivery without robust quality monitoring. Pay-for-performance and value-based payment approaches show promise in linking financial incentives to health outcomes, though implementation evidence in dentistry remains limited.

These conclusions are drawn from an evidence base of variable methodological quality; findings supported by RCT or quasi-experimental evidence carry stronger causal weight than those derived from expert opinion or narrative review, and should be prioritised when designing payment reform.

A mixed payment model — integrating the activity incentives of fee-for-service, the cost-sharing principles of capitation, and the quality orientation of value-based payment — appears most appropriate for promoting both treatment and preventive oral health services. The design of such a model must be context-sensitive, accounting for the structure of the existing health system, patient demographics, and provider capacity. Governance mechanisms, including outcome monitoring and transparent quality metrics, are as important as the choice of payment model itself in achieving equitable oral health outcomes.

Further research is needed to evaluate the long-term effects of mixed payment approaches on clinical oral health outcomes and to develop context-specific implementation frameworks that can guide oral health policy reform across diverse healthcare settings.

Authors’ contributions

PG: Conceptualization of the scoping review, development of the protocol, acquisition of data (literature search, screening, charting), interpretation of the data, and writing of the original draft and critical review / editing of the manuscript.NC: Contribution to conceptualization, data acquisition, data interpretation, critical review and editing of the manuscript.TT: Contribution to conceptualization, data acquisition, data interpretation, critical review, editing of the manuscript, and corresponding for this paperWS: Supported data interpretation, provided methodological expertise, and critically revised the manuscript for intellectual content.All authors reviewed the manuscript.

Funding

Open access funding provided by Mahidol University. This study was funded by the National Health Foundation of Thailand (Grant No ORH 2/2564). The funder had no role in the study design, data collection, analysis, interpretation of data, or writing of the manuscript.

Data availability

All data analysed during this study are included in this published article and its supplementary information file.

Declarations

Ethics approval and consent to participate

Not applicable

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.