4
Special Report A critique of existing national dental health services systems S. J, H. Hendricks* Dental care syste?-ns are predo!ninanily based on the engineering and curative approaeh to the body, which does nol necessarily improve dental health. In many western coun- tries, including some developing countries, tooth loss is still prevalent amid sophistica- ted systems of dental vare. The two major dental diseases, dental caries and periodon- tal disease, are almost entirely preventable. Against this background, a dental care sys- tem should encourage those working in it lo apply known effective methods lo improve and maintain the oral health of the population. The perceptions of people toward dental health have long been disregarded by the profession, to the extent that individuals are victim-blamed, irrespective of the existing soeioenvironmental factors that may influ- ence an individual's attitude towards dental services. The community must be involved in the planning and decision-making processes of any health service program to facili- tate coope!-ation by the population in oral care. (Quintessenee Int t990;2J:¡63-l6ñ.) Intrn auction Evaluation of a poptilatioti's needs for dental health services requires (1) a knowledge of the state of the health of the population; (2) the existenee of well- defined standards of good health; and (3) a knowl- edge of what contemporary dentistry can do to im- prove ill health. However, there is no consensus among dentists on what constitutes good health and which methods are the most effective in achieving that state. Neither is there consensus on what eonstitutes a need for treat- ment.' The approach to dental care that has come to dom- inate dental health eare systems in much of the de- veloped world, as well as in most developing eountries, can be broadly characterized by a number of seperate but related trends: The Oral and Dental Hospital, Department of Community Den- tistry, Faculty of Dentistry, University of tbe Western Cape, Pri- vate Bag X12, Tygerberg 7500, South Alrica. 1. An orientation toward treatment and attempted care, rather than prevention, with the exception of the use of fluorides 2. An increasingly teehnologieal approach to diag- nosis and treatment 3. Inereasing specialization and fragmentation of care; eg, third-party payment systems thai reim- burse the dentist only for eertain types of treat- ment, which could beeome a determinant of the type of dentistry practiced by the profession in areas where such payment systems are dominant. The dominant philosophy of modern dental care is based on the engineering approach" to the body and the germ theory of disease.' The mouth is considered a collection of parts to be rescued, primarily by tech- nical intervention, from the effects of malfunction and breakdown. The dentist is seen as a biotechnician who repairs and occasionally services the machine. This philosophy promotes the concept that a society ean make progress in health by investing in the ever-in- creasing provision of highly sophisticated and tech- nological serviees. Indeed, it may undermine preven- tion by diverting resources away from prevention and by encouraging treatments of questionable necessity (although not to the exclusion of the importance of fluoridation). Quintessence i Vni|irnp?i Number 2/1990 163

A critique of existing national dental health services systems

  • Upload
    others

  • View
    1

  • Download
    0

Embed Size (px)

Citation preview

Special Report

A critique of existing national dental health services systemsS. J, H. Hendricks*

Dental care syste?-ns are predo!ninanily based on the engineering and curative approaehto the body, which does nol necessarily improve dental health. In many western coun-tries, including some developing countries, tooth loss is still prevalent amid sophistica-ted systems of dental vare. The two major dental diseases, dental caries and periodon-tal disease, are almost entirely preventable. Against this background, a dental care sys-tem should encourage those working in it lo apply known effective methods lo improveand maintain the oral health of the population. The perceptions of people toward dentalhealth have long been disregarded by the profession, to the extent that individuals arevictim-blamed, irrespective of the existing soeioenvironmental factors that may influ-ence an individual's attitude towards dental services. The community must be involvedin the planning and decision-making processes of any health service program to facili-tate coope!-ation by the population in oral care. (Quintessenee Int t990;2J:¡63-l6ñ.)

Intrn auction

Evaluation of a poptilatioti's needs for dental healthservices requires (1) a knowledge of the state of thehealth of the population; (2) the existenee of well-defined standards of good health; and (3) a knowl-edge of what contemporary dentistry can do to im-prove ill health.

However, there is no consensus among dentists onwhat constitutes good health and which methods arethe most effective in achieving that state. Neither isthere consensus on what eonstitutes a need for treat-ment.'

The approach to dental care that has come to dom-inate dental health eare systems in much of the de-veloped world, as well as in most developing eountries,can be broadly characterized by a number of seperatebut related trends:

The Oral and Dental Hospital, Department of Community Den-tistry, Faculty of Dentistry, University of tbe Western Cape, Pri-vate Bag X12, Tygerberg 7500, South Alrica.

1. An orientation toward treatment and attemptedcare, rather than prevention, with the exception ofthe use of fluorides

2. An increasingly teehnologieal approach to diag-nosis and treatment

3. Inereasing specialization and fragmentation ofcare; eg, third-party payment systems thai reim-burse the dentist only for eertain types of treat-ment, which could beeome a determinant of thetype of dentistry practiced by the profession inareas where such payment systems are dominant.

The dominant philosophy of modern dental care isbased on the engineering approach" to the body andthe germ theory of disease.' The mouth is considereda collection of parts to be rescued, primarily by tech-nical intervention, from the effects of malfunction andbreakdown. The dentist is seen as a biotechnician whorepairs and occasionally services the machine. Thisphilosophy promotes the concept that a society eanmake progress in health by investing in the ever-in-creasing provision of highly sophisticated and tech-nological serviees. Indeed, it may undermine preven-tion by diverting resources away from prevention andby encouraging treatments of questionable necessity(although not to the exclusion of the importance offluoridation).

Quintessence i Vni|irnp?i Number 2/1990 163

Special Report

It would appear that governments, populations, anddentistry have come to accept dental disease, tooth-ache, tooth loss, and regular dental care as inevitable,and that the present system of dentistry, while notperfect, only requires minor changes. The criticistnsare confined to:

1, The nonavailability of dentists,*2, Costs,3, The insufficiency of preventive practice by dentists.

However, these do not extend to the fundatnentalhmitations of dentistry, namely the failure to pre-vent avoidable disease,' inappropriate intervention-ist approaches,' inappropriate antibaeterial orien-tation,^ and the way di.seasc and need are defined,̂

The present pattern of dental care may underminethe effeetiveness of prevention by diverting resourcesaway to engender a treatment approach to dental care.This aspect has been brought to attention by the find-ings of the Committee of Enquiry into UnnecessaryTreatment' in the United Kingdom, The cotnmitteeconcluded thats forms of unnecessary treatment oftenstemming from an out of date philosophy of care aremore widespread than deliberate unnecessary treat-ment.

The major shorteomings of the current systems ofdental care have been highlighted recently. The Inter-national Collaborative Study'" (ICS) has provided im-portant insights into both the strengths and weak-nesses of dominant systems. The tnost significant find-ing was that none of the dental systems studied wasable to prevent a large number of teeth from beingextracted from people by age of 35—44 years.

These findings highlight four important factors re-lated to the improvetnent of dental health:

1, Oral health is closely affected not only by manpow-er arrangements, but also by consumer behaviorand beliefs.

2, Utihzation of dental services in the areas studieddoes not reduce the incidence of dental disease.

3, Availability and accessibility of even the best sys-tem does not encourage good utilization by thepublic,

4, Even well-organized, widely available, school-based dental services do not necessarily lead to asatisfactory level of oral health in adult life.

These findings have an important policy implica-tion: The preventive efforts of the public and the

profession are both important, but as yet, inade-quate.'"

The alternative dental systems studied in the ICSsurvey showed httic difference in effectiveness ifjudged by their ability to prevent tooth loss in middleage. However, some individuals benefited from eachsystem. This suggests that no single system of dentalcare is suited to all sections of a population or suitablefor ail countries.

This study points to the importance of involvirtgconsumers in discussions concerning the acceptabilityof dental care. It also highhghts the relationship be-tween a repair-oriented dental service, the rate of den-tal diseases, whether increasing or decreasing, the wayadults pay for dental care, and the socioeconomic sta-tus of the community In countries with health insur-ance and private paytnent systems, a small part of thepopulation takes up a large part of the dentist's timeand finaneial resources. It has become increasinglyclear that the ruling assumptions among the dentalprofession, about the rational use of dental servicesand what eonstitutes acceptable and appropriate care,arc not necessarily accepted in the population at largeand indeed may vary greatly in their acceptanceamong different soeial groups. The desirability of pre-serving the natural dentition and regular maintenaticecare by dentists is predominantly taken up by the"middle-class strata," This philosophy finds few ad-herents among those that lie outside these strata thatare closest to the profession, that is, as refiected bythe needs of the minority groups, the rnajority ofwhom are not covered by third-party insurance.

The popular conception of dentistry is associatedmore with cosmetics than with health, given the de-creasing trend in dental decay in tnost of the developedcountries, and therefore does not relate directly to theassumptions of objectivity that underhe the medicaldisease concept. This brings to question and under-mines claims to objectivity based on the disease con-cept of oral health need. How people experience poordental health and perceive their own dental health sta-tus may provide sotue information on their dentalhealth e.\pectations and about the actions they willtake regarding dental health, including service use.Linn" found that for teenagers appearance is probablymore important than either function or health as areason for seeking dental care.

In reality, widely ranging treatment philosophieshave emerged under different conditions, retlecting theinfluence of contrasting national tradifions. Whilethere is variety in the delivery of care, the dominant

164 Quintessence International Volume 21. Numhpr 2/t990

Special Report

professional ideal remains that of technically profi-cient restorative dentistry'- Therefore, instead of un-critically following the convention of a 6-month inter-val for reeall for maintenance of dental care, plannersshould estabhsh eruption date profiles of teeth, thepattern of dental caries, the rate of progression ofdental decay the severity of periodontal disease, andhygiene and suerose habits. Thereafter a more rationaldental manpower system can be developed.

While attempting to characterize underutilizers ofdental services, researchers have concentrated on spe-cific characteristics, such as fear, ignorance, neglect-fulness, and distrust and have neglected the sociocul-tural determinants of utilisation, such as the availa-bihty of services and cost. Blaming "unmotivated"people or the poor does not assist the dental healthplanner; instead it may do more harm than good.Laheling people and making them conscious of them-selves as "deviants" may evoke the very behavior thatis inappropriate.

Sweden is one of the countries that has the mostfavorable dentist-population ratios in the world. How-ever, Hugoson and Koch'̂ report that, despite the con-siderable effort that has been made, it has not beenpossible in dental care to keep the two major diseases,dental decay and periodontal disease, under control.

It is therefore evident, in the absenee of broadlybased preventive measures, that an increasingly great-er proportion of resources will be devoted to technicalprocedures on a small segment of the population,'''Important steps to halt this trend will have to include(Ij prevention on a large scale; (2) change in thephilosophy of restorative dentists; and (3) the orga-nization of dental services that are acceptable andaccessible to that sector of the population most inneed of dental care."

The above may only be achievable if dental servicesare planned in line with the Primary Health Care Ap-proach (PHCA), which was formulated at the AlmaAta Conference in 1978.''' Primary health care, in itsnarrowest sense, means frontline or first eontact care.The broader philosophy of this approach was ex-pressed in the following declaration of the Alma Ata:"Primary health care is essential health care based onpractical, scientifically sound and socially acceptablemethods and technology, made universally accessibleto individuals and families in the community throughtheir participation and at a cost that the communityand the country can afford to maintain at every stageof their development in the spirit of self-rehance andself-determination.""

This approach is underlined by five principles:/, Equitable distribution. Dental services must be

more equally accessible and not neglect minority, ru-ral, isolated groups, and the poor. Hereby will be pro-vided the continuing and organized supply of can; thatis geographically, financially, culturally and function-ally within easy reach of the whole community. At-tempts should be made to reduce the inequity of dentalservice to develop a sound dental health system andto integrate oral health with general health services.

2. Community participaiion. Active participation bythe community in its own health decisions is essential.Oral health eare systems have been planned and de-veloped for the most part without much communityparticipation. Where communities have demanded or-al health services, the govemment, municipalities, andthe dental profe.ssion have usually provided serviceswith a restorative emphasis. More participation ofboth the community and the health profession is nee-essary to harmonize views and activities. The role ofsignificant members of the community serving as gooddental role models is important in establishing goodhealth practices. Decisions need to be made with thecommunity and not for them. Public decision makersshould be fully informed about comparative benefitsand costs of oral health programs before policy de-cisions are made. The benefits of the use of ñuorides,the reduction of the availahility of sugar-containingmedicines, baby foods, drinks, foods, and eonfections,optimal oral hygiene, and appropriate oral health careservices should be carefully explained.

3. Focus on prevention. Preventive and health-pro-moting approaches rather than curative servicesshould he the foeus of care. The two major dentaldiseases, dental caries and periodontal disease, can beeffectively prevented by available methods. Populationstrategies based on optimal oral hygiene, to controlperiodontal disease, should be implemented with com-munity participation at all stages of development.

4. Appropriate technology. The methods and mate-rials used in the health eare system should be accept-able, realistic, and relevant to the population. Tech-nology refers to an association of methods, techniques,and equipment, which, together with the people usingit, can contribute significantly to the solution of ahealth problem (eg, dental caries). Currently, in SouthAfrica, there is a so-called surplus of white dentists ata ratio of 1:2000, while the dentist-population ratiofor the blacks is 1 ;2 million, What is presently requiredis the effective redistribution of manpower, irrespectiveof population groups. It may be better at present to

Quintessence International VnliimP 7^. Numher 2/1990 165

Special Report

train more dental health educators and dental thera-pists with an acceptable career structure, than to trainmore dentists in this country, unless the approaeh lothe training of demists at the undergraduate level ischanged from a trealment to a preventive orientation.

5. Mulliseetoral (intersectoral) approach. Themouth must be seen as a part of the body and not asan isolated entity. Health is only a part of total care(along with education, shelter, and nutrition) and canbe improved involving the agricultural, food manu-facturing, economic, and employment sectors. An ac-ceptable level of health cannot be achieved by thehealth care system alone. It can only be achievedthrough the national, political will of the people of acountry and coordination of all sectors involved.

The World Health Organization, the FederationDentaire Internationale, and some national dental or-ganizations are committed lo ihe goal of "health forall by the year 2000." The dental goals have been setat a level that is achievable, rather than based on theabsence of disease, disability, discomfort, and stress.The adoption of the relevant concepts of the PHCAwill make a significant impact on oral health for all,as well as on the achievement of these goals.

In spite of evidence showing that current methodsand systems are ineffective, civil servants and the ma-jority of that part of the dental profession concernedwith the determination of policy and oral care strat-egies remain preoccupied with data showing that thenumber of restorations and courses of trealment areincreasing, on the assumption that the more treatmentprovided, the better will be the health of the public.

The Boston Dental Health Care Program has dem-onstrated ihat in a participatory program, wherebythe consumer is engaged and encouraged, the healthstatus of the ncighorhood improves because of theconcern of a dentally oriented consumer constituency.The dental profesión should think of dental publichealth as the first line of defense for the preservationof private practice. Furthermore, if the needs of thedisadvantaged are not met, then society may legislatea system to meet Ihose needs in the same way, andthey will involve the private sector in doing that."'

A dental care system should encourage those work-ing in it to apply known effective methods to improveand maintain oral heallh for the population. It shouldbe personally and financially satisfying to the profes-

sion, encourage innovation and the integration of ef-forts with other health and educational services, andbe supporied by the community.

References

1. Shi?ili;im A: Pkinning for manpower requirements in dental pub-lit; heulih. in Sl;ick GL (eii]: Dentat Pubtic Health, Bristol, JohnWright & Sons, Ltd, 1981, chapter 8, pp 148-200.

2. McKeown T: The Rote of Medicine. Oxford, Blackwell, Scien-tific, 1979.

3. Dussault G. Sheiham A; Medical theories and professional de-velopmcnl. The theory of focal sepsis and dentistry in eurl>twentieth century Britain. Soc Sei Med 1982;!6:1405-1412.

4. Dreyer WP. Lemmer J, Dreyer AG: The dental manpower sit-uation in Sotith Africa. J Dent Assoc S Air 1984; 10:696-706.

5. Frandsen A: Dentat Heailh Care in Scandinavia. Chicago, Quin-tessence Publ Co, I9B2, pp 107-117.

(i. Elderlon RJ: Assessment and clinical management of early car-ies in young adults: invasive versus non-invasive methods. BrDem J 1985c; 158:440-444.

7. Sims W: Streptococcus mtitans and vaccines lor dental caries:a personal commentary and critique. Commun Dem Heoltii J1985;2:129-147.

8. Sheiham A, Maizeis JE, Cushing A: The concept of need indental care. Im Dem J 1982;32:265-269.

9. Committee of Enquiry into Unnecessary Denial Trealment. Lon-don, HMSO, 1986.

10. Arnljot HA, Barmes DE. Cohen LK. et al; Attitudes and be-haviour related to oral health, in Arnljot HA. Barmes DE, Cob-en 1,K, et al (eds)' Oral Heattli Care Systems. An ImernativnaiCollaborative Study (coordinated by the World Health Organi-zation). London, Quintessence Publishing Co. 1985. chapter 5,pp 101-138.

11. Linn EI: Teenagers' attitudes, knowledge and behaviors reiatedto oral health. / Am Dent As.ioc 1976;92;946-93l.

12. Elderton RJ; The quality of amalgam restorations, in AUredHA (ed): Series of Monograptis in the Assessment ofthe Qualityof Dental Care. London, London Hospital Medical College.1974, pp 45-79.

13. Hugoson A, Koch G: Oral Health in 1,000 individuals aged 3-70 years in the community of Jonkoping, Sweden. SnedDentJl979;3:69-87.

14. Strifñer D: Dental treatment need, demand and utilization, inSlrilller D. Young WO. Burt BA (eds): Dentistry. Denta! Prac-tice, and tiie Connnunitv. Philadelphia, WB Saunders Co, 1983,pp 293-339.

15. Alukian MA; The role of LI city dental program in improvingthe dental health of inner-city communities. J Public HeaitiiDem l981;4i:98-102.

16. Alukian MA: Aiukian's goal: bring dentistry together. ADANews I989;2OÍ5):I5.

17. World Health Organization: Primary Health Care: A Report ofthe International Conference on Primary Health Care (AlmaAta, USSR, Sept 1978). Geneva, World Health Organisation,1978. a

166 Quintessence International Volume 21, Number 2/1990