Integrating dental care with general health care / by Aubrey Sheiham

Integrating dental care with general health care by Aubrey Sheiham Professor Aubrey Sheiham is with the Department of Community Dental Health and Dental Practice, University College, London, U.K. 0 ral diseases affect a very high proportion of people and, although the conse- quences are not fatal, they are seri- ous. Among the consequences are toothache, anxiety about dental treatment, limitations of the foods that are chosen, embarrassment about appearance. Children with teeth that hurt when they eat will restrict their diet, and so will old people with no teeth. People with decayed or missing front teeth may avoid social contact. In addition to these social and psychological consequences the costs in financial terms are consid- erable. In the United Kingdom oral diseases are the third most expen- sive of all diseases to treat; the cost of dental treatment runs to about one thousand million pounds a year. Because oral diseases are chronic and require regular treat- ment and re-treatment under the current systems of dental care, the lifetime costs are high. However the challenging and exciting fact is that the two main oral diseases, dental caries and periodontal dis- ease (gum infection), are entirely preventable by currently available measures. The dramatic potential of pre- vention has been clearly demon- strated by the marked improve- ment in oral health in the past 15 28 years. Most industrial countries have recorded improvements in dental caries of between 30 and 40 per cent in ten years. In some coun- tries the annual decrease in caries among 12-year-olds was 10 per cent per year. This has led to the closure of some dental schools in Holland, Sweden, and the United States, and to a marked reduction in dental stu- dents. WHO predicts that there will have to be a decrease in the num- bers of full-time dental personnel from about 650,000, at present, in industrialised countries to 150,000 within the next 40 years-a 75 per cent reduction. If planners adopt a public health approach stressing the use of fluo- rides, reducing sugar consumption and improving oral cleanliness, fur- ther improvements in oral health should occur. And in developing countries such a step should halt the rapid worsening of oral health. There are good reasons for plan- ners to adopt a radical public health approach. WHO's Health for all strat- egy calls for the health sector to move increasingly towards positive health promotion, instead of being mainly concerned with providing conventional health services. Tradi- tional dental care is based mainly on curative services and individ- ual responsibility. A collaborative study undertaken by WHO and the US Public Health Service showed conclusively that such an approach has not achieved the desired im- provements in oral health. And since it is also very expensive, it is beyond the financial capacity of most countries. On the other hand, adopting a public health approach will im- prove oral health efficiently and cheaply, and at the same time en- hance general health. Indeed a health promotion approach to im- proving oral health could provide decision-makers with interesting guidelines on how to tackle other health problems. The first of several ways in which oral health may illustrate how to approach health promotion is by tackling causes that are common to a number of chronic diseases. Several non-communicable dis- eases such as coronary heart dis- ease, diabetes, cancer, bowel dis- eases, gall stones, and oral disease have diet as a common risk factor: a diet high in fat, sugar and salt, and low in fibre. An integrated pro- gramme is preferable to one direct- ed at specific diseases. Reducing sugar consumption for certain pop- ulations by a wide-ranging food and health policy which includes all levels of the food chain from food production to consumption so as to reduce a range of conditions should W oRLD HEALTH, October 1988 replace the present non-integrated programmes to reduce dental car- ies, heart disease, diabetes and obe- sity. WHO's Countrywide Integrated Non-Communicable Disease Inter- vention Programme (CINDI) ad- dresses the problem of an un- healthy diet as part of a broader strategy which includes a national health policy, district health pro- jects and the "healthy cities" cam- paigns. Such a multiple response on a broad front is more likely to make healthy choices the easier choices. Alternative approach Another way is to incorporate oral health into general health pro- grammes. The control of the other major oral conditions-periodontal disease, oral cancer, traumatised teeth and temporo-mandibular joint dysfunction-should all bene- fit from an integrated approach. For example, periodontal disease is mainly a dirt disease, caused by poor oral cleanliness. Oral cleanli- ness is related to body cleanliness. A logical approach to controlling periodontal disease is to include oral hygiene in the teaching of gen- eral hygiene carried out by parents, teachers and primary health work- ers. Such an approach encourages self-care. WoRLD HEALTH, October 1988 Yet another way is to adopt a population.:directed strategy other than one aimed at the individual. Oral diseases are public problems and are essentially socio-political in character. To concentrate on indi- vidual behaviour is not only over- simplification but even an evasion of public health responsibility. Indi- vidually-oriented programmes can and should be encouraged, but more attention must be given to an environmental approach directed at the whole population. The latter makes individual choice and op- tions easier and therefore increases freedom of choice. A cornerstone of the Health for all approach is the focus on preven- tion. Treatment of dental diseases is both relatively ineffective and be- yond the financial resources of much of the world. The effective- ness of prevention has been con- vincingly demonstrated : it should be allocated the highest priority. Treatment of disease to alleviate pain and discomfort is the next pri- ority. Here WHO's Three-Level Strat- egy for planning oral health has al- ready had some effect. The strategy emphasises firstly the use of appro- priate technology, that is, simple and inexpensive materials; then, simple clinical measures carried out by non-dental personnel or dental auxilliary personnel working in pri- Traditional dental treatment in Papua New Guinea. Left : Participants in an international seminar on the primary health care approach to oral health examine a patient in Pasang, northern Thailand. Photos WHO and WHO/P. Ozorio mary health care facilities; finally, specialist personnel to do the more complicated work at the third refer- ral level. The strategies available to pre- vent dental caries and periodontal disease can virtually eradicate them in the near future, and therefore can and should be incorporated into a primary health approach. They include a multisectoral food policy to increase the availability of fluoride, where less than optimal levels exist, either as fluoridated water or salt, or in toothpaste, and to develop guidelines for tolerable and adequate levels of refined sug- ar. A meeting will take place in Ge- neva early in 1989 with the object of tackling this subject. A popula- tion approach to improving general hygiene should serve to increase oral cleanliness and thereby reduce periodontal disease. Dental disease is increasing at a frightening rate in many develop- ing countries, and in some the level is higher than in industrialised countries. An integrated preventive approach offers the only realistic solution to the increasing problem of oral disease in developing coun- tries. For the treatment-oriented dentists in industrialised countries, it may however raise a quite differ- ent problem-that of over- manning. • 29