Integration of oral health into primary health care: the role of dental hygienists and the WHO stewardship

Abstract:  Interest in addressing the unmet oral health needs of the citizens of the world has manifested itself, lately, in noteworthy expressions of commitment. Oral health is integrated with general health and support for community programmes offering 'essential oral health' within primary health care (PHC) is increasing. The WHO Global Goals for Oral Health 2020 has assumed a more directed public health orientation, and the Global Oral Health Programme has its focus on modifiable oral risk behaviours. Last, but not the least, opportunities are being created, under the 'stewardship' of the World Health Organization (WHO), for the expansion of oral disease prevention and health promotion knowledge and practices in communities. A review of the literature on community-oriented oral health primary care reveals one dominant and disease-oriented practice model with dental practitioners being the principal and exclusive actors. One alternative to this biomedical model of care that may be better suited to translate health promotion principles into action at community levels is the practice that involves hygienists serving as primary oral health care providers. The WHO 'stewardship' should include the support of dental hygiene practice within PHC, many legislative restrictions and regulatory barriers would be relaxed, thus enabling dental hygienists to respond to the WHO's call for community-based demonstration projects. With their focus on preventive oral care, hygienists are 'best poised' to help accelerate the integration of oral health with primary care, particularly in the light of the compelling evidence confirming the cost-effectiveness of the care delivered by intermediate providers.     

The military oral health care system as a model for eliminating disparities in oral health

BACKGROUND: Healthy People (HP) 2010 is a national health promotion and disease prevention initiative of the U.S. Department of Health and Human Services. The HP 2010 report highlighted a range of racial/ethnic disparities in dental health. A substantial portion of these disparities appear to be explained by differences in access to care. Members of the U.S. military have universal access to care that also has a compulsory component. The authors conducted a study to investigate the extent to which disparities in progress toward achievement of HP 2010 objectives were lower among the military population and to compare the oral health of the military population with that of the civilian population. METHODS: The participants in this study were non-Hispanic white and non-Hispanic black males aged 18 to 44 years. They were drawn from the Tri-Service Comprehensive Oral Health Survey (10,869 including 899 recruits who participated in the TSCOHS Recruit Study) and the Third National Health and Nutrition Examination Survey (4,779). RESULTS: We found no disparities between black and white adults in untreated caries and recent dental visit rates in the military population. Disparities in missing teeth were much lower among military personnel than among civilians. CONCLUSIONS: A universal access-to-care system that incorporated an aspect of compulsory treatment displayed little to no racial disparity in relevant oral health outcomes. This demonstrates that it is possible for large, diverse populations to have much lower levels of disparities in oral health even when universal access to care is not provided until the patient is 18 or 19 years of age.     

The Central Massachusetts Oral Health Initiative (CMOHI): a successful public–private community health collaboration

Objectives: The Central Massachusetts Oral Health Initiative (CMOHI) aimed to improve access to quality oral health care in central Massachusetts. Methods: A broad‐based public and private organization partnership with local and national funding created a steering committee to organize school administrators, community leaders, and a medical school to collaborate on five goals: advocate for changes in oral health policy, increase oral health care access, provide school‐based dental services for underserved children, establish a Dental General Practice Residency, and educate medical professionals about oral health. Results: A state legislative Oral Health Caucus helped secure sought‐after policy improvements; more regional dentists now accept Medicaid; community health center capacity to provide dental services was expanded; school‐based programs were designed and delivered needed dental services; a dental residency was created; and methods of educating medical professionals were established. Conclusions: Significant sustainable gains in oral health care access were created through our multifaceted approach, ongoing evaluation and communication, coordination of CMOHI partner resources, and collaboration with other involved parties.     

Issues in Financing Dental Care for the Elderly

The elderly make up an increasingly larger segment of the patient population in dental practices. This article reviews recent epidemiologic, demographic, and health services research, and concludes that significant segments of the elderly are at high risk for oral disease and/or limited access to dental treatment, and consequently warrant classification as high-risk groups for policy considerations. It then proposes policy options to the dental community and public decision makers. Oral care can be viewed as having three components. Two basic components are the primary care component--which includes diagnostic, preventive restorative, and periodontal care--and the acute care component--i.e., the treatment of oral pain, trauma, and infection. The third, rehabilitative component, has to do with the restoration of oral function, including prosthodontics and cosmetic dentistry. Viewing dental care in this perspective may help link funding for dental primary care services with that for other primary health services, and link restoration of function and improvement of quality of life with similar health services, like hearing, vision, and social services. In addition, approaching dental care policy makers on several levels--i.e., federal, state, and local--will contribute to our ability as a profession, in the decades ahead, to meet the oral health needs of more elders: including the frail, those at high risk for oral disease, and those with limited access to care.     

Geriatric oral health issues in Africa: Tanzanian perspective

A review of oral health issues for the elderly in Tanzania is presented and conclusions drawn from the analysis are applied to the broader African situation. It must be remembered that life expectancy (at birth) in Tanzania has been below or equal to 50 years, which places adults aged 35+ years in the elderly group of citizens. Access to professional care is limited, especially in rural areas, resulting in most people seeking care only when in severe pain and often leading to extraction. People aged 40+ years, who live in rural areas, are at higher risk of destructive periodontal disease and it is recommended that oral health education, focusing on behaviour change should be initiated from childhood. Innovative training programmes for primary health workers already working in rural areas can improve both access to professional care and accurate preventive oral health messages. Health professional training programmes should emphasise the importance of good oral health to overall health. Such an emphasis will help galvanise health care workers in the delivery of services. The ultimate goal for the government, health professionals and educators should be to move the Tanzanian people toward a greater understanding of oral health and the prevention of oral diseases, a goal which might also be set elsewhere in Africa.     

Dental hygiene in Australia: a global perspective

Aim: This article reports on the practice of dental hygiene in Australia from a global perspective. The aim is to examine how access to qualified dental hygiene care could be improved and how current professional challenges might be met. Method: Secondary source data were obtained from a survey questionnaire presented to members of the House of Delegates of the IFDH or by fax and e‐mail to experts involved in the national professional and educational organization of dental hygiene in non‐IFDH member countries. Responses were followed‐up by interviews, e‐mail correspondence, visits to international universities, and a review of supporting studies and reference literature. Results: The introduction of dental hygiene in Australia was inspired by the delivery of preventive care in Great Britain. Today dental hygiene is a paramedical profession, generally studied at institutions of higher education. Study duration is 2 (diploma and associate degree programmes) and 3 years (Bachelor of Oral Health Programs). A recent trend to combine dental therapy and dental hygiene education poses the challenge to maintain a stand‐alone degree in dental hygiene as it is practiced worldwide. Low access to qualified dental hygiene care may be a result of insufficient funding for preventive services, social and cultural lack of awareness of the benefits of preventive care, and of limitations inherent in the legal constraints preventing unsupervised dental hygiene practice. These may be a result of gender politics affecting a female dominated profession and of a perception that dental hygiene is auxiliary to dental care. Changes are expected to reflect the global trend towards a decrease in supervision and towards higher education. An example of innovative practice of public health is the involvement of dental hygienists in the educational process of aboriginal health workers in order to promote access to oral health education for indigenous populations.     

Priorities in oral health care in non-EME countries

This paper describes the prevailing problems pertaining to oral care in non-established market economy (non-EME) countries. The current situation with large numbers of untreated cases of oral diseases, the inequality in delivery systems and the virtual non-existence of an adequate community oriented prevention calls for action. What is needed is a turn towards an oral care system that meets the principles of primary health care (PHC). This implies an oral health care system which makes use of the existing health care infrastructures and which applies an appropriate technology with emphasis on community oriented prevention directed to all at an affordable price. Four components of oral care are proposed as priorities in basic oral care, aiming to achieve the objectives of the PHC philosophy. These four components are: emergency care; exposure to fluoride; oral health education (OHE); atraumatic restorative treatment (ART). These components should be available for all. The exact content and extent of each component in various countries depends on local existing supporting conditions and on the level of development as well as on specific perceived needs of the population. Therefore, small-scale demonstration projects containing one or more of the described components should firstly be launched in various countries to evaluate the acceptability, effectiveness and sustainability of the proposed basic oral care programme.     

Dental status and oral health quality of life in economically disadvantaged French adults

Expansion of French health insurance coverage has increased funding for dental care for economically disadvantaged adults. This study aimed to measure clinical and self-perceived oral health, behaviors, and use of dental services by adults who were eligible for such coverage. The regional agency that gives administrative services for the health insurance funds provided a sample of 900 adults aged 35–44 years, insured through this program. We reached 805 of these adults by mail; of these 18% were surveyed and clinically examined. Self-perceived oral health was measured by the Global Oral Health Assessment Index (GOHAI) and participants' attitudes to dental health, by questionnaire. Decayed and Missing teeth constituted 40% of the DMFT. Participants reported poor oral health (63%), and 79% perceived a need for care, although they used dental services infrequently and had poor knowledge of available services. Cost of care and number of carious teeth were important predictors of the GOHAI.     

Evidence and the Practice of Prosthodontics: 20 Years after EBD Introduction

Prosthodontics has a rich history related to the principles embedded in evidence‐based health care. This paper reviews the evidence‐based prosthodontics activity over the past 3 decades. It also discusses the impact of health care reform on evidence‐based medicine as it relates to broader context of care outcomes. Finally, the value associated with an Evidence Stewardship emphasis in prosthodontics is presented. This emphasis suggests that combining evidence from clinical trials with evidence from clinical practice environments best equips clinicians for the management of patients in the future. Adoption of a strategic Evidence Stewardship direction is an extended commitment to change that recognizes health care reform aims and seeks to be an accountable provider group in the broader health care arena. The vision to form a representative network of prosthodontic practitioners that augments a commitment to Cochrane “clinical trial” data demonstrates a responsibility to professional transparency about who we are, adds value for patients and oral health care providers, impacts teachers and students in dental education, and provides a measure of care accountability unique in dentistry.     

Compliance with infection prevention and control in oral health‐care facilities: a global perspective

Many publications are available on the topic of compliance with infection prevention and control in oral health‐care facilities all over the world. The approaches of developing and developed countries show wide variation, but the principles of infection prevention and control are the same globally. This study is a systematic review and global perspective of the available literature on infection prevention and control in oral health‐care facilities. Nine focus areas on compliance with infection‐control measures were investigated: knowledge of infectious occupational hazards; personal hygiene and care of hands; correct application of personal protective equipment; use of environmental barriers and disposable items; sterilisation (recirculation) of instruments and handpieces; disinfection (surfaces) and housekeeping; management of waste disposal; quality control of dental unit waterlines, biofilms and water; and some special considerations. Various international studies from developed countries have reported highly scientific evidence‐based information. In developed countries, the resources for infection prevention and control are freely available, which is not the case in developing countries. The studies in developing countries also indicate serious shortcomings with regard to infection prevention and control knowledge and education in oral health‐care facilities. This review highlights the fact that availability of resources will always be a challenge, but more so in developing countries. This presents unique challenges and the opportunity for innovative thinking to promote infection prevention and control.     

Poor oral health as an obstacle to employment for Medicaid beneficiaries with disabilities

Objectives: To inform policy with better information about the oral health‐care needs of a Medicaid population that engages in employment, that is, people ages 16 to 64 with Social Security‐determined disabilities enrolled in a Medicaid Buy‐In program. Methods: Statistically test for significant differences among responses to a Medicaid Buy‐In program satisfaction survey that included oral health questions from the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System and the Oral Health Impact Profile (OHIP) to results for the state's general population and the US general population. Results: All measures of dental care access and oral health were significantly worse for the study population as compared with a state general population or a US general population. Differences were particularly pronounced for the OHIP measure for difficulty doing one's job due to dental problems, which was almost five times higher for the study population. Conclusions: More comprehensive dental benefits for the study population could result in increased oral and overall health, and eventual cost savings to Medicaid as more people work, have improved health, and pay premiums for coverage.     

Self-reported oral health perceptions of Somali adults in Minnesota: a pilot study

Abstract: Objective: To assess self‐reported oral health perceptions and associated factors in an adult Somali population living in Minnesota, USA. Methods: We analysed data from a cross‐sectional study of Somali adults aged 18 to 65+ years attending a dental school clinic for care. A comprehensive oral examination was performed by the dental school outreach team on all patients who attended a 2‐week designated Somali dental clinic. Adults who consented were given an oral health questionnaire to collect information on sociodemographics, marital status, language preference and self‐rated oral and general health. We performed summary statistics and differences between proportions using Fisher’s exact test and a comparison of means using one‐way anova or a two‐sample t‐test. Results: The sample consisted of 53 adults, 75% of whom were females. About 49% of subjects reported poor/fair oral health and 38% reported poor/fair general health. Seventy‐four percent rated their access to dental care as poor/fair and 83% reported that they did not have a regular source of dental care. Self‐rated oral health was significantly associated with marital status (P < 0.05) and self‐rated general health (P < 0.01) using Fisher’s exact test. Conclusion: A substantial proportion of Somali adults rated their oral health and access to dental care as poor/fair. These findings suggest that this population would benefit from improved access to oral health care and culturally appropriate oral health education and promotion programs.     

Oral health care delivery in Denmark: a system of private enterprise and public accountability

Abstract The Danish oral health care delivery system is a publicly funded, predominantly school based system of care for children and adolescents and a private practice copayment national health insurance mode for adults. Study of this dualistic system can provide useful information to dental public health practitioners. Interviews with experts in the Danish oral health care system and a selected review of the literature demonstrate that improvement trends are occurring in the oral health status of both adults and children. These improvement trends can be directly related to a combination of treatment and preventive measures undertaken by the country as a whole, and to specific interventions for certain subpopulation groups, such as preschoolers. Four key variables can be defined which have contributed to the success of the Danish oral health care delivery system (DOHCDS). These include 1) the role of private sector input into the development of the DOHCDS, 2) demography, 3) the Danish value system, and 4) the structure of the DOHCDS.     

Primary care‐based facial pain unit in Vantaa: the first experiences 2003–2009

As an attempt to tackle the challenge in serving facial pain patients, the first primary care‐based facial pain unit was founded in 2003 as part of public dental primary care of Vantaa, Finland. Data were collected, consisting of sex, age, sources of referrals, reasons for seeking care, diagnoses made, therapeutic procedures, and numbers of visits to dentists and phone consultations. To describe the development of the present pain management system, we divided the observation periods into two parts: 2003–2006 and 2007–2009 and compared frequencies of the studied parameters between the two follow‐up periods. During 2003–2006, 370 patients were examined and the number of visits was 659, corresponding patients′ number was 437 and visits′ number 960 during 2007–2009. Referrals to the primary care facial pain unit came from primary care dentists (80%), respective primary care pain unit GPs (6%), oral hygienists (3%) and ordinary GPs (2%). Four percentage of the patients′ referrals came from secondary and tertiary care clinics of various types and 5% from private sector dentists and specialists. The average number of telephone consultations per year increased from 51 to 300 between study periods. During the follow‐up period, the main reason for seeking care from our unit was temporomandibular disorders. Education in self‐care, oral appliance therapy and physiotherapy were mostly used as management for these pain problems. The facial pain management unit in primary health care could be a useful model to serve increasing numbers of chronic facial pain patients.     

Access to dental care in two long-term refugee camps in western Tanzania; programme development and assessment

Objective: To analyse the demographics surrounding and the sustainability of a course in Emergency Dental Care and Health Promotion developed and taught by a team of dentists from the United States to refugee camp health‐care workers in two long‐term refugee camps in Western Tanzania. Methods: Refugee camp dental patient log books from Mtabila and Nyarugusu camps Kigoma, Tanzania were analysed and demographic data collected on each patient visit from the programme inception in November 2007 until August 2009. Data collection included information relevant to 1961 patient visits. Data were entered into SPSS Statistics 17.0 using the Freq application. Outcomes: Patient visit data included demographics involving both the resident camp populations and the surrounding communities. The distribution of patients treated by nationality was: 58% Burundian (Mtabila), 14% Congolese (Nyarugusu), and 28% Tanzanian citizens residing near both camps. Extractions accounted for 95.5% of procedures performed. Recorded incidences of post‐operative complications were 1 > % of patient visits. Patient visits were steady over time and a referral system was implemented for complex cases. Health promotion sessions were held in both camps. Conclusion: This dental programme has been self‐sustaining and is providing some access to care where none existed previously. Programmes such as this may be one solution to the access to dental care problem in long‐term refugee camps.     

A Systematic Review of Oral Health Assessment by Nurses and Carers for Residents with Dementia in Residential Care Facilities

This paper presents systematic review findings to best summarize the assessment of oral health and the use of oral assessment tools by nurses and carers for adults with dementia living in residential aged care facilities. The systematic review searched electronic databases for articles in English (1980 to 2002) and supplemented these with a secondary search of references cited in articles meeting the review inclusion criteria. Delineation is needed between a comprehensive dental examination conducted by a qualified dentist and a dental assessment screening by a carer, nurse, allied health professional or medical practitioner. Dental examinations should be supplemented with oral health assessments and screenings by trained nurses and carers to monitor residents' oral health, evaluate oral hygiene care interventions, act as a trigger to call in a dentist when required, assist with residents' individualized oral hygiene care planning and assist with triaging and prioritization of residents' dental needs. To date, the most comprehensive, validated and reliable assessment screening tool for use by nurses and carers with cognitively impaired institutionalized residents is the Brief Oral Health Status Examination. Other less comprehensive oral assessment tools that are useful for nurses and carers of institutionalized dementia populations include the Index of Activities of Daily Oral Hygiene and the Mucosal Plaque Score. These review findings presented evidence to support the use of oral assessment screening tools by nurses and carers for cognitively impaired residents living in residential aged care facilities. Few validated and reliable tools have been published for use by carers in the cognitively impaired residential care population, and continued evolution of oral assessment screening tools needs to embrace the complete spectrum of residents' levels of cognitive impairment. A. Pearson²     

Characteristics of African‐American Male Caregivers in a Study of Oral Health in Detroit – A Brief Communication1

Objective: The role of fathers among African‐American men, particularly related to oral health, has received relatively little scholarly attention. This paper describes the characteristics of African‐American men who self‐identified as primary caregiver to an index child participating in the Detroit Dental Health Project. Methods: Of 1,021 caregiver–child pairs recruited to this oral health study, 52 were male. Data were collected at a central site in Detroit on: 1) demographics; 2) social support; 3) oral health beliefs, behaviors, and knowledge; 4) caregivers' and child's oral health. Results: Participants reported good availability of social support and high perceived self‐efficacy to take care of their child's teeth, yet, they possessed limited knowledge on preventing oral health problems. Moreover, male caregivers had high levels of caries, missing teeth, and poor hygiene. Conclusions: Findings may inform the development of effective interventions aimed at male caregivers to improve knowledge and understanding of the caries process, particularly concerning their children.     

What contributes to self‐rated oral health among community‐dwelling older adults? Findings from the ElderSmile program

Objectives: As part of ongoing efforts by the Columbia University College of Dental Medicine to devise community‐based models of health promotion and care for local residents, we sought to answer the following query: “What contributes to self‐rated oral health among community‐dwelling older adults?” Methods: The present study is cross sectional in design and centrally concerned with baseline data collected during community‐based screenings of adults aged 50 years and older who agreed to participate in the ElderSmile program in northern Manhattan, New York City. The primary outcome measure of interest is self‐rated oral health, which was assessed as follows: “Overall, how would you rate the health of your teeth and gums – excellent, good, fair, or poor?” Results: More than a quarter (28.5 percent) of ElderSmile participants aged 50 years and older reported that their oral health was poor. After adjustment for age (in years), place of birth, educational level, and dental insurance status in a logistic regression model, recent visits to the dentist (within the past year versus more than a year ago) contributed to better self‐rated oral health and non‐Hispanic Black race/ethnicity, dentate (versus edentulous) status, tooth decay as measured by decayed missing filled teeth, and severe periodontal inflammation contributed to worse self‐rated oral health in this population. Conclusions: Recent dental care contributed to better self‐rated oral health among community‐dwelling older adults living in northern Manhattan. Significant gradients were evident in the caries experience and periodontal inflammation of dentate adults by self‐rated oral health, suggesting that untreated oral disease contributes to poor self‐rated oral health.     

Will improving access to dental care improve oral health‐related quality of life?

Background

The aim of this study was to determine if Australian Defence Force (ADF) members had better oral health‐related quality of life (OHRQoL) than the general Australian population and whether the difference was due to better access to dental care.

Methods

The OHRQoL, as measured by OHIP‐14 summary indicators, of participants from the Defence Deployed Solomon Islands (SI) Health Study and the National Survey of Adult Oral Health 2004–06 (NSAOH) were compared. The SI sample was age/gender status‐adjusted to match that of the NSAOH sample which was age/gender/regional location weighted to that of the Australian population.

Results

NSAOH respondents with good access to dental care had lower OHIP‐14 summary measures [frequency of impacts 8.5% (95% CI = 5.4, 11.6), extent mean = 0.16 (0.11, 0.22), severity mean = 5.0 (4.4, 5.6)] than the total NSAOH sample [frequency 18.6 (16.6, 20.7); extent 0.52 (0.44, 0.59); severity 7.6 (7.1, 8.1)]. The NSAOH respondents with both good access to dental care and self‐reported good general health did not have as low OHIP‐14 summary scores as in the SI sample [frequency 2.6 (1.2, 5.4), extent 0.05 (0.01, 0.10); severity 2.6 (1.9, 3.4)].

Conclusions

ADF members had better OHRQoL than the general Australian population, even those with good access to dental care and self‐reported good general health.     

Correlation between health‐care costs and salivary tests

The burden of health‐care costs relative to gross domestic product in Japan is increasing. A large percentage (7.6% in 2009) of the Japanese gross domestic product has been spent on health care, and this percentage has been increasing annually. Soaring health‐care costs have been recognised as a serious social problem. In this study, we attempted to estimate the relationship between periodontal disease and health‐care costs. Subjects consisted of teachers and staff members (35 men, 26 women; mean age, 45 ± 9 years) from two high schools. The salivary levels of lactate dehydrogenase and haemoglobin were adopted as biomarkers to assess periodontal disease. After salivary tests, data for the health‐care costs over the subsequent 6 months were provided by the mutual association of the public schools on an individual basis. Curve‐fit estimations were then performed where health‐care costs were used as a dependent variable and age or salivary levels of haemoglobin or lactate dehydrogenase were used as independent variables. However, no good fitness was obtained. Subsequently, multilayer perceptron neural networks were applied. With the neural networks, good fitness was obtained by using lactate dehydrogenase as an independent variable. The results of this study show that oral health, particularly periodontal disease, is correlated with total health‐care costs. The data presented in this study suggests that, from the perspective of both oral and systemic health, oral health can be a signpost in well‐being and health promotion.