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Library of Congress Cataloging-in-Publication Data
Names: Chestnutt, I. G., author.
Title: Dental public health at a glance / Ivor G. Chestnutt.
Other titles: At a glance series (Oxford, England)
Description: Chichester, West Sussex, UK ; Ames, Iowa : John Wiley & Sons, Inc., 2016. |
Series: At a glance | Includes bibliographical references and index.
Identifiers: LCCN 2015043947 (print) | LCCN 2015044762 (ebook) | ISBN 9781118629406
(paper) | ISBN 9781118629376 (pdf) | ISBN 9781118629390 (epub)
Subjects: | MESH: Public Health Dentistry—Handbooks. | Dental Health Services—Handbooks. | Oral Health—Handbooks.
Classification: LCC RK56 (print) | LCC RK56 (ebook) | NLM WU 49 | DDC 617.6—dc23
LC record available at http://lccn.loc.gov/2015043947
A catalogue record for this book is available from the British Library.
Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.
Cover image: © Tai11 / Shutterstock
Members of the dental team are in a unique position to offer tailored and personalized advice and to thereby educate their patients on the steps that are necessary to secure oral health. However, there is only so much that can be achieved by such one-to-one, ‘downstream’ interventions. It is crucial that all members of the dental team appreciate the wider determinants of health and the impact of lifestyle and life circumstances on the health and oral health of their patients. The population has not benefited equally from the significant improvements in oral health observed over the past four decades. That one half of all diseased teeth are concentrated in just 7% of 5-year-olds serves to highlight the health inequalities that pervade our society. It is crucial that from the earliest stage of their training, the next generation of dental professionals have an appreciation that the lives of others are frequently very different from their own.
Dental students rightly spend the majority of their time learning the theoretical, practical and clinical skills necessary to practise their chosen profession. Often it is only relatively late in their course that their attention turns to the environment in which they will have to deliver dental care and earn their living. It is important to have an appreciation of the issues involved in the organization, commissioning and delivery of oral healthcare at dental practice, regional, national and international levels. The principles of evidence-based practice are of ever-increasing significance in achieving this. In its guidance Preparing for Practice, the General Dental Council has placed great emphasis on learning outcomes that fall within the remit of dental public health. All of these factors emphasize the need for an understanding of the discipline.
The intention of this book is that ‘at a glance’ dental professionals will be able to come to a basic understanding of the principles and practice that relate to the science and the art of improving oral health at both an individual and a population level. Of course, the factors influencing public health practice evolve at a pace – a change of government, new guidance and new policies affect dental public health at a greater rate than other dental specialties. For this reason, the intention of this book is to raise awareness and provide pointers and flags that can be followed up via more exhaustive information sources.
While the basic principles of the discipline are universal, a complicating factor in writing a book on dental public health in the United Kingdom is the four different – sometimes very different – models of care that have evolved in the constituent countries following devolution in 1999. Where possible, attempts have been made to illustrate differences across the United Kingdom, but at times this is limited by the constraints of space.
The primary audience for this book is undergraduate dental, dental therapy and dental hygiene students, together with those in Dental Foundation and Core training and those preparing for MDFS or MJDF examinations. The book should also prove a useful resource for those preparing for the Diploma in Dental Public Health examination or the Overseas Registration examination. While at an entry level, the book may also act as an aide mémoire for those undertaking specialty training, and may indeed be of use to any member of the dental team who has an interest in the vast range of topics now embraced within dental public health.
The concepts arising in dental public health can be challenging from an academic perspective. Twenty years teaching the subject have taught me that it is one that students tend to love or hate. It is my hope that this book might go some way to encouraging more of the former and less of the latter.
I.G. Chestnutt
Cardiff
April 2015
Chapters
Dental public health is the science and the art of preventing oral disease, promoting oral health and improving the quality of life through the organized efforts of society.
In contrast to clinical dental practice, where the focus is on looking after individual patients, in dental public health practice the focus is on populations or defined groups within a population. The definition here refers to science. Dental public health requires a sound knowledge of the factors influencing the aetiology, detection, measurement, description and prevention of oral disease and the promotion of oral health. It also refers to art. This involves advocacy, policy development and the politics of how dental care is prioritized, organized, monitored and paid for in societies.
The key components of dental public health practice and how these relate to one another are shown in Figure 1.1. The core values of public health practice are as in Table 1.1.
Figure 1.1 Components of Dental Public Health Practice
Table 1.1 Core values of public health practice as defined by the Faculty of Public Health in the UK
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A comparison between clinical dental practice and dental public health practice is shown in Table 1.2
Table 1.2 A comparison between clinical dental practice and dental public health
| Individual clinical practice | Public health practice |
| Individual patients | Populations and defined groups within populations |
| Examination | Epidemiology, surveys |
| Diagnosis | Assessment of need |
| Treatment planning | Prioritization and programme planning |
| Informed consent for treatment | Ethics and planning approval |
| An appropriate mix of care, cure and prevention | Programme implementation |
| Payment for services | Programme budgeting/finance |
| Evaluation | Appraisal and review |
The Faculty of Public Health, the professional body that is responsible for setting standards in public health practice in the UK, describes the public health approach as:
How this applies to dental public health is shown in Table 1.3.
Table 1.3 The public health approach as applied to dentistry
Dental public health:
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In order to practise dental public health, knowledge of the following disciplines is important.
Oral epidemiology is the study of oral health and oral disease and their determinants in populations.
This refers to measurements and statistics that describe populations. It involves recording factors such as the age structure of the population, ethnic composition and educational attainment.
Understanding numbers and the inferences that can be drawn from them in reviewing disease trends and service provision is a key skill, as is the ability to appraise and conduct dental research.
Health promotion is the process of enabling people to increase control over their health and its determinants and thereby to improve their health. Health improvement recognizes that the determinants of health can be outside an individual’s control and is designed to address so-called wider determinants of health such as education, housing and employment. It is also designed to address the gaps in health between areas of high and low social and economic provision – gaps known as ‘health inequalities’.
Sociology is the study of the development, structure and functioning of human societies. An understanding of these factors is important in improving health and organizing healthcare services.
Psychology is the branch of science that deals with the human mind and its functions. In a public health context, an understanding of psychology is important in relation to behaviour change.
Health economics concerns the need for, demand for and supply of health and healthcare. In the context of dental public health, it relates to how resources are distributed and the effectiveness and efficiency of services. How care is commissioned and paid for is an important element of how dentistry is organized and delivered, and dental public health practitioners need a clear understanding of these issues.
Dental services are in competition with other forms of healthcare, whether paid for by the state or by individuals. They therefore need to be organized, managed and planned. Allocation of resources within a publicly funded dental service should be done in proportion to need and likelihood of benefit. Dental public health practitioners will be called on to give advice to health service managers and finance officers on the appropriate allocation of resources and to offer guidance on how dental services are planned and delivered.
Evidence-based practice is designed to ensure that wherever possible, the dental care that is delivered has been shown to be that which is most efficient and effective. It is the role of dental public health practitioners to facilitate such practice. Those responsible for dental public health need to understand the theory of evidence-based dentistry to support the improvement of oral health and the delivery of effective care.
The most widely accepted definition of health is that offered by the World Health Organization in 1948, which states:
Health is a complete state of physical, mental and social well-being and not merely the absence of disease or infirmity.
The key point in this definition is that health is more than simply not being ill. It encompasses all of an individual’s being. Today, health is also recognized as not solely a desired state to acquire, but a means to enable individuals to live their lives to the full and ‘be all they can be’.
Mirroring the definition of general health, oral health can be defined as follows:
Oral health is a standard of health of the oral and related tissues without active disease. That state should enable the individual to eat, speak and socialize without discomfort or embarrassment and contribute to general wellbeing.
This means that while a patient may have no active dental decay, or periodontal disease, if they are embarrassed by the appearance of their teeth when they smile, then they cannot be said to be have true oral health. This definition also recognizes that good oral health is integral to good overall health. Older people who cannot eat properly because they lack sufficient teeth or have inadequate dentures may become compromised nutritionally.
The impact of oral disease on individuals can be measured using social-dental indicators (Chapter 4).
Determinant simply means ‘factor influencing’. Many things can influence health. The diagram in Figure 2.1 was drawn by Dahlgren and Whitehead in 1991. It illustrates the concept of health being influenced by factors that operate at different levels.
Figure 2.1 The determinants of health. Source: Adapted from Dahlgren and Whitehead (1991). Reproduced with permission from Institute for Futures Studies.
First, health is determined by factors innate to the individual. So age, gender and genetic make-up will all influence health. These determinants are not easily amenable to change. For example, a degree of attachment loss and periodontal recession is almost inevitable as a patient ages, although this will probably reflect a mixture of ageing and exposure to the next level of determinants, lifestyle.
Health and oral health can be markedly influenced by lifestyle. Diet, smoking, consumption of alcohol and lack of exercise all have the potential to influence health. Dental caries is caused by exposure to excess fermentable carbohydrates (sugars), and smoking tobacco is a significant risk factor in the aetiology of periodontal disease and oral cancer (Figure 2.2).
Figure 2.2 Life circumstances and lifestyle as determinants of health
While lifestyle can be thought of as things people do to themselves (behaviours), life circumstances are things that are done to people and are to a large degree outside their direct control. As an example, peer pressure may lead a teenager to feel compelled to have an intra-oral piercing, or advertising may persuade people to consume foods that are high in sugar (Figure 2.2).
Interaction with others and the support that they provide are recognized as important determinants of health. Peer support and social interaction are necessary components of health for most people.
At the highest level, social and economic factors have a major influence on health. Policies decided at national and international levels have impacts on health. The ability of a community or country to provide basic education for its population, for example, will have an impact on health literacy. The proportion of a country’s gross domestic product (GDP; i.e. the country’s wealth) that is devoted to health services can influence how easy it is to access medical and dental care. There are large variations in the proportion of national wealth that is spent on health in different countries. In 2012 the United States spent 17.9% of GDP on healthcare, while the United Kingdom devoted 9.4% and France spent 11.7%. In developing countries the proportion of national wealth spent on health services is typically low, of the order of 3–5%, while at the same time vast sums are often spent on military and defence services.
The impact of the environment on health is of major concern. Worldwide issues such as global warming may in the long term have significant implications for health. However, even in the present environmental issues can influence health and oral health. Overexposure to sunshine and lack of use of protective sunscreens can cause skin cancers in the head and neck region. Underexposure to sunshine can result in lack of vitamin D and in diseases such as rickets.
This approach to understanding the determinants of health looks at how events in early life or across generations can affect susceptibility to disease in adulthood. Lifecourse studies investigate biological, psychological and behavioural factors and how these operate during gestation, childhood, adolescence and young adulthood to influence disease in later life (Figure 2.3). These types of study involve following up a cohort of people over time. An example is the Dunedin Multidisciplinary Health and Development study. This recruited a pool of children born in the Otago Region in New Zealand in 1972 and 1973 and has examined them at ages 3, 5, 7, 9, 11, 13, 15, 18, 21, 26, 32 and, most recently, at age 38 (2010–12). Oral health has been investigated as part of this study.
Figure 2.3 Lifecourse analysis as a means of investigating the determinants of health
Chapters