PubL HIth, Lond. (1979) 93, 25-30

Planning Dental Services for a University Population Joan E. Stoner M.D.S.

Department of Oral Medicine, Turner Dental School, Bridgeford Street, Manchester M 15 6FH An investigation was conducted to determine the appropriate dental service for a university, using one university dental service as a model. The aims, population, demands, needs and alternative strategies were examined. It was concluded that clear aims must be expressed before a university dental service can be planned.

Introduction The provision o f dental services for students is seen as a recent offshoot from the establishment o f student medical centres. One o f the first student dental services was established within the National Health Service at the University of Birmingham in 1948, because of the inability o f l h e local general dental practitioners to provide care for the student population. Several other universities have followed suit by establishing.comprehensive dental services, providing prophylactic and conservative dentistry to students who have been quick to appreciate the benefits of this facility. Among the earliest to provide such services were University College, London (t952) and the University o f Edinburgh (I954). I An investigation was conducted to determine the appropriate dental service for a university population using one university dental service as a model. It was decided that the investigation should be conducted in four stages: (1) Determination o f the aims .of the service and a delineation of the population; (2) Determination o f the demand for dental treatment from the population; (3) Determination o f the need for dental treatment among the priority group; (4) Investigation o f alternative strategies. Methods Determination o f the ahns of the service and definition o f the population A.n evaluation o f any serv{ce must be based on an understanding o f the stated aims o f that service. The aims of the dental service at the university under consideration were identified by a structured interviewwith the university dental surgeon and an examination of any relevant documents. The dentist's replies were tape recorded and then he was asked to listen to the recording, off;r further comments or confirm the validity o f his replies. Finally, the tape was scripted so that a permanent record o f the interview was made. In addition, any formal documents o f the university that might shed further light on these factors were examined. The documented data included the total number in the population in the academic years 1967-8 (Year 1) and 1970-1 (Year 2) broken down by status (undergraduates, postgraduates, staff), sex, faculty, age and place o f permanent residence (home or overseas). Information was also gained on any future plans for changes in sex ratio o f undergraduates, ratio o f home to overseas students and faculty undergraduate numbers. 0038-3506/79/010025 +06 $0 l.O0/0

@ ! 979 The Society of Community Medicine

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J. E. Stoner

Determination of the itemand for dental treatmel,;t from the population .Demand for dental treatment from the university dental surgeon was divided into the effective (met) demand of the total population and of the priority (undergraduales) group and the potential demand o f the priority Jzroup. The effective demand o f the total population (i.e. those using the clinic) was found by identi|~,ing those actually using the service, the reasons for their attendance, and the nature of the treatment they received. The people .using the clinic were determined during the structured interview with the dental surgeon and an examination of the clinical records held at the dental clinic. A random sample o f approximately 200 patients treated by each dental surgeon (university dental surgeon and assistant dental surgeon) was selected from 40 weeks o f Years I and 2. The data from Year 2 provided the material from which the main conclusions were drawn while data from Year I were used for comparison o f types of.treatment and o f trends in the population. Dental treatment was classified as emergency, routine and advanced. It was possible for a patient to receive one, two o r all three of these types of treatment. The decision on the type of treatment given was arrived at directly from the record made b y the dental surgeon involved. In addition, a survey was planned to investigate the effective and potential demands for treatment from the university dental surgeon by the priority group. In order to measure the changes in demand during the undergraduate"s stay at the university, a random selection of students was taken from the population o f first and third years because the majority of undergraduale courses are three years long. The sample was drawn from those students whose initial registration for first degrees was during the years 1970 and 1972. The target sample .of students was 234 in fl~e first year (1972)and 244 in the third year (1970).. The target sample was invited by a series o f three letters to attend a mobile dental examination van sited conveniemly within the university precinct. The effective sample was increased by allocating a second period o f t i m e in order to accommodate any student who had been unable to attend during the 'first. A third letter was sent to this group and on this occasion aquestionnaire was included, together with a stamped, addressed envelope and a request to the student to complete and return the questionnaire if he was unable to attend personally. Those subjects who attended the examination van received a dental inspection and were asked to complete the same questionnaire designed to ~etermine the effective demand for dental treatment from the university dental surgeon, dental attendance pattern and k-nowledge.of the student health centre dental clinic. Thus, two effective samples o f undergraduates were obtained; one sample agreed to a dental examination and the completion o f a questionnaire, while a second, smaller sample, returned the questionnaire but did not undergo dental examination.

Determination of the needfor dental treatment among the priority group (undergraduates) The denta;l treatment needs of the priority group were assessed in two ways: by appropriate items in the questionnaire and by direct examination o f their mouths. The oral examination was conducted under standard and constant conditions, the time taken being approximately two minutes. Each permanent tooth present was classed as sound, satisfactorily filled or decayed. Decayed teeth were divided into those requiring filling (not more than one wall missing) o r extraction (two or more walls missing, carious exposure o r abscess formation). Any student with a fractured incisor tooth was asked if he wished to have the tooth restored; the tooth was only classed as requiring extraction when the student did not wish to have the tooth restored and .there was a visible, traumatic or carious exposure, or abscess formation. New or replacement dentures were needed for aesthetic and/or functional purposes. All interproximal papillae and gingival margins, buccaI and lingual (or palatal) to the teeth were examined and classed either as free fi:om .acute ulcerative gingivitis (A.U.G.), o r having

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suffered from attack(s) o f A.U.G. if one or more papillae were flattened or cralered. A present attack was .shown by necrosis and ulceration in one or more .areas; in the last two events, treatment was indicated. Each third molar present in the m o u t h was examined and the gingiva distal to the tooth pressed firmly with the mirror-head. Treatment was needed when distal gingivae was soft or covering the o~:clusai surface o f the tooth.

Determhl~tion of alternatire strategies In order to compare and .contrast methods of organizing dental services for university populations, the management o f three different types of university dental service was studied. At the university under review, lhe dental surgeons work on a salaried basis and there is a dental hospital in the university precinct. At a college of another university, the dental ~urgeons practice on a contractual basis within the National .Health Service (N.H.S.) and there is a dental hospital nearby. The third type o f organizalion is a university dental sel vice where the dental surgeons work for a salary and there is no associated dental hospital. The salaried services were represented by the dental surgeon in charge o f one and an assistant dental surgeon who worked for the other. Both dentists agreed ~o a structured interview wh;,vh was recorded, checked and subsequently documented for future analysis. The dental surgeon in charge of the college dental clinic could not spare the time for a structured interview; however, he replied in writing to the questionnaire and gave the author a short appointment in which to clarify any difficulties in interpretation. Results The aims of the service and the population served The only aims that were defined at the beginning of the dental service were included in the conditions o f service given to the dental surgeon on his appointment. These were that he should carry out examination of students as may from time:to t i m e b e determined and should provide a service and treatment for all students. It was clear from the structured interview that he had formed his own unstated aims while developing the service. These were to relieve pain, preserve his patients" dentitions and to provide dental health education for the students who were among his patients so that they would b e able to .influence the attitude to dental care of their fellow contacts in society outside the university. From information obtained from the university dental surgeon and the Registrar's department, it became clear that the population.to be served was the total number of undergraduate and postgraduate students who were registered at the university, and the total number ofacademic, clerical and service staffwho wereon its payrol 1. It also became apparent that withinthe total population, there existed a priority group which was defined as the total number of undergraduate students who were registered with the university, but the dental surgeon emphasized that his first responsibility was to emergency treatment, regardless of the patient's position in the university. After this, routine treatment of undergraduates was given precedence because he thought that undergraduates had greater difficulty in obtaining -treatment than the.restofthe population. The total numbers in the undergraduate population for the academic years :I and 2 were 8607 and 9502 respectively. The planned rate o f increase during the quinquennium 1972-77 for undergraduates and postgraduates was an overall figure o f 30%. 2 The Registrar's department did not know if there would be a change in sex ratio or in the ratio o f home and overseas .students in the future. The increase in staff in general and in students in the Faculty o f Medicine would have a proportionally greater effect because they would be in the population f o r longer than the rest.

J. E. Stoner

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The demand for dental treatment fron~ the population Examination of a sample o f the records o f the t/Jinic population treated during years 1 and 2 showed that all three academic groups were represented (Table I). The ratio o f overseas to home students was one to six compared with one to eight in the university population. Ivwas queried whether distance o f the subject's home from the university was a factor associated with the use of the service; 10-7 °./oo f the subjects lived within a day's return journey o f the city centre and it was thought that only these st,udents could reasonably have been expected to attend ~hrir family dentist during term. More routine treatment was given than either emergency or advanced treatment. No subjects requested orthodontic :treatment (advanced treatment) initially and only one subject wanted advanced restorative treatment (Table 2). TAnLE 1. Distribution of subjects treated bY the dental surgeons in the clinic sample by status (percentages in parentheses)

Undergraduates Postgraduates Staff

1967-8

1970-1

256 (60"2) 106 (25.0) 63 (14-8)

250 (59"1) 115 (27.2) 58 (t3-7)

TAnL~E2. Reason for initial attendance at university dental clinic (1970-1971) (percentages in :parentheses) Reason Emergency Routine Advanced

Undergraduates 78 (31.4) 169 (68-I) I (0.4)

Postgraduates

Staff

32 (27"8) 85 (72.1) --

16 (27.6) 42 (72.4)

The need for dentM treatment f"om the priority group (undergraduates) All 281 students examined were free from A.U.G. and pericoronitis but there was the possibility that the f o a r (1.4 ~o) students who had suffered a past attack of A.U.G. would have a recurrence. However, potentialpericoronitis seemed more probable, particularly in the 39-9 ~o o f students who had gingivai tissue covering the occlusal surface o f third molars. No edentulous students were seen and only four (1-4 ~ ) required partial dentures. It was found that the main need was restoration o f 260 teeth in 123 subjects.

Alternate strategies The three dental surgeons who took part in this section o f the investigation differed in respect to conditions of remuneration. At the university under review, the dental surgeon and his assistant received a salary from the university. The university dental surgeon presented a quinquennial estimate o f dental service expenses. Another university had a satariedservice and the professional staffconsisted o f the dentat surgeon in charge and two assistants. This university insisted that the dental service should cover its expenses and the maximum subsidy was £500 per annum. At a college of the third university, the dental surgeon and his assistant were independent practitioners on a contractual basis with the N.H.S.

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20

Patients from the fir,sl and third dental services were referred to the local denial hospitals for advanced treatment but the only denial treatment which could be offered to patients from the second dental service was advanced oral surgery carried out by the consultant regional dental surgeon z also opinions could ,be sought for orthodontic treatment or biopsies performed. Discussion This study analyzed a dental service for a defined community in an attempt t o identify the reasons for its establishment, todiscover lhe present organization and to measure the effectiveness in meeting its aims. The analysis was planned to uncover weaknesses and strengths in the present universitydental service and t o p e r m i t synthesis of alternative strategies in order to render it more effective, efficient and appropriate. The only aims ever set by the university were for dental examination o f students and the provision o f a dental advisory and treatment service with priority for students. The first aim has never been achieved.Aims are the expected achievements o f a service but are insufficient as a basis for planning. It was clear from tiffs investigation that ,the total population of the universily ( 15,000 in 1970"71) could not be providedwith traditional comprehensive care by any un iversi ty den~al service and is an excellent example of the failure to express clear aims, to identify a realistic .population and to gather relevant facts before beginning a planned dental service. In fact,, only 13 ~ of the undergraduate sample had sought dental treatment from the service, although as many as 52 ~o expressed a desire for the service. The proportion o f undergraduate visits to the dental ~linic appeared small for a service that gave priority to this section o f the population and possibly reflects the difficulty o f providing a treatment service for undergraduates. The fact that undergraduates are only at university for approximately 30 weeks .of the year creates a problem in the organization o f any service. Any high resource ~ervice such as dentistry has the diffieu~ity o f covering expenses during vacations which probably explains the reason for including staff in the population as eligible for treatment, for there appears to be n o other reason for .offering them treatment already available through general demal practitioners. Using the staff as a means o f keeping the dental service active during vacat ions, is a consequence o f inadequate planning. The undergraduates showed a greater demand for emergency treatment, 30~o having a~tended the university dental service for this reason and 8 ~o having suffered de~ltal pain or infection which had affected their university studies. In the light of these findings it would seem that an emergency service for undergraduates is very desirable, Oral examination of the undergraduates showed that most of~t.heir past treatment demand had been adequately met, for the majority had clean, well-restored mouths. This was supported by evidence .from the questionnaire sample, 80 70 o f whom had received treatment •during the previous 15 months. It is interesting in this respect that Anderson and his coworkers a enpected university students to possess an ~nc:'eased awareness of dental health in view of their higher than average intelligence. They fo~Jnd that 80 ~o of their sample were regular dental attenders which is remarkably .similar Io that o f the present study. It was apparent on examini~gvarious dental services that the method o f remuneration fiad a direct influence on the type ofservice offered and should be one of tile main considerations in the development of plans for a university dental service. A dentist paid on a fee-for-item basis, will, in his own interests, work rapidly and efficiently. This is a satisfactory arrangement for both the dentist and the funding agency provided that the objectives of both are met. However, one dental surgeon had set himself the objective of educating those of the population who sought his he{p to a higher appreciation of dental health so that these •future leaders could disseminate this in their postgraduate life. An objective o f this nature is

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J. E. Stoner

difficult to include under a fee-for-item arrangement and if the university accepted it as an aim, then it would need to finance it on a separate basis. Some dentists might feel that the same principle would hold for the provision ofan emergency service or for advanced restorative treatment. An alternative strategy which might resolve the conflicts o f t h e two systems o f remuneration would be a combination of basic salary coupled with a bonus scheme similar to that being tested at the Woodside Health Centre. 4 Is there another possible strategy available that might overcome some o f the difficulties encountered in this investigation ? It might be questioned whether a university should provide full dental treatment for students and staff or whether it would be more appropriate to establish an .advisory service guiding students to local general dental practitioners or other treatment centres. The reorganization o f the N.H.S. with the establishment o f a community dentist to each Area Health Authority and an advisory dental committee to effect integrated planning would seem to provide the forum for a cons.ideration o f this possibility. It may be that some or all of tile general dental.practitioners might be able to provide a restorative and emergency service if this were planned by the Area Dental Officer in coIJaboration with the university and the dentists involved. 5 Under these circumstances it might be possible for the university health centre to direct a student to an appropriate local practitioner on an agreed basi~. Surgical problems associated, for.example, with impacted third molar teeth might be dealt with by the existing hospital dental service. A service o f this nature coupled with a good information system to the undergraduates and associated with advice to obtain dental care before .commencing their university studies might meet the objectives in the most efficient manner. In conclusion, the appropriate strategy will depend on the objectives set~ the population to be served and.the prevailing conditions o f that university; but whicheverplan is adopted it should provide an emergency service for all undergraduates, a routine restorative service for those undergraduates who demand it and who have no available dental practitioner, and a surgical and advanced restorative service for those undergraduates in need.

Acknowledgements I should like to thank Dr P. J. HoIIoway for introducing me to this branch of Community Dentistry. My thanks are also due to the university dental surgeons and students who assisted me with this investigation. References 1. Verney, R. E. (1954). The history of student health services in Great Britain. University Quarterly 9, 23. 2. Armitage, A. L. (1973). Communication, Feb. t. University of Manchester. 3. Anderson, R. J., James, P. M. C., James, D. M. & Norden, H. (1971). Dental caries experience and treatment patterns. British Dental Journal, 131, 67-70. 4. Crerar, E. R. (1974). Personal communication. 5. Taylor, G. O. (1976). Co-operation between school dental service and general dental service. British Dental Journal 141, 59-60.

Planning dental services for a university population.

PubL HIth, Lond. (1979) 93, 25-30 Planning Dental Services for a University Population Joan E. Stoner M.D.S. Department of Oral Medicine, Turner Den...
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