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THE CONCEPT OF HEALTH IN COMMUNITY DENTISTRY By Inkeri Barenthin, DDS* During the past few decades a number of efforts have been made to define health. For practical reasons, a need has developed to state a clear definition for measuring health in various contexts of research and health administration. If an investigator is to have a rational basis for forming official policies, planning and evaluating health programs, conducting health practice and research, or just making everyday decisions in health matters, he requires a precise understanding of the concept for health and the possibilities for measuring health. Definitions of health have been proposed, but none of them has gained universal acceptance. Growing agreement exists, however, that health is not merely the opposite of disease, but something positive and enjoyable, and closely related to the concept of wellbeing and a life of good quality. For the report to follow, the definitions of health should be examined first. Definitions of Health A frequently quoted definition of health, that of the World Health Organization,34 states that health is a state of complete physical, mental, and social well-being, and not merely the absence of disease and infirmity. This definition has been criticized for being too abstract and for oversimplification. Many writers accept it as expressing the ultimate goal in health rather than a guideline for concrete action. It brings out two essential components of a concept of health: (1) man is an entity of biological, psychological, and sociological elements, and (2) health is a state which concerns the individual and must be described in terms of an individual’s reactions.4 From a sociological point of view, the meaning of health varies with social and cultural conditions. Parsons22 relates health to capacity for effective performance of roles and tasks for which an individual has been socialized. Optimum health then can be defined with reference to the individual’s participation in a social system. Purola,*6 in terms of systems, looks at health as a state of adjustment and harmony between an individual and his surrounding systems, ecological and sociological. Wylie’s36 definition is similar, inasmuch as he states that health is the perfect, continuing adjustment of an organism to its environment. While most writers agree with the content of the definitions listed or other definitions (for reviews one may consult Goldsmith,l3 Sullivan,*I and Twaddle”), they object to the difficulty for transforming them into operational terms. The difficulties are similar to those encountered when one tries to construct social indicators, which is an effort of great concern in many countries at present. It is not data which are lacking, as Grogono15 puts it, because the collection and dissemination of facts about health service has become a minor industry in itself.

The Health Indexes In addition to a definition of health, indexes for measuring health are important. Mortality and morbidity are the long-used measures of health or, as many prefer to say, measures of ill-health. The pattern of disease has altered during the recent decades so that changes in mortality no longer denote changes of equal degree in the standard for health. Data on morbidity, disability, and functional impairment are more sensitive indicators of the amount of ill-health experienced. Although these indicators are suitable for certain purposes, their one serious drawback is that they measure illness, not health. *Department of Community Medicine, University of Uppsala, Akaderniska Sjukhuset, 750 14 Uppsala,

Sweden.

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One hardly can expect to get a universal index to express the combined effect of a number of components in a single figure, at least in the early future. Several indicators are available today, but they are limited in their use to certain well-defined conditions. The inferences and conclusions which can be drawn from them about most conditions may be of doubtful validity.10 Validity, one must keep in mind, is the degree to which a measure or procedure succeeds in accomplishing what it is supposed to do-in this instance, the success of the indicator in measuring total health and satisfaction. In spite of the severe methodological dangers associated, a number of efforts have been made to find simple and practical ways to measure the highly complex phenomena characterizing health. Fanshel” points out that an investigator should use different definitions for health suitable for specific studies. For the epidemiologist, he proposes an index of health status derived from the judgments on social value that a person is well if he is able to carry on his daily activities. He enumerates 11 stages of dysfunction, all characterized by different degrees of ability to carry on activities, regardless of the reasons for the handicaps. The index of Grogono and Woodgatel6 uses the sum of 10 numerical values allocated to its components of work, recreation, pain, worry, communication, sleep, dependency on others, feeding, excretion, and sexual activity, each considered equally important. Breslows proceeds, on the basis of the definition by WHO, to measure physical, mental, and social well-being on three different axes and classifies individuals by where they fall on these axes. Several additional indexes are described in the world’s literature, that one can examine. Examples are from the American Public Health Association,l Chiang,20 Goldsmith,I3 Lerner,l7 Patrick,23 and Sullivanm. The variety of these indexes can be used in different contexts or frames of reference. As Sullivan21 states, health, defined without reference to a specific situation or purpose of measurement, may be merely a verbal artifact. The Nature of Oral Health and Disease The next question to obtrude is “How does dentistry fit into the context of well-being and a life of good quality?” Oral health is a part of general health and, hence, affects the total well-being of individuals. The frequently used indexes are D M F (decayed-missedfilled teeth), PI (periodontal index) and GI (gingival index). These indexes are useful for measuring certain biological phenomena, but do not measure the perception of the individual whose dental health is being evaluated. Before any attempt to construct any index which would include measurement of subjective elements, such as the individual’s own judgment of his condition, the question has to be explored whether anything is gained by considering the individual‘s opinion. Dentists and patients often deviate in what they think is good oral health. The dentist may disapprove of the dental status of many patients who consider their teeth to be in good condition.6 The patient, however, may consider even the worst of dentures, by the dentist’s objective criteria, to be very satisfactory.6.19 Discrepancy between expert and lay judgment sometimes has been called a technological gap. The experts will know what is technologically feasible and why some conditions need not exist. People who are not aware of these possibilities may be persuaded to change their values and begin to realize that conditions, once accepted as inevitable, are capable of improvement. The technological gap becomes a value-gap. It is a discrepancy between what is desired and what actually has been achieved.’ Dental treatment, it should be pointed out, is performed to improve the dental and oral health of an individual. It is not performed to protect the health of other people as often exists with other types of health treatment. Dental disease seldom threatens a person’s life or causes major disability. When teeth are lost, artificial substitutes are available, but substitutes are unavailable for many other parts of a person’s body. Oral disease also

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differs from many other diseases in that it can be prevented to a great extent by the individual himself. In view of this discussion, it is obvious that a person’s own opinion is relevant and must be considered in the administration of programs for dental public health. Practicing dentists generally do listen to a patient’s opinion when deciding on treatment. Differences between subjective and objective judgments seldom cause great problems in an individual’s treatment. These differences may not be resolved so easily in other contexts, however, such as planning and evaluating community dental health programs. The dental health status of today’s adult generation is, in most communities, far from optimum and the resources often are too few to meet all of the treatment needed. These and other factors make the goal of perfect oral health for an entire community unrealistic.2 An administrator has to choose between different alternatives when planning programs of dental care for communities. The problem is selection of proper criteria as his guide. In most countries, the utilization of the available dental health services depends strongly on the socioeconomic status of the consumers, not alone on their ability to pay for services but also, and principally, on their style of living, education, norms, and the values in their particular socioeconomic grouping. To explore utilization further, read Richards.27 If the criteria of well-being and a life of good quality are to guide the distribution of dental care, today’s pattern of utilization cannot be used as a basis for future planning. Instead, the goal should be to provide dental care so that each person attains a level of oral health which gives him satisfaction and contributes to his well-being. This’level, of course, should be established in proportion to how much personal attention, in the form of preventive measures, he gives to his teeth. There seems to be a maximum amount of attention that people are willing to expend on their teeth and when this ceiling is reached no matter what measures an administrator uses, he can expect little or no additional improvement.’* In the following report, the two different criteria, subjective dental well-being and the long-used objective measures of status for oral health, will be tested experimentally. An attempt will be made to combine them in a model which can be used as a tool or an aid for planners of community dental health when they allocate limited resources to adult programs for oral health. The model was tested in a small-scale dental survey. The Testing Model 1. The Subjective Assignment. One encounters the same difficulties when attempting to evaluate a person’s dental well-being as when evaluating his total well-being. In everyday life, it is simple and customary to accept the person’s own judgment on his state of health. This procedure has many methodological weaknesses, however, because it provides an image at one particular time only. Many people, for example, who are satisfied with their teeth at the time of the study, will have a much worse dental status later because of their poor dental health habits. Laymen cannot be expected to make a dental prognosis or to know what kind of dental status may satisfy them in the future. People’s subjective feelings cannot be accepted as a solid base for decision on major social concerns, because their feelings can be manipulated by various means. People can be made to feel satisfied without any objective improvement in their situation. Satisfaction may be related to the expectations that people think they should have and can expect to have.9 Life has different meanings for people, too, at different ages as they change their values or weights. The components of a health index must be the same for everyone, but the weights assigned to a component may vary.” Three investigators have studied what people think of their complete or partial dentures.8J2x28Their studies have shown that adults differentiate between a t least two levels of dental well-being-satisfactory and unsatisfactory. Satisfaction does not arise from technically good dental treatment always. It may, for instance, arise from the patient’s confidence in his dentist.24 4

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When people say thay are satisfied, they may not be answering the question: “DO YOU have good or bad teeth.” To this question they may answer either what they think by themselves or what the dentist or some other persons may have told them. They may recall that their dentist told them, “Your teeth are in bad condition,” but his statement does not bother them, nor do they want any dental treatment. They may have no idea about how good or bad is their status for oral health as judged by objective standards, but they are the only ones who can judge their own satisfaction. The health planner who wants to improve the quality of human life has to include personal satisfaction in his accounting. 2. The Objective Assignment. In deciding status of oral health dentists use many different scales or indexes. For community dental health planning the multitude of information gained from clinical examinations needs to be compressed. Writers have pointed out a wrong practice, common for dental care. Instead of combating the disease or infection itself, attention is centered primarily on its manifestations.7 A person either has cariesactivity, or does not; the degree of the disease is of reduced importance. Though disease may vary over a wide range of degrees, borderlines must be determined for practical purposes; for instance, decisions about what needs to be treated and what does not. The lines often are drawn arbitrarily and then depend on a consensus of what is and is not acceptable. The borderlines vary between populations as well as between different individuals within a population.29 Even diseases, which permit no sharp distinction between optimum health and various degrees of departure from it, permit classification into different grades of severity.32 Resources, traditions, and ambitions concerning the delivery of dental care vary greatly for different communities. Oral conditions which are unacceptable in one community must be accepted in another because there are no means available to treat them. One way to get around the differences is to group dental observations into three categories-optimum, acceptable, and unacceptable dental status, depending on the community in question. Inasmuch as dental habits impinge on the administrator’s testing, some definitions of health devote consideration to two separate conditions in accounting. They consider the functional status, or the level of well-being at a certain date, and also a prognosis, or the probability of transition to other levels at future dates.23 A person’s future dental health depends greatly on his present dental habits, which thus constitute, together with the present status of his dental health a basis for making a dental prognosis. Dental habits can be studied in two different ways too. People can be asked how often they brush their teeth, if they go to the dentist for preventive purposes, and what they eat, or a dentist can examine them and deduce their dental habits from their oral health and standard of hygiene. The borderline between good and bad habits often depends on the community also. 3. Combining Subjective and Objective Criteria. In the model presented in Table 1 the dentist’s judgment of the dental health level (objective criterion) is shown vertically and the persons’ (patients’) judgments on their own dental well-being (subjective criterion) horizontally. The upper horizontal division in the table refers to dental habits which can be assessed from the information collected by the dentist or from the persons themselves. When each person in the population considered is put in his proper “compartment,” the distribution of people in the different compartments gives an image of the dental health situation in the population and demonstrates the nature of the dental problems present in the community. One may expect that a substantial majority of people will fall into a few compartments and that some compartments even may be empty. When allocating resources to different dental health programs the planner may ask, when referring to his model, “What is the purpose of the program? Which compartments are most concerned? What should be the goal of the planned change?” Depending on the criterion selected, the planner allocates resources to programs which try to move people from lower to higher Compartments, or from “dissatisfied” to “satisfied” or, changes after dental health education, from “unsatisfactory dental habits” to “satisfactory dental habits.” Combined move-

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ments, “left and up,” are possible goals, as well as no movement at all, which measures attempts to prevent people from falling into lower compartments.

TABLE 1

A model combining dental health status (vertically), dental health habits and patients’ satisfaction (horizontally) Dental status according to dentist’s assessment

Dental Habits satisfactory

Dental habits unsatisfactory

Person satisfied

Person satisfied

Person dissatisfied

Person dissatisfied

Optimum Acceptable Unacceptable

Applying the Model In order to study how the theoretical model would fit a real-life situation it was tested in a small-scale, dental survey. The survey was conducted in a simple manner to see whether the model could be used even when resources for a survey were limited. 1. Population Selected. Hallnas is a rural district in the commune of Tierp in middle Sweden. Its population of 1,608 persons is relatively old, because 26 percent was 65 years and older and only 14 percent was under 15. No dentist worked full-time in the area. A dentist from a neighboring district came once a week mainly to treat school children. In August 1974, all the inhabitants aged 15 years and older (1,321 persons) were invited to a routine health examination which included chest radiographs and blood-testing. Appointments were made in a geographical sequence, with the order depending on the location of the household. Altogether, 1,044 persons (79 percent) reported. The planner recorded the dental health status of those who reported the first week (398 persons). No prior notice of the dental investigation was given, so it was added to the routine physical examination. Having reported, no one refused the dental examination. 2. 7he Examination. No dental chair was installed, but the examination was performed in good daylight with the aid of a mirror and explorer. The dental examination consisted of an inspection and an interview. The procedure for the inspection was based mainly on the recommendations of the World Health Organization’s Manual.35 The condition of the oral mucosa and gingivae was recorded as directed in the basic survey of the Manual, and the presence of dentures, or a requirement for repair of a denture, as in the World Health Organization’s International Collaborative Study. The hierarchical method, described by Poulsen and Horowitz,25 was used in determining carious lesions and recording them. Oral cleanliness was ranked according to the Oral Hygiene Index, OHI-S.14 The patients were interviewed on three topics: (1) their satisfaction with their teeth or dentures, (2) their habits of toothbrushing, and (3) their visits to a dentist. The Findings Since it had been decided that the examination should be simple and inexpensive to carry out, no radiographs were exposed. Consequently, no person could be classified as

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possessing optimum dental health. Instead, the model was abbreviated to include only two classes, acceptable and unacceptable dental status, which depended on the result of the dental inspection. The status was considered acceptable if the following conditions were met: (I) no mucosal disease; (2) no periodontal disease-absence of conspicuous change of color in gingival tissues (noted at first glance) and absence of periodontal pockets35; (3) no need of denture or repairs for dentures; (4) no untreated carious lesions exceeding the severity of zone 1 (untreated lesion permitted on pit and fissure surfaces of posterior teeth)25 Edentulous persons were regarded as having acceptable dental health if they had, and used, full dentures classified as satisfactory. Altogether 179 persons qualified for the acceptable group. The rest, 219 persons, presented an unacceptable dental health status. Most participants had no trouble about saying whether they were satisfied with their teeth or whether they had dental problems; 329 persons were satisfied and 69 were not. Dental health habits were recorded as satisfactory if the following conditions were met: (1) toothbrushing at least once a day, (2) dental check-ups at least every other year, and (3) OHI-S less than 1.2. Since dental habits are used in the model for prognostic purposes and the future dental health of edentulous persons cannot be changed essentially by preventive dental habits, those people (I 34 persons) were classified as having satisfactory dental habits. Altogether, 227 persons qualified for this group. The rest, 171 persons, were classified as having unsatisfactory dental habits. Table 2 shows the abbreviated model with the results of the survey inserted.

TABLE 2 Results of the study in Hiillnas inserted in the abbreviated model. ~

~~

Dental status according to dentist's assessment Acceptable Unacceptable Total

Dental habits satisfactory Person satisfied 113 72 185

Dental habits unsatisfactory Person dissatisfied 20 22

Person satisfied 41 103

42

144

Total

Person dissatisfied 5

22

179 219

27

398

Some Discussion As was expected, a majority of participants fell into a few compartments representing challenges of different kinds for the community dental health planner. Facing a distribution, such as is found in Table 2, the planner may decide to give priority, when allocating new resources, to people who have an unacceptable dental health status and who are not satisfied with this condition. When taking a closer look at people in these groups, the planner may find, as was found in Hallnls, that old, badly fitting dentures were often to blame for dissatisfaction. This finding indicates which type of dental care is required. The benefit from restorative dental treatment is greater when performed for people with good dental habits. The planner must be aware that people with unsatisfactory dental habits require the greatest expenditure of resources. Restorative treatment, hence, should be combined with educational efforts. The dental investigation in Hallnas should be viewed as an effort to test the applicability of the model developed. It was not carried out to estimate the dental health status of the

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population. Such a determination would require a n examination of a statistically representative sample. Combining the dental examination with other screening procedures obviously saves money. People, furthermore, who would be unlikely to come for a routine dental examination can be reached this way. In Hallnas, people who had never been to the dentist and people who had made their last visit several decades ago were examined. The results of the study in Hallnas, based on a simple dental inspection and interview, also indicate that the model is able, in a real-life situation, to divide a population into groups with different levels of oral health, both on objective and subjective grounds. The use of traditional indexes has such a strong position in dental epidemiology that the introduction of people’s subjective feelings into measurements may raise opposition. It can be argued that the total absence of dental disease must be the best guarantee for dental well-being. Such an elevated level of oral health will continue for some decades to be an unrealistic goal, however, for the health management of a community. At present, many choices are presented to community dental health planning. Assignment of priority to a dental health program for children has scientific support. In addition t o the utilization of a community’s resources for such programs many also want to improve adult dental health through special programs. It is for this situation that the question of priorities and criteria for decision-making arises. In the literature on public health practice, considerable discussion is found on the importance of the difference between need and demand. It is clear, however, that neither one by itself supplies a n adequate basis for decision-making; both are necessary. The problem is to find ways to combine the The model presented here indicates a way in which a problem of this kind may be tackled. This model is no substitute for judgment by the planners, nor does it provide a simple guide to priorities, but it helps the planners to realize the existence of different systems of values and the complexities associated. Dental needs and dental resources may vary from community to community, so each community has to plan a strategy to meet its own needs. There are few, if any, universally applicable “best” sets of criteria for planners.

Bibliography I . Report of the chairman of the technical development board to the governing council 1959-60. Am. J. Pub. Health, 51:287-91, Feb. 1961. 2. Barenthin, Inkeri. Goals in community dentistry. Community Dent. Oral Epidemiol. In press. 3. Blum, H. L. Priority setting for problems, solutions and projects by means of selected criteria. Internat. J. Health Serv., 2:85-99, Feb. 1972. 4. Bonnevie, P. The concept of health. Scand. J. SOC.Med., 1:41-3, 1973. 5. Breslow, Lester. A quantitative approach to the WHO definition of health: physical, mental and social well-being. Internat. J. Epidemiol., 1:347-55, Winter 1972. 6. Bulman, J. S., et al. Demand and need for dental care. London, Oxford University Press, 1968. 103 p. 7. Camara, V. L. Public Health and individual measures in the prevention of dental caries. Internat. Dent. J., 23:415-9, Sept. 1973. 8. Carlsson, G. E., Otterland, A. and Wennstrom, A. Patient factors in appreciation of complete dentures. J. Prosth. Dent., 17:322-8, Apr. 1967. 9. Dallas, J. L. Health education: enabler for a higher quality of life. Health Serv. Rep., 87:910-8, Dec. 1972. 10. Donabedian, Avedis. Evaluating the quality of medical care. p. 186-218. (In Schulberg, H. C.,

Sheldon, Alan, and Baher, Frank, eds. Program evaluation in the health fields. New York, Behavioral Publications, c1969. xvii + 582 p. 11. Fanshel, S. A meaningful measure of health for epidemiology. Internat. J. Epidemiol., 1:319-37, Winter 1972. 12. 13. 14.

Jan. 1964.

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15. Grogono, A. W. Measurement of ill health: a comment. Internat. J. Epidemiol., 25-6, Spring, 1973. 16. Grogono, A. W., and Woodgate, D. J. Index for measuring health. Lancet, 2:1024-6, Nov. 1971. 17. Lerner, Monroe. Conceptualization of health and social well-being. Health Serv. Res., 8:6-12, 1973. 18. Lightner, L. M., et al. Preventive periodontic treatment procedures; results over 46 months. J. Periodont., 4235-61, Sept. 1971. 19. Marhen, K. E., and Hedegard, B. Gerodontologiska studies: 111. Oral status och tandvardsbehor hos aldre personer i Stockholms stad. Sven. Tandlak. Tidskr., 63:963-80, Dec. 1970. 20. National Center for Health Statistics: An index of health: mathematical models, by Chiang, C. L. PHS Publ. No. 1000-Ser. 2-No. 5, Washington, Government Printing Office, 1965. 19 p. 21. National Center for Health Statistics: Conceptual problems in developing an index of health, by D. E. Sullivan. PHS Publ. No. 1000-Ser. 2-No. 17. Washington, Government Printing Office, 1966. 18 p. 22. Parsons, Talcott. Definitions of health and illness in the light of American values and social structure. p. 107-27. (In Jaco, E. G., ed. Patients, physicians and illness; a sourcebook in behavioral science and health. 2nd ed. New York, Free Press, 1972. xiv + 413 p.) 23. Patrick, D. L., Bush, J. W., and Chen, M. M. Methods for measuring levels of well-being for a health status index. Health Serv. Res., 8:228-45, Fall 1973. 24. Payne, S. H. Discussion of “Test of balanced and nonbalanced occlusions.” J . Prosthet. Dent., 10:488-9, May-June 1960. 25. Poulsen, S., and Horowitz, H. S. An evaluation of a hierarchical method of describing the pattern of dental caries attack. Community Dent. Oral Epidemiol., 2:7-11, 1974. 26. Purola, T. A systems approach to health and health policy. Med. Care, 10:373-9, Sept.-Oct. 1972. 27. Richards, N. D. Utilization of dental services, p. 209-40. (In Richards, N. D., and Cohen, Lois K., eds. Social sciences and dentistry; a critical bibliography. London, Federation Dentaire Internationale, 1971. 381 p.) 28. Seifert. I., Langer, A., and Michmann, J. Evaluation of psychologic factors in geriatric denture patients. J. Prosth. Dent., 12516-23, May-June 1962. 29. Smith, Alwyn. The science of social medicine. London, Staples Press, 1968. 221 p. 30. Sullivan, D. F. A single index of mortality and morbidity. HSMHA Health Rep., 86:347-54, Apr. 1971. 31. Twaddle, A. C. The concept of health status. SOC.Sci. Med., 8:29-38, Jan. 1974. 32. Wadsworth, G. R. Nutrition surveys: clinical signs and biochemical measurements. Proc. Nutrit. SOC.,22:72-8, 1963. 33. Wessen, A. F. On the scope and methodology of research in public health practice. Social Sci. Med., 6:469-90, Aug. 1972. 34. World Health Organization, The first ten years of the World Health Organization. Geneva, WHO, 1958. 538 p. 35. World Health Organization. Oral health surveys; basic methods. Geneva, WHO, 1971. 51 p. 36. Wylie, C. M. The definition and measurement of health and disease. Pub. Health Rep., 85:100-4, Feb. 1970.

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The Poor Have Better Teeth

London, England, A special to the News, reports from the meeting of the International Association for Dental Research in London, England, that poverty protects against decay of the teeth. Nathaniel H. Rowe, Associate Professor of Dentistry and Associate Professor of Pathology at The University of Michigan, reported that a tooth-by-tooth analysis, recalculated by computer, of nutritional surveys in 10 states produced this finding. Whether the level of unemployment, in which Michigan leads the United States, should be continued as a preventive measure to reduce dental caries was not stated. From Ann Arbor News for April 11, 1975

The concept of health in community dentistry.

Vol. 35, No. 3-Summer 177 Issue THE CONCEPT OF HEALTH IN COMMUNITY DENTISTRY By Inkeri Barenthin, DDS* During the past few decades a number of effo...
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