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Oral Health Needs Assessments Aubrey Sheiham and Georgios Tsakos Chapter overview
The purpose of oral health needs assessment within health service planning is defined. The two main theoretical approaches for defining health needs assessment, namely the ‘humanitarian’ and the ‘realistic’, and the different types of need are presented. The shortcomings of normative need and the elements of a more comprehensive measure of oral health needs are highlighted. Concepts of impairment, functional limitation, disability and handicap are defined. Oral health-related quality of life indicators are discussed and how closely they relate to clinical measures of oral health. A new system termed the socio-dental approach to assessing dental needs is outlined. Key words
Need for care, need for health, normative need, perceived (felt) need, expressed need (demand), social impact, impairment, functional limitation, disability, handicap, oral health-related quality of life (OHRQoL) indicators, socio-dental approach
Introduction The purpose of needs assessment in health care is to assess unmet health and health care needs in a systematic manner and to gather the information required to bring about change beneficial to the health of the population. Health needs assessment is a systematic approach attempting to ensure that the health service uses its resources to improve the health of the population in the most efficient way. The concept of need is at the core of health care planning (Box 4-1). Planning health services is, in turn, rooted in the ethical imperative to use
resources appropriately. Needs assessment involves setting priorities on the basis of health needs: that is taking into account the severity of illness, and/or health care needs, which refers primarily to the capacity to benefit (Stevens and Raftery, 1994a; 1994b). A common assumption in the organisation and provision of health services, including dental health services, which is being challenged, is that the need for health care can be objectively determined by professionals. Now it is known that health care needs may be defined in other ways, because the definition of any given state of ill-health has become open to much wider 1
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pyrig No Co t fo rP ub lica tio n te 4 Chapter ss e n c e
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influencing policy; assessing the burden of illness and need, that is describing the size of the problem and patterns of need in the local population and the differences from district, regional, or national disease patterns; understanding the needs and priorities of patients and the local population; highlighting the areas of unmet needs and providing a clear set of objectives to work towards meeting these needs; determining goals, objectives and priorities ; definition of feasible treatment aims for the service; quantitative calculation of the total dental treatment needs for the population; deciding rationally how to use resources to improve their local population's health in the most effective and efficient way; interdisciplinary collaboration, or research and development priorities. providing a method of monitoring and promoting equity in the provision and use of health services and addressing inequalities in health. (Modified from Wright, 1998)
interpretation than in the past. Health care needs now extend beyond a narrow clinical interpretation to issues like: • the impact of ill-health on individuals and on society • the degree of disability and dysfunction that ill-health brings • the perceptions and attitudes of patients themselves towards ill-health • the social origins of many common illnesses. These factors influence the utilisation of health services and, ultimately, the effectiveness of treatment. In this sense, they represent key concepts 2
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Health care needs assessment provides the opportunity for:
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pyrig No Co t fo rP ub that should be seriously considered in the process lica tio of planning health care services. n te e s This chapter will initially focus on the different se nc
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approaches for the definition of need. Then it will move on to present the shortcomings of the normative need, which is the most commonly used type of need, before highlighting the necessary elements of a measure of health needs assessment. This will be followed by a review of the development of oral health-related quality of life measures, their applications and important characteristics, as well as on the studies examining their relationship with clinical status outcomes. Finally, a new sociodental model for assessing dental treatment needs will be presented; firstly, its main components will be introduced and then their incorporation into a comprehensive system will be highlighted.
Definitions of Need Old concepts of need were based on a simple but unrealistic approach that unfortunately still dominates the service-related approach. That approach puts the main responsibility on the medical/dental professional to evaluate whether there is need for treatment. This is epitomized by a definition of need by Cooper (1975): ‘a state of health assessed as in need of treatment by a medical practitioner.’ There are two distinct theoretical approaches to the assessment of needs for health care: a) the ‘humanitarian’ approach, which focuses more on the burden of disease; b) the ‘realistic’ approach, which encompasses the concept of ‘ability to benefit’ and focuses on health gain (Acheson, 1978; Stevens and Gabbay, 1991; Wright, 1998) (Box 4-2). The ‘humanitarian’ approach considers need as a state of the client that creates a requirement for care and therefore represents a potential for service (Donabedian, 1973). The key word in Donabedian’s definition is potential. Need does
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capacity to benefit. If health needs are to be identified, then there should be an effective intervention available to meet these needs and improve health. There will be no benefit from an intervention that is not effective or for which there are no resources available.’ (Wright, 1998)
framework. The main types of need are presented in Box 4-3 and their interrelation is illustrated in Fig 4-1.
Shortcomings of Normative Need The most commonly used type of need assessment in oral health care planning is normative or professionally defined need. Most national and local oral health surveys adopt this approach (WHO, 1997). Normative need identifies diseases and impairments without considering the subjective perception of the subject. Estimates of dental needs are expressed in terms of numbers of people, numbers of procedures, hours of work, division of labour or costs. Despite its usefulness and extensive use, normative need is not free from limitations.
Box 4-3 Bradshaw’s taxonomy of Need: Types and definitions Normative need:
Is that which the expert or professional, administrator or social scientist defines as need in any given situation
Perceived (felt) need:
This reflects the individual's own assessment of his or her requirement for health care
Expressed need (demand):
This is felt need converted into action by seeking assistance
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not always lead to use of services and use of services does not always result from need, but the existence of disease and normatively defined need does create a potential for the use of services (Spencer, 1984). The ‘realistic’ approach is based upon Matthew’s (1971) service-related definition that enriched the humanitarian approach with the concept of effectiveness of care and claimed that: ‘a need for medical care exists when an individual has an illness or disability for which there is an effective and acceptable treatment or cure.’ The concern with effectiveness and acceptability is central to any formulation of health care needs. Matthew’s definition focuses on the ‘need for care’, which should be distinct from ‘need for health’. Health needs represent the distribution of particular forms of morbidity, as well as the distribution of those environmental, social and economic variables that influence health and illness. Therefore it is important to distinguish between the need for health and the need for health care. Health care is one way of dealing with the need for health. The need for health is perceived as relief from distress, discomfort, disability, handicap and the risk of mortality and morbidity (Acheson, 1978). With the growing demand for treatments based on evidence-based medicine, Matthew’s definition has become widely accepted. Bradshaw (1972) constructed a paradigm of need that incorporates those concepts and forms a sociological background that sets up a useful definitional
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pyrig No Co t fo rP bli Even within those agreements, there is uintraca examiner and inter-examiner variability tion te ss e n c e among different judgements. The significant n
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Fig 4-1 The relationship between Normative Need, Perceived (Felt) Need, and Expressed Need (Demand).
The shortcomings of the normative method of assessing need are: 1) Lack of objectivity and reliability. Normatively defined need is not as precisely quantifiable as the term suggests. It may be expressed in terms of items of dental service or resource supply equivalents, such as work value units or cost (Spencer, 1980). Resource supply equivalents are usually specific to various levels of dental technology, use of auxiliaries, practice organisation and administration; as such they may hold little validity from one area to another (Spencer, 1984). Apart from the aforementioned variation between areas, the critique extends even to assessments in the same area. Professional judgements in normative need are neither valuefree nor objective. Indeed, the lack of objectivity of normative treatment decisions has been extensively demonstrated (Elderton and Nuttall, 1983; Elderton, 1990; Gjermo, 1991). The so-called objective assessment often depends upon a consensus agreement from a number of subjective approaches. 4
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variations in dentists’ decisions on diagnosis, prognosis and treatment plan have been recently confirmed by systematic reviews (NHS Centre for Reviews and Dissemination, 1999). Therefore, objectivity cannot be regarded as a property of measures of normatively assessed health status and needs. 2) Neglect of psychosocial aspects and quality of life concepts. The global definition of health (WHO, 1948) adopts a much wider perspective than that of normative need and incorporates the concepts of functional, psychological and social well-being. Nevertheless, the standard norm of measures of disease accepted by dentists is not always the norm in terms of functional or social requirements of people examined. This problem occurs particularly in conditions which lack easy definition, such as occlusal disharmonies (Sheiham et al, 1982). Oral health problems, but not necessarily the specific pathological conditions, are related to a person’s ability to carry out usual daily activities and affect the individual's personal comfort and quality of life. People’s dental satisfaction bears little relation to the clinical assessment of oral conditions (Giddon et al, 1976; Barenthin, 1977; Davis, 1980). The assessment of health by lay persons differs from that of professionals. Furthermore, there are differences in concepts of health and disease among lay people in different cultures. As a result, normative measures fail to assess the level of health-related quality of life (Leao and Sheiham, 1995; Locker and Jokovic, 1996). 3) Lack of consideration for health behaviours and patient compliance. Normative criteria are insufficient for deciding treatment needs because they do not take into
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romantic rather than humanitarian. Despite the numerous and serious shortcomings, normative need assessment remains useful in many cases. Very few would argue, for example, that a reliably diagnosed cavitation does not require filling. But such consensus cannot be reached in the case of need to replace missing teeth or extract third molars. The inadequacy of normative need is also evident in the case of malocclusion, where traditional indicators require supplementation by more subjective lay assessments of need. Malocclusion is not a disease and it would be incorrect to consider any deviation from an average as an abnormality. The demarcation between acceptable and unacceptable occlusions is influenced by psychological and social factors, and methods of measuring subjective or perceived need. The shortcomings of normative need in oral health care were cogently summarised by Locker (1989). He said that ‘from the point of view of contemporary definitions of health, clinical measures have serious limitations; they tell us nothing about the functioning of either the oral cavity or the person as a whole and nothing about subjectively perceived symptoms such as pain and discomfort.’ (Box 4-4)
Elements of a Measure of Oral Health Needs Though dental ill-health affects populations in epidemic proportions and oral diseases are the most prevalent group of chronic disorders, neither the definition of dental health, nor current treatment need assessments correspond to or reflect the origins of dental disease. A measure for dental need should incorporate not only clinical assessment, but also psychological and social dimensions 5
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account the attitudes and behaviours of patients, which in turn have considerable influence on the effectiveness of treatments and improvement of oral health. Patients’ behaviours, such as diet, fluoride exposure and oral hygiene, are essential for the effectiveness of restorations and the progression of dental caries (Kidd et al, 1992; Blinkhorn and Davies, 1996; Burt, 1998). Oral hygiene is the single most important factor for the success of periodontal treatment (Sheiham, 1997). In orthodontics, lack of cooperation from patients was the most common cause of failures (Shaw et al, 1991). It seems, therefore, that the effectiveness or achievement of treatments depends not only on professional services, but also on the individuals’ oral health behaviours (Maizels et al, 1993); neglecting to measure any of the aforementioned factors indicates a limited and unsuccessful approach for the assessment of treatment needs. 4) Neglect of consumer rights. The need justified by purely professional assessment is questioned in terms of human or consumer rights. The clinical definition, based on the disease analogy, rarely coincides with consumer definitions. Decisions of priority in health care must be discussed publicly and should not be the sole prerogative of any single professional group or agency of government. In addition, recent developments in consumerism and marketing have highlighted the importance of patient attitudes in health care decisions. 5) Unrealistic estimates for treatment planning. Finally, normative need is criticized for its paradoxical approach. Although it recommends treatment, in the belief that all the sick should be helped, it fails to consider the consequence of limited health care resources. As Acheson (1978) emphasised: ‘If some of the needy receive complete care, nothing may be
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opyrig t fo rP ub left for others. We cannot be endlessly genlica tio erous and continue to be fair.’ This is why n te e s Fuchs (1972) described normative needs easn c C NoAssessment Oral Health Needs
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because the presence of a clinical impairment alone is neither necessary nor sufficient basis for need. The loss of molars, for example, is a clinical impairment. But this does not necessarily mean that there is a need for dental treatment. A further question should be asked: is this impairment disabling? Furthermore, does it lead to handicap? More realistic assessments of treatment need should include the functional and the social dimensions of dental disease and an assessment of the social motivational factors which predispose people towards dental illhealth and influence the effectiveness of treatment and health promotion. Consequently, a comprehensive measure of dental needs should include the following elements: • a clinical dimension based upon sound concepts of the life history of the diseases • measures of social dysfunction • the perceived need of the individual • assessment of the propensity of the individual to take preventive action and the perceived barriers to prevention • a prescription of effective and acceptable treatments or cures • assessment of the skills and manpower required. The clinical dimension refers to normative need, which has already been adequately described. The other elements have not been traditionally the area of focus and, consequently, they will be discussed further in this chapter. One of the main elements of a measure of dental needs, namely measures of social dysfunction, can be assessed by indicators of oral health-related quality of life.
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Clinical indices are essential for measuring oral disease, but the problem arises when these indices are used as measures of health and treatment need.
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pyrig No Co t fo rP ub Development of Oral Health-Related lica tio Quality of Life (OHRQoL) Indicators n te ss e n c e
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The new concerns about the impact of the mouth on quality of life and the shortcomings of professionally defined need for health care have led to the development of broader measurements of health need. The bio psychosocial model of health proposes that diseases are influenced not only by the underlying pathology, but also by the individual’s perceptions, personality and stress (Engel, 1977). Rising expectations have led to a shift away from viewing health in terms of survival, through a phase of defining it in terms of freedom from disease, thence to an emphasis on the individual’s ability to perform daily activities, and now to the current emphasis on positive themes of happiness, social and emotional well being, and quality of life. In this expanded theoretical framework, a variety of new subjective indicators that attempt to measure the health-related quality of life have been developed and used (Bowling, 1995, 1997; Carr et al, 2003). These indicators are multidisciplinary with major contributions from psychology, sociology, economics, operational research and biostatistics. They cover a wide non-clinical spectrum, from condition-specific to general health assessments, from individual-specific to population outcome measures, from health profiles to single score indices. Consequently, physiological outcome measurements were substituted by health status measurements, allowing insight into patients’ experience, and ‘health-related quality of life’ has evolved as an appropriate term to describe this domain of measurement (Guyatt et al, 1989; Testa and Nackley, 1994). This is a multifaceted concept, attempting to simultaneously assess how long and how well people live. The development of oral health-related quality of life indicators demonstrated many similarities with the respective trends in the medical field. While a great deal of effort has been devoted to the construction of valid and reliable indices of oral
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Socio-dental indicators are:
“measures of the extent to which dental and oral disorders disrupt normal social role functioning and bring about major changes in behaviour such as an inability to work or attend school, or undertake parental or household duties”. Locker (1989)
• Impairment is a loss or abnormality of mental, physical, or biochemical function either present at birth or arising out of disease or injury, such as edentulousness, loss of periodontal attachment or malocclusion. All pathology is associated with impairment, but not all impairments lead to functional limitations. • Functional limitation is restriction in function customarily expected of the body or its component organ or system, such as limitation of jaw mobility. • Disability is any limitation in or lack of ability to carry out socially defined tasks and roles that individuals generally are expected to be able to do (Pope and Tarlov, 1991).
Death
Disease
Im pair ment
Function al Limi tation
Disabil ity
Ha ndic ap
Discomfort
Fig 4-2 The conceptual model of consequences of oral impacts (modified from Locker, 1988).
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disease, behavioural or subjective measures of oral health have been used less frequently. There has generally been less development of alternative definitions of need in dental than in general health care. Cohen and Jago (1976) were the first to argue that clinical indicators of oral health would be greatly improved and be more relevant for policy making by adding a dimension of social impact, thus defining a new type of oral health indicator (Box 4-5). Following similar trends in the general health field, the term ‘oral health-related quality of life measures’ has been adopted for these subjective health status measures. They are subjective indicators that provide information on the impact of oral disorders and conditions, and the perceived need for dental care. Their use should be complementary to the clinical measures of oral status and needs (Cushing et al, 1986; Locker and Jokovic, 1996). The concepts of impairment, functional limitation, disability, and handicap have become pivotal to the development of oral health-related quality of life indicators. Locker (1988) suggested a coherent theoretical framework, based on those concepts (Fig 4-2), which is an adaptation of the WHO model for the International Classification of Impairments, Disabilities and Handicaps (1980). The main definitions of this conceptual model are:
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The relationship between impairment, disability, and handicap is a dynamic continuum that is reversible. Impairment may or may not lead to disability and handicap. For example, a malposed or missing tooth (impairment) can, but does not inevitably, lead to a restriction in eating or to avoidance of hard foods (disability), which in turn can make people feel embarrassed and avoid eating in front of others (handicap). Some impairments may – but not necessarily – give rise to different forms or severities of disability and some disabilities may have handicapping effects. Malocclusion, gingivitis or missing teeth are impairments but do not always disable nor handicap individuals. However, an individual may be impaired and not disabled but nevertheless handicapped, because disability is measured by restriction of activities and function whereas handicap is socially defined. Although this approach presents operational difficulties (it is not possible, for example, to predict that a given degree of impairment will produce a similar degree of disability or handicap), it nonetheless focuses attention on the importance of the socio-psychological aspects of health needs assessment.
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• Handicap is concerned with the broader social effects and is defined as the disadvantage experienced by impaired and disabled people because they do not or cannot conform to the expectations of society or the social groups to which they belong. It is the disadvantage or restriction experienced by individuals in their personal and social life consequent upon disability or impairment. In this sense, a handicap results from interactions between physical impairment, the adjustment to it and the physical and social environment (WHO, 1980). The disadvantage is multidimensional and can involve loss of opportunity, actual material and social deprivation and dissatisfaction (Locker, 1988; Pope and Tarlov, 1991).
pyrig No Co t fo rP ub The development and testing of health-related lica quality of life outcome measures have become pri- tion te ss(Bader, ority research areas in social epidemiology e nc e
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1992; Frazier, 1992), though this trend has proceeded at a slower pace for measures of oral than general health (Coulter et al, 1994). A variety of oral health-related quality of life indicators have been developed and used in oral health surveys (Slade, 1997). They have demonstrated some content similarities, but are characterized by considerable variation in their precise aims, number of items and technical characteristics. They vary with respect to the presence or absence of subscales, the method of administration, the response choices offered, the incorporation or lack of weights, and the provision or not of a final score. Most of the oral health-related quality of life indicators have been used in cross-sectional oral health surveys, while only a handful have been introduced to longitudinal or intervention studies, in order to measure change in quality of life (Locker, 1996, 1998; Slade et al, 1998). Measurement of oral health-related quality of life has been characterized by complex conceptual issues. Like health-related quality of life, oral health-related quality of life is a multidimensional concept that incorporates relatively abstract and not clearly demarcated domains such as: survival, illness and impairment, social, psychological and physical function and disability, oral health perceptions, opportunity, as well as interactions between the aforementioned domains (Gift and Atchison, 1995). Furthermore, the respective indicators are predominantly subjective and constantly evolving and influenced by the social, cultural, political and practical contexts, in which they are measured (Locker, 1997).
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Apart from the conceptual background for the development of oral health-related quality of life indicators, the determination of the context of their potential applications remains a crucial issue, since it may affect the desirable characteristics of an indicator. Ware et al (1981) identified five broad categories of use of the major health status measurements: • measuring the efficiency or effectiveness of health interventions • assessing the quality of life • estimating the health needs of a population • improving clinical decisions • understanding the causes and consequences of differences in health. The application of oral health-related quality of life indicators for each specific purpose may vary considerably. Thus, it is essential when selecting indicators to assess needs, to see which matches the purpose and qualities of currently established indicators. Locker (1996) suggested three non-exclusive broad categories of applications for these measures, namely political, theoretical and practical (Box 4-6). The theoretical role relates to the facilitation of the investigation of important relationships (e.g. disease and illness) in the fields of medical sociology, health psychology and health services research. Practical applications are further categorised into research (e.g. use in clinical trials or health policy studies), public health, which refers to populations (e.g. assessing oral health needs), and clinical practice, which concentrates on the individual rather than the population level (e.g. monitoring the course of a patient’s illness).
resources) ■
Theoretical Applications
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Practical Applications - Research - Public Health - Clinical Practice
Choosing an Oral Health-Related Quality of Life Indicator Apart from identifying the possible applications of an oral health-related quality of life indicator, considerable effort should be dedicated to making an informed choice of instrument, thus evaluating its key characteristics. There are five major factors that must be considered in choosing an instrument for measuring health status (Ware et al, 1981), namely: • practicality • reliability • validity • objectivity/subjectivity, and • whether global measures are preferable to more specific ones. Specifically in relation to the needs assessment in a population, at least three major qualifications should be considered as crucial for health planning: • the index should be brief and easy to use in a large population within a reasonable time • scaling according to units should be relevant to decision-making criteria, and • the index should measure variables specified by a system model to provide cause and effect relationship information for policy makers.
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Applications of Oral Health-Related Quality of Life Indicators
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opyrig t fo rP ub lica tio Box 4-6 n te e s se nc ■ Political Applications (allocation of health care C NoAssessment Oral Health Needs
Relationship between Oral Health-Related Quality of Life Indicators and Clinical Oral Health Measures Although relationships between clinical and social variables were weak, those that were significant could be used as a stepping stone to start building a picture of characteristics, both clinical and social, of people who experience dental problems. From the different clinical measures used in a study exploring the relationship between the social impacts of dental disease and clinical status (Cushing et al, 1986), only the number of functioning teeth, that is the sum of sound teeth and filled teeth (Sheiham et al, 1987), was significantly associated with the overall prevalence of oral impacts. Other clinical measures were significantly associated with specific impact dimensions but not with the overall prevalence. People who reported having eating problems, for instance, had a higher DMFT and fewer functioning teeth than those with no problems. In a later study of employed adults (Rosenoer and Sheiham, 1995) that used the same indicator of the social impact of dental diseases, oral impacts correlated positively with DMF-T and negatively with the number of teeth, but the significant associations were weak. In addition, participants with five or more posterior occluding pairs of teeth (POPs) had significantly lower levels of impacts. Atchison and Dolan (1990) compared the Geriatric Oral Health Assessment Index (GOHAI) scores with clinical variables in people aged 65 years and over. Those with 21 to 32 teeth and no removable denture had higher GOHAI score (that is lower levels of impacts) and did not perceive a need for dental treatment. Again, those significant correlations were relatively weak. The same pattern of associations was also observed by Locker (1992) in a study of adults aged 50 years or older. Clinical
odontal attachment loss were significant predictors of impact scale scores. These findings were reinforced by findings from a study (Locker and Slade, 1994) that used the Oral Health Impact Profile (OHIP) indicator. The number of missing teeth, number of functional units and number of posterior functional units were significantly correlated with all OHIP subscales and total scores, while significant correlations were also revealed for the number of decayed and filled teeth, DMF-S and loss of attachment indices. Despite being the relatively strongest clinical predictor, the number of missing teeth could only explain 18% of the variation in OHIP scores. An additional 14% was accounted to the effects of general health status, life stress, dental insurance coverage, household income and age. Slade and Spencer (1994) used the OHIP in older adults in South Australia and showed that edentulous persons reported significantly more social impact in four sub-scales: functional limitation, physical disability, social disability and handicap. Among dentate persons, tooth loss was associated with all seven sub-scales of social impact. Anterior tooth loss was associated with more impact, whether or not there was replacement of the missing teeth by prosthetic units, while posterior tooth loss was associated with social impact only when there were unfilled spaces. Similar findings were reported using the Dental Impacts on Daily Living (DIDL) index in a population aged 35–44 years (Leao and Sheiham, 1995). The worse the oral status, the worse the subjective impact. These findings suggest that despite their overall significance, clinical variables, together with socio-demographic determinants, could explain less than 30% of the variation in the total DIDL score. Using the Oral Impacts on Daily Performance (OIDP) indicator in an elderly population, Srisilapanan and Sheiham (2001a) showed
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Existing subjective measures of oral health have not been shown to conform well to all of these criteria.
pyrig No Co t fo rP ub variables were weakly, but significantly, correlatlica ed with subjective measures except for pain symp- tion t ss eperitoms. The number of missing teeth and emean nc e
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A new system for the assessment of dental treatment needs should overcome the deficiencies associated with the sole assessment of normative need, thus considering dental treatment need not only from professional judgement, but also incorporating the related socio dental impact and behavioural factors such as people’s perception and propensity. The development of this new system conforms to the modern theoretical multifactorial approach for the assessment of needs for oral health care and incorporates the following elements: 1) clinical estimates of normative need 2) general health status 3) subjective perceptions, including perceived treatment needs and oral health impacts in relation to functional, psychological and social dimensions 4) propensity to adopt health promoting behaviours 5) scientific evidence of the effectiveness of treatments. This new system, that is termed a socio-dental approach to assessing dental needs, aims to rationalize the needs assessment process and, consequently be more useful for oral health care planning. The clinical component associated with normative need has been extensively reviewed earlier in this chapter. The only modification at the normative need level is that general health factors should be taken into account. Dental care will be planned for people with normative need who also experience general health problems affecting the prognosis of dental disease or the maintenance of acceptable oral health after treatment (Srisilapanan and Sheiham, 2001b). High priority groups for dental care are those in greatest need due to their 11
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significant associations between oral impacts and a variety of clinical measures. More specifically, edentulous people experienced higher levels of impacts in comparison to the dentate. Within the dentate group, higher impact scores were observed in people with anterior tooth loss, posterior tooth loss, mobile teeth and loss of attachment, but the relationship between OIDP and caries (both coronal and root) was not significant. Overall, the associations between clinical status indicators and measures of oral health-related quality of life were weak. But the associations were better for specific clinical conditions such as missing teeth, particularly anterior teeth, and occluding pairs of natural teeth (Locker and Slade, 1994; Slade and Spencer, 1994; Leao and Sheiham, 1995; Srisilapanan and Sheiham, 2001a). Different levels of oral status have different impacts on people’s daily living. In some instances, the weak associations between clinical and subjective oral health indicators are to be expected given the nature of the measures employed; they exist because the clinical indicators are mediated by functional and experiential variables, such as chewing capacity and pain, and by socio-demographic factors (Locker, 1992). A more comprehensive explanation relates to the conceptual distinction between health and disease (Hunt et al, 1986; Locker, 1992; Bowling, 1997). Disease does not always negatively affect subjective perceptions of well-being, and even when it does, its impact is influenced by expectations, preferences, material, social and psychological resources and, more importantly, socially and culturally derived values (Locker, 1992). Therefore clinical status and multiple social and psychological dimensions should be assessed simultaneously when assessing people’s dental needs.
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There is a strong association between perceived impacts, perceived oral health and needs (Atchison and Dolan, 1990; Matthias et al, 1995; Locker and
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The role of subjective perceptions and perceived needs for dental care is an essential part in the concept of dental need. Perceived needs are frequently inconsistent with normative needs. In addition to the well documented significant gaps between professional and lay perception of need, more recent literature strongly emphasises the importance of patients’ feelings and their relative priority to professional assessments (Bowling 1997; Anderson, 1998). Bradshaw’s (1972) taxonomy of needs (Box 4-3) illustrates the difference between perceived and normative needs, and puts great emphasis on perceived and expressed need. Such differences imply that people measure different concepts of health to professionals. Subjective measures seem to relate to human experiences and the process of people’s perceptions involves interaction between various factors in people’s life, namely, biological, psychological and socio-environmental factors. Subjective perceptions include the assessment of: • perceived need for dental treatment • oral impacts and oral health-related quality of life.
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general health problems and to those where dental disease will affect the condition of a chronic disease or their general health status. This integration of general health factors with normative need may facilitate the prioritization of treatment needs, as well as adopting a more selective approach. The remainder of this section will concentrate on briefly reviewing the rationale for the inclusion of the other components of the socio-dental approach. Finally, the method of incorporating them all into a coherent system will be described.
pyrig No Co t fo rP ub Jokovic, 1996; Gift et al, 1998; Tsakos et al, 2001). lica Furthermore, people that perceive need for den- tion te ss efrom tal treatment are the most likely to benefit nc e
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the provision of treatment and may be considered as a high priority group at a time of scarce resources (Locker and Jokovic, 1996). While the assessment of dental treatment needs is carried out by asking a direct question, oral impacts are measured through an oral health-related quality of life indicator. The Oral Impacts on Daily Performance (OIDP) is an indicator of oral health-related quality of life that specifically allows for the assessment of treatment needs (Aduyanon and Sheiham, 1997). The theoretical framework on which the OIDP index is based is modified from the WHO's International Classification of Impairments, Disabilities and Handicaps (1980). The main modification is that different levels of the concepts are established (Fig 4-3), namely: • Level 1: oral status and oral impairments, which most clinical indices attempt to measure. • Level 2: ‘intermediate impacts’, which refer to the possible early negative impacts caused by oral health status – pain, discomfort, functional limitation or dissatisfaction with appearance. Any of these dimensions may lead to impacts on performance ability. • Level 3: ‘ultimate impacts’, which reflects the translation of the aforementioned dimensions into impacts on the ability to perform daily activities. This level covers the concepts of disability and handicap. The OIDP index focuses on the third level of measurement, thus assessing impacts on the ability to perform daily activities. It is a way to screen for the significant impacts, by eliminating very small negative perceptions from oral conditions which do not lead to an impact on daily performances. In addition, it is more accurate to measure the behavioural impacts in terms of performance than the feeling state dimension. More impor-
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Level 2
Fig 4-3 Theoretical model for the development of the Oral Impact on Daily Performance (OIDP) index.
Level 3
Pain Functional limitation Physical
tantly, though, the screened outcomes should be more useful in the context of policy planning. The OIDP covers major oral impacts in relation to daily activities and behaviours (e.g. eating, speaking, sleeping, maintaining usual emotional state, meeting people) and provides a final score that incorporates the measurements of both the frequency and the severity of the effect those impacts had in the daily life of the person in the last six months. Furthermore, through the additional calculation of the Condition-Specific OIDP, it allows for the impacts to be attributed to specific oral conditions, thus making the index suitable for needs assessment and treatment planning.
Propensity for Health Promoting Behaviours Achieving and maintaining good oral health and successful treatment outcomes depends on both the professional intervention and the individual attitudes and behaviours. Indeed, people’s attitudes and behaviours have a strong inf luence on the effectiveness of treatment and improvement of oral health (Maizels et al, 1993). The socio-dental approach in needs assessment focuses on achieving the optimal benefits from available resources. Consequently, on a population level, different strategies may be planned for different groups in order to gain the maximum benefit within available resources. Accordingly, in addition to assessing the perceived need for treatment, factors that
Discomfort Appearance dissatisfaction
Psychological Social Impacts on daily performance (Disability and Handicap)
predict whether a person will comply with treatment and with oral health instructions must be assessed. Within a certain level of need, people that are more likely to benefit from treatments should be given a higher priority in comparison to those less likely to benefit. Therefore, the system should be flexible enough to allow dental service planners to prioritise needs and make rational decisions in resource allocation, and behavioural factors affecting health gain from dental therapies should also be included in needs estimations (Maizels et al, 1993). These behavioural factors are the propensity to carry out preventive behaviours and self care and compliance with treatment instructions. Most definitions of need have emphasised the need for treatment. Little attention has been given to the needs for the promotion of health and the primary prevention of disease. Since health/sickness and function/dysfunction can each be conceived as being on a single continuum parallel to one another, attention should be given to the needs of people at all points along the continuum and not just to those at the sickness and dysfunction ends. Despite the fact that dental diseases are virtually avoidable by preventive measures, little is known about the factors which underlie the propensity of individuals to undertake preventive care or their response to health education. Thus, while preventive methods hold the greatest potential for drastically reducing dental disease, knowledge is lacking of the very factors which are crucial to the success of any preventive programme. 13
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All four factors influence oral health status and treatment outcomes. The use of fluoride toothpaste has been strongly associated with the decline of dental caries; in industrialised countries, in particular, it has been considered as the single most important factor (Petersson and Bratthall, 1996; Milgrom and Reisine, 2000). A recent systematic review of the effectiveness of fluoride concluded that the high quality trials provide clear evidence
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When clinicians assess the need for treatment they establish the clinical status, the medical history, the attitudes and past behaviours of the individual with a view to assessing the propensity of that person to respond to treatment. In periodontal treatment, in all instances, whatever the degree of periodontal destruction, the effective control of reasonably accessible plaque by the patient is paramount. Success of both non surgical and surgical treatments has been shown to depend primarily upon the maintenance of a high level of supragingival plaque control by the patient. Prescribing a partial denture or surgical periodontal treatment for someone with poor hygiene and dietary habits would be considered bad treatment planning. Yet all the normative need assessments ignore measures of propensity or compliance. In addition, survey manuals, such as Oral Health Surveys: Basic Methods (WHO, 1997), which is widely used for dental public health planning, do not incorporate the propensity to adopt health promoting behaviours into the process of planning for treatment need. The behavioural factors included in the new comprehensive system for the assessment of dental treatment needs refer to the propensity to adopt health promoting behaviours and cover four basic behaviours with established importance for oral health care. They are: • use of fluoride toothpaste • frequency of tooth brushing • sugar intake • pattern of dental attendance.
pyrig No Co t fo rP that fluoride toothpastes are efficacious inubprelica venting caries (Marinho et al, 2003). The impor- tion te ss e npertance of tooth brushing, in terms of improving ce
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sonal oral hygiene, relates to the promotion of periodontal health and to the prevention of dental caries. Effective plaque control and maintenance of sound oral hygiene affect the success of periodontal treatment (Sheiham, 1997; McDonald and Avery, 2000). In addition, the frequency of tooth brushing played an important role in the effectiveness of f luoride toothpaste (Sutcliffe, 1996). Furthermore, Rodrigues and Sheiham (2000) showed that children brushing their teeth less than once daily were more likely to have higher caries increments. The direct and strong association between sugar consumption and dental caries has been clearly established (Arens, 1998; The British Nutrition Foundation, 1998; Sheiham, 2001; Moynihan, 2002; WHO, 2003). A recent systematic review concluded that limiting sugar intake is an important factor for preventing dental caries (Burt and Pai, 2001). Finally, the pattern of dental attendance is a measure of compliance that is closely related to the perception of dental treatment needs (Tickle and Worthington, 1997) and plays an important role, particularly in treatments that require several dental visits (McDonald and Avery, 2000). The consideration of the aforementioned behavioural aspects in the system of treatment needs assessment facilitates the completion of the system and makes it directly relevant for planning dental health services.
The Effectiveness of Treatment Sackett and Snow (1979) caution that the strategies applied to change compliance behaviour must meet at least three preconditions: the diagnosis must be correct; the therapy must do more good than harm; and the patient is an informed, willing partner in the execution of all interventions. It follows logically that clinical judgment includes the balancing
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shown by the performance of good quality research to be effective. If interventions are of unproven efficacy or are doing more harm than good, decision-makers must ensure that either they are not introduced – ‘stop starting them’ – or, if they have already been introduced, that they are no longer practiced – ‘start stopping them’ (Muir Gray, 1997). Health policy planners should not solely base their decisions on effectiveness on textbooks or individual studies. Systematic reviews, like those available from the Oral Health Group of the Cochrane Collaboration, have appraised the published papers and reports and provide valuable information on the effectiveness of interventions. Up to now (September 2005), 51 systematic reviews present and evaluate the evidence on a variety of dental care interventions, thus forming the backbone of an increasing library of evidence appraisal in oral health. In the era of evidencebased health care, uncritical decisions are unacceptable.
Incorporating the Components into a Whole New System Having described the different components of the needs assessment system, the field is considerably broadened and complicated and the crucial issue ahead relates to their meaningful incorporation into a coherent system. The theoretical framework of the system could be described as a gradual integrating process, whereby normative need assessments are incorporated with subjective perceptions, as well as with information on the effectiveness of treatments (evidence-based dentistry) and people’s propensity for health promoting behaviours. Evidence-based dentistry is a concept
Chapter 5: Reviewing Existing Data: Appraising the Evidence
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of probabilities for benefit and harm. The need for care is widespread while cure is rare (Cochrane, 1972)5. Accordingly, the point on the distribution at which therapy begins to do more good than harm should be established. An important criterion of need is whether there is an effective treatment for the condition. Matthew (1971) considers that a need for treatment exists, only if there is an effective and acceptable treatment. Epidemiological data for the distribution of diseases in a population can only be useful for planning services when there is effective treatment or care available. The treatment which is professionally judged to be needed for a specific impairment should be evaluated for its effectiveness. The need for health technology assessment arises from the concern that health technology may neither be used wisely, nor produce the expected health benefit. Many studies using the randomized controlled trial (RCT) have given ample warnings of how dangerous it is to assume that well established medical therapies which have not been tested are always effective (Cochrane, 1972). Few dental therapies have been subjected to rigorous randomized controlled trials, and there are limited quantitative assessments of effectiveness. Where analyses have been done, using systematic reviews, most commonly performed treatments, such as removal of supragingival calculus and orthodontics were found to be relatively ineffective without unrealistic compliance regimens (Shaw et al, 1991; Antczak Bouckoms et al, 1993; Addy and Koltai, 1994). Furthermore, there was little evidence to support or refute the practice of encouraging the 6-monthly dental check-ups (Davenport et al, 2003). Considerations of dental treatment effectiveness should be based on the investigation of available therapy appraisal data, as well as the possible resources and qualified personnel to perform such treatment effectively in each planning setting. An important future challenge is to help professionals
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The first level of measurement refers to Normative Treatment Need. This is followed by the assessment of Impact-related Need, through the incorporation of subjective assessments into the system. People that have normative needs and oral impacts have ‘Impact-related Needs’ and they can be further prioritized according to the third level of measurement. People with normative need but without oral impacts are not following the treatment pathway; instead, they are considered as needing dental health education, thus forming a population group in need of oral health promotion with the aim to modify their health behaviours. After that, they may further follow the treatment pathway and follow the third level of measurement, that is the Propensity-related Need. At this third level, treatment is prescribed in the light of probability of success, using the best available evidence on effectiveness of 16
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underlying and covering all levels of the socio-dental system of treatment needs assessment. Planners should refer to published guidelines when deciding on appropriate treatments. Moreover, selection of treatments depends on the local setting, available resources and extent of general needs in the community. This process allows for three levels of treatment needs measurement, each taking into account gradually more key factors (Fig 4-4). The three levels are: • Normative Need • Impact-related Need • Propensity-related Need
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* Evidence-based treatment is a factor considered throughout the socio-dental system
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Key Factors Clinical impairments General health status Clinical impairment Impact-Related Need General health status Perceived oral health impacts and needs Clinical impairment Propensity-Related Need General health status Perceived oral health impacts and needs Behavioural propensity for treatment * Evidence-based treatment is a factor considered throughout the socio-dental system.
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Fig 4-4 Levels of dental treatment needs and relevant key factors.
treatments and the individual’s behavioural propensity. Propensity-related Need categorizes the population into appropriate treatment groups, by considering the behavioural propensity of the person. In this sense, people may be categorized into high, medium and low propensity-related need groups, according to their behaviour in relation to the use of fluoride toothpaste, frequency of tooth brushing, sugar intake and pattern of dental attendance. Then, different options of effective treatment and care may be available for the different groups. Taken together with the availability of resources, this concept of propensity would allow health authorities to estimate the amount of different types of care required for a defined population. Having explained the basic concepts and measurement levels of this system of gradual integration, discussion needs to be directed towards areas of potential confusion. Indeed, there are important issues to be considered when combining clinical with subjective measures. There are conditions where normative need is of prime importance: • life threatening conditions, such as oral cancer or precancerous lesions, fractures of jaw, and severe infections. • chronic progressive oral conditions, such as active dentinal caries. In life-threatening or chronic progressive conditions, treatment or further investigation is essential even without the impact being assessed. Dental need is based on the best available evidence in relation to the natural history of diseases. Con-
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ferent decision trees for restorative, periodontal, prosthetic, orthodontic treatment and so on. The classifications of propensities vary for different dental treatments. Good propensities for dental attendance are important for orthodontic assessment whereas oral hygiene is an important consideration for periodontal needs. Therefore the relative weight attributed to each behaviour will vary depending on the type of treatment. All aforementioned algorithmic models set the general rules and methods for the estimation of treatment needs, but also provide the necessary flexibility to allow health planning to adjust to local priorities and resources. Finally, after calculating treatment needs with the socio-dental approach, health planners may convert the treatment estimates into time units to carry out different types of treatment and may also indicate the necessary skills required. Thereafter, manpower estimates are made. In conclusion, the shortcomings of the traditionally used normative need and the conceptual developments in the health field have led to the theoretical exploration of complementing the norma-
DHE/OHP: Dental Health Education/Oral Health Promotion
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Fig 4-5 Model of Dental Treatment Needs for Lifethreatening and Chronic Progressive Oral Conditions.
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Those algorithmic models are broad representations that provide the overall ‘umbrella’ framework for the assessment of needs in the socio-dental approach. They can, and should, be further adjusted in relation to specific types of treatment
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sequently, Impact-related Need is not considered for those people and the system covers the assessment of Normative and Propensity-related Needs. The latter facilitates decision-making, for example whether – and at what degree of priority – one should advise restorative treatment be carried out in people with poor oral hygiene or irregular patterns of dental attendance. In every other case, apart from life-threatening or chronic progressive oral conditions, the system allows for needs assessment using all three levels (Normative Need, Impactrelated Need and Propensity-related Need). The aforementioned distinction implies that there are two broad models of assessing need using the socio-dental approach, namely: • a Model of Dental Treatment Needs for Lifethreatening and Chronic Progressive Oral Conditions (Fig 4-5), and • a Basic Model for Dental Treatment Needs, referring to all other conditions (Fig 4-6).
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opyrig t fo rP ub required, thus allowing for more disease-specific lica tio needs assessment models. A separate decision tree n te e s is done for each treatment type, resulting in sdife nc C NoAssessment Oral Health Needs
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Fig 4-6 Basic Model for Dental Treatment Needs, referring to all other conditions.
tive approach with socio-psychological and broader system factors. As Mechanic (1995) has accurately stated: ‘the irony is that while so much of the challenge in health care is social – to enhance the capacity of individuals to perform desired roles and activities – the thrust of the health enterprise is substantially technologic and reductionist, treating complex socio-medical problems as if they are amenable to simple technical fixes.’ The new sociodental approach to assessing dental needs attempts to overcome these inadequacies, by incorporating the normative assessment with measurements of subjective perceptions and of the propensity to adopt health promoting behaviours, while also accounting for the provision of effective care. Thus, it provides the theoretical framework necessary to reorient needs assessment from the narrow normative focus towards the broader socio-environmental perspective. And as such, it is a useful tool in planning oral health services. The incorporation of such systems in the process of policy planning and evaluation should be seen as a priority. 18
Summary of Main Points • There are two distinct theoretical approaches to defining health needs: the “humanitarian” approach, which focuses more on the burden of disease, and the “realistic” approach, which encompasses the concept of “ability to benefit” and focuses on health gain. • The most commonly used type of need assessment in oral health care planning is normative or professionally defined need. Nevertheless, it has been severely criticized. • Measures of perceived need, which reflects the individual’s own assessment, should also be used. This implies using oral health-related quality of life indicators, which are subjective indicators that provide information on the impact of oral disorders and conditions, and the perceived need for oral health care. • The socio-dental approach is a comprehensive system for the assessment of oral health
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Discuss the implications of these for Dental Public Health.
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