Dentistry and distributive justice

Behavioural intervention to promote the uptake of planned care in urgent dental care attenders: a feasibility randomised controlled trial

BACKGROUND

Urgent dental care may be the only place where many people, especially vulnerable groups, access care. This presents an opportunity for delivery of a behavioural intervention promoting planned dental visiting, which may help address one of the factors contributing to a socio-economic gradient in oral health. Although we know that cueing events such as having a cancer diagnosis may create a 'teachable moment' stimulating positive changes in health behaviour, we do not know whether delivering an opportunistic intervention in urgent dental care is feasible and acceptable to patients.

METHODS

The feasibility study aimed to recruit 60 patients in a Dental Hospital and dental practices delivering urgent care within and outside working hours. Follow-up was by telephone, e mail and post over 4 months.

RESULTS

Although the recruitment window was shortened because of COVID-19, of 47 patients assessed for eligibility, 28 were enrolled (70.1% of screened patients provided consent). A relatively high proportion were from disadvantaged backgrounds (46.4%, 13/28 receiving State benefits). Retention was 82.1% (23/28), which was also the rate of completion of the Oral Health Impact Profile co-primary outcome. The other primary outcome involved linking participant details at recruitment, with centrally-held data on services provided, with 84.6% (22/26) records partly or fully successfully matched. All intervention participants received at least some of the intervention, although we identified aspects of dental nurse training which would improve intervention fidelity.

CONCLUSIONS

Despite recruitment being impacted by the pandemic, when the majority of clinical trials experienced reduced rates of recruitment, we found a high recruitment and consenting rate, even though patients were approached opportunistically to be enrolled in the trial and potentially receive an intervention. Retention rates were also high even though a relatively high proportion had a low socio-economic background. Therefore, even though patients may be in pain, and had not anticipated involvement before their urgent care visit, the study indicated that this was a feasible and acceptable setting in which to position an opportunistic intervention. This has the potential to harness the potential of the 'teachable moment' in people's lives, and provide support to help address health inequalities.

TRIAL REGISTRATION

ISRCTN 10,853,330 07/10/2019.

Dentistry's social contract and dental students' moral inclusiveness

BACKGROUND

Under dentistry's social contract with the public, dental professionals have a social responsibility to address the oral health needs of the population at large. However, dental education places little emphasis on such moral commitments. By ascertaining dental students' stance regarding these notions, we may be able to inform changes in dental education. This paper thus explores dental students' comprehension of dentistry's social contract using the concepts of moral inclusion, moral community and empathy.

METHODS

A cross-sectional online survey collected information from undergraduate dental students at the Faculty of Dentistry, University of Toronto (N = 430). Moral inclusion was assessed through the breadth of students' moral community by computing a "moral inclusion score" (MIS) from Likert scale responses to statements that asked students about their duty of care for different population groups, wherein a higher MIS indicated a broader moral community and in turn greater moral inclusiveness. Empathy was assessed using Likert scale responses to statements that gauged the extent to which students understood the effect of social determinants on people's health. Association of the MIS with environmental, institutional and student-related factors was also investigated using non-parametric tests and linear regression.

RESULTS

The survey yielded a response rate of 51.4% (n = 221). Overall, students in this sample were morally inclusive and displayed empathy. Regression results showed that the MIS was most strongly associated with choosing a small town/rural area as a future practice location (β = 4.76, 95% CI: 0.52, 9.01) and viewing patients as consumers (β = -3.71, 95%CI: -7.13, -0.29).

CONCLUSION

Students in this sample made morally inclusive choices, which implied that they had a basic understanding of the obligations under dentistry's social contract. Improving knowledge and experience with regards to addressing the social and economic determinants of oral health and access to oral health care may positively influence students' perceptions of their professional duties under the social contract.

Dentists´ and Dental Hygienists´ experiences of the Capitation Contract System-the dilemma of conflicting loyalties

OBJECTIVE

The Capitation Contract system (CCS) is a payment model adopted by the Swedish Public Dental Health Service (PDHS). Patients enrolled in the CCS are usually assessed as being at lower risk of dental disease and are more regular dental attenders than those treated by Fee for Service (FFS). With increasing numbers of patients and CCS enrolments, Sweden faces a shortage of dental personnel. Our aim was to analyse dentists´ and dental hygienists´ perceptions and experiences of the capitation contact system.

MATERIAL AND METHODS

Eleven dentists and dental hygienists from three Swedish regions participated in online qualitative interviews conducted according to the Grounded Theory methodology.

RESULTS

When working with CCS the informants tried hard ´to find a balance between attitudes, compliance with guidelines and clinical resources´. Not all patients were offered CCS, even though they qualified: among other determinants were the informants' interpretations of guidelines and regulations, clinical resources, and patient interest.

CONCLUSIONS

When dental resources are in balance, the informants appreciate the CCS and consider it to be favourable to patient health but are aware of conflicting loyalties of their dual roles of insurance sales agent and care provider. The informants´ individual mindset affects which patients are offered CCS enrolment.

Autonomía profesional del odontólogo en instituciones prestadoras de servicios de salud públicas y privadas de Bogotá en el marco del sistema de salud colombiano

Objetivo: identificar la influencia del sistema de salud colombiano sobre la autonomía profesional de odontólogos que ejercen en IPS públicas y privadas de Bogotá. Metodología: estudio cualitativo comprensivo, llevado a cabo con herramientas etnográficas como la entrevista semiestructurada. Las categorías de análisis fueron: autonomía profesional, modelos de atención, toma de decisiones y sistema contractual. La información se analizó de manera categorial, contextual y de contenido. Resultados: se evidenció que la autonomía profesional está limitada por el tiempo de atención para los pacientes (veinte minutos). Otra limitante es la restricción en la realización de procedimientos y, en ocasiones, los protocolos de atención. Por estas limitaciones, el odontólogo pierde habilidades y conocimientos adquiridos en la academia, sus habilidades y la seguridad en sí mismo. Discusión: el sistema de salud colombiano limita la autonomía profesional de los odontólogos que ejercen en IPS públicas y privadas. La autonomía profesional, relacionada con la toma de decisiones, es un eje importante del ejercicio asistencial. Ejercer la autonomía profesional permite lograr razonamientos ético-clínicos, desarrollar destrezas y promover el bienestar de los pacientes, es decir, el compromiso bioético (beneficencia, no maleficencia y justicia), y el respeto.

Dentistry's social contract is at risk

BACKGROUND

The implications of the social contract for medicine and those it serves has been debated by bioethicists, political scientists, and physicians. Far less attention, however, has been given to dentistry's social contract.

METHODS

The existing literature from medicine is used to explore the social contract and the role of dentistry in today's society, focusing on several areas of interest.

RESULTS

The authors' analysis discusses the history of the social contract and its implications for professionalism. The authors examine the failure of the dental profession to adequately address population needs and inequities in oral health, situating this in the context of an increasingly commodified, commercialized, cosmetically oriented, and proprietary culture in the profession. The authors highlight the important role of organized dentistry in facilitating change and renewing the social contract.

CONCLUSIONS

The authors conclude that reforms are necessary for dentistry to remain a profession.

PRACTICAL IMPLICATIONS

The authors' findings may inform oral health policies and underscore the need for change among dental providers and organized dentistry to maintain dentistry's professional status.

Some orthodontists' experiences of volunteering for a community orthodontic initiative

INTRODUCTION

In society, dental professionals, including orthodontists, are often viewed as being solely motivated by money. Nevertheless, numerous orthodontists volunteer for community initiatives where they provide free or heavily subsidized treatment for underserved populations. This study explores the motivations of a group of New Zealand orthodontists who volunteered for one of these initiatives, Wish For A Smile (WFAS), as well as the high and low points of this work.

METHODS

Qualitative telephone interviews were conducted with 11 orthodontists who volunteer for WFAS. An inductive data analysis of the data was undertaken and a descriptive qualitative method was chosen.

RESULTS

Most participants volunteered for WFAS because they desired to give back to the community. High points of their voluntary work were seeing patients' self-esteem, happiness, and future life chances increase as a result of treatment. Low points included seeing the challenging life circumstances of some WFAS patients and treating some adolescents who appeared not to qualify. A number of participants said WFAS patients were more grateful and cooperative than fee-paying patients, whereas others reported the opposite.

CONCLUSIONS

There are many reasons why orthodontists volunteer for orthodontic community initiatives, although many may be motivated by a sense of social responsibility to give back to the community.

Exploring Social Justice Advocacy in Dietetic Education: A Content Analysis

PURPOSE

To explore the extent to which knowledge- and skill-based learning regarding social justice and/or social justice advocacy is included in the course descriptions of required courses of accredited, English-speaking dietitian training programs in Canada.

METHODS

This study is a mixed-methods content analysis of required course descriptions sampled from university academic calendars for accredited, English-speaking dietitian training programs across Canada.

RESULTS

Quantitative analysis showed that required course descriptions (n = 403) included few instances of social justice-related terminology (n = 63). Two themes emerged from the qualitative analysis: competing conceptualizations of social issues and dietitians' roles; prioritization of science-based knowledge and ways of knowing.

CONCLUSIONS

Accredited, English-speaking dietitian training programs in Canada appear to include little knowledge- or skill-based learning regarding social justice issues and advocacy. Supporting future dietitians to pursue leadership roles in redressing social injustices and socially just dietetic practice may require more explicit education and training about social justice issues and advocacy skills.

Community dental clinics in British Columbia, Canada: examining the potential as health equity interventions

Community dental clinics (CDCs) have emerged to provide oral healthcare for those with low incomes. In British Columbia, the establishment of community clinics has been quite rapid in recent years. However, the expansion has occurred with very little assessment of their impact or effectiveness. While oral health inequities are well recognised, there is limited documentation on healthcare interventions to reduce oral health inequities. This study examines CDCs as health equity interventions from the perspectives of individuals establishing and operating the clinics. The study included interviews with 17 participants--4 dentists, 6 dental hygienists and 7 clinic managers--from 10 clinics operating in British Columbia, Canada in 2008-2009. A thematic analysis of the interview transcripts, explored through a health equity framework, found many ways in which the CDCs exemplify health equity interventions. Although their design and mandates are varied, they potentially enable access to dental treatment, but without necessarily ensuring sustainable outcomes. Moreover, the scalability of CDCs is questionable because frequently they are limited to emergency care and are less responsive to the gradients of needs for populations facing multiple barriers to care. Many of them operate on a charitable base with input from volunteer dentists; however, this foundation probably eases the pressure on dentists and dental hygienists rather than offering a safety net to underserved populations.

Tough luck and tough choices: applying luck egalitarianism to oral health

Luck egalitarianism is often taken to task for its alleged harsh implications. For example, it may seem to imply a policy of nonassistance toward uninsured reckless drivers who suffer injuries. Luck egalitarians respond to such objections partly by pointing to a number of factors pertaining to the cases being debated, which suggests that their stance is less inattentive to the plight of the victims than it might seem at first. However, the strategy leaves some cases in which the attribution of individual responsibility is appropriate (and so, it seems, is asking people to pick up the tab for their choices). One such case is oral health or significant aspects of this. It is appropriate, the paper argues, to hold people responsible for a number of factors that affect their oral health. A luck egalitarian approach inspired by John Roemer can assess whether people have acted responsibly by comparing their choices to those of their peers. A luck egalitarian approach to oral health would recommend prioritizing scarce resources in a responsibility-weighted queuing system and include copayment and general taxation among its measures of financing.

Access to dental care for low-income adults: perceptions of affordability, availability and acceptability

The objective of this study was to explore access to dental care for low-income communities from the perspectives of low-income people, dentists and related health and social service-providers. The case study included 60 interviews involving, low-income adults (N = 41), dentists (N = 6) and health and social service-providers (N = 13). The analysis explores perceptions of need, evidence of unmet needs, and three dimensions of access--affordability, availability and acceptability. The study describes the sometimes poor fit between private dental practice and the public oral health needs of low-income individuals. Dentists and low-income patients alike explained how the current model of private dental practice and fee-for-service payments do not work well because of patients' concerns about the cost of dentistry, dentists' reluctance to treat this population, and the cultural incompatibility of most private practices to the needs of low-income communities. There is a poor fit between private practice dentistry, public dental benefits and the oral health needs of low-income communities, and other responses are needed to address the multiple dimensions of access to dentistry, including community dental clinics sensitive to the special needs of low-income people.

A scoping review and research synthesis on financing and regulating oral care in long-term care facilities

BACKGROUND

Oral health care for frail elders is grossly inadequate almost everywhere, and our knowledge of regulating and financing oral care in this context is unclear.

OBJECTIVE

This scoping study examined and summarised the published literature available and the gaps in knowledge about regulating and financing oral care in long-term care (LTC) facilities.

METHODS

We limited the electronic search to reports on regulating and financing oral care, including reports, commentaries, reviews and policy statements on financing and regulating oral health-related services.

RESULTS

The broad electronic search identified 1168 citations, which produced 42 references, including 26 pieces of grey literature for a total of 68 papers. Specific information was found on public and private funding of care and on difficulties regulating care because of professional segregation, difficulties assessing need for care, uncertainty on appropriateness of treatments and issues around scope of professional practice. A wide range of information along with 19 implications and 18 specific gaps in knowledge emerged relevant to financing and regulating oral healthcare services in LTC facilities.

CONCLUSIONS

Effort has been given to enhancing oral care for frail elders, but there is little agreement on how the care should be regulated or financed within the LTC sector.

Reforming dental workforce education and practice in the USA

The USA dental education programmes are facing challenges similar to those confronting countries around the globe, particularly amongst the industrialised nations. The purpose of this study was to evaluate the educational programmes of 15 USA dental schools to determine their impact on improving workforce diversity and oral health care access. The study investigates the predictors of public service plans of dental school seniors in Pipeline and non-Pipeline Program dental schools. We analysed baseline and post-intervention data collected in the American Dental Education Association (ADEA) Annual Survey of Dental School Seniors and a set of contextual variables. Public service plans (dependent variable) was predicted by four types of independent variables: intervention, contextual, community-based dental education (CBDE), and student characteristics. Findings from the study show that access to a state or federally sponsored loan repayment program was the most significant predictor of public service plans and that increasing educational debt was the most significant barrier. In the short-term we may be able to sustain the USA loan repayment programs to motivate senior dental students to provide public service to address the oral health care access crisis. However, in the long-term, a new workforce development initiative will be required to transform dental education and practice, modelled after the well-respected licensure programmes for Physician Assistants and/or Advanced Practice Registered Nurses, to expand oral health care access, particularly amongst vulnerable population subgroups, such as low-income children and families.

Nurturing social responsibility through community service-learning: Lessons learned from a pilot project

BACKGROUND

Community service-learning (CSL) has been proposed as one way to enrich medical and dental students' sense of social responsibility toward people who are marginalized in society.

AIM

We developed and implemented a new CSL option in the integrated medical/dental curriculum and assessed its educational impact.

METHODS

Focus groups, individual open-ended interviews, and a survey were used to assess dental students', faculty tutors' and community partners' experiences with CSL.

RESULTS

CSL enabled a deeper appreciation for the vulnerabilities that people who are marginalized experience; students gained a greater insight into the social determinants of health and the related importance of community engagement; and they developed useful skills in health promotion project planning, implementation and evaluation. Community partners and faculty tutors indicated that equal partnership, greater collaboration, and a participatory approach to course development are essential to sustainability in CSL.

CONCLUSIONS

CSL can play an important role in nurturing a purposeful sense of social responsibility among future practitioners. Our study enabled the implementation of an innovative longitudinal course (professionalism and community service) in all 4 years of the dental curriculum.

Bridging a gap: the (lack of a) sociology of oral health and healthcare

This article provides an historical review of international research related to sociology and oral health and healthcare. I begin by considering the relevance of the mouth and oral health to social interactions and physical health, and outline existing inequalities in oral health and healthcare experiences. The paper examines critically some of the existing published research in the field - considering both what might be described as sociology of oral health and healthcare and sociology in oral healthcare - and demonstrates the dearth of sociological research related to this subject compared to other areas of interest within the field of sociology of health and illness. I conclude by suggesting some ways in which this area could be expanded and developed further. I suggest that sociological analyses of how individuals experience, understand and manage their mouth and oral health, can add to and enhance the broader field of the sociology of health and illness. Further, examining experiences and provision of oral healthcare may provide sociology with a new opportunity to explore the neglected field of private healthcare, but also to engage with health policy makers who seek to address oral healthcare needs.

Predictors of oral health quality of life in older adults

There is limited information regarding oral health status and other predictors of oral health-related quality of life. An association between oral health status and perceived oral health-related quality of life (OHQOL) might help clinicians motivate patients to prevent oral diseases and improve the outcome of some dental public health programs. This study evaluated the relationship between older persons' OHQOL and their functional dentition, caries, periodontal status, chronic diseases, and some demographic characteristics. A group of 733 low-income elders (mean age 72.7 [SD = 4.71, 55.6% women, 55.1% members of ethnic minority groups in the U.S. and Canada) enrolled in the TEETH clinical trial were interviewed and examined as part of their fifth annual visit for the trial. OHQOL was measured by the Geriatric Oral Health Assessment Index (GOHAI); oral health and occlusal status by clinical exams and the Eichner Index; and demographics via interviews. Elders who completed the four-year assessment had an average of 21.5 teeth (SD = 6.9), with 8.5 occluding pairs (SD = 4.6), and 32% with occlusal contacts in all four occluding zones. Stepwise multiple regressions were conducted to predict total GOHAI and its subscores (Physical, Social, and Worry). Functional dentition was a less significant predictor than ethnicity and being foreign-born. These variables, together with gender, years since immigrating, number of carious roots, and periodontal status, could predict 32% of the variance in total GOHAI, 24% in Physical, 27% in Social, and 21% in the Worry subscales. These findings suggest that functional dentition and caries influence older adults' OHQOL, but that ethnicity and immigrant status play a larger role.

Anterior dental extractions among Dinka and Nuer refugees in the United States: a case series

Few U.S. adults today experience life without permanent anterior teeth and know little about how an incomplete anterior dentition affects adult well-being. Sudanese refugees, who had resettled in the U.S. and who had six mandibular anterior teeth ritually extracted during youth, provided an opportunity to examine the significance of the effect of this partial edentulism. The authors interviewed five adult refugees whose anterior dentition was restored using dental implants. Factors considered before and after restoration included incisal ability, food item recognition, food consumption patterns and related social factors. Before restoration of the anterior dentition, participants could not incise typical foods eaten in the U.S. and expressed embarrassment about their dental status, which limited smiling, speaking and social interaction. This case series offers insight into the bio-cultural importance of the anterior dentition for all populations living with a visible gap in the lower jaw.

Caring for elderly long-term care patients: oral health-related concerns and issues

Much work is needed to resolve the many issues of prevention in the complex environment of long-term care facilities and to provide effective curative care for individuals, no matter how frail, who could benefit from comprehensive dental services.

A Specialism of Primary Dental Care?

This opinion paper contends that a wide gap exists between the theory and practice of preventive dentistry. The reasons for this lie partly in the lack of recognition given to the potential for general dental practitioners (GDPs) to deliver health-focused care to their community of patients. This lack of recognition begins at undergraduate level and is also found among GDPs themselves. The creation of a specialism of primary dental care would help to bridge the gap between theory and practice, and help practitioners to create significantly improved levels of oral health within their respective communities.