Oral care as a life course project: A qualitative grounded theory study

The phenomenological approach in dentistry - a narrative review

PURPOSE

Phenomenology is a branch of philosophy that focuses on human lived experience. Illness including dental diseases can affect this living experience. Within the dental literature, there is very little reported on the use of phenomenology compared to other healthcare sciences. Hence, the aim was to review the literature and provide an overview of various applications of phenomenology in dental research.

METHODS

This study was a narrative review using literature in the last 10 years identified by web-based search on PubMed and Scopus using keywords. A total of 33 articles that were closely related to the field and application in dentistry were included. The methodology, main results, and future research recommendations, if applicable, were extracted and reviewed.

RESULTS

The authors in this study had identified several areas such as orofacial pain and pain control research, dental anxiety, dental education, oral healthcare perceptions and access, living with dental diseases and dental treatment experience in which the phenomenological method was used to gain an in-depth understanding of the topic.

CONCLUSIONS

There are several advantages of using the phenomenological research method, such as the small sample size needed, the diverse and unique perspective that can be obtained and the ability to improve current understanding, especially from the first-person perspective.

Capturing the smile: Exploring embodied and social acts of smiling

Smiling is an embodied and complex social act. Smiling is presented as facilitating individual health and wellbeing, but the value placed on smiling raises questions about structural conditions acting on the body. While smiling has been considered sociologically, psychologically and historically, we argue that further exploration of the embodied smile offers fruitful avenues for future research. This article attempts to advance understanding of the smile and its importance by: (I) Bringing together literature on smiling as a social act and smiling as embodied. (II) Systematically identifying key themes, which recognise sociological insights and the relevance of oral health. (III) Pointing to useful directions for future sociological research into smiling. In this article, we review literature on body techniques; impression management and social interaction; gender, race and smiling; and emotional, aesthetic and affective labour. We move on to embodiment, considering the mouth as a body project and in relation to the ageing body, before reflecting on the significance of oral health and dentistry. We highlight future directions for sociological research on smiling, building on eight interrelated and cross-cutting themes: norms and expectations, aesthetic ideals, self and identity, health and wellbeing, body work, commodification and labour, inclusion and exclusion and resistance.

Dentists' Approaches to Treatment Decision-Making for People with Dementia: A Qualitative Study

INTRODUCTION

Globally, the number of people living with dementia (PLwD) is projected to increase substantially. Dentists will encounter an increasing number of PLwD retaining natural teeth who need dental care. Dental treatment planning can be complex for PLwD as both oral diseases and dental treatment can be detrimental to patients' oral and social function and comfort. In addition, patients may lack the capacity to make decisions about their treatment, posing further challenges for dentists.

OBJECTIVE

This study aimed to explore dentists' approach to treatment decision-making with or for PLwD.

METHODS

Semistructured one-to-one interviews were completed with 22 dentists between April 2020 and March 2021. Data generation and analysis followed the principles of constructivist grounded theory with data being collected and analyzed simultaneously using a maximum variation sample. Interviews were recorded, transcribed verbatim, and then analyzed, leading to a theoretical understanding of how dentists approach treatment decisions for PLwD.

RESULTS

Four data categories describe dentists' approaches to treatment decision-making for PLwD. Dentists sought to provide individualized care for PLwD. However, they described planning care based on risk-benefit analyses that primarily considered biomedical factors and generic assumptions. There was an underemphasis on the psychological or social implications of dental care or its delivery. Furthermore, while some dentists attempted to involve patients in treatment decisions, they reported fewer attempts to identify the views and preferences of PLwD identified as lacking decisional capacity. In this scenario, dentists reported leading the decision-making process with little regard for patients' known or identified preferences and minimal involvement of PLwD's family.

CONCLUSIONS

Dentists acknowledge the complexity in treatment decision-making for PLwD yet focused heavily on biomedical considerations, with an underemphasis on individuals' preferences and autonomy. Considering psychosocial aspects of care alongside biomedical factors is essential to support holistic person-centered care for this growing patient cohort.

KNOWLEDGE TRANSFER STATEMENT

This study highlighted that dentists may only be considering biomedical aspects of care when considering what treatment is appropriate for people living with dementia. When making or supporting treatment decisions, dentists should explore patients' preferences and actively consider relevant psychosocial factors. These can be actively identified through considered discussions with patients as well as their family members. Gathering this information should support more person-centered and value-concordant decision-making for people living with dementia.

'It's like being in a tunnel': Understanding the patient journey from tooth loss to life with removable dentures

INTRODUCTION

The aim of this study was to conceptualise the key stages of the patient journey in the provision of a new denture and examine the factors leading to successful patient-related outcomes.

METHODS

Two partially dentate patient samples were included: (i) Denture wearers - patients who had a denture fitted within the previous five years and (ii) New dentures - patients receiving treatment for a new or replacement denture. The methods involved direct targeted participant observations of the denture fitting process, debriefing interviews and a follow-up focus group exploring the patient journey. Data were analysed through the use of phenomenology and grounded theory.

RESULTS

Interviews were completed with twenty participants of the denture-wearing sample (11 males and nine females, age range 22 to 86 years). Thirteen participants were included in the treatment journey sample in two primary care settings (six males and seven females, age range 55 to 101 years). Tooth loss and recovery was described as being in an 'emotional tunnel' resulting from 'bodyphonic processes' associated with tooth loss. 'Bodyphonia' subsequently became the context for 'taking control' and 'managing disclosure' when living with a removable denture. Different courses through this process can be readily observed, moderated by different variables (i.e., previous experience, working knowledge, a good fit, the treatment alliance, negotiated compromises and bounded responsibility).

CONCLUSIONS

An'integrating framework' that seeks to describe the patient journey from the experience of tooth loss to recovery with a denture is proposed. This framework could be used to aid development of a clinical pathway to guide treatment options.

CLINICAL SIGNIFICANCE

This paper conceptualises the patient journey. It stresses the importance of understanding the stages patients go through and highlights that for the dental team, the try-in stage is perhaps the best stage to give information about the denture and plans for continued care.

Exploring dental treatment decision-making experiences of people living with dementia and family carers

INTRODUCTION

People living with dementia can have complex dental care needs. Dentists and patients should make treatment decisions together, yet some people living with dementia may be unable to make their own decisions about their dental care. Dental treatment decision-making and patients' experiences of this process have not been comprehensively researched.

OBJECTIVE

This study aimed to explore the dental treatment decision-making perspectives and experiences of people living with dementia and their family members.

METHODS

Semi-structured interviews were undertaken with 8 people living with dementia and 17 family caregivers. A constructivist grounded theory approach was adopted, using a maximum variation sample. Qualitative data collection and analysis occurred concurrently. Data underwent initial open coding followed by more focused coding, supported by reflexive memo writing, which supported data categorisation.

RESULTS

People living with dementia reported wanting to be understood as unique individuals with specific needs. All participants described wanting to be actively involved in dental treatment decisions. However, many felt that they were insufficiently involved in treatment decision-making. This perceived underinvolvement meant that some people living with dementia and family members felt the treatment outcomes they sought were neither discussed nor considered.

CONCLUSION

People living with dementia and carers had specific expectations of dental care yet felt passive in decision-making despite their desire to be involved in this process. Dentists should seek to actively establish patients' preferences, regardless of mental capacity and consider these in discussions and decisions about dental treatment.

Measuring oral health-How can the International Classification of Functioning help?

There is a need for a theoretically informed, contextualized approach to measuring oral health from a multidisciplinary perspective that goes beyond the commonly used clinical indices and sociodental measures. This commentary aims to discuss the potential for the WHO's International Classification of Functioning, Disability and Health (ICF) to provide a model for the development of indicators for oral health. It is suggested that the ICF might provide both a theoretical model and an operational classification for indicators of oral health. The ICF model states that human experience of physical, cognitive and social functioning is universal and, thus, can be described and qualified. Human function is given social and environmental context within the model at both an individual and population level. The ICF can not only capture data regarding oral health and function at the physiological level (e.g. chewing) but also at the social level (e.g. sharing meals). It is able not only to capture aspects of preventive behaviour (e.g. caring for teeth) but also aspects of social facilitation (e.g. economic self-sufficiency) or ability to fulfil a social role (e.g. remunerative employment). It also includes aspects of social environment, such as healthcare services or political, economic and legal systems. Case studies are given as examples of the potential use of the ICF in the oral health domain. Examples are also given of the first steps that have been made towards operationalization of the ICF in data collection and oral health research. The challenges of encompassing such a comprehensive model into a practical oral health measure are discussed.

A cross-sectional analysis of oral health care spending over the life span in commercial- and Medicaid-insured populations

BACKGROUND

Life course theory creates a better framework to understand how oral health care needs and challenges align with specific phases of the life span, care models, social programs, and changes in policy.

METHODS

The authors obtained data from the 2018 IBM Watson Multi-State Medicaid MarketScan Database (31 million claims) and the 2018 IBM Watson Dental Commercial and Medicare Supplemental Claims Database (45 million claims). The authors conducted analysis comparing per enrollee spending on fee-for-service dental claims and medical spending on oral health care for patients from ages 0 through 89 years.

RESULTS

Oral health care use rate and spending are lower during the first 4 years of life and in young adulthood than in other periods of life. Stark differences in the timing, impact, and severity of caries, periodontal disease, and oral cancer are seen between those enrolled in Medicaid and commercial dental plans. Early childhood caries and oral cancer occur more frequently and at younger ages in Medicaid populations.

CONCLUSIONS

This life span analysis of the US multipayer oral health care system shows the complexities of the current dental service environment and a lack of equitable access to oral health care.

PRACTICAL IMPLICATIONS

Health policies should be focused on optimizing care delivery to provide effective preventive care at specific stages of the life span.

Provision of Oral Health Care by Dentists to Community-Dwelling Older Patients

BACKGROUND

Research into oral health care for older people has shown that dental care in general decreases with increasing age and frailty and, therefore, oral health care provision may be complex. The aim of this study is to identify the oral health care dentists provide to community-dwelling older people and which barriers they experience in doing this.

METHODS

In this cross-sectional study, a representative sample of dentists in the Netherlands was asked to prospectively select one older patient and describe this patient using a specially developed registration form; the patient was requested to fill out a questionnaire. The relationship between experienced barriers in providing oral health care to older patients and characteristics of the dentists and the patients was studied by means univariate and multivariate logistic regression analysis.

RESULTS

In total, 923 dentists were asked to participate in the study. Data were available for 39.4% dentist-patient pairs. In most cases (87.4%), oral health care was focussed on conservation of the dentition. In all, 14.0% of the dentists experienced barriers in providing oral health care for older people. Some patient factors increase the risk of experiencing barriers, eg, the more difficult behaviour of older patients and the greater disease burden.

CONCLUSIONS

Oral health care was mostly focussed on conservation of the dentition, and dentists especially experience barriers in oral health provision to older patients if they are already frail.

Disentangling a web of causation: An ethnographic study of interlinked patient barriers to planned dental visiting, and strategies to overcome them

OBJECTIVE

To explore barriers to planned dental visiting, investigating how barriers interlink, how they accumulate and change, and how individuals envisage overcoming their combination of barriers through personal strategies.

METHODS

An ethnographic study was conducted of adult urgent dental care attenders who did not have a dentist, including 155 hours of nonparticipant observations, 97 interviews and 19 follow-up interviews in six urgent dental care settings. Data were analysed using constant comparison, first identifying barriers and personal strategies to overcome them, and subsequently analysing interlinks between barriers and personal strategies.

RESULTS

Accounts of barriers to planned dental visiting encompassed multiple barriers, which related to socioeconomic circumstances as well as experiences of oral health care. Barriers were multi-layered and more difficult to overcome when occurring together. Personal strategies to overcome diverse barriers often hinged on increasing importance of oral health to individuals, yet this was not always sufficient. The combination of barriers participants experience was dynamic, changing due to personal, family, or employment circumstances, and with increasing severity of barriers over time. Over time, this could lead to higher cost, and additional barriers, particularly embarrassment.

CONCLUSION

Barriers to planned dental visiting are complex, multi-layered and change over time, constituting a 'web of causation'. This adds a novel perspective to the literature on barriers to dental visiting, and requires that researchers, dental practitioners and policy makers remain open to barriers' interlinked effects, changes in primacy among individual patients' barriers, and their accumulation over time to better support uptake of planned dental visiting.

'I didn't want to pass that on to my child, being afraid to go to the dentist': making sense of oral health through narratives of connectedness over the life course

While previous sociological research on oral health has identified the relevance of personal relationships, there is more scope to analyse the mouth through a lens of connectedness. Recent qualitative interviews with 43 older people (65+) in England and Scotland found that participants constructed relational narratives to make sense of their oral health practices. By drawing on ideas of family practices, family display and personal life, we illustrate how the mouth can be understood relationally. Participants presented their own embodied experiences as connected to the actions of their parents. Narratives also reflected how, as parents and grandparents themselves, participants tried to shape the experiences of others. In this way, oral health practices were conceptualised as being about family. This can be seen in self-narratives that demonstrated how participants located themselves as embedded in webs of ongoing relationships. We highlight the importance of narrated practices of thinking and feeling, whereby participants imagined doing oral health, and indeed family, in different ways. We thereby demonstrate how oral health practices are constituted through family connectedness and at the same time how these practices contribute to the constitution of family. Policy should therefore pay attention to family relations when promoting improvements in oral health practices.