The platform for better oral health in Europe--report of a new initiative

Public health practitioners are required to apply their competencies at a range of levels from governmental to small community groups. A recurring theme at BASCD conferences has been the need to influence policy at the highest level if improvements to oral health and better treatment of oral ill-health are to occur. This paper presents a clear example of such dental public health action at a European level. This report outlines the reasons why it is necessary to try to improve oral health within Europe, in general, and the European Union in particular. It goes on to describe how the newly formed Platform for Better Oral Health in Europe is trying to work at a macro level, and bring interested associations, groups and individuals together. Collectively they can then alert European institutions and national governments to oral health problems and promote policies to improve the current situation. It describes the current problems, their resource implications, the objectives of the Platform, its actions so far and its plans for the immediate future. It suggests that, if the problems are to be addressed, it will be necessary for all interested parties to work together at a European level to raise oral health issues higher on the E.U. agenda.

A curriculum for the new dental practitioner: preparing dentists for a prospective oral health care environment

The emerging concept of prospective health care would shift the focus of health care from disease management to disease prevention and health management. Dentistry has a unique opportunity to embrace this model of prospective and collaborative care and focus on the management of oral health. Academic dentistry must better prepare future dentists to succeed in this new health care environment by providing them with the scientific and technical knowledge required to understand and assess risk and practice disease prevention. Dental schools must consider creating career pathways for enabling future graduates to assume important leadership roles that will advance a prospective oral health care system.

Organisation and management of public dentistry in Sweden. Past, present and future

Professional organisations present challenges in management compared to producing companies, as control of the work lies within the professional groups themselves. Management in the Public Dental Health Service (PDHS) has an added difficulty in the two-tiered political governance in Swedish public dentistry. The aim of this thesis was to contribute to better understanding of the organisation and management of Human Service Organisations, especially the PDHS in Sweden, thereby contributing to long-term sustainability with due regard to the professionals. The aim was also to point to some future difficulties facing the PDHS and possible solutions to these. Four papers are included in the thesis. The first paper set out to define the professions in dentistry in Sweden from theories on professions. Dentists and, to a lesser degree; dental hygienists were the identified professional groups. The second paper scrutinised the external environment for dentistry in Sweden in the form of political decisions, i.e., laws and regulations. The findings were that there can be a gap between the formal objectives and the factual behaviour from the political level, and that certain politically attractive ideas might reoccur at a later time despite good scientific arguments against them. Also indicated in this paper were ways to influence the political processes, by active participation in the early stages of decision-making The third paper dealt with the heads (CDOs) of the PDHS in the counties and is based on a questionnaire to them on management. It was found that ideas on management and organisation usually were embedded in the way the respective county council was organised. A strong belief in advantages of scale was noted, both for administration and also for dental care itself. The fourth paper compared overall job satisfaction among publicly employed dentists in Denmark and Sweden. A focus on size of clinic, on professional development and on influence at the work place was found to be important. The Danish dentists were generally more satisfied with their overall job situations than the Swedish ones. One explanation might be found in the environment for the respective service, with a much stronger element of competition in Sweden. Another aspect could be that the expectations of the Danish dentists might be more realistic when they entered the public service. In an appendix the history of the Swedish Public Dental Health Service is outlined.

CONCLUSIONS

Dentists in Sweden are an established profession and dental hygienists are an emerging profession; they and society would benefit from a clearer delineation and definition of their unique competences. Political decision-making is not necessarily rational, and garbage can models or similar can give a better understanding of political processes. CDOs have a widespread belief in advantages of scale in administration as well as in care, which may pose future problems for the provision of dental care in sparsely populated areas. Overall job satisfaction, as part of Good Work, is founded in an atmosphere at the clinic that is focussed on professional values. It is noteworthy that PDHS dentists not born in Sweden had a lower job satisfaction than those born in Sweden. Perhaps a closer cooperation between the dental colleges and the PDHS might give the newly qualified dentists a more realistic view of the professional challenges in public dentistry, as well as giving the colleges access to the vast material on patients in the PDHS. The future division of tasks between the general dentists, dental hygienists and specialist care dentists has a great impact on the future need for personnel, and needs to be carefully analysed. The future diminishing numbers of dentists and the difficulty for the PDHS to retain dentists may be met by adapting the organisations to a much greater flexibility by allowing different teams to organise their own work. The possibilities to give the patients good service quality will depend on continued democratisation and less managerial control. Producer cooperatives, franchising, or similar, could be revisited and tried. However, such forms will require carefully designed contracts where the objectives and the outcomes are possible to define and to evaluate. The balance between good work for dentists, an efficient organisation and perceived good service to the public will be objects for further studies.

[The dental aspects of public health in Hungary. Review article]

Despite great improvements in the oral health status of the population, public health and dental public health continue to be a major problem in society. A number of epidemiologic studies revealed the importance of the social, behavioral and environmental factors contributing to inequalities in the maintenance and restoration of oral health. Dental public health is the science and art of preventing oral diseases, promoting oral health and improving the quality of life through the organized efforts of the public. The aim of the authors was to provide an overview about the development and the functions of the Hungarian public health and dental public health system, its associations with international dental public health organizations and about the present dental public health status of the Hungarian population. According to WHO pathfinder studies, the Hungarian population has a usual cariologic and periodontal status in Europe, but a number of WHO statistical analyses reveal the sad situation regarding the high frequency of oral malignancies in our country. The social support system is given, the tasks are in front of us, and Hungary intends to follow the oral health strategies of the WHO for 2020 in order to improve the dental public health status of the nation, but it is necessary to declare that not only behavioral but also political decisions are necessary for that goal.

Dental public health: the "big picture" specialty

The specialty of dental public health is focused on improving oral health in the aggregate. Its principal tools include assessment, policy development, and assurance of effective outcomes. Although there are fewer than 200 active diplomates of the American Board of Dental Public Health, the effect of this specialty is large because of its impact on the interpretation of oral health issues and its influence on allocation of funding resources. Diplomates in dental public health work primarily in the federal government and academic settings, performing administrative, research, and teaching functions. In the current debate over the level, effectiveness, and distribution of health resources, dental public health can be expected to play an increasing role in helping to set the agenda.

[The reasons of tooth extraction taking into consideration the socio economical status during changes in the public health service in the West-Pomeranian voivodeship]

INTRODUCTION

There are many possibilities of diagnosing and treating, but the fact of an increasing number of patients who have resigned from expensive procedures in place of teeth extraction is still noticeable.

MATERIAL AND METHODS

Poll analysis based on the population of a big city--Szczecin and small towns in West Pomerania revealed that one's wealth considerably impacts both the frequency of visits in dental practices and the decisions regarding a mode of treatment.

RESULTS

It further occurs that the most common reason of tooth extraction is caries and its later complications. Over 25% of patients from Szczecin and nearly 20% of interrogated people in provinces had to extract teeth because of an economical reason due to the lack of money for restoring treatment. It also appeared that a majority of people feel unsatisfied with the proceeding reorganization of the national health service and have not observed any positive tendencies effecting from this process so far.

Serving the public good: challenges of dental education in the twenty-first century

The purpose of this study was to explore perceptions of the roles and responsibilities of dental education in serving the public good, and the extent to which they are being met, from the vantage point of leaders at the university and state level. Five questions were developed to gather views on dental education's success in meeting the expectations and needs of the public. Fifty-one interviews were conducted with leaders at seven institutions and with public officials in six states. Overall, dental education was perceived as fulfilling its public purpose in promoting oral health, providing access to care, and conducting relevant research. However, significant areas for improvement were noted including better communication of accomplishments to key stakeholders, graduating a more socially aware, culturally sensitive, and community-oriented dental practitioner, and being a committed partner with other community leaders in improving access to care for all citizens. Current programs aimed at addressing these gaps (e.g., Pipeline, Profession, and Practice program) are discussed. Dental education can address these perceptions only by producing graduates who desire to fulfill their obligations to society and serve the public good.

Zahngesundheit deutscher und türkischer Schüler - Ein 10-Jahresvergleich

The purpose of this cross-sectional study was to assess the changes in dental health in 12- and 15-year-old Turkish immigrants and German students who were included in a school-based caries-preventive programme for ten years (1993-2003). In 1993 352 and 402 12- and 15-year-olds and in 2003 352 and 402 12- and 15-year-olds were investigated, respectively. 23.6% of the 12-year-olds and 21.5% of the 15-year-olds were of Turkish origin. The clinical examination was performed with support of artificial light at school. Caries was diagnosed according to the WHO standard using the DMFT Index for permanent dentition. Within the ten-year period the highest increment of caries-free dentitions was found in 12- and 15-year old Germans attending grammar schools with 41,5% and 27% and secondary modern schools with 22,3% and 17%, respectively. The proportion of caries-free Turkish students attending secondary modern schools, only increased imperceptible in both age groups (1.2%). A significant caries decline of 1.5 DMFT was observed in 12-year old Germans at grammar schools, only. In 15-year olds caries declined in German students at secondary modern schools (2.5 DMFT), and at Grammar schools (2.2 DMFT), significantly, however caries experience in Turkish students remained nearly unchanged (0.3 DMFT). A strong polarisation of dental caries was found in 2003. Among the 12-year-olds 23% of those at secondary modern school accumulated 70% of the total caries experience (>3 DMFT) and at grammar school 9% of students accumulated 76% of the whole amount of caries (>1 DMFT). Among the 15-year-olds 73% of the total caries experience (>3 DMFT) was concentrated in 32% of the students at secondary modern schools, while 25% of the students at grammar schools exhibited 84% of the whole amount of caries (>1 DMFT). Intended concepts in caries prevention in the future should aim to improve dental health especially in Turkish students at secondary modern schools while taking social inequality of this risk group into account.

Developments in oral health policy in the Nordic countries since 1990

PURPOSE

There is a number of systems for the provision of oral health care, one of which is the Nordic model of centrally planned oral health care provision. This model has historically been firmly based on the concept of a welfare state in which there is universal entitlement to services and mutual responsibility and agreement to financing them. This study reports and analyses oral health care provision systems and developments in oral health policy in the Nordic countries (Denmark, Finland, Iceland, Norway and Sweden) since 1990.

MATERIAL AND METHODS

Descriptions of and data on the oral health care provision systems in the Nordic countries were obtained from the Chief Dental Officers of the five countries, and contemporary scientific literature was appraised using cross-case analyses to identify generalisable features.

RESULTS

It was found that in many respects the system in Iceland did not follow the 'Nordic' pattern. In the other four countries, tax-financed public dental services employing salaried dentists were complemented by publicly subsidised private services. Additional, totally private services were also available to a variable extent. Recently, the availabilty of publicly subsidised oral health care has been extended to cover wider groups of the total population in Finland and Sweden and, to a smaller extent, in Denmark. Concepts from market-driven care models have been introduced. In all five countries, relative to the national populations and other parts of the world, there were high numbers of dentists, dental hygienists and technicians. Access to oral health care services was good and utilisation rates generally high. In spite of anticipated problems with increasing health care costs, more public funds have recently been invested in oral health care in three of the five countries.

CONCLUSION

The essential principles of the Nordic model for the delivery of community services, including oral health care, i.e. universal availability, high quality, finance through taxation and public provision, were still adhered to in spite of attempts at privatisation during the 1990 s. It appeared that, in general, the populations of the Nordic countries still believed that there was a need for health and oral health care to be paid for from public funds.

[Orthodontic treatment needs and indications assessed with IONT]

The aim of this work was to determine the usefulness of the Index of Orthodontic Treatment Need (IOTN) in epidemiological studies undertaken to assess orthodontic treatment need of a given population, as well as in the process of defining indications to orthodontic treatment in individual cases with regard to objective treatment need and expressed demand for treatment. The correlation of the Aesthetic Component of IOTN (AC degree) with demand for treatment, usefulness of IOTN for screening studies, necessary modifications to make IOTN more acceptable to Polish orthodontists, and value of IOTN as a diagnostic and measuring tool for the assessment of orthodontic treatment need were addressed. The correlation between AC and demand for treatment, as well as the usefulness of IOTN in epidemiological studies were investigated with questionnaires and clinical examination using both components of IOTN (Figs. 1, 2, 3). The study group consisted of 264 schoolchildren aged 12 years. The results show that poor dental aesthetics is the main motivating factor to undertake orthodontic treatment (Tab. 1) and that demand for orthodontic treatment exceeds treatment need determined by IOTN (Tab. 2, 3). A regular distribution of AC degrees relative to the demand for treatment was obtained (Fig. 4) revealing the necessity to modify treatment need categories of this component in order to identify individuals with significant subjective treatment need. The modified aesthetic component would comprise the following treatment need categories: Grades (photographs) 1-2--"no demand for treatment"; 3-4--"borderline demand for treatment"; 5-10--"great demand for treatment". Excellent reproducibility of the Index (high values according to Kappa statistics), its universality, usefulness for various purposes, and simplicity in practice make the Index valuable for screening studies and assessment of treatment need in a given population. In order to test the reliability of the Dental Health Component of IOTN (the degree of conformity of this component with treatment tendencies among orthodontists), DHC criteria and subjective evaluation of treatment need were compared. This part of the study was carried out in a group of six orthodontists. 50 pairs of plaster casts covering a wide range of occlusal anomalies were analyzed. The subjective need for orthodontic treatment was stated for each case taking into account treatment priority and occlusal features determining treatment need. The results reveal a moderate conformity of DHC criteria with the orthodontist's opinion (Tab. 4 A, B) and a tendency among orthodontists to qualify for treatment also cases without treatment need according to IOTN recommendations. The discrepancy between the orthodontist's assessment of treatment need and DHC criteria applies mainly to cases with reverse overjet, front open bite, front or total crossbite and crowding in buccal segments of dental arches (Tab. 4 A, B). Matching the dental health component with opinions of Polish orthodontists requires shifting of some criteria from the moderate treatment need to the great treatment need category (Fig. 5).

Advances in dental public health

Dental public health has been defined as 'the science and art of preventing oral diseases, promoting oral health and improving the quality of life through the organised efforts of society'. Dental practitioners most often have the oral health of individual patients as their primary focus but the aim of public health is to benefit populations. Early developments in dental public health were concerned largely with demonstrating levels of disease and with treatment services. With greater appreciation of the nature of oral health and disease, and of their determinants has come recognition of the need for wider public health action if the effects of prevention and oral health promotion are to be maximized.

Dental public health for the 21st century: implications for specialty education and practice

A panel of public health practitioners sponsored by the Health Resources and Services Administration met December 6-8, 1994, to examine current roles and responsibilities for dental public health workers and to recommend changes in education and training to meet challenges posed by an evolving health care system. Overall, at least the same number, if not more, dental public health personnel will be needed in the future. While some new roles were identified, the panel felt that only small numbers of personnel will be needed to fill these new roles. Not all of these roles necessarily require a dental degree. The panel felt that a need exists for more academicians for dental schools, schools of public health, dental public health residencies, and dental hygiene programs; oral epidemiologists and health services researchers; health educators; and specialists in utilization review/outcomes assessment, dental informatics, nutrition, program evaluation, and prevention. To meet these personnel needs: (1) dental public health residency programs should be structured to meet the educational needs of working public health dentists with MPH degrees through on-the-job residency programs; (2) the standards for advanced specialty education programs in dental public health should be made sufficiently flexible to include dentists who have advanced education and the requisite core public health courses; (3) flexible MPH degree programs must be available because of the rising debt of dental students and the decreased numbers of graduating dentists; (4) loan repayment should be available for dentists who have pursued public health training and are working in state or local health departments; and (5) standards for advanced education in dental public health should be developed for dental hygienists.

Leadership in dental public health? Wanted: a catcher in the rye

Changes in the structure of the health services have resulted in a vacuum in leadership in dental public health. The competitive model, introduced in 1993, had several serious effects on the delivery of publicly-funded dental health services. Some Crown Health Enterprises greatly reduced their expenditure by employing fewer public health dentists. This resulted in major disparities in the supervision of school dental services, and in a reduction in health-services research. Problems in publicly-funded dental health services are accumulating, but no leadership to meet these problems seems to be emerging. Because of this failure, it may now be up to the providers to assume the leadership role.

Trends in dental caries experience of school children in Australia--1977 to 1993

Data on the dental health of Australian school children from 1977 to 1985 have previously been reported. Significant features included a secular decline in caries experience as defined by the number of decayed, missing and filled teeth in both the deciduous dentition (dmft index) and permanent dentition (DMFT index), and a change in the distribution of caries experience within the child population in Australia, indicated by increasingly smaller percentages of children accounting for greater proportions of total disease experience. The aim of the present paper was to extend the annual reporting on caries experience in Australia up to and including 1993, and to document the change in the distribution of caries within the child population since 1977. In addition, the data are compared with dental targets for children for the year 2000 in Australia and internationally. Caries data were obtained for the years 1977-1993 for children who were patients at School Dental Services in each State and Territory of Australia. Caries experience was recorded by uncalibrated dentists and dental therapists during routine dental examinations. From 1977-89 data were weighted by State and Territory estimated resident populations. From 1989, the data were stratified according to age, year, and State, and weighted to reflect proportions in the national estimated resident population for each State/age stratum. Between 1977 and 1993 there has been a decline in caries experience for 6 year old children from a dift++ of 3.13 to a dmft of 1.90, and an increase in the per cent with dmft = 0 from 33.1 per cent to 53.2 per cent with dmft = 0 in 1993. Over the same time period the DMFT for 12 year olds reduced from 4.79 to 1.10 and the per cent while DMFT = 0 increased from 10.5 per cent to 53.1 per cent. Projection of the decline in DMFT indicates the dental health target for 12 year old children of DMFT = 1.0 by the year 2000 should have been achieved by the end of 1995.

Future treatment needs in children, adults and the elderly

Future treatment needs for dental services are discussed in the perspective of the objective which the services are meant to fulfill. These are, broadly speaking, equal distribution of services and economic efficiency. Within the Nordic countries, the emphasis has been on equity, perhaps less on efficiency. Equity of utilization is best understood as being a situation where patients with equal needs for oral health care receive equal treatment, in terms of both the volume and the quality of the services. The justification for arguing that equality of utilization is the appropriate measure is mainly based on the externality argument: health-care consumption by one person may be the source of utility to another person. According to that view there are two beneficiaries of dental care: the patient who is sick, and the rest of society who care for the sick patient and who derive utility from seeing the patient become healthy. The public dental services for children in the Nordic countries are organized according to the principle of equity of utilization. Equity of access is best understood as being a situation where people with equal needs have equal opportunity to use dental services. It is a supply-side phenomenon; equal access is achieved when patients with the same needs face the same costs of dental-care consumption in terms of both time and money. The oral health situation among children, adults and the elderly is exemplified by national service data and recent studies.

Dental public health in California: a view of the future

This article has described two recent successful initiatives that have utilized the unique knowledge and skills of dental public health specialists--the enactment of California's new fluoridation law and the first oral health needs assessment of California children--as examples of the types of activities in which practitioners of this specialty of dentistry are engaged on a day-to-day basis. It has also underscored how dental public health can be considered not only a specialty of dentistry, but also a specialty of the broader field of public health, as a result of its mission to assure, promote and protect the oral health of communities. We believe that assuring the oral health of Californians and the nation is far too large an undertaking for any one group or organization. The individual orientation of dental clinicians and the community orientation of dental public health practitioners will both be needed, as will be the collaboration of many other individuals and organizations, if we are to look forward to the 21st century as one in which barriers to oral health are overcome, oral diseases become distant memories, and Americans can look forward to a lifetime of oral health.

The NHS reform programme: implications for dental public health and the community dental services

The structure and funding of the National Health Service in the United Kingdom has undergone major changes in recent years. A survey was conducted among senior personnel working within the dental public health and the community dental services to identify their roles and responsibilities, their views on the effects of the changes, and the future opportunities and challenges. A response rate of 76 per cent was obtained using a postal questionnaire. In general the reforms were viewed as positive, although purchasers were consistently more optimistic than providers. The survey also highlighted that until the uncertainty surrounding the future direction of oral health care services has been clarified, the future role of senior personnel within the Community Dental Service and dental public health will remain unclear.

Dental public health: new opportunities--new responsibilities

Major changes affecting oral health in the United States have provided new leadership challenges for public health dentistry. Two new roles for dental public health are proposed: leadership in the incorporation of expanded public health skills into the education of every clinical dentist; and a broadening of the specialty in a manner similar to that of preventive medicine, involving the creation of subspecialties in public health dentistry, occupational environmental dentistry, and management policy dentistry. The current status of community dentistry departments in dental schools and programs of public health education for dental personnel in schools of public health are reviewed. Content is suggested for the incorporation of expanded public health skills into the education of every clinical dentist.

New directions--constituencies and responsibilities

Six critical questions are discussed as background information for the participants as the future direction for dental public health in North Carolina is considered. (1) Why should a dental program exist as part of the state public health program? (2) Who are the current and future constituents? (3) What programs will be necessary? (4) Where will dental public health programs function in the future? (5) How will dental public health programs function in the future? and (6) When will dental public health programs change? The Future of Public Health Report and the Year 2000 Objectives consider many of these questions for public health and dental public health. In addition to this information, the inequities of oral health status, access to care among various population groups, constituency building, and the roles of government agencies have to be considered. This presentation challenges public health to visualize possibilities for a future that cannot be seen, but that needs to be anticipated.

Anticipating the future and change

As in all of medicine, there are basic assumptions underlying the present system of dental education and delivery. These basic assumptions are facing challenges due in part to the marked reduction in the incidence of caries and the development of more effective therapies. This current period of time is described as an era of true change, rather than the mere modification of existing technology. Changes are going to occur in a number of areas. The move will be from government to private, from small to large, from generalist to specialist. Since change is inevitable, one can learn about and prepare for the stress of change, the changes happening now, and how to adapt to change. Although many changes are beyond the individual's control, their occurrence may be beneficial.

What should dental public health be in the future?

Many factors contribute to a successful dental public health program. Each of these must be developed and constantly cultivated to ensure the continuation and improvement of the program. In looking to the future, dental public health must remember its commitment to the community as its patient and its long history of public/private partnership. To best serve the citizens of the state, participants in this partnership must carefully consider which activities are appropriate for the different providers of dental services.