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I've been thinking
For a very long time
A model for oral health care delivery based on recent developments in dental materials, breakthroughs in the etiology of dental decay and periodontal disease, and ideas from evolutionary biology, sociobiology, evolutionary psychology, behavioral psychology, and a few other ideas tossed in for good measure
A recipe for change
Dr Kevin Scally
The Big Picture in oral health care delivery can be viewed from the perspective of sustainability. In a recent address to the American Association for the Advancement of Science, the President of that organization, Dr Peter Raven outlined the current predicament for humanity: there are 6.1 billion people on the planet, 35,000 children die every hour, the earth will have to be cloned several fold to give each individual a western standard of living. The current expectations are unsustainable.
Now turning to oral health FDI statistics tell a grim story about the growing oral health debt. First world models of oral health care delivery simply are too expensive and will have to be altered for at risk societies and social groups in both worlds
And to get things into perspective, dental caries and periodontal disease are below the radar when the other devastating oral diseases are considered:
Craniofacial abnormalities craniomandibular disorders, Oropharyngeal carcinoma, Severe oral infections: NOMA, Aids related oral conditions, periodontal disease, enamel and dentine loss, dental decay, tooth erosion, abrasion, and other tooth-to-tooth contact tooth tissue loss.
Fortunately there are a number of opportunities on the horizon that promise to decrease the incidence and management of dental decay. Some to them include: chemical removal for dental decay, increasing acid resistance of the enamel and cementum, advances of biomimic materials and the advances in digital radiography to image the mineral status of demineralised dentine dentistry
One of the outcomes and recommendations of a recent pre WHO meeting of Commonwealth Health Ministers in 1999 was to encourage local Dental Associations to improve oral health and to increase their initiatives in finding ways to improve the oral health in deprived communities
To meet this challenge several components of knowledge and skill transfer need to be integrated: the philosophy, the procedures, who does it, and the political environment. Management includes: how to manage the load of pathogenic bacteria, the development of vaccines against the principal organisms in the pathogenesis of dental decay and periodontal disease, the use of Casein Phosphopeptides as remineralisation systems and the role of GE in oral health care. But most of all a questioning and innovative profession
Some suggestion towards a sustainable dental profession:
The training in dentistry is based on the surgical model. Only recently has the profession been moving towards a medical model with the introduction of caries susceptibility tests, prescribing remineralising treatments and identifying risk factors in diet.
But there is a third
The grooming pleasure model
The evolutionary model would suggest that teeth evolved along with the oral flora to be a self-protecting system. The principal cause of caries (apart from the anatomical fault lines of fissures) is an acidogenic environment and a susceptible tooth surface. The pathogenesis of the mineral loss is an imbalance of the mineralisation and remineralisation cycle. As primates, there is an evolutionary predisposition to seek out sweet food sources. It is the high sugar food and beverage choice, driven by commercial forces that is the potent etiological factor in the incidence of dental disease.
The evolutionary and behavioral model asks the question: what is the nature of teeth and their role in evolution of the human species and what is the role of oral grooming in dental care? I have developed arguments elsewhere that suggest that we have an excess of enamel and destine. This is a consequence of the lack of interproximal wear; which in turn is a consequence of exogenous mastication and digestion (food preparation and cooking). Now 32 teeth are well in excess of what is required for survival. Thirty-two teeth can be seen as a culturally acquired anatomical abnormality.
A new foundation of oral care delivery is primarily could be based on a grooming model. Out with scrubbing your teeth and gums and in with caressing, massaging and grooming your mouth.
Just as we have hairdressers, beauty therapists, I believe it is time to develop a new class of oral heath worker, oral groomers with a well-defined scope of practice.
I believe that this model of health care, or the grooming pleasure model is the third leg or health care delivery, the other two being the surgical and medical model.
What are some of the barriers to this view?
The user pays education model has seen a rise in expectations of a number of auxiliary groups in health and education. The training has moved from the craft and guild based training in a polytechnic or specialist school environment to diploma based courses in universities. This process of academisation of a number of professions: teaching, nursing, dental hygiene, dental technology, dental therapy has at it heart a need for training to be recognized so that it forms the foundation on which to build a career. Prior to this, many auxiliaries had very little career development. In contrast, when seen from a public health viewpoint, we need lots of adequately trained human resource to manage the bulk of the simple restorative and preventive treatment. You don't need a university degree to do this, but you may need a system of reentry with acknowledgement of prior training and experience. As it is, there is a growing gulf between the needs of the community and the needs of the individual clinician. As I see it, the current situation is unsustainable, and I think we had it right with the original School Dental Nurse, but with a few modifications.
Care should be a pleasurable experience. The advertising industry knows this. If a trip to the oral health provider was a pleasure then a major barrier to care would be substantially reduced. The provider needs to be a trusted person in the individual's community. Its no coincidence that dentistry started via the surgeon barber. This metamorphosed into the general surgeon and dentistry tagged along. There is merit in returning to our roots and analyzing what drew people to the barber in the first place.
What are some of the remaining treatment challenges to oral health dentistry?
Simple diagnostic tests for precancerous changes in the oral mucosa. Simple endodontic treatment that quickly replaces the space occupied by the pulpal contents with a biomimic soft tissue analogue, and a deep, and easily reversible, graded anaesthetic delivery system that allows analgesia at a local level along anxiety reduction and hypnotic properties for the surgical management of caries and endodontic and exodontic procedures, especially for children.
Dr R G Every for his insights into how teeth work and the psychology of the dentist patient relationship. His experience and research suggested the oral grooming approach to oral health care. Also Canterbury Hospital in its various metamorphosises for challenging environment that has helped stimulate my thinking.
Ideas should freely spread from one to another over the globe, for the moral and mutual instruction of man, and the improvement of his condition.
This paper is a work in progress and is incomplete with respect to references I intend to develop these ideas and arguments in the near future for publication and fully reference my sources there.
Oral Health Centre