Community Dent. Oral Epidemiol. 1975: 3: 45-51

{Key words: couimiinity health services)

Community Dentistry

A review^ and discussion of goalsin community dentistry

INKERI BARENTHIN

Department of Social Medicine^ University of Uppsala, Uppsala, Sweden

ABSTRACT - The author discusses the need for clearly stated goals in community dentistry,the choice of goals, and the chances to achieve them. Goals in community health planningshould be based on the values, needs and resources of the community in question. Whenanalyzing goals a distinction should be made between dental heahh and dental care. Somegoals for dental care, e.g. equity of access, may concern social justice but do not necessarilylead to better dental health. It is generally agreed that good dental health for a whole com-nninity cannot be achieved by restorative treatment alone; good dental health habits areconsidered to be a better way to promote dental health. Existing research indicates thattliere are chances to attain an acceptable level of dental health if the connnunity effort issystematically planned and executed. There are indications that a reduction in the preva-lence of dental disease can be brought about by new and effective means in the future.Long-term planning should be fle.xible enough to respond to new opportunities.

(Received for publication 19 September, accepted 25 November 1974) :,:

Social institutions, whether medical, economic,educational, or political, must provide "proof" oftheir legitimacy and effectiveness in order to justifymodern society's continued support. Increasingpressure is being put on public service and com-munity program workers to evaluate their activitiesand to judge the worth of their programs''''.

Evaluation is an essential part of planning andmanagement. It relates results to objectives orgoals; it is the process of relating the actual achieve-ment of a service or program to the results pre-dicted in the plan^°. The most essential feature ofevaluative research is the presence of a goal, theachievement of which constitutes the main purposeof this research''''.

Dental health services have been analyzed innumerous studies. (For reviews, see FLOOK & SANA-

ZARo''' and RICHARDS".) However, goals for den-tal activities have seldom been discussed. The dentalprofession is guided by an intuitive idea of whatgood dentistry is. Good community dentistry is of-ten understood as good individual dentistry for allinhabitants of the community (which may be the

world, a nation, a municipality, a factory, or aschool). Since the level of unmet need for dentaltreatment by most objective standards is high, pos-sibly even higher than for physician service^", needfor a precise definition of goals has not arisen. Mostdental activities are accepted as a step in the rightdirection. However, the complexity and cost ofmodern dentistry are increasing at such a rate thatintuitive planning is no longer adequate, especiallyif dentistry is considered to be of public interest, acivic right, and not merely a matter between den-tists and patients.

The purpose of this paper is to discuss the choiceof goals for community dentistry and the chances toattain different goals. It is the hope of this authorto provoke further discussion on this matter.

DENTAL CARE AND DENTAL HEALTHAn increasing amount of attention is presently beingfocused on the study of health services in general.Health services research is concerned with the or-ganization, staffing, financing, utilization, and eval-uation of health services. It produces knowledge

46 BARENTHtN

that will contribute to improved delivery of healthcare''. It is concerned with understanding the inter-play of psychologic, social, cultural, and economicfactors that condition both the availability and utili-zation of services'̂ ̂ .

According to a WHO Expert Committee^'', den-tal health services may be defined as those serviceswhich are designed to promote, maintain or restoredental health. Public or community dental healthservices are those dental health services of an edu-cative, preventive or curative nature which are or-ganized by governments (central, regional or local),with government resources only or with participa-tion from other individuals or agencies, or throughorganized community efforts. Dental health may bedefined as a state of complete normality and func-tional efficiency of the teeth and supporting struc-tures and also of the surrounding parts of the oralcavity and of the various structures related to masti-cation and the maxillofacial complex'* .̂

The general objectives of the health sei^ices sys-tem are often expressed as health promotion, andthe prevention and treatment of diseased Analogi-cally, the general goals of dental care (in currentliterature understood as the result of the activities ofdental health services or the utilization of these ser-vices) could be expressed as dental health promo-tion, and the prevention and treatment of dentaldisease.

Goals can be analyzed at different levels. Mostresearchers dealing with program evaluation agreethat although clarification of a program's ultimategoals is one of the most difficult phases of the eval-uation, it is also one of the most critical. Studies ofintermediate goals are often easier to carry out, butthe information gained is more limited. These arejustified only when the relationship between inter-mediate and ultimate goals has already been dem-onstrated or will be tested in subsequent studies''\When analyzing goals in dentistry a distinctionshould be made between dental care and dentalhealth. The relationship between them is more eom-plex than is generally realized.

Providers of medical care have long been awareof a health paradox: the more care given, the morecare is needed. Saved life and cured disease oftenimply further care for a long time in the future.This paradox applies in dentistry, too. Teeth thatsome decades ago would have been lost, can nowbe saved but are very likely to require further treat-

ment later on. The more treatment given today, themore treatment is needed tomorrow'̂ ". Dental treat-ment alone does not guarantee good dentalhealth^'".

The discrepancy between the ambitions of healthcare — not only of dental eare — and what is actu-ally achieved, has made some authors question thevery foundations of the present system of healthcare delivery^"'̂ '''''̂ . According to HELT^", manyhave unrealistic assumptions eoneerning the rela-tionship between medical care and health. The pre-sent American health care system produces moreinequality than health. STRAUSS"'' is concernedabout the possibilities of lower income groups in the^United States to get medical care. The medical caresystem has never adequately served the lower in-come groups in the past because it was not designedto do so. Good care for these people cannot be ex-pected without far-reaching reforms in the presentsystem.

The planners are becoming increasingly awarethat additional expenditure for medical services willnot in itself guarantee a favorable return in;health''". Investments in dentistry, for instance train-^ing more dentists, do not as such guarantee better:dental health. As TEELtNG-SMtTH''* points out, the|existing shortages in health care delivery might beibetter met by a reallocation of existing resourcesthan by simply increasing the total resources avail-able. - - •

Utilization of dental health services is easier tostudy than is dental health status because exact in-formation on use ean be found in existing records.^Analysis of dental health is connected with more!difficult problems (consistency of diagnoses, diffi-1culties in organizing surveys, etc.). Before consider-'ing dental care, for instance in the form of in-creased utihzation of dental health services, as agoal for community dentistry, it should be madecertain that maximizing this eare also maximizes!dental health. Programs and plans should be care-fully evaluated in this respect. There can, of course,be special goals for dental health services, such asequity of access, moderation of costs and assuranceof quality. Many communities may wish to alter thepresent pattern of utilization of dental health ser-vices to promote equality between different socio-economie groups. A change of this kind may resultin greater social justice but not necessarily in betterdental health in the long run.

Goals in community dentistry 47

HOW TO STATE GOALSThe procedure of "goal-setting" for health carestarts with some value judgment, either explicit orimplicit — for instance, that it is good to live a longtime. The goal to be formulated is then derivedfrom this value''''. In dentistry the value could be: itis good to have healthy natural teeth. There areseveral alternatives for formulating goals from thisvalue.

Perfect dental health for each person is an un-realistic goal. Philosophically, the goal of completefreedom from disease and struggle is almost incom-patible with the progression of life'"̂ . Giving thepresent generation all the dental treatment it needsaccording to prevailing dental treatment standardsis also economically unrealistic. KRASSE"'' has ap-proximated how much it would cost to give Swed-ish people the dental treatment they need for thetime being. Although Sweden is one of the weal-thiest nations in the world and has a high standardof dentistry, KRASSE'S conelusion is that the costwould be far beyond all available economic andpersonal resources.

Reducing the goal to "good dental health formost people" implies a choice. What is good dentalhealth and who should have it? For planning pur-poses there is no universal answer. Health planningm.ust be related to the community and period oftime in question. A large number of measurementsand standards must be defined: health status andneeds of the community, resources, activities andattitudes of staff and clients, standards of practice,and impacts of effects of the programs^". This ap-plies also to community dentistry.

The assessment of priorities is a difficult task.Most often it is conducted by a series of informedguesses, value judgments, and percentage additionsto or subtractions from past effort'. Economists eancontribute to decision-making by advising on the al-location of scarce resources between competing uses.ABEL-SMITH' suggests that rather than giving asuperficial description of the areas where cost-effec-tiveness analysis might be applied, the economistsshould help the health planner to rethink his endsand question the means by which these ends are tobe achieved. Will this program result in improvedhealth, and if so, eould the gain be achieved atlower cost or a much greater gain achieved at thesame cost?

HARO & PUROLA'* point out that the ultimate

goals of health services are similar in all countries.They are derived from basic ethical norms and so-cial values. Very different methods and immediateobjectives ean be used to achieve them. For in-stance, the role society plays in organizing healthservices varies from country to country.

Most people agree that dental eare should beprovided at least to the extent that everybody canget relief in case of toothache and that everybodyis able to chew in some way. Consideration of thesebasic wishes may constitute a reasonable goal foradult dentistry in some communities.

The dental profession is becoming more andmore aware that good dental health, no matter howgenerously it is defined, will never be gained for awhole community by means of restorative dentistry.Instead, prophylaxis has long been eonsidered to bethe right way to dental health. Having acceptedthat prophylaxis is a rational way to reduce dentaldisease, the next step for the planner is to investi-gate how this ean be achieved and how long it willtake.

MEANS TO ATTAIN THE GOALSDetermining the causes of cariesMuch is known about how to prevent dental dis-ease. The problem is that the transition from know-ledge to implementation is difficult. It is very pos-sible that continuing research in caries causationand pathogenesis will result in better routes to pre-vention than any now being pursued^ Currentstrategy in caries research at the National Insti-tute of Dental Research in Washington involvesfinding effective, safe and practical methods of al-tering each element in the etiologie triad: the micro-biologic agent, the dietary environment, and thehost tooth enamel. CARLOS" says that the elimina-tion of caries as a public health problem, which 10years ago was an optimistic hope, is now a realisticexpectation. Few other contemporary health prob-lems seem more certain to succumb to intensive,balanced and tenacious scientific effort as that donein caries research. But even if current researeh suc-ceeds in making caries almost completely preven-table, the benefits will take at least two decades tobe fully felt on a national scale".

Although this optimism is not shared by all re-presentatives of the dental profession, serious con-sideration, at least in long-term planning, should be

48 BARENTHIN

given to the possibility that the caries problem willbe solved this way.

Changing dental health habitsMuch research has also been done regarding themore traditional ways of fighting dental disease. Inreeent years, increasing numbers of social and be-havioral scientists have been devoting their atten-tion to dental problems. (For reviews see KEGELES

& CoHEN^̂ YOUNG".) They, as well as many den-tists, are trying to answer questions like: which fac-tors, psychologic, social, etc., determine the actualdental behavior; ean people be motivated to changethis behavior in favor of better prophylactic habits?As is often true in medical sociology, the approachhas mostly been applied, not theoretical. To date,dental sociology lacks theories. Much of what passesfor dental sociology has consisted of eolleeting factsand statistics''".

One of the few theoretical approaches to healthservices utilization, in addition to the "classic" theo-ries of KEGELES''^, has been made by ANDERSEN &NEWMAN" who analyzed societal and individual de-terminants of utilization in the United States. Theirmodel assumed that there is a special sequence ofconditions that contributes to the volume of healthservices use. Use is dependent on the predispositionof the individual to use services, his ability to secureservices and his illness level. Some individuals havea propensity to use services more than others, andthis propensity can be predicted by individual char-acteristics existing prior to specific episodes of ill-ness.

A striking feature of dental behavior is its strongassociation with socioeeonomie faetors. Nearlyall studies, national as well as on a smaller scale,give evidence of this eorrelation''^'"'^'''"'^^

O'SHEA & GRAY^' analyzed a national survey ofthe attitudes, beliefs, and behavior in the UnitedStates conducted by the National Opinion ResearehCenter (NORC) in 1965. Personal and social char-acteristics sueh as age, education, sex, race, income,and size of community were related to positive ac-tions and beliefs about preventing oral disease.They concluded that income and education havethe greatest influence on preventive behavior. Themajority of the well-to-do, educated people had re-cently gone to the dentist and gone for the rightreasons. Beliefs in the efficacy of dental visits andtoothbrushing were almost universally accepted, but

these attitudes seem to have relatively little effect onactual behavior. As to other knowledge, lack of ac-curate information on dental health facts is indi-cated in several studies. However, the same studiesand many others indicate also that even those whoare well informed do not take appropriate action toimprove or maintain their dental health status.Dental knowledge is not necessarily translated into

8 .15 .22 .33action

NEWMAN & ANDERSON'̂ " used the Automatic In-teraction Detector program (AID) on the 1965NORG data and found the relative importance ofdifferent predictors of utilization to be (in descend-ing order): dental health status, education and oc-cupation, and family income. The utilization wasdirectly related to the population per dentist ratioalthough the relation is not strong. It seems that thedecision to seek dental eare is made within the con-text of a few proximate influences which are indi-vidual and family based.

TASH, O'SHEA & COHEN'" analyzed NORG datafrom 1959 and combined all major social and psy-chologic concepts related to dental health behavior.Almost every factor considered in the social-psycho-logic theory of preventive medicine explained atleast some of the differences between people whodid and did not go to the dentist frequently andthose who did and did not go for preventive rea-sons. The authors stated that changing dental beha-vior involves a composite of interrelated factors andthat the use of the dentist for preventive eare is re-lated to a complex of factors, each of which may bethought of as predisposing or motivating, but noone of whieh explains everything.

GHAMBERS"* found that dental health is a habitand part of a person's style of living that is not easi-ly influenced by a dentist. He proposed a concept ofdental susceptibility, both to disease and to itsmanagement, and one of his hypotheses is that thenumber of people who are susceptible to preventionis a small fraction of those who need it. Aeeordingto GHAMBERS'", evidence supports a negative corre-lation between need for care and susceptibility totreatment. As a result, those who need it least arethe ones most likely to benefit from the present sys-tem of delivering treatnient. The AMERICAN DEN-

TAL ASSOCIATION^ presented data from a nationalsurvey showing that persons with low socioeeonomiestatus show the least concern for their teeth, con-sider them to be less important and often feel that

Goals in community dentistry 49

losses are inevitable. This finding suggests that thesepeople are the ones whose life style and orientationto health makes them the least susceptible to pre-ventive programs'. CHAMBERS'" gives a warningwhen talking about motivation in dental eare. Whatdentists mean by motivating patients to better careat home is not motivation but persuasion or an at-tempt to change attitudes. Motives refer to a verysmall set of general needs that are shared by allhuman beings, e.g. food and water, love, and self-respect. Preventive dentistry is not one of them.

Preventive action has been compared in dentaldisease, tuberculosis, and cancer. It was found thatpeople who took one preventive action were theones most likely to take the other preventive actions.People of higher socioeeonomie status consistentlytook more preventive actions than people at a lowersocioeeonomie level. The authors point out thatthere is as yet little scientific basis for proposing ef-fective ways of changing social group norms''. Thegeneral population is not eagerly awaiting and ac-cepting preventive measures whieh may increasethe probability of improving their health'".

Some small-scale studies show more promising re-sults, at least on a short-term basis^''". Most studieswhich have indicated some change in dental beha-vior are characterized by highly enthusiastic dentistsor dental educators, good material resources (for in-stance free toothbrushes and toothpaste to partici-pants, and free dental examinations at regular inter-vals) and a somewhat selected group of participants(military personnel, employees of a factory). Thelowest socioeeonomie groups are usually not in-cluded.

Studies with another than purely dental orienta-tion also indicate that the public's concern aboutdental health is not what dentists might wish. Whencomparing teeth with other bodily parts, such as thenose, ear, thumb, and big toe. New Yorkers con-sistently ranked teeth last".

Forming dental health habitsDuring the past two decades much time, effort, andresearch throughout the world have been devoted tothe study of school dental health education. RAY-NER & GoHEN'''' refer to over 100 publications intheir review of school dental health.

School dental health programs as such do notguarantee better dental health. Few school healthadministrators bother to evaluate their programs.

Knowledge of dental health facts is often the cen-tral theme in dental education. Measurement ofdental conditions and practices after these programsusually show negative results". Dental health factsmay be learned after childhood but this knowledgedoes not alter preformed habits. If a child has notlearned proper dental health habits during his earlyyears, it is vtry unlikely that any education will sub-stantially change his habits'".

Learning dental health habits does not seem tofollow the traditional sequence of the "knowledge-^belief^temporary actions-habit" model. SCHIAM-

BERG'"' points out that children learn best from ac-tivity. According to PIAGET'S''" theoiy, learning isdoing and the child makes substantial progresswhen he has opportunities for sensory-motor activi-ties. Gognitive knowledge, with which educators areprimarily concerned, may not develop until beha-vior, i.e. activity, has occurred. GOHEN & LUCYE"

point out that children are very interested in how tobrush their teeth. Ghildren are more likely to retainideas obtained in a practical and useful way ratherthan what has been taught theoretically. In orderto take up the brushing habit it is not necessary toknow which are your bicuspids.

RAYNER^'' has found that children's dental prac-tices are closely related to their mothers' dentalpractices. She also stresses that dental attitudes areproducts of behavior rather than predecessors.KRIESBERG & TREIMAN" have also found that den-tal health values are a family affair. If parents go tothe dentist for preventive treatment, a high percen-tage of their teenage children also do so - in highand low income groups alike.

In some countries free dental treatment is offeredto schoolchildren. Treatment alone, when not com-bined with any educational effort, does not givelong-term relief from caries'. Systematic combina-tion of education and treatment has given good re-sults. An example is the county of Kronoberg inSweden. Mothers are informed already at maternitycenters about the importance of diet and preventivemeasures for their babies' teeth. Gontacts are re-peated, and when the ehild is 4 years old a dentalexamination is made. Dental treatment is giveneaeh year throughout the preschool and schoolyears. Fluorprophylaxis is given collectively toschool elasses. Ghildren are taught very early tobrush their teeth and the habit is maintained and re-fined through theoretical dental education and dis-

50 BARENTHIN

cussion later at school. The reduction in the cariespre\'alence has been remarkable compared with ear-lier years when early contacts were not made. Sincethe Swedish county councils are required by law toarrange free dental care for all schoolchildren, thecaries reduction represents a considerable saving forthis county. Ghildren have shown their appreciationand there is good reason to believe that they willcontinue good dental habits beyond school age".

Ghildren who do not respond to education butshow a high caries incidence can be identified al-ready at 7 years of age. Identification at the age of9-10 years is almost too late; the risk is then thatthe child will need more and more treatment^MARTINSSON'^", who studied schoolchildren withhigh caries frequency, also emphasized the great im-portance of timely intensive prophylaxis in thesechildren.

Short-term goals are usually eonsidered as thoseto be attained within 1 or 2 years, long-term goalsin 5—10 years''̂ . Keeping in mind that it is easier toform a habit than to change it, it might be sug-gested that the planning for long-term goals shouldbe done with a view to a whole generation and notonly to 5—10 years.

Long-term planning for better health services isfraught with difficulties. There is a serious dangerof planning on assumptions which in a few yearswill be obsolete'. The pace of change in scientificand social development is such that rigid planningmay restrict future capacity to respond to newopportunities. This is true in dentistry, too.

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