We dental professionals acknowledge that oral health is an important aspect of general health and well-being.
Oral diseases are readily preventable but we face many challenges in creating opportunities and conditions for change.
Clinical techniques in dentistry have advanced to make dental treatment more effective but treatment approaches alone will never eradicate oral diseases. Thus we seek to empower patients, helping them to help themselves.
Through our oral health advice, not only can patients recognise and deal with the difficulties they encounter, we are also instilling in them the belief that they can take action and bring about a change. Patients can improve their oral hygiene and in the process gain a sense of mastery and control.
There are a number of different approaches that are used in oral health promotion, all aimed at making an effort to bring about a positive change. This article will discuss three of these approaches:
• The ‘lifestyle’ approach
• The ‘high-risk’ approach
• The ‘population’ approach.
Individualistic, top-down, paternalistic and prescriptive are a few of the words that have been used to describe the approach to oral health promotion we use on a daily basis.
A lifestyle approach
The lifestyle approach is where oral health professionals focus on preventive and educational action to alter the behaviour, that causes dental disease. We focus on changing lifestyles and we use threats or fear. These are powerful statements, or so I thought, until I had a look at the evidence that supported these statements; we are ignoring the broader context and essentially our approach is theoretically flawed.
So, we traditionally focus on prevention and educational action to alter those behaviours that we see to be the cause of, or adding to, dental disease.
This is part of our daily professional practice, where we give oral hygiene instructions, as well as diet and smoking cessation advice. For many decades now this lifestyle approach has dominated preventive practice.
What we need to question is this: are we seeing evidence that this approach is ineffective? One recent article on the Dentistry website (www.dentistry.co.uk) entitled Shock pictures show kids’ tooth decay reported on the oral health status of children in Southampton in the UK. It claimed that: ‘High-profile schemes to educate patients have failed. The message about regular brushing is not getting through. Campaigns in the city have included handing out toothbrushes and fluoride toothpaste to under-sixes, promoting healthy eating, improving access to dental care and daily brushing schemes in nurseries. But there was no improvement in spite of the extensive dental health promotion activities carried out by the Primary Care Trust’s oral health team.’
There has been a shift towards evidence-based practices in dentistry, and preventive intervention has been investigated to determine what is effective.
Our lifestyle approach has come under scrutiny. According to Richard Watt of the Department of Epidemiology and Public Health, University College London, ‘The assumptions underlying this narrow and reductionist approach are fundamentally flawed’ (2005).
It is further observed that human behaviour is extremely complex and, furthermore, it is incorrect to assume that lifestyles are freely chosen and can easily be changed by everyone.
We can identify with this. We have all had patients that, despite our best efforts, did not change or alter their behaviour. We expect that once our patients acquire the relevant knowledge and skills, their behaviour will be modified in order to maintain good oral health. But according to a systematic review by Watt and Marihno (2005), provision of information alone does not produce long-term behavioural changes. Studies show that short-term improvements in oral health knowledge were achieved but the effects on behaviour and clinical outcomes were limited. In addition, the evidence does not support mass media campaigns, as they are thought to be ineffective at promoting knowledge or behaviour change.
Watt and Marihno (2005) found some positive results for health education interventions in periodontal disease, although it is being described as a ‘short-term’ reduction in plaque and gingival bleeding.
It is observed that further studies should use long-term follow-up periods to assess whether ‘short-term’ beneficial changes are sustainable.
Nevertheless, it is well established that adequate plaque control is the most important measure used to prevent periodontal disease.
Watt (2005) further described the lifestyle approach as ‘narrow, isolated and compartmentalised’. It is a fact that oral health programmes are often developed in isolation from other health initiatives. Oral health is further marginalised, as it is not considered to be life-threatening.
There are many practices that are influenced by living conditions such as smoking, poor diet and lack of exercise. Individuals are often blamed for choosing health-damaging behaviour; however, the broader socio-environmental factors will affect individual choice. Furthermore, many socio-economic constraints are beyond the control of individuals. Therefore, to be more effective, intervention needs to be at a community level.
A more progressive oral health promotion approach should take into account the social, political and environmental determinations of health. This cannot be achieved by isolated oral health programmes. Oral health professionals will need to forge a team approach with other professionals, organisations and the community, in relation to advocacy and education.
Multi-spectral working is essential for this to be successful.
The high-risk and population approaches
The high-risk approach, which focuses on individuals with a high risk, is identified through standard screening.
It is a very popular approach with many health professionals, as it fits well with a clinical approach to prevention.
Geoffrey Rose, author of The strategy of preventive medicine, has described another approach called the population approach.
He writes: ‘In the population approach, public health measures are implemented to reduce the level of risk in the whole population and aim to address the underlying cause of disease across the whole population’.
It is now being acknowledged that a combination of high-risk and population approach are the best options.
Policy development, organisational change, community action and legislation are initiatives that can all play a part in prevention.
In the past, the school has been the main setting for oral health intervention, but a range of other settings could be used. This would include nurseries, youth centres, colleges, the workplace, places of worship and community centres, all of which are suitable settings for defining target population groups.
It may also be useful to target action at decision-makers and influential individuals within the local community.
Locker KL (1998) A systematic review of the effectiveness of health promotion aimed at improving oral health. Community Dental Health 15(3): 132-44
Sheiham A (2000) Improving oral health for all: focusing on determinants and conditions. Health Education Journal 59: 351-63
Watt RG (2005) Strategies and approaches in oral disease prevention. Bulletin of the World Health Organization 83(9)
Watt RG, Marinho VC (2005) Does oral health promotion improve oral hygiene and gingival health? Periodontology 2000 37(1): 35-47