public health approaches to prevention of oral diseases

Saturday, April 8, 2023 public health approach to prevention oral health disease

1

PUBLIC HEALTH APPROACH TO PREVENTION ORAL HEALTH

DISEASEGroup 7

Supervisor : Dr NorKhafizah Saddki


2

Topic to be covered..

Definition of oral health Definition of dental public health Determinants of health The changing pattern of oral diseases Health promotion action means (Ottawa

Charter) Strategies in oral health promotion

Whole-population vs. risk approach Common risk factor approach


3

Definition

Dental Public Health can be defined as the science and practice of preventing oral diseases, promoting oral health and improving quality of life through the organized efforts of society.

(Essential of Dental Public Health, pg 1)


4

Oral health definition 1. WHO – completely healthy dentition (with

32 sound straight teeth and no periodontal or other soft tissue lesions) which result in ‘a state of physical, mental and social well being’.

2. Dolan 1993 – A comfortable and functional dentition that allows individuals to continue their social role.


5

DETERMINANTS OF HEALTH


6

What are health determinants?Why do we need to know about it?

Factors influencing health Failure to address the underlying causes of

disease in society will mean that sustainable improvements in the health of population and a reduction in health inequalities will never be achieved


7

The Broader Picture

According to Prof Thomas Mckeown (1979), a pioneer in public health research, concluded that the most important reasons for the decline in mortality rates were social changes in society such as improvements in living conditions and sanitations, access to clean water, better nutrition and reduced family size.

Medical treatments contributed only 17% to the gain in life expectancy that occurred in twentieth century


8

Social Determinants of Health

Public health research over the last 20 years has highlighted the impact on health of such factors as poverty, poor housing, unemployment, and social isolation ( Marmot and Wilkinson 1999)

Adverse conditions and influences can have a particularly significant effect at critical points in the life course (Bartley at al 1997)


9

Figure1: Determinants of health. By Daphlgren and whitehead, general factors that affect health


10

Limitations of the Lifestyle Approach

Lifestyle approach: Focus upon changing the behaviour of their patients as the main means of promoting health and preventing disease

Solely focusing on changing the lifestyle of individuals is ineffective and costly (Syme 1996)

Such an approach diverts attention away from the causes of the causes (Sheiham 2000)


11

Behaviours are enmeshed within the social, economic and environmental conditions of living (Graham 1999)

Individuals’ behaviours are therefore largely determined by conditions in which they live in (Sheihem 2000)

Focusing solely on changing lifestyle can be considered as ‘victim blaming’ approach which is not only ineffective but may also widen health inequalities (Schou and Wight 1994)


12

HEALTH INEQUALITIES

Teenager is far more likely to be physically fit than a man aged 75. the differences are due to effect of ageing or biology and are therefore unavoidable.

The differences that are both avoidable and considered unacceptable in modern society


13

In the UK research into health inequalities, Health inequality is widespread: the most

disadvantaged have suffered most from poor health

The Black report (Townsend and Davidson 1982) demonstrated that for almost all reported conditions the mortality and morbidity rates were higher in people from lower socio-economic groups


14

The Black Report outlined four possible explanations for health inequalities ( Townsend and Davidson 1982)

Artefact. The inequalities are not real, but rather a function of how social class and health are measured

Selection process. This explanation process that people in poor health drift down the social scale. Based upon this analysis, health therefore determines social class position

Lifestyle effects. The social distribution of risk behaviour such as smoking and drug misuse is higher amongst the lower social class

Materialistic and structuralistic factors. This argument places emphasis upon the effects of poverty and disadvantageon health


15

DETERMINANTS OF ORAL HEALTHCOMMON RISK FACTOR APPROACH WHO 2000

The basis of this approach is the importance of focusing attention on changing factors that determine disease

Diet, smoking, alchohol, hygiene, stress, and exercise are linked with wide range of important diseases such as cancers, heart disease and diabetes

Altering these factors will reduce the risks of these systemic conditions as well as oral diseases such as caries, periodontal disease, and oral cancer (Sheiham and Watt 2000)


16

DETERMINANTS OF ORAL HEALTHCOMMON RISK FACTOR APPROACH WHO 2000


17

PARTNERSHIP WORKING

Focusing action on the risk factors and promoting health factors that provide a supportive environment for good health and well being

Health professionals need to work in partnership with a range of different organizations and agencies to effectively rpomote health


18

Changing Patterns of Oral Diseases


19

Introduction

Globally, there have been dramatic changes in the pattern of oral condition.

Periodontal disease is found to be the prevailing problem for the younger adult.

Hence, National Oral Health Survey was conducted To monitor the progress of oral diseases To evaluate the overall effectiveness of its oral healthcare

delivery system To estimate the present oral health status and future needs of

population


20

Age Group Selection

Malaysian adult oral health surveys covered those aged 15 years and above.

Others : Singapore – 20 years and above Hong Kong – 35-44years & 65-74 years only WHO – as used by Hong Kong


21

• Oral status involved :

–Dental caries status (tooth decay)–Periodontal status (gum disease)–Oral and pharyngeal cancers–Dentition status– Prosthetic status


22

(A) Dental Caries

Dental caries is still a major global oral health problem in most industrialized countries

The prevalence is increase in developing country but stable/decline in developed country

Caries prevalence remained high exceeding 85% for all age groups in Malaysia


23

EPIDEMIOLOGY

Dental caries were uncommon in Western industrialized countries such as England before 1850.

Thereafter the caries rate increased rapidly due to the rise in sugar consumption.

There have been dramatic changes in the pattern and distribution of dental caries in children and adult in all over the world (especially in UK) over the last 25 years.


24

In pre-school children The biggest changes in decay experience

were seen in 5 y/o between 1973 and 1983, when the percentage who were caries free had almost doubled and the dmft index had halved (Murray and Pitts, 1997)

In Malaysia, dmft index of pre-school children decrease from 6.3 (in 1970-1971) to 5.6 (in 2005)(NOHPS 2006)


25

dmft 6 years Year

6.3* 1970-71

5.5* 1988

5.8 (5 years) 1995

4.1 1997

5.6 2005


26

Among 11-and 12-year-olds the annual reduction rates were 3.8% in The Hague and in Shropshire, England; 4.8% in Denmark; 5.1% In the USA; 5.0% in Bristol and 8.7% in Finland. (Downer, 1984)

Study done by NOHPS shown that:


27

DMFT 12 years Year

3.7* 1970-71

2.4* 1988

1.6 1997


28

Adult dental health Steady and substantial improvement in adult dental

health were seen in the 1988 national survey compared to the previous national survey (Downer, 1998).

The proportion of the adult with some natural teeth rose from 17% in 1978 to 79% in 1988 and 87% in 1998, and it expected to reach 90% in 2008 (Downer, 1991).

Younger adult had the most dramatic improvement; sharp increase in the proportion with no restored teeth( otherwise sound) from 9% in 1978 to 13% in 1988 and 30% in 1998.(Nunn et al,. 2001)


29

In Malaysia (NOHPS 2005):

DMFT 12 years

Year

3.7* 1970-71

2.4* 1988

1.6 1997

DMFT 16 years

Year

4.8 1970

4.35 1988

2.8 1997

DMFT 15-19 years

Year

6.2* 1974/75

4.6 1990

2.9 2000

DMFT 20-24 years

Year

8.8* 1974/75

6.9 1990

4.4 2000


30

DMFT 20-24 years

Year

8.8* 1974/75

6.9 1990

4.4 2000

DMFT 25-29 years

Year

11.5* 1974/75

9.1 1990

6.0 2000

DMFT 30-34 years

Year

12.1* 1974/75

10.9 1990

8.4 2000

DMFT 35-44 years

Year

14.5* 1974/75

12.9 1990

12.1 2000

DMFT 45-54 years

Year

17.8* 1974/75

15.6 1990

15.4 2000

DMFT 55-64 years

Year

20.7* 1974/75

20.3 1990

20.1 2000


31

Elderly: Edentulousness become decreased in UK

1968 - 37% 1998 - 13% - (Kelly et al,. 2000)

Many older people have retained natural teeth in their mouth

The improvement in adult with ‘20 functional teeth’ was very marked between 1978 (83%) and 1988 (81%)

(Murray and Pitts, 1997)


32

DMFT 65+ YEAR

25.2 1975/75

22.8 1990

23.5 2000

(NOHPS 2006)


33

Root caries: As people retained their teeth for longer into

old age, root caries may become a problem. Recent survey done by oral health and diet and

nutrition of adult age ≥65 found that 80% of the root of retained teeth had root decay and some root restoration (Steel et al,. 1998)

Infrequent tooth brushing and heavy plaque deposits in association with a partial denture were strongly associated with primary root caries in older people (Steel et al,. 1998)


34

The National Oral Health Survey of Adults 2000 in Malaysia has shown that caries prevalence among elderly aged 65-74 and 75 years and above was 95.2% and 94.1% respectively, DMFX(T) index for age-group of 65-74 years was 23.20 (Oral Health Division, 2004).


35

An oral health survey done in Japan, from October 1988 to February 1989 among elderly population living in public and private institutions found that, in dentate persons, the mean number of remaining teeth present and the number of decayed (D) and filled teeth (F) as follows:

(Miyazaki et al.,1992)

Age Decay Filled

65-74 y/o 13.4 8.6

75-84 y/o 9.5 6.8

> 85 y/o 8.4 6.5


36

CAUSES OF CHANGES IN ORAL HEALTH TREND

Major cause of caries is the consumption of fermentable carbohydrate (sugar)

Greater availability of sugar is a/w increase dental caries experience in children (Screebny, 1983)

A recent survey of oral health and diet and nutrition in young people found that there were links between the frequency of consumption of sugary foods and dental decay (Gregory et al,. 2000)


37

Of 20 countries where two surveys had been conducted on 12-yearolds, 15 have recorded marked increases in caries.

Examples of increases in DMF are; from 2.8 to 6.3 in Chile, 2.7 to 5.3 in four years in Mexico, 0.2 to 2.7 in Jordan, 1.2 to 3.6 in Lebanon, 0.6 to 4.4 in Thailand and 4.7 to 9.8 in the Philippines.

(Janczuk Z, 1983, WHO 2000)


38

Fluoride exposure Reduces the enamel's solubility in acid and

influences remineralization of lesions In addition, fluoride may interfere with the

metabolism, transmission and implantation of cariogenic organisms.

Availability of dental services


39

(B) Periodontal Disease

CPITN data from the WHO Global Oral Data Bank show: 15-19 years old in developing countries have high

levels of bleeding on probing and calculus

In age group 35-44, the prevalence and severity of periodontal disease vary widely

Elderly; no data available due to great variation between country due to loss of teeth


40

Country/year Age Group

% persons coded

Healthy Bleeding on probing

Calculus Shallow pockets(4-5mm)

Deep pockets(6mm>)

Thailand, 89 18 3 3 87 7 0

Singapore, 94 15-18 26 14 59 1 0

Sri Lanka Na

Indonesia, 90 15 0 3 54 41 2

Laos, 91 15-19 9 8 83 0 0

Malaysia, 90 15-19 17 10 69 4 0

Comparison of CPITN data between selected country for age group 15-19


41

Country/year Age Group

% persons codedHealthy Bleeding on

probingCalculus Shallow

pockets(4-5mm)

Deep pockets(6mm>)

Thailand, 89 35-44 1 0 53 35 11

Sri Lanka, 84 35-44 5 4 55 27 10

Indonesia, 88 35-44 1 0 56 36 6

Laos, 94 35-44 0 0 94 4 2

H Kong, 90-91 35-44 0 0 26 57 17

Japan, 91-92 35-44 3 3 38 48 8

Australia, 95-96 35-44 6 10 47 24 13

NZ, 89 35-44 11 3 38 44 4

UK, 88 35-44 4 1 20 62 13

Malaysia, 90 35-44 5 3 61 23 9

Comparison of CPITN data between selected country for age group 35-44


42

Community Periodontal Index of Treatment Needs (CPITN) 1990: 7.2% free from periodontal disease 2000: 9.8% free from periodontal disease


43

Studies have shown that the prevalence of periodontal diseases increases with age

However, severe periodontal disease only affects a much smaller proportion compared to gingivitis and shallow periodontal pockets

only 0.4% of those from the 65–74 years age-group were found to have healthy gingivae (NOHSA 2000)


44

The traditional ‘progressive’ disease model has been replaced by the ‘burst’ theory – periodontal disease have short ‘bursts’ of activity followed by long periods of remission and healing

Findings of the study indicate some improvement in periodontal profile

Dental plaque causes periodontal disease, but other factors such as stress, smoking, poor restoration contour leads to plaque accumulation


45

(C) Oral Cancer

Oral cavity cancer is amongst the most prevalent cancers worldwide

Oropharygeal cancer is the 11th most common cancer

Each year, increase number of new cases

Incidence rate are higher in men than women

Tobacco use, including smokeless tobacco and excessive alcohol consumption are estimated to account for about 90% of oral cancer


46

Country Sex Location

Mouth Tongue

China(Hong Kong)

M 1.9 2.1

F 0.8 1.2

India M 10.8 6.5

F 8.9 3.7

Thailand M 2.5 2.0

F 3.0 1.2

Australia M 2.8 2.8

F 1.3 1.0

USA M 3.0 1.0

F 1.7 0.7

Oral cancer in selected country,WHO


47

1967 to 1991 : 150 – 200 cases 1998, oral cancers accounted for 7.1% of cancer

deaths 60% occur in the Indian ethnic group Indians in estate communities have a 6- to 7-fold

propensity for betel quid chewing habit and a 4-fold predilection for alcohol consumption

Also a higher occurrence of oral precancerous lesions noted among the Indigenous (Other Bumiputera) groups in the states of Sabah and Sarawak


48

Oral cancer is not a notifiable disease in Malaysia

A pilot study in Kelantan from 1994 – 1998 quoted an incidence rate of oral cancer adjusted to world population of 1.13 ± 0.15 per 100,000 among Kelantanese Malays

Over the 20-year period data (1974-1994), it would seem as though there was an increase in prevalence of lesions – from 5.5% that was inferred in 1974 to that of 9.6% for oral lesions in 1993/1994


49

Health Promotion Action

(Ottawa Charter)


50

The Ottawa Charter for Health Promotion is a 1986 document produced by the World Health Organization

It was launched at the first international conference for health promotion that was held in Ottawa, Canada


51

Action areas of the Ottawa Charter

Five action areas for health promotion were identified, these are:

Developing personal skills Strengthening community action Re-orientating health care services toward

prevention of illness and promotion of health Build healthy public policy Create supportive environments


52

1. Developing personal skills

Development of personal & social skills: can be achieved through health education

Health education: defined as opportunities created for learning specifically aimed at producing a health related goal (WHO 1984)


53

Health education

Aims to equip individuals and/or communities with the necessary knowledge, attitudes, and skills to maintain and improve health

One of the strategies in health promotion=> specifically concerned with promoting some form of educational change

Ex: to increase patient’s knowledge about the role of sugar and plaque in aetiology of dental disease

Promotion of self care is now seen as being of fundamental importance.


54

2. Strengthening community action

Can be achieved through a community development approach

Involves the mobilization of community resources (human & material)

“a process in which the community defines its own health needs, decides how these can be best tackled, and then takes appropriate action


55

Problems adopting this approach: Time consuming nature of the work Difficulty of evaluation Potential conflicts that may arise within

communities

Requires skills in consultation, empowerment, and communication


56

3. Reorienting health services

Work together towards a health care system which positively contributes to the pursuit of health

A reorientation towards health promotion requires changes in many aspects of health services.


57

4. Build healthy public policy

Placing health onto the policy agendas of influential decision makers

Either national or local level Ex: the legislation required to fluoridate public

water supplies


58

5. Creating supportive environments

Recognizes the impact of the environment on health and seeks to identify opportunities to make changes conducive to better health.

Ex: water fluoridation, to change at national level, action can also take place at local level Developing policies within local

organizations (school, workplaces, and hospitals)

Termed as organizational change


59

Strategies in Oral Health Promotion


60

Whole-population VS Risk Approach

Common Risk Factor Approach


61

Strategy Approaches

Risk Approach

Targeted-population Approach

High-risk Approach

Whole-population Approach


62

The Whole-Population Approach

If a disease is normally distributed in the population then everyone has some disease.

Assuming that the decision is made to try to reduce the overall disease burden, the choice is between:-A. To reduce everybody’s exposure to the agents that

are responsible for the disease, ORB. To select a subgroup of the population at the right-

hand end of the distribution, those at highest risk.


63

Rose (1992) is strongly in favor of the whole-population approach in this case.

He considers that the risk factors affect all who live in society and it is therefore more effective to work the whole population.

The Whole-population Approach


64


65

Does a small increase in risk in a large number of individuals

generates more cases than a large increase in risk in a few

individuals??



66

Another justification is when the results of not intervening to prevent a condition in even one person are very severe.

The outcome in that person may be devastating or the costs to society of not treating that condition may be very great.



67

Radical•This approach seeks to remove the underlying impediments by addressing the social and political factors confronts the root causes.

Powerful•A small shift in the population distribution of the risk factors may have a large effect on the number of people affected.

Appropriate

•Changing the normal behaviour of the population to accepted behaviour for good health.

Strengths of the whole-population approach

(Adapted from Rose 1992.)


68

Limitations of the whole-population approach

Acceptability

•It may not be acceptable to the population and they may not be willing to make personal changes or support environmental changes.

Feasibility •Other pressures within society may make the changes very hard to bring about.

Costs and safety

•The costs have to be paid immediately but the benefits are more long term.•Reducing access to risk factors may adversely affect some people.

(Adapted from Rose 1992.)


69

Water fluoridation is an excellent example.

Dental caries is one which affects most people and the strategy is to alter the environment by adjusting the level of fluoride in the water supply.

Everyone on the centralized water supply receives the intervention so that compliance is not a problem.



70

The Risk Approach

A) The Targeted-Population Approach Some groups of the population are at greater

risk compared with the whole population.

A variety of interventions: Clinical intervention, More of an environmental approach, OR The developing of community and individual

skills.


71

Not all people who are at risk of the disease will be included within the target group.

Useful when resources are limited or where one group is clearly more disadvantaged than another.

It differs from the high-risk approach in that not every person within the targeted group is at higher risk but as a whole the group is.

The Risk Approach – Targeted-population


72

Identifying a section of the population as being at greater risk of dental caries may lead to the decision to provide a targeted-population approach.

Example: the schools are identified and a decision is made to introduce a fluoride toothpaste brushing scheme.



73

B) The High Risk Approach Is used when the treatment of only those at

greatest risk is considered most appropriate.

Rather than using the whole population or part of it, only specific individuals are identified by a screening programme.

It is only of benefit if it can identify those in the population who are at most risk of developing a condition and if there is an effective way of preventing it.


74

It will inevitably miss some people who will contract the condition of interest.

This may or may not be acceptable to either decision makers or the public.

If a screening test is used, the specificity and sensitivity must be of an acceptable level.

High values of these ensure that people with a high risk will be identified and those without will not. The Risk Approach – High-risk


75


By definition “high risk” omits those who are at

“low risk”, but “low risk” does not mean

“NO risk”!!!!


76

Intervention is appropriate to the individual. It avoids interference with those who are not

at special risk. It is readily accommodated within the ethos

and organization of medical care. It offers a cost-effective use of resources. Selectivity improves the benefit-to-risk ratio.

Strengths of the high-risk approach

(Modified from Rose 1992.)


77


78

Prevention become medicalized. Success is only palliative and temporary. The strategy is behaviourally inadequate. It is limited by a poor ability to predict the

future of individuals. There are problems of feasibility and cost. The contribution to overall control of a disease

may be disappointingly small.

Weakness of the high-risk approach

(Modified from Rose 1992.)


79

Example 1: Dental students are required to demonstrate

their hepatitis status before entering the dental course.

There are 2 reasons:-1. To ensure public’s safety by not letting infected

people undertake invasive procedures.2. To enable an effective immunization to be

administered as part of the strategy to stop the dental students contracting a potentially fatal illness.



80

Example 2: In people who have received irradiation of

their salivary glands, it is highly appropriate to provide a very intensive programme of clinical prevention because of their known greatly increased risk of developing dental caries.



81

Strategies in oral health promotion

Common risk factor


82

Strategy action based on common risk approach

Many health problems share common risk factor ; eating an unhealthy diet which is high in fat and sugars and low in fibre can lead to development of obesity, coronary heart disease, and diabetes as well as dental caries.

Therefore it offer the potential for effectively dealing with a combination of health problems together.


83


84

The common risk factor approach (adapted from Petersen, 2003)


85

Oral health promoter need to work closely with the people in general health promotion

They have a key role of placing oral health matters on the wider health promotion agenda


86

Periodontal disease

Aetiology Dental plaque,others include : smoking, certain

systemic disease, stressful life events Cigarette smoking and diabetes mellitus (with

poorly controlled diabetes) are two major risk factors associated with periodontal disease and appear markedly to affect the initiation and progression of the disease (Genco 1996; Papapanou 1999).


87

Public health Strategy Promote oral cleanliness and reduce

smoking Treatment of periodontal diseases consists

of plaque removal, scaling, and sometimes surgery, plus motivation and instruction in oral hygiene


88

Oral cancer Aetiology

It is not well documented Most important risk factor are tobacco and

alcohol In Malaysia, betel quid chewing has been

suggested as the most important risk factor Public health strategy

Early detection of cancer and health promotion activities aimed at reducing the consumption of alcohol and tobacco product


89

Policy instruments include regulating tobacco advertising and promotion; enacting smoking bans in work-places, restaurants, and public buildings and on public transportation; and increasing excise taxes on tobacco products (Fiore, Hatsukami, and Baker 2002; WHO 2002).

The WHO Framework Convention on Tobacco Control (WHO 2003) summarizes tobacco control policies and programs related to regulation, taxation, and education.

Da Costa e Silva (2003) shows prioritized treatment approaches for tobacco cessation, based on countries' levels of resources


90

Excessive alcohol use accounts for 20 to 30 percent of liver and esophageal cancer (WHO 2001). Interventions to reduce excessive consumption of alcohol have many principles in common with tobacco control, including the effectiveness of regulatory and taxation measures along with health promotion and addiction treatment programs


91

Dental caries

Aetiology Consumption of fermentable carbohydrates,

this is dose – response, between quantity of sugar and the development of dental caries.

Public health strategy Reduction in sugar consumption ‘Kempen Kurangkan Gula’


92

Hence, based on the common risk factors approach, our oral health promotion activities should move towards facilitating the adoption of healthier lifestyles. I am pleased that the ongoing “reduction of sugar consumption campaign” has the strong support of the dental profession, as sugar is a common risk factor for obesity, cardiovascular disease, diabetes, dental caries and other health problems-SPEECH BY YB DATO’ SRI LIOW TIONG LAI,MINISTER OF HEALTH MALAYSIA


93

Disease or condition Causes Actions needed and methodsDental caries High or frequent sugar consumption,

plaque present, highly cariogenic microorganisms, nonuse of fluorides, reduced saliva flow, systemic diseases, and other individual risk factors

-Targeted actions against causative factors on community and individual levels-Health education toward self-care capacity, fluoride programs, sugar restriction, actions based on risk assessment of individuals and groups

Periodontal diseases Plaque present, pathogenic bacteria, influence of systemic diseases, tobacco use

-Improved oral hygiene, professional cleaning, antibiotics, identification and treatment of systemic diseases-Elimination of pockets if present and removal of local dental irritants, such as rough fillings-Tobacco cessation

Oral precancer and cancer

Tobacco and alcohol use; -Tobacco cessation;

Oral and Craniofacial Diseases and Disorders, Disease Control Priorities in Developing Countries. 2nd edition


94

References http://en.wikipedia.org/wiki/

Ottawa_Charter_for_Health_Promotion Chapter 38, Oral and Craniofacial Diseases and

Disorders, Disease Control Priorities in Developing Countries. 2nd edition.Jamison DT, Breman JG, Measham AR, et al., editors.Washington (DC): World Bank; 2006

Essential dental public health,blanaid Daly et al.,1st edition ,oxford university press

Oral health care in Malaysia,oral health divison, Ministry of health, April 2005

public health approaches to prevention of oral diseases

Documents

h h public health research

health of population

oral health definition

health inequality

health failure

h h h h artefact

oral health promotion

h h h lifestyle approach