Promoting Health and Preventing Disease within Groups

 

2: Promoting Health and Preventing Disease within Groups

Case 2Promoting Health and Preventing Disease within Groups

CASE STORY

The dental hygienists that are members of a local component have been awarded funds by the regional dental society to conduct research with the purpose of determining and implementing the most effective and efficient caries prevention options to meet the needs of the children at New East Elementary School. There are 182 children ranging from first to sixth grade (see Figure 12.2.1A). The target elementary school is located in a nonfluoridated, rural community that has limited access to dental health care (see Figure 12.2.1B). However, there is a school nurse that is responsible for all students. The closest dental office is located 45 minutes away from New East Township and there is no public transportation available. The one local dentist volunteered on a limited basis to accompany the dental hygienists to the elementary school during this research. He informed the dental hygienists that members of this community often come to his dental office for restorative or emergency treatment, not for prevention. Water in the community contains less than 0.1 ppm natural fluoride. Five years ago, water fluoridation was sent to legislation, but it was defeated. After a conversation with the school nurse, the dental hygienists were told the referendum had failed due to the lack of education of the community on the benefits of fluoride and lack of awareness of other preventive modalities. A survey went home with each child to have the parents complete and give consent to an oral examination for initial assessment. The results of the survey showed a lack of knowledge in oral health and disease prevention. Of the parents, 98% provided consent for their children to participate in the screening. The dental hygienists conducted decayed/missing/filled teeth (DMFT)/dmft indices on the children to determine their current oral health status. This showed a high rate of decayed teeth on the older children and the dental hygienists noticed a prevalence of demineralized teeth on children of all ages (see Figure 12.2.1C). After compiling results of the assessment data, it was determined that a fluoride varnish program would be the most efficient and effective method of preventing decay, which was affordable by the program (see Figure 12.2.1D). The dental hygienists will also be placed on the agenda at the parent‐teacher organization meeting in October for Children’s Dental Health Month and in April for the school‐wide health fair. The dental hygienists will train the school nurse to support teachers in the inclusion of classroom oral health education. At the conclusion of this program, 178 students were examined and varnish was placed as needed. A year later, the dental hygienists wanted to evaluate the effectiveness of the varnish and education program and the hygienists decided they would conduct another DMFT/dmft index. They found a decrease in decay rate by 26%, filled rate increased by 13%, and noticed a decrease in demineralization.

Figure 12.2.1: (A) Children in elementary school. (B) Elementary school setting. (C) Children with signs of demineralization.

Source: Courtesy of Travis Nelson.

(D) Variety of fluoride varnish products.

PROBLEM‐BASED LEARNING GOALS AND OBJECTIVES

• Explain the three levels of disease prevention
• Identify possible barriers to dental health care
• Describe the evaluation of dental health programs in the dental hygiene program planning paradigm
• Differentiate between qualitative and quantitative methods and data
• Describe the use and purpose of indices in community programs

Discussion

Public health focuses on the prevention of disease. Three levels of disease prevention have been identified: primary, secondary, and tertiary (Mason 2010, p. 112). Primary prevention is the intervention in disease before it occurs. Examples of primary preventive interventions include community water fluoridation, fluoride varnish, pit and fissure sealants, and preventive education. Secondary prevention is the treatment or control of disease early in the process. Remineralization of early caries and periodontal debridement are examples of secondary prevention methods. Tertiary prevention involves strategies to replace lost tissues through rehabilitation to restore the functions of the oral cavity to as close to normal as possible. An example is the replacement of a missing tooth with an implant.

Preventive oral health services are essential in maintaining the dental health needs of the population. However, there are many barriers that should be considered when providing these services. Examples of major factors that prevent or deter the population from gaining access to care are the following (Darby and Walsh 2015; Nathe 2017):

1. Financial barriers – unaffordable costs, no spendable income, cannot afford time off if an hourly paying job.
2. Transportation – public transportation is often unreliable, unaffordable, nonexistent, and confusing. Homebound, hospitalized, or institutionalized clients frequently cannot be transported for care.
3. Psychological barriers – fear or inability to comprehend dental procedures, feelings of anxiety, low pain tolerance.
4. Special needs – needs to rely on others for transportation or care impact scheduling and compliance; sensory and physical impairments.
5. Geographic barriers – shortages of providers in rural areas, regional maldistribution of health‐care personnel.
6. Physical facilities – nowhere to park safely, too many stairs, narrow doors, and entryways, bathrooms without grab bars, dimly lit hallways, and small signage, and inconvenient office hours.
7. Cultural diversity/influences – based on cultural, family, and individual beliefs patients will have different orientations toward health; language barriers.

School‐based oral health programs are designed to improve access to dental care by reducing barriers. Barriers that may be reduced may include parents taking time off of work to take their child to the dentist during the day, children missing classroom time for dental visits, dealing with limited access to oral care in rural communities, and lack of reliable transportation (MCOH 2011). All children and often parents can benefit from children receiving oral health screenings in school, which is a familiar, nonthreatening environment. Services that are typically performed in this setting include dental education, oral screenings, fluoride applications, sealant placement, and referral for follow up treatment if needed (MCOH 2011). School‐based health programs can also be included in the curriculum in all grades so teachers can incorporate oral health into the classroom.

Health preventive programs are created to prevent disease in a target population (Nathe 2005, p. 171). Preventive programs may occur in a wide range of settings in addition to schools, such as communities and health‐care facilities. Dental health programs that involve dental hygienists have included oral health education programs to provide dental health tools to large populations, use of fluoride to prevent caries, dental sealants, athletic mouth guards, nutritional advising, and provision of other preventive services to large populations of need. Regardless of the preventive program designed, the program planning paradigm must be considered to be able to address the specific needs of the target population and available evidence‐based resources.

The dental hygiene program planning paradigm is similar to the dental hygiene process of care consisting of the same steps: assessment of the situation, formulation of a dental hygiene diagnosis, planning the program, putting the plan into action, and evaluation. During the evaluation stage in the program planning paradigm, the results of the program are measured against the objectives developed during planning. Evaluation is ongoing throughout the program and upon its completion. The dental provider uses scientific techniques to discern the program effectiveness. A combination of quantitative and qualitative methods should be used to measure if objectives were met (Kaur 2016). Quantitative methods are based on numbers to claim objectivity; whereas, qualitative methods generate theories relying on subjectivity (Kaur 2016, p. 94). Quantitative data is precise and qualitative data is descriptive.

To aid in assessment and evaluation by providing quantitative data, indices are used by community programs to determine and record the oral health status of groups (see Table 12.2.1). They can assess the needs of a community, assist in planning community‐based health promotion/disease prevention programs, and compare the effects or evaluate the results of community‐based programs (Wilkins et al. 2017, p. 371). Indices provide a way to express clinical observations in the use of numbers.

Table 12.2.1: Indices and purposes.

Source: Adapted from Wilkins et al. (2017).

Indices that measure oral hygiene status to determine daily oral care and monitor results of oral hygiene education programs.
Index	Purpose
Biofilm Index (also known as PI I)	To assess the thickness of plaque biofilm at the gingival area.
Biofilm Control Record (also known as plaque control record)	To record the presence of plaque biofilm on individual tooth surfaces to permit the patient to visualize progress while learning biofilm control.
Biofilm‐Free Score (also known as plaque‐free score)	To determine the location, number, and percentage of biofilm‐free surfaces for individual motivation and instruction. Interdental bleeding can also be documented.
Patient Hygiene Performance (PHP)	To assess the extent of plaque biofilm and debris over a tooth surface.
Simplified Oral Hygiene Index (OHI‐S)	To assess oral cleanliness by estimating tooth surface covered with debris and/or calculus.
Indices that measure gingival and periodontal health to assess need for treatment, treatment success or treatment failure.
Index	Purpose
Community Periodontal Index (CPI)	To screen and monitor the periodontal status of populations. Later modified to form the PSR index for scoring individual patients.
Periodontal Screening and Recording (PSR)	To assess the state of periodontal health of an individual patient. Designed to indicate periodontal status in a rapid and effective manner and motivate the patient to seek necessary complete periodontal assessment and treatment. Used as a screening procedure to determine the need for comprehensive periodontal evaluation.
Sulcus Bleeding Index (SBI)	To locate areas of gingival sulcus bleeding and color changes in order to recognize and record the presence of early (initial) inflammatory gingival disease.
Gingival Bleeding Index	To record the presence or absence of gingival inflammation as determined by bleeding from interproximal gingival sulci.
Eastman Interdental Bleeding Index (EIBI)	To assess the presence of inflammation in the interdental area as indicated by the presence or absence of bleeding.
Gingival Index (GI)	To assess the severity of gingivitis based on color, consistency, and bleeding upon probing.
Indices that measure dental caries to determine number of persons in any age group who are affected by dental caries, the number of teeth that need treatment, or the portion of teeth that have been treated.
Index	Purpose
Permanent Dentition: Decayed, Missing, and Filled Teeth (DMFT) or Surfaces (DMFS)	To determine total dental caries experience, past, and present, by recording either the number of affected teeth or tooth surfaces.
Primary Dentition: Decayed, indicated for Extraction, and Filled (df and def)	To determine the dental caries experience for the primary teeth present in the oral cavity by evaluating teeth or surfaces.
Primary Dentition: Decayed, Missing, and Filled (dmf)	To determine caries experience for children. Only primary teeth are evaluated.
Early Childhood Caries (ECC and S‐ECC)	To provide case definitions that determine dental caries experience of children aged five years of age or younger.
Root Caries Index (RCI)	To determine total root caries experience for individuals and groups and provide a direct, simple method for recording and making comparisons.
Indices that measure dental fluorosis to investigate the effects of fluoride concentration on dental enamel.
Index	Purpose
Dean’s Fluorosis Index	To measure the prevalence and severity of dental fluorosis.
Tooth Surface Index of Fluorosis (TSIF)	To measure the prevalence and severity of dental fluorosis. More sensitive than Dean’s Fluorosis Index in identifying mildest signs of fluorosis.
Indices that are community oral health screenings to monitor health status and determine population access to or need for oral health services.
Index	Purpose
WHO Basic Screening Survey (BSS)	To collect comprehensive data on oral health status and dental treatment needs of a population. Suitable for surveying both adults and children.
Association of State and Territorial Dental Directors (ASTDD) Basic Screening Survey (BSS)	To screen adult, school age, and/or preschool populations for a variety of categories (untreated caries, treated decay missing, sealants, treatment urgency, dentures, number of natural teeth, root fragments, need for periodontal care, suspicious soft tissue lesions).

Take‐Home Hints

1. Although evaluation is listed as the last step in the program planning paradigm, the program must be evaluated continuously throughout each step.
2. If fluoride varnish is not an available option for a caries prevention program in a community that does not have a fluoridated public water supply, an alternative would be to investigate fluoridation of the school water supply.