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E uro Obser ver

Newsletter of the European Observatory on Health Systems and Policies

Autumn 2005 For the last 30 years Aubrey Sheiham, Professor of Dental Public Health at University College
Volume 7, Number 3 London, has been a radical voice in public health. His wide area of interests include evidence-
based dentistry, health promotion and food policy. Recently in London a special two-day
conference was held to mark his distinguished career. This edition of Euro Observer, with Guest
Editor, Dr Richard Watt, covers a range of issues on dentistry to commemorate his work.

Contents
Strategies for oral 1
Strategies for oral health care
health care
Aubrey Sheiham
Evolving dental 5
Dramatic changes in the extent and patterns – In 1978 the average 16–24 year old had 17
care services of disease are a good test bed to evaluate the sound teeth and 8 fillings; by 1998 they had
principles, scientific rigour and openness to 24 sound teeth and 2.9 fillings. In 1978
change of a health profession. Questions such 25–34 year-olds had 13.9 sound teeth. That
Public health 6 as ‘Have they made good rational analyses of increased to 19.7 in 1998.1
strategies for oral reasons for the changes?’ ‘How has the
European populations’ oral health profiles
health improvement profession and governments responded to
changed in three ways: (1) Each new birth
changes?’ ‘Are the shifts in policy appropri-
cohort has lower caries levels than the
ate?’ This article will review such questions in
preceding cohort and children and young
relation to dental care in Europe because
Redefining the way 7 adults have low levels of dental disease.
there have been dramatic improvements in
dental needs are Young cohorts will need some regular low
oral health in last 30 years.
assessed technology care. (2) Middle-aged adults’ teeth
are heavily restored and will need life-long
Changes in oral health in Europe maintenance and complex treatment.
In 1970, 12 year-olds in countries like (3) Older people can be divided into two
Norway had about 10 DMFT teeth groups. Those with their own teeth and those
(DMFT=Decayed Missing and Filled Teeth). without natural teeth. The former group is
Now the DMFT is around 1. And the loss of increasing in size as tooth loss declines.
all teeth fell from 17% in 1973 to 4% in 2004.
The prevalence and severity of caries and Reasons for improvements
destructive periodontal diseases are now low
Dentists played an insignificant role in
and still declining in Europe. Further
improvements in oral health, indicating that
examples of changes from the United
dental diseases are readily prevented without
Kingdom (UK) are:
dentists. The major improvements are due to
– Percentages with no caries experience external factors. Dental care accounted for
increased from 22% to 54% in 5 year-olds about 3% of reduction in caries in 12 year-
and from 7% to 50% in 12 year-olds. olds whereas broad socioeconomic factors
(including or excluding fluoridated tooth-
– In 15 year-olds the DMFT decreased from
pastes) explains 65% of this reduction.2 The
5.9 to 2.5.
improvements in periodontal health are due
– 16–24 year-olds with 18 or more sound to decreases in smoking, and improvements
teeth increased from 44% to 83% in 20 in self-care using anti-plaque and calculus
years. toothpastes.

The Observatory is a partnership between the WHO Regional Office for Europe, the Governments of Belgium, Finland,
Greece, Norway, Spain and Sweden, the Veneto Region of Italy, the European Investment Bank, the Open Society
Institute, the World Bank, CRP-Santé Luxembourg, the London School of Economics and Political Science (LSE) and
the London School of Hygiene & Tropical Medicine (LSHTM).
Euro Obser ver V o l u m e 7, N u m b e r 3

Implications of changes not likely to be justified because they public health promotion, and retrain
are no longer cost effective. dentists to changed needs, evidence-
– The need for dental care has markedly
based treatments and to public expecta-
reduced in about 90% of the popula- – The success of public health
tions such as maintaining their teeth for
tion under 50 years. Most people will prevention strategies may necessitate
their lifetime, not getting tooth decay
need little regular dental care. governmental policies to protect
and not having to attend dentists every
consumers. Professional self-control
– Most dental intervention will be simple year. Better regulation of the public and
may not be sufficient.
treatments. private sectors and reviews of effective-
ness are essential. Having fewer dentists
– The reduction in need among younger Suggested policy changes will ensure that they maintain their high
people will not be compensated for by Some individuals and groups have sug-
increased need by middle-aged and professional status and reasonable
gested what changes in oral care policies income as befits their long professional
older people.
should be implemented in the 21st training. These views were echoed by the
– Today’s over-50s may need a lot of oral century due to changes in oral health UK think-tank, Demos,6 which conclud-
health care as they should retain their patterns and increased public awareness. ed that the dentistry industry ‘should
teeth and have already received much shrink to a core of dental hygienists …
Barmes, the WHO Chief Dental Officer
treatment, requiring repeated mainte- and a small number of specialists in trau-
in 1978, concluded that use of dental
nance. Older adults will need relatively ma, cosmetic dentistry and orthodontics.’
services did not reduce dental disease. He
little care since many are edentulous.
recommended the need for a closer inte- The emphasis should be placed on quali-
– As populations are ageing with many gration of the dental and general health ty issues and evidence-based dentistry.
natural teeth there will be a greater service systems. The UK Dental Strategy Others have stressed that a more open
total consumption of oral health care Review Group considered that there is a approach to clinical governance is
during their lifetimes, unless evidence- need to change the emphasis of dentistry essential if the professions are to recover
based dentistry is implemented. from technological repair by encouraging and retain public confidence. Control by
However, the total lifetime consump- practitioners ‘[T]o limit intervention to the profession through self-regulatory
tion is cohort-dependent. the absolute minimum and to give mechanisms is currently a myth. Self-
– The consequences of more people prevention the opportunity to work’. regulation is being challenged by bodies
keeping their teeth into old age are During the 1980s there was considerable like the Healthcare Commission, increas-
uncertainty in forecasting demand and over-treatment. A UK Government ing cost-containment and by putting
supplier-induced demand for treatment enquiry on over-treatment severely more responsibility for dental costs onto
and prevention. criticized the restorative approach. ‘[T]he the individual. The growing focus on
– The content of treatment courses will restorative approach was at the heart of openness and public scrutiny, clinical
be markedly changed. For example, in unnecessary treatment’ and ‘[W]e have governance and emphasis on treatment
Norway, there was an increase in those gone beyond the stage where there are in outcomes and requirements for revalida-
having nothing except scale and polish the profession two respectable alternative tion will have a profound effect on
– from 31% in 1983 to 55% in 1993.3 approaches, the “restorative” and the dentistry and personnel projections.
In 1994 less than 43% of UK adult “preventive”. It is now clear that those
The World Oral Health Report 20037
claims were No Dental Intervention.4 who follow the restorative approach and
made recommendations for evidence-
carry out more than the minimum
Most importantly, there has been a based dental care and the appropriate use
number of restorations necessary are
change in the types of tooth sites affected of personnel. The British Dental
undertaking unnecessary treatment’.5
by caries. Lesions are predominantly on Association also stressed that evidence-
easily accessible sites, are much smaller The problem with dentistry is that based dentistry is particularly important
and progress very slowly or not at all, so dentists treat two diseases – caries and because ‘there was little health gain from
treatment is simpler or not required. periodontal diseases – both easily pre- some of the dental services provided and
ventable without dentists. Dentists fail to lack of evidence-based treatment
– As DMFT scores decrease the percent-
prevent and do not practice evidence- decisions’. The selective elimination of
age of the population needing regular
based dentistry. I have recommended inappropriate care would free resources
care will decrease. At scores of 0–5,
that there should be fewer dentists, inter- to provide care to more people. One way
33% of UK 16–24 year-olds attended
vening less and reorienting their efforts to do this is by developing high-quality
clinics regularly compared to 57%
to improving effectiveness and quality. and flexible appropriateness criteria to
with a score of 16+.
Reducing the numbers of dentists will guide clinical decision-making. Indeed,
– At lower levels of dental caries the tra- allow them to use their skills more evidence-based dentistry applied to two
ditional preventive methods like appropriately by delegating the propor- dental procedures – recall intervals and
professionally applied fluorides and tionately more simple dental procedures. scale and polish – would reduce the
chair-side dental health education is The profession needs to reorient towards workloads of dentists by about 20%.

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The profession’s responses focal sepsis – the idea that oral conditions Suggested changes in approach
The most common response of dental can affect heart disease, diabetes or The decline in caries has lead to advocat-
policy-makers to changes in oral health pregnancy outcomes. The conclusions ing a ‘high-risk’ approach for preventive
has been to propose increased access and of systematic reviews are inconsistent, strategies. That approach has been
numbers of dentists. This is illustrated by making these questions for additional challenged. The pivotal factor used to
policies in Norway, which has the high- research rather than the basis for determine the choice of preventive
est population per person-labour years assessing need or scaring the public. strategy should be the distribution of
for dental practitioners (about 1,150).8 As stated previously, most reforms disease in the population. Here, the
There, the number of dentists being are confined to the non-availability of fundamental axiom ‘that a large number
trained is increasing. Similarly, in the services, costs, and insufficient preventive of people exposed to a small risk may
UK, the government is recruiting from practice by dentists. They do not extend generate many more cases than a small
overseas and training more dentists. The to the fundamental limitations of number of people exposed to a high
main reasons for increasing dental dentistry, namely: risk’, needs to be considered.9 To decide
personnel when logic suggests that with whether to adopt a population or risk
major improvements in oral health there – inappropriate use of interventionist approach, Rose poses the fundamental
should be fewer, are supplier-induced approaches leads to a spiral of damage. question – namely, does a small increase
demand, over-treatment, increased priva- Dentists think they are looking after a in risk in a large number of individuals
tization of dentistry and the growth of machine which is constantly breaking generate more cases than a large increase
bodies corporate – ‘the McDonaldization down; they do not allow it to repair in risk in a few individuals?
of dentistry’ – and the failure to practice because they do not consider the
evidence-based dentistry. Supplier- natural history of diseases; The patterns of dental caries in
induced demand, coupled with a populations displays the same shifting
– the way disease and needs are defined; distributions as seen in systolic blood
redefinition of need, lies at the root of
problems with dental care. They lead to – failure to prevent avoidable disease and pressure and body mass index highlight-
debates about lack of access to care – the tackle the determinants of oral disease. ed by Rose. As the mean decreases the
‘Scarborough phenomenon’ where long whole distribution shifts to the left
A feature of dental diseases is that simple pulling the tail with it so that the so-
queues of patients wait for a new
and cheap public health methods are called high risk group declines. These
National Health Service dentist.
available to prevent and control them shifts in distribution from a normal to a
Grytten8 has summarized the folly of because the causes are known; they are reverse-J can occur in 10 years. The
supplier-induced demand. It has lead to a diet, dirt, smoking, stress, and accidents. implication is that the shift in the whole
situation in Norway where current esti- A major factor making dental care so distribution had a markedly beneficial
mates, based on 200 working days per expensive is the limitations of the effect on those at relatively high risk,
year, indicate that a dental practitioner dominant restorative approach to treat who need far fewer fillings than the cor-
sees about five to six patients per day! and prevent disease. I will mention some responding children at an earlier period.
‘More dentists will treat fewer patients, of the main limitations and propose
with higher fees.’ They will have to find The implications for strategy selection
alternatives because the current
more work to do on people who have are that the majority of caries in
approaches can only perpetuate and not
healthier dentitions. Dentists who are European populations occurs in the
solve the problems.
concerned with decreasing disease majority of the population and not in the
levels, a lowering of their earnings, and Conventional dental approaches must small tail of the distribution. Therefore, a
rising costs are hungry and therefore change because: policy for caries preventive strategies
dangerous. They tend to carry out much should be based on a ‘population’ or
– Whereas oral health should be the
unnecessary treatment and redefine need. ‘directed population approach’ rather
overriding goal, it has been displaced
than a high-risk strategy.
A good dentist will only do appropriate by dental treatment, which is a strategy
treatment and effective prevention. But not a goal. Population strategies to promote oral
since patients are poorly informed and in health should include:
– Treatment strategies may ensure better
vulnerable positions lying on the dental care for the few and a dependence on 1. Focusing on determinants of health.
couch with their mouth open, the dentist
professionals, but little is done on
can influence the nature of care 2. Preventive rather than curative
health promotion and inter-sectoral
provided.8 What we are seeing now strategies.
working.
throughout Europe is that dental special-
3. Tackling causes common to a number
ties are redefining need by adding an – Clinic-based, capital-intensive
of chronic diseases.
interesting twist that was used by approaches to treat disease are
dentistry to establish its profession in the unrealistic given the high costs and 4. Incorporating oral health into general
19th century, namely, the rediscovery of inadequate coverage. health strategies.

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5. Encouraging self-care. Estimating dental needs should be geared to create environments


Estimating dental needs is fundamental where it is easier for the dental team to
6. Deploying the available resources to
to public health. Yet approaches to do good dentistry.
meet needs on the basis of priority.
assessing dental need have not pro-
7. Equitable distribution of services. gressed. There are major shortcomings Conclusions
8. The use of appropriate technology in the normative needs approach and a The dental profession has fared badly on
based on sound scientific, evidence- service-oriented definition of dental the questions set in this article to test its
based principles. need. Instead of the conventional rigour and responsibilities as a health
approach to assessing need, there is an profession. In spite of evidence that the
The improvement of health is achieved alternative broader, socio-dental current methods and systems of dental
via social changes embodied in health approach which takes into account the care are relatively ineffective, costly and
promotion and is not confined to caries. impact that oral state has on quality of not well-accepted by the public,
Major improvements in the prevention of life, peoples’ wants and behaviours, their decision-makers and influential dental
disease tend to follow social changes, propensity to change their behaviours, professionals remain preoccupied with
whether these are alterations in social and importantly, evidence that the availability of care and finance.
norms (dietary patterns, oral cleanliness, recommended treatment is effective.
contraception), in the availability of key
resources (fluoridated toothpaste, quality
Evidence-based dentistry REFERENCES
and quantity of food) or as a result of
engineering (fluoridation of water sup- Increases in demand for care have 1. Kelly M, Steele J, Nuttall N, et al. Adult
plies, clean water, effective waste focused attention on meaningful criteria Dental Health Survey. Oral Health in the
disposal). There is no reason why a for using technologies and approaches. United Kingdom 1998. London: The
similar approach should not prove This has led to greater attention being Stationery Office, 2000.
equally successful in the future. given to the effectiveness of interventions
2. Nadanovsky P, Sheiham A. The relative
relative to their cost. Closer scrutiny of
contribution of dental services to the
what works should allow planners to
Oral health promotion prescribe what treatments are permissible.
changes in caries levels of 12 year-old
Recent systematic effectiveness reviews children in 18 industrialized countries in
That would allow limited resources to be
of dental health education have highlight- the 1970s and early 1980s. Community
used more efficiently and effectively.
ed its limitations. A more progressive Dentistry and Oral Epidemiology
health promotion approach which 1995;23:231–39.
The role of dentists
recognizes the importance of tackling 3. Grytten J, Lund E. Future demand for
Dentists should be diagnosticians, carry
the underlying social, political and dental care in Norway; a macro-economic
out complex procedures, supervise
environmental determinants of oral perspective. Community Dentistry and
primary oral health teams and act as
health, is needed. For this approach to Oral Epidemiology 1999;27:321–30.
advocates. Their future lies in fewer
be successful in achieving sustainable
procedures of higher quality, together 4. Dental Practice Board. Digest of
changes in oral health, multi-sectoral
with population-based prevention. What Statistics 1997/98 Part 1. Detailed analysis
working is essential.
is their appropriate role in prevention? of GDS Treatment Items.
There are basically two approaches for At the lower levels of dental caries now www.dpb.nhs.uk/gds/digest.shtml
an equity-oriented health policy: one prevailing, traditional preventive meth-
5. Department of Health and Social
being to focus on reducing specific ods are no longer cost-effective. Much of
Security. Report of the Committee of
diseases and the other upon specific risk the treatment by dentists can be done by
Enquiry into Unnecessary Dental
factors and public policies aimed at auxiliaries. If effective health promotion
Treatment. London: HMSO, 1986.
improving health conditions in general – is implemented the need for expensively
the Common Risk/Health Factor trained dentists should decline. 6. Demos. Open Wide. Futures for
Approach (CRHFA). The strategy Dentistry in 2010. London; Demos, 1996.
Most dental practitioner involvement in
should include efforts to improve health 7. Petersen PE. The World Oral Health
strategy will be as health advocates.
by reducing risks, promoting health and Report – continuous improvement of oral
Health advocacy involves educating
strengthening possibilities to cope with health in the 21st century. Community
senior government and community lead-
‘given’ risk factors – creating supportive Dentistry and Oral Epidemiology
ers and journalists – decision-makers in
environments, reducing the negative 2003;31(Suppl.1):3–24.
general – about specific issues and setting
effects of certain risk factors and facilitat-
the agenda to obtain political decisions 8. Grytten J. Models for financing dental
ing behaviour changes. A major benefit
that improve the health of the population. services. A review. Community Dental
of the CRHFA is the focus on improving
health conditions in general for whole In keeping with the concept of health Health 2005;22:75–85.
populations and groups at high risk, promotion and making healthy choices 9. Rose G. The Strategy of Preventive
thereby reducing social inequities. the easy choices, a policy for dental care Medicine, Oxford University Press, 1993.

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Evolving dental care services allocated to dentistry, the population will


need to find dental care outside the
NHS.

Paul Batchelor With respect to both the adoption of


new and existing treatment modalities,
along with the performance of care
providers, clinical governance is being
introduced. Clinical governance is
Oral diseases have declined throughout and time-consuming than that required defined as ‘A framework through which
most of Europe. While in some coun- for other care options. NHS organizations are accountable for
tries, particularly those of Eastern continually improving the quality of
Such issues pose at least three major
Europe, clinical disease remains a major their services and safeguarding high
challenges for governments. First, while
problem and the overall improvements in standards of care by creating an environ-
disease levels have fallen, clinical decay
levels of oral health means that a growing ment in which excellence in clinical care
still remains prevalent in some sections
percentage in each age cohort can now be will flourish’.1 Developments are being
of society. As with health in general,
expected to have many more and healthi- pursued to provide the standards neces-
those with the least resources have higher
er teeth than in previous generations. sary to evaluate both performance and
levels of disease. Within the resource
However, this transformation in oral how the components within the system
constraints found in any care system,
health poses a series of challenges to are performing. For performance evalua-
how can arrangements be altered to help
governments. The main one is to solve tions initiatives include the Healthcare
the paradox that despite the improve- ensure that those with the higher levels
Commission (for organizations) and the
ments, the costs of oral care have contin- of clinical disease obtain care in the face
National Patient Safety Agency (for
ued to increase. There appears to be an of competing demands from the middle
individuals) while the National Institute
insatiable demand for dental care, possi- classes for cosmetic interventions?
for Health and Clinical Excellence will
bly supplier-induced. Many countries Second, with more treatments from
assess treatments.
report a shortage of dentists and growing advances in materials and techniques,
how can government best play its stew- European governments are prescribing
public dissatisfaction with access to
ardship role to ensure that only those reforms to their dental systems prior to
dental care. Why has this happened and
treatments that are effective are provid- making a thorough analysis. The biggest
how have governments responded?
ed? Finally, what processes need to be in challenge is the ability to control what
The main issue centres on the growing place to ensure that when care is provid- happens within the system. With a lack
expectations of what dental care can ed it is to an appropriate standard? The of appropriate outcome measures and
provide. Where previously the public greater the controls in place, the greater poor information systems for monitoring
were satisfied with removal of painful the bureaucracy and costs. performance, a reliance on market-type
teeth this is no longer acceptable. solutions and increasing the dental work-
Individuals want teeth saved. In England and Wales, the issue of allo- force, the most popular solution will cre-
Furthermore, expectations surrounding cation of resources is being ‘solved’ by ate more problems. Problems such as
the type of restoration have risen. fragmenting the national contract supplier-induced demand and over-
However, as with all treatment, any through which dentists have been paid treatment. The development of appropri-
restoration has a limited life and continu- since 1948. From April 2006, a new con- ate outcome measures and proper incen-
al maintenance is required. Indeed nearly tract will be negotiated between dentists tive mechanisms are far more important
three quarters of the cost of dental care and more localized commissioning in achieving equity and success than
under the NHS involves replacing exist- bodies, the Primary Care Trusts (PCTs). increasing the numbers of dentists.
ing interventions. Generally, the more It is argued by the government that
PCTs can better identify the needs of REFERENCES
complex the intervention, the greater the
maintenance. This restorative cycle offers their resident population than the 1. Scally G, Donaldson LJ. Clinical
a partial explanation as to why there are previous, centrally-driven system that governance and the drive for quality
far higher dentist/population ratios in was based on the premise that the entire improvement in the new NHS in England
Scandinavia where similar practices exist. population needed care. As the commis- BMJ 1998;317: 61–65.
The levels of advanced dentistry is high- sioning process evolves, PCTs with an
er, despite having similar dental disease allocated budget for all of health (and
levels. Scandinavian dentists are as busy social) care will make local decisions Paul Batchelor is a Consultant in Dental
as their UK counterparts as complex about how best to address all the local Public Health and Honorary Senior
dentistry was introduced far earlier in health needs. Of course, this may mean Lecturer of Dental Public Health in the
Scandinavia than in the United Kingdom. that should the dental needs be defined Department of Epidemiology and Public
The ongoing level of care to maintain as very low in comparison to more Health, University College London
crowns and implants is far more costly general health needs and few funds Medical School.

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Euro Obser ver V o l u m e 7, N u m b e r 3

Public health strategies for oral often developed in isolation from other
aspects of health improvement. This can
lead to conflicting and contradictory
health improvement messages being delivered to the public
who, in many places, are increasingly
sceptical of health education messages.
Richard Watt Lastly, with limited resources available
it is impossible to deliver preventive
interventions to all those that may
require support.
Oral diseases are highly prevalent and approach? A list of limitations are
their impact on both society and the outlined in Table 1 . At the most funda- Public health agenda
individual is significant. Dental treatment mental level this individualistic approach
Based upon contemporary public health
is expensive for the individual, for the fails to achieve sustainable improvements
research and WHO guidance7,8 future
health system and for society as a whole. in oral health as the interventions are pal-
oral health strategies should be based
Although overall improvements in oral liative in nature, and largely ignore the
upon the following guiding principles:
health have occurred in many European underlying determinants that create poor
countries over the last 30 years, oral oral health, the ‘upstream’ factors. As a Empowering: initiatives should enable
health inequalities have emerged as a result, inequalities rather than being individuals and communities to assume
major public health challenge. Dental reduced inequalities, may indeed be more power over the personal, socio-
treatment alone will never eradicate oral increased as those with resources are able economic and environmental
diseases. The causes of oral diseases to benefit the most from the interven- determinants of their oral health.
are understood so the potential for tions delivered.2 Effectiveness reviews of
Participatory: individuals and communi-
preventive action is great. However, the oral health interventions have highlighted
ties should be actively engaged in all
dominant preventive approach adopted the ineffective nature of most educational
stages of planning, implementation and
by the dental prevention is ineffective, programmes.3-6 With professionals domi-
evaluation of oral health programmes.
costly and indeed exacerbates inequali- nating this ‘top down’ approach, patients
ties. Public health strategies are needed and communities are largely passive Holistic: rather than have a narrow and
to create the opportunity and conditions recipients of support, and therefore fail isolated focus, oral health strategies
to enable individuals and communities to to engage or acquire a sense of owner- should foster physical, mental, and social
enjoy good oral health. This article will ship. As a result, a dependency culture is health, and focus upon the common risks
outline the limitations of preventive often created rather than an empowering and conditions that influence both
dentistry and highlight a public health one. Professional domination also means general and oral health.
approach for the promotion of oral that programme costs are high. In
health across Europe. addition, oral health interventions are Inter-sectoral: oral health professionals
should work in collaboration with other
professional groups, agencies and sectors
Limitations of preventive Table 1: Limitations of the clinical preventive
approach to promote general and oral health.
dentistry
Limited long term impact – fails to address Equitable: oral health initiatives should
In dentistry, preventive activities have underlying determinants of poor oral health be guided by a concern for equity and
largely followed a clinical and behaviour- social justice.
May increase health inequalities – ‘inverse
al model.1 The approach is dominated by
preventive care law’ Evidence-based: future action should be
the use of clinical preventive measures
such as fluoride applications and fissure Often minimal community involvement – ‘top developed from existing knowledge of
sealants, and dental health education down’ approach good practice and findings from
techniques. The educational component Expensive – heavily reliant on costly effectiveness reviews to achieve
focuses primarily on developing the professional input sustainable improvements in oral health
individuals’ oral health knowledge based across the population.
Partner fatigue – schools and other partners
upon the assumption that this will lead bombarded with external input Multi-strategy: a variety of complemen-
to changes in oral hygiene and dietary
Isolated approach often leads to conflicting tary strategies are needed, including
behaviours. This approach to prevention
messages policy development, organizational
has been applied to individuals at the
change, community development,
chair side, and high-risk groups in the Limited coverage of population legislation, advocacy, education and
community, mostly through school-
communication. Clinical prevention and
based programmes. Public apathy – loss of confidence in expert health education alone are ineffective at
scientific advice
What are the limitations of this producing long-term oral health gains.

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Professional development: appropriate 2005;37:35–47. 8. Petersen PE. The World Oral Health
training is needed to develop the skills 7. World Health Organization. The Report 2003. Continuous improvement of
and knowledge of dentists and their Ottawa Charter for Health Promotion. oral health in the 21st century.
teams to enable them to engage Health Promotion 1. i-v. Geneva: World Community Dentistry and Oral
effectively in public health efforts to Health Organization, 1986. Epidemiology 2003;31(Suppl 1):3-24.
promote oral health
Evaluation: resources need to be invested Richard Watt is Professor of Dental Public Health in the Department of Epidemiology and
to develop better systems of evaluation Public Health, University College London Medical School. Email: r.watt@ucl.ac.uk
to assess and monitor the effectiveness
and delivery of interventions.

Conclusions
Future action to improve oral health and
reduce inequalities requires a public
health approach. Clinical prevention and
Redefining the way dental needs
dental health education alone will have a
minimal effect and may increase inequali-
are assessed
ties across society. A public health
agenda which seeks to tackle the under- Georgios Tsakos
lying causes of poor oral health, through
the implementation of a range of comple-
mentary actions provides the best way
Oral health care is very expensive. In – Normative need does not take into
forward. The success of this approach
European Union countries, total account the behaviours and compliance
depends upon establishing good working
expenditure on dentistry varies from 3% of patients – factors which are essential
partnerships with the relevant agencies
to 13% of total health expenditure.1 for the effectiveness of treatments.
and sectors. In addition, it is essential
Faced with such an expensive service, it
that the population is involved in all – At a political level, the normative
is necessary to have a clear perspective
stages of action planning. approach falls short in terms of human
on needs assessment methods as they are
or consumer rights, as it excludes
REFERENCES at the core of health care planning.
recipients of care from planning
1. Towner E. The history of dental health The most commonly used type of needs decisions.
education: a case study of Britain. In: assessment in oral health care planning is – The normative approach usually
Schou L, Blinkhorn A. (eds). Oral Health normative or professionally defined
results in very high estimates of need,
Promotion. Oxford: Oxford University need. Most national and local oral health
thus being unrealistic and, therefore,
Press, 1993. surveys adopt this approach. Normative
of limited usefulness in treatment
2. Schou L, Wight C. Does dental health need uses clinical measures alone and
planning.
education affect inequalities in dental identifies diseases and impairments with-
health? Community Dental Health out considering the subjective percep- Despite the serious shortcomings,
1994;11:97–100. tions of people. Locker2 has summarized normative need assessment remains use-
the shortcomings of normative need: ful in some cases, for example, in reliably
3. Brown L. Research in dental health
‘from the point of view of contemporary diagnosing a cavity requiring a filling.
education and health promotion: a review
definitions of health, clinical measures But the sole use of normative need is
of the literature. Health Education
have serious limitations; they tell us definitely not appropriate in other cases,
Quarterly 1994;21:83-10.
nothing about the functioning of either such as missing teeth replacement, third
4. Kay L, Locker D. Is dental health edu- the oral cavity or the person as a whole molars extraction or orthodontics. In
cation effective? A systematic review of and nothing about subjectively perceived those cases, subjective perceptions play a
current evidence. Community Dentistry symptoms such as pain and discomfort.’ pivotal role and therefore a broader
and Oral Epidemiology 1996;24:231–35. The limitations of normative need are:3 approach is required.
5. Sprod A, Anderson R, Treasure, E. – It is neither objective, nor reliable, nor The broader approach of needs assess-
Effective oral health promotion. Literature precisely quantifiable. ment should address the aforementioned
Review. Cardiff: Health Promotion – While conceptually important, norma- conceptual and practical limitations, thus
Wales, 1996. tive need neglects the psycho-social extending beyond the traditional
6. Watt RG, Marinho VC. Does oral aspects of health and the concept of normative model. Following this
health promotion improve oral hygiene quality of life. It therefore contradicts rationale, a broader system for assessing
and gingival health? Periodontology 2000 the global definition of health. dental treatment needs has recently been

7
THE EUROPEAN OBSERVATORY ON HEALTH SYSTEMS AND POLICIES IS A PARTNERSHIP BETWEEN

World Health Government Government Government Government Government Government European Veneto Region Open Society World Bank London London
Organization of Belgium of Finland of Greece of Norway of Spain of Sweden Investment of Italy Institute School of School of
Regional Bank Economics Hygiene &
Office for and Political Tropical
Europe Science Medicine

developed.3,4 The socio-dental needs assess- assessment of need is based on all Editor
ment system is guided by measures of the components of the system. Consequently, Anna Maresso
impact of oral conditions on quality of life the socio-dental system allows for different
Deputy Editor
and principles of evidence-based dentistry models of needs assessment, according to
Nadia Jemiai
and focuses on need ‘as capacity to the nature of the dental condition.
benefit’,5 implying that needs are identified Editorial Team
Despite their importance, the components
when there are effective interventions avail- Josep Figueras
of the socio-dental approach have not been Martin McKee
able to meet them. The development of the
systematically used in dental needs Elias Mossialos
socio-dental system conforms to the mod-
assessment. Where they have been, large Ellen Nolte
ern, theoretical, multi-factorial approach for
differences in estimates of need are reported Sarah Thomson
the assessment of oral health care needs and
in both elderly and child populations, with
incorporates the following components: To join the mailing list,
the socio-dental needs estimates being
– clinical estimates of normative need; significantly smaller than normative need please contact
estimates. Anna Maresso
– subjective perceptions, including
Observatory – London Hub
perceived treatment needs and oral This broader socio-dental system addresses Tel: +44 20 7955 6288
health-related quality of life (OHRQoL) the limitations of the sole use of normative Fax: +44 20 7955 6803
measures; assessments. It is conceptually coherent and Email: a.maresso@lse.ac.uk
– propensity to adopt health promoting practical. In addition, it provides treatment Euro Observer is published
behaviours; and needs assessments that are closer to needs quarterly by the European
– scientific evidence of the effectiveness of identified by good clinicians, as it combines Observatory on Health Systems
treatments. the key factors considered during the and Policies, with major funding
individual decision-making process. provided by a grant from
The socio-dental system uses these compo- Therefore, it identifies and quantifies needs Merck & Co., Inc., Whitehouse
nents and gradually integrates them to at the population level more explicitly and Station, New Jersey, USA.
determine needs. Normative assessments in line with clinical decision-making, thus The views expressed in
are integrated with OHRQoL measures, adhering to the principles of clinical gover- Euro Observer are those of the
which assess how the mouth affects daily nance and being useful in service planning. authors alone and not necessarily
performances, in order to define and priori- those of the European Observatory
tize treatment need. Then, behavioural REFERENCES
on Health Systems and Policies or its
propensity levels that facilitate the specifi- 1. Widstrom E, Eaton KA. Oral healthcare participating organizations.
cation of required treatments are further systems in the extended European Union.
© European Observatory on Health
integrated in the needs assessment system. Oral Health and Preventive Dentistry
Systems and Policies 2005.
Behaviour propensity mainly refers to four 2004;2:155–94.
basic behaviours with established impor- No part of this document may be
2. Locker D. An Introduction to Behavioural
tance for oral health care; they are use of copied, reproduced, stored in a
Science and Dentistry. London: Routledge, retrieval system or transmitted in
fluoride toothpaste, toothbrushing frequen-
1989. any form without the express
cy, sugars intake, and pattern of dental
3. Sheiham A, Tsakos G. Oral health needs written consent of the European
attendance. Finally, evidence-based guide-
assessment. In: Pine CM and Harris R (eds). Observatory on Health Systems
lines on the effectiveness of interventions
Community Oral Health. Edinburgh: and Policies.
cover all stages of the socio-dental system.
Elsevier Science Limited (in press).
Obviously, the integration of normative For information and ordering details on
need with OHRQoL is not appropriate for 4. Gherunpong S, Tsakos G, Sheiham A. A
any of the Observatory publications
each dental condition. In life threatening socio-dental approach to assessing dental
mentioned in this issue, please contact:
conditions, such as oral cancer or precan- needs of children: concept and models. Int J The European Observatory on Health
cerous lesions, or in chronic progressive Paediatr Dent (in press). Systems and Policies
conditions, such as active dentinal caries, 5. Wright J. Health Needs Assessment in WHO ECHP
clinical measures are of prime importance Practice. London: BMJ Books, 1998. Rue de l'Autonomie, 4
and treatment need is decided without B - 1070 Brussels, Belgium
considering OHRQoL. However, in Tel: +32 2 525 09 33
Fax: +32 2 525 0936
conditions that are unlikely to progress or Georgios Tsakos is Clinical Lecturer of
Email: info@obs.euro.who.int
cause adverse health consequences in the Dental Public Health in the Department of
Website: www.observatory.dk
absence of treatment, such as orthodontics Epidemiology and Public Health,
and replacement of missing teeth, the University College London Medical School. Design and production by
Westminster European
westminster.european@btinternet.com

8 ISSN: 1020-7481