Helen C. Gift

ORAL HEALTH, HEALTH, AND HEALTH-RELATED QUALITY OF LIFE

Health-related quality of life is a multidimensional concept with five broad domains: opportunity/resilience, health perception, functional states, impairments/diseases, and duration of life. It addresses the tradeoff between how long and how well people live. The health-related quality of life approach has provided greater opportunity for investigation of the interrelations among oral health, health, and related outcomes. The inclusion of patient-driven measures, such as perceptions and functional status, is critical. Oral health-related quality of life measures are being developed and used in research on aging populations. Clinical measures of oral health, perceptions of general and oral well-being, and reported physical, social, and psychological functioning are independent, but correlated, components of overall oral health-related quality of life. An oral health-related quality of life approach benefits 1) clinical practitioners in selecting treatments and monitoring patient outcomes; 2) researchers in identifying determinants of health, tracking levels of health risk factors, and determining use of services in populations; and 3) policy-makers establishing program and institutional priorities, policies, and funding decisions. This overview indicates substantial value in pursuing several recommendations. A theoretical framework from which concepts, measures, and models can be derived must be developed to address oral health, oral health-related quality of life, health, and health-related quality of life. Oral health outcomes or states must be identified and classified along some continuum of impairment, function, disability, and opportunity. Indicators of appropriate concepts and domains must be adapted or established. Extended analyses on the relations among oral health, oral health-related quality of life, health, and health-related quality of life should be conducted with use of the Boston VA Normative Aging Study and other appropriate data sets.

Conceptualizing oral health and oral health-related quality of life

This investigation considers oral health from a health-related quality of life perspective using a multidimensional concept representing a combination of impairment, function, perceptions, and/or opportunity. A subset of dentate individuals aged 18 and older from a national probability sample of the U.S. was selected for the reported analysis with data available from personal interviews, self-administered questionnaires, and oral examinations. Impairment was represented by clinically assessed active diseases and sequelae of diseases and self-reported acute symptoms. Other domains are represented by self-reported problems with function, perception of control over oral health, satisfaction with teeth, value attributed to oral health, and opportunity to obtain dental care. Principal components analysis with varimax rotation provided a structure to interpret four factors: accumulated oral neglect, self-perceived symptoms and problems, reparable oral diseases, and oral health values and priorities. Approximately 50% of the variance was explained by these four factors. Factor-based scores, envisioned as an index or summary measure representing the combination of variables identified in each factor, were used to assess potential validity. Whites had lower levels of accumulated oral neglect, fewer symptoms, and less reparable oral disease, but similar oral health values, than non-whites. Level of formal education was associated with each of the four factor-based scores. Age was directly associated with accumulated oral neglect, but the youngest age group had significantly more reparable oral diseases. Individuals with a dental visit in the past two years had considerably less accumulated oral neglect, fewer self-perceived problems, less reparable oral disease, and higher values of oral health than those without a dental visit in the past two years. Ordinary least square regressions were performed on each of the four factor-based scores using eight sociodemographic and economic variables. All four regression models were significant, with only the education variable being significant across all models. These analyses provide no evidence for one unique factor representing oral health. Rather, a conceptual framework for oral health appears to be represented by a set of reasonably independent components, including two groups of clinically assessed oral health, which together more fully represent oral health than any one single variable. Conceptualizing and measuring oral health multidimensionally leads us closer to examining it as part of general health.

Health Behavior Research and Oral Health

For over four decades, health behavior research has been an important tool in understanding the actions of dental practitioners, patients, and administrators of oral health services. Early investigations of fluoridation of public water supplies provided information on health behaviors of organizers and policy makers at the community level. Following World Wa. II., there was increased interest in the characteristics of dentists and their practice activities and in the impact of practitioner behavior on oral health status, access, and cost. With the increasing availability of additional preventive strategies, such as topical fluoride applications and dental sealants, compliance with these new regimens on the part of the public, patients, and health care professionals was the object of considerable behavioral research (Richards & Cohen, 1971). The evolution of the profession from a treatment to a prevention orientation in the 1960s and 1970s brought increased interest in the organization of dental practices and the types of services provided, the employment of dental hygienists and auxiliary personnel, and dentist-patient interactions. Concurrently, as the population of the United States increased, there was a surge of interest in estimating the size and composition of the dental workforce. This increasing interest resulted in other thrusts for behavior research: understanding what type of health professional was attracted to dentistry, training the ideal dentist, assuring that appropriate practice strategies were developed and used, and expanding the function of dental auxiliaries.

Prevention of Dental Caries The Sum of Community, Professional, and Individual Efforts

The focus of this article is how the primary prevention of dental caries has been effected utilizing a combination of community, professional, and individual efforts. The review demonstrates that improvements have been made in the dental caries level and that a complex offactors are implicated in the disease process. The information presented demonstrates that measures are available currently to prevent dental caries. Based on what is known, this article shows that a combination of water fluoridation, professionally applied sealants, and individually or professionally applied topical fluorides (including dentifrices) provides the best opportunityforpopulations to be caries-free or have a low caries rate. Basic to the success of these approaches is awareness and compliance at both the professional and individual levels. Further acceptance is shown to be more dependent on social and psychologicalprocesses than on the actual efficacy of any mechanical, immunologic, or chemical techniques, existing or developing. This is the basis of future research directions.