Memorandum by Professor Aubrey Sheiham
and Dr Georgios Tsakos
The questions addressed relate to how Science
and Technology can help improve people's prospects of healthy
and active life expectancy and whether Government policies are
in place to achieve this.
ORAL HEALTH
AND AGEING
The evidence we present is on how three aspects
of research in technology relating to oral health can help improve
people's prospects of healthy and active life expectancy. The
first two aspects are related to how the mouth and teeth affect
the health and quality of life and diet and nutrition of people
in general and older people in particular. The third relates to
the methods for assessing needs for dental care and oral health
promotion.
1. How the mouth and teeth affects health
and quality of life and diet and nutrition of people in general
and older people in particular
The two main ways that the mouth and teeth affect
the health and therefore the ageing process are:
1.1 The mouth contributes significantly
to the quality of life. Quality of life is concerned with "the
degree to which a person enjoys the important possibilities of
life". A person's oral health status can affect them physically
and psychologically and influence how people enjoy life; how they
look, speak, chew, taste and enjoy food, socialise, as well as
their self-esteem, self image and feelings of social well-being.
Successful ageing is related to maintaining quality of life, which
in turn is dependent on how well individuals can fulfil these
performances. Normal oral functions such as chewing, speaking,
laughing and appearance can be impaired by dental pain and discomfort,
aesthetically displeasing teeth and loss of natural teeth. Social
functions such as communication and aesthetics may be more important
than biting and chewing and may be the main determinants in an
individuals' subjective need for replacement of missing natural
teeth and their feelings about the loss of teeth.
In a national study of randomly selected free
living (753 persons) and institutionalised (202) subjects from
the British National Diet and Nutrition Survey (NDNS) aged 65
years and over, the impact of oral status on 10 aspects of daily
life was considerable; 17 per cent of free-living edentate older
people reported having one or more severe oral related impact
in the past six months. Considering that these impacts are "ultimate
impacts" and not merely "intermediate impacts",
then the effect of dental and oral disorders on quality of life
is serious. Oral impacts levels were lowest in dentate subjects
with the greatest number of teeth. For the dentate, the most common
oral impacts were on eating and speaking. Impacts relating to
emotional stability, sleeping, relaxing, carrying out physical
activity and social contact were infrequent, but were severe when
they did occur. Among those with an impact on eating, 25 per cent
said it was severe and 42 per cent had the impact nearly every
day or in a spell of three or more months. Oral impacts were more
prevalent among the institution sample. The impacts were associated
with the inability or difficulty to eat a range of 16 common foods.
The impacts had large effects on whether people could not eat
or eat with some difficulty a range of common foods such as sliced
bread, cheese, roast potatoes, lettuce and apples. A strong significant
relationship between having a socio-dental eating impact and perceived
difficulty of eating was reported for almost all the 16 foods
in dentate and all 16 foods in edentate subjects.
More edentate than dentate people had an oral
impact. This reflects how badly fitting dentures affects oral
health related quality of life among people with false teeth.
Free-living dentate people with less than 11 natural teeth were
more likely to have had an oral impact than those with 11 or more
teeth. Eating related oral impacts were the most common impact
reported by all groups. Speaking, emotional stability, sleeping,
contact with people and smiling were also affected by oral impacts,
although less frequently. This indicates that the quality of life
of older people was fairly frequently and severely compromised
by dental and oral disorders. In particular, the ability to eat
several common types of foods was impaired.
1.2 Dental health status influences diet
and nutrition. Oral health status is considered to be particularly
important in older people and to influence their nutritional status.
Tooth loss has been associated with nutritional deficiency. The
presence of dentures and number of natural teeth are associated
with masticatory efficiency and ability and being without natural
teeth is related to being underweight. One of the most likely
mechanisms by which impaired oral health may affect diet is that
difficulty chewing causes dietary restrictions. Joshipura et
al (1996) found that edentulous health professionals consumed
fewer vegetables, less dietary fibre, and carotene and more cholesterol,
saturated fats and calories than people with 25 or more teeth.
Tooth loss was associated with a lower intake of hard-to-chew
foods such as apples and carrots. Ranta et al (1988) found
higher proportions of dentate people had eaten vegetables and
fruit than their edentate counterparts. Studies which have analysed
the effects of dental status on consumption of non-starch polysaccharides
(dietary fibre) reported a reduction in intake with tooth loss
(Moynihan et al 1994, Joshipura et al 1996). Older
people have fewer natural teeth, and are also vulnerable to dietary
restrictions for other reasons (disability, medical or social
conditions). Tooth loss was associated with changes in foods preference
and nutritional deficiency in older people (Chauncey, et al
1984, Brodeur et al 1993, Moynihan et al 1994, Krall
1998). The evidence generally available for elderly populations
suggests that tooth loss alters food choice resulting in lower
intakes for key nutrients such as iron and fibre. This evidence
suggests that eating ability and masticatory efficiency are affected
by oral health, and specifically by the number and distribution
of natural teeth. Whether or not somebody reported that they had
a problem with eating which impacted on their day to day life
has been shown to be strongly related to difficulty eating certain
foods (Smith and Sheiham 1979, Sheiham et al 1999). In
the NDNS study about one in five dentate free-living British people
aged 65 and over had difficulty eating raw carrots, apples, well
done steak or nuts. More edentate subjects had difficulty eating
than dentate. Foods such as nuts, apples and raw carrots could
not be eaten easily by over half edentate people in institutions.
In random national samples of free-living British
older subjects who had a dental examination, interview shown to
be strongly related to difficulty eating certain foods (Smith
and Sheiham 1979, Sheiham et al 1999). (NDNS) aged 65 years
and over study, intakes of most nutrients were lower in edentate
than dentate. Intake of non-starch polysaccharides, protein, calcium,
non-haem iron, niacin, vitamin C were lower in edentate subjects.
People with 21 or more teeth consumed more of most nutrients,
particularly of non-starch polysaccharide. This relationship in
intake was not apparent in the haemotological analysis. Plasma
ascorbate and plasma retinol but not a number of key nutrients,
were the only analytes associated with dental status.
An important finding in the NDNS study is that
intake of non-starch polysaccharide (dietary fibre) was much higher
in people with more teeth and significantly associated with the
number of occluding pairs of posterior teeth. Intake of intrinsic
and milk sugars, derived from foods such as fresh fruit and its
derivatives, was also significantly associated with having more
occluding pairs of natural teeth. Dietary fibre are an important
component of diet, associated particularly with gastro-intestinal
health, so the relationship with oral health in the elderly is
of considerable importance, emphasizing the role that maintaining
a functional natural dentition may have in improving the general
health of the elderly.
The important conclusion from the national survey
of older people is that dental status can have an impact on food
choice and on the intake of key nutrients, and this can ultimately
translate into variation in the blood levels of number of key
nutrients, arguably, the most important of which is vitamin C
RESEARCH AND
POLICY IMPLICATIONS
1.2.1 More research is needed to explore
how the teeth and mouth affect ageing. There is a strong case
for dentistry to concentrate more on psychological and social
functioning, than on functional restoration, particularly for
older people.
1.2.2 Traditional oral epidemiologic indicators
do not tell us much about people's capacity to carry out desired
roles and activities and whether people enjoy the important possibilities
of life. Moreover, from the point of view of contemporary definitions
of health, clinical measures used to define health status and
needs in populations are subject to more serious limitations;
they tell us nothing about the functioning of the oral cavity
or the person as a whole, nor about subjectively perceived symptoms.
Socio-dental indicators are measures of oral health-related quality
of life and range from survival, through impairment, to function
and perceptions. They measure the extent to which dental and oral
disorders disrupt normal social-role functioning and bring about
major changes in behaviour such as an inability to work, or undertake
parental or household duties. They are subjective and their use
should be complementary to the clinical measures of oral status
and needs.
Recommendation: Socio-dental technology
for assessing oral health-related quality of life should be developed
to assess oral health related subjective impacts on quality of
life and the impacts of the mouth on enjoying eating, and on diet
and nutrition.
1.3 Assessing needs for dental care and
oral health promotion. The purpose of needs assessment in health
care is to assess unmet health and health care needs in a systematic
manner and to gather the information required to bring about change
beneficial to the health of the population. Health needs assessment
is a systematic approach attempting to ensure that the health
service uses its resources to improve the health of the population
in the most efficient way. The concept of need is at the core
of health care planning. Planning health services is, in turn,
rooted in the ethical imperative to use resources appropriately.
Needs assessment involves setting priorities on the basis of health
needs that is taking into account the severity of illness and/or
health care needs, which refers primarily to the capacity to benefit.
A common assumption in the organisation and provision of health
services, including dental health services, which is being challenged,
is that the need for health care can be objectively determined
by professionals. Now it is known that health care needs may be
defined in other ways, because the definition of any given state
of ill-health has become open to much wider interpretation than
in the past. Health care needs now extend beyond a narrow clinical
interpretation to issues like the impact of ill-health on individuals
and on society, the degree of disability and dysfunction that
ill-health brings, the perceptions and attitudes of patients themselves
towards ill-health and the social origins of many common illnesses.
These factors influence the utilisation of health services and,
ultimately, the effectiveness of treatment. In this sense, they
represent key concepts that should be seriously considered in
the process of planning health care services so that resources
are more rationally distributed by the ability to benefit. Because
improving the quality of older people's lives is central to allocation
of resources.
The concern with effectiveness and acceptability
is central to any formulation of health care needs. Matthew's
definition focuses on the "need for care", which should
be distinct from "need for health". Health needs represent
the distribution of particular forms of morbidity, as well as
the distribution of those environmental, social and economic variables
that influence health and illness. Therefore it is important to
distinguish between the need for health and the need for health
care. Health care is one way of dealing with the need for health.
The need for health is perceived as relief from distress, discomfort,
disability, handicap and the risk of mortality and morbidity (Acheson,
1978). With the growing demand for treatments based on evidence-based
medicine, Matthew's definition has become widely accepted. Bradshaw
(1972) constructed a taxonomy of need that incorporates those
concepts and forms a sociological background that sets up a useful
definitional framework. The main types of need are presented in
Box 1 and their interrelation is pictured in Figure 1.
BOX 1 BRADSHAW'S TAXONOMY OF NEED: TYPES
AND DEFINITIONS
| Normative need: | Is that which the expert or professional, administrator or social scientist defines as need in any given situation
|
| Perceived (felt) need: | This reflects the individual's own assessment of his or her requirement for health care.
|
| Expressed need (demand): | This is felt need converted into action by seeking assistance
|
The relationship between Normative Need, Perceived (Felt)
Need, and Expressed Need (Demand)
The shortcomings of the normative method of assessing need
are:
(1) Lack of objectivity and reliability. Professional
judgements in normative need are neither value-free nor objective.
The so-called objective assessment often depends upon a consensus
agreement from a number of subjective approaches. Therefore, objectivity
cannot be regarded as a property of measures of normatively assessed
health status and needs.
(2) Neglect of psychosocial aspects and quality of life
concepts. The global definition of health (WHO, 1948) adopts a
much wider perspective than that of normative need and incorporates
the concepts of functional, psychological and social well-being.
Nevertheless, the standard norm of measures of disease accepted
by dentists is not always the norm in terms of functional or social
requirements of people examined. Oral health problems, but not
necessarily the specific pathological conditions, are related
to a person's ability to carry out usual daily activities and
affect the individual's personal comfort and quality of life.
People's dental satisfaction bears little relation to the clinical
assessment of oral conditions. The assessment of health by lay
persons differs from that of professionals. Furthermore, there
are differences in concepts of health and disease among lay people
in different cultures. As a result, normative measures fail to
assess the level of health-related quality of life.
(3) Lack of consideration for health behaviours and patient
compliance. Normative criteria are insufficient for deciding treatment
needs because they do not take into account the attitudes and
behaviours of patients, which in turn have considerable influence
on the effectiveness of treatments and improvement of oral health.
(4) Neglect of consumer rights. The need justified by
purely professional assessment is questioned in terms of human
or consumer rights. The clinical definition, based on the disease
analogy, rarely coincides with consumer definitions.
(5) Unrealistic estimates for treatment planning. This
is particularly important because the use of Normative needs,
as illustrated in the latest Department of Health Report of
the Primary Care Dental Workforce Review, February 2004.
There are comprehensive measures of dental needs that include
the following elements:
A clinical dimension based upon sound concepts of the life
history of the diseases; measures of social dysfunction; the perceived
need of the individual; assessment of the propensity of the individual
to take preventive action and the perceived barriers to prevention;
a prescription of effective and acceptable treatments or cures;
assessment of the skills and manpower required (Sheiham and Tsakos
2004). Such measures should be used instead of the inappropriate
normative approach.
POLICY IMPLICATIONS:
Recommendation: Research on assessing dental needs sociodentally
is not used to inform policy. The Department of Health should
reconsider the manpower estimates based on normative need. That
would encourage a more equitable distribution of care and more
rational prioritisation of services.
SOME REFERENCES
TO STUDIES
CITED:
Sheiham A, Steele JG, Marcenes W, Tsakos G, Finch S and Walls
AWG. The impact of dental and oral disorders on social well-being
among older people; a national survey in Great Britain. Community
Dentistry and Oral Epidemiology 2001: 29;195-203.
Sheiham A, Steele JG, Marcenes W, Finch S, Walls AWG. The
Impact of Oral Health on Ability to Eat Certain Foods; Findings
from the National Diet and Nutrition Survey of older people in
Great Britain. Geriodontology 1999: 16; 11-20.
Sheiham A, Steele JG, Marcenes W, Lowe, C, Finch S, Bates
CJ, Prentice A, Walls AWG.) The relationship among dental status,
nutrient intake, and nutritional status in older people. Journal
of Dental Research 2001: 80 (2); 408-413.
Sheiham A, Steele J Does the condition of the mouth and teeth
affect the ability to eat certain foods, nutrient and dietary
intake and nutritional status amongst older people? Public
Health Nutrition 2001: 4(3); 797-803.
Sheiham A, Tsakos G Oral health needs assessment. Chapter
in Community Oral Health, edit C Pine. Wright Publishers, Oxford,
2004.
Smith J M, Sheiham A How dental conditions handicap the elderly.
Community Dentistry Oral Epidemioogy, 1979:7; 305-310
Srilapananan P, Sheiham A Assessing the difference between
sociodental and normative approaches to assessing prosthetic dental
treatment needs in dentate older people. Geriodontology
2001: 18; 25-34.
October 2004
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