UnitEighteenNote:PleasepayattentiontotheunderlinedwordsorphrasesNote:Pleasepayattentiontotheunderlinedwordsorphrasesinadditiontothebluewords.ORALHEALTHFORALLTHROUGHALTERNATIVEORALHEALTHCARESYSTEMSThepreventionandcontrolofdentalcariesinindustrializedcountrieshavebeenduemainlytouseoffluoridesinmanydifferentwaysandtothewidespreadadoptionofeffectiveoralhygienehabits.Inspiteofthesesuccessesthediseaseisnotconqueredinallcommunities.Itmightstillbecalledaneglectedepidemicinunder-privilegedandlow-incomegroups.Therearemanyhigh-riskpopulationsintheUSA:97%ofthehomelessneedoralcare,blackchildrenhave65%moreuntreateddecaythantheaveragecitizen,lowincome91%andAmericanNatives265%.Morethan50%ofthehouseboundelderlyhavenotseenadentistfor10years.Traditionalsystemsfororalcarearebasedonvariouscombinationsofpublicsalariedservicesandprivatepractice.Thepublicservicesareusuallyresponsibleforprevention,careofschoolchildrenanddisadvantagedgroups;andprivatepractitionersprovideawiderangeoftreatmenttothegeneralpublic.Allthesesystemsareorientedinsuchawaythatthedentistprovidesmostofthecare.IntheUSA:84%of17yearoldshavehadtoothdecayandanaverageof11toothsurfacesisdamaged.Peopleaged40to44haveanaverageof30toothsurfacesaffectedbydecay.41%ofpeopleaged65oroverhavenoteethatall.Indevelopingcountries,thelevelofdentalcarieswasrarelyashighasinindustrializedcountriesand,insome,successfulpreventiveactivitieshavebeenimplemented.However,inmanythereisstillthethreatofincreasingcariesrelatedtochangingdietandlifestyles.CommonoraldiseaseindevelopingcountriesTheburdenofdemandfortreatmentonlyofseverecariesorperiodontaldiseasecanbe"estimated".Inaboutonethirdofthesepopulations,about1350millionpeoplewillrequirepainrelieftreatment(extractions)3timesintheirlives.Abouttwo-thirdsor2400millionpeoplewillneed5ormoreextractions.Howeverinmanycommunitiesthesesystemsdonotmeeteventhebasicneedsofthepublic.Mostpublicserviceshaveonlyverylowcoverage;communitiesinlow-incomeruralandurbanareascannotaffordprivateoralcare.Further,developingcountriescannotaffordtoestablish,staffandruneducationfacilitiesfordentists;orhopetoprovideadequateemploymentopportunitiesfordentiststrainedabroad.Inallcountrieseconomicrestraints,changesindemandfororalhealthcare,politicalpressurestoextendservicestounder-privilegedgroups,concernaboutquality,costsandeffectivenessofcaredemandthatalternativewaysoforganizingoralhealthandcareareexaminedandimplemented.Costandlackofaccessforunder-privilegedandlow-incomegroupsconstrainalloralhealthcaresystems.Whatactionscanbetakentocombatthisneglect,breakdownthebarriersofcostandimproveaccesstooralhealthandcare?Alternativeoralcaresystemsneedtobedevelopedmthatamaximumnumberofpeoplecanhaveaccesstoandcanaffordoralhealthandcare.Severalrecentadvancesgivegreatscopeforthetransformationofthedeliveryandqualityoforalcare.Theseare:Neweducationaltechnologiesthatmakelearning-bothknowledgeandskills-simplerandfasterforalltypesofpersonnel;Simplifiedandlogicaldesignoforalclinicsthatimprovetheworkplaceandsubstantiallyreducecapitalcostsofequipmentandneedformaintenance;Bettermaterialsthatareeasierandsimplertouse.Usingthesetechnologicaladvances3typesofcarecanbedefined:Rathersimple,verycosteffective,Moderateleveltechnologythatisratherexpensive,andHightechnology,oftenextremelyexpensive..Arational,healthpromotingandaffordablemixofcaremustbeplannedandimplementedinallcountries.Firstlevelcareincludes:Prophylaxis,removalofcalculus,applicationofsealant,restorationofsinglesurfacecariescavitiesAsaconsequenceofimprovingoralhealthinmostindustrializedcountriestheneedformoderatelycomplexcareisdecreasing.Withfurtheremphasisonprevention,needanddemandforfirstlevelinterventionswillincreaseslightly;whiletheneedforhightechnologycarewillprobablyincreaseforseveraldecadesduetothedesiretopreservenaturalteethandtheincreasingnumbersofelderlypeople,whohavesomenaturalteeth.Firstlevel,mainlynon-interventivecarewillcontinuetobethemajorneedinmostdevelopingcountries.Thistypeofcarecannowbeprovidebyspeciallytrainedhealthcenterpersonnel,ratherthanbythetraditionaldentistorauxiliaryworker.Inthosedevelopingcountrieswherecariesisincreasing,arisingdemandformoderatetechnologycarewillcontinueoverthenextfewdecades.Arathersmallneedforhightechnologycare–mainlyrelatedtorepairoftraumaandreconstructionafterseverepathology–willremainandwilleventuallyincrease.Moderatelycomplexcareincludesmultiplesurfacerestorations,removalprosthesesandextractions.Complexoralcareincludesprecisionprosthetics,implantsorthodontics,complexsurgeryandoralmedicine.Inallcountriespreventionandcontrolcarecanminimizetheneedforintervention.Inanysociety,hightechnologycanonlybeaffordedinlimitedamounts.Itmustbeofgoodqualityandappropriate.AlternativesystemsinindustrializedcountriesIncreasingaccesstobasicoralcareFirstlevel,mainlynon-invasiveinterventionshavebeenpreparedandarebeingtestedaspartoftheworkofcommunityhealthclinicsforminoritygroupsandlow-incomeinnercityandruralcommunities.Theelderlyandgroupswithspecialneedswouldalsobenefitfromout-reachactivitiesfromsuchclinicswhichwouldprovidehealtheducationandpromotioncoordinatedwithhealth-checkprogrammesbymultidisciplinarypersonnel.Aseffective,simpleandacceptablecarereducesthereferralneedsforthemoderateandhightechnologytypeofcare,oralcarecostscouldbereducedbythisapproachtoalevelthatcanbesustainedbymostcommunities.Somelocationsareexperimentingwithdifferentrelationshipsbetweenoralcareprofessionals,e.g.hygienistsworkingindependentlyinoffices,inpatient'shomesandininstitutions.Greateraccessisthemainaimofsuchoutreachactivities.FinancingoralcareSomeofthedifferentapproachesbeingusedtofinanceoralcarearequalitycontrolguidelines,fixedfeeagreements,capitationschemes,healthmaintenanceorganizations,andrewardingincreasedpreventivecare.Usinginformationaboutthedurationofacceptablecareprocedures,qualitycontrolguidelinesarebeingpreparedthatindicatetheaveragenumberofyearseachtypeofcareshouldlast.Ifacareproceduredoesnotlastthespecifiedtime,theclinicianisthenobligedtogiveretreatmentfreeofcharge.Suchguidelinesareaimedatreducingunnecessarytreatment,whichcausesprogressivedestructionoftoothsubstanceandhighercostsoforalcare.Insomecountries,formostprocedures,dentistscanonlychargefixedfeesthatareagreedbetweenthehealthauthoritiesandtheprofessionals.Theycanonlyexceedthosefeesforspecialtreatmentandafterareviewofthediagnosisandproposedprocedure.Incountriesusingthissystemcostsoforalcarearenotrisingandinsometheyaredecreasing.Capitationschemespaythedentistafixedsumforeachpersonenrolledasapatientintheirdentalclinic.Forthisfixedannualfeeadentistcontractstomaintaintheoralhealthoftheenrolledpatients.However,patientsmustundertaketoattendforcheckupsonaregularbasis,ortheylosetheirrightsandhavetopayforthetreatmenttheyneedtorestoretheiroralhealth.Itseemslikelythatthistypeofprogrammewillreducecosts.Healthmaintenanceorganizations(HMO)contractwithagroupoforalcareprofessionalstoprovidecaretoagroupofcommunitiesorindividuals,atagreedfees.HMOsareusuallyorganizedandmanagedbycompaniesthatspecializeinhealthinsurance.Thishasprovedaneffectivewaytolimitthecostsofprovidingcomprehensiveoralcare.Inonecountryaprojecttoencouragepreventivecaregivesdentalcaremanagersafinancialrewardifdiseaselevelsdonotincreaseinthepatientsintheircatchmentarea.AlternativeapproachesindevelopingcountriesWhereasthevarioussystemsbeingtriedinindustrializedcountriescanbeofuniversalrelevance,thedevelopingcountrieshavespecialproblemsinactuallyprovidingcare.Althoughmostcareneededisofthefirstlevel,minimallyinvasivetype–dentistsusuallyprovidealltypesofcare.Themostcommonmoderatelevelcaregivenisextractionandfrequentlydentistsresistthetraininganduseofothertypesofpersonnelforthisandevenlessinvasivetasks.Therearealsosituationswhereteethwithratherminorcariesproblemsareextractedbecausethatistheonlytreatmentavailable,duetolackofsupplyoffillingmaterials.Inruralareasitisclearthat,becauseoflackoforalcarepersonnelofanytype,mostcariousorinfectedteetharenottreatedintime.Ratherthediseaseprogresses,causingintermittentpainthatisenduredbythesuffererandmanagedbyavoidinguseoftheaffectedareaofthemouth.Onlywhenextremepainorsevereinfectiondevelopsisanattemptmadetofindtreatment.Thisisoftenprovidedbyageneralhealthworkeroratraditionalhealerinprivatepractice.Thistreatmentmaybeextremelycostlywhencountedintermsoflossofearnings,productionlost,travelcostsandfeesthatmaybeashighasthosechargedbydentists.Delayingtreatmentuntilthereissevereinfectioncausesahighrateofdebilitatingandevenlifethreateningconditionsinsuchcommunities.TheapproachthatseemslikelytoprovideaneffectivealternativesolutioniscalledAtraumaticRestorativeTechnique(ART)combinedwithcommunityparticipationinlocaloralcareorganization.ARThasthepotentialtorevolutionizethetypeofcarethatcanbegiveninthecommunity.Itisbasedonusingdentalhandinstrumentsandglassionomer,aratherrecentlydevelopeddentalfillingmaterial.Thetechniquedoesnotneedelectricityorcleanpipedwaterasdotraditionaldentaldrillsandequipment.Asglassionomersticksverywelltotoothtissues,thecariousteethdonotneedtobecutandshapedwithadentaldrillasisneededwhenamalgamisused.Thismeansthatsmallcariescavitiescanbetreatedusinghandinstrumentstoscrapeoutandremovethediseasedpartsofteeth,andthencavitiescanbefilledwithglassionomerwhichisalsocapableofhavingapreventiveeffect.Forthisapproachtobesuccessful,itneedstobepartofacommunityorganizationthatprovidesbothpreventionanddiseasecontrolcare.Membersofthecommunityneedtofeelresponsibleforthegoodfunctioningandsuccessoftheservice.Otherwise,peoplewillcontinuetodemandcareonlywhentheyhavepainandbythattimethecarieslesionswillbetoolargetobeadequatelytreatedwiththistechnique.Theaimistoavoidhavingtousemoretraditionaltypesofcare,whichareinvasiveandtoocostly.CommunityparticipationAlternativeoralcaresystemsbasedoncollaborationwithandparticipationofmembersofthecommunityhavethepotentialtochangethewayoralhealthandcareservicesfunction.Thecommunitycanparticipatethrough:■Involvingpeopleinpreventionandpromoting"selfcare”.Whenpeoplerealizethattoothacheisnotaninevitablepartoflife,theresponsibilityforactivereductionoftheneedformoderatelevelinterventivetreatmentactsasacatalystforchange;■Organizingregularcommunitycampaignstoexaminepeople'smouthstoidentifyearlylesionswhilestillsmallenoughtotreatwithART;■Participatingindecisionmakingaboutneedsandprioritiesfororalcare;■Trainingmembersofthecommunityofprovidelowlevelcare;■Useoflocallyconstructedequipment;■Devisingandmanagingthefinancingarrangementsfororalcare.Associatedwiththisandotherapproachesaretrainingsystemswhichfocusonoptimalergonometricprinciples.Asetofmanualsforlearningtheseproceduresandasetofwelldesigned,lowcostequipmentforbothlearningandcareisavailablefromWHOandUNICEF.ItisimportanttorealizethattheuseofapproachessuchasARTandthenewtypeofequipmentandtrainingtechnologyarenotbeingpromotedonlyfordevelopingcountries.TheARTmethodologyhaspotentialforqualitycareatanylevelofdevelopmentorsociety.TheergonometricapproachtodeliverservicesnomatterwhichsystemisusedwaspioneeredinJapanbasedonperformancelogic.Ithasnowbeenusedandadaptedovermanyyearsinseveraldentalschools,notablyinSanFranciscoandMaryland,USA,Otago,NewZealandandVancouver,Canada.Therereallyisagreatpotentialtoextendhealthpromotingoralcaretolargernumbersofunder-servedcommunitiesaroundtheworld.VOCABULARYl.oralhealthfora