Advancing Universal Oral Health Coverage via Person-Centred Outcomes

Introduction

In 2021, the World Health Organization (WHO) proposed a comprehensive “Global Strategy on Oral Health,” epitomising a milestone to achieving universal oral health coverage (UHC) by 2030.¹ The report highlights challenges and barriers to achieving UHC, particularly when persistent inequalities strongly influence the burden of oral disease and access to oral health care.² The bold proposal requires more than the cliché of placing oral health on the global health agenda. It implies an analysis of the countries’ needs, including training of oral health professionals in line with the philosophy and optimisation of existing resources. The oral health of many people has been neglected, especially in low- and middle-income countries, thus leading to a drain on resources and increasing inequalities. In high-income countries, conversely, available resources are rarely allocated according to the needs of those populations; some people receive too much dental care, whilst others—particularly those with higher needs—receive too little.

Alternatives to improve the efficient and equitable use of the available resources are paramount in operationalising the proposal. However, dental professionals tend to perpetuate the “dentist-centred approach” by focusing mainly on their clinical experience, values, perspectives, and clinical findings (“normative” assessment) at the expense of neglecting the perceptions of the people they should be looking after. Deviation from the “person-centred approach” (subjective/“sociodental” assessment) has occasioned individual and societal problems, including but not limited to under-/overdiagnosis and under-/overtreatment, resulting in health and financial hazards.³

Patient-reported outcomes (PROs) and patient-reported outcome measures (PROMs), such as self-rated and -reported health, reflect an individual's overall perception of health and are designed to mediate human biology (ie, the disease) and psychology and thus provide valuable information for the person-centred approach.⁴ Whilst PROs and PROMs have been used in several medical fields, dentistry has lagged far behind, and most attempts to use self-perceived oral health have been made to replace clinical diagnoses and not for screening purposes, for example. Undoubtedly, accurate disease detection and monitoring are essential to adequately control its burden and impact on public health; however, dentists must be aware that perceived health has value on its own, independent of the “objective” health status. Even though PROs have been receiving more attention lately, little, if any, progress has been made in the use of such information except for research.5, 6, 7

Given the conflict amongst the need (and desire) for UHC, the available resources, and the current oral health framework based on “normative” assessments, we discuss and advocate for the use of self-perceived oral health indicators from a clinical and public health perspective to advance universal delivery of effective dental care.

Dental patient-reported outcomes (dPROs) and measures (dPROMs)

Although objective and subjective measures appear to be divergent, they are “symbiotic” components of health care. Whilst the objective assessment is performed by the dental professional (eg, clinical examination), the subjective evaluation is captured by dPROs. A dPRO is formally defined as “any report of the status of a patient's oral health condition that comes directly from the patient, without interpretation of the patient's response by a clinician or anyone else.”⁷ Importantly, dPROs are constructs that cannot be inferred directly from measured and observable characteristics. The instruments, developed over the last 40 years and today commonly referred to as dPROMs, capture the individuals’ perceptions with questionnaires/questions that assess the various dimensions on which oral conditions affect quality of life or how the individuals evaluate or perceive their oral health.7, 8, 9, 10, 11, 12, 13

The use of dPROMs has several advantages from clinical and population perspectives. Foremost, it measures factors that are relevant from an individual's perspective. The impact of tooth loss depends on many factors, such as tooth location and function and individual preferences and values. Therefore, using dPROMs may also advance patient participation in clinical decision-making. dPROMs outperform clinical examination reliability, in addition to being less demanding as they do not require training or calibration prior to use.⁸ Finally, dPROMs are often flexible in their use, and the mode of administration does not significantly affect the instrument scores. Thus, they can be performed using a self-administered questionnaire in the waiting room, by text messages before and/or after visits, or as a telephone interview in epidemiologic studies.

For some conditions, such as temporomandibular disorders (TMD), using dPROs in clinical practice is a prerequisite for adequate management, not an additional tool,¹⁴ as pain is a highly subjective experience. However, this has not been the case for long. In 1992, the revised TMD diagnostic criteria included a psychosocial axis and thus aimed to provide a shift from clinician-based outcomes to dPROs.¹⁴ However, as Manfredini et al¹⁵ put it, such diagnostic approaches and their implications for treatment modalities are “hard to be accepted by the general dental practitioners, who had been accustomed for years to provide occlusally based treatments to their patients with TMD and are reluctant to accept any paradigmatic shifts in their daily practice.” After 30 years, improvements in the measurement and use of dPROs in the screening, diagnosis, and care of TMD are needed.⁹ Fortunately, dPROs are receiving more attention in other dental specialties, but they are far from widespread clinical or population health applications.^16,17

Caution must be exercised, however, in the interpretation of dPROs and dPROMs.¹⁸ First, most dPROMs were developed, applied, and validated using the general population or clinical patient samples, thus, by default, excluding marginalised groups with the heaviest oral disease burden.¹⁹ On that note, it is paramount to be attentive to the inequalities within inequalities, especially amongst those with disabilities. On the other hand, clinical measures currently in use may also lack clinical significance if built without solid evidence to support specific thresholds for disease definition.^20,21 dPROs and dPROMs are closely related to social, cultural, economic, and environmental factors, which should be considered when interpreting or extrapolating results from individuals to populations. If we do not account for oral disparities, we risk perpetuating them by masking the actual impact of oral diseases amongst the more disadvantaged groups in society.²²

Moreover, dPROS and dPROMS provide a narrow understanding of oral health, as they mainly consider the negative aspects of oral health.¹¹ Whilst the presence of oral diseases and disabilities are essential aspects to account for, a shift towards a broader understanding of health comprising oral health and ability becomes necessary. Some dPROMS, including self-rated health and oral health, which will be discussed in this manuscript, are able to consider positive aspects of oral health as well.²³ However, individuals must be able to value elements other than those accounted for in the prevailing normative biomedical model. This requires support and encouragement from dental professionals who should be able to move away from the "normative" model and have an appreciative attitude towards the positive aspects of oral health.²³

The added value for clinical care and public health

Hitherto, we have discussed the relevance of self-rated and -reported oral health information in addition to the need to adopt the concepts of a person-centred approach and the use of dPROs and dPROMs. Given the increasing burden of oral diseases, especially periodontitis, the shortage of trained personnel, the delivery of unnecessary treatment, and the ambitious proposal for UHC by 2030, it remains unclear why self-rated and -reported information is underutilised in dentistry. These measures should not be seen as a replacement for measures of physical illness or objective health measures,⁴³ but as potentially time-saving and cost-effective approaches in screening strategies to identify potential relevant and impactful disease cases to the individual.

Many medical settings implemented self-reported strategies with comparable or even superior results to traditional strategies.^44,45 In a paediatric hospital in Boston, self-reported information about an individual's current illness was more sensitive than physician diagnostic coding in correctly identifying several illnesses, including fever and respiratory, gastrointestinal, and dermatologic problems.⁴⁴ The authors claim that patient involvement in the disease definition process is an effective method for improving accuracy and augmenting capabilities for accurate disease surveillance. Similarly, in a prospective study using US military medical records,⁴⁵ self-reported conditions were consistent with diagnoses but more accurate in indicating the absence than the presence of certain conditions. Real-world application of oral health measures in clinical practice as well as public health programs remains scarce, and their application is mainly restricted to trials or cohorts. Learning from medical cases, one can advocate that self-rated and -reported health should be used as valuable tools for screening purposes to properly identify individuals who need oral health care.

Ideally, “normative” and “sociodental” approaches should reflect each other. Disease definitions should represent individual and societal values and the public health impacts of disease, so there should not be a large gap between “normatively” and “sociodentally” determined needs.^20,46 In this sense, at least some “normative” criteria of oral health needs would likely require revision to be more aligned with their individual and public health impact, as it is uncertain how they would contribute to providing evidence-based and equitable dental care for individuals and populations (Table 1). For example, using the most recent periodontitis classification, Norwegian studies have shown an almost ubiquitous prevalence of periodontitis amongst older adults.^47,48 Whenever a disease reaches such high prevalence, one shall speculate whether the classification accurately distinguishes between health and disease and whether the condition is a disease or, for instance, a natural consequence of ageing.²¹ These disease definitions may undermine the provision of sustainable, efficient, or equitable dental care in clinical and public settings Table 1).

Whether we treat our patients according to clinical (“normative”) or subjective (“sociodental”) parameters likely has a massive impact on costs, the practice dental model, public health programs, and workforce planning. Incorporating the population needs (objective and subjective) is fundamental to ensuring sustainable oral health care. Estimating workforce requirements is challenging and multifactorial (political, economic, and social values).⁵⁰ However, it seems that a “sociodental” mixed-skill approach in determining the population needs would require fewer dentists than “normative” strategies.^3,51 Likewise, the “normative” approach to treatment needs and the traditional way of practicing dentistry are associated with such high costs that UHC remains unaffordable (Table 2).⁵² In countries already spending resources on such systems, we expect that under the “sociodental” paradigm, these resources would be reallocated to individuals with higher oral health needs or at a higher risk. Evidently, a new approach to serving currently underserved people would require considerable effort and resources, which may originate from a decrease in overdiagnosis and -treatment.

Greater patient involvement in clinical practice, guidelines, and defining oral health needs for individuals and societies could serve as strategic decisions regarding the prioritisation of interventions consistent with the monetary expenditures, thereby reducing the risk of over- or underdiagnosis and -treatment. Using self-reported information could help identify cost-effective public policies, such as food labelling or tobacco control, at the population level. Unfortunately, little is known about how widely used normative clinical measures and definitions are associated with dPROs; for instance, evidence on whether more severe periodontitis is associated with worse dPROs is lacking.⁵⁵ Dental curricula should support minimally invasive dentistry, patient participation, and evidence-based practices. Evaluation and measurement of the health impact of dental care (including the effects on dPROs) should be part of every oral health system. However, first, the idea of using dPROs should be bought into by stakeholders, which would then develop or identify measurement tools and finally implement them at all levels (practice, research, and population health surveillance).^5,55

Current oral health care systems fail to improve the population's oral health and reduce oral health inequalities. Despite researchers’ efforts to operationalise a standard set of patient-centred outcomes for adult oral health,⁵⁶ implementation of the "sociodental" approach will only be possible with a paradigm shift supported by all stakeholders. Hence, dentistry should shift from its “normative” paradigm to a “sociodental” approach, not only by incorporating the individual's perceptions but also by replacing the dentist with the patient when it comes to the centre of care. Double standards should not be applied to implement the "normative" and "sociodental" approaches. Barriers must be addressed by governments, dental schools, research institutions, and professionals. Such a shift may impact the number of professionals and working hours needed, including, but not restricted to, increased capacity to provide better care, efficient public health programs, faster system responses to patient needs, and maximising the skills and competencies of the dental team. Therefore, it seems to be a way forward to implement the WHO plan, to actually improve oral health, reduce inequalities, and transfer the control of people's lives and health to the people.

CRediT authorship contribution statement

Gustavo G. Nascimento: Conceptualization, Investigation, Writing – original draft, Funding acquisition. Eero Raittio: Conceptualization, Investigation, Writing – review & editing. Vanessa Machado: Conceptualization, Investigation, Writing – review & editing. Fábio R.M. Leite: Investigation, Writing – review & editing. João Botelho: Conceptualization, Investigation, Writing – review & editing.