[Ethical decision making in dental care for frail older people]. / Ethische kwesties in de mondzorg voor kwetsbare ouderen.

Vurnerable older people often need intensive preventive and curative oral health care. However, their physical and cognitive decline does not always allow for lege artis implementation of dental treatments. This causes practical problems often with related moral issues. Including these moral issues in planning and implementation will make oral healthcare more effective and will also alleviate moral pressure on oral healthcare providers. Mostly the moral issues relate to every day ethics, which can be solved by all persons involved collectively, in open consultation and with an ethics of care approach. This means aiming at 'doing the right thing in the right way', including all the relevant aspects of the person of the patient and his/her environment. To achieve this, oral health care should be embedded in the overall care process for the elderly and care providers should feel involved with the older person and have reflective skills.

[Dissertations 25 years after date 24. Barriers to effective periodontal care]. / Proefschriften 25 jaar na dato 24. Belemmeringen bij effectieve parodontale behandeling.

In the thesis 'Barriers to effective periodontal care, published in 1984, an investigation was described on professional periodontal care lagging behind the development of periodontology. The objectives of the investigation were to assess whether dentists were treating periodontal disease as a behavioural problem using effective communication techniques, and whether serious periodontal disease had such low frequency that dentists had not the opportunity to become experienced in recognizing the disease. It was concluded that serious periodontal disease had a low frequency and was not influenced by communication on periodontal care. After 25 years, these conclusions are still valid: the percentage of risk patients is still 5-10% and the correlation between seriousness of periodontal disease and periodontal care provided is still limited. Not all dentists do have affinity to periodontal care, but they do have affinity to practical aspects, such as removing dental calculus deposits. A classification of obvious recognizable diseases and treatments would make periodontal care more manageable for dentists.

[Discussing and evaluating professional behaviour. 1. Academic Centre for Oral Health Groningen]. / Bespreken en beoordelen van professioneel gedrag. 1. Centrum voor Tandheelkunde en Mondzorgkunde Groningen.

Professionalism is considered as a core competency for dentists. As a result of changes in the healthcare sector, it is becoming increasingly important for dentists to be more transparent to the community in their delivery of care. The ability'to provide justification' thus becomes an important skill. To train dentists to become professionals who can account for their actions, we developed an educational programme in Groningen which trains students in the following professional skills: 1. make explicit; 2. concretize; 3. analyze; 4. diagnose; 5. generalize; and 6. formulate learning points and experiment with them. This educational programme is given, under the supervision of a coach (generally a practicing dentist), during the entire curriculum, in small groups. Professionalism is integrated with other course programmes (work placement, working in the clinic), because professionalism is a competency which is only expressed by practicing other competencies. The professionalism of the student is also assessed.

[Specialties in dentistry. 4. Post-academic specialization in geriatric dentistry]. / Beroepsdifferentiatie in de tandheelkunde. 4. De differentiatieopleiding tot tandarts-geriatrie.

In recent years, a specialization in geriatric dentistry has been established and along with it an educational programme. A specialist in geriatric dentistry is a dentist general practitioner with special knowledge and skills for delivering oral care to frail elderly people. The educational programme aims at an increase in dentists serving in geriatric care who are well prepared for delivering care. In the programme attention is paid to the special aspects of care delivery and the special somatic, mental, and social characteristics of frail elderly people. The goal is to formulate an individual oral care programme for every frail elderly person. An individual oral care programme may contain 5 different oral care activities: continuing care, prevention, support, treatments, and evaluation. These activities define the scope of specialists in geriatric dentistry. This scope in turn defines the profile of required knowledge and skills, and the profile is the foundation of the educational objectives of the educational programme. The educational programme contains 7 modules: affinity; somatic and mental disabilities; communicative skills and coping with behavioural disturbances; emergency medical care; history taking, assessment, prevention, treatments and evaluation; organization and legislation; scientific training.

[Blueprint 2000 Education of dentists in the Netherlands. Objectives of undergraduate dental education. A summary]. / Raamplan 2000 Tandartsopleiding Eindtermen van de tandartsopleiding. Een overzicht.

Blueprint 2000 Education of dentists in the Netherlands includes nationally developed objectives for the dentist at graduation. The changing state of oral health of the population and oral health care require a dentist trained in a broad range of dental subjects. Intellectual and scientific training should be an important aspect of undergraduate education. Developments in teaching methods support these requirements. The differences in the implementation of educational developments in the three Dutch dental schools made a uniform description of objectives not yet possible. The actual objectives therefore are presented in four different ways: (1) the profile of the dentist in broad terms, (2) general objectives by way of competencies, (3) discipline-based objectives and (4) a list of problems. These problems are derived from every day practice and can serve as starting point in the learning process of the student. It is expected, that Blueprint 2000 Education of dentists in the Netherlands will be used as a basis for curriculum development. What type of objectives, or combinations, will be used will be seen in the future.

[Oral health care for the elderly. More than care for the mouth only]. / Mondzorg voor ouderen. Meer dan zorg voor de mond alleen.

Dental treatment is changing to oral health care, integrating curative treatment and care. This development is based on the present state of oral health of elderly people. In the future, elderly persons are expected to receive adequate oral health care. This requires gerodontic knowledge and skills, as most oral health problems of elderly persons are chronical and related to ageing processes. For about 25% of elderly people substantially adapted oral health care is needed. This geriatric oral health care can be best provided in collaboration between dentists, dental hygienists and other careproviders. This procedure is already common practice in the care for the chronically ill. Then oral health care will become more than care for oral health.

Perception and significance of dental appearance: the case of missing teeth.

The perception and significance of dental appearance was investigated in three groups of patients. One group had a missing front tooth replaced by partial dentures, which were taken out during the tests. A second group had some missing (pre-)molars. A third group had a complete natural dentition and they acted as control group. Color photographs of the teeth were made and a clinical examination was carried out. The psychological impact of dental appearance was measured by way of a scale of words with affective connotations. Social impact was assessed by way of changes in daily activities. Dentists and lay-persons were asked to give an opinion of the dental appearance on the basis of the pictures. It was found that a missing front tooth resulted in less positive feelings and more negative feelings and also that this condition affected daily life activities strongly. Missing (pre-)molars caused less of an aesthetic problem. Dentists and lay-persons were quite alike in their appreciation of dental appearance, whereas the respondents themselves had different opinions. An explanation for these differences and their implications for dentists are discussed.

Dental hygienists' influence on the patients' knowledge, motivation, self-care, and perception of change.

The purpose of this study was to assess the success of the dental hygienist in the dental health education of dental patients in general dental practice. Special emphasis was laid on health education in the field of periodontics. The answers on a questionnaire of 159 dental patients who visited a dental hygienist were compared with the answers of 302 dental patients who had never visited a dental hygienist. The comparison was done by means of t-test and regression analysis on specially developed scales with regard to knowledge, motivation, self-care, and perception of change. On all scales the dental patients who visited a dental hygienist scored better. This difference remained when social demographic variables and the dentist's influence were taken into account. This indicates that the dental hygienist is successful in the behavioral aspect of her work.

Attitudes of two groups of dentists towards dental hygienists.

The purpose of the study was to assess whether cooperation with a dental hygienist was based on pursuit of financial gain or on aspirations to improve patient care. To this end a questionnaire was sent to 972 dentists. 412 dentists replied, of whom 178 had patients treated by a dental hygienist. Questions were asked regarding practice profile, preventive orientation and dentists' opinion about the material and immaterial value of cooperation with a dental hygienist. Discriminant analysis showed that the main distinguishing factor between dentists who did and dentists who did not cooperate with dental hygienists was their opinion about the quality of the dental hygienists' work in relation to the non-financial costs for patients, insurance companies, and dentists. The difference in the dentists' opinions about the direct profitability of dental hygienists was not significant. The conclusion can be drawn that the orientation of Dutch dentists towards care for their patients plays a more important role in a dentist's decision to cooperate with a dental hygienist than is usually presumed.

Significance of dental problems to the public and their comparability with general health problems.

A group of 109 subjects received a short questionnaire concerning their general health status. The subjects were invited to recall all the (health) problems experienced in the foregoing 6 months. Every participant in this study had visited the dentist, in the 6 months preceding the investigation, because of a dental problem. If these dental problems were important for the respondents they would recall them spontaneously, when a general question regarding health problems was posed. Only eight subjects mentioned dental problems spontaneously, of which seven concerned "pain-complaints". Only in two cases had the dental complaints been experienced more than 3 months ago. Eighteen respondents said that they could not remember the dental visit or their specific dental problem. Thirteen of these 18 persons visited their dentist because of an aesthetic problem. The results indicate that the impact of (some) dental problems on a person's feeling of being healthy was small. On the other hand, this study shows that the comparability of (most) dental problems and general health problems is limited. A typology of the significance of dental problems for the public and comparability with the concept of general health is presented and discussed in this study.

Social and psychologic implications of missing teeth for chewing ability.

The impact of loss of teeth on chewing ability was investigated in three groups of patients. One group already had missing teeth replaced by partial dentures, which were taken out during the tests. This group was taken as not being adapted to chew without a complete dentition. A second group had their missing teeth not replaced by partial dentures. During the test they were considered adapted to chew without a complete dentition. A third group had a complete natural dentition and they acted as control group. Tests were carried out regarding chewing ability and swallowing threshold. In addition, a clinical examination was carried out. It was found that the loss of molars significantly reduced chewing performance. Moreover the number of chewing-strokes before swallowing the food-bolus and the mean of the particle size at the point of swallowing were increased. Loss of molars resulted in less positive feelings concerning chewing. Both groups of persons with missing molars showed a similar chewing performance. The group of not adapted patients felt on average more negative about their chewing ability and they indicated more changes in daily activities because of missing teeth.

Spontaneous recall as an indicator of the impact of dental complaints.

A hypothesis was developed that the impact or importance of oral health problems may be reflected in a person's ability to remember these problems occurring in a given period spontaneously. That means that the recollection should occur on a nonspecific stimulant, i.e. a general question regarding recall of health problems. This hypothesis was first tested on existing data. A representative sample (n = 1622) of the Dutch population was asked to list all the health problems they had experienced the preceding year. Only 13 persons mentioned an oral health problem. From more specific questions on dental matters it appeared that about 15% of the sample had experienced oral health problems in this period. One hundred and forty-six respondents indeed had received dental care because of acute pain. These data indicate that the impact of oral health problems on a person's daily life is small. Otherwise the oral health problem would have been mentioned spontaneously more often. Three possible explanations for this phenomenon are discussed.

Pathways to full mouth extraction.

The process of not attending the dentist is a vicious cycle in which anxiety plays a crucial role. A research project concerning the disease and non-disease reasons for full mouth extraction provided an opportunity to describe the dental histories in terms of dental attendance pattern and related factors which resulted in full dentures. Three profiles of dental histories could be outlined: 1) The regular attenders (19%). Because of their age (means = 47 yr), their positive attitude towards dentistry together with their positive attitude towards full dentures, it is suggested that the possibilities of keeping the natural dentition were exhausted so that full mouth extraction was an acceptable solution. 2) The symptomatic attenders (38%). Because anxiety, which was widespread in this group, was not based on negative experiences, it is suggested that anxiety is caused by social learning. Together with their positive attitude towards full dentures, the high prevalence of full dentures in their social environment and their low socioeconomic status, the conclusion is drawn that these patients lived in a culture which supports behavior that leads to total tooth loss. 3) Once regular attenders (43%). In this group anxiety leads to a negative perception of dental visits and to a negative attitude towards dentists. As a consequence dental visits are deferred, which results in deterioration of the dentition. Experiences with dentists are distorted in a negative way, which increases dental anxiety. Facilitated by a positive attitude towards full dentures, their bad dental condition finally urges them to take full dentures at early age.

Decision processes preceding full mouth extractions.

Full mouth extraction is the final step in a continuous process in which not only dental but also social processes play a role. In a research project concerning the reasons for full mouth extractions in The Netherlands, it was found that over one-third of the patients had considered full mouth extractions at least once before, and 16% considered it frequently over a period of many years. Anxiety was the most important reason for not visiting a dentist. In the patients' view in 86% of the cases they were the initiator of the decision to have all their teeth extracted. According to the dentist the patients initiated full mouth extraction in 70% of the cases. Dentists and patients agreed that irregular attenders more often took the initiative than regular attenders. Most patients (87%) had discussed the decision to have all teeth extracted with one or more persons; different contacts were reported by 14% percent of the patients. According to Freidson's lay referral theory two groups could be identified: a group with a severely truncated lay referral structure and a group characterized by a more extended lay referral structure. The first group was older (46 versus 36 yr) and had a more positive attitude towards full dentures. In order to avoid problems dentists are recommended to involve (a representative of) the patient's social network when important decisions have to be taken.

Dentists' and patients' opinions of the dental condition at moment of full clearance.

Reasons for full mouth extraction in an urban and a rural area in The Netherlands (dentist-patient ratio 1:2500 and 1:5700 respectively) have been studied. Patients who participated in this combined sociodental research project were those who received full mouth extractions over a period of 1 yr. The combined patient response was 75% and the overall dentist response 90%. In the urban and the rural areas respectively 137 and 237 cases of full mouth extraction were recorded. When comparing the dentists' diagnoses with the conditions of the dentitions there appeared to be a fair degree of agreement in most of the cases, although some striking deviations were also found. In the relationship between the patient's opinion and the condition of the dentition some unexplained discrepancies were found: 37% of the dentitions in which the teeth and attachment were in a healthy condition were perceived as bad by the patients. Dentists and patients agreed in their perceptions of the dental conditions in 60% of the cases. In 27% there was a strong disagreement. In most of the discrepancies found plausible explanations could be given. In some cases this was not possible. As this involves a substantial minority of cases, dentists should be aware of reasons other than the clinical condition in the disabling treatment of full clearance.

Relative importance of periodontal disease for full mouth extractions in the Netherlands.

In order to determine the relative importance of periodontal disease, caries and non-disease reasons for full mouth extractions, a combined sociodental study was carried out in an urban and a rural area in the Netherlands. In the largest proportion of patients (57%) caries was the predominant disease. In only a small group (13%) was periodontal breakdown the predominant characteristic. In 16% of the patients non-disease factors possibly played a role because in this group no generalized periodontal disease or caries was found. It was concluded that in urban and rural areas and in all age groups caries and not periodontal disease was the most important reason for full mouth extractions. Non-disease factors may play a role in the decision to carry out full mouth extractions. Patients living in areas with different dentist-population ratios have a comparable caries status and periodontal condition at the time of full mouth extractions.

Caries status at the moment of total tooth extraction in a rural and an urban area in the Netherlands.

Edentulousness varies with the availability and accessibility of dental care. Comparing the dental status of groups of patients getting full dentures might give insight into the effect of different levels of supply of dental care on the dental condition. Therefore a research project has been started in the Netherlands in an urban and a rural area, having dentist-patient ratios of 1:2,500 and 1:5,700 respectively. In the urban and rural area an equal proportion had partial dentures prior to losing the last of their teeth. However, in the urban area 33% of the patients wearing partial dentures had full maxillary or mandibular dentures; in the rural area this figure was 73%. In the rural area a larger proportion had lost 21 or more teeth at the moment of total extraction. Therefore, it was concluded that in the urban area more effort was spent in maintaining the natural dentition. Looking at DMF-T figures and separate components of DMF-T, no differences could be established between people living in areas with a high and a low dentist-patient ratio.