Sobre la necesidad de implementación de la tutela ambiental efectiva en el derecho ambiental

Traditionally norm ative m ethod has been used to assess den tal need, as m entioned in the previous section. The following section will be a review of the m ethods currently used to estim ate dental tre atm e n t need in older people. Tables 2.1, 2.2, 2.3 sum m arises d ata from recent studies on tre a tm e n t needs estim ation. Only prosthodontic, restorative and periodontal tre a tm e n t needs were sum m arised in th is review.

Table 2.1 Summary of d a ta from recent studies on prosthetic treatment n e e d estimations in older p e o p le

Country Authors Sam ples Criteria Type of d e n ta l n e e d s Norm ative N eed Realistic N eed P erceiv ed N e e d Australia v a n W aas e t al. 1993 1144 (Inst)' professional ju d g e m e n t

(WHO, 1977)

prosthetic c o re 70% - - Slade e t al. 1993 178(lnd)2 professional ju d g e m e n t prosthetic c a r e 23.6% - -

C a n a d a Slade e t al. 1990 299 (lnd)2 professional ju d g e m e n t (Hunt e t al, 1985b)

full den tu res partial d e n tu re

46.2% 35.4%

- “

Mojon a n d M acE ntee, 1992

269 (LTC)3 professional ju d g e m e n t prosthetic c a r e 83% 36% 54% D enm ark Vigild, 1987 486 (NH)4

199 (LTC)3 professional ju d g e m e n t prosthetic c a r e 67% 71% 19% 32% - England Smith a n d Sheiham , 1980* 300 (lnd)2 professional ju d g e m e n t som e form of

tre a tm e n t

78% 5.3%** 28%

Wilson e t al. 1987* 150(RH)5 professional ju d g e m e n t g e n e ra l d e n ta l c a r e

65% 32% 11%

Diu a n d Gelbier, 1989* 293 (CCC)6 professional ju d g e m e n t g e n e ra l d e n ta l c a re

82% 76% 53%

H oad-R eddick, 1991 41 (Inst)' professional ju d g e m e n t prosthetic c o re 75.6% - 36.5% J a p a n Miyazaki e t al. 1995 1908 (Inst)' professional ju d g e m e n t

(WHO, 1977)

new full a n d /o r partial d en tu res

36% - -

Switzerland Stuck e t al. 1989 219 (GH)7 professional ju d g e m e n t (Hunt e t al, 1985b) g e n e ra l d e n ta l c a re prosthetic c o re 97.8% (d e n ta te ) 31.5% (e d e n ta te ) 34.9% (d e n ta te ) 30.0% (e d e n ta te ) 30.4% (d e n ta te ) 13.1 (e d e n ta te )

9

5 *5»

(Inst)’ = institutionalised, (lnd)2= In d ep en d en tly living, (LTC)3= long term c a re , (NH)'‘= nursing h o m e, (RH)^=residential h o m e, (CCC)6= com m unity c a r e c e n tre , (GH)^= geriatric hospital, *= g e n e ra l d e n ta l tre a tm e n t n e e d , not prosthetic n e e d only, ** ex p ressed n e e d or d e m a n d

Table 2.2 Sum m ary of d a t a from r e c e n t studies on restorative tre a tm e n t n e e d estim ations in older p e o p le

Country Autliors Sam ples Type of d e n ta l n e e d s Criteria N orm ative N eed

Realistic N eed

P erceiv ed N eed Australia v a n W aas e t al. 1993 1144 (Inst)’ so m e restorative

tre a tm e n t

professional ju d g e m e n t

(WHO, 1977)

47%

Slade e t al. 1993 178(lnd)2 so m e restorative tre a tm e n t

professional ju d g e m e n t

50.8%

C a n a d a Slade e t al. 1990 299 (lnd)2 so m e restorative tre a tm e n t

professional ju d g e m e n t

42.1%

Italy Angelillo e t al. 1990 234 (Inst)’ so m e restorative tre a tm e n t

professional ju d g e m e n t

37.2% - -

New Z ealand C au tley e t al. 1992 815(lnd)2 so m e restorative tre a tm e n t professional ju d g e m e n t (WHO, 1977) 89% 18.9% Nigeria A d e g b e m b o a n d el N ad eef, 1995 154(lnd)2 so m e restorative tre a tm e n t professional ju d g e m e n t (WHO, 1977) 19.7%

Switzerland Stuck e t al. 1989 219 (GH)3 so m e restorative tre a tm e n t professional ju d g e m e n t 58.4% - -

g

I C 5 M » P M. P 3

Table 2.3 Summary of d a ta from recent studies on periodontal treatment n e e d estimations in older p e o p le

Country Authors Samples Criteria Type of dental

needs

Normative Need Realistic

Need

Perceived Need

Australia v a n W aas e t al. 1993

S lade e t al. 1993 1144 (Inst)' 178(lnd)2 CPITN (Ainamo e t al.,1982) CPITN (1982) (Ainamo e t al.,1982) scaling co m p lex p erio d o n tal tre a tm e n t p eriodontal tre a tm e n t 56% 17% 95%

C a n a d a Leake e t al. 1990 perio d o n tal c a r e 86% - -

New Z ealand C au tley e t al. 1992 815(lnd)2 CPITN

(Ainamo e t al.,1982) simple p eriodontal tre a tm e n t co m p lex p eriodontal treatm ent* 93% 10.5% - 4.2% Nigeria A d e g b e m b o a n d el N ad eef, 1995 71 (lnd)2 CPITN (Ainamo e t al.,1982) p eriodontal tre a tm e n t 75% - -

Switzerland Stuck e t al. 1989 219 (GH)3 PI (Russell, 1956) periodontal ttierap y 91%: - -

9

% 'S I G (% 5 A % P M. P 3

C h a p te r 2 - R eview o f lite ra tu r e 42

Norm ative and perceived needs in older people

M ost of th e studies on prosthodontic tre atm e n t needs were based only on professional judgem ent. Therefore dental tre atm e n t needs were assessed norm atively. Perceived need was assessed in some studies. The differences in needs assessm ent for prosthodontic tre atm e n t in different countries are presented in Table 2.1. Prosthodontic tre a tm e n t needs for the m axilla and m andibular arch ranged from 23.5% to 83% (Vigild, 1987; Wilson et al. 1987; Stuck et al. 1989; Slade et al. 1990; Hoad-Reddick, 1991; Mojon and M acEntee, 1992; Slade et al. 1993; van W aas et al. 1993; M iyazaki et al. 1995). N orm ative need for prosthodontic tre a tm e n t is m uch larger th a n perceived need in all studies (Table 2.1).

Norm ative need for restorative tre atm e n t based on the professional judgem ent, m ainly followed the WHO criteria (Table 2.2). The restorative tre a tm e n t need w as low (19.7%) in N igerian older people (Adegbembo an d el Nadeef, 1995). In other studies, the restorative tre a tm e n t need ranged from 37.2% to 50.8% (Stuck et al. 1989; Angehllo et al. 1990; Slade et al. 1990; Cautley et al. 1992; v an W aas et al. 1993; Slade et al. 1993) (Table 2.2).

V arious m ethods have been used to estim ate tre a tm e n t needs for periodontal disease. In th e early US N ational survey (NHANES I), periodontal tre a tm e n t need was assessed using the score from Periodontal Index (Oliver et al. 1989). A system to classify the need for periodontal tre a tm e n t was first developed in 1973 by incorporated tre a tm e n t tim e and methods combined w ith disease m easures in the Periodontal T reatm ent Need System (PTNS) (Johansen et al.

C h a p te r 2 - R eview o f lite ra tu r e 43

1973). PTNS is a precursor of a more recent index, the Com m unity Periodontal Index of T reatm en t Needs (CPITN) (Ainamo et al. 1982). CPITN has been widely used worldwide despite changing concepts of th e pathogenesis and the tre a tm e n t of periodontal disease (Stuck et al. 1989; Slade et al. 1993; van W aas et al. 1993; Adegbembo and el Nadeef, 1995). The CPITN index h as been criticised as having several lim itations. The index h as been used for purposes it w as not originally designed for, and because of recen t advanced knowledge of th e disease process (Holmgren, 1994). Both PTNS and CPITN were developed w hen it was accepted th a t the n a tu ra l history of periodontal disease progressed from gingival inflam m ation to periodontitis to tooth loss (Loe et al. 1978a , Loe et al. 1978b ). T reatm ent need estim ation were based on preventing progression by controlhng the gingivitis thro u g h the rem oval of calculus. Because the life history of periodontal disease are now know n to differ from the e a rh er models, and gingivitis does not invariably progress to periodontitis. Therefore, th e need to elim inate all pockets, remove all calculus an d achieve plaque free te e th is questionable. Thus, the use of th e CPITN is not recom m ended for assessing tre a tm e n t needs of populations (Sheiham , 1991). F u rth erm o re, in term s of using CPITN for planning, Lennon (1994) com m ented th a t CPITN h as its deficiency th a t it is not easy to in te rp re t or u n d e rsta n d by decision m akers or h e alth care plan n ers.

Periodontal tre a tm e n t need assessed by CPITN ranged from 56% to 95% for simple periodontal tre a tm e n t (Table 2.3). Perceived need for periodontal tre a tm e n t w as very low. Cautley et al. (1992) found th a t only 4.2% of subjects

C h a p te r 2 - R eview o f lite ra tu r e 44

perceived th a t they needed gum tre a tm e n t while 93% were judged by clinical m easures to need periodontal treatm ent.

Perceived need is usually assessed by asking the subjects directly about th eir perception of dental problems. The term ‘perceived need’ w as defined in different ways. It could be used for subjects who could identify a problem (Mojon and M acEntee, 1992), for persons who express a need as a w ish w ithout actually being offered treatm ent, or for subjects who have com plaints regarding th e ir dental sta tu s (Wilson et al. 1987; Diu and Gelbier, 1989; Stuck et al. 1989).

Some researchers have included other aspects of h e a lth into tre a tm e n t need estim ations. They used the term ‘reahstic need’ as an attem p t to combine professionally assessed need w ith reahstic tre a tm e n t possibilities. ‘Reahstic need’ has several m eanings. In a study by Wilson et al. (1987) ‘R eahstic need’ reflected the norm ative need in the context of w hat the exam iners heheve to be of benefit to the patient. ‘Reahstic need’ considered different aspects which related to th e need of each individual, for example, h ealth an d general condition, abihty to coorporate in and u n d erstan d the reason for treatm en t, and th e p atie n t’s desire for the tre a tm e n t to be carried out. In th e ir study, the percentage of subjects who h ad a ‘realistic need’ w as about h a lf of the norm ative need.

In a review by Schou (1995), she categorised subjects who would benefit from tre a tm e n t into groups w ith ‘reahstic need’. Diu and Gelbier (1989) p resented

C h a p te r 2 - R eview o f lite r a tu r e 45

d ata on persons who m ight benefit from dental care which m ight be com parable to those w ith ‘reahstic need’ in Wilson’s study. Similarly, Mojon and M acEntee (1992) presented d ata on subjects who would seek and benefit from treatm e n t. The m agnitude of the ‘reahstic need’ in both studies w as h alf or less th a n h a lf of the norm ative need (Diu and Gelbier, 1989; Mojon and M acEntee, 1992).

E ttin g er and Beck (1984) proposed the Rational D ental Care Model w here they hsted all factors which could affect tre a tm e n t plans of individual patients. Factors needed to be considered of the p atien t were: life expectancy, m ental and m edical status, mobihty and dexterity, dental expectation and financial capability. This model was aim ed to assist clinicians to m ake thoughful decisions for the most appropriate care after w eighting all the modifying factors. This model concerned m any im portant factors. However, it w as aim ed to be used in a chnical environm ent, and not for pubhc h ealth purposes.

Some authors included finance as one factor to consider w hen assessing dental need. F enton (1994) proposed th e Elderly H ealth Index to assist decision­ m aking for removable p a rtia l dentures. This index evaluated the h ea lth of the patient, the h e a lth of dental tissues, and the h ealth of subjects’ finances. He concluded th a t the resu lts from th is index should respect the subjects’ wishes, be feasible to accomphsh, and financially manageable.

Mojon and M acEntee (1992) also proposed th a t the need for prosthodontic tre atm e n t could be considered u n d er theoretical, chnical, an d practical

C h a p te r 2 - R eview o f lite ra tu r e 46

conditions. They proposed a ‘theoretical need’ for tre atm e n t assessed solely on the q u ah ty of the dentures, a ‘clinical need’ for tre a tm e n t based on an assessm ent of the denture and the condition of the residual ridge, a ‘practical need’ for tre a tm e n t considered only in subjects who complained of a problem. The first two considerations involved only the clinical aspect of th e oral problem. A ‘practical need’ took the subject’s com plaint of th e problem into account. They found th a t alm ost h alf of the subjects w ith a ‘clinical treatm ent need’hsià no ‘practical need’îov treatm ent.

The Socio-dental approach

Norm ative tre a tm e n t need has several shortcomings in dental tre a tm e n t need estim ation. Firstly, it lacks objectivity. Norm ative tre a tm e n t need depends m ainly on the opinions of professionals which are not infallible an d could vary greatly. The two most common causes of variability among professionals are inter-exam iner and intra-exam iner variabihty. It is very difficult to get absolute agreem ent on these, even w hen previously agreed criteria are used.

Secondly, it lacks accuracy. Norm ative tre a tm e n t need assum es th a t the stan d ard s of care accepted by dentists are the norm for each person exam ined (Sheiham e t al. 1982). B ut it is difficult to set a sta n d a rd for each tre atm e n t especially for the conditions which lack clear definition such as occlusal disharm onies.

C h a p te r 2 - R eview o f lite ra tu r e 47

Thirdly, norm ative tre a tm e n t need neglects th e opinion of th e consumer. N orm ative tre a tm e n t need does not take into account th e p atien ts a ttitu d e and needs. Concepts of h ealth and disease as visuahsed by lay persons often differ considerably from th a t of professionals.

Fourthly, norm ative tre a tm e n t need could be overestim ated. It assum es the need for tre atm e n t for every im pairm ent found chnicaUy. It does not take into account the reahstic situation such as lim ited h ealth care resources an d the fact th a t the p a tie n t m ay not desire such tre atm e n t nor gain m uch benefit from it.

The m ethod of estim ating tre atm e n t need norm atively m ay not be appropriate nor accurate, since it does not consider factors such as the general h ealth of the subject, the subject’s desire for treatm ent, discomfort, perceived tre a tm e n t needs, and financial abihties which could influence tre a tm e n t decisions. Moreover, th e norm ative estim ation of tre a tm e n t needs based on the professional approach does not take into account the outcome of oral diseases an d the consequence of hm ited resources for h e alth care. M ost of these needs would possibly not be perceived by people who would not seek th e tre a tm e n t proposed. To overcome the shortcomings of norm ative tre a tm e n t need, Sheiham et al. (1982) suggested th a t an assessm ent of need should include social and psychological factors in addition to the clinical assessm ent. The individuals’ perceptions of th eir own needs as well as the propensity of the individual to tak e preventive action and the perceived need and b arriers to prevention should also he tak en into account. Table 2.4 presents th e sum m ary

C h a p te r 2 - R eview o f lite ra tu r e 48

of th e different dimensions which should be included in th e m easurem ent of d ental needs by Sheiham and Spencer (1997).

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