Politics gets into everything. Our lives are dominated by the attitudes of those in power in Whitehall. The current government, though a coalition, is fairly true to Tory governments of the past that place emphasis upon personal responsibility with the state playing less of a role in governing peoples’ lives. In contrast, Labour has often looked at those who have less as being victims, feeling that the state has a duty to try and equalise society’s inequalities.
So what does this have to do with patient education? Well it is a subject which can be viewed with perspectives that mirror the two main parties’ points of view. Patients can be either held fully responsible for their health, or their health can be seen as a result of the environment which they inhabit and are not able to control. These two different viewpoints have often been in conflict. In recent times of financial hardship the general public is less likely to accept that responsibility has less of a role in health and as welfare is stretched, the public’s tolerance of those affected by their environment is waning.
When considering the responsibility of individuals over their oral health we must ensure we do not promote victim-blaming. This must be avoided as it serves no useful purpose and is potentially dangerous.
For example let’s consider smoking. None of my friends or family smoke, therefore I am less likely to take this up; if I did I would likely receive heavy criticism from those around me. If we imagine a fictional patient who has come from a family where both parents smoke, along with friends and other family members, the avoidance and giving-up of smoking is likely to be considerably harder. This example works with oral health behaviours too; how is it reasonable to expect a patient to start brushing their teeth when they never have before and nobody else in the family does either? It’s a similar mentality to putting a patient trying to give up an addiction in a room with active users - it won’t work.
The ‘telling-off’ of patients is also risky, it can potentially alienate and demoralise patients, even if it is said in the most tactful of ways. Different people respond in different ways to the same advice. Being told “Unless you brush your teeth better you will lose them all” may result in an adoption of that behaviour, or perhaps more likely a patient complaining or finding another dentist. It is well documented that the giving of knowledge does not necessarily lead to a change in attitude and behaviour. If it did we would have a lot less work to do, no one would eat unhealthily and the tobacco corporations would be out of business.
So, having just slated what for some is the basis of oral disease prevention, what’s the answer? My view is that patient education is important still, but more as an adjunct to oral health promotion strategies. Health promotion is about empowerment for people to deal with the social determinants of health in society; making unhealthy behaviours harder to maintain through healthy legislation and public policy, working to create a healthier environment for people to exist in and reducing social prejudices and inequalities that disadvantage certain groups and minorities. Whilst not ignoring high-tech and curative medical approaches, we need to acknowledge that these are not helpful to all in society (there will be many who cannot afford these interventions or access them because they are in a certain area). A good example of this in dentistry is dental implants; I am happy to go on record saying that I don’t like them, not because they aren’t a fantastic clinical option, but because they increase the oral health inequalities of society by only being available to the affluent.
This might be well and good, but what can we do as dentists? After all, we aren’t politicians and even those who get involved in dental politics have very little influence upon the legislative framework of health promotion. This is where the current UDA contract is short-sighted - it doesn’t provide any leeway for dentists and DCPs to engage in meaningful prevention strategies outside the practice and get paid for it. It shouldn’t be about the money, but we have to be realistic about things. Tooth brushing clubs in schools have proved very effective. They are simple to set-up and maintain with regular supervision and liaising with a DCP, they reach children who might not normally be brought to the dentist. It’s all about creating supportive environments and patient education is but a small part of this. The Department of Health guidance, Delivering Better Oral Health, is useful in helping us to provide better preventive care, but I think things need to go beyond this as well. As dentists, we need to be better advocates for better oral health. We all work in communities where we can make a difference to those who are most vulnerable. Where this becomes more difficult is when we are given crippling targets that don’t allow community action. We can’t just leave this kind of work to the public health dentists and those in the salaried services, they don’t know our patients like we do and we should be more involved in delivering more advocacy and support for those that need it. Sitting in a surgery pontificating is not effective.
Some patients are happy to listen and be told about oral health. That’s great, I love it when patients respond well. The trouble is, it is usually the patients that don’t need to be told that listen; how do we reach those that won’t, or can’t because they don’t come to the surgery? It seems to be a dereliction of duty to simply spiel off a learnt script for oral health education. In my mind that isn’t helpful to patients, and to be frank, who doesn’t know they are supposed to brush twice a day? I see patients with extremely poor oral hygiene, when we speak about oral hygiene they can tell me what I’m about to say; they’ve had it for years from previous dentists. There are some health philosophers who suggest we shouldn’t have a health service at all, the money should be spent on negating the effects of the social determinants of health that are responsible for the chronic conditions most individuals die of in this country; the preventable illnesses. I don’t agree to that extent, but I feel that the oral health services in this country are far too directed towards down-stream approaches, towards shutting the barn door after the horse has bolted. Oral health education in this system is merely a facade pertaining to a service that isn’t prepared to fund preventative treatment. I have high hopes for the new contract to improve this, but with the current political climate as it is, I’m not holding my breath.