Introduction

Peter G. Robinson, Sarah R. Baker and Barry J. Gibson,    School of Clinical Dentistry, Claremont Crescent, University of Sheffield, Sheffield, UK

Keywords

Concepts of health; Oral Health Related Quality of Life; Patient-Centred

Diseases, people, and society

The purpose of this book is to present a case for adopting a person-centered approach in oral health care and oral health research. We have used dentine hypersensitivity (DH) as a case study, because in many different ways, it exemplifies the interaction between the person and the disease, the part of that person’s body affected by the disease, and the society in which that person lives.

The current definition tells us that “Dentine hypersensitivity is characterized by short, sharp pain arising from exposed dentine in response to stimuli, typically thermal, evaporative, tactile, osmotic, or chemical and which cannot be ascribed to any other dental defect or pathology.”1 This definition reveals that the dental view immediately focuses on pain through abnormal loss of tissue that exposes the underlying dentine. Thus, the definition also tells us something about dentistry; there is no mention of the person who has the condition.

The omission of the person undermines the definition considerably. First, it encourages the mistaken belief that the diagnosis of DH is objective. The definition requires there to be pain in the absence of any other cause. This means that the person with the condition must identify the pain for the condition to be present. That person’s perception of pain is based on his or her experiences, interpretations, and beliefs. That is to say, it is subjective. Consequently, the entire existence of DH in a tooth is, of necessity, based on a subjective opinion, and no matter how much one may wish to, it is impossible to ignore the person. The “person” is central to the diagnosis of the condition. In DH, despite this key role of the person, little research has studied what it is like for a person to live with it.

It might also be worth thinking about the name of the condition. It tells us the dentine is overly sensitive. However, shouldn’t exposed dentine be sensitive? Does the name imply that the person is too sensitive, too? Put another way, does the name reflect professional views on an acceptable level of sensitivity?

There is also the question of why the dentine is exposed. Recession of the gingivae (gums) may be a manifestation of a more severe disease. In which case, why does this person have that disease? Recession often exposes dentine if the person brushes too aggressively or uses a hard toothbrush or abrasive toothpaste. Perhaps the social pressures to keep the mouth clean and fresh and worrying about the appearance of the teeth have led to brushing ferociously or using gritty toothpaste. In all these cases, things happening beyond the person influence the cause of the condition.

The existence of consumer products for DH also reveals how the condition is more than merely dental. It is people, and not teeth or tubules, who buy products. Television advertisements for those products also convey meanings beyond exposed dentine. They show people wincing in pain, whose enjoyment of food or drink or social occasions is spoiled. Some of those advertisements feature dentists in surgeries, whereas others involve an anonymous (but usually decorative) narrator in a public place. The narrator advocates the use of a product that apparently brings immediate and powerful relief. During our research, we discovered that these two advertising styles reflect whether products were conceived as medicaments or cosmetics. Thus, the way a product is placed in a legal framework directly influences the messages received by the public about an oral condition.

The influence of these advertisements on people’s purchasing also shows how the consumer products industry (as part of wider society) affects our personal knowledge and behavior related to DH. If the products reduce pain, then we can congratulate the industry on creating and disseminating effective products. And yet, this industry also carries a danger. If the advertisements draw viewers’ attention to a condition they did not know they had, if they sensitize subjective opinions to sensations that they hadn’t noticed, then they will encourage people to identify the pain. In this way, the advertisements will be making people ill!

These examples all illustrate the role of factors outside the mouth regarding the causes, diagnosis, and consequences of DH, and all involve the person. In doing so, they widen the idea of what oral health is. They demonstrate the role of the mouth and oral health, the way it is viewed, and its effect on everyday life, not simply in terms of the consequences of toothache, but what the mouth means, and what it communicates. One very direct result of thinking about the mouth in this way is considering the effect of oral conditions on the everyday life of the person affected.

The operation was a success, but the patient died

It is hardly surprising that dentists and oral health researchers focus so much on disease and the technical aspects of dental treatment. A strong image we all share of dentistry involves someone looking down at us, working on our teeth. The work is clearly very intricate, highly skilled, and demanding of enormous concentration. It is even very difficult for people to communicate with their dentist during these procedures! Young people for whom this kind of work resonates will therefore be attracted to dentistry. At dental school, students must spend a huge amount of time acquiring these necessary and exacting technical skills. Even after graduation, dentists have been paid according to the number of these treatment procedures they undertake. Cumulatively, these processes select and reinforce a biomedical focus.

In contrast, many of us have encountered a clinician, either as a teacher or as someone caring for us, who showed a gift for seeing beyond the teeth and seeing the patient as a person. Clinicians like this know what it is that is bothering their patients, and they regard treatment success as when those problems have been overcome. This difference between concentrating on pathology and the technical aspects of dentistry as opposed to thinking about the person reflects the distinction between two contrasting ideas of health.

The biomedical model of health defines health as the absence of disease. This perspective has been useful in health care, because it directly links clinical signs to the mechanisms of disease, therefore guiding diagnosis and treatment. The model evolved from the premise that diseases are organ-specific pathological processes that affect the function of cells within the organs. Its focus is on clinical, physiological, and biochemical outcomes, and its foundations are in the physical and biological sciences.

In many respects, this approach has served us well. The dominance of the basic sciences of genetics, biology, pathology, physiology, biochemistry, and molecular biology in clinical practice and medical research (including dentistry) has provided the understanding that has underpinned huge advances in health care over the centuries.2 Nevertheless, the model has limitations. Its core problem is that it restricts the way we think about health and health care, because it is reductionist.

The term “reductionist” refers to the reduction of health and disease to their smallest common denominators and the exclusion of “peripheral” or complicating factors. One aspect of reductionism is mind–body dualism, which treats the mind and body as discrete and unrelated objects. Physicians have been known to argue that their responsibility is to treat only “real diseases” rather than to be concerned with psychological and social problems.3 Thus, the physical and biological sciences are seen in isolation from their personal and social etiologies and consequences.

The definition of DH gives us a perfect example of reductionism, where the disease is seen purely as a problem of specific organs (the teeth or the mouth). It exemplifies how the biomedical model characterizes specific diseases when their etiologic and pathogenic processes are obvious, and we have already seen how treatments are specific to the disease. And yet, we also saw how DH, like so many other human diseases, is not a specific disease with a specific etiology. The condition can only be diagnosed when all other diseases have been ruled out, therefore...