Demanci for dental care in Sri LankaTreatment Needs

Saman WarnakulasuriyaDepartment of Oral Medicine, University DentaiSchool. Peradeniya, Sri Lani<a

Warnakulasuriya S: Demand for dental care in Sri Lanka. Community Dent OralEpidemiol 1985; 13: 68-9.

Abstract - The demand for dental eare was assessed ainong 3000 dental patientsvisiting an out-patient clinic in Sri Lanka. 46% of the patients sought treatmentfor complaints related to advanced stages of dental caries whilst 18% requestedtreatment for early stages of decay. 20% had complaints related to periodontaldisease of which two-thirds had advanced symptoms of mobility. The majority of thedemands reflect a need for emergency care such as exodontia and dressings forcavities, which is currently being carried out by dentists but could easily be done byauxiliaries at low cost.

Key words: demand: dentai care: dentai caries:dentistry in Sri Lani<a: periodontai disease:symptoms, orai: toothache: treatment needs

Department of Orai Medicine, Dental School,Peradeniya, Sri Lanka

Accepted for publication 9 Aprii 1984

In many underdeveloped countries den-tal health care is poor. The utilization ofhealth services to some extent dependson perceptions and attitudes of patientstowards ill health, although other factorssuch as degree of disability that ill healthbrings may play a role (1). In underdevel-oped countries a large majority of thepopulation only seek dental treatment onan emergency basis, such as for the reliefof pain. Regular attendance for dentalcare in such situations is mostly limitedto the upper social classes. As a result itcould be envisaged that in Third Worldcountries the expressed need or demandfor dental care falls far short of the nor-mative need.

Little accurate data is available atpresent on the two parameters, needs anddemands, in many underdeveloped coun-tries. While oral health need is very mtichthe essence of traditional investigationsin oral epidemiology, wants and demandsare the subject of social science researchin, respectively, the culture and social or-ganization of dentistry (2). The presentstudy was undertaken to assess the de-mand for dental treatment among a semi-urban communiiy in Sri Lanka. In thisstudy an attempt was made to assess thedental Ireatment demand by analyzingthe frequency of chief complaints of pa-tients presenting for therapy.

Material and Methods

3000 patients attending the UniversityDental Clinic, Peradeniya, for dentaltreatment were screened for their firstcomplaint for attendance, on their firstvisit. This clinic provides free dentaltreatment on an out-patient basis and

those seeking care are mainly adolescentsand adults, as a separate children's clinicwas in operation at the same premises.Patients presenting with a referral letterfrom a dental or medical practitioner,amounting to 41 in nuinber, were ex-cluded from the data analysis. The studywas carried out during 52 consecutiveweeks in two admission clinics per week.

The age of the patient and the chiefcomplaint was recorded. Following aninitial clinical examination appropriatetherapy related to the presenting com-plaint was planned. A distinction wasmade between toothache (related to pul-pitis and peridontitis) and transient heatand cold sensitivity (relating to decay notextending to pulp) by appropriate ques-tioning and clinical examinations.

For the analysis of treatment demand,the chief complaint was linked to appro-priate therapy available at the institution,such as exodontia, endodontics, restora-tive treatment, scaling and prophylaxis,orthodontics and prosthetics.

Results

Table 1 shows the nuinber and percent-age of chief complaints recorded, catego-rized into 10 major symptoms. Resultsshow that 31.5% of the patients attendedthe clinic demanding treatment for tooth-ache on their first visit. An additional14.9% attended for septic roots left as aresult of progressive decay. Coinbiiialionof these two groups amounted to 46.4%of the attendents, who were in fact seek-ing treatment for advanced stages of de-cay following denial caries. In conlrasi18% of the attendents sought treatmentIbr early stages of dental caries, present-

ing with transient heat and cold sensi-tivity in whom clinical examination re-vealed cavities which could be restored.

In total 19.6% of the patients soughttherapy for periodontal disease. Of these,two-thirds demanded treatment for ad-vanced periodontal disease. Thirty-sevenpatients (1.2%) presented with an acuteswelling of the jaw and nine children withtrauma to the teeth. 5.8"/o were demand-ing treatment for the impairment of oc-clusion. Prosthetic demands were ex-tremely meagre, amounting to little lessthan 100 patients out of a total of 3000.Even among the 51-70 age group onlyI3.5%i requested a prosthesis.

Symptoms related to [\\c age strata areshown in Table 1. When percentage ofattendents in the live age strata are ad-justed to standard age groups, it is seenthat almost equal proportion of patientsseek treatment for toothache amongst13-18 and 19-31 age groups. In all agegroups a higher proportion had tooth-ache than earlier sytnptoins of decay(complaint of sensitivity to hot and cold).Ainong the 13-18-yr-olds this proportionwas 1:1.9 compared with 1:1.4 among the19-31-yr-olds.

The most common reason for attend-ence ainong the 51-70 age group wasmobility of teeth. Out of 173 subjects, 36(21 %i) with the complaint of an adverseocclusion and demanding orthodontictreatment were over the age of 18 yr.

Discussion

In assessing the requirements for trainingof denial manpower and organization ofdental services, the treatment demand isan important parameter to be taken into

Dental care in Sri Lanta 69

Table 1. Frequeticy of cotnmon dental complaints and their age distributiion

Chiefcomplaint

ToothacheIncreased heat & cold sensitivityRetained rootsBleeding gumsDepositsMobilily of teethTrauma to IccthAcute swellingsImpaired occlusionProsthetic needsOther complaints

2-12 13-18Age distribution

19-30 31-50 51-70

945539AAl10528619793717399163

31.518.014.93.59.56.6.31.25.83.35.4

50174072*935706

2301186723596*0880760

4773432397118427015353645

17256130113512401014740

16570I

38010912

Total 3000 100.0 155 658 1472 626 89

Physiological mobility in primary teeth.

consideration. If the majority of the de-mands in the population reflect a needfor etnergency care such as exodontiaand dressings for cavities, it may wellreflect a need for training, at low cost,auxiliaries who could carry out thesetasks. This wotild reduce the burdeit onhighly skilled, over-ttained detitists,available in a litnited quantity, atid en-able them to cany out more skilled tasks.Little attentioti has hitherto beeti paid tothis aspect of health care platining. Thepresent trend of utilizing "Western style"over-trained dentists to tackle etnergencycare at a tnass scale appears to be ineflec-tive and uneconotnical.

Although the data presented relates toa dental teaching hospital, they reflect asituation prevailing elsewhere in Sri Lan-ka. Two main conclusions could be de-rived frotn the present study. First, peo-ple appear to seek treatment only whenan acute disturbing symptom is apparent.Secondly, although epidemiologic dataindicates that periodontal disease is moreprevalent than dental caries, only 19.6%of the subjects were detnanding therapyfor periodontal disease.

Dematiding treatment at late stages ofdisease tnay relate to several soeioeco-nornic factors. Factors responsible forthe delay in translation of perceived needinto professional contact (2) are of rel-evance to health planners. Organization-al factors such as the ecotiotnic ones, timeand psychic costs, ease and convenienceof access and incotne (3) are known tobe responsible for such delays.

As a result, in a sociocconomically de-prived community demand tnay be trig-gered off only when pain is intolerable. InSoutheast Asia personal priorities, beliefs

and attetnpts to use traditional healingtnethods tnay also contribute to thisdelay.

This study indicates that there is alarge componetit of "untnet need" forthe treattnent of periodontal disease. Theinsidiotis nalure of the disease is largelyresponsible for a lack of detnand. Appro-priate strategies need to be developed toteduce the severity of periodontal diseasein the cotiitnunity. The dentist/hygieniststrategy, the most cotntnoti one used ititnany developed countries, has beenshown to be ineflective in reducing peri-odontal disease in the cotiitnunity (4).Social and educational strategies directedat groups are tnore likely to bo elTectivcand less costly (5).

There is growing intetest atnong iatgesections of health providers to attemptto convert normative needs into demandlor care. This involves raising the levelof perceived need by attitudinal change.Such an attituditial change would tnini-mize the delay in expressing treattnentneeds. However, such attempts at social-ization of the country should be balaticedby an appropriate increase in dental

tnanpowet\ to deal with inereased de-mands. The present dentist to populationratio in Sri Lanka is about 1:40()00. Re-sults frotn the present study confirtnHOBDISLL'S remark (6) that the presentmanpower is probably adequate to tneetpresent detnand, but considerable in-creases in tnanpower would be requiredto cover the present need. Thus, new ap-ptoaches to improve existing tnanpowerare urgently needed. Sri Lanka has awell-developed pritnary health care deliv-ery systetn which reaches a large majorityof the rural eotntnunity. At present thissystetn is litnited to preventative tnediealcare, A recent study has shown the feasi-bility of utilizitig primary health careworkers for screening oral malignancies(7). Utilization of sueh an existing pri-tnary health eare systetn tnay be appro-priate to enhance dental tnanpowetv inorder to improve oral cleanliness anddietary practices of the rural tnasses. Inaddition, new approaches are requiredto strengthen the existing tnanpower, toprovide cost effective therapists and aux-iliaries for etnergency care and to caterfor "nntnet needs".

References1. SttiiiHAM A. MAI/.I:LS JE. CtiSHiNC. AM. The concept of need in dental care. //;/ Deni J

1982; 32: lb^-10.2. DAVIS P. Converting the need for care into demand for services. //// Dent J 1982; S2: 271-8.3. Cooi'l'R M. The demand and need for dental care. Sue Pol Admin 1979; /.?.' 91 (only).4. WoRtJj I IHALTH ORCPANIZAIION: Epideniidiagy, etiology and prevention oJ periodontal dis-

ea,\e,s. 1978; Geneva: Tech Rep Series 621, WHO.5. SMI;MIAM A. Promoting periodontal health. Effective progratnmes of education and pro-

motion. Int Dent J 198̂ 3; 33: 182-7.6. I 1()I!DI;LL M H . A.ssignnient report on primary oral hcalih in Sri Lanka. Geneva; World I lealtli

Organization; 1983.7. WARNAKtii.AStiKiYA KAAS, EKANAIAKi! ANI. SiVAYnAM S. ct at. Can primary health

workers screen I'oi' oial cancer? World Health Forum 1983; 3: 202-4.