The main oral diseases and conditions have common risk factors with many systemic diseases (Petersen 2003; Sheiham 2005), which in turn can directly or indirectly compromise oral tissues (Dyer 2006). In response to the evidence linking oral health and general health, recommendations have been made to staff in dental healthcare settings to adopt a common risk factor approach (Petersen 2008; Sheiham 2000). The key principle of this integrated approach is that general health promotion in dental healthcare favours the control of many social and behavioural risk factors and has more of an impact on a large number of diseases than disease-specific approaches (Petersen 2003; Watt 2005). Risks factors for oral and general health tend to co-occur and to cluster among population subgroups at the lower levels of the social gradient (Sheiham 2011). Thus, multiple health behaviour change interventions, which are activities targeting two or more health behaviours, either simultaneously or sequentially, within a limited time period (Prochaska 2010), are likely to have greater impact on public health than single behaviour interventions (Prochaska 2008).
Description of the condition
In this review, health promotion is defined as the planned change of lifestyle and life conditions having an impact on health, using a variety of specific strategies including health education, social marketing and mass communication on the individual side, as well as political action, community organization and organizational development on the collective side, in order to improve the health and well-being of populations (O'Neill 2006), and to reduce social health inequalities (Ridde 2007). This definition is more practical and holistic because it considers individual as well as collective interventions.
Dental healthcare settings may provide valuable opportunities to adopt health promotion practices, as many patterns of disease are not strictly limited to oral health. Through health promotion practices, dental healthcare providers can address both systemic and oral diseases and conditions (Greenberg 2010; Greenberg 2012a; Reznik 2012; Tremblay 2011; Vernillio 2003), including among others, dental caries and sports-related craniofacial injuries (U.S. Community Preventive Services Task Force 2002), periodontal diseases (Petersen 2005), diabetes mellitus (Esmeili 2010; Lamster 2012), adverse pregnancy outcomes (Xiong 2006), oral cancer (Lancet Editorial 2009; Mashberg 1989), oral lesions associated with human papillomavirus (Cleveland 2011; Laronde 2008), and HIV/AIDS (Petersen 2006; Zakrzewska 1999).
Health promotion practices may affect the utilization of other health services; reduce treatment expenses; improve quality of life (Sheiham 2005) for the patients, their family and society; and reduce health inequalities (Lévesque 2009; Sheiham 2011; Vibeke 2011; Watt 2007).
Description of the intervention
Interventions designed to increase health promotion practices in dental healthcare settings come in varied forms. Given that dental healthcare providers work in an organizational context, these interventions can be addressed towards the individual clinician, as well as towards the organizational structure of practice.
Strategies for increasing health promotion practices may include theory-driven interventions (Bonetti 2006; Godin 2008), and educational meetings. For example, training dental healthcare providers through education may allow staff to keep abreast of the latest developments in dentistry and update their knowledge. Training dental healthcare providers enhances their knowledge and skills, and increases their self efficacy to perform health promotion practices (Amit 2011; Reena 2012). For instance, given that a compromised dentition can impede the achievement of dietary goals (Moynihan 2004; Moynihan 2007), so tailored interventions such as nutritional counselling by dental healthcare providers may enhance quality of life among edentulous (toothless) people by facilitating increased consumption of fruits and vegetables (Bradbury 2006).
Interventions that aim to increase health promotion practices are also organizational interventions involving all members of the dental healthcare team, which could promote discussion between dental staff and could reinforce their knowledge, awareness and skills (Rosseel 2011). This could lead to the adoption of agreements by dental organizations, which could increase the promotion of best evidence practices, such as the use of sealants (Clarkson 2008).
How the intervention might work
Due to an ageing population, and increasing rates of systemic diseases and conditions, dental healthcare providers need to adapt their practices. Research examining behaviour change among healthcare professionals (Godin 2008), and complex behaviour change processes (Michie 2009), allows us to make certain hypotheses regarding the mechanisms by which interventions might support health promotion practices. For example, the distribution of printed educational materials may improve the attitudes and skills of dental healthcare providers concerning the adoption of guidelines for tobacco cessation (Albert 2005). Continuing professional development activities can increase the clinical performance of dental healthcare providers and their compliance with infection control practices such as use of gloves, masks and protective eyewear (Cohen 1996; McCarthy 1996).
Considering that individual factors as well as social, physical and environmental conditions influence behaviour (Bartholomew 2011; Kitson 2009; McLeroy 1988; Richard 2011; Rycroft-Malone 2008; Spallek 2010), the social ecological model provides a useful framework to consider the complex interplay between individual, and physical and social influences from the wider environment over time (McLeroy 1988). The ecological approach integrates environmental and individual targets of intervention across a variety of settings including organizations, communities, societies and supranational systems (Richard 1996). In order to capture the mediating mechanisms at multiple levels of influence and to understand how interventions work in dental healthcare settings, the application of the ecological perspective represents a comprehensive approach to identifying and analysing interventions that target multiple influences on dental healthcare providers' behaviours (Bartholomew 2011) (Figure 1 from Richard 1996).
Why it is important to do this review
Dentistry is a dynamic profession and a complex socio-technical domain (Song 2010), continually reshaped by new scientific knowledge, devices, techniques and materials (Beauchamp 2008). There is an increasing body of knowledge of the aetiology of oral diseases and conditions, and the relationship between oral and systemic health. Oral signs and symptoms can be precursors to systemic diseases and conditions. Moreover, the ageing population and the growing prevalence of chronic diseases and conditions, as well as the large number of infectious diseases are all factors that could favour the involvement of dental healthcare providers in general health promotion. Given that certain interventions of general health promotion are not directly within the scope of dental practice, oral health promotion could be a strategy to improve overall health.
Systematic reviews have addressed oral health promotion in dental settings (Satur 2010; Victorian Department of Health 2011), among specific people (McGrath 2009), or using behaviour change models (Yevlahova 2009). However, some reviews in the oral health education and promotion literature conducted in certain contexts have identified the limitations of many interventions to produce sustained improvements in oral health (Brown 1994; Kay 1998).
Previous systematic reviews have addressed the effectiveness of health promotion interventions in specific topics in dental settings, such as tobacco cessation (Carr 2012; Needleman 2010; Studts 2009; Warnakulasuriya 2002), obesity (Suvan 2011), dietary counselling (Harris 2012), and alcohol consumption counselling (McAuley 2011). Only one previous systematic review has considered simultaneously different health promotion practices (Dyer 2006). Despite its relevance, this review only included circulatory disease and cancer and the participants were different healthcare workers and not only dental healthcare providers. Consequently, our review will fill some of the gaps in the current knowledge by considering health promotion practices broadly for all oral and systemic diseases and conditions, and by focusing on dental healthcare providers only.
Furthermore, there is a reported willingness on the part of dental healthcare providers to become more involved in health promotion and prevention programmes, and on the part of patients to receive these interventions (Barasch 2012; Campbell 1999; Greenberg 2012b; Jontell 2009; McAuley 2011; Victoroff 2006). Dental healthcare settings offer a promising venue to perform general health promotion by dental healthcare providers and an opportunity to improve social costs related to oral diseases and systemic conditions. Adopting an integrated approach to health promotion may be beneficial through an impact on the trade-off between resource inputs and resource consequences. For instance, dental healthcare providers' investment in resources (physical, human) could result in beneficial effects, such as more preventive care (Conrad 2010; Pourat 2009), more screening and enhanced quality of life for people with systemic or oral diseases and conditions, or both. Thereby, identifying which interventions can help dental healthcare providers in their work to promote the general and dental health of their patients is expected to improve patient outcomes.