Monday, 27 June 2011

Power Foucault Dental Hygiene

Power  All work,including dental hygiene, like social life itself, is a collective. Power as analyzed by Foucault(1980)[i] is something that circulates. Power relations are rooted in the system of social networks, rather like the capillaries forming a total network in the body or the fine meshes of a living spider web states philosopher Foucault.  It never resides in any one person or group’s hands.  His approach  to power opens up the possibility for applying the sociological imagination and studying the micro-practices surrounding the oral cavity, and dental hygiene a provider of care. 

Power is only power when addressing individuals who are free (autonomous) to choose to act in one way or another.  Power is exercised with intention.  Power is actions upon others' actions in order to interfere with them.  Power presupposes freedom in the sense that power is not enforcement, but ways of making people by themselves behave in other ways than would have done. One way of doing this is by threatening with violence. However, suggesting how happy people will become if they buy an off-roader is an exercise of power as well. Marketing provides  a large body of knowledge of techniques for how to (try to) produce such behavior.

The ordinarily mundane and academically unexplored area of the oral cavity provides an opportunity to examine multiple processes.  These various processes create the conditions for the possibility of reorganization of oral health care delivery. 

Dental hygiene students must meet criteria  to enter  dental hygiene programs. She/he must  pass exams successfully to exit dental hygiene programs. Then, write more exams to qualify for registration/licensure  to legally practice as a dental hygienist. In Canada the National Dental Hygiene Examing Board examinations and a Jurisprudence exam in Ontario must be completed successfully to be able to gain admittance to a dental hygiene operatory. After payment of fees the  dental hygienist gains authorization to practice.

Specified objectives are expected to be  accomplished in effective and efficient ways. Dental hygienists are trained/educated to: gather information about a client’s health and medical history, to examine the mouth and teeth to identify, itemize and quantify plaque/biofilm deposits,  note areas of bleeding and calculus  and periodontal pocket depths. Much of this is done with sharp instruments

Through technology of the chair (Nettleton, 1992) the DH controls the client’s posture, back and forth  and up and down. The strong sometimes blinding light shines in the client’s mouth. The client provides intimate exposure of her/his mouth. The client must be taught lessons, trained  in proper mouthkeeping. This lesson is not learned at the 1st teaching so must be repeated at regular three, four six month intervals. Although the DH has control of the client in the chair, the dentist controls the practice and the employment situation.

Foucault  M. (1980) Power/Knowledge: Selected Interviews and Other Writings.  Ed.  C. Cordon.  New York: Pantheon
Nettleton  S. (1992)  Power Pain and Dentistry Great Britain: St Edmunsbury Press.

Friday, 24 June 2011

What‘s the Mouth got to do with other diseases?

The reporter from the local newspaper was interviewing me. He wanted to know more about the  Breath Odour Clinic. The conversation somehow moved from the topic of treating clients with oral malodor at the  clinic to bacterial plaque removal for residents in long term care facilities. As I rambled on about lowering the bacterial 'loads' in the mouth to prevent other illnesses Jim, the reporter, interrupted. "What's the mouth got to do with other diseases?" "Various bacteria in the mouth have been found to contribute to other disease in the body," I replied.
During our conversation, I had 'introduced' Jim to Prophyromonas Gingivalis, Treponema Denticola and Bacteriodes Forsythus in relation to periodontal disease and chronic bad breath. He was 'mildly' interested. After all, he had a job to do. He had to prepare an article for the health section of the paper. He was being appropriately attentive as I supplied information about testing for breath odor.
Then I remembered something on my desk. My sister had e-mailed an article prepared by Christian Millman,  for a Men's Health section for ABC News. I was able to quote: "Farmers, cowboys and other sensible men always examine a horse's mouth before buying the animal. One good look can sum up the horse's health history and predict how long the old boy will live. A human mouth isn't much different. Keep your pie hole clean so disease causing bacteria don't gain entry to your blood stream."
I could tell that I 'caught' his attention. It was my good fortune that another part of the article referred to bacteria we had previously mentioned when we talked about breath odor problems.
Dr. Robert J. Genco of the University of Buffalo studies 1372 people at the Gila River Indian community in Arizona. He found that those with gum disease had triple the risk of heart attacks in a 10-year period. He believes that oral bacteria enter the blood stream through small tears in the gums. The bacteria Genco suggests, may infect the liver and cause it to produce artery clogging proteins, or the bacteria may directly infect the heart arteries and somehow cause blockages. The exact mode of attack is still a mystery, but porphyromonas gingivalis bacteria have been found in fatty arterial blockages that cause heart failure.
A further portion of the article related to our discussion about residents in long term care: "With every breath, your lungs suck down a stew of bacteria including chlamydia, pneumonia and pseudommas aeruginosa, two bugs that cause respiratory disease. Our immune systems usually destroy these invaders, but when a person's resistance is low, such as during an illness or after surgery, these bugs can infect our lungs and cause bacterial pneumonia."
I explained to Jim that if a person in a long term care facility has a great deal of bacterial accumulation in their mouth, the 'barrier systems' of the mouth may 'break down' resulting in respiratory pneumonia. If a resident has to be moved to an acute care facility for treatment, this is costly to the publicly funded health care system. Therefore, it is cost effective to keep the mouth clean.

Monday, 20 June 2011

Sociological imagination oral health care

Adopting a sociological imagination involves questioning our own views and assumptions about the world. A critical sociological imagination is based on an acceptance that some things may contradict and challenge what we believe. Therefore it is important to avoid being biased. Bias can arise when we believe something even when there is no evidence to support our belief. Using the sociological imagination  provides an opportunity  to get a fresh view of the world of oral care, the mundane topic of the mouth, teeth and gums, dental hygiene and dentistry, all seldom considered in Sociology.
Dentistry  developed in the mid to late 1800s. It  arose out of the public health movement. Adams(2000 p90) [i]tells us that in Canada the public health movement centered around the belief that there was direct connection between physical health, cleanliness and morality. Dentists were very active in these movements and they worked to improve the health, cleanliness and morality of the public. A  discourse of the mouth,  delivery of care and treatment of the mouth, was structured. In the Professions Ideology Change course, in addition to looking at historical development  of dental hygiene  we can consider the genealogical study,  the relations between dental power and the establishment of dental knowledge. Nettleton (1992 p124)  [ii]  In her text Nettleton examines the circumstances, the small things, events and techniques such as regular 2x daily toothbrushing, professional cleaning, that led to the mouth and the teeth becoming the focus of a distinct discipline called dentistry. She  demonstrates  how  in Britain, the dental profession established its object- teeth subject to decay- by allying itself with public health. Public health helped dentistry justify the need for monitoring children’s mouths to ensure the prevention of infectious disease.
Dental hygiene was created in the early 1900s as ‘dentistry’s agent’ to provide education and ‘mouth keeping’ to ensure the prevention of decaying teeth and infectious disease. “ Dental hygienists it was suggested, could work either in schools or dental offices, performing the unremunerative  but important public health and preventive dental work, for a fraction of the cost and with little training” (Adams 2000p122)[iii]Dentistry was more interested in extracting and  filling teeth than teaching children or treating gums.
Dentistry views itself, as does society, as the profession that has control over professional oral care, the restoration and   maintenance of the teeth and tissues in the  mouth.  Dentistry possesses  power as expressed in the social organization of oral health care delivery. Power they worked hard to establish. Dentistry became an official profession Canada in 1867. Society gave to  dentistry the authority and professional autonomy to be the dominant profession in  oral health care delivery.
 In a course DH331  Professions Ideology and Change,  students examine and analyze the institution and practice of dentistry, and the emergence of dental hygiene practice within the oral health care field.  This ordinarily mundane and academically unexplored area of the oral cavity provides an opportunity to examine multiple processes.  These various processes create the conditions for the possibility of reorganization of oral health care delivery.  As networks of professions, consumers, bureaucrats, and politicians oscillate between the curative, medical treatment model and the preventive wellness model of health, new knowledge of oral health  will emerge.  Adopting a sociological imagination involves questioning our own views and assumptions about the world. A critical sociological imagination is based on an acceptance that some things may contradict and challenge what we believe. Therefore it is important to avoid being biased. Bias can arise when we believe something even when there is no evidence to support our belief. It is understandable that we prefer not to be criticized or to admit errors in judgment. It is more comforting to believe that our opinions are right rather than wrong. Hopefully students  gain a broader perspective, as they examine the social landscape of oral health care, beyond the confines of the  dental hygiene cubicle in the dental office. 
[i] Adams, T. L(2000) A Dentist and a Gentleman Toronto: University Toronto Press
[ii] Nettleton, Sarah (1992) Power, Pain and Dentistry.  Great Britain: St. Edmunsbury Press.
[iii] Adams, T. L(2000)  ibid p90

Lynda McKeown Mickelson’s MA thesis 1995 The Regulated Health Professions Act and Dental Hygiene: A Study of the Changing  Social Organization of Health Care Delivery in Ontario.[i]  casts light on the RHPA 1994. McKeown Mickelson  “describes the problematic relationship between public legislation and  its actual enactment or implementation. The  fractious relationships  between dentistry and dental hygiene are described and analyzed.” (Coburn 1995)[ii] Her research showed that the  legislation, which governs twenty-four health professions, is a site of power relations.  Part of the intent of the R.H.P.A. 1994 was to increase the accountability of professionals and to increase the consumer's ability to access affordable options for health care.

Michel Foucault provided McKeown Mickelson with a way to examine the initial impact of the R.H.P.A.  .  He thinks and conceptualizes power as diffused through multiple social sites, as something that is exercised, not as something such as a position that is held in a hierarchical structure.  Rather like a spider web or the capillary vascular system of the  human body. Foucault insists on a close connection between power and resistance. Resistance is not external to power but inherent in power relations. Power provokes resistance

Using personal experience of the professional self-governing process and Foucault's approach to power relations, the seemingly mundane and ordinary practice of oral health care delivery was examined to find evidence of change in the social organization of health care.  The relationship between two providers of services surrounding the mouth and oral health care, dental hygiene and dentistry exemplify the power relations and the inherent resistance emerging as the legislation is enacted.  Dental hygiene  struggles to attain autonomy and is still advocating for more interdependent provision of health services and the public's freedom to choose their access point to preventive oral health services.   Dentistry is struggling to preserve the 'status quo.'  A 'tug of war' continues  in 2011 to take place between the implementation of more community based, preventive services of interrelated health care providers, and the preservation of the traditional, independent, fee-for-serve treatment practices.  However, legislation has legitimized and enabled many emerging professions such as dental hygiene to voice their concerns through open consultations and public forums.
For McKeown Mickelson the  evidence in 1995  indicated that the existing professional monopolies would not be disrupted easily. This appears to be the case in 2011.
Thus, distribution of nontraditional health care providers to alternate practice settings in urban communities or Northern, remote and rural areas, was not an immediate result of the passing of this new legislation RHPA.  McKeown Mickelson identified  themes that emerged from the struggle to reframe the relations between dentistry and dental hygiene under the new R.H.P.A. These  are: discourse/language, professional dominance, technologies of bureaucracy, gender, and power/knowledge.
   This research was initiated to determine what effect new health legislation has on the social organization of health care delivery in Ontario.  Does the Regulated Health Professions Act, 1994 in fact change the social organization of health care delivery in Ontario?  As the research progressed, it became evident that there is a division between the changes for the newly regulated providers and the changes for consumers.  There is a definite change in social organization for the providers with the introduction of the R.H.P.A.  Legislation has legitimized and enabled many emerging professions, such as midwifery, nursing and dental hygiene, to voice their concerns through open consultations and public forums.  Also, it has become apparent that the existing professional monopolies may not be ruptured easily and that the distribution of non-traditional health care providers to alternate delivery settings in urban communities or in Northern, remote and rural areas will not be immediate and will require consumer advocacy for freedom to choose previously unavailable or inaccessible health care services.
                As a participant observer, knowledgeable and experienced in the regulatory process, qualitative research was the method chosen for this study.  Using personal experience and Foucault's approach to power relations and the inherent resistances, a seemingly mundane and ordinary practice, oral health care delivery, is explored.  The study provides an opportunity to look at contrasting perceptions regarding practices surrounding the mouth.
The Regulated Health Professions Act, 1994, new health legislation in the province of Ontario, proclaimed December 31, 1993, is a site of power relations and health politics.  Included with this legislation are twenty-one profession specific Acts regulating twenty-four health occupations (Appendix A).  Many of these health occupations are independently regulated for the first time.  This study takes the new legislation as a starting point and also looks at pre-proclamation events such as previous health legislation and the findings of the Health Professions Legislative Review.  The R.H.P.A. and the twenty-one profession specific Acts establish a whole series of power networks that invest in the body.
                For the purpose of this study, dentistry and dental hygiene are used as examples of resistance and, thus, new power relations that are occurring with this new professional regulatory legislation.  Gross has stated that:

... changes in licensing regulations that enhance competition and accountability will create other changes which will shape professional services to raise quality, reduce cost, and increase public self-protection (Gross, 1984 xii  Of Foxes and Henhouses.  Connecticut: Quorum Books).  

                Looking at dental hygiene's attempt to regulate itself independently of dentistry provides, for this researcher, a starting point and a point from which to stand.  As the regulatory body of dental hygiene (the College of Dental Hygienists of Ontario) attempts to have the word ‘order’ removed for prophylaxis, the non contraindicated procedures of scaling and root planing, the possibility for change in the social organization of health care delivery and the opposition and resistance to the 'status quo' emerge.  These two health occupations provide a contrast between dental hygiene, an emerging preventive/health promotion, wellness oriented health care provider, and dentistry, an established, curative medical treatment-focused health care provider.  These two valued perspectives openly clashed as both regulatory bodies prepared for proclamation of new health legislation.  The study focuses on dentistry's attempt to maintain control of dental hygiene through dentistry's interpretation of the word 'order' in its regulations, and dental hygiene's resistance to continued subordination by its attempt to amend the Dental Hygiene Act.  It will be shown that this struggle indicates a change in the social organization of health care delivery for providers.
                Hopefully, this new regulatory system for health care professionals will result in positive changes in health care delivery.  It is possible that the way society thinks and perceives of health care in general and oral health care in particular could be so different in the future that it would be unrecognizable from this present stand point.  I present my perspective to avoid any misinterpretation by the reader.
                Independent regulation for dental hygiene' means increased accountability and autonomy.  My perspective is that this autonomy does not mean freedom to be entrepreneurs nor freedom to reproduce the established traditional patterns of hierarchy and patriarchy, rather it is freedom to form new alliances and to work in nontraditional practice settings.  The freedom to form new alliances with health care professionals such as nutritionists, chiropodists, massage therapists, nurses, etc., could provide the opportunity to re-establish the link between the mouth, the gateway to the body and the rest of the person.  Good oral health is inextricably linked to good general health.  Oral health is not just a matter of appearance.   The mouth is essential to speech and the digestive system.  Poor oral conditions affect social interaction and appearance and contribute unnecessarily to pain and erode the individuals morale and overall attitude.  Oral health problems can have significant consequences on an individuals general health and quality of life.  However, the present funding system appears to separate the mouth from the rest of the body.  Countries such as Norway, Sweden and Scotland recognize that oral health is important to total health and include oral health in publicly funded health care programs.
                I see a collaborative approach to health care, one which includes a "circle" of providers of care, not a "ladder" or hierarchy of curative treatment providers.  This freedom will enable and empower providers to work interdependently in their preferred location with other health care providers of their choice.  I conceive these alliances perhaps in community health centres, to be a new version of the "old time" family physician who knew and understood the family with all of its interactions and its social, spiritual, physical and emotional components.  The body and person will be recognized as a unified whole, connected to the external environment.  The various health care providers will collaborate with each other and the client in attempts to achieve good health and total well-being.  So, it is my hope that clients will have the freedom to choose health care providers in appropriate practice settings in all communities in all parts of the province.
                Discourse/language can be effective in changing the public's perception and awareness of certain practices within society.  However, discourse/language can also perpetuate established traditions of power/knowledge.  The word 'order' is an example.  The word 'order' is included in a few, mainly female dominated, profession specific Acts.  The word 'order' in the Dental Hygiene Act acts as a catalyst which reveals two different and valued perspectives, dentistry (treatment) and dental hygiene (prevention).  The word 'order' carries with it historical, military language (Appendix B).  It is a coded sign of obedience.  It is a word that traditionally differentiates values and levels of knowledge.  Thus, the inclusion of the word 'order' is questionable in new health legislation as it is impregnated with professional dominance, power, and the privileges of specialized knowledge, technologies of bureaucracy, and gender inequities.
                The social organization of oral health care is generally considered a rather ordinary and mundane practice.  However, looking at this rather mundane practice provides the opportunity to observe speech and language practices that surround the mouth.  It becomes evident to this researcher that the mouth and its care are examples of the way power is exercised. The research reported here shows that this new, multi-health occupational legislation is a site of power relations with their inherent resistances.  The relationship between two providers of services surrounding the mouth and oral health care, dentistry, and dental hygiene exemplify power relations and sites of resistance.  Related themes and patterns emerge.  [iii]

There was really no necessity for the development of dentistry as a distinct discipline. Adopting a genealogical perspective and applying sociological imagination we can look at the circumstances that enabled  this particular study of the mouth, discipline of dentistry. These conditions of possibility arose out of the public health movement, monitoring mouths to prevent disease. The mouth was a vulnerable part of the body which had to be protected. The mouth is the boundary between the internal body and the external  sources of pollution. This original concept fits with the theories of ecology today. The dental services in schools  created a market for treatment, as disease was discovered when children’s mouths were observed and examined.  Nettleton (1992) p26-7 quotes several writers of the early 1900s. ‘By far the greatest number germ infections gain entrance by the mouth. The mouth and nose are the portals of the greatest importance, from the infective agents which are introduced through them.’  Dentistry originally  implemented dental public health  programs to monitor  and treat teeth.  The aims of  dentists were not always implemented, nor always successful. When the dental programs were carried out they often met with problems, conflict and resistance. Resistance is found between professions, patients /clients and among professionals themselves and within vocational disciplines.(Nettleton p140)
Dental education  focuses on restorative  treatment, surgical procedures, not observation, collection of statistical data or educating patients in prevention. Community dental health may be marginalized in dental schools. The orthodontist and oral maxillary surgeon get greater respect than the expert in nutritional counseling.
Dental hygiene was assigned the preventive  and housekeeping/mouthkeeping tasks by dentistry. Much the same can be said about dental hygiene curriculum as stated about the dental curriculum. Students studying dental hygiene  focus on  fine motor skill development for  debridement, removal of calculus deposits. Although nutritional counseling and tobacco cessation are part of the curriculum, public and community health  education of society is   a small part of the curriculum.
Resistances, squabbles and struggles serve as a catalyst and bring to light power relations. The amendment to Dental Hygiene Act in 2007 in Ontario (authorizing self initiation) reignited power struggles that were evident when dental hygiene was granted self regulation by ON government in 1991.  When the legislation was Promulgated  in 1994 many dental hygienists could not get an ‘order’ as required by the Dental Hygiene Act to proceed with controlled acts.  As this requirement was not in the Dentistry Act most dentists ignored the dental hygiene legislation and continued with the status quo in their private practices.
 Power struggles continue. Dentistry maintains control as an employer.  With the proliferation of dental hygiene programs there are increased numbers of graduates. So in many parts of Canada dental hygienists can’t find employment with dentists.  As a result dental hygienists  are establishing independent practice without, not surprisingly, dentistry’s blessing. 
The oral care field is changing. It is possible that how we currently think about, and see oral care delivery could be so very different that it will be unrecognizable to us from our present standpoint. New power struggles will create new knowledge. In this  21st C there is an increased link between fashion, and treatment and an increasing consumerism.

[i] McKeown Mickelson ( 1995)The Regulated Health professions Act and Dental Hygiene: A Study of the Changing Social Organization of Health Care delivery in Ontario. unpublished Sociology Master thesis Lakehead  University: Thunder Bay ON
[ii] Coburn, D. external  reader for McKeown Mickelson’s thesis The Regulated Health professions Act and Dental Hygiene
[iii]   McKeown Mickelson (1995) ibid  introduction pp 1-5