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We are a group of senior scientists—researchers, academics and intellectuals—from various parts of the world, with over 250 years’ combined experience of working to improve the oral health of communities. The group is entirely independent of any institution, government body or corporate entity. This article is protected by copyright. All rights reserved.
La Cascada Declaration
We are concerned that the dental profession, worldwide, has lost its way.
We are a group of senior scientistsresearchers, academics and intellectualsfrom various parts of the
world, with over 250 years’ combined experience of working to improve the oral health of communities.
The group is entirely independent of any institution, government body or corporate entity.
We met for a few days in March 2017 under the hospitality of Prof Emeritus Alfonso Escobar at his home in
the Andes of Colombia, known as La Cascada Mare, to share our concerns about the future of dental care
and dental education.1 Each of us prepared a detailed paper of our experiences over the last half century, our
assessment of the problems, and suggestions for the way forward. Each paper was discussed in detail.2 The
following statement represents our analysis of the problem and provides some recommendations about what
should be done.
The problem
Despite current knowledge of the causes of oral diseases, globally most people continue to experience
significant levels of disease and disability. Although technological and scientific developments over the last
50 years have contributed to improvements in the quality of life for some, oral diseases continue to cause
pain, infection, tooth-loss and misery for a vast number of people. While in many middle and high income
countries, there have been marked overall improvements in oral health, oral health inequalities both between
and within countries are now a major problem. The overall improvements in oral health have been the result
of general improvements in living standards and conditions, changing social norms in society
(improvements in personal hygiene and reduction in smoking) and the widespread use of fluoride
toothpastes, rather than due to the clinical interventions of dentists.
Globally the profession has had little direct impact on the scale of the problem. Clinical interventions
account for only a small proportion of improvements in the health of populations. This is as true of oral
health as of general health.
The world has witnessed significant growth in social inequalities between the rich and the poor: the
wealthiest 1% own more than half of global wealth, with only eight individual men, according to OXFAM,
owning the same wealth as half of the world’s population. Austerity policies worldwide (commonly referred
to as ‘structural adjustment programs’ in the global South) have diverted social and welfare spending away
from the public to the private sector in the belief that ‘the market’ can meet social needs, despite evidence to
the contrary. This has led to the creation of a two-tier health serviceone for the rich, and the other, limited
and often of poorer quality, for the majority.
Corporations and insurance companies are increasingly taking over the provision of health services,
including dental services, in many countries. The treatment regimens that they promote are designed more to
ensure adequate returns on investment for their shareholders than to improve the health status of the
community, resulting in a tendency for the provision of excessive and sometimes inappropriate treatments.
We are fearful that with the decline in public funding for universities, research is losing its independence as
funding is increasingly sought from industryfor example from manufacturers of pharmaceutical, surgical,
dental materials and equipment, hygiene and cosmetic productswhich warps both research priorities and
clinical procedures.
Major food and beverage companies continue to promote the consumption of refined carbohydrates, free
sugars in drinks, confectionary and in processed foods, even though these are major contributory factors for
dental decay, not to mention obesity and diabetes. Advertisements of these products frequently and
unjustifiably imply health benefits.
We believe that the dental profession, as presently constituted, is inappropriately educated for dealing
adequately with oral health problems faced by the public. In many countries, there is an overproduction of
dentists, most of whom provide services only in the main urban centers where private practice is more
lucrative and services often fail to reach those in more remote areas of the country. In some cases,
overproduction results in unemployment.
While there is no doubt that the intention of the profession is to improve health, commonly used treatment
regimens for tooth decay (drillings and fillings) and gum diseases (scaling and polishing) do not by
themselves arrest or control their progression. Furthermore, filling teeth inevitably leads to a cycle of
replacements of increasing size, ultimately shortening the life of the dentition.
Dentists are paid for, or evaluated based upon, the number of such procedures performed, rather than for
establishing health. In the private sector, dentists are under constant pressure to ensure adequate returns on
investment. Frequently, this results in overtreatment.
The two most common oral diseases, dental caries and gum diseases are both reversible and, in most cases,
can be controlled by individuals and communities using simple measures. The progress of dental decay can
be arrested even in teeth with open cavities provided the pulp (the “nerve”) has not become infected. The
use of dentists who have been trained for some 4-6 years to undertake such simple measures seems
Diseases of the soft tissues of the mouth and of the jaw bones are debilitating and sometimes fatal. The
prevalence of cancers of the mouth and throat continue to rise at an alarming rate in some populations, but
with sometimes inadequate attention from the profession.
Studies of populations having little or no access to dental care show that, despite often poor oral hygiene,
most people keep most of their teeth for most of their lives. Dental caries is the main reason for teeth
needing to be extracted, and dentists are the principal cause of tooth loss because of the cycle of repair
referred to above.
There has been a disturbing growth of specialization within dentistry, which has tended to result in excessive
and inappropriate treatments. For example, more than half of all root-fillings fail. Certain specializations,
where there are many lucrative opportunities, are turning dentists into ‘cosmeticians’. Many of the
specializations are based on stimulating desires amongst the public which then justify the provision of
interventions based on ‘responding to demand’.
Dentistry is drifting, it seems, away from its task of prevention and control of the progression of disease and
of maintaining health. The mouth has become dissociated from the body, just as oral health care has become
separated from general medicine.
We believe dentistry is in crisis. Things must change.
What needs to be done?
Since clinical interventions account for only a small proportion of health improvements, the dental
professions should be in the forefront of efforts that call for a reduction in income disparities and for a more
just world in which everyone has access to resources and conditions for good health and well-being. Those
industries whose products are harmful to health, especially producers of free sugars in foods, drinks, and
producers of foods containing refined carbohydrates, should be required to label their products as harmful
(just as has been done in many parts of the world in relation to tobacco and alcohol). The decline in
government spending on the social sector cannot be justified in the light of excessive expenditures on war,
the military, arms and other destructive initiatives. Corporations and industry should not be permitted to
unduly influence research or clinical practice.
The dental profession is over-trained for what they do and under-trained for what they should be doing.
Control of the most common oral diseases requires relatively little training and could and should be
performed in most cases by community healthcare workers. Demonstration projects on the effectiveness of
such approaches are needed.
With the over-production of dentists in most parts of the world, there is an urgent need for a reassessment of
the training of dentists.
Dentistry should become a specialism of medicine, just as ENT (ear, nose & throat), ophthalmology,
dermatology, etc. are specialisms of medicine. As such, oral health physicians would be responsible for
providing leadership of the oral health team, in the management of advanced disease and the provision of
emergency care, relief and management of pain, infections and sepsis, management of trauma, diagnosis and
management of soft-tissue pathologies and, where justifiable from the point of view of the maintenance of
health, interventions to re-establish a functional dentition and orofacial reconstruction. Since the
management and control of most common diseases could be undertaken by primary healthcare workers, a
relatively small number of such oral health physicians would need to be trained. In addition, a relatively
small number of public health dentists would be needed to coordinate oral health needs assessments,
implement and evaluate community-based oral health improvement strategies and to act as oral health
advocates to ensure the closer integration of oral health into wider policies.
The growth of specializations within dentistry, while resulting in lucrative practice for the specialist, does
little to improve public oral health. Such growth should be limited.
There needs to be more public discussion about the achievements and limitations of the way the dental
profession is currently structured.
The implications of the above recommendations are obvious: changing dentists into oral health physicians
necessitates thorough revision of the education profiles of dental schools: an overhaul of the current
curriculum for training of dentists; a reduction in the number of dentists trained; and an improvement in the
quality of courses, especially ensuring that training is linked to the needs of the population. Inevitably, this
will mean the closure of many of the existing dental schools in those countries that have created a disturbing
number of new schools in the past decade or so. Proposals for the establishment of new dental schools
would need to be seriously reassessed.
Meanwhile, efforts need to be made to dissuade dentists and other oral health personnel from carrying out
procedures (such as drilling and filling, scaling and polishing) that shorten the life of the dentition. Such
procedures should be restricted to exceptional conditions where the restoration of a functional dentition
justifies the risk. Dentists need to be rewarded for maintaining health rather than for carrying out invasive
and often unnecessary procedures. Oral healthcare interventions should be determined by the best interests
of attaining health and a functional dentition rather than by the financial interests of individual practitioners
or shareholders of corporations and insurance companies.
The current state of dentistry worldwide is dire. It requires radical solutions. This short declaration has been
produced to stimulate discussion about what needs to be done in the interest of the health of the majority of
humankind. We recognise that the changes may take time to implement. Each country will need to assess
how best to bring these about.
Dr Lois Cohen PhD (USA)
Professor Emeritus Gunnar Dahlen PhD, Dr Odont (Sweden)
Professor Emeritus Alfonso Escobar PhD (Colombia)
Professor Emeritus Ole Fejerskov PhD, Dr Odont (Denmark)
Professor Emeritus Newell W Johnson, CMG, FMedSci (Australia/UK)
Dr Firoze Manji (Kenya/Canada)
... Compromised nutrition resulting from oral disease leads to delayed growth and impaired cognitive and social development, which negatively impact concentration and school participation [27,34]. While the focus of care is mainly on individual treatment and chair-side oral health advice, most oral disease is largely untreated due to limited access to dental care owing to the often prohibitive cost of services and lack of education about preventing oral disease that mainly affects those who have been socially disadvantaged, including Aboriginal children [24,35]. ...
... Studying the powerful can help identify how hegemonic relations are constructed and reproduced [55]. La Cascada Declaration [35] and other international work [56] acknowledge the need to shift focus by identifying a crisis in dentistry, centred on treating disease at an individual, biomedical level rather than on prevention. ...
... Dental services focus mainly on individual treatment and have done little to prevent disease at a population level. Individual treatment fails to take into account the social context in which Aboriginal children's lives are embedded that impact on decisions related to oral health [35,59]. Instead, Aboriginal participants often felt blamed for the state of their or their children's oral health [46,47]. ...
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Inequitable social environments can illustrate changes needed in the social structure to generate more equitable social relations and behaviour. In Australia, British colonization left an intergenerational legacy of racism against Aboriginal people, who are disadvantaged across various social indicators including oral health. Aboriginal Australian children have poorer health outcomes with twice the rate of dental caries as non-Aboriginal children. Our research suggests structural factors outside individual control, including access to and cost of dental services and discrimination from service providers, prevent many Aboriginal families from making optimum oral health decisions, including returning to services. Nader's concept of ‘studying up’ redirects the lens onto powerful institutions and governing bodies to account for their role in undermining good health outcomes, indicating changes needed in the social structure to improve equality. Policymakers and health providers can critically reflect on structural advantages accorded to whiteness in a colonized country, where power and privilege that often go unnoticed and unexamined by those who benefit incur disadvantages to Aboriginal Australians, as reflected in inequitable oral health outcomes. This approach disrupts the discourse placing Aboriginal people at the centre of the problem. Instead, refocusing the lens onto structural factors will show how those factors can compromise rather than improve health outcomes. This article is part of the theme issue ‘Evolutionary ecology of inequality’.
... In fact, the current understanding of the main oral diseases as caries, is that they are non-communicable chronic diseases, and thus, are more sensitive to dietary and self-care habits than manual professional interventions, and therefore, they decisively depend on the caregiver's attitudes. 25,26 Thus, empowering the caregivers roles in routine oral hygiene care will be extremely beneficial and rational in the long run. 25,26 As a limitation of the study, it is noteworthy that it was carried out in two institutions specialized in care of individuals in Brazil and therefore, the external validity of the findings must be considered. ...
... 25,26 Thus, empowering the caregivers roles in routine oral hygiene care will be extremely beneficial and rational in the long run. 25,26 As a limitation of the study, it is noteworthy that it was carried out in two institutions specialized in care of individuals in Brazil and therefore, the external validity of the findings must be considered. ...
Introduction: Basic and daily oral hygiene care is essential for maintaining oral health in adults with special needs. The caregivers act in this process and need to be understood about the difficulties and the resources they use to deal with this demand. The aim of this qualitative study was to understand the difficulties and strategies of caregivers regarding oral hygiene for adults with special health care needs (SHCN) METHODS: Twenty-one caregivers of adults with SHCN participated in an interview in which the following questions were asked: What are the greatest difficulties in performing oral hygiene for the adult with SHCN you take care? and "How do you overcome these difficulties?" The interviews were recorded and the qualitative data were analyzed using the Discourse of the Collective Subject technique RESULTS: All respondents were female with a mean age of 58.5 years (± 10.8) and the adults with SHCN presented mean age of 30 years (± 18). The greatest difficulty pointed out by caregivers regarding oral hygiene for adults with SHCN was their non-cooperation to do such activity. Regarding coping strategies, caregivers pointed out several strategies to perform oral hygiene in adults with SHCN, such as supervising their brushing, seek for a qualified dentist to assist with this task, performing oral hygiene during the bath, performing physical restraint, among others CONCLUSION: The caregivers' perspectives indicate feelings of failure, discomfort, but also the use of creative resources to deal with the task. The results bring up themes that refer to anxieties and are related to technical and dental issues, that could be explored and need to be recognized by the reference oral healthcare team, whose responsibility it is also to work for the empowerment of caregivers.
... Despite the fact that 92.8% of those surveyed perform conservative dentistry in their daily practice and 82.5% recognize the application of minimal intervention concepts, 99.0% indicated fillings with Black's class II cavities, 3.0% indicate remineralizing treatments and 4.0% indicate radiographic control of the proximal areas. The concept of minimal intervention implies the philosophical concept of disease prevention and the preservation of dental structure (35)(36)(37); only with our change of attitude and patient education will we avoid over-treatment (38)(39)(40)(41). ...
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Background: The diagnosis of caries, the stage of the disease and the indication of treatment are among the most controversial issues in dentistry. Studies comparing the diagnosis and treatment indication of different professionals show the lack of a unifying criterion in the diagnosis and treatment plan of the disease. The Objectives of this research is to evaluate the attitude of a group of odontostomatologists to a clinical case with lesions compatible with caries, evaluating whether their criteria and attitude in diagnosis and treatment depend on their academic level, years of professional practice, the application of minimal intervention dentistry criteria and the usual practice in conservative restorative treatments. Material and methods: A survey was applied to dentists registered at the Illustrious Official College of Dentists of the Balearic Islands. The questionnaire was developed by the researchers from a real clinical case. A descriptive statistical analysis was performed of all the generated data and, to evaluate the association between the survey responses and the variables of interest, the χ^2 of independence test was performed. In addition, tests comparing the corresponding proportions were conducted using Fisher's exact test. Results: Regarding pit and fissure significant differences were found in the diagnosis in 46 in terms of dentists' qualifications and in the treatment between the application of minimal intervention dentistry criteria and the usual practice in conservative restorative treatments. No significant differences were found in the other variables analyzed. As regards caries lesions on proximal surfaces, no significant differences were found in the diagnosis or treatment in any of the variables analyzed. Conclusions: That there is no change in the professional attitude towards the diagnosis and treatment of caries lesions in this group of professionals, having very interventionist criteria and attitudes in all variables analyzed. Key words:Atraumatic restorative treatment, caries detection, demineralization, non-cavitated caries lesions, radiography.
... 5 Education critics suggest that current dental education models over-emphasize invasive treatment compared to preventative care, increasing tooth degradation instead of bolstering natural healing. 6,7 Oral public health research is criticized for 'downstream drift' 8 and point-of-care solutions (eg accommodation and charity) which lack engagement with, and advocacy regarding, the structural roots of disparities. 9,10 If public health problems are so muddled together with solutions, how do we know if our own work is part of the problem or part of the solution? ...
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This paper is the third in a series of narrative reviews challenging core concepts in oral health research and practice. Our series started with a framework for Inclusion Oral Health. Our second review explored one component of this framework, looking at how intersectionality adds important complexity to oral public health. This current manuscript drills into a second component of Inclusion Oral Health, exploring how labels can lead to ‘othering’ thereby misrepresenting populations and (re)producing harms. Specifically, we address a common oral public health label: vulnerable populations. This term is commonly used descriptively: an adjective (vulnerable) is used to modify a noun (population). What this descriptor conceals is the ‘how,’ ‘why,’ and ‘therefore’ that leads to and from vulnerability: How and why is a population made vulnerable; to what are they vulnerable; what makes them ‘at risk,’ and to what are they ‘at risk’? In concealing these questions, we argue our conventional approach unwittingly does harm. Vulnerability is a term that implies a population has inherent characteristics that make them vulnerable; further, it casts populations as discrete, homogenous entities, thereby misrepresenting the complexities that people live. In so doing, this label can eclipse the strengths, agency and power of individuals and populations to care for themselves and each other. Regarding oral public health, the convention of vulnerability averts our research gaze away from social processes that produce vulnerability to instead focus on the downstream product, the vulnerable population. This paper theorizes vulnerability for oral public health, critically engaging its production and reproduction. Drawing from critical public health literature and disability studies, we advance a critique of vulnerability to make explicit hidden assumptions and their harmful outcomes. We propose solutions for research and practice, including co‐engagement and co‐production with peoples who have been vulnerabilized. In so doing, this paper moves forward the potential for oral public health to advance research and practice that engages complexity in our work with vulnerabilized populations.
... The existing model of dental care, which largely depends on late stage and often expensive individual treatment by a limited supply of dentists, most of whom work in the private sector, 29 is clearly not adequately addressing the extent of the problem given ongoing rates of dental caries in children. 30 We are in agreement with Watt and colleagues that there is a need to focus on upstream factors associated with oral health-related inequalities. 31 We argue that without mid-range theory (including social practice theory) unpicking the 'black box', we will never have enough detailed analysis to identify the policy levers we might use to reduce inequalities. ...
Oral disease in early childhood is highly prevalent and costly and impacts on the child and family with significant societal costs. Current approaches have largely failed to improve young children's oral health. This paper proposes a different approach to conceptualize poor oral health in preschool children (0‐5 years) using social practices. Social practice theory offers an innovative perspective to understanding oral health by shifting emphasis away from the individual and onto how practical, social and material arrangements around the oral health of preschool children exist, change or become embedded in the social structures they inhabit. This novel approach contributes to the growing theoretical understanding in this area and has the potential to offer insights into the problem and ways it might be addressed.
... Professional narratives often take a neo-liberal approach (for example, marketoriented reforms such as eliminating cost barriers that minimize access to health care services) to oral health injustice which focuses upon the importance of personal responsibility for lifestyle choices and the affordability of care [3,4]. To ensure that the dental profession remains 'fit-for-purpose' into the 21st Century, having an immutable voice in advocating for global reductions in oral health disparities [5], dental curricula need to correct their focus; incorporating the social determinants of health as a theme running through every learning activity. Dental schools must ensure that students not only understand how the social determinants of health impact the mouth and oral wellbeing, but also develop a deep sense of social responsibility and capacity to act towards their amelioration and management. ...
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Background Social conditions have a significant impact on the health of individuals and populations. While the dental curriculum is focused on teaching students about the diseases that affect the dentition and oral structures from a biomedical perspective, education about the social determinants of health is frequently regarded as less important. Thus, it occupies a smaller and disconnected part of the dental curriculum. The aim of this study was to explore the ways dental students conceptualised the social determinants of health after one year in dental school. Methods Reflective statements written by first year dental students at the end of the first year of study were collected. This qualitative study has an interpretivist basis and a thematic analysis of the reflections was conducted by two researchers. Metzl’s structural competencies were used as a further analytic device. Results Four inter-related themes were identified: First, professional attitudes taken up by students influence their conceptions. Second, structural barriers to students understanding social determinants of health generate partial understandings. Thirdly, the social gulf that exists between the student body and people of different circumstances provides context to understanding the student’s perspectives. Finally, we described how students were learning about the social determinants of health over the academic year. Conclusions Dental students face several challenges when learning about the social determinants of health, and translating these learnings into actions is perhaps even more challenging. Metzl’s structural competencies provide a framework for advancing students’ understandings. One of the most important findings of this research study is that coming to an understanding of the social determinants of health requires sustained attention to social theories, practical experiences as well as institutionalised attitudes that could be achieved through an intentional curriculum design.
Poor oral health affects the health and well-being of older adults in many ways. Despite years of international research investigating poor oral health among older adults, it has remained a largely unresolved problem. The aim of this article is to explore the combination of 2 key frameworks, ecosocial theory and intersectionality, to guide our exploration and understanding of oral health and aging and help inform research, education, policy, and services. Proposed by Krieger, ecosocial theory is concerned with the symbiotic relationship among embodied biological processes and social, historical, and political contexts. Building on the work of Crenshaw, intersectionality explores how social identities such as race, gender, socioeconomic status, and age interconnect in ways that can enhance privilege or compound discrimination and social disadvantage. Intersectionality offers a layered understanding of how power relations reflected in systems of privilege or oppression influence an individual's multiple intersecting social identities. Understanding this complexity and the symbiotic relationships offers an opportunity to reconsider how inequities in oral health for older adults can be addressed in research, education, and practice and increase the focus on equity, prevention, interdisciplinary care, and use of innovative technology.
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Introduction The role of primary caregivers in setting the foundation for a child’s oral health throughout life is well recognised. Due to the dominant behaviour-based approach, research to date has mainly focused on exploring individual primary caregivers’ oral health knowledge and behaviours. A social science approach involving social practice theories moves beyond individual attitudes, behaviour and choices to offer a better understanding of the ways in which collective activity relates to health. This qualitative metasynthesis will involve an interpretive synthesis of data found in published qualitative literature from developed countries. The aim of the metasynthesis is to identify social practices in families from published qualitative research with caregivers on preschool children’s oral health. Methods and analysis This is a protocol for qualitative metasynthesis. The following databases will be used: MEDLINE, EMBASE, Global Health and Dentistry & Oral Sciences Source (DOSS) using the web-based database search platform Ovid, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Scopus. The research team has determined search strategies by using relevant key terms. Qualitative studies published in English language on family factors related to preschool children (aged 0–5 years) from developed countries (2022 United Nations classification) will be included. Qualitative data analysis will involve thematic analysis of the reported factors influencing oral health of preschool children, from the perspective of social practice theory. Researchers will use NVivo software for organising and managing the data. Ethics and dissemination No ethics approval is required, as this study does not involve human subjects. Findings will be disseminated through professional networks, conference presentations and submission to a peer-reviewed journal.
BACKGROUND: According to the literature and statistical data, an increase in PND was noted, as well as a number of dental pathologies with PND in children. The structures and frequencies of occurrence of defects in the dentition of patients with PND were studied. As a result, a high risk of developing these pathologies was noted, while oxidative stress and the immune system were indicated as the leading links in the pathogenesis of dental pathology. AIM: is to determine the structure and frequency of occurrence of dentition deformities in children with PND to study etiopathogenetic factors and mechanism of pathology formation, followed by to develop preventive measures. MATERIAL AND METHODS: Was conducted on the basis of study in 299 patients aged 7-18 years; of them - 143 diagnoses of ICD based on the international classification of the disease (ICD-10). CONCLUSION: It was found that the prevalence of caries in temporary teeth in children MG-1 was 97.33%, in CG-1 84.61%; in permanent teeth, MG-2 and CG-2 amounted to 95.58 and 87.91%, hypoplasia 20.97%; violation of the timing of dentition 49.65%; - primary adentia 47.55%; - anomalies of completeness of teeth 64.33%; - endemic dental fluorosis 2.79% in PND and only -12.17%; -12.17%; -26.92%; -11.53%; and -0.6% in children and adolescents in the CG, respectively. CONCLUSION: Thus, non-carious lesions of the teeth and a shift in the timing of dental dentition in patients with MG are more common compared with CG and lead to a violation of the anatomy of the teeth and worsen the aesthetics of a smile, recorded hypertrophic gingivitis and periodontitis were characteristic of children with a severe form of PND and were a high-risk contingent for the development of dental pathology associated with the process of oxidative stress and with genetically determined dysfunction of the immune system, especially in older children with PND.
Oral healthOral health is an important but usually neglected healthHealth issue. Such as other aspects of healthHealth, it is under the influence of several factors at various levels. Thus, promoting the populationPopulation’s oral healthOral health requires an interdisciplinaryInterdisciplinary and multi-dimensional approach. This chapter defines oral healthOral health, and its relation to general healthGeneral health will be presented. It reviews disciplinesDiscipline that contribute to oral health promotionOral health promotion. Then, the conceptsConcept of oral health promotionOral health promotion will be reviewed, and finally, the teamwork approachTeamwork approach in the oral healthcare deliveryHealthcare delivery system will be emphasized. A schematic illustration to show how the implementation of interdisciplinaryInterdisciplinary and interprofessionalInterprofessional approaches will help to promote the populationPopulation’s oral and general healthGeneral health. The code of this chapter is 01110010 01,101,10101,101,11001,101,11101,101,11101,101,00101,101,11101,110,100 01,010,000.
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