Formal care services depend on informal care-givers to ensure good health. For example, dentists rely on patients to restrict their children’s diet and to teach them the importance of oral hygiene during the socialization process. If lay members of society did not form their own care networks, the dental profession would be overwhelmed by disease. The importance of this is illustrated by the attempts to encourage self-care, as shown by the publication of self-care advice to the public on prevention of dental disease. This advice is summarized as this:

– Reduce the consumption and especially the frequency of intake of sugar-containing food and drink
– Clean the teeth thoroughly twice every day with fluoride toothpaste
– Request the local water supply company to adjust to the optimum fluoride content
– Have an oral examination by a dentist every year

These are explicit attempts to encourage the informal health care system. The emphasis is upon individuals developing control over aspects of their diet and oral hygiene. There is evidence that populations are improving their oral hygiene activity, with most people in industrialized countries brushing their teeth one or two times a day. As people develop these informal health care skills, their understanding and practice of what is appropriate behavior in terms of diet and oral hygiene may affect their relationship with formal health care workers. There could be both positive and negative effects of their increased personal control.
If people feel confident about their personal knowledge and skills, then they might develop a greater sense of competence. However, at the same time, they might not readily accept the value of what a dentist says. On the one hand, the informal health workers are expected to accept responsibility for personal health and know when they should access the formal care system, but on the other hand they are expected to be passive when meeting the professional. This has been described as a “double-blind”.
In general, studies of the dentist-patient relationship have not considered this double blind in detail. Research has been mainly concerned with variations in the behavior, feelings and attitudes of patients as these relate to patient management.
One outcome of the finding that informal health workers may have particular ideas about the management of symptoms is the discovery in many surveys of what has been termed the ‘clinical iceberg’. When people are asked to keep diaries of their health symptoms, many more symptoms are recorded in the diaries than are actually reported to the formal health care system. Thus, health professionals see only a small part of the illness in the community, just as only a small part of the iceberg is visible above the surface of the water.
There is a large discrepancy between the need for medical and dental care and the demand for formal health care services. Self-care is used to treat symptoms. A gradient of the likelihood of symptom experience leading to a consultation has also been established. People are much more likely to consult if they have a major disabling or threatening symptom, such as pain in the chest, than if they feel the symptom is more minor, such as a change in energy.
There are many oral health examples of this phenomenon. The UK National surveys of adult dental health, conducted every 10 years, usually report an almost universal presence of the clinical signs of gingivitis and periodontal disease in the general population.
Similarly, Locker (2009) asked a sample of Canadians to report any symptoms of oral or facial pain in the previous four weeks. Forty percent reported at least one symptom within this time period, but of these only 44% had sought professional attention. Indeed, only 62%of those with severe toothache had sought formal help.
This finding was not dissimilar to those reported by Anderson and Newman (2006), who found that 75% of their respondents with toothache would visit the dentist 61% with tooth loss, 54% with sensitivity to hot or cold and 45% with sore or bleeding gums. As with general health, there is a gradient of response to symptoms.