Effectiveness of the ICCMS caries management system for children: a 3-year multicentre randomised controlled trial.

OBJECTIVE: This 3-year multicentre randomised controlled trial compared, in 6-7-year-old Colombian children, the effectiveness of the ICCMS (International Caries Classification and Management System) with a conventional caries-management system (CCMS) in terms of individual caries-risk, caries lesions, and secondarily, oral-health-related knowledge/attitudes/practices, and number of appointments. MATERIAL AND METHODS: With ethical approval, 240 6-7-year olds from six Colombian clinics were recruited. Trained examiners conducted the following baseline/follow-up assessments: Caries risk (Cariogram-ICCMS); caries severity/activity staging (ICDAS-merged combined radiographic/visual); sealants/fillings/missing teeth, and oral-health-related knowledge, attitudes and practices. Children received their randomly allocated (ICCMS/CCMS) care from dental practitioners. Outcomes: caries-risk control (children); caries-progression control (tooth surfaces); oral-health-related knowledge/attitudes/practices improvement (parents/children), and appointments' number (children). Descriptive and non-parametric/parametric bivariate analyses were performed. RESULTS: Three-year-follow-up: n = 187 (77.9%; ICCMS: n = 92; CCMS: n = 95) disclosed a baseline-to-3-year overall high-caries-risk children decrease (ICCMS: 60.9-0%, p < .001; CCMS: 54.7-5.3%, p < .001) (p > .05). ICCMS versus CCMS showed: fewer tooth-surface caries progression (6.2% vs 7.1%, p = .010) and fewer active-caries lesions (49.8% vs. 59.1%, p < .05); higher proportion of children with ≥2/day fluoride-toothpaste tooth-brushing practice (p < .05); similar mean number of appointments (10.9 ± 5.9 vs. 10.0 ± 3.8, p = .15). CONCLUSION: Both caries-management systems showed similar effectiveness in caries-risk control, with ICCMS more effectively controlling tooth-surface caries progression and improving toothbrushing practices.

CariesCare International adapted for the pandemic in children: Caries OUT multicentre single-group interventional study protocol.

BACKGROUND: Comprehensive caries care has shown effectiveness in controlling caries progression and improving health outcomes by controlling caries risk, preventing initial-caries lesions progression, and patient satisfaction. To date, the caries-progression control effectiveness of the patient-centred risk-based CariesCare International (CCI) system, derived from ICCMS™ for the practice (2019), remains unproven. With the onset of the COVID-19 pandemic a previously planned multi-centre RCT shifted to this "Caries OUT" study, aiming to assess in a single-intervention group in children, the caries-control effectiveness of CCI adapted for the pandemic with non-aerosols generating procedures (non-AGP) and reducing in-office time. METHODS: In this 1-year multi-centre single-group interventional trial the adapted-CCI effectiveness will be assessed in one single group in terms of tooth-surface level caries progression control, and secondarily, individual-level caries progression control, children's oral-health behaviour change, parents' and dentists' process acceptability, and costs exploration. A sample size of 258 3-5 and 6-8 years old patients was calculated after removing half from the previous RCT, allowing for a 25% dropout, including generally health children (27 per centre). The single-group intervention will be the adapted-CCI 4D-cycle caries care, with non-AGP and reduced in-office appointments' time. A trained examiner per centre will conduct examinations at baseline, at 5-5.5 months (3 months after basic management), 8.5 and 12 months, assessing the child's CCI caries risk and oral-health behaviour, visually staging and assessing caries-lesions severity and activity without air-drying (ICDAS-merged Epi); fillings/sealants; missing/dental-sepsis teeth, and tooth symptoms, synthetizing together with parent and external-trained dental practitioner (DP) the patient- and tooth-surface level diagnoses and personalised care plan. DP will deliver the adapted-CCI caries care. Parents' and dentists' process acceptability will be assessed via Treatment-Evaluation-Inventory questionnaires, and costs in terms of number of appointments and activities. Twenty-one centres in 13 countries will participate. DISCUSSION: The results of Caries OUT adapted for the pandemic will provide clinical data that could help support shifting the caries care in children towards individualised oral-health behaviour improvement and tooth-preserving care, improving health outcomes, and explore if the caries progression can be controlled during the pandemic by conducting non-AGP and reducing in-office time. TRIAL REGISTRATION: Retrospectively-registered-ClinicalTrials.gov-NCT04666597-07/12/2020: https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S000AGM4&selectaction=Edit&uid=U00019IE&ts=2&cx=uwje3h . Protocol-version 2: 27/01/2021.

Cariology consensus for undergraduates at dental schools in the Caribbean region.

AIM: To obtain a consensus on the domains of cariology for undergraduates in dental schools in the Caribbean. MATERIALS AND METHODS: Dental school deans from the Dominican Republic (DR) and Puerto Rico (PR) were invited to participate. Afterwards, 24 cariology faculty members from the dental schools in the DR received a 40-h workshop on the current understanding of dental caries. Then, representatives from participating dental schools in the DR and PR were divided into six groups and tasked with exploring the cariology domains described in the European and Colombian consensus. For each domain, the competencies in what the dental student, upon graduation, would have to (1) be proficient in, (2) have knowledge of, (3) and be familiar with were described. Two cariology consensus meetings to work on the domains and suggest changes for the Caribbean region were done, and representatives from the DR and PR agreed on a cariology consensus. For the second stage, Caribbean English-speaking countries were invited to participate in the consensus. Meetings were held with representatives from dental schools in Trinidad and Tobago (TT) and Jamaica (J) to include their suggestions on each consensus domain. RESULTS: A total of 15 dental schools (DR = 12; PR = 1; TT = 1; and J = 1) participated; they agreed on a new consensus considering the realities of the Caribbean participating countries. CONCLUSION: A cariology consensus for undergraduates was achieved for 15 dental schools in the Caribbean region. This accomplishment will promote a shift for the Caribbean dental schools' graduates towards a current understanding of dental caries.

How do dental practitioners, educators and students diagnose and manage caries risk and caries lesions? A COM-B analysis.

OBJECTIVE: The International Caries Classification and Management System (ICCMS™), a comprehensive, evidence-informed, best clinical practice system, comprises a 4D cycle: 1D-Determine risk; 2D-Detect and assess lesions; 3D-Decide on a personalized care plan; and 4D-Do preventive and tooth-preserving care. The aim of this study was to establish how Colombian dental practitioners, educators and students diagnose and manage caries risk and caries lesions using the COM-B model and the ICCMS™ system. METHODS: A total of 1094 participants (practitioners: n = 277; educators: n = 212; students: n = 605) completed a previously validated 79-item questionnaire which explores, based on the COM-B model, the practitioners' self-reported caries diagnosis and management behaviours. Descriptive statistics, Welch's ANOVAs and multiple linear regressions were computed. RESULTS: All groups generally performed the behaviours within the 4-D categories 'Most of the time' to 'Always' (students: 4.06 ± 0.95; educators: 3.94 ± 0.98; practitioners: 3.86 ± 1.01). The most frequently performed diagnosis behaviours (1D/2D) were for practitioners assessing initial/moderate lesions (4.09 ± 1.01) and for educators and students cleaning teeth before lesion assessment (4.41 ± 0.80 and 4.38 ± 0.77 respectively). The least frequently performed decision/management (3D/4D) behaviour was non-operative care for moderate-caries lesions (when applicable) (practitioners: 2.64 ± 1.23; educators: 2.68 ± 1.17; students: 3.22 ± 1.41). Opportunity (Resources and Relevance) was the best COM-B predictor for diagnostic behaviours, whereas capability and opportunity (Relevance) were the strongest predictors for management behaviours. CONCLUSION: Colombian practitioners, educators and students diagnose and manage caries risk and caries lesions implementing best practice with a high to very high frequency.

Core Cariology Curriculum Framework in Spanish for Latin American dental schools: development and consensus.

The aim of this study was to develop and achieve consensus on a cariology teaching framework for dental schools in Latin American Spanish-speaking countries. The Delphi process, with a ≥8 0% pre-defined participants' agreement, included three phases and a Coordinating Group. During the Preparation phase three panels of experts were selected and invited to participate: a) Regional academic/professional Dental Associations (Associations-Panel): n = 12; b) Regional Dental Schools (Dental-Schools-Panel): existing dental schools (n = 263) from the 19 Spanish-speaking regional countries; c) International academic/professional associations Peer Experts (Peer-Panel): n = 4. Based on consensus documents from Europe, Colombia, the Caribbean, USA, Chile and Spain, and updated scientific evidence, the Coordinating Group developed a baseline framework proposal of domains, main competencies (MC) and specific competencies (SC). The Consultation-Agreement and Consensus phases included three rounds of questionnaires with a step-wise sharing of the MC updated version of the consensus framework with the Dental-Schools-Panel and including SC with the Associations-Panel. Diverse communication strategies were used ( e.g ., independent google-form questionnaires and workshops). Consensus was reached after an on-site Associations-Panel workshop and secret voting, followed by an online meeting with the Peers-Panel. A total of 127 academic/professional institutions participated (Associations-Panel: 11, 91.6%; Dental-Schools-Panel: 112, 42.6%, all countries; Peers-Panel: 4, 100%). The baseline Cariology teaching framework of 5 domains, 10 MC and 92 SC underwent modifications after agreements for a final consensus framework consisting of 5 domains, 10 MC and 85 SC. A Core Cariology curriculum framework in Spanish for Latin American Dental Schools was successfully developed and agreed upon with regional dental academic and professional institutions.

Oportunidades y problemáticas para la adopción del paradigma actual de caries dental en Colombia desde la perspectiva de los docentes / Curricular-perspective analysis of opportunities and problematics around the new-caries paradigm in Colombian Dental Schools

RESUMEN Objetivo: Analizar oportunidades y situaciones problemáticas para la adopción del paradigma actual de caries dental, desde las reflexiones de docentes, acerca de aspectos curriculares y de los planes de estudio de los programas de odontología pertenecientes a la Asociación Colombiana de Facultades de Odontología. Metodología: Construcción participativa (n=44 docentes). Se realizaron grupos de discusión y entrevistas semiestructuradas con profesores del área de cariología e integrantes del comité de currículo, para acercarse al contenido de los planes de estudio, entendidos como expresión de la orientación curricular. Resultados: Se consideraron para el análisis 2 categorías: la primera, relacionada con las oportunidades identificando una tendencia que mostró la presencia de la temática de caries dental a lo largo de todo el plan de estudios. En la segunda se identificaron 4 tendencias relacionadas con situaciones problemáticas, y una de ellas reportó que la enseñanza de la caries dental continúa anclada en el enfoque de riesgo, con un escaso acercamiento a la dimensión social de la enfermedad, la otra planteó que en los aspectos teóricos hay una aproximación al paradigma actual, pero en la clínica predomina la concepción tradicional de la enfermedad; y el énfasis restaurativo. La tercera tendencia deja ver que se relacionan las teorías actuales de cariología con la adopción de algunos criterios diagnósticos. Por último, un manejo predominante respecto al paradigma actual de caries por parte de los Odontopediatras. Conclusión: Persisten concepciones reduccionistas de salud y de educación en los enfoques curriculares, que se reflejan en planes de estudio fragmentarios, poco posibilitadores de la incorporación del paradigma actual de caries dental.

ABSTRACT The Global Alliance-for-a-Cavity-Free-Future Colombian Chapter has embraced since 2010 to achieve by 2015 a national-wide cariology-teaching consensus on the new- caries paradigm as a disease continuum, with a series of stages from early to cavitated lesions. Aim: To analyse the opportunities and problematic situations around dental education in the new-caries paradigm from the curriculum perspective in the Colombian Dental Schools Association. Methodology: Two teachers from each school (n=23) were invited to participate: the responsible of most-caries teaching and the representative of curricular design (n=46). Discussion groups were conducted to analyse within the curriculum, facilitanting or limiting aspects, the new-caries paradigm incorporation process. These were complemented with a caries-management-guideline questionnaire answered by each school. Results: 44 teachers of 22 schools participated. Within the opportunity category, a relevant trend was found related with the presence of cariology as a transversal axis of the curriculum. In the problematic situations category, four trends were observed: 1. Cariology teaching continues being linked to the risk approach, without embracing the social dimension of the patology; 2. In the theoretical aspects related with cariology, there is an approximation to the new paradigm, but in the clinical practice the traditional patology conception and the restorative emphasis predominate; 3. The current evidence of cariology is related to the adoption of the diagnostic criteria; and 4. There is a predominant caries-new paradigm management within the paediatric dentists. Conclusion: Caries cirricula delivered in University dental schools in Colombia are fragmented and require the incorporation of the new caries paradigm.

Risk factors for early childhood caries experience expressed by ICDAS criteria in Anapoima, Colombia: a cross-sectional study.

The aim of this study was to assess whether caries risk, nutritional status, access to dental care and socio-behavioral factors are associated to two caries experience outcome variables using the Epidemiologic International Caries Detection and Assessment System (ICDASepi), which includes initial enamel caries lesions: 1- The presence of ICDAS-epi caries experience (dmf-ICDASepi ≥ 1), and 2- Having an ICDAS-epi caries experience (dmft-ICDASepi) higher than national figures for the same age. The sample included 316 eight- to 71-month-old children from the municipality of Anapoima, Colombia. Assessments included: prevalence and mean of caries experience using the ICDASepi system without compressed air-drying of teeth surfaces (dmf-ICDASepi), caries risk and nutritional status. Caregivers completed an elevenitem questionnaire assessing oral health-related social determinants, practices and quality of life (OHRQoL), and children's access to dental care. Data were analysed using the Wilcoxon-rank-sum test, the test, the Fisher-exact test, and bivariate-linear and non-conditioned logistic-multivariate regression models. Prevalence and mean number of teeth with dmft-ICDASepi were 65. 2% and 3. 5±4. 13, respectively. Nutritional status outside the normal status, lower educational level of caregivers and age were significantly associated with dmf-ICDASepi≥ 1. OHRQoL, access barriers to miss and to attend dental care, operative-treatment or emergency being the reason to attend dental care, high caries risk, and age were significantly associated with a higher-than-national dmft-ICDASepi. The significant associations found between early childhood caries experience and other variables represent oral-health inequalities in early childhood in Anapoima, Colombia.

El objetivo de este estudio fue evaluar en la primera infancia la asociación entre el riesgo de caries, el estado nutricional, el acceso a la consulta odontológica y los factores socio-comportamentales y dos variables de desenlace de experiencia de caries usando el Sistema epidemiológico Internacional de Detección y Valoración de Caries (ICDASepi), que incluye lesiones de caries en el esmalte: 1-La presencia de experiencia de caries ICDAS-epi (ceod-ICDASepi ≥ 1) y, 2- Tener una experiencia de caries ICDASepi (ceod-ICDASepi) mayor que los datos nacionales correspondientes para la misma edad. La muestra fue de 316 niños del municipio de Anapoima, Colombia, de 8 a 71 meses de edad. Las valoraciones incluyeron: prevalencia y promedio de experiencia de caries usando el sistema ICDASepi sin secado de las superficies de los dientes con aire comprimido (dmf-ICDASepi); riesgo de caries y estado nutricional. Los cuidadores respondieron un cuestionario de once ítems que valoraba en relación con salud oral, determinantes sociales, prácticas y calidad de vida y, el acceso de los niños a la consulta odontológica. Los datos fueron analizados con la prueba de suma de rangos de Wilcoxon, la prueba de χ2, la prueba exacta de Fisher y, modelos de regresión logística multivariada tipos bivariantelineal y no condicionada. La prevalencia de experiencia de caries (ceod-ICDASepi) fue de 65. 18% y el promedio de dientes con ceod-ICDASepi de 3. 5 ± 4. 13. El estado nutricional por fuera de rangos de normalidad, el bajo nivel educativo de los cuidadores y la edad se asociaron significativamente con ceo-ICDASepi ≥ 1. Se encontró asociación estadísticamente significativa entre tener un ceod-ICDASepi mayor que el promedio nacional y, calidad de vida relacionada con salud oral, barreras de acceso para perder y asistir a consulta odontológica, tratamiento operatorio o urgencia como motivo de consulta odontológica, alto riesgo de caries y edad. Las asociaciones estadísticamente significativas encontradas en este estudio entre la experiencia de caries de infancia temprana y demás variables representan inequidades en salud oral en la primera infancia en Anapoima, Colombia.

Core Cariology Curriculum Framework in Spanish for Latin American dental schools: development and consensus

Abstract The aim of this study was to develop and achieve consensus on a cariology teaching framework for dental schools in Latin American Spanish-speaking countries. The Delphi process, with a ≥8 0% pre-defined participants' agreement, included three phases and a Coordinating Group. During the Preparation phase three panels of experts were selected and invited to participate: a) Regional academic/professional Dental Associations (Associations-Panel): n = 12; b) Regional Dental Schools (Dental-Schools-Panel): existing dental schools (n = 263) from the 19 Spanish-speaking regional countries; c) International academic/professional associations Peer Experts (Peer-Panel): n = 4. Based on consensus documents from Europe, Colombia, the Caribbean, USA, Chile and Spain, and updated scientific evidence, the Coordinating Group developed a baseline framework proposal of domains, main competencies (MC) and specific competencies (SC). The Consultation-Agreement and Consensus phases included three rounds of questionnaires with a step-wise sharing of the MC updated version of the consensus framework with the Dental-Schools-Panel and including SC with the Associations-Panel. Diverse communication strategies were used ( e.g ., independent google-form questionnaires and workshops). Consensus was reached after an on-site Associations-Panel workshop and secret voting, followed by an online meeting with the Peers-Panel. A total of 127 academic/professional institutions participated (Associations-Panel: 11, 91.6%; Dental-Schools-Panel: 112, 42.6%, all countries; Peers-Panel: 4, 100%). The baseline Cariology teaching framework of 5 domains, 10 MC and 92 SC underwent modifications after agreements for a final consensus framework consisting of 5 domains, 10 MC and 85 SC. A Core Cariology curriculum framework in Spanish for Latin American Dental Schools was successfully developed and agreed upon with regional dental academic and professional institutions.

Risk factors for early childhood caries experience expressed by ICDAS criteria in Anapoima, Colombia: a cross-sectional study / Factores de riesgo de experiencia de caries temprana expresada con criterios ICDAS en niños de Anapoima, Colombia. Estudio de corte transversal

The aim of this study was to assess whether caries risk, nutritional status, access to dental care and sociobehavioral factors are associated to two caries experience outcome variables using the Epidemiologic International Caries Detection and Assessment System (ICDASepi), which includes initial enamel caries lesions: 1The presence of ICDASepi caries experience (dmfICDASepi ≥ 1), and 2Having an ICDASepi caries experience (dmftICDASepi) higher than national figures for the same age. The sample included 316 eightto 71monthold children from the municipality of Anapoima, Colombia. Assessments included: prevalence and mean of caries experience using the ICDASepi system without compressed airdrying of teeth surfaces (dmfICDASepi), caries risk and nutritional status. Caregivers completed an elevenitem questionnaire assessing oral healthrelated social determinants, practices and quality of life (OHRQoL), and children's access to dental care. Data were analysed using the Wilcoxonranksum test, the test, the Fisherexact test, and bivariatelinear and nonconditioned logisticmultivariate regression models. Prevalence and mean number of teeth with dmftICDASepi were 65.2% and 3.5±4.13, respectively. Nutritional status outside the normal status, lower educational level of caregivers and age were significantly associated with dmfICDASepi≥ 1. OHRQoL, access barriers to miss and to attend dental care, operativetreatment or emergency being the reason to attend dental care, high caries risk, and age were significantly associated with a higherthannational dmftICDASepi. The significant associations found between early childhood caries experience and other variables represent oralhealth inequalities in early childhood in Anapoima, Colombia (AU)

El objetivo de este estudio fue evaluar en la primera infancia la asociación entre el riesgo de caries, el estado nutricional, el acceso a la consulta odontológica y los factores sociocomporta mentales y dos variables de desenlace de experiencia de caries usando el Sistema epidemiológico Internacional de Detección y Valoración de Caries (ICDASepi), que incluye lesiones de caries en el esmalte: 1La presencia de experiencia de caries ICDASepi (ceodICDASepi ≥ 1) y, 2Tener una experiencia de caries ICDASepi (ceodICDASepi) mayor que los datos nacionales correspondientes para la misma edad.La muestra fue de 316 niños del municipio de Anapoima, Colombia, de 8 a 71 meses de edad. Las valoraciones incluyeron: prevalencia y promedio de experiencia de caries usando el sistema ICDASepi sin secado de las superficies de los dientes con aire comprimido (dmfICDASepi) ; riesgo de caries y estado nutricional. Los cuidadores respondieron un cuestionario de once ítems que valoraba en relación con salud oral, determinantes sociales, prácticas y calidad de vida y, el acceso de los niños a la consulta odontológica. Los datos fueron analizados con la prueba de suma de rangos de Wilcoxon, la prueba de χ2, la prueba exacta de Fisher y, modelos de regresión logística multivariada tipos bivariantelineal y no condicionada. La prevalencia de experiencia de caries (ceodICDASepi) fue de 65.18% y el promedio de dientes con ceodICDASepi de 3.5 ± 4.13. El estado nutricional por fuera de rangos de normalidad, el bajo nivel educativo de los cuidadores y la edad se asociaron significativamente con ceoICDASepi ≥ 1. Se encontró asociación estadísticamente significativa entre tener un ceodICDASepi mayor que el promedio nacional y, calidad de vida relacionada con salud oral, barreras de acceso para perder y asistir a consulta odontológica, tratamiento operatorio o urgencia como motivo de consulta odontológica, alto riesgo de caries y edad. Las asociaciones estadísticamente significativas encontradas en este estudio entre la experiencia de caries de infancia temprana y demás variables representan inequidades en salud oral en la primera infancia en Anapoima, Colombia (AU)

Formación del talento humano en salud / Educational like a part of the life

La precaria situación de salud de los colombianos genera hoy grandes retos para la formación del talento humano en salud, el cual está inscrito en un mundo diverso y globalizado en donde los grupos poblacionales sufren y viven cambios continuos en sus condiciones y calidad de vida, aumentando los índices de pobreza e inequidad. Las exorbitantes cantidades de dinero que fluyen en los mismos y pequeños grupos de poder, fomentan hoy el uso de una racionalidad de económica de mercado como rectora de la vida privead y públicas, con el pretesto de un interés modernizador del Estado como una de las expresiones del modelo Neoliberal. Este modelo trae consigo nuevos interrogantes; la re-emergencia de enfermedades ya controladas, las estructuras sociales que soportan la impunidad, la injusticia social y las violencias que alcanzan dimensiones incomprensibles, conflitos que no pueden ser ajenos a la formación del profesional de la salud como agente de cambio y como sujeto que pertenece al mundo compartido.

Construcción de un modelo educativo apoyado en las técnicas: táctil y audio-táctil a partir de la percepción en niños invidentes de 7 a 12 años / Construction of an educational model supported in the audio-tactile and tactile techniques from the perception in blind children from 7 to 12 years old

Esta investigación responde a la necesidad de introducirnos en el amplio campo de la promoción y prevención odontológica en poblaciones que presenten limitaciones físicas o mentales, en este caso concreto, niños invidentes. Se diseño un modelo educativo basado en técnicas táctiles y audio-táctiles que parten de la forma como los niños se perciben a sí mismos y al medio que los rodea. Participaron 24 niños pertenecientes a centros educativos especiales, cuya edad estuviera entre 7 y 12 años. Ambos sexos se desarrollan en dos fases, cada una de las cuales comprende diferentes talleres. Según la prueba estadística aplicada (U de Mann-Whitney) se concluyó que no hay diferencia significativa entre los resultados obtenidos con los dos modelos. Ambos modelos permitieron un cambio de actitud y conductas y lograron concienciar a los niños acerca del sentido que tiene la boca en el contexto de su cuerpo.

Representación social del proceso salud enfermedad en comunidades del resguardo de puerto Córdoba (yucunas) y del yaigoje apaporis (Bajo Apaporis), Amazonas-Colombia / Social representation of the health-disease process in the Indians of the Amazon, Colombia

La presente investigación de tipo cualitativo, desarrollaba en las comunidades indígenas de la Amazonía Colombiana, se propuso identificar y analizar las representaciones sociales del proceso salud-enfermedad y los métodos de curación y prevención, con el fin de adecuar y rescatar antiguas prácticas indígenas en salud. La metodología utilizada fue de corte cualitativo, enmarcando en la Investigación Acción Participativa IAP, con técnicas como: observación participante, acción participante, diarios de campo, entrevistas semiestructuradas, charlas educativas y talleres, por medio de las cuales se encontró que las comunidades indígenas amazónicas aún conservan sus métodos de curación y prevención, aunque algunos de sus pobladores han ido perdiendo sus creencias, debido principalmente a la cercanía del hombre blanco. Esta visión del mundo indígena frente al saber tradicional lleva a plantear que la representación social de la salud y la enfermedad está ligada a las creencias milenarias, a la funcionalidad y, definitivamente , al complejo cuerpo-espíritu-medio ambiente.