First Impressions Magazine

Broad View of Dental Care
For dental public health professionals, the community is the patient

"Dental public health" can be a tough term to get one’s mind around. It’s not as easy to grasp as, say, periodontics or endodontics. But here’s a simple way to look at it, courtesy of the American Dental Association.

In its definition of the term, the ADA says that dental public health is that form of dental practice that serves the community as patient rather than the individual. Yes, many public health professionals also practice chairside. But the fact of the matter is, when they put on their dental public health hats, they are looking at the dental health of broad populations of people rather than individuals in the chair.

As such, First Impressions readers probably won’t find themselves carrying their bag to the office of a dental public health professional, who typically works for a governmental body (federal, local, county, state) or an academic institution. However, distributor reps should keep in mind that the programs initiated by public health professionals in a given community – say, a consciousness-raising campaign about oral cancer screening – may translate to procedures being performed in dentists’ offices in that community.

Misconceptions
Dental public health is a recognized specialty of the American Dental Association, just as endodontics, pediatric surgery, prosthodontics, etc. Its standard-bearer is the American Association of Public Health Dentistry (www.aaphd.org), based in Springfield, Ill.

"There’s generally very little understanding of what public health dentistry is," says Scott Tomar, DMD, DrPH, Department of Community Dentistry and Behavioral Science, University of Florida College of Dentistry in Gainesville (and current president of the American Association of Public Health Dentistry). "Most people believe it’s general dentistry for poor people. Certainly, the safety net role has fallen on dental public health as a provider of last resort, but that’s not what the specialty is all about."

Indeed, the American Dental Association says that dental public health is "the science and art of preventing and controlling dental diseases and promoting dental health through organized community efforts …. It is concerned with the dental health education of the public, with applied dental research, and with the administration of group dental care programs as well as the prevention and control of dental diseases on a community basis."

That definition is well and good, says Tomar, but it is a bit dated. He’s hoping that it will be streamlined to read something like this: "Dental Public Health is the specialty of dentistry that applies the principles of public health in research, education, policy and services to prevent and control oral diseases and promote oral health in populations."

Who is a public health dentist?
Many dental health professionals run state or local dental programs, or are involved in dental academia and research, says Tomar. Like other dental specialties, public health has a board certification process. Today, there are probably about 200 or so Diplomates in the country. There are probably 500 or more AAPHD member dentists, and 500 or 600 ADA members who regard dental public health as their specialty.

The overwhelming majority of dental director positions at the local and county level are occupied by general dentists, many of whom still maintain practices. Unfortunately, relatively few have formal training in public health, let alone board certification. Even at the state level, the majority of dental directors have a master’s of public health degree in addition to a dental degree, but few are board-certified. And a more recent trend, according to Tomar, finds non-dentists, such as hygienists, filling some of these positions.

"A lot of jurisdictions don’t really understand the different types of skill sets required for dental directors," he says. "It’s one thing to run a dentist’s office, but it’s another to look after the oral health of the population." The latter calls for a variety of skills, such as creating outreach programs; building oral health coalitions; partnering with other constituencies, such as schools; and building oral health surveillance systems to monitor oral health status and the needs of the community.

In other words, the dentist stepping into a public health role has to adopt a different perspective of patient care, says Tomar. "No matter how good a clinician you are, you’re lucky if you see 10 to 20 patients a day. But an effective county dental director can reach thousands, if you set up school sealant programs, [get involved with] Head Start programs, and adopt population-focused approaches to treatment and prevention.

Targeted efforts
"The image of the public health dentist is of someone who’s doing the same general dentistry as a private practitioner, only for people on Medicaid or the uninsured. It’s true they could be serving some of these populations with disproportionate need, but they’re not necessarily delivering care in that way.

"For example, if you’re dealing with an underserved inner-city population that is experiencing very high decay rates, one way [to deal with it] is to drill and fill your way out," says Tomar. "The other is trying to set up preventive programs, such as school-based sealant programs, to substantially reduce the incidence of disease. Then you link that with a referral program, so that those with the most severe needs can be treated before they become symptomatic. Even if you’re dealing with vulnerable populations, you’re not necessarily addressing it strictly with a private-practice mentality."

Although dental public health shouldn’t be construed as a program solely for the impoverished, the fact is, certain populations experience a disproportionate burden of oral disease, says Tomar. Low-income people are one such group, as are a number of racial and ethnic minorities. People with special needs, such as the physically and developmentally disabled, also have a tough time finding appropriate care. In addition, dental care for institutionalized older adults is almost nonexistent, he says. "Particularly in a state like Florida, where [many older people live], it’s astonishing how few providers are available to serve people who are institutionalized."

It’s not surprising, then, that many of public health’s efforts are geared toward these groups.

Challenges to the public health
Healthy People 2010 is the federal government’s agenda to promote health and prevent disease nationwide, and oral health is an important part of it. (See accompanying piece for its oral health objectives.) A significant portion of people in the United States have oral diseases and many suffer from oral and facial pain, according to the government.

Indeed, tooth decay among children, which has declined from earlier years, remains a problem, says Tomar. About half of kids experience tooth decay by the age of nine, and the incidence of tooth decay among 2-to-4-year-olds is actually rising, he says. And he points to the potential dental-care crisis that awaits the elderly in the coming years.

And, as noted before, dental care for the elderly is a looming public health problem. "Older people will make up an increasingly large part of our population, and most of them will have a relatively intact set of teeth. They’ll be reaching old age with chronic diseases and multiple medications that can put their [oral health] at risk. This will happen at the same time that we lack the system in place to deal with it. I see this as a huge challenge – how dentistry will meet the needs of an older population with intact dentition."

Access to oral health care, just as access to medical care, will be a critical issue in the years ahead, says Tomar. Expanding the number of community health centers that provide dental health services is a positive step advocated by many. Indeed, a portion of the $508.5 million in federal stimulus funds targeted to community health clinics will go to dental care facilities.

Providing general dental services is an important component of public health dentistry, says Tomar. "But we really need to look at the problem more broadly than that," he says. "It’s important to provide 1-on-1 services to those who come to [community health centers] for care, but our challenge in public health is to look more broadly at the community and ask, ‘What can we do to reduce disease burden, rather than waiting for people to show up for treatment?’"

Educating the public about proper diet, brushing, regular checkups and oral cancer screening can all work to reduce disease burden. And that’s the job of the dental public health professional.

Sidebar
Healthy People 2010

Healthy People 2010 is a set of health objectives for the United States to achieve over the first decade of the new century. Developed for the federal government through a broad consultative process, it identifies the most significant preventable threats to health. It builds on initiatives pursued over the past two decades, including the 1979 Surgeon General’s Report, Healthy People; and Healthy People 2000: National Health Promotion and Disease Prevention Objectives. In short, Healthy People 2010 aims to achieve two goals: increase the quality and years of life, and eliminate health disparities.

Seventeen of the Healthy People 2010 objectives relate directly to oral health, and a number of others reflect the connection between oral disease and other chronic illnesses, such as diabetes and cancer. The overall goal of the Healthy People 2010 oral health objectives is to prevent and control oral and craniofacial diseases, conditions, and injuries, and improve access to related services.

Following are the oral health objectives of Healthy People 2010:

Objective: Reduce the proportion of children and adolescents who have dental caries experience in their primary or permanent teeth. Eighteen percent of children aged 2 to 4 years, 52 percent of children aged 6 to 8 years, and 61 percent of adolescents aged 15 years had dental caries experience in 1988-94. Target: Reduce those numbers to 11 percent, 42 percent, and 51 percent, respectively.
Objective: Reduce the proportion of children, adolescents and adults with untreated dental decay. Sixteen percent of children aged 2 to 4, 29 percent of children aged 6 to 8, 20 percent of adolescents aged 15 years, and 27 percent of adults aged 35 to 44 had untreated dental decay in 1988-94. Target: Reduce those percentages to 9 percent, 21 percent, 15 percent and 15 percent, respectively.
Objective: Increase the proportion of adults who have never had a permanent tooth extracted because of dental caries or periodontal disease. Thirty-one percent of adults aged 35 to 44 had never had a permanent tooth extracted because of dental caries or periodontal disease in 1988-94. Target: Increase to 42 percent.
Objective: Reduce the proportion of older adults who have had all their natural teeth extracted. Twenty-six percent of adults aged 65 to 74 years had lost all their natural teeth in 1997. Target: Reduce to 20 percent.
Objective: Reduce periodontal disease. From 1988-94, 48 percent of adults aged 35 to 44 years had gingivitis, and 22 percent had destructive periodontal disease. Target: Reduce those percentages to 41 percent and 14 percent, respectively.
Objective: Increase the proportion of oral and pharyngeal cancers detected at the earliest stage. Thirty-five percent of oral and pharyngeal cancers (stage 1, localized) were detected in 1990-95. Target: Increase to 50 percent.
Objective: Increase the proportion of adults who, in the past 12 months, report having had an examination to detect oral and pharyngeal cancers. Thirteen percent of adults aged 40 years and older reported having had an oral and pharyngeal cancer examination in 1988. Target: Increase to 20 percent.
Objective: Increase the proportion of children who have received dental sealants on their molar teeth. From 1988-94, 23 percent of children aged 8 years, and 15 percent of adolescents aged 14 years had received dental sealants on their molars. Target: Increase those percentages to 50 percent and 50 percent, respectively.
Objective: Increase the proportion of the U.S. population served by community water systems with optimally fluoridated water. Sixty-two percent of the U.S. population was served by community water systems with optimally fluoridated water in 1992. Target: Increase to 75 percent.
Objective: Increase the proportion of children and adults who use the oral healthcare system each year. Forty-four percent of persons aged 2 years and older in 1996 visited a dentist during the previous year. Target: Increase to 56 percent.
Objective: Increase the proportion of long-term-care residents who use the oral healthcare system each year. Nineteen percent of all nursing home residents received dental services in 1997. Target: Increase to 25 percent.
Objective: Increase the proportion of low-income children and adolescents who received any preventive dental service during the past year. Twenty percent of children and adolescents under age 19 at or below 200 percent of the federal poverty level received any preventive dental service in 1996. Target: Increase to 57 percent.
Objective: Increase the proportion of school-based health centers with an oral health component.
Objective: Increase the proportion of local health departments and community-based health centers -- including community, migrant and homeless health centers -- that have an oral health component. Thirty-four percent of local jurisdictions and health centers had oral health components in 1997. Target: Increase to 75 percent.
Objective: Increase the number of states and the District of Columbia that have a system for recording and referring infants and children with cleft lips, cleft palates and other craniofacial anomalies to craniofacial anomaly rehabilitative teams. Twenty-three states and the District of Columbia had systems for recording and referring children with craniofacial anomalies in 1997. Target: Increase to all states and the DC.
Objective: Increase the number of states and the District of Columbia that have an oral and craniofacial health surveillance system. No states or the District of Columbia had oral and craniofacial health surveillance systems in 1999. Target: Increase to all states and the District of Columbia.
Objective: Increase the number of tribal, state (including the District of Columbia), and local health agencies that serve jurisdictions of 250,000 or more persons that have in place an effective public dental health program directed by a dental professional with public health training.

Source: http://www.healthypeople.gov/Document/HTML/Volume2/21Oral.htm#_Toc489700401