Dental Public Health
Suparna Argekar, D.D.S.
Kristin A. Williams, D.D.S.
Dental Public health is the science and art of preventing and controlling dental diseases and promoting dental health through organized community efforts. It is that form of dental practice that serves the community as a patient rather than the individual. It is concerned with the dental 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. 1
Along with definition, it is imperative that the dental public health specialist, whether that is the dentist or dental hygienist, has an in depth understanding in the field of public health administration, research methodology, and the control and prevention of oral diseases. 2 The goal of dental public health is directed towards the protection and improvement of the oral health of the whole population. This goal can only be accomplished by the cooperation and understanding between both the public and private sectors. The dental needs of many people can be met if this partnership between the two sectors exists.
From a patient care perspective there are many similarities between a private practice and the care given to a community from the dental public health specialist. In the practice of public health, it is the community that is the patient and not the individual. Instead of an examination on an individual, a survey will be conducted in the community. Like the examination of a patient, a survey is often initiated from a chief complaint- for example, lack of access to care, high caries rate, and higher prevalence of oral cancer. The survey can be a statistical assessment of oral health problems or it can be a reflection of the attitudes and behaviors of the public. 3 The general health history normally performed on the individual is known as the situational analysis, defined by the World Health Organization as the “assessment of population demographics, mobility, economic resources, and infrastructure.” 4
In public health the diagnosis made after the examination is represented by the analysis of the survey. Treatment planning for a patient is paralleled by program planning for a community. 5 When a patient is presented his or her treatment options, they ultimately have the final say whether or not to accept the treatment plan. Similarly the public health specialist must remember that communities decide which program(s) to accept and support as well as which they will not buy into.
The United States Surgeon General has reported that 80% of the oral disease is found in 25% of the population. The 25% is found in the underserved, at or below poverty level communities of the population. Dental caries is the most common infectious and chronic disease in children.6 Over half of school children have untreated dental disease. One in seven preschoolers also has dental disease. In the San Ysidro Community Health Study, it was found that 82% of the 4 to 6 year olds had at least one cavity and 28% of the 4 to 6 year olds had 7 or more infected teeth.7 Lack of insurance, cultural issues, lack of awareness of how to prevent dental disease, misdistribution of resources and public indifference are some of the reasons why getting dental care is not always accessible.
A goal of the public health dentist is to design programs which will reduce these tragic percentages. This can only be accomplished through the incorporation of public health programs which involve many sources. All successful health programs need to utilize the community leaders as well as having the input of the population being served.
Fluoridation has become known as one of public health dentistry’s greatest accomplishments. Fluoridation is defined as “the controlled addition of a fluoride compound to a public water supply in order to bring its fluoride concentration up to an optimal level to prevent dental caries.” 8 The use of fluorides in the United States has made a significant impact on the prevention of dental caries. It is thanks to the epidemiological studies of Dr. H. Trendly Dean in the 1930’s which demonstrated the relationship between dental fluorosis, the concentration of fluoride in the water and caries prevention. Prior to the 1945 controlled study of adjusted fluoride levels in the public water supply, in Grand Rapids, Michigan, there was not the consideration of fluoridating public water. Before the discovery of fluorides, dentists commonly treated significant anterior lesions, periapical abscesses and extracted first molars on children. The elderly population expected to have full extractions and complete dentures. Although oral health awareness has increased and the standards of the middle class have improved, it is fluoride that is the main influence for better oral health. It has shown to have “demonstrated to patients and non-patients alike that caries and subsequent tooth loss were not inevitable.” 9
There are now many public health programs which target populations with high caries rates to supplement the fluoride they have available. Some of the programs are on an individual basis while others are implemented on the community level. Many of the community fluoride interventions are designed to be completed while the children are attending school- i.e. school fluoride tablets, fluoride rinses, and sealant programs all of which are dispensed/performed in school-based programs.
In the Unites States, the mean temperature of a climate determines optimal water fluoridation levels. This is based on the assumption that people who live in hotter regions will drink more water. In a temperate climate, the optimal level of fluoridation is set by the US Public Health Service to 1.0 to 1.2 parts per million (ppm). It is decreased to 0.7ppm in hotter climates. Many other countries use the US Public Health Service guidelines, which have been developed using data from various epidemiological studies.10 These seem to be sufficient enough for developed areas of Europe, but the validity for Africa and Asia are still debatable. Because the world with its temperature fluctuations have changed since these guidelines for fluoride use were created, it becomes necessary to periodically monitor these levels. The unit of ppm is used in the United States, and since many other countries use the metric system, the unit of milligrams per liter (mg/L) is used.
Fluoridation information for the US is maintained by the Division of Oral Health of the Centers for Disease Control (CDC) in Atlanta. The data is forwarded voluntarily from the states to the CDC, and then is published periodically in the Fluoridation Census. The information provided contains specific data down to the community level in each state. By the end of 1988, the CDC estimated that some 132 million people in the US, 53% of the population, and over 9,700 different communities were receiving fluoridated water. Nine million of these people lived in areas where they received 0.7ppm fluoride occurring naturally in the water supply. The greatest concentration of natural fluoride is found in New Mexico, Illinois, and Texas.11
Local communities make the decision to fluoridate or not, with little involvement from the state government. While many applaud the concept of allowing states to make their own decisions regarding fluoridation, it requires an efficient and powerful state dental director to secure funds for fluoridation against other popular state programs.
The process of fluoridation affects everybody in a community. This is its greatest strength, and also its greatest weakness regarding social policy.
While fluoride has shown that it is the best approach to prevent caries, it is the most effective on the smooth surfaces of the teeth. The pit and fissure grooves- the chewing surfaces- are not protected by fluoride; instead they are protected best with the use of dental occlusal sealants. Dental sealants have been in use for the last 30 years in the United States and have proven to have an effective rate of 51%-67%.12
As part of the oral health objectives of the Healthy People 2010, 50% of the children in the United States should have their permanent molars sealed by the ages of 8 and 14. Unfortunately this is not the case; recent data show only approximately 15-20% is actually sealed. With this in mind, many programs have been devised to reach this target population. The School of Dentistry at Case Western Reserve University has begun an innovative sealant program to help achieve many of the Surgeon General’s oral health goals.
While many sealant programs have been devised and implemented throughout the United States the program at CWRU have many unique qualities which make that program one of the most successful public health dental outreach programs currently running. This program takes dental professionals into the Municipal School District whose primary population is at or below poverty level. There is a health educator whose job is to not only teach the 2nd and 6th graders proper dental care, she also teaches them the increased risk of oral cancer if using any tobacco product, more healthful ways of eating and snacking, the importance of using a mouth guard and overall promote good oral health. She also informs the teachers of emergency protocol for mouth injuries and leaves them with lesson plans for them to implement in their curriculum which use proper oral health goals. This program employs dentists and a dental assistant whose job is to take the dental students into the schools to see the children. The children who have returned their consent forms are treated to a dental screening – detecting abnormalities including cavities, infections, tongue ties, malocclusions and any thing else that needs to be noted. The child will then get dental sealants placed if needed. One of the unique qualities of this program is that there is also a referral system with a social worker set up to have the child with an abnormal check-up seen by a dentist, irregardless of insurance coverage. This program also has the support of the community. The program is funded with local private foundation money as well as Robert Woods Johnson money. The school district is fully supportive of the program as well as the university, all forming a unique coalition which when present almost guarantees the success of a public health program.
Of all the conditions that the dental professionals come in contact with, oral cancer is the one that can have life or death implications. The occurrence and distribution of oral cancer is varied throughout the world; yet, the most persistent environmental risk factor is the use of tobacco in its many forms. Another area of interest to dentistry is the cessation of smoking and spit tobacco usage. This is an area where the private practitioner often has reservations about the extent to which tobacco cessation routine can fit into the scope of their general practice. However, all agree that tobacco cessation education is part of the dental professional’s responsibility. Tobacco use in general has been shown to have a wide range of serious adverse health effects. A host of oral problems including cancers of the tongue, lip, throat, pharynx, and mouth, as well as delayed oral wound healing, and oral mucosal changes all have been associated with the use of tobacco. In addition, tobacco use has been associated with adult periodontitis, worsening of periodontal treatment outcomes, halitosis, tooth staining and discoloration. Despite the advances in the treatment of oral cancer, the 5 year survival rates continue to be poor. “Therefore improvement in prevention and control of oral cancer is of critical importance.”13 The knowledge that many oral cancers are amenable to treatment, deem that a more aggressive public media plan needs to be put in place the disease would then be diagnosed at the first signs/ symptoms of onset. With the hope that the dental professional will take a more active role in the early detection of oral cancer, the American Dental Association continues to promote the dissemination of information about tobacco cessation to the profession.
“Unintentional oral-facial injuries may result in broken and avulsed teeth, facial bone fractures, concussion, permanent brain injury, tempromandibular joint dysfunction, blinding eye injuries, and even death.”14
Nothing alone can prevent all unintentional injuries; yet, since sports account for a high percent of the oral-facial unintentional injuries and it is estimated that 20-25 million American children participate in sports each year, it goes to reason that the use of mouth guards has the potential of positively affecting the number of injuries. “In Healthy People 2010 one of the national prevention objectives is to increase the proportion of public and private schools that require use of appropriate head, face, eye, and mouth protection for students participating in school-sponsored physical activities.”15 This provides a great opportunity for the dental profession as a whole to increase the knowledge base and availability of relatively inexpensive mouth protection. The American Dental Association has stepped to the forefront of this by making the use of mouth guards for school age children playing sports one of their current initiatives in programming.
The extent of programs covered by public health dentistry often varies widely in their method of delivery and content. These programs can encompass topics such as nutrition- diet and plaque control, smoking and spit tobacco cessation, mouth guard protection, fluoride, pit and fissure sealants and any other program which promotes oral health. They may also include areas like treatment of the handicapped, elderly, care for the chronically ill, and more recently disaster training including identification of outbreaks and identification of the dead. Since these programs have such variety, they often are overlapped with other public health curriculum from other fields of interest. One quality that must stay in the forefront is that part of our job is to disseminate information in a format that can be incorporated into an already formed community. We may have the most current information but if it can not be implemented into the already present culture, the information will not be put to use.
“In the field of dental care delivery, the great need now is for more teamwork. The diverse needs of world populations and the rapid scientific growth of professional dentistry have overshadowed the leadership of the superb clinical dentist keeping a tight rein upon his or her office staff. The licensed dentist must continue to be the leader, but of a more far-flung and responsible team than ever before. Dental public health is the special discipline for such leadership- to be built upon general dentistry with a quality approach to all levels of care from primary upward.” 16