Dental Public Health
Suparna Argekar, D.D.S.
and
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
References
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