Dental Public Health Practice, Infrastructure, and Workforce in 

the United States 

Astha Singhal, 
BDS, MPH, PhD 
a,*, Susan C. McKernan, 
DMD, MS, PhD 
b, Woosung Sohn, 
DDS, DrPH, PhD 
a 
KEYWORDS 
Dental public health Access to dental care Dental workforce Alternative dental providers 
KEY POINTS 
Dental public health is one of the nine specialties of dentistry that are recognized by the 
American Dental Association. Dental public health focuses on prevention of oral diseases and improving oral health of 
vulnerable populations. The infrastructure comprises a wide range of federal, state, local, and private organizations that 
employ dental public health workforce to operationalize the mission of dental public health, that is, to improve population oral 
health. 
INTRODUCTION 
The  dental  profession  is  primarily  responsible  for  the  oral  health  of  patients,  and dental public health evolved from it to address 
oral  health at a population level with a strong emphasis on prevention of oral diseases and ensuring provision of adequate preven- 
tive  and  treatment  services  among  vulnerable  groups.  Dental  public  health  is  a unique discipline that is formed by a marriage of 
multiple  broad  fields  that  include  dentistry  and  public  health.  Hence  the  definition,  scope,  and  infrastructure  included  under 
dental public health are broad and varied. 
DEFINITION OF DENTAL PUBLIC HEALTH 
The American Dental Association (ADA) defines the vision of dentistry as “Improved health quality of life for all through 
optimal oral health” and its mission is to “protect 
a Department of Health Policy & Health Services Research, Boston University Henry M. Gold- man School of Dental Medicine, 
560 Harrison Avenue, Boston, MA 02118, USA; b Preventive and Community Dentistry, University of Iowa College of 
Dentistry and Dental Clinics, 801 Newton Road, Iowa City, IA 52242, USA * Corresponding author. 560 Harrison Avenue, 3rd 
Floor Suite #342, Boston, MA 02118. E-mail address: [email protected] 
Dent Clin N Am 62 (2018) 155–175 https://doi.org/10.1016/j.cden.2017.11.001 dental.theclinics.com 0011-8532/18/© 2018 
Elsevier Inc. All rights reserved. 
 
Singhal et al 156 
and  preserve  the  oral  health  of  public.”  Dental public health is an integral part of this mission and it is one of the nine specialties 
of dentistry. It was established and recog- nized by the ADA as a dental specialty in 1950.1,2 
Dental  public  health  is  also  a  field  of  study  within  the  broader  discipline  of  public  health.  A  widely  accepted  traditional 
definition  of  public  health  is  “the  science  and  art  of  preventing  disease,  prolonging  life  and  promoting  human  health  through 
organized  efforts  and  informed  choices  of  society,  organizations,  public  and  private,  communities  and  individuals.”3  The 
Institute  of  Medicine  (IOM)  defines  public  health  as  “activities  that  society  undertakes  to assure the conditions in which people 
can  be  healthy.  This  in-  cludes  organized  community  efforts to prevent, identify, and counter threats to the health of the public.” 
IOM  also  identified  the  broad  mission  of  public  health  as  to “fulfill society’s interest in assuring conditions in which people can 
be healthy.”4 
The  professional  certifying  board  in  the  field  of  dental  public  health,  American Board of Dental Public Health (ABDPH) and 
its  parent  host  organization,  the  American  Asso-  ciation  of  Public Health Dentistry (AAPHD), have defined dental public health 
as  “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 admin- istration of group dental care programs as well 
as the prevention and control of dental diseases on a community basis.”5 
SCOPE AND PRACTICE OF DENTAL PUBLIC HEALTH 
Dental  public  health  distinguishes  itself  from  other  disciplines  of  dentistry  in  its  pursuit  and  practice  to achieve the goal of oral 
health.  Unlike  dental  practitioners  and  all  other  dental  specialties  that  focus  on  individual  patients’  oral  health,  dental  public 
health focuses on group of individuals or populations. 
The  conventional  view  of  dental  public  health  limits  its  scope  to  disease  prevention  (ie,  fluorides,  sealants,  and  oral  health 
education)  and  mainly  providing  oral  health  care  services  to  the  most  vulnerable  populations.  Although  these  are  its  major 
concerns,  dental  public  health  also  has  a  much  wider  scope  and practice. Reflecting on the mission of public health by the IOM, 
the scope and mission of dental public health is to prevent oral disease and promote oral health and general health and well-being, 
by ensuring the conditions in which people can achieve highest level of oral health. 
The World Health Organization defines oral health as follows6: 
Oral  health  is essential to general health and quality of life. It is a state of being free from mouth and facial pain, oral and throat 
cancer,  oral  infection  and  sores,  peri-  odontal (gum) disease, tooth decay, tooth loss, and other diseases and disorders that limit 
an individual’s capacity in biting, chewing, smiling, speaking, and psy- chosocial wellbeing. 
Similarly, the World Dental Federation defines oral health as follows7: 
Oral  health  is  multi-faceted  and  includes  the  ability  to  speak,  smile,  smell,  taste,  touch,  chew,  swallow  and  convey  a  range  of 
emotions  through  facial  expressions  with  confidence  and  without  pain,  discomfort  and  disease  of  the  craniofacial  com-  plex. 
Further attributes of oral health include the following: 
 It is a fundamental component of health and physical and mental well-being. It exists along a continuum influenced by the values 
and attitudes of individuals and communities; 
 
Dental Public Health Practice 157 
It reflects the physiologic, social and psychological attributes that are essential to 
the quality of life; It is influenced by the individual’s changing experiences, perceptions, expecta- 
tions and ability to adapt to circumstances 
Clearly,  the  scope  of dental public health to improve oral health should embrace not only physical but also psychosocial health 
and  well-being,  including  social  functions, connec- tions, and interactions with one another. The field also expands its practice to 
improving  the dental care delivery system and effective and efficient payment systems for dental ser- vices to ensure an effective, 
economical,  and  sustainable  dental  care  delivery  system  for  the  public.  This  wide  and  complex  scope  of  dental  public  health 
practice  increasingly  de-  mands  a  wide  range  of  advanced knowledge, skills, and experience in dental, behavioral, public health, 
education, social, and political sciences from dental public health workers. 
SPECIALTY RECOGNITION 
Dental  public  health  is  one  of  the  nine  dental  specialties  recognized  by  the  ADA.  ADA  recognizes  DPH  as “unique among the 
specialties  in  that  it  is not primarily a clinical specialty; it is a specialty whose practitioners focus on dental and oral health issues 
in  communities  and  populations  rather  than  individual  patients”  and  “part  of  dentistry  providing  leadership  and  expertise  in 
population-based  dentistry,  oral  health  surveil-  lance,  policy  development,  community-based  disease  prevention  and  health 
promo- tion, and the maintenance of the dental safety net”. 
Accordingly,  dental  public  health  practice  requires  comprehension  of  an  additional  body  of  knowledge  and  a  set  of  skills 
beyond  those  obtained  in  a  predoctoral  dental  ed-  ucation.  To  be  certified  as  specialists  in  dental public health, educational and 
training requirements are specified by the Commission on Dental Accreditation (CODA).5 
As  of  December  31,  2017,  there  were  228  active  ABDPH-certified  diplomates.8  Considering  that  there  were  196,441 
professionally  active  dentists  in the United States in 2016,9 dental public health specialists comprise less than 0.08% of all active 
den-  tists,  thus  making  dental  public  health  one  of  the  smallest  dental  specialties.  However,  there  were  732  dentists  who 
identified  their  work  as  being  in  the  area  of  public  health dentistry, comprising about 0.37% of all active dentists in 2016.9 This 
demonstrates  that  even  though  formally  board-certified  dental  public  health  specialists  are  few,  other  dental  professionals’ 
activities contribute to the work of dental public health. 
COMPETENCIES IN DENTAL PUBLIC HEALTH 
Specific  dental  public  health  expertise  is  required  to  ensure  oral  health  and  groups  of  people,  or  populations  of  concern. 
Advanced  education  and  training  in  such  areas  as  epidemiology,  biostatistics,  policy, management, administration, and research 
pro-  vide  tools  to  help  a  population  achieve  better  oral  health.  There  are  certain  founda-  tional  knowledge,  practical 
understanding  and  skills,  and  professional  values  that  a  dental  public  health  professional  must  possess  to  be  effective  in  the 
practice  of  public health. These competencies provide guidance for dental public health specialists’ ed- ucation and qualifications 
and benchmarks for specialty education and training. 
The early attempts to establish dental public health competencies identified 165 competency objectives under the following four 
broad categories (1988)10: (1) health policy and program management, (2) research methods in dental public health, (3) oral 
health promotion and disease prevention, and (4) oral health services and delivery. In 1998, a total of 10 competencies were 
identified (Table 1), which emphasized prac- tical skills in addition to knowledge that a specialist trained in dental public health 
is 
 
Singhal et al 158 
Table 1 Dental public health competencies, 1998 and 2016 
1998 Competences New Competencies 1. Plan oral health programs for populations 2. Select interventions and strategies for the 
prevention and control of oral diseases and promotion of oral health 3. Develop resources, implement and 
manage oral health programs for populations 
1. Manage oral health programs for popu- 
lation health 
4. Incorporate ethical standards in oral 
health programs and activities 
3. Demonstrate ethical decision-making in 
the practice of dental public health 5. Evaluate and monitor dental care delivery 
systems 
2. Evaluate systems of care that impact oral 
health 6. Design and understand the use of sur- 
veillance systems to monitor oral health 
4. Design surveillance systems to measure oral health status and its determinants 7. Communicate and collaborate with 
groups and individuals on oral health issues 
5. Communicate on oral and public health 
issues 6. Lead collaborations on oral and public 
health issues 8. Advocate for, implement, and evaluate 
publish health policy, legislation, and regulations to protect and promote the public’s oral health 
7. Advocate for public health policy, legisla- tion, and regulations to protect and pro- mote the public’s oral health, and overall 
health 9. Critique and synthesize scientific 
literature 
8. Critically appraise evidence to address oral 
health issues for individuals and populations 10. Design and conduct population-based 
studies to answer oral and public health questions 
9. Conduct research to address oral and 
public health problems 
10. Integrate the social determinants of 
health into dental public health practice 
From Altman D, Mascarenhas AK. New competencies for the 21st century dental public health specialist. J Public Health Dent 
2016;76:S21; with permission. 
expected  to  master.11  Since  then,  society  and  individual  lives  have  undergone  significant  changes:  arrival  of  the  digital  age, 
changes  in  demographics  and  disease patterns, eco- nomic instability, and changes in social trends, to name a few. There are also 
widening  gaps  between  the  rich  and  the  poor  in  health  and  access  to  health  care,  changes  in  health care delivery system and its 
finance,  and  advancement  of  science  and  new  discoveries.  All  of  these  changes  impose  new  challenges  to  dental  public  health 
specialists  in  the  practice  of  improving  population  oral  health.12  In  2016,  the  ABDPH,  in  partnership  with  the  AAPHD  and 
others,  updated  competencies  for  the  dental public health specialist as listed in Table 1.13 The new competencies are expected to 
provide better guidelines for the expertise of dental public health specialists in the twenty-first century. 
PREVENTION: CORNERSTONE OF DENTAL PUBLIC HEALTH 
Although  the  new  competencies  do  not  include  specifically  the  word  “prevention,”  it  is  the  cornerstone  of dental public health. 
The  field  has  had  exemplary  achievements  in  primary  prevention  of  oral  disease  at  the  population  level.  The  discovery  of 
fluorides for caries prevention and wide dissemination of community water fluoridation are 
 
Dental Public Health Practice 159 
epic  examples  of  dental  public  health’s  focus  and  success in primary prevention at the population level. With the introduction of 
fluorides,  most  populations  in the United States no longer experience severe and rampant tooth decay, pain and swelling, or early 
loss  of  their  teeth  -  common  features  of  life  in  the  first  half  of  the  twentieth  cen-  tury.  Consequently,  community  water 
fluoridation  for  caries  prevention  was  recog-  nized  by  the  Centers  for  Disease  Control  and  Prevention  (CDC)  as  1  of  10  great 
achievements  in  prevention  during  the  twentieth  century.14  Community  water  fluorida-  tion  specifically  demonstrates  dental 
public  health’s  strategies  to  prevent  oral  disease  and  promote  oral  health  at  population  level  rather  than  individual  level,  by 
ensuring  “conditions  in  which  people  can  be  healthy.”4  Ubiquitous  use of fluoridated tooth- paste, school-based dental sealants, 
and fluoride varnish programs also exemplify primary prevention strategies of dental public health. 
Poor  oral  health  and  oral  diseases,  such  as  dental caries, periodontal disease, and oral cancer, develop through a multifactorial 
process  that  includes  biologic,  behav-  ioral,  psychosocial,  and  socioenvironmental  determinants.15  Hence,  preventing  oral 
disease  from  developing  also  requires  multilevel  complex  solutions.  Dental  public  health  professionals  conceptualize  this 
complexity  and  develop  preventive  ap-  proaches  that  target  factors  at  various  levels  of  risk  and  stages  of  disease,  drawing  on 
primary, and to a lesser extent, secondary and tertiary prevention. 
Public  health  does  not  only  affect  population  health,  but  it  is  an  essential  component  of  social  justice.16  The  World  Health 
Organization  Constitution  enshrines  “.the high- est attainable standard of health as a fundamental right of every human being.”17 
Dental  public  health  also  aims  to  ensure  equitable  and  just  access  to  resources  and  living  conditions  to  enable optimal oral and 
overall  health and benefit all sections of the society. An example is community water fluoridation, a primary prevention approach 
that  benefits  all  individuals  who  drink  fluoridated  water  through  community  water  supply  regardless  of  their  income  level, 
employment,  age,  gender,  and  race/ethnicity.  This  exhibits  dental  public  health’s commitment to the mission of public health by 
ensuring  that  the  environment  in  which  all  people  lead  their  lives  promotes  health  and  social  justice;  everyone is entitled to the 
conditions  that  can  maintain  health.16,17  Because  dental  public  health  plays  an  integral  role  in  carrying  out  this  so-  cietal 
function,  it  often  includes  advocating  for  and  providing  services  for  vulnerable  and  disadvantaged  population, such as children, 
the elderly, the low income, the developmentally disabled, uninsured or underinsured, and racial/ethnic and cultural minorities. 
CORE FUNCTIONS OF (DENTAL) PUBLIC HEALTH 
Public  health  comprises  a  wide  variety  of  functions  and  services,  which  are  classified  into  10  essential  services  that  form  a 
framework  (Fig.  1).  These  10  essential  services  are  broadly  grouped  into  three  core  public  health  functions  (1)  assessment,  (2) 
policy  development,  and  (3)  assurance.  Fig.  1  shows how the 10 essential services align within the three core functions of public 
health. These core functions were first outlined in the 1988 IOM report “The Future of Public Health.”4 
Assessment 
The  core  function  of  assessment  includes  collection,  assembly,  analyses,  and  distri-  bution  of  information  on  the  community’s 
health. It includes the following two essential public health services: 
1. Monitor health status to identify community health problems: This includes accu- rate and periodic assessment of the 
community’s health status to identify health 
 
Singhal et al 160 
Fig.  1.  Core  functions  and  essential  services  of  public health. (From National Center for Envi- ronmental Health. Core functions 
of  public  health  and  how  they  relate  to the 10 essential services. Available at: https://www.cdc.gov/nceh/ehs/ephli/core_ess.htm. 
Accessed July 23, 2017.) 
risks, disparities, and barriers and resources to address them. Examples of this type of activity are surveillance and maintaining 
health registries. 2. Diagnose and investigate health problems and health hazards in the community: Using regularly collected 
information to identify and investigate threats to commu- nity health and plan a response to address such threats. Examples of 
this activity are epidemiologic investigations of disease outbreaks. 
Policy Development 
Like  the  name  suggests,  this  core  function  involves  the  development  of  comprehen- sive policies based on scientific knowledge 
and decision making. It includes the following essential public health functions: 
3. Inform, educate, and empower people about health issues: This essential service relates to how well-informed the community 
is about health issues facing them. It involves such activities as health education and promotion programs and making health 
educational resources available and accessible. 4. Mobilize community partnerships to identify and solve health problems: This 
service reflects how are community members engage to solve health problems that arise. It involves such activities as community 
engagement, coalition building, and identi- fying and working with stakeholders to address threats to community health. 5. 
Develop policies and plans that support individual and community health efforts: This relates to how public and private policies 
promote community health. Activities include appropriate resource allocation to ensure optimal health and systematic health 
planning and emergency preparedness at all levels of the population. 
Assurance 
Assurance  refers  to  making  sure  that  all needed health services are available. It fo- cuses on maintaining a competent capacity of 
public and personal health services. It includes the following essential public health services: 
 
Dental Public Health Practice 161 
6. Enforce laws and regulations that protect health and ensure safety: This refers to enforcing existing laws in a competent, fair, 
and effective manner. This includes reviewing and evaluating existing laws, educating the community about them, and also 
advocating for new regulations to promote health. 7. Ensure a competent public health and personal health care workforce: 
Making sure that the health workforce is competent and up to date with new developments is included under this essential 
service. Examples of activities include cultural compe- tency training and regular review of public health competencies and 
credentialing. 8. Link people to needed personal health services and ensure the provision of health care when otherwise 
unavailable: Identifying population groups that are facing barriers to care and ensuring an effective entry to health care system, to 
facilitate ongoing care are the foundation of this essential service. Examples of activities include enabling services, such as 
providing transportation, day care, or care coordination to facilitate health care access. 9. Evaluate effectiveness, accessibility, 
and quality of personal and population- based health services: Ongoing evaluation of personal and population health ser- vices 
must be conducted to improve quality and performance of these services. An example is examination of use of care to identify 
their effectiveness. 10. Research for new insights and innovative solutions to environmental health prob- lems: This involves 
ensuring that new ways to achieve better health for the com- munity are being discovered and used. It includes identifying and 
monitoring innovative methods to advance public health. Examples include epidemiologic, health policy, and health systems 
research. 
INFRASTRUCTURE OF DENTAL PUBLIC HEALTH 
Several  public  and  private  organizations  at  federal,  state, and local levels perform activities that fall under several core functions 
and  provide  essential  services  as  described  previously.  These  organizations  play  a  unique  role  in  ensuring optimal health of the 
communities. Many of these organizations are described next. 
United States Department of Health and Human Services 
The  US Department of Health and Human Services (HHS) is the principal federal agency that administers public health programs 
in  the  United  States.  The  HHS  has  a  stated  priority  of  protecting  the  health  of  all  Americans  and  providing  essential  hu-  man 
services,  especially  for  those  least  able  to  help  themselves.  The  President’s  budget  for  the  HHS  for  fiscal  year  (FY)  2017  was 
$1145 billion and the HHS has approximately 79,400 full-time equivalent employees of personnel.18 
Unite States Public Health Services 
The  US  Public  Health  Service  is  one  of  the  seven  uniformed  services  in  the  nation  and  is  comprised  of  more  than  6,000 
Commissioned  Corps  Officers  and  50,000  Civil  Service  health  professionals  who  serve  in  the  HHS  and  other  federal agencies. 
The  Surgeon  General  heads  this  uniformed  commissioned  corps.  The  Chief  Dental  Officer  is  appointed  by  the  US  Surgeon 
General  and  is  responsible  for  providing  leadership, co- ordination, and professional growth of the dental personnel in the Public 
Health Service. In 2017, there were more than 600 Commissioned Corps and Civil service dentists.19 
Indian Health Services 
The Indian Health Service is the primary health care provider and health care advocate for American Indian and Alaska Native 
communities. The Indian Health Service serves 
 
Singhal et al 162 
a  population  of 2.2 million American Indians and Alaska Natives across 36 states belonging to 567 federally recognized tribes.20 
The  Indian  Health  Service  has  been  actively  involved  in  the  development  of  programs  to  address  the  oral  health  needs of rural 
Alaska Natives who have substantial difficulty in accessing oral health services.21 
Centers for Disease Control and Prevention 
The  mission of the CDC is to promote health and quality of life by preventing and con- trolling disease, injury, and disability. For 
FY  2017,  the  President’s  budget  request  for  the  CDC  was  $6.98  billion.22  The  Division  of  Oral  Health  (DOH)  is  1  of  10 
divisions  within  the  National  Center for Chronic Disease Prevention and Health Promotion, with a budget of $14.4 million in FY 
2010.23  The  DOH  helps states, territories, and other countries collect oral health data, apply new methods for oral health surveil- 
lance,  monitor  the  status  of  community  water  fluoridation,  and  train  state  and  local  fluoridation  engineers  and  state  program 
leaders  on  fluoridation.  The  DOH  also  pro-  motes  and  provides  technical  assistance  on  school-based  and  school-linked  dental 
sealant  programs,  investigates  outbreaks  of  infectious  diseases  in  clinical  dental  set-  tings,  and  provides  infection  control 
information  for  dental  personnel  and  serves  as  a  resource  within  CDC  on  oral  health.  In  addition,  CDC  also  hosts  a  residency 
program in dental public health. The goals of DOH are 
To prevent and control dental caries (tooth decay) across the life stages To prevent and control periodontal (gum) disease To 
prevent and control oral and pharyngeal (throat) cancers and their risk factors To eliminate disparities in oral health To promote 
prevention of disease transmission in dental health care settings To increase state oral health program capacity and effectiveness 
National Center for Health Statistics 
The  National  Center  for  Health  Statistics  is  the  nation’s  principal  agency  for  providing  health  statistics  and  it  is  a  part  of  the 
CDC.  This  information  is  used  to  develop  policies  and  programs  to improve health. Oral health-related activities at the National 
Center  for  Health  Statistics  are  primarily  concentrated  in  the  Division  of  Health  and  Nutrition  Examination  Surveys,  which  is 
responsible  for  planning,  implementing,  conducting,  and  evaluating  examination  and  nutrition  surveys  at  National  Center  for 
Health Statistics. 
Office of Disease Prevention and Health Promotion and Healthy People 2020 
Healthy  People  2020  is a set of health objectives for the nation to be achieved by 2020 and administered by the Office of Disease 
Prevention  and  Health  Promotion.  Oral health is 1 of 42 priority areas, with 17 objectives and many subobjectives and a target of 
10%  improvement  over  the  decade  from  baseline.  The  oral  health  objectives  are  for  preventing  and  controlling  oral  and 
craniofacial  diseases,  conditions,  and  in-  juries,  and  improving  access  to  related  services.  Healthy  People  2020  is  available  at 
www.healthypeople.gov.24 
National Institutes of Health 
The  National  Institutes  of  Health  is  the  primary  federal  agency  conducting  and  sup-  porting  medical  research,  with  an  annual 
budget  of  more  than  $32  billion.25  The  dis-  coveries  from  these  institutes  have  prevented  diseases  and  improved the quality of 
people’s lives. This 100-year HHS agency achieves this by awarding competitive 
 
Dental Public Health Practice 163 
grants  to  researchers  in  its  own  laboratories,  universities,  medical  and  dental  schools,  and  other  research  institutions.  The 
National  Institutes  of  Health  is  made up of 27 different components, called institutes and centers, with specific research agendas, 
such as the National Cancer Institute, National Institute of Mental Health, and others. 
National Institute of Dental and Craniofacial Research (NIDCR) is one of the National Institutes of Health Institutes. The 
organizational mission is accomplished by: 
Performing and supporting basic and clinical research Conducting and funding research training and career development 
programs to ensure an adequate number of talented, well-prepared, and diverse investigators Coordinating and assisting relevant 
research and research-related activities 
among all sectors of the research community Promoting the timely transfer of knowledge gained from research and implica- 
tions for health to the public, health professionals, researchers, and policy makers 
The  NIDCR  plans,  develops,  and  manages  basic,  translational,  and  clinical  research  supported  by  grants,  cooperative 
agreements,  and contracts in dental, oral, and craniofacial health and disease. Some of the areas into which research is being done 
include  infectious  diseases,  health  disparities,  behavioral  and  social  aspects  of  health  and  disease,  temporomandibular  joint 
dysfunction,  developmental  biology  and  mammalian  genetics,  AIDS  and  oral  manifestations  of  immunosuppression,  bio- 
materials,  and  tissue  engineering  and  regenerative  medicine.  The  NIDCR  annual  budget  is about $400 million, 75% of which is 
distributed to grantees at universities, dental schools, and medical schools in the United States.26 
Health Resources and Services Administration 
The  primary  purpose  of  the  Health  Resources  and  Services  Administration  (HRSA)  is  to  improve access to health care services 
for  people  who  are  uninsured,  isolated,  or  medically  vulnerable.27  HRSA  grantees  provide  health care in all states to uninsured 
people;  people  living  with  human  immunodeficiency  virus  (HIV)/AIDS;  and  pregnant  women,  mothers,  and  children.  HRSA 
activities  are  managed  centrally  and  through  the  10  public  health  service  regions,  some  of  which  have  dental  consultants  with 
mostly  nondental  responsibilities.  The  bureaus  most  active  in  oral  health  are  HIV/AIDS,  Maternal  and  Child  Health,  Primary 
Health  Care,  and  Health  Professions.  In  addition,  HRSA  developed  the  Integrating  Oral  Health  and  Primary  Care  Practice 
initiative  that  seeks  to  improve  knowledge and skills of primary care clinicians and pro- mote interprofessional collaborations.28 
In  2013,  HRSA  awarded  funds  to  pilot  five  oral  health  competencies  in  three  health  centers  to  the  National  Network  for  Oral 
Health Access.28 
The  HIV/AIDS  Bureau  provides  clinical  care  and  support  for  uninsured  and  underin-  sured  individuals  and  families  of 
individuals  with  HIV/AIDS.  All parts of the Ryan White HIV/AIDS Program support the provision of oral health services for the 
recipients.  Spe-  cifically,  the  Dental  Reimbursement  Program  and  the  Community-Based  Dental  Part-  nership Program provide 
funds  for  dental  services  and  education  and  training  of  oral  health  providers.29  In  2010,  almost  $80  million  was  spent  on  oral 
health within all Ryan White HIV/AIDS Program parts and more than 141,000 clients received oral health care services.30 
The  Maternal  and  Child  Health  Bureau  is  responsible  for  ensuring  that  necessary  services  are  made  available  to  American 
mothers and children. Programs coordinated by the Maternal and Child Health Bureau, which include oral health, have as their 
 
Singhal et al 164 
objective  to  support  the  development  and  implementation  of comprehensive, cultur- ally competent, coordinated systems of care 
for  children  who  have  or  are  at  risk  for  chronic,  physical,  developmental,  behavioral,  or  emotional  conditions,  and  who  also 
require  health  and  related  services  of  a  type  or  amount  beyond  that  required  by  chil-  dren  generally.28  Within  the  Bureau,  the 
National  Maternal  and  Child  Oral  Health  Resource  Center  strengthens  state  and  community  oral  health  programs  that  increase 
access  to  quality  oral  health  care  for  all  maternal  and  child  health  populations  through  knowledge  building,  program 
development, and information sharing.28 
Several  other  programs  within  HRSA  address  oral  health,  including  the  Office of Planning, Analyses and Evaluation; Bureau 
of Health Workforce; Bureau of Primary Health Care; and Office of Rural Health Policy. 
National Health Service Corps 
This  HRSA  program provides incentives to health professionals to work in commu- nities that would otherwise be without health 
care.  Some  of  the  strategies  adopted  by  the  National  Health  Service  Corps  are  forming  partnerships  with  communities  and 
organizations,  student  loan  repayment,  and  recruiting  culturally  competent  clinicians.31  The  National  Health  Service  Corps 
program  has  field  strength of more than 1000 dentists and dental hygienists as of October 2010.32 Currently, the National Health 
Service  Corps  uses  loan  repayment  as  the  main  incentive  to  attract  profes-  sionals  to  work  with underserved populations. Fully 
trained and licensed dentists and dental hygienists may receive an initial, tax-free loan repayment award up to $60,000 for 2 years 
of service. Continued service provides the opportunity to pay off all dental profession student loans.32 
Centers for Medicare and Medicaid Services 
The  Centers  for  Medicare  and  Medicaid  Services  (CMS)  is  the  federal  agency  respon-  sible  for  administering  the  Medicare, 
Medicaid, the Children’s Health Insurance Pro- gram (CHIP), and the Health Insurance Marketplace. Medicaid is the federal- and 
state-funded  program  that  offers  benefits  to  eligible  low-income  and  needy  individuals  and  families.  States  are  required  to 
provide  dental  benefits  to  children  covered  by  Medicaid  and  CHIP  but  dental  benefits  are  optional  for  adults  covered  by 
Medicaid.33  Children  enrolled  in  Medicaid  receive  dental  coverage  under  the  Early  and  Periodic  Screening,  Diagnostic  and 
Treatment  program.  CMS  has  made  important  progress  in  improving  access  to  dental  care  among  children.  For  example,  from 
2007  to  2011,  almost  half  of  all  states  (24) achieved at least a 10 percentage point increase in the proportion of children enrolled 
in Medicaid and CHIP that received a preventive dental service during the reporting year.34 
The  dental  public  health  workforce is often intimately involved on the national, state, and local level, helping to improve these 
CMS  programs  and  to  provide  access  to  these  resources  for  vulnerable  populations.  There  are  two  public  health  dentists  who 
work  in  the  CMS.  CMS  launched  an  Oral  Health  Initiative  in  April  2010,  with  a  national  goal  to  have  at least 52% of enrolled 
children  ages  1  to  20  receive  a  preven-  tive  dental  service  in  federal  FY  2015.  Each  state  has  its own federal FY 2011 baseline 
and  federal  FY  2015  goal,  with  interim  yearly  improvement  goals  of  2  percentage  points.  Between  federal  FY  2011  (baseline) 
and federal FY 2012, a total of 15 states achieved at least 2 percentage point improvement in use of preventive dental services.35 
Medicare  is  the  federal  government–sponsored  and  –funded  health  insurance  pro- gram that covers people who are older than 
65 years and people less than 65 years who have certain disabilities or end-stage renal disease. It is administered in Parts 
 
Dental Public Health Practice 165 
A,  B,  C,  and  D  for  hospital  care,  outpatient  visits,  and  prescription  drugs.  Dental  ben-  efits  are  not  routinely  covered  under 
Medicare, except under certain conditions, such as oral cancer.36 
Agency for Healthcare Research and Quality 
The  agency  for  Healthcare  Research  and  Quality  (AHRQ)  is  a  federal  agency  that  in-  vests  in  research  on  the  nation’s  health 
delivery  system  that  goes  beyond  the  “what”  of  health  care  to  understand  the  “how”  to  make  health  care  safer  and  of  better 
quality.  It  also  helps  by  creating  materials  and  tools  to  teach  and  train  health  care  sys-  tems  and  providers  to  put  research  into 
practice, and generating measures and data used by providers and policymakers.37 
The  agency  collects  and  provides  data  for  research  and  administrative  purposes,  some  of  which  focus  on  oral  health.  For 
example,  the  Dental  Plan  Survey  asks  patients  to  report  on  their  experiences  with  care  and  services  from  a  dental  plan,  the 
dentists,  and  their  staff.38  Another  major  source  of  secondary  data  on  dental  care  use  in  the  United  States  is  the  Medical 
Expenditure  Panel  Survey  (MEPS),  conducted  by  AHRQ.  The  MEPS  is  a  set  of large-scale surveys of families and individuals, 
their  med-  ical  providers,  and  employers across the United States. MEPS is the most complete source of national data on the cost 
and use of health care and health insurance coverage.39 
Food and Drug Administration 
The  Food  and  Drug  Administration  is  responsible  for protecting the public’s health by ensuring the safety, efficacy, and security 
of  human  and  veterinary  drugs,  biologic  products,  medical  devices,  the  nation’s  food  supply,  cosmetics,  and  products that emit 
radiation. 
State Dental Public Health Infrastructure and Oral Health Programs 
Each  state’s  department  of  health  is  important  for  improving  the  oral  health  of  the  pop-  ulations  they  serve.  Most states have a 
dental  director  who  coordinates  efforts  and  helps  ensure  that  necessary  programs  and services are provided. These may include, 
but are not limited to, programs for the following40: 
Access to oral health services and workforce studies Early childhood caries (formerly baby bottle tooth decay) Fluoridation 
advocacy School fluoride mouth rinse and dental sealants Fluoride supplements and fluoride varnish Mouth-guard and injury 
prevention Clinical services and infection control Dental screening, needs assessment, and oral health surveys Oral health 
education and promotion Smoke and spit tobacco cessation Water fluoridation monitoring and private well fluoride testing 
Prevent abuse and neglect through dental awareness 
State  dental  directors  may  be  full-time  or  part-time.  There  is  considerable  variation  in the professional training and academic 
qualification  of  these  directors.  As  of  2014,  a  total  of  46  states  had  a  full-time  state  dental  director  position.41  Of  the 46 filled 
posi-  tions  24  were  managed  by  a  dental  public  health professional. The budget for dental activities in different states in 2014 to 
2015 ranged from $183,377 to $5,878,386.41 In 2014 to 2015, 12% of the states spent less than $500,000 on dental programs.41 
 
Singhal et al 166 
Local Health Department Infrastructure and Oral Health Programs 
The  local  health  departments  (LHDs)  in  the  cities,  towns,  and  counties  of  the  United  States  are  the  building  block  of  a 
functioning  public  health  infrastructure.  They  are  defined  as  an  administrative  or  service  unit  of  local  or  state  government 
concerned  with  health,  and  carrying  some  responsibility  for  the  health  of a jurisdic- tion smaller than the state.42 The LHDs are 
meant to understand the unique health problems facing their communities and develop programs and policies to meet these needs. 
They  are  guided  by  a  set  of  regulations  that  ensure they offer ser- vices to improve the health of their jurisdiction. In 2016, there 
were  2,533  LHDs  in  the  United  States.43  Rhode  Island  and  Hawaii do not have any substate units, hence no LHDs. All of these 
health  departments  are  unique  in  their  size,  activities,  jurisdiction,  and  infrastructure.43  In  the  2016  National  Profile  of  Local 
Health  Department  Report,  about  50%  of  LHDs  assessed  gaps  in  access  to  dental  care,  32%  to  37%  of  LHDs  implemented 
strategies to target and increase acces- sibility of existing services, and 24% of LHDs addressed gaps through direct pro- vision of 
dental services.43 
Dental Safety Net 
The  dental  safety  net  comprises  the  facilities,  providers,  and  payment  programs  that  support  the provision of dental care for the 
underserved  populations.44  This  is distinct from the broader dental care delivery system, which does not have a specific focus on 
care  provision  to  the  underserved  populations.  Although  several  sociodemographic  factors  are  associated  with  access  to  dental 
care,  cost  is  one  of  the  biggest  barriers  to  accessing  dental  care.45  Hence,  an  underserved  population  is  most  often  identified 
based on the household income, in addition to age, health status, geographic location, and language. 
The  dental  safety  net  is  heterogeneous  and  varies  considerably  in  availability,  comprehensiveness,  continuity,  and  quality  of 
care.44  The Federally Qualified Health Centers (FQHCs) and other community health centers form a significant part of the safety 
net.  These health centers serve low-income residents, migrants, homeless, pub- lic housing residents, and racial-ethnic minorities. 
Health  centers  serve  as  a  medical  home  for  more  than  24  million  people  nationally.  More  than  70%  of  FQHC  patients  have 
incomes at or below poverty level, 47% have Medicaid, 28% are uninsured, and about 50% reside in rural parts of the country.46 
Other than the health centers, dental schools, dental hygiene programs, and mobile dental programs, private practices that serve 
a  high  proportion  of  underserved  pa-  tients  and  other  volunteer  free  care  programs  also form essential components of the safety 
net. Lastly, hospital emergency rooms serve as a part of the safety net, often as a last resort for patients to seek care. 
PROFESSIONAL ORGANIZATIONS American Public Health Association, Oral Health Section 
The  American  Public  Health  Association  (APHA),  founded  in  1872,  is  the  oldest  and  largest  public  health  association  in  the 
world.  It  is  also  the  Secretariat  for  the  World  Federation  of  Public  Health  Associations  and  publishes  the  American  Journal  of 
Public  Health.  Because APHA is a multidisciplinary public health association, it provides its dental public health members with a 
forum  to  obtain  support  for  oral  health  programs  and  initiatives  from  nondental  public  health  leaders  and decision makers. The 
mem-  bers  of  the  Oral  Health  Section  in  APHA  promote  oral  health  issues  that  are  in  the  pub-  lic’s  interest  to  a  large 
multidisciplinary audience.47 
 
Dental Public Health Practice 167 
American Association of Public Health Dentistry 
The AAPHD began in 1937 and strives to improve oral health through promotion of effective efforts in disease prevention, health 
promotion,  and  service  delivery;  educa-  tion of the public, health professionals, and decision makers regarding the importance of 
oral  health  to  total  well-being;  and  expansion  of  the  knowledge  base  of  dental  public  health  and  fostering  competency  in  its 
practice.48 
The  AAPHD  started  as  a  group  of  state  dental  directors  with  restricted  membership.  Since  then  the  membership  criteria  has 
been  broadened  to  include  any  one  working  to  improve  oral  health.48  The  AAPHD  is  the  sponsor  of  the  American  Board  of 
Public  Health, publishes the Journal of Public Health Dentistry, and is a cosponsor of the yearly National Oral Health Conference 
with the Association of State and Territorial Dental Directors (ASTDD). 
American Board of Dental Public Health 
The  ABDPH  is  a  not-for-profit  organization  incorporated  in  1950,  and  is  the  national  examining  and  certifying  agency  for  the 
specialty  of  dental  public  health.  The  Board  was  organized  in  accordance  with  the  Requirements  for  Approval  of  Examining 
Boards  in  Dental  Specialties  of  the  ADA  Council on Dental Education and Licensure.49 The principal purposes of the Board, as 
defined  in  its  Articles  of  Incorporation,  are  to  protect  and  improve  the  public’s health by the study and creation of standards for 
the  practice  of  dental  public  health,  grant  and  issue  dental  public health certificates to dentists who have successfully completed 
the  prescribed  training  and  experience  requisite  for  the  practice  of  dental  public  health,  and  ensure  continuing  competency  of 
diplomates.49 
Association of State and Territorial Dental Directors 
The  ASTDD  is  primarily  made  up  of  state  dental  directors and provides information and advocacy to the states and territories in 
the  United  States.  The  ASTDD  supports  programs  and  initiatives  for  community  water  fluoridation,  school  fluoride  programs, 
school  sealant  programs,  workforce  development,  special  health  care  needs,  and  ac-  cess  to  oral  health  services,  which  may 
include  services  to  special  groups,  such  as  adults  and  seniors.  The  ASTDD helps develop state oral health surveillance systems, 
state  oral  health  coalition,  and  oral  health  plans,  and  promotes  best  practices  for  state,  territorial,  and  community  oral  health 
programs. The ASTDD is also an important resource for meeting the oral health objectives of Healthy People 2020.50 
American Association of Community Dental Programs 
The  American  Association  of  Community  Dental  Programs  (AACDP)  supports  the  ef-  forts  of  those  with an interest in serving 
the  oral  health  needs  at  the  community  level.  Members  include  local  dental  directors  and  staff  of  city-,  county-,  and 
community-based  health  programs.  The  AACDP  has  developed  several  publications  to  help  local  public  health  agencies 
incorporate  oral  health  into  public  health  ser-  vices.  These  include  “A  Guide  for  Developing  and  Enhancing  Community  Oral 
Health  Programs,”  “A  Model  Framework  for  Community  Oral  Health  Programs  Based  Upon  the  Ten  Essential  Public  Health 
Services,” and “Seal America: The Pre- vention Invention.”51 
American Dental Education Association 
The mission of the American Dental Education Association (ADEA) is to lead individ- uals and institutions of the dental 
education community to address contemporary 
 
Singhal et al 168 
issues  influencing  education,  research,  and  the  delivery  of  oral  health  care  for  the  improvement  of  the  health  of  the  public.52 
ADEA  has  a  section  on  community  and  pre-  ventive  dentistry  and  behavioral  sciences.  ADEA  also  publishes  the  Journal  of 
Dental Education and the Bulletin of Dental Education. 
National Network on Oral Health Access 
The  National  Network  on  Oral  Health  Access  is  a  nationwide  network  of  dental  pro-  viders  who  care  for  patients  in  migrant, 
homeless,  and  community  health  centers.  Members  have  displayed  commitment  to  improving  the  health  of  the  underserved 
through increased access to oral health services.53 
DENTAL WORKFORCE ASSURANCE 
Dental  public  health  emphasizes  the  availability  of  a  competent  oral  health  workforce  to  serve  the  American  population,  with 
particular  focus  on  ensuring  access  to  dental  care  for  traditionally  underserved  populations.  The  current  dental  workforce  is 
predo-  minated  by  dentists,  dental  hygienists,  and  dental  assistants.  However,  dental  thera-  pists,  community  dental  health 
workers, and other emerging provider models are becoming increasingly common. 
Dentists 
Since  2001,  the  US  dentist  workforce  has  increased  by  20%,  from  163,345  to  196,441  professionally  active  dentists.7  This 
translates  into  a  current  dentist/popula-  tion  ratio  of  approximately  61  dentists  per  100,000  Americans.  However,  wide 
geographic  variation  in  dentist  ratios  exists:  Arkansas  has  41  dentists  per  100,000  population,  whereas the District of Columbia 
has  88.5  dentists  per  100,000  popula-  tion.  It  should  be  noted  that  these  figures  include  dentists  working  in  a  variety  of  pro- 
fessional settings, including private practice, residencies, public health, research, and administration. 
Ten new dental schools opened in the United States from 2008 to 2016,54 for a total of 66 dental schools currently operating in 
the  United  States  and  10 in Canada.55 The number of dental graduates has increased consistently over the last decade, with 5811 
new  graduates  in  2015.55  After  completion  of  a  4-year,  university-based  curriculum  approved  by  CODA,  dentists  must  pass 
national  board  examinations  and  fulfill  a  clinical  examination  as  requirements  for  licensure.  Licen-  sure  requirements  vary  by 
state.  In  several  states,  dentists  may  complete  an  accredited postgraduate dental education program in lieu of, or in addition to, a 
clinical  licensure  examination.56  Dentists  may  choose  to  pursue  additional  education  in  an  advanced  education  program  for 
general practice or a dental specialty. 
Most  dentists  (79.0%)  are  general  practitioners.  The  three  most  common  dental  specialties  include  orthodontics  (5.4%  of 
practicing  dentists),  oral  and  maxillofacial  surgery  (3.9%),  and  pediatric  dentistry  (3.7%).7  As  the  newest  ADA-recognized 
dental  specialty,  oral  and  maxillofacial  radiology  has  shown  the  greatest  increased in work- force supply, from eight recognized 
specialists  in  2001  to  116  in  2016.  However,  pe-  diatric  dentistry  has  also  shown  substantial  growth,  with  that  workforce 
increasing by 84% since 2001, with 7337 specialists in 2016.7 
Recent  changes in the US dentist workforce reflect national shifts in demographics and professional work patterns. As of 2016, 
women  make  up  30%  of  professionally  active  dentists  in  the  United  States,  up from 16% in 2001, and dentists age 65 and older 
now make up 15% of the professionally active workforce.7 
 
Dental Public Health Practice 169 
The  US  HRSA  currently  estimates  that  8,323  dentists  would  be  required  to  alleviate  existing  designated  shortage  areas.57 
However,  this  estimate  does  not  necessarily  indicate  that  there  is  an  overall dentist shortage of this magnitude; workforce short- 
ages can also be created by geographic maldistributions of dentists relative to the overall population. 
Along  with  the  resultant  increases  in  dental  graduates,  retirements  from  the  Baby  Boomer  generation  will  also begin to slow 
down  over  the  coming  decades.  These  changes  are  expected  to  contribute  to  an  increased  per  capita  supply  of  dentists  in  the 
United  States  through  2035,  when  dentist/population  ratios  are  expected  to  be  nearly  67  dentists  per  100,000  population.54 
Increases  in  dentist  supply  are  expected even if adjustments are made for expected reductions in the number of hours worked per 
dentist and reductions in patient visits per dentist. 
Most  private  practitioners  employ  additional  nondentist  staff.  In  2013,  a  total  of  69%  of  dentists employed dental hygienists, 
87% employed chairside assistants, and 20% employed expanded-function dental assistants.58 
Dental Hygienists 
As  of  2014,  there  were  200,500  dental  hygienists  employed  in  the  United  States,  with  employment  projected  to  grow  19%  by 
2024.59  Hygienists  are  health  care  providers  who  must  graduate  from  an  accredited  education  program,  complete  a  national 
written  examination,  and  then  obtain  licensure  by  state  or  regional  clinical  examination.  Dental  hygiene  education  programs 
include  certificate  programs,  associate’s,  bachelor’s,  and  master’s  degree  programs;  most  hygienists  in  the  workforce  have  an 
associate’s de- gree. There are currently 336 accredited education programs in the United States.60 
Most  hygienists  work  in  private  dental  offices,  where  they  typically  provide  pro-  phylaxis,  scaling  and  root  planing,  take 
radiographs,  apply  sealants,  and  provide  topical  fluoride  treatment.  However,  they  are  also  employed  in  a  variety  of  other  set- 
tings, including community-based public health settings, and work under various degrees of dentist supervision. Scope of practice 
and  required  level  of  dentist  su-  pervision  are  established  by  state  law.  Under  direct  supervision,  a  dentist  is  required  to  be 
physically  present.61  With  general  supervision,  a  dentist  is  required  to  have  examined  a  patient  or  specifically  authorized 
services to be provided without an examination. 
Many  states  permit  less  supervision  in  certain  public  settings.  In  2016,  a  total  of  39  states  permitted  hygienists  to  provide 
preventive  oral  health  services  in  community-based  settings  (eg,  schools  and  nursing homes) without requiring direct or general 
supervision  by  a  dentist.60  Dental  hygienists  working  under  direct  access  requirement  can  assess  patients and initiate treatment 
without  the  specific  authoriza-  tion  of  a  dentist.62  In  1995,  five  states  permitted  direct  access;  in  2016,  a  total  of  39  states 
permitted  some  form  of  direct  access for hygienists. Direct access models include collaborative agreements with a dentist, public 
health  practice,  and  extended  care  permits.  Typically,  licensure  for  direct  access  has  additional  requirements,  often  including 
specified lengths of clinical experience, annual reporting, and carrying pro- fessional liability insurance.63 
California’s  direct  access  model,  the  registered  dental hygienist in alternative prac- tice, allows hygienists to receive advanced 
licensure  to  provide  unsupervised  services  in  practice  settings  that  are  traditionally  considered to be underserved: residential fa- 
cilities,  hospitals, dental health professional shortage areas, and residences of the homebound.62 One study of alternative practice 
in  California  found  that  most  patients  treated  by  a  registered  dental  hygienist  in  alternative  practice  were  medically  compro- 
mised or physically disabled.64 
 
Singhal et al 170 
Dental Assistants 
Dental  assistants  are  also  regulated  at  the  state  level,  with  allowable  tasks  and  super-  vision  requirements  varying  based  on 
education  and  training.65  Titles  also  vary  by  state,  with  certified  dental  assistants,  registered  dental  assistants,  and  expanded 
function  dental  assistants;  qualifications  and  scopes  of  practice vary considerably by state. In many states, dental hygienists may 
also apply for expanded duties as expanded function dental auxiliaries. 
There  are  a  variety of educational pathways for dental assistants, ranging from on- the-job training to formal training programs 
in  community  colleges, trade and technical schools, and dental schools. There are currently approximately 270 CODA-accredited 
dental  assisting  education  programs  in  the  United  States.  In  2014,  these  programs  graduated  a  total  of  5,756  dental  assisting 
students.65  Dental  assistants  may  directly  enter the workforce, although many states require additional credentialing or licensure 
to provide specific services.65 
Recent  national  data  indicate  that  there  are  approximately  300,000  jobs  for  dental  assistants  in  the  United  State,  with  job 
growth  projected  to  be  25%  by 2022. Since 1990, the ratio of dental assistants per dentist has remained stable, with 1.7 assistants 
per dentist in 2012.65 
Other Dental Providers 
Other  dental  providers,  often  referred  to  as  midlevel  providers,  include  dental  health  aide  therapists  (DHATs)  and  dental 
therapists.  Introduced  by  the  Alaska  Native  Tribal  Health  Consortium  in  2004  to  provide  care  for  Alaska  Natives  in  tribal 
villages,  DHATs  were  the  first  recognized  dental  therapists  in  the  United  States.  The  Alaska  Dental  Health  Aide Initiative also 
introduced  primary  dental  health  aides,  expanded function dental health aides, and dental health aid hygienists.66 By 2013, there 
were 58 dental health aides in Alaska, including 25 DHATs. 
The  Alaska  model  is  based  on  New  Zealand’s  dental  therapists,  originally  referred  to  as  dental  nurses.  DHATs  complete  2 
years  of  education  post–high  school,  complete  a  preceptorship,  and  are  certified  (rather  than  licensed)  by  Alaska’s Community 
Health  Aide/Practitioner  Program.  Curricula  and  standards  are  aligned  with  similar  providers nationally and with dental therapy 
programs in other countries.66 
The New Zealand model is now used in 54 countries.67 A review of the global liter- ature related to practice of dental therapists 
since inception of this model in 1921 found that most dental therapists are employed by government agencies to care for children, 
often in school-based programs.67 Because their scope of practice is primar- ily limited to children, studies have found that 
dental therapists improve access to care for that population. Studies have also consistently found that dental therapists provide 
more economical care, with quality comparable with that of a dentist.67 Dental thera- pists also have favorable patient and parent 
support in countries where they practice. Minnesota legislation authorized the practice of dental therapy in 2009.68 Originally, 
two programs were developed to educate dental therapists: a bachelor’s program leading to licensure as a dental therapist, and a 
master of dental therapy program leading to licensure as an advanced dental therapist. Since their inception, both pro- grams have 
been modified to provide the same curriculum. The bachelor’s program is a 32-month full-time program, whereas the master’s 
program is 16 months. Future Minnesota dental therapists will be dually licensed as dental therapists and dental hygienists.68 
Dental therapists in Minnesota are primarily limited by legislation to practice in set- tings that serve low-income populations, 
the uninsured, or in shortage areas.68 Dental 
 
Dental Public Health Practice 171 
therapists  are  required  to  work  under  a  collaborative  agreement  with  a  licensed  Min-  nesota  dentist,  with  scope  of practice and 
level  of  supervision currently varying for advanced dental therapists and dental therapists. By 2014, there were 32 licensed dental 
therapists  in  Minnesota.69  A  recent  evaluation  of  Minnesota’s  dental  therapists  found  that  84%  of  patients  served  by  dental 
therapists  were  enrolled  in  public  health  insurance  programs.69  Patients  reported  reduced  travel  times,  reduced  wait  times  for 
dental  care,  and  improved  satisfaction  with  dental  care.70  Dental  clinics  that  employ  therapists  report  increased  productivity, 
direct costs savings, improved patient satis- faction, and reduced broken appointment rates.69 
Recently,  Alaska’s  DHAT  model  has  been expanded to American Indian tribes in Washington and Oregon, with several tribes 
in  those  states  beginning  pilot  projects  to  hire  dental  therapists.70  Currently,  Maine  and  Vermont  also  recognize  dental  thera- 
pists as licensed providers; several states are considering legislation that would authorize dental therapy.71 
SUMMARY 
Dental  public  health  is  a  unique  specialty  of  dentistry  where  the  focus  is  on  the  commu-  nity  rather  than  an  individual,  and on 
prevention  rather  than  only  treating  existing  dis-  ease.  The  target  population  is  often  vulnerable  with  poor  access  to  the  dental 
care  delivery  system,  at  higher  risk  of  developing  dental  disease,  and  with  limited  resources  at  their  disposal.  This  presents  a 
complex  and  challenging  problem  that  requires  multi-  pronged  solutions  borrowing  constructs  from  multiple  disciplines.  As  a 
result,  dental  public health professionals and their training are an amalgamation of diverse disciplines including but not limited to 
preventive  dentistry,  epidemiology,  biostatistics,  behavioral  health,  health  economics,  health  policy,  and  health  care 
administration.  Although  there  are  only  154  active  board-certified  public  health  dentists  in  the  United  States,  the  dental  public 
health  workforce extends beyond that to include other dentists, dental hygienists, and nondental professionals who are working to 
further  the  goal  of  this  specialty.  These  professionals  work  at  local,  state,  and  national  levels,  and  in  private  organizations  to 
improve oral health and overall health of the population. 
ACKNOWLEDGMENTS 
The  authors  wish  to  acknowledge  Myron  Allukian  and  Olubunmi  Adekugbe’s  previ-  ous  article  titled  “The  Practice  and 
Infrastructure  of  Dental  Public  Health  in  the  United  States”  published  in  a  2008  special  issue  of  this  journal  (Allukian  & 
Adekugbe,  2008).  The  current  article offers an update and describes current dental public health practice and infrastructure in the 
United States. 
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