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 CONTRIBUTORS

Van B. Afes, MS, MA Public Health Commission, Boston,

Assistant Professor and Curator, New York Massachusetts
University School of Medicine; Adjunct
Associate Professor and Director of the Library, Lester E. Block, DDS, MPH
New York University College of Dentistry, Director of Graduate Studies in Public Health,
New York Division of Health Services Research and
Policy, School of Public Health, University of
Myron Allukian, Jr., DDS, MPH Minnesota, Minneapolis
Director of Oral Health, Boston Public Health
Commission, Boston, Massachusetts David 0. Born, PhD
Professor and Director, Division of Health
Howard L. Bailit, DMD, PhD Ecology, University of Minnesota School of
Professor and Director, Health Policy and Dentistry, Minneapolis
Primary Care Research Center, University of
Connecticut Health Center, Farmington, Hillary L. Broder, PhD, MED
Connecticut Professor, Department of Community Health,
University of Medicine and Dentistry of New
Tryfon Beazoglou, PhD Jersey-NJ Dental School, Newark, New Jersey
Associate Professor, Department of Pediatric
Dentistry, School of Dental Medicine, JamesCrall, DDS, ScD
University of Connecticut, Farmington, Division of Community Health, Columbia
Connecticut University School of Dental and Oral Surgery,
New York
Muriel J.Bebeau, PhD
Professor, Department of Preventive Sciences, Marianne B. De Souza, RDH, BA, MS
School of Dentistry; Executive Director, Center Director, Greater New Bedford Tobacco Control
for the Study of Ethical Development; Faculty Program, New Bedford Department of Public
Associate, Center for Bioethics, University of Health, New Bedford, Massachusetts
Minnesota, Minneapolis
Eliezer Eidelman, DrOdont, MSD
Helene Bednarsh, BS, RDH, MPH Professor and Chairman, Department of
Clinical Instructor, Health Policy and Health Pediatric Dentistry, Hadassah School of Dental
Services, Boston University Goldman School of Medicine, The Hebrew University, Jerusalem,
Dental Medicine; Director, HIV Dental, Boston Israel

V
d CONTRIBUTORS

JamesR. Freed, DDS, MPH David C. Pendrys, DDS, PhD

Clinical Professor of Bentistry School of Associate Professor, Department of Behavioral
Dentistry, University of California at Los Sciences and Community Health, School of
Angeles Dental Medicine, University of Connecticut,
Farmington, Connecticut
Eugene Hittelman, MA, EdD
Associate Professor, Epidemiology and Health Benjamin Peretz, DMD
Promotion, New York University College of Clinical Associate Professor, Department of
Dentistry, New York Pediatric Dentistry, Hadassah School of Dental
Medicine, The Hebrew University, Jerusalem,
Alice M . Horowitz, PhD Israel
Senior Scientist, National Institute of Dental
and Craniofacial Research, National Institutes Burton R. Pollack, DDS, ID, MPH
of Health, Bethesda, Maryland Professor and Dean Emeritus, Dental Medicine
(Health Law), School of Dental Medicine, State
JeffreyP. Kahn, PhD, MPH University of New York at Stony Brook
Director, Center for Bioethics; Professor of
Medicine, University of Minnesota, Lynda Rose, MS
Minneapolis Senior Programmer/Statistical Analyst,
Division of Preventive Medicine, Brigham and
Bennett Klein, Esq., BA, JD Women’s Hospital, Harvard Medical School;
Director, AIDS Law Project, Gay and Lesbian Adjunct Faculty, Boston University School of
Advocates and Defenders, Boston, Medicine, School of Public Health, Boston
Massachusetts University, Boston, Massachusetts

Nancy R. Kressin, PhD Yvette R. Schlussel, PhD

Research Health Psychologist, Center for Epidemiologist, Department of Family Practice
Health Quality, Outcomes, and Economic and Community Medicine, St. Vincent’s
Research, Bedford VA Medical Center; Catholic Medical Center, Jamaica, New York
Associate Professor, Health Services
Department, Boston University School of Rima Bachiman Sehl, DDS, MPA
Public Health, Bedford, Massachusetts Associate Professor, Epidemiology and Health
Promotion, New York University College of
Mark D. Macek, DDS, Dr PH Dentistry, New York
Assistant Professor, Department of Oral Health
Care Delivery Baltimore College of Dental Michael Skolnick, BS
Surgery Dental School, University of University of Medicine and Dentistry of New
Maryland, Baltimore Jersey-New Jersey Dental School, Newark,
New Jersey
Madalyn L. Mann, BS, RDH, MS
Director of Extramural Programs, General
Dentistry, Boston University Goldman School
of Dental Medicine, Boston, Massachusetts
 PREFACE

he fifth edition of Jong’s Community Den- health has broadened to include social, polit-
tal Health is keenly aware of its historical ical, economic and cultural factors that affect
perspective. The new century, coupled with all aspects of health. Finally, affecting all of
the rapid emergence of new technology, prom- these areas is the discussion of bioethics.
ises a rapidly changing dental public health Part I (Dental Care Delivery) includes
landscape. This edition begins with a discus- Chapters 1through 4.Chapter 1defines public
sion of the organizational evolution of public health, describes the public health process,
health during the last century and launches us and explains the impact of public health on
into the future through the first Surgeon Gen- public policy. The author has compiled an
eral’s Report devoted to dentistry. appendix that describes government structure
A brief summary of public health over the and interrelationships of agencies that affect
last two hundred years reflects an accelerating public health activities. Chapter 2 summarizes
pace of change and suggests an important role the first Surgeon General’s Report on dentistry
for dentistry. Public health during the nine- and underscores the reasons why dentistry
teenth century was marked by urbanization has assumed such an important role in the
and need for better sanitation. Key functions health of the U.S. population. The next two
included the organization of health depart- chapters describe the make-up of the dental
ments and dealing with the epidemiologic care delivery system: from managed care to
conundrum of the nature of disease. care for the indigent. The poorly understood
The twentieth century saw the application Medicaid program is brought up to date, and
of the germ theory and implementation of the the role of dentistry within the Medicaid
scientific method. Also during this period one program is brought into perspective.
of the most exquisite of public health discov- Part I1 (Demographic Shifts and Dental
eries was made: the relationship between den- Health) comprises Chapters 5 through 7.
tal caries and the fluoride ion. Frederick Chapter 5 anticipates the increasing diversity
McKay, a Colorado dentist, observed that his of the U.S. population. The social and cultural
patients had chocolate-like stains on their health behaviors of these populations are con-
teeth. However, few of his patients had tooth sidered. Strategies for communication be-
decay. H. Trendley Dean, director of dental tween providers and individuals from diverse
research at the National Institutes of Health, population groups are suggested, and cultur-
collected water samples. He examined chil- ally determined attitudes are described. Chap-
dren’s teeth and ultimately established the ter 6 describes demographic shifts and focuses
relationship between fluoride and the reduc- on the aging population and the special needs
tion in dental caries. Today the scope of public of the elderly. Chapter 7, at the other end of

vii
viii PREFACE

the aging continuum, discusses the nature of 14) confronts the notion that the researcher
caries in children-and some elements of may manipulate statistical data to support a
prevention. biased position. The author then develops the
Part In (Distribution of Dental Disease and concept of biostatistics to demonstrate how
Prevention) consists of Chapters 8 through 13. bias becomes less likely through the applica-
Chapter 8 describes the distribution of dental tion of statistical concepts and discipline.
disease. An updated epidemiologic version of Chapter 15, through a discussion of the basic
the nature and distribution of oral disease, tenets of research design and a discussion
oral disease trends, and changes in the manner of evidence-based dentistry, explains how
in which certain diseases are described is "evidenced-based" provides a powerful tool
presented. Chapter 9 summarizes the status for an analysis of the scientific literature.
of the human immunodeficiency virus (HIV) Part V (Ethics and the Law in Community
and describes current infectious-disease chal- Dental Health) deals with public health and
lenges. The authors also review current community-based issues from a bioethical and
infectious-disease-related litigation and de- legal perspective. Chapter 1 4 defines some
scribe its impact on the practice of dentistry. basic principles of bioethics. The authors con-
Chapter 10 describes community programs clude that bioethics is about dilemmas that
that are designed to alleviate and prevent arise in individual cases. They spend the bulk
dental disease. In tandem, the authors of of the chapter presenting ethical dilemmas
Chapter 11 (two dental hygienists) continue that arise in reality-based dental cases.
the discussion of prevention, comparing re- They subsequently provide analysis from an
cent health promotion programs with pre- ethical-philosophic perspective. Among the
vious approaches and strategies and com- several cases, the authors lay out an in-depth
menting on recent innovations. Chapter 12 portrayal of third-party dentistry, sketch out
introduces and emphasizes the importance of dilemmas derived from third party scenarios,
planning, and lists the steps that comprise the and demonstrate how dentists and dental
initial and subsequent stages of successful hygienists are involved. Chapter 17, which
planning. Chapter 13 contrasts program eval- provides a description of the basics of the U.S.
uation and conventional research design. The legal system, comments on contemporary is-
discussion includes a definition and an expla- sues and how they affect the future of dental
nation of outcomes assessment. The process of public health. The author suggests that the
outcomes assessment has become the core new technology is bound to bring about a
process for the development of dental educa- burst of malpractice cases.
tion curriculum. The first edition of long's Community Dental
Part IV (Research in Dental Public Health) Health was created for the purpose of support-
describes two interdependent approaches to ing the educational curriculum of dental and
the analysis of public health research, behav- allied health students. The fifth edition, how-
ioral research, and community-based research: ever, includes matters that all those interested
(1) biostatistics and (2) evidenced-based re- in the nature of dental delivery in the United
search. The chapter on biostatistics (Chapter States will find edifying.
GEORGEM. GLUCK
WARREN
M. MORGANSTEIN
 ACKNOWLEDGMENTS

Any book is a collaborative enterprise. Cer- ever, most of all, the book owes its theme, its
tainly a book such as this one, which inte- organization, and the commitment of many
grates the works of various contributors, of the contributors to the early work of Dr.
owes much to the work of many individuals. Anthony Jong. At the time of his death,
The co-editors are responsible for the selec- Dr. Jong was an associate dean and chair-
tion of topics and contributors. At times, the man of the department of dental public
editors have felt like the organizers of a health at the Boston University dental
community dental health symposium. school. He forged this book out of his dual
This book has benefited from the inspira- interests: providing dental care for the un-
tion, cooperation, assistance, wisdom, and derserved and inspiring dental students
generosity of many people. Our acquisitions and dental hygiene students to pursue their
editor, Penny Rudolph, and the staff at interest, if not their career, in the field of
Mosby have been especially helpful. How- dental public health.
GEORGEM. GLUCK
WARREN
M. MORGANSTEIN

ix
This page intentionally left blank
 PERSPECTIVE

tists would be forestalled but will nonetheless

A N EXPANDING affect dental care delivery within the decade.
ROLE FOR DENTAL Additionally, population demographics
PUBLIC HEALTH suggest that workers who might normally
enter dental paraprofessional fields will have
The September 11, 2001, terrorist attack has expanded opportunities in other sectors of the
had an important impact on the nation’s econ- economy, and many states will be forced to
omy, and both national and local governments rely on immigration as a workforce resource if
have had to focus on security issues and the they are to maintain levels of economic
reallocation of scarce resources. Leading up to growth. These shortages will, of course, have
September the nation was once again locked an impact on dentists and their practices,
in debate over the increasing costs of health driving up employee wages and indirect costs;
care, and greater attention was being drawn to productive capacity of practices could easily
a burgeoning crisis in dental care delivery. be compromised. Then, too, although few
Reports from various states and at the national persons expect large-scale military drafts such
level focus on an impending shortage of den- as those seen during World War 11, the Korean
tists across the country. This shortage is mul- War, or the Vietnam War, the direct impact of
tifaceted but is chiefly the result of the fact that a prolonged military conflict on the dental
large numbers of dentists trained during the workforce is uncertain but could have a com-
1970s and into the 1980s are rapidly reaching pounding negative effect.
retirement age. With the cutbacks in enroll- In addition to a very real workforce crisis in
ments and the closures of dental schools that dentistry, managed care, health care financing
occurred from the early 1980s into the late pressures, stagnating rural economies, fewer
1990s, diminishing numbers of dentists have social and health service resources, an aging
been trained, and current production will not population, student indebtedness, minority
keep up with retirement and mortality losses health disparities, new challenges from an
to the profession over the next decade or two. array of diverse ethnic communities, and a
With the flattening of the stock market, some multitude of other factors are converging,
have speculated that many planned dental putting enormous pressure on the dental care
retirements may be delayed several years delivery system. The impact of these forces is
while dentists wait for their retirement port- yet to be felt; however, major, indeed revolu-
folios to recover. Should that speculation tionary, changes face the profession over the
prove accurate, the projected shortage of den- next 10 to 25 years. Among the changes that

xi
Xii PERSPECTIVE

seem most certain is_thatof the role of dental agencies, to explore new avenues of preven-
public health: as a field of study and as a tive dental education and care, to evaluate
career, dental public health seems destined to alternative methods of outreach and care de-
expand its influence and its realm of respon- livery, and, ultimately, to rethink the entire
sibility. Dental educators, professional associa- system of dental education and dental care
tions, and governmental bodies will find it delivery.
necessary to expand the role of public health
0.BORN,PHD
DAVID
 DENTAL PUBLIC HEALTH:
A N OVERVIEW
. Lester E. Block James R. Freed

he goal of the dental profession is to WHAT I S PUBLIC HEALTH?

protect and preserve the oral health
3f the public. Each dentist, dental hygien-
st, dental assistant, and dental laboratory
MISSION
OF PUBLIC -
HEALTH
technician is a member of a team of health “Public health is a coalition of professions
:are workers combating diseases that jeop- united by their shared mission,” states the
irdize the health of the public. As with any Institute of Medicine of the National Acad-
300d team, each member has an important emy of Sciences.’ The phrase “coalition of
role to play for the team to be successful. professions” stresses that the achievement
!&e purpose of this chapter is to examine of better public health requires more than
the discipline of dental public health and the participation of the various health pro-
the. contribution that dental public health fessions. It includes contributions from en-
practitioners make to protect and preserve gineers, educators, statisticians, political sci-
the oral health of the public. Perhaps most entists, policy analysts, and administrators,
importantly, this chapter seeks to empha- among many others. So one distinguishing
size the importance of teamwork among aspect of public health is individuals and
dental health professionals to achieve the groups banding together to achieve a com-
goal of optimal oral health for the public mon goal.
and the importance of teamwork between The next distinguishing characteristic of
them and other health professionals be- public health is the “shared mission” that
cause dental public health is an integral this coalition of professions seeks to achieve.
component of public health and is directly The public health mission statement devel-
affected by public health programs and oped by the Institute of Medicine is “fulfill-
policies. ing society’s interest in assuring condi-

3
4 DENTAL CARE DELIVERY

tions in which people can be healthy."' In example, is not simple. The traditional dic-
1995 a blue ribbon committee convened by tionary definition of health is being free
the Public Health Service published both from pain or d i ~ e a s eThis
. ~ limited defini-
a vision and a mission statement for pub- tion has proved insufficient to address is-
lic health: "Vision: Healthy People in sues of public health concern. In 1948 the
Healthy Communities" and "Mission: Pro- World Health Organization (WHO) created
mote Physical and Mental Health and Pre- a more encompassing definition of health in
vent Disease, Injury, and Disability."* These its constitution. WHO defines health as "a
mission statements are similar to those of state of complete physical, mental and social
the American Dental Association (ADA) well-being and not merely the absence of
and America'n Dental Hygienists' Associa- disease or infirmity."' The concept of a close
tion (ADHA). The "History and Mission relationship among mind, body, health, and
Statement" of the ADA calls for the protec- society is not new. Aristotle espoused it in
tion, enhancement, improvement, and pro- the third century BCE. He wrote that the
motion of the public's oral and general "health of body and mind is so fundamental
health and well-being3 The ADHA mission to the good life that if we believe men have
statement begins with, "To improve the any personal rights at all as human beings,
public's total health."4 then they have an absolute moral right to
The primary public health mission, how- such measure of good health as society
ever, differs from those of the ADA and alone is able to give them.'"
ADHA in that its primary focus is on "soci- Some believe that the WHO concept of
ety's interest." Public health is concerned health may be unrealistic in that freedom
with communitywide concerns and the from disease, stress, frustration, and disabil-
overall public interest, rather than the health ity is actually incompatible with the process
interests of particular individuals or groups of living and aging. Rene Dubos, for exam-
(which is not to negate the important part ple, wrote, "Complete and lasting freedom
that individual health care concerns have in from disease is but a dream remembered
public health). Although the concerns of from imaginings of a Garden of Eden de-
public health are broader than those of the signed for the welfare of man."" Pickett
many distinct and diverse professional dis- and Hanlon' suggest considering health as a
ciplines, including those of dentistry and continuum under which a disease or injury
dental hygiene, these disciplines are neces- may lead to an impairment, which may lead
sary for the attainment of optimal public to a disability, which may lead to a depen-
health.' Public health can accomplish its dency requiring external resources or aids to
mission only if partnerships can be fostered carry out activities of daily living. Health in
and nurtured among governmental and this continuum then can be defined as "the
nongovernmental public health agencies, absence of a disability."'
private organizations, and individual^.^,^ In 1920 Winslow" developed a widely
used definition of public health:
DEFINITION
OF PUBLIC
___-__- HEALTH
The science and art of preventing disease, prolong-
How public health is defined can provide ing life, and promoting physical and mental
insight into the complexity surrounding the efficiency through organized community effort for
use of the term. Defining the word health, for the sanitation of the environment, the control of
.-

DENTAL PUBLIC HEALTH: AN OVERVIEW 5

communicable infections, the education of the plans, implements, and evaluates the ap-
individual in personal hygiene, the organization of propriate interventions."
medical and nursing services for the early diagno- Another way to view public health prac-
sis and preventive treatment of disease, and the
development of the social machinery to insure
tice is to divide it, somewhat arbitrarily, into
everyone a standard of living adequate for the six categories:
maintenance of health, so organizing these benefits
as to enable every citizen to realize his birthright of 1. Epidemiology. Epidemiology is consid-
health and longevity." ered the basic science of public health.
2. Statistics. Although epidemiology and
This definition shows great understand- statistics are two separate disci-
ing in that Winslow recognized the impact plines, they combine to form the basis
of social, educational, and economic fac- for the assessment functions in pub-
tors on health. Although he did not in- lic health and for the collection and
clude either health care services or mental analysis of information and data.
health within his concept of public health, 3. Biomedical sciences. Because a major
his definition was advanced for its time. portion of disease is caused by microor-
Since then the focus of public health ganisms and genetic factors, the pre-
has continued to expand. It has moved vention and control of diseases in
from its earliest beginnings dealing with populations require an understanding
individual hygiene to include sanitary of how these factors affect the body.
engineering, preventive physical and men- 4. Environmental health sciences has always
tal medical science, social behavioral as- been a classic part of the public health
pects of personal and community medicine, infrastructure and is concerned with
and more recently the promotion and preventing the spread of disease
assurance of comprehensive health services through water, air, and food. Much of
for the great improvement in the health sta-
Public health now can be thought of as tus of Americans is because of im-
being concerned with four broad areas: proved environmental health.
(1) lifestyle and behavior, (2) the environ- 5. Social and behavioral sciences form the ba-
ment, ( 3 ) human biology, and (4) the orga- sis for understanding the role of be-
nization of health programs and systems. havior and social status in relation to
Thus public health is concerned with keep- health status, life expectancy, and utili-
ing people as healthy as possible and con- zation of services. Research, and its
trolling or limiting factors that impede application in these sciences, is most
health; it is the organization and application likely to have a significant impact on
of public resources to prevent dependency solving public health problems.
that would otherwise result from disease or 6. Health policy and management or health
injury. administration. As part of its assur-
Public health, in essence, determines ance function, public health seeks to un-
the health status of the community; identi- derstand the dimensions and operation
fies populations potentially affected or at of the health care delivery system to ad-
risk for a particular problem; analyzes the dress problems such as quality of care
dimensions of the problem through the use and disparities in regard to obtain-
of epidemiologic methodology; and then ing care.I3
6 DENTAL CARE DELIVERY

-P-m---w**--%*M

PUBLICHEALTH HEALTH though the terms dental and oral in regard to

AND COMMUNITY
---___I- ~I"II-x-__
health still are being used interchangeably,
The title of this book uses the term commu- use of the term dental is still more common.
nity dental health, whereas this chapter uses That may not be the case in the future. The
the term dental public health. Although both use of the term oral will most likely continue
terms often are used interchangeably, a dis- to increase because the term dental, in the
tinct difference exists between them. Both eyes of the public, is limited primarily to the
community and public mean a collection of teeth. The term oral, however, refers to not
people, a population, or a group of people only the teeth and gingivae and their sup-
having something in ~ o m m o n From .~ that porting tissues and bone but also the hard
perspective the terms public health and com- and soft palate, the lining of the mouth, the
munity health can be considered equivalent. throat, the tongue, the lips, the salivary
Current usage, however, tends to define glands, the masticator muscles, the lower
public to mean a general collection of people and upper jaws, and the temporomandibu-
without regard to a specific geographic area lar joints.14
in which they live. Community is used to
indicate a collection of people who are
THEPUBLIC'SPERSPECTIVE
located in a defined geographic area such as ON PUBLIC HEALTH
a city, nation, or state. In this regard, a
community is more commonly defined as a What much of the public, including many in
group or collection of people who live in the clinical health professions, does not re-
a specified geographic area that is of a alize is that public health has been primarily
limited size.7For example, although one can responsible for the most dramatic and sig-
refer to the community of St. Louis, the nificant improvements in the health of the
home base of the publisher of this book, one U.S. population. Since 1900 the average life
would not refer to the public of St. Louis. expectancy of persons in the United States
Another concept of community is a group has increased by more than 30 years, with 25
or collection of people having similar at- of those years (83%) being attributed to
t r i b u t e ~ .For
~ example, although one can advances in public health. The Centers for
refer to a community of dentists, dental Disease Control and Prevention (CDC) se-
hygienists, or dental assistants, one would lected a public health "top 10 list" for the
not refer to a public of those professions. twentieth century. Fluoridation of drinking
Another meaning of community is that of a water, which was initiated in 1945, is on the
particular location in which someone lives. list because it has played an important role
For example, one might ask someone in in the reduction of tooth decay in children
which community she or he lives, but it (40% to 70%) and of tooth loss in adults
would not make sense to ask someone in (40%to 60%) in the United States. The other
which public she or he lives.7 nine are vaccinations, motor-vehicle safety,
safer workplaces, control of infectious dis-
ORALHEALTH eases, decline in deaths from coronary heart
disease and stroke, safer and healthier
This book also has in its title the term dental foods, healthier mothers and babies, family
health. The term oral health has recently come planning, and recognition of tobacco use as
into greater prominence and is replacing in a health hazard.15
certain instances the term dental health. Al- Thus public health practitioners must
 DENTAL PUBLIC HEALTH: A N OVERVIEW 7

.face the reality that the public has a limited Regardless of the definition of public
understanding of the role and function of health, a lack of understanding associated
public health. A major reason for this is that with it will continue. One way to more
when public health is functioning optimally, clearly explain public health and to describe
it is invisible. For example, when a person its mission and purpose is by indicating that
eats at a restaurant in the United States and public health’’
does not get sick, turns on the tap to get a Prevents epidemics and the spread of
drink of water and out comes uncontami-
disease
nated water, walks outside and breathes the
Protects against environmental hazards
air and does not choke, walks into a building
Prevents injuries
and does not become enveloped by second-
Promotes and encourages healthy
hand smoke, he or she probably does not
behaviors
think of it, but the reality is that public health Responds to disasters and assists com-
has been doing its job. The public takes for
munities in recovery
granted a safe water supply, that food is not Ensures the quality and accessibility of
contaminated, that garbage is collected, and
health services
that a system safely removes and treats hu-
man waste. When we eat at restaurants, we More specifically, public health is less
expect that someone has established food food poisoning because of food inspection
safety standards and that the restaurant has programs, less death and disability from car
been inspected to ensure that those stan- accidents because of requirements for seat
dards have been met. And we expect that a belts and air bags, less lung cancer because
monitoring system is in place to detect out- of smoking cessation programs, less heart
breaks of disease in case of a breakdown in disease because of public education regard-
the established standards of hygiene. ing diet and blood pressure screening, less
In 1996 a poll conducted by Louis Harris childhood disease because of immunization
and Associates found that few Americans programs, fewer infant deaths because of
have any real idea what the term public prenatal care programs, and fewer dental
health means. When, however, its meaning caries because of water fluoridation.
was explained to them, “almost everyone
believed it to be very important.”16
Although media coverage of public WHAT IS
health issues has continually increased, the DENTAL PUBLIC HEALTH?
stories are rarely labeled as public health
stories and most people do not recognize Dental public health is a field of study
them as such. Even though the stories deal within the broader field of public health. Its
with obvious public health problems such philosophy and substance reflect public
as acquired immunodeficiency syndrome health and its focus on the community
(AIDS), food-borne diseases, lead or mer- rather than on the individual patient. An
cury poisoning, harmful drug interactions, early dental public health worker, J. W.
or polluted air, most people do not recog- Knutson, defined public health as follows:
nize them as public health stories because of
the multidisciplinary nature of the field and Public health is people’s health. It is concerned
the complex ethical and political issues that with the aggregate health of a group, a community,
are inherently part of each story.17 a state, or a nation. Public health in accordance
8 DENTAL CARE DELIVERY

with this broad definGion is not limited to the programs, and less oral cancer because of
health of the poor, or to rendering health services tobacco cessation and cancer screening
or to the nature of the health problems. Nor is it programs.
defined by the method of payment for health
services, or by the type of agency responsible for
The ADA has recognized dental public
supplying those services. It is simply a concern for health as one of nine specialties of dentistry.
and activity directed toward the improvement and The American Board of Dental Public
protection of the health of a population group in Health (ABDPH), which is the regulatory
the aggregate." agency for the specialty, was established in
1954. Dental public health's mission is set
As applied to dentistry, this definition forth in the definition adopted by the
implies that dental public health is con- ABDPH. It is a modification of the previ-
cerned only with the dental health of aggre- ously mentioned Winslow definition of
gate populations and not individuals. Now public health." The ABDPH defined dental
is a good time to reevaluate definitions such public health as
as these and amend them to more accurately
reflect that individuals, as well as groups, [Tlhe science and art of preventing and controlling
are of concern to the activities and interests dental disease and promoting dental health
of public health. A modification of h u t - through organized community efforts. It is that
son's definition to include this concept form of dental practice that serves the community
would be the following: Dental public as a patient rather than the individual. It is
concerned with the dental health education of the
health is a concern for and activity directed
public, with research and the application of the
toward the improvement and promotion of findings of research, with the administration of
the dental health of the population as a programs of dental care for groups, and with the
whole, as well as of individuals within that prevention and control of dental disease through a
population. This expanded concept of pub- community approach.""
lic health to include a focus on individuals
recently has been gaining increasing accep- Dental public health, like public health,
tance with the emergence of the term the recently has expanded its focus to include
new public health, in which the traditional the dental care delivery system and its
conception of public health is expanded to impact on oral health status. The reason for
include "the health of the individual in this is that the development of alternative
addition to the health of population^."^ delivery systems such as dental health
As with the more general term public maintenance organizations, independent
health, a better-understood explanation of practice associations, point-of-service orga-
dental public health may be best achieved nizations, and preferred-provider organiza-
by giving specific examples. Dental public tions are having an increasing impact on the
health is less tooth decay because of fluori- public's health. Public health's interest in
dated water and school fluoride programs, access to comprehensive and quality dental
less periodontal disease because of public care for the American public requires that
education programs, greater access to high- attention be paid to the increased role of
quality early diagnosis and treatment of third-party payers (e.g., insurance compa-
dental disease because of dental care deliv- nies, managed care plans) and the increas-
ery programs and research, less tooth dam- ing emphasis on cost control.
age among athletes because of mouthguard In today's complex society, therefore,
 DENTAL PUBLIC HEALTH AN OVERVIEW 9

dental health issues cannot be the exclusive that period led people to look more to
concern of any one sector of dentistry. In government to intervene in the social and
view of current economic, political, and economic structure of their lives.
social factors, which are increasingly influ-
encing the health services delivery system
A REPORTON THE FUTURE
in the United States, dental public health,
organized dentistry, and dental hygiene will -_ PUBLICHEALTH
_ OF
I____
II 11"-- lll_

of necessity find it mutually beneficial to In 1988 the Institute of Medicine (IOM)

work together more closely because the published The Future of Public Health.' The
overall mission of these groups is the same: report stated that public health in this coun-
optimal dental health for all Americans and try has deteriorated "like a two-lane high-
universal access to comprehensive care. way in the shadow of an interstate." The
landmark report declared the current sys-
tem to be fragmented and rudderless to the
PUBLIC HEALTH PRACTICE point of "disarray" and exposed a litany of
weaknesses, gaps, and challenges that
Two themes determine public health prac- threatened to overwhelm "this nation that
tice: the scientific knowledge regarding the has lost sight of its public health goals."''
causes and control of disease and the belief Part of the cause for the decline in public
of the public that the disease can be con- health has been that advances in technology
trolled and that doing so is a public respon- and science over the past decades have led
sibility.' An early example in this country of society to focus on diagnosis and cure of
the importance of both of these themes is disease rather than a public health infra-
Lemuel Shattuck's Report on the Sanitary structure that deals with community efforts
Conditions of Massachusetts. This report was aimed at the prevention of disease and
published in 1850 and is considered one of promotion of health.
the most important documents in the his- The major problems cited in the report
tory of public health in the United States.'T8 that require public health action include the
The scientific basis in Shattuck's report con- AIDS epidemic, pollution-related diseases,
sisted of vital statistics that demonstrated the surge in chronic diseases characteristic
differences in disease rates in different com- of an aging population, inadequate funding
munities. Although he considered that indi- of public health agencies, and the growing
vidual behavior was responsible in part for health care needs of the indigent.
these differences, he argued that because the The IOM report identified three core pub-
larger community could be affected, as well lic health functions: assessment, policy de-
as the individual, public action was neces- velopment, and assurance.' The American
sary. It was not until after the Civil War that Public Health Association, the national or-
increased public acceptance of the govern- ganization that addresses issues of public
ment's role developed, and Massachusetts health concern, delineated these three core
established a state board of public health in functions as follows":
1869.' The Great Depression in the 1930s
was another event that affected public Assessment can be best understood
health by altering the beliefs of people. The as a process whereby factors that
great social and economic insecurity during threaten the health of a population
10 DENTALCAREDELNERY

are identified, followed by a determi- prominent role in recent years. As we enter

nation as to whether resources are the twenty-first century, heart disease,
available to effectively deal with the stroke, and cancer are the leading causes of
identified health problems. Public death in the United States, whereas pneu-
health agencies must assess personal monia and tuberculosis led the list at the
health, environmental health, com- beginning of the twentieth century. Cur-
munity concerns and resources, and rently, public health efforts seek to reduce
data on the quality, range, and use of cigarette smoking and improve diet. Work-
public and private medical and place safety has become an increasing con-
dental services. cern for many occupational groups, such as
Policy development is the develop- convenience store clerks who are at high
ment of policy by public health risk for violent attacks. The leading cause of
agencies in response to specific com- death among children under age 14 in in-
munity and national health needs. dustrialized countries is preventable inju-
Public health agencies must develop r i e ~ . *Because
~ automobile accidents are a
comprehensive public health poli- major cause of death and injury, public
cies to improve health conditions, en- health measures for ”assuring conditions in
sure that policies are politically and which people can be healthy” include en-
organizationally feasible, and respect suring well-designed highways and cars
community values; devise measur- and the use of seat belts.’
able objectives and implementation
strategies; and identify resources
OF THEFUTURE OF PUBLIC
IMPACT HEALTH
needed to implement the health poli- REPORT
ON PUBLICHEALTH PRACTICE
cies developed.
Assurance means that public health The IOM report, The Future of Public Health,
agencies are responsible for seeing served as a catalyst to wake up and bring
that conditions contributing to good together the public health community at
health, including high-quality ser- the federal, state, and local levels, along
vices, are available to all. These agen- with other members of society concerned
cies also must provide essential with the health of the public, in the
public health and environmental realization that all was not well with the
health services; respond to personal country’s public health system. Arguably,
and environmental health emer- the report’s most important contribution
gencies; administer quality assurance was the development of the previously
programs; and guarantee care for mentioned three core public health func-
those not served in the current health tions of assessment, policy development,
care marketplace, including recruit- and assurance.
ing and retaining health care Since publication of the IOM report, a
practitioners to provide appropriate number of agencies and organizations have
services.21,22 worked to respond to the problems and
recommendations in the report. This section
With the increasing public health focus traces some of the responses devised by
on chronic diseases and injury prevention, these groups. Immediately recognizing the
the assurance function has taken on a more value of these core functions, the CDC, a
 DENTAL PUBLIC HEALTH: AN OVERVIEW 11

federal agency in the Department of Health c. Evaluate programs and provide qual-
and -Human Services (DHHS), created the ity assurance
Public Health Practice Program Office d. Inform and educate the public
(PHPPO) in 1989 for the purpose of further
clarifying the role of public health agencies
DENTAL RESPONSE
PUBLICHEALTH’S
in addressing the core functions. TOPUBLICHEALTH
COREFUNCTIONS
Soon after its formation, the PHPPO con-
vened a meeting of representatives from A work group of dental public health lead-
the major public health organizations: the ers was convened by the CDC and the
Association of State and Territorial Health Association of State and Territorial Dental
Officials (ASTHO),American Public Health Directors (ASTDD) in 1993 to elaborate on
Association (APHA), National Associa- the three core public health functions for
tion of County and City Health Officials dental health. The group developed the
(NACCHO), Association of Schools of following functions26:
Public Health (ASPH), U.S. Conference of
Local Health Officials (USCLHO), and 1. Assessment
Health Resources and Services Administra- a. Establish and maintain a state-based
tion (HRSA). Their task was to clarify and oral health surveillance system for
describe the local public health agency ac- ongoing monitoring, timely com-
tivities that are necessary to ensure that the munication of findings, and the use
three core functions of public health are of data to initiate and evaluate
implemented. The deliberations of these or- intervention.
ganizations led to the following set of 10 2. Policy development
organizational practices, organized under a. Provide leadership to address oral
the three core public health function^'^,^^: health problems with a full-time state
dental director and an adequately
1. Assessment staffed oral health unit with compe-
a. Assess the health needs of the tence to perform public health
community functions.
b. Investigate the occurrence of health b. Develop and maintain a state oral
effects and hazards in the community health improvement plan and,
c. Analyze the determinants of identi- through a collaborative process, select
fied health needs appropriate strategies for target
2. Policy development populations, establish integrated in-
a. Advocate for public health, build terventions, and set priorities.
constituencies, and identify resources C. Develop and promote policies for
in the community better oral health and to improve
b. Set priorities among health needs health systems.
c. Develop plans and policies to ad- 3. Assurance
dress priority health needs a. Provide oral health communications
3. Assurance and education to policy makers and
a. Manage resources and develop orga- the public to increase awareness of
nizational structure oral health issues.
b. Implement programs b. Build linkages with partners inter-
12 DENTAL CARE DELIVERY

ested in reducing the burden of oral problems and health hazards in the
diseases by establishing a state oral community.
health advisory committee, com- 3. Inform, educate, and empower people
munity coalitions, and governmental about health issues.
work groups. 4. Mobilize community partnerships to
c. Integrate, coordinate, and implement identify and solve health problems.
population-based intervention for 5. Develop policies and plans that sup-
effective primary and secondary pre- port individual and community health
vention of oral diseases and efforts.
conditions. 6 . Enforce laws and regulations that pro-
d. Build community capacity to imple- tect health and ensure safety.
ment community-level interventions. 7. Link people to needed personal health
e. Develop health system interventions services and ensure the provision of
to facilitate quality dental care ser- health care when otherwise
vices for the general and vulnerable unavailable.
populations. 8. Ensure a competent public health and
f. Leverage resources to adequately personal health care workforce.
fund public health functions. 9. Evaluate effectiveness, accessibility,
"'-w-w-
and quality of personal and
population-based health services.
I l j - m - p

PUBLICHEALTHFUNCTIONS
STEERINGCOMMITTEE 10. Conduct research toward new insights
- lll_ll_ll-- ----I 111 -"_" "-~"1"1

and innovative solutions to health

By 1993 public health leaders had realized problems.
that although the three core functions of
public health were widely accepted in the In 1997 the ASTDD developed a compa-
public health community, they had failed to rable set of 14 essential state dental public
communicate public health's role to elected health services to promote oral health in the
officials, policy makers, and the public. To United States.28
remedy that, public health officials decided
that public health needed a list of essential
~ ~ ~ - ~ ~ - ~ ~ ~ ~ -
THE1995 INSTITUTE
OF MEDICINE
public health services. In 1993 and 1994 the FOLLOW-UPREPORT
Public Health Service convened the Public
I

_ I --11 _-
I ~ - I - _ _

Health Functions Steering Committee. The In 1995 the TOM formed the Committee on
committee included representatives of fed- Public Health to determine the progress
eral, national, state, and local public health made since the release of its 1988 report. To
agencies. In 1995 the committee released a assist the committee, the IOM assembled a
document, "Public Health in America,'' that panel of people from government, acade-
specified the following 10 essential public mia, industry, and citizen and other private
health service^^,*^: sector groups. After a 9-month period of
study, the IOM published a report detailing
1. Monitor health status to identify com- the committee's analysis of the progress
munity health problems. made since the 1988 report was published.29
2. Diagnose and investigate health This report concluded that since 1988 a
7

DENTAL PUBLIC HEALTHAN OVERVIEW 13

significant strengthening of public health public health workforce's capacity and com-
practice in governmental public health petency, information and data systems,
agencies and in other settings had occurred. and organizational capacities of local and
In addition, however, the committee "en- state health departments and laboratories.
countered evidence that many of the prob- The public health infrastructure is defined as
lems identified in the Future of Public Health the underlying foundation that supports the
were still with us."29 planning, delivery, and evaluation of public
-------- health a~tivities.~~
This report, in asserting that the nation's
NATIONAL PUBLICHEALTH
current public health system could not pro-
PERFORMANCE STANDARDS
tect Americans from emerging threats, was
In 1997the IOM published Performance Mon- proved unfortunately to be prescient. This
itoring to Improve Community Health, which deterioration, which had been virtually
promoted the use of performance measures, overlooked by much of the country, was
standards, and monitoring to help ensure suddenly placed in the national spotlight on
that needed public health functions are September 11,2001. On that day, the United
pr~vided.~',~' States was suddenly and deliberately at-
In that same year the Public Health tacked by terrorists who flew two airplanes
Practice Program Office at the CDC, in into New York's World Trade Center, result-
partnership with the major national public ing in the collapse of its Twin Towers, and
health organizations, began a new initia- another plane into the Pentagon in Wash-
tive, the National Public Health Perfor- ington, D.C.36
mance Standards Program. The purpose of Unfortunately, it had to take September
this initiative was to advance the capacity 11 and the subsequent days of public anxi-
of public health agencies to better address ety caused by the fear of future biological
the public health weaknesses highlighted attacks for the state of the nation's public
in the Future of Public Health r e p ~ r t . ~ ~health
- ~ ~ system to be questioned. It has be-
The Standards Program will focus on the come apparent that the system is not sound
following goals: (1) improve quality and and lacks support. We must acknowledge
performance, (2) increase accountability, the need of repair immediately. Only time
and (3) increase the science base for public will tell whether the impact of 9/11 will
health pra~tice.~' result in the revitalization of public
--- health.36a
Since 1988 several other public health
---n7-

OF MEDICINE
INSTITUTE
YEAR2000 STUDY OF PUBLICHEALTH threats have emerged. Among these are the
_ " I _ _ _ _ - - I _

following2':
_ _ _ ~ I x _ - . ~ ^

In March 2001 a report prepared by the CDC

for the U.S. Senate was released. The report New and reemerging infectious diseases
found that the U.S. public health infrastruc- (e.g., a resurgence of tuberculosis),
ture is insufficient to protect Americans which have been identified as an urgent
from emerging threats. The CDC proposed a public health problem demanding a
major national initiative linking local, state, response that may be beyond the finan-
and federal agencies to address gaps in the cial means of many public health
14 DENTAL CARE DELIVERY

agencies. A number of these diseases health. The report suggests that dental pub-
have become resistant to antibiotics, lic health leadership ”must strive to articu-
threatening to reverse hard-won late the public’s oral health needs more
gains. clearly to dental, public health and health
The rising tide of violence that has policy makers.”37The following five inter-
come to be viewed as a major public related goals are recommended for dental
health problem. public health as a pathway to improved
An antiregulatory movement that has effecti~eness~~:
been sweeping through Washington,
threatening government’s ability to 1. Earn support from the public.
enforce standards and regulations, espe- 2. Earn support from policy makers.
cially in the areas of environmental and 3. Earn support from program
occupational health and safety. administrators.
Food-borne and waterborne microbes 4. Earn support from the dental
going undetected and environmental community.
hazards not addressed. 5. Ensure recruitment and professional de-
velopment of dental public health
personnel.

THEFUTUREOF___PUBLIC HEALTH ELEMENTSFOR SUCCESSFULPUBLIC

- HEALTH PROGRAMS
_I I I _ _ _ _ _ _ I - _ _

Leaders in the dental public health commu- II _lll ”- __--

l^l^_llllI I

nity recognized that the important pro- Public health successes include reductions
nouncements contained in the IOM report in lead poisoning, traffic fatalities, smoking,
also applied to dental public health.’ As a and dental caries. Although much is still to
result, an in-depth review of dental public be accomplished in regard to these suc-
health’s origins, scope of responsibilities, cesses, they are the result not of dental or
and future challenges and roles was in- medical technology but of social, behav-
cluded. The findings from this review were ioral, and environmental change. Issacs and
published in The Future of Dental Public S ~ h r o e d e rhave
~ ~ suggested four elements
Health Report. In response to the question responsible for successful public health
”Where does dental public health stand programs:
today?” the report acknowledged that the
current environment in which federal, state, The need to have highly credible
and local dental health programs exist is scientific evidence that can persuade
conflicting, inconsistent, and infused with policy makers and withstand attack
ambiguous policies. Although the oral from those whose interests are
health needs are documented with persis- threatened.
tent and emerging oral health problems, The need for passionately dedicated ad-
oral health is given a low priority by health vocates committed to solving a public
planners. The report states that the contri- health problem who can withstand
butions of dental public health professionals the tremendous pressure applied by
are not well understood by either the dental those who are not committed to solving
profession or the broad field of public the problem.
 DENTAL PUBLIC HEALTH: AN OVERVIEW 15

The need for a strong partnership with so treatment can be initiated to reduce the
.the media because it is only through the effect of the disease. Tertiary prevention
media that the public can be reached would involve the rehabilitation of cancer
sufficiently to express its support of patients.17
solving a public health problem. Another approach to developing inter-
The realization that laws and regula- vention programs is to consider a disease or
tions at the state, local, and especially injury as a result of a chain of causal events
federal levels of government have been involving an agent, a host, and the environ-
critical elements in addressing and ment. In regard to dental caries, for exam-
solving public health problems. Despite ple, the agent is a disease-causing microor-
all the criticism that has been directed ganism, the host is a susceptible person, and
at governmental regulation, it is that the environment includes the means of
regulation which has significantly im- transmission by which the agent reaches the
proved people's health. Regulations will host. Prevention can be accomplished by
continue to be "the underpinning that breaking the chain of causation at any of
protects the health of the American these stages.17
public. 'I3'
xam-wIul-n__.(m----P-

- e x . . *---- RECENTDEVELOPMENTS
IN DENTAL
PREVENTION
IN PUBLICHEALTH
PRACTICE PUBLICHEALTH
PRACTICE
Prevention has always been the bedrock of
public health practice. The essence of public EVIDENCE-BASED PUBLlC HEALTH PRACTlCE
health will continue to remain what it has Since the publication of the last edition of
been for the past 2000 years: prevention this book, the term evidence-bused practice has
rather than cure. The Roman poet Ovid best been adopted, popularized, and incorpo-
captured this essence 2000 years ago when rated within both dental and medical prac-
he wrote, "Resist beginnings: the prescrip- tice, as well as within public health practice.
tion comes too late when the disease has The major reason for the increasing popu-
gained strength by long larization of the term is the increasing belief
Prevention can be viewed from a three- that clinical practice was too often based on
tiered perspective: (1) primary prevention opinions and not on demonstrated effective-
seeks to avoid the occurrence of an illness or ness and knowledge that benefits outweigh
injury by preventing exposure to risk fac- harms. Evidence-based care is the integra-
tors; (2) secondary prevention attempts to tion of clinical judgment with the best avail-
minimize the severity of the illness or the able research and evidence and the patient's
damage because of an injury-causing event values in making clinical decision^.^'
once it has occurred; and ( 3 )tertiary preven- The goal of evidence-based practice is to
tion attempts to limit the disability resulting facilitate the timely and appropriate trans-
from an injury or disease. Using oral cancer lation into practice of research findings that
prevention as an example, primary preven- results in improved practice outcomes.
tion would include efforts to discourage Evidence-based practice incorporates the
teenagers from smoking or chewing to- judicious use of the best evidence available
bacco. Secondary prevention would include from systematic reviews, when possible,
screening programs to detect cancer early, with knowledge of patients' preferences
 16 . DENTAL CARE DELIVERY

and practitioners' experiences, to make or reduce the problem. At the systems level,
recommendations =for the processing of a population-based intervention would fo-
the right care for the right patient at the cus on creating changes in organizations,
right time.41,42 policies, laws, and structures and would not
The current belief that too many proce- focus directly on individuals or communi-
dures and programs have been based on ties but rather on the systems that serve
insufficient evidence makes it highly likely them. Changing the system often offers a
that the term will continue to gain increas- long-lasting and cost-effective way to have
ing acceptance in public health. The expec- the greatest impact on the individuals who
tation is that use of an evidence-based ap- collectively form the community. An exam-
proach will improve the health return on ple of such an intervention is water
investments, improve the nation's health, fluoridation.
and reduce expenditures for interventions A population-based approach at the com-
that are found to be ineffe~tive.~~ munity level would focus on creating
change in communities and would be di-
POPULATION HEALTH rected toward groups of persons within the
The term population health has been increas- community or, at times, toward all persons
ingly appearing in the literature. Although in the community. An example of such an
the dictionary definition of population is intervention is a school dental sealant
similar to that of public, and one could program.
correctly equate the terms public keaZth and A population-based approach at the indi-
population kealth,7,44 the word population vidual level would focus on creating im-
often is used in connection with the clini- provements in the health status of individu-
cal care setting, such as in the phrase als, either singly, in families, or in groups.
"population-based health services." In this An example of such an intervention is the
context it describes services in the clinical distribution of fluoride mouth rinses to any
setting that are focused on improving the child who lacks access to a public fluori-
health status of the public, rather than on dated water s u ~ p l y . ~ ~ , ~ ~
the actual treatment of that population.
These services include "health promotion, FOCUS O N HEALTH CARE AT THE EXPENSE
community health protection, personal pre- OF P UBLK HEALTH
vention and assistance in gaining access In 1977 D e ~ e proposed
r~~ a model for devel-
to are."^^,^^ oping health policy that incorporated a
The term population health is also now broader concept of health that included, in
being used in the public health setting be- addition to the system of health care orga-
cause of the increasing awareness that, de- nization, lifestyle (self-created risks), envi-
pending on the identified public health ronmental risk, and human biology. Dever
problem, the selected intervention should was concerned with the apparent mis-
be targeted at the appropriate population, match of public resources expended on
be it at the systems, community, or individ- health care-related activities and factors
ual level. For example, the level at which the contributing most prominently to morbid-
intervention would be targeted would de- ity and mortality. He noted that the United
pend on which level is determined to be the States focused most of its health resources
most effective and efficient way to prevent on health care despite the extensive role
 DENTAL PUBLIC HEALTH: AN OVERVIEW 17

that these other factors played in the level ered as engaging in the processes and activ-
a€ health of its population. Although ities required to carry out the three previ-
more than two decades have passed since ously mentioned IOM core public health
Dever’s observations were made, they re- functions: assessment, policy development,
main valid.50 and assurance. To address and respond to
A 1990 analysis of causes of death in the those core functions, three categories of
United States found that the role of lifestyle management-related activities have been
in mortality rate had changed little since identified: program planning, implementa-
1977. Half of all deaths could still be attrib- tion, and evaluation.9r52
uted to tobacco, diet and activity patterns,
alcohol, microbial agents, toxic agents, fire-
II(msx^---uxI-

(See Chapter 13)

- PLANNING
PROGRAM
arms, sexual behavior, motor vehicles, and -- Ix 1-1- l-_--_ll_l_

illicit drug use. With health resources Planning is the process of establishing goals
continuing to be focused on personal health and objectives then determining the optimal
care, the mismatch between resources and course of action to achieve them.53 Dun-
health determinants continues. When it is ning54 has raised a number of important
noted that less than 1% of the aggregate questions that should be addressed if a
amount for all health care in the United program is to be planned effectively:
States is spent on population-based public
health activities, the mismatch is even more 1. What are the dental needs of the com-
extensive than many may realize.50 Public munity or population?
health receives only 3% of the total health 2. How extensive is the demand for dental
dollar.51 treatment in the population?
3. What dental personnel are available to
serve the population, and what is the
DENTAL PUBLIC HEALTH political climate in regard to the type of
PRACTICE staffing that can be used?
4. What is the prevailing philosophy of
As previously mentioned, prevention is the the people regarding the extent of
bedrock of public health practice, and it is health care they expect to receive and
also the foundation for the practice of the manner in which they are willing to
dental public health. Dental public health receive it?
practitioners share the belief that the pub- 5. To what extent will the prevention of
lic’s dental health ”can be improved by disease obviate the need for treatment?
altering conditions-behavior, the environ- If preventive measures could accom-
ment, biological interactions, and the orga- plish this goal, would they be accept-
nization of services-that might otherwise, able for a particular society or segment
at a future time, have an adverse impact on of society?
health.”’ The practice of dental public 6. What scope of service will be offered in
health requires a set of methods and skills to a public program, who will receive the
make that belief a reality. This section de- service, and in what manner will the
scribes how those who practice dental pub- service be delivered?
lic health seek to accomplish their goals. 7. How can the service be adjusted to the
Dental public health practice can be consid- mores of the population?
18 DENTAL CARE DELIVERY

A similar approach to planning has been mation regarding conditions that existed
devised by the WHO Expert Committee on before a program has begun (baseline infor-
Dental Health. The committee identified six mation), it is not possible to determine the
phases of planning that should be followed program’s impact.58
in this sequence: (1) collection of prelimi- The main criteria for evaluation of dental
nary information, (2) establishment of pri- health programs include the following:
orities, (3) selection of targets and objec-
tives, (4) consultation and coordination, 1. Effectiveness. Has the stated objective
(5) drafting of the plan, and (6) periodic been attained?
assessment and readjustment. Those plan- 2. Efficiency. How much has the attainment
ning a program should view a perceived of the siated objective cost, and how
dental health problem within the context of did that cost compare with the antici-
the prevailing health problems and the pated costs?
overall situation of the respective country 3. Appropriateness. Has priority been given
region, or ~ o m m u n i t y . ~ ~ , ~ ~ to the most useful strategy for the at-
tainment of the stated objectives, and is
PROGRAM IMPLEMENTATION the strategy acceptable?
4. Adequacy. Has the program addressed
The implementation phase is comparable to the overall health problem, or was it di-
the leading organization and directing as- rected at only part of it? Did the pro-
pects of the management process. Imple- gram equitably address the needs of all
mentation essentially involves the design segments of the population?
and development of the organizational
structure that will be used to carry out From a public health perspective it is
the plan.57 important to understand that quality of
dental care is not just the quality of
PROGRAM EVALUATION individual services. S ~ h o n f e l dhas
~ ~ sug-
gested that four levels be used to evaluate
Evaluation is comparable to the monitor- the quality of dental care programs: the
ing or controlling function in the manage- first would evaluate the provided individ-
ment process. It attempts to determine ual restoration, procedure, or service; the
whether the problem has been improved by second would evaluate the impact of that
the implementation of the program and procedure or service on the overall health
whether progress has been made toward the of the mouth; the third would consider the
stated goals. Action should be taken to patient’s total oral health and the influence
correct any performance that impedes that that dental care has had on the attitude
progress. Program evaluation is required if toward dentistry and on dental-related
one is to know what, if anything, the pro- behavior; and the fourth would look at the
gram has accomplished, whether the objec- family and the community, evaluate the
tives have been achieved, and to what ex- level of dental care provided for groups
tent the program has contributed to the and communities, and determine the num-
improvement of the dental health of the ber and social distribution of persons
community (see Chapter 14). Without infor- receiving adequate dental care.59
 DENTAL PUBLIC HEALTH: A N OVERVIEW 19

A continuing system of evaluation can tion, and evaluation of dental public

indicate the following: health programs; the policy-making pro-
cess; regulation; management information
1. Whether the prevalence of dental dis- systems; human resources management;
ease is changing financial management; marketing; com-
2. Whether existing disease is being munications; quality assurance; and risk
treated at a greater or lesser rate than managemen~~l-~~
new disease is occurring
3. If any groups in the community are not
receiving the appropriate level of care CONTRAST
BETWEEN CLINICAL
AND DENTAL
that is needed PUBLICHEALTH PRACTICE
4. If providers of services are performing The question often is asked, "What are the
at acceptable levels differences between clinical dental practice
5. Whether the provided preventive or ed- and dental public health practice?" Box 1-1
ucational measures are effective in re- indicates the major conceptual differences.
ducing needs or promoting de- Although differences exist between clini-
mands for treatment6' cians treating individual patients and public
health workers who deal primarily with
DENTAL PUBLIC HEALTH PRACTITIONERS populations, the interdependence of these
1 1 1 -
_ ^ I _ _ I I -
I I

groups cannot be overemphasized.

People who are interested in careers and *
w*I.lIxxxII

leadership roles in dental public health

w"**a%*==-"m lI - I 1 " I I I * x I I I I I x - I ~ i x
i

PUBLICHEALTH PERSPECTIVE
should be knowledgeable in both oral ON DENTAL DISEASE
health practice and dental public health.
Most dental public health practitioners are To better understand the public health per-
initially educated as dentists or dental hy- spective on dental disease, one should keep
gienists then pursue graduate-level training in mind that a treatment component is an
in dental public health. Dental public health essential element of any dental public health
training programs are offered primarily at program. This is the case because dental
schools of public health and schools of diseases are generally not self-curing. Al-
dentistry. A committee established by the though preventive procedures are highly
American Board of Dental Public Health has successful in reducing the prevalence and
developed competency objectives for dental incidence of the major dental diseases, pre-
public health specialists. The objectives fall vention has not been able to eliminate them.
within four overall categories: (1) health A comprehensive public health program
policy and program management and ad- therefore includes both a preventive and a
ministration, (2) research methods in dental treatment c ~ m p o n e n t . ~ ~
public health, (3) oral health promotion and At least three unique characteristics of
disease, and (4) oral health services delivery the two most common 'dental diseases of
system^.^'-^^ the mouth, dental caries and periodontal
The specific areas of knowledge and disease, are important to consider: (1) they
expertise, aside from those in oral health, are of almost universal prevalence; (2) after
include planning, implementation, opera- they progress to a certain point they gener-
20 DENTAL CARE DELIVERY

Contrasting Aspects of Dental and Dental

Public Health Models of Practice

DENTAL MODEL DENTAL PUSLIC HEALTH MODEL

Purpose: to maximize the dental interests of Purpose: t o maximize the dental health status
individual patients of a population, community, or public
Work content: to provide personal dental Work content: to develop, implement, and
health services for patients to improve their evaluate dental health programs and to cre-
dental health ate health services for improving the pub-
lic’s oral health
Practitioner is conccrned with risk-benetit cal- Practitioner is concerned with relative cost
culus for individual patients benefits of different community interven-
tions or strategies
Practitioner’s primary moral ohligCitionis tci Practitioner is obliged to think in terms o f how
individual patients best to allocate community resources
The ideal is the provision of state-of-the-art The use (if appropriate technology, which may
services not be state-of-the-art
Patient-specific needs art’ ri4evant tor decision 1”cipulation-based measures o f need are o f pri-
making mary importance
Outcrimes are measured in terms of changes in Outcomes are measured in terms of commu-
individual patients nity change
L 1
Modified from Gray BH: Milbunk Q 70:535, 1992.

ally do not undergo remission or termina- communities across the United States. He
tion if left untreated, but accumulate to cited the following facts that he said “were
result in a backlog of unmet needs; and staring us in the face”:65
(3) they usually require technically de-
manding, expensive, and time-consuming More than 20 million U.S. workdays are
professional treatment. Both clinicians and lost annually because of oral disease or
nondental public health practitioners fre- the need for dental care.
quently underestimate the importance of Each year, 8600 people die as a result of
these characteristics.@ oral cancer, much of which should be
At a forum held in 1994 on the occasion preventable.
of World Health Day/The Year of Oral Early childhood caries is preventable
Health, Richard L. Wittenberg, the presi- but still affects thousands of young
dent and chief executive officer of the children because of lack of awareness of
American Association for World Health, proper infant feeding.
stated that “for too long oral health has The elderly have special oral health
been a topic overlooked or dismissed as a needs and are vulnerable to periodontal
secondary health issue.” He called for disease and oral cancers.
raising the awareness of critical and oral Many populations in the United States
health issues and motivating change in do not have access to fluoridated water,
 DENTAL PUBLIC HEALTH: AN OVERVIEW 21

a highly effective means of preventing missions of dental public health is address-

tooth decay. ing these inequities in our society.65
Dental sealants can be nearly 100% ef-
fective in preventing dental decay but ~~ ~~ ~ ~~ ~

are woefully underused. PUBLIC HEALTH PERSPECTIVE

ON T H E USE A N D DELIVERY
After these comments, Carlyle Guerra de OF DENTAL ZLRVICES
Macedo, then the director of the Pan Amer-
ican Health Organization (PAHO), pointed Several important distinctions, especially
out that oral health’s role as an integral part concerning dental care, exist in regard to the
of general wellness has been long over- need for care, the demand for care, and the
looked by the citizens of the world. Because actual use of services. A dental need is
health encompasses more than just the ab- considered to exist when an individual has
sence of disease, the maintenance of good dental disease, although the individual may
oral health in relation to the entire healthy not perceive this need. A demand for care
self should be stressed. Yet in the case of oral exists when an individual perceives a need
health, preventive measures have not been for and wishes to receive care, even though
implemented to their fullest potential, even that person may not actually obtain treat-
though relatively small investments would ment. Use occurs only when the individual
yield lifelong benefits.65 actually receives care. Sheiham’s concept of
Approximately 150 million Americans need and demand considers that one may
lack dental insurance, an important factor in perceive a need, may desire that the need be
seeking care. Although the overall dental treated, and then, in an attempt to make a
health of Americans has improved signifi- demand on the delivery system, find the
cantly since the 1960s, low-income popula- system unable or unwilling to provide treat-
tions continue to have high levels of dental ment.67 For example, the individual may
disease. Large disparities continue to exist, not be able to afford care, an available
as evidenced by the following key dental source of care may not exist, or the pro-
health indicators: untreated tooth decay, re- vider might not accept the individual for
stricted activity days because of pain and treatment.
discomfort from oral health problems, and As stated, a major concern of public
tooth loss. Low-income children and adults health is the issue of access to care and the
continue to experience higher levels of den- fact that access to health services is not
tal disease and use dental care less fre- equitably distributed among population
quently than higher-income people do. In groups in this country. This has been espe-
1996, for example, 28% of low-income peo- cially true in regard to the delivery of dental
ple reported making a visit to the dentist in services. Access to basic medical and dental
the preceding year, compared with 56% of care for all our citizens is still not a reality.
high-income people.66Approximately 40% The uneven distribution of health services
of Americans do not visit the dentist each hits the poor and minorities hardest, with
year, and a much larger percentage do not substantial numbers of underserved people
receive what the readers of this book would ”who are different ethnically from the con-
call comprehensive care. One of the primary trolling group.”14 The United States and
22 DENTAL CARE DELIVERY

South Africa are the only developed coun- ADA established the Council on Dental
tries with no national policy ensuring that Health. One of the fundamental principles
all citizens have access to health care. formulated by a council subcommittee was
The term rationing has been used in re- that the responsibility for the health of the
gard to limiting the distribution and alloca- people of the United States is first that of
tion of health services. Aside from the Ore- the individual, then the community, then
gon Health Program, there is currently no the state, and last the nation.” This attitude
official government policy to ration care. that the individual has the first responsibil-
The term defucto ra timing, however, is being ity contrasts with an attitude in European
used to describe situations in which care is countries suggesting that society as a whole
denied or not provided because of economic is responsible. By the 1970s state-operated
or social factors that are brought about by social programs were the norm in Europe.
the nature of society and its health care Some suggest that the catastrophic events
system.@ That term can be applied to the Europe experienced, primarily the effects
United States to describe the situation in of two wars in the first half of the twenti-
which millions of Americans do not get the eth century, hastened the development
care that they need. Although the term of social welfare programs in European
rationing has to date been applied primarily countries. The United States largely es-
to medical services, it should not be long caped the physical and social devastation
before it begins appearing in the dental of those
1iteratu1-e.~~
IMPACT
OF HEALTH
CAREREFORM
AND MANAGEDCAREON PUBLICHEALTH
Historically, dental health services in the During the past 15 years an evolving revo-
United States have been classified into three lution has occurred in the financing and
groups: delivery of health care services. Although
this revolution to date has affected medicine
1. Services provided by dental health per-
and public health significantly more than it
sonnel and financed by the patient or
has dentistry and dental public health, this
a source other than the government
change has increasingly affected dentistry.
2. Services provided by nongovernment
The revolution has involved the increas-
dental personnel partly or entirely
ing movement toward a health care system
remunerated by the government
driven by market forces. The initial projec-
3. Services provided by dental personnel
tion was that the majority of Americans
employed by the government, such
would be enrolled in managed care plans in
as military personnel
which one of the emerging integrated health
The prevailing philosophy in the United systems would manage the care of their
States continues to place the primary re- subscribers primarily under a capitated
sponsibility for health and the acquisition of payment system. Under such a payment
health services on the individual and not on system, unlike that of a fee-for-service sys-
society, even though increased involvement tem, a predetermined payment is made to
for payment by the federal, state, and local the integrated health system, which essen-
governments has occurred. In the 1940s the tially agrees to provide all needed health
 DENTAL PUBLIC HEALTHAN OVERVIEW 23

services. Under the fee-for-service system, ciplines, such as epidemiology, administra-

payment is made only for those services that tion, environmental health, biostatistics,
have been provided. By 1999 approximately health services research, and health educa-
92% of persons with employer-sponsored tion. In fact, the skills and competencies of
health insurance coverage were enrolled in the public health disciplines are the basic
managed care plans.72a tools for assessing the health needs of popu-
What had not been projected is that there lations, developing programs of interven-
would later be a diminishing interest in a tion, and evaluating their costs, efficacy, and
capitated payment system and an increas- outcomes.73
ing interest in a modified fee-for-service However, at the same time that health
system. It was also not projected that there care plans are employing public health-
would be a reversal from more restrictive to trained personnel and focusing more on the
less restrictive plan^.^^^,^^^ health status of their subscribers, concern is
What is ironic about this reversal from developing that this focus will be directed
the public health policy perspective is that only at those aspects of health that have an
the very mechanisms that were put into impact on the bottom line of the plan’s
place to hold down health care costs are the financial statement, rather than on a concern
ones that are now opposed by both consum- for all aspects of a population’s health and
ers and providers.72dAs health policy ana- environment (the focus of public health).74
lyst Drew Altman suggested, the American The question that is most asked in regard
people ”want to have their cake and eat it to the role of public health in a managed
too. At the same time, they are demanding care environment is, ”Who will be respon-
forms of managed care that are least able to sible for maintaining the public’s health?”
control health care spending.”72b Will it still be public health agencies, will it
The theory underlying capitated plans be integrated health care systems, or will it
was that organizations providing care un- be a combination of both? It was stated
der a capitated system become accountable earlier that the capitation system for paying
for the health and wellness of their subscrib- for health care gives managed care organi-
ers. Theoretically, the healthier their sub- zations (e.g., health maintenance organiza-
scribers, the fewer services required and the tions [HMOs], the prototype of prepaid
less it costs the health care plan. If these managed care plans) a potential interest in
plans are to be accountable for the health actively improving their enrollees’ health
and financial risks associated with the com- status because the plans’ expenses should
munity of the individuals they enroll, the be lower and their profits higher if the
plans will be required to manage the care enrollees use fewer services. An HMO inter-
of their ”communities,” or population of ested in truly taking responsibility for meet-
subscribers. ing its enrolled population’s health needs
The concept of health care providers could take a public health approach and
managing the health and health care of a address these needs as if they occurred in a
population is a relatively new one for pro- community of enrollees, and focus on over-
viders but a traditional one for public all prevention.
health. The management of a population’s Although prevention may pay in the lon-
health requires the skills and competencies ger run, it is an investment in the future;
encompassed within the public health dis- therefore it may be in a plan’s interest to
24 DENTAL CARE DELIVERY

expend resources on keeping an enrollee spectrum of nongovernmental agencies,

healthy only if ;hat enrollee remains with groups, organizations, and individuals. The
the plan long enough to allow the plan to governmental public health agency, how-
realize savings from the reduced use of ever, has a unique and crucial role to play in
more expensive services. Prevention mea- ensuring that the vital elements are in place
sures such as exercising, developing health- so that the public health mission can be
ful eating habits, and dental health educa- adequately addressed and achieved.’ For
tion require up-front investments that may this reason the governmental role in public
not ”pay off” until years later. Efforts to health receives the most emphasis in this
control more general public health prob- chapter.
lems such as community violence and Government can be defined as ”the
reducing environmental hazards require formal institutions and processes through
complex and expensive programs that which binding decisions are made for a
would benefit the entire community, as society.”77 Government is the institutions
well as the plan’s subscribers in a given or processes by which individuals and
community. In this type of situation the groups within a society or state are con-
incentive for cooperative agreements be- trolled and regulated for various purposes,
tween plans and public health agencies such as the common defense, general
could exist. Although the potential exists welfare, or internal peace. Virtually all
for public health agencies and managed political theorists have regarded govern-
care organizations to develop closer work- ment as indispensable for the functioning
ing relationships, agencies that operate in of society. James Madison, the fourth
the name of public health should be wary president of the United States, in his
of delegating core functions and responsi- contention that a society could not exist
bilities to managed care organization^.^^ without government, pointed out that the
The challenge facing the dental care de- differing opinions, passions, and interests of
livery system will be no different than the individuals and groups inevitably create
one now facing the rest of the health care friction, conflict, and strife within society. As
delivery system. The mandate in health care a result, government is needed to regulate
today is to realign economic incentives to and resolve these conflicts in an orderly and
produce fair prices, real value, reasonable peaceful fa~hion.~’ Historical analyses make
profits, and predictable cost growth while it clear that a society requires people to
improving or maintaining access to care, make and enforce decisions that affect con-
reducing inappropriate care, improving duct within that society.
quality, and promoting optimal health. The Much has recently been publicly pro-
challenge from a public health perspective claimed about the evils and ineffectiveness
is to ensure that access and quality are not of government, such as former President
sacrificed in the effort to control (see Ronald Reagan‘s statement that ”govern-
Chapters 3 and 5). ment is not the solution to our problems,
government is the problem.” Whether one
believes, as did patriot Thomas Paine, that
PUBLIC HEALTH PROGRAMS government “is a necessary evil” or as
Thomas Jefferson did that ”that government
Achieving the overall mission of public is best which governs least,” government is
health involves the activities of a broad a vital part of every society.78Without gov-
 DENTAL PUBLIC HEALTH AN OVERVIEW 25

ernment no effective means would exist of and then regularly measuring the progress
ensuring safe water, food, and products; made during the process of achieving the
controlling environmental hazards; licen- goals.
sure of health care providers; or police and The first set of goals to be developed was
fire protection. Without governmental in- for the year 1990. These goals were pub-
volvement in public health, daily life could lished as Healthy People: The Surgeon Gener-
revert back to the days when sewage was al's Report on Health Promotion and Disease
running down the streets of our major cities. Prevention. A set of specific objectives di-
Without government public health anarchy rected toward meeting those goals was de-
would fined. The Healthy People planning process
No constitutionally defined role exists was designed to encourage states and local
for the federal government in the mainte- communities to use these national objectives
nance of public health, and such activities as a basis for developing objectives of their
have traditionally been the province of the own. In 1987 the Public Health Service
states under their police power. Nonethe- began the process of setting objectives for
less, over the years a continuing gradual the year 2000: Healthy People 2000. Most
development of a federal presence in the states subsequently developed their own
health field has occurred. This has come 2000 objectives.
about primarily because of (1) the respon- In 1995 the Public Health Service pub-
sibility for special population groups, such lished a status report on the progress made
as merchant seamen, members of the toward the year 2000 goals. Of the 17
armed forces, veterans, and Native Ameri- Healthy People 2000 oral health objectives,
cans; (2) constitutional power to regulate the only one that has been met was the
interstate commerce, from which most of reduction of deaths from oral and pharyn-
the regulatory power of the federal govern- geal cancers. Progress was made in the
ment in health is derived; (3) grants-in-aid majority of the objectives, and the decline in
to states and institutions for a wide variety dental decay among 15-year-olds nearly
of activities; and (4) sponsorship and met the ~bjective.'~,'~
financial participation in the payment The federal government has recently
for health services (for example, Medicaid published its set of goals for the year 2010.
and Medicare).81r82(See Appendix A for These goals have been set at even higher
a description of the departments of the levels than the year 2000 goals. Healthy
federal government.) People 2010 for the first time establishes the
*-mm--w*
nation's preventive agenda along with a
scoreboard for monitoring health status.
-__Im_C_I-B-Xm-w*ammmsm*

FEDERAL
GOVERNMENT
PROGRAMS
The publication has two broad types of
objectives-measurable and developmen-
HEALTHY PEOPLE 201 0 tal. The measurable objectives are similar to
Beginning in 1979, the U.S Public Health the majority of the preceding Healthy People
Service adopted a management by objec- 2000 objectives, but they now have baselines
tives (MBO) approach to addressing public and available data for national measure-
health problems. This MBO process requires ment purposes. The developmental objec-
the development of a set of measurable tives represent desired outcomes or health
goals; using these goals as a guide to devel- status for which current surveillance sys-
oping interventions, programs, and actions; tems cannot yet provide data.
26 DENTAL CARE DELIVERY

Heulthy People 2010 has two major goals: increase the percentages for both groups to
to increase the quality and years of life 50% by 2010.
and to eliminate health disparities. Unlike Objective 21-11 addresses the lack of den-
Healthy People 2000, Healthy People 201 0 in- tal care for the special population of those in
cludes a focus on infrastructure with the long-term care institutions. The objective is
goal of ensuring the capacity to provide the to "increase the proportion of long-term
essential public health services at the fed- care residents who use the oral health care
eral, state, and local levels so that the year system each year." Baseline data showed
2010 goals can be acc~mplished.~~ that only 19% of all nursing home residents
received dental services in 1997. The target
ORAL HEALTH 0B)ECTIVES AND HEALTHY is to raise the percentage from 19% to 25?'0.'~
PEOPLE 2010
Goal 21 of Healthy People 2010 addresses oral FEDERAL AGENCIES
health. The overall goal is to "prevent and The beginnings of a formalized federal gov-
control oral and cranial facial diseases, con- ernment role in public health began in 1798
ditions, and injuries and improve access to in response to the expanding hazardous and
related services." Goal 21 is based on the unregulated maritime trade. In that year
contentions that "Oral health is an essential Congress passed a Marine Hospital Service
of health throughout the life" and that "no Act for the relief of sick and disabled sea-
one can be truly healthy unless he or she is men. The sum of 20 cents per month was
free from the burden of oral health and required to be paid to the government by
craniofacial diseases and conditions."24Un- ship owners for every seaman employed on
der Goal 21, 17 specific objectives were their ships. This represented the first pre-
developed. Three examples of these objec- paid medical and hospital insurance plan in
tives are presented here. the world. This plan was under the admin-
Objective 21-5 is to "reduce periodontal istration of what eventually became a public
disease." Available research showed a base- health agency. In 1878 Congress passed the
line of 48% of 35- to 44-year-olds with first port quarantine act. In 1902 Congress
gingivitis and 22% with destructive peri- renamed the Marine Hospital Service the
odontal disease in the 1988-1994 baseline Public Health and Maritime Service and
period. The target is to reduce these percent- placed it under the director of the Surgeon
ages from 48% to 41% for gingivitis and General. In 1912 the Public Health and
from 22% to 14%for destructive periodontal Maritime Service was renamed the Public
disease. Although the percentage reductions Health Service. At that time Public Health
might appear modest, the effect of just a Service involvement in public health was
small percentage change would affect mil- limited to research at its Hygiene Labora-
lions of people. tory (predecessor of the National Institutes
Objective 21-8 is to "increase the propor- of Health), a small number of field epide-
tion of children who have received dental miologic studies, and direct care to mer-
sealants on their molar teeth." The 1988- chant seamen through a network of hospi-
1994 baseline data indicate that the percent- tals and relief station^.'^ In 1912 the Army
age of 8-year-olds with sealants was 23% Dental Corps was established, and in 1913
and the percentage of 14-year-olds with the Navy Dental Corps was created. Also in
sealants was only 15%. The target is to 1913 the Department of the Interior initi-
 DENTAL PUBLIC HEALTH: AN OVERVIEW 27

ated contractual arrangements with itiner- the US. Public Health Service Commis-
ant dentists to provide care on Indian sioned Corps come under the category of
reservation^.'^ Health Service Officers, 1 of the 11 Public
In March 1919, after the end of World War Health Service professional categories. Al-
I, veterans of that war were made a new though a graduate degree is not required for
category of federal beneficiary and were the commissioning of a dental hygienist (the
eligible to receive dental services from the minimum academic requirement is a bach-
Public Health Service. In June 1919 Dr. elor’s degree), a master’s degree is preferred
Ernest E. Buell, who had served as a major for hygienists interested in working in a
in the Army Dental Corps, became the first public health position.
commissioned dentist in the Public Health
Service and later the first Chief of the Dental FEDERALLY FUNDED HEALTH CENTERS
Section.84 Dental health care programs that are part of
The US.Public Health Service Commis- neighborhood, rural, migrant, and homeless
sioned Corps should be distinguished from health centers-funded largely through fed-
the current U.S. Public Health Service, an eral dollars-have experienced extreme dif-
umbrella agency composed of eight constit- ficulties in recent years. Approximately half
uent agencies. The US. Public Health Ser- of these centers lack a dental program, and
vice Commissioned Corps is one of the no standards have been established for pre-
seven uniformed services and is primarily ventive dental care for children. Between
composed of commissioned corps officer^.'^ 1984 and 1989, the dental personnel at these
Dentistry is 1 of 11 categories of health centers declined by 11%’and approximately
professionals in the U.S. Public Health Ser- 60 centers previously offering dental ser-
vice Commissioned Corps, and dentists vices no longer provided them.87
have been commissioned since 1919. Clini-
cal positions available to entry-level dental FEDERALLY FUNDED DENTAL ACTIVITIES
officers are found in the Federal Bureau Dental activities undertaken by the federal
of Prisons (FBOP), the Indian Health Ser- government can be placed in two categories
vice (IHS), the National Health Service and are distributed among the several agen-
Corps (NHSC), and the US.Coast Guard cies of the Department of Health and Hu-
(USCG).86Research, regulatory, and admin- man Services, which has been allocating
istrative programs are found in the National approximately 1.25%of its budget for these
Institute of Dental Research (NIDR), the activities.”
CDC, the Food and Drug Administration The first group of dental activities con-
(FDA), and the Agency for Healthcare Re- sists of programs that seek to improve the
search and Quality (AHRQ).s6 nation’s capability to provide better oral
A sign of progress made in the past 15 health protection. They include biologic re-
years is that dental hygienists can now be search, disease prevention and control,
commissioned in the U.S. Public Health planning and development programs in
Service with a focus either on public health dental labor, education and services re-
planning and evaluation activities or on the search, and regulation and compliance func-
clinical treatment of patients and the imple- tions such as quality assessment. These pro-
mentation of community prevention and grams account for approximately 40% of the
promotion programs. Dental hygienists in Department of Health and Human Services’
28 DENTAL CARE DELIVERY

dental budget. The remaining 60% is as- improve the oral health of vulnerable
signed to the second group, which includes populations, particularly low-
those programs concerned with the provi- income and special-needs children
sion of dental services.88 and the elderly
LEADERSHIP MEETING ON ORAL HEALTH Although the initial meeting results
Leaders of both governmental and nongov- showed promise, it is too soon to tell if this
ernmental agencies and associations inter- thoughtful and well-intentioned beginning
ested in addressing the nation’s dental will result in an ongoing and productive
health problems and the dental health of process.
the public realize that better coordination
among the leaders from the communities of ORAL HEALTH INITIATIVE
interest (including the public, professions, Recently, an initiative of two agencies in
all levels of government, academia, busi- the US. Department of Health and Human
ness, and grant makers) is a necessity. Better Services-the Health Care Financing Ad-
coordination among federal health agencies ministration (HCFA), now known as the
is also a necessity. Centers for Medicare and Medicaid Ser-
A good start was made in an attempt to vices (CMS), and the HSRA-has been in
better achieve this goal when, in June 2000, discussion. The purpose of the initiative
the Deputy Secretary of the Department of would be to
Health and Human Services convened the
Strengthen public and private oral
“Leadership Meeting on Oral Health.” At
health delivery systems
this meeting, dental health leaders gathered
Enhance collaboration among Depart-
to discuss issues of mutual concern and to
ment of Health and Human Services
begin to address the need for better and
agencies to maximize the effectiveness
more coordination and cooperative working
of dental Medicaid and Children’s
agreements in order to solve dental public
Health Insurance Programs (CHIP)
health problems. The attendees expressed
Encourage the application of scientific
agreement on the need for better coordina-
advances to the practice of dentistry to
tion and in coordinated public-private part-
reduce the burden of disease
nerships. The goals of the meeting were as
follows89: Determining whether this initiative will
achieve its mission and goals is not yet
To acknowledge that disparities in oral possible.90
health and access to care constitute both
a personal health and public policy U S . SURGEON GENERAL’S PROPOSED NATIONAL
problem ORAL HEALTH PLAN
To explore facets of oral health with In the first year of the new millennium,
communities of interest the U.S. Surgeon General released the first
To invite state government and private official and comprehensive report on oral,
sector groups to partner with the dental, and craniofacial health in the na-
Department of Health and Human tion’s history. The report alerts Americans
Services in a coordinated campaign to to the full meaning of oral health and its
 DENTAL PUBLIC HEALTH: AN OVERVIEW 29

importance to general health and well- dentist directing their dental health pro-
being. 14,90a,90b grams. More recently, in addition to the
The surgeon general, in his report to the downsizing of these state dental programs,
nation, suggested the creation of a National few dentists have been directed to the
Oral Health Plan “to eliminate oral health programs. The status of dental public
disparities and improve the quality of life by health programs at the state level indicates
facilitating collaborations among individu- that the status of these programs has been
als, health care providers, communities and on the decline in regard to staffing, organi-
policy makers at all levels of society and by zational status, and financial and organiza-
taking advantage of existing initiative^."'^ tional support. Evidence unquestionably
For more information on the proposed plan, suggests that ”state dental public health
see Chapter 2. It is too soon to determine programs have been weakened by ever
whether the National Oral Health Plan will tightening budgets, poorly articulated oral
come to fruition and if so whether it will health needs and priorities, and the failure
achieve its goals. to modify and integrate traditional dental
program activities into more broadly based
health programs.”37
DENTAL ACTIVITIES
In 1995 the Association of State and
OF STATEAND LOCALPUBLIC
HEALTHAGENCIES- Territorial Dental Directors published the
^____“ll__ 1-11 -l_“_“ll
I_ _ _ _ _ i ”~
Future of Dental Public Health Report. The
Unfortunately, few national data exist on report indicated that “little information
current activities of either the dental had been gathered about local dental
or medical activities of state and local public health programs and that local
health departments. The reason is that programs varied widely across the nation,
funding formerly available from the Public but a lack of data about them made
Health Service for collection of this infor- generalization about differences, clientele
mation has been withdrawn.” Although all served, population density, organizational
states have public health departments or structure, and funding diffic~lt.”~’Over
agencies with responsibilities for state pub- the years, however, the number of local
lic health functions, not every state health dental public health programs has de-
agency has an oral health program. Nor creased significantly. A study of 150 lo-
have all state oral health programs suffi- cal dental programs published in 1988
cient resources to adequately address oral found that 20% reported that their den-
health needs. Only 30 states and 5 territo- tal program ranked “low” or ”lowest” in
ries in the year 2000 had full-time dental the organizational structure in which they
directors. In 20 states the state dental operated, and only 34% believed that
director position was part time or vacant. their programs had a high priority in
Twenty-one had two or fewer full-time their organization^.^^ The most current
equivalents staffing their dental health data indicate that of the 50 states and
programs. In 25 states, fewer than 10% of the District of Columbia, 71% have full-
counties with local health departments had time dental directors and 17% have part-
dental health programs.14 At one time time dental directors; in 11% the dental
virtually all state health departments had a director’s position is vacant.94
30 DENTAL CARE DELIVERY

N0NC O V E R NME NTA L DENTAL joined the ASTDD for their first joint
PUBLIC HEALTH annual meeting. The purpose of the two
ORGANIZATIONS major dental public health organiza-
tions meeting is to more effectively ad-
Four national-level organizations exist dress the population’s oral health
whose primary mission is the advancement needs.96r97
of dental public health: American Board of Dental Public Health
(ABDPH). This organization is responsi-
American Association of Public Health Den- ble for certifying dental specialists in
tistry (AAPHD). This organization in- the field of dental public health. It is
cludes dental public health practitio- one of the nine dental specialty boards
ners. AAPHD is affiliated with the and is affiliated with the American Den-
American Dental Association. tal Association. All members of the
Oral Health Section of the American Public ABDPH are dentists. No specialties in
Health Association (APHA). The APHA the field of dental hygiene currently
is the major national association for exist.
public health practitioners and is com-
parable to the American Dental Hygien- In addition to these organizations, both
ists’ Association and the American the ADA and the ADHA address issues of
Dental Association. The section’s mem- public health interest. Both organizations
bership is composed primarily of recently have been focusing more on dental
dental hygienists and dentists. public health-related issues in their attempt
Association of State and Territorial Dental Di- to increase the strength and effectiveness of
rectors (ASTDD). ASTDD’s membership the profession and to improve the oral
is composed of the dental directors of health of the population. The major reason
state and U.S. territorial health de- for this increased interest is the perception
partments. The Surgeon General’s Re- on the part of organized dentistry that it is
port acknowledged the important facing critical issues, such as the rising cost
role of ASTDD in assessing the re- of dental education, the increased indebted-
sources needed to achieve the national ness of students, the supply and distribu-
objectives included in Healthy People tion of dental personnel, the increasing
2010. Significant gaps were identified by number of alternative forms of developing
ASTDD in the dental public health in- services, deregulation, and a highly compet-
frastructure and the capacity of state itive marketpla~e.~’
and local public health agencies of most In the early 1980s, to address the pro-
states. The report indicated that states jected future problems confronting the den-
had a significant need for oral health tal profession, the ADA established the Spe-
surveillance systems and for staff with cial Committee on the Future of Dentistry,
public health expertise. Similar gaps which produced a report covering a series of
in regard to many local public health issues and their implication^.^' Although
departments without adequate oral this document is almost two decades old, its
health programs or appropriately concern that the future would bring to the
trained personnel were highlighted in dental profession a more complex and more
the report.14r95In May 2000 the AAPHD challenging set of problems that will need to
 DENTAL PUBLIC HEALTH: AN OVERVIEW 31

be addressed using the knowledge and Increasing levels of chronic diseases

Skills of the dental public health field is still among the aging
relevant. Properly utilizing available genetic and
In 1999 the ADA established a task force technical knowledge about human
to explore the future of dentistry. Since health
then, the ADA has been sponsoring the Providing access to high-quality pri-
Future of Dentistry Project. The Future of mary and preventive care for all citizens
Dentistry Project report has been com- Improving quality of health care de-
pleted and it suggests that public health livery, including both physical and
has an important role to play in helping mental health services
dentistry accomplish its twenty-first cen- Changing behaviors and lifestyles to
tury n - ~ i s s i o n . ~ ~ , ~ ~ ~ improve quality of life
Improving the safety of domestic and
imported food
PUBLIC HEALTH CHALLENGES Reducing global death and disease rates
FOR THE TWENTY-FIRST resulting from smoking
z 8 CENTURY Improving the quality of the
environment
The first revolutionary public health Reducing the number of hungry and
achievement of the late nineteenth and early malnourished children
twentieth centuries focused on environmen-
tal intervention to reduce the effects of Dental public health challenges for the
infectious agents. The second revolution, twenty-first century include the following:
later in the twentieth century, was the
progress in methods and interventions to To achieve the recognition that dental/
reduce the toll of chronic diseases and re- oral health means more than healthy
lated behavioral risk factors. Looking ahead teeth-it means the health of the entire
as we enter the twenty-first century, an craniofacial complex
increasing need will develop for more inter- To close the gap between levels of med-
organizational cooperative intervention to ical and dental access to care and be-
counter the human-generated threats to our tween untreated and undiagnosed
physical e n ~ i r o n m e n t . ~ ~ medical and dental disease
The American Public Health Associa- To better recognize that oral health
tion, in addressing the question of what can have a significant impact on the
major twenty-first century public health overall health and well-being of the US.
challenges will need to be addressed by population
the public health field, suggested the To increase the use of public-private
f 0110wing~0~J0~: partnerships to improve the nation’s
oral health
Protecting against terrorists and bioter- To build an effective dental health infra-
rorist threats structure that meets the oral health
Global health risks caused by environ- needs of all Americans
mental disasters and disease outbreaks To develop a viable, effective National
Racial disparities in health status Oral Health Plan to improve the oral
32 DENTAL CARE DELIVERY

health status of the entire U.S. ences, such as genetics, will be of increasing
population importance. She indicates, however, that no
To more effectively influence lifestyle matter what technologic advancements may
behaviors that negatively influence oral unfold in the twenty-first century, the basic
health factors essential to maintaining and improv-
To increase the use of evidence-based ing the public’s health are ancient and non-
practice in both clinical dental practice technologic: ”clear water and waste dis-
and public health practice14 posal; correct social and medical control of
To prevent the potential that the imple- epidemics; widespread or universal access
mentation of evidence-based methodol- to maternal and child health care; clean air;
ogy will be used to control costs knowledge of personal health needs admin-
without sufficient concern for the qual- istered to a population sufficiently educated
ity of care to be able to comprehend and use the infor-
mation in their daily lives; and, finally, a
Alfred Sommer, dean of the School of health care system that follows the primary
Hygiene and Public Health, Johns Hopkins maxim of dentistry and medicine: do no
University, in an address to a group of harm.”lo5 Public health in the twenty-first
public health professionals describing the century ”will rise or fall with the ultimate
future of public health, stated that its course of globalization. If the passage of
viability lies in ”developing a data system time finds ever-widening wealth gaps, a
for measuring and tracking the health of disappearing middle class, international fi-
the public more effectively; integrating nancial lawlessness, and still rising individ-
curative and preventive services at both ualism, the essential elements of public
individual and societal levels; and evaluat- health will be imperiled, perhaps non-
ing success and modifying the system existent, all over the
when needed to achieve it.“103 Former Surgeon General C. Everett Koop
In examining its challenges for the made the most concise and meaningful
twenty-first century, the CDC concluded statement on the value and importance of
that the fundamental challenge is ”improv- public health in the twenty-first century:
ing the quality of people’s lives by prevent- ”Health care is vital to all of us some of the
ing disease, injury and disability through time but public health is vital to all of us all
collaboration with public and private part- of the time.”106
ners throughout the world.’’ In its 1999 In 1977 Harold Hillenbrand, former
report An Ounce of Prevention, What Are the executive director of the ADA, stated the
Returns? CDC outlined 19 cost-effective following:
strategies to prevent disease and injury and
promote healthy lifestyles. One of these The United States is the only industrially devel-
strategies was the promotion of water fluo- oped country in the world without a coherent,
ridation to prevent dental caries.lo4 identifiable national health program and has only
Health care writer Laurie Garrettlo5per- now reached the stage of making a statement of
ceptively points out that although method- intent. . . . The delivery of dental health care is not
now, if it ever was, solely a problem for the dental
ologies discovered in the twentieth century profession. Real solutions must be found in the
will continue to form the basis of global unselfish collaboration of dentists, the other health
public health efforts in the twenty-first cen- professions, the dental auxiliaries, social and
tury, innovations based on biomedical sci- behavioral scientists, epidemiologists, educators,
 DENTAL PUBLIC HEALTH: AN OVERVIEW 9 33

statisticians, government and public health offi- 13. Turnock BJ: Public health: what it is and how it works,
&ah, consumers, and a whole host of others. There Gaithersburg, MD, 2001, Aspen.
are enough problems to challenge and plague 14. US Department of Health and Human Services: Oral
us a11.107 health in America: a report of the surgeon general,
Rockville, MD, 2000, US Department of Health and
Human Services, National Institute of Dental and
Since then little has changed. Hillen- Craniofacial Research, National Institutes of Health.
15. Centers for Disease Control and Protection: Ten
brand’s words are as appropriate in the new Great Public Health Achievements-United States,
d e n n i u m as they were in 1977. The dental 1900-1999, MMWX Morb Mortal Wkly Rep 48(12):241,
and dental public health professions still 1999.
must accomplish much to meet the dental 16. Taylor H: Public health: two words few people under-
stand though almost everyone thinks public health func-
needs of the people in the United States and tions are very important, New York, 1997, Louis Harris
”enough problems to challenge and plague & Associates, Inc.
us all.’’ 17. Schneider MJ: Introduction to public health, Gaithers-
burg, MD, 2000, Aspen.
18. US Department of Health and Human Services:
NPHSP: national public health performance standards:
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99. Furlong A: Gazing into the future, A D A News 32(6):1, 107. Ingle J, Blair P, editors: International dental care deliv-
2000. ery systems, Cambridge, MA, 1978, Ballinger.
100. American Dental Association: Future of dentisty,
Chicago, 2001, American Dental Association.
 THE SURGEON GENERAL’S REPORT ON
ORAL HEALTH IN AMERICA: DEFINING
CHALLENGES FOR THE FUTURE
Mark D. Macek

I n April 1997 Donna Shalala, then Secre-

tary of the Department of Health and
Human Services, commissioned the Sur-
cial complex and its many integral parts. It
lists the epidemiology of common oral and
craniofacial diseases and disorders. It ex-
geon General’s Report on Oral Health in plains the potential and established links
America (Surgeon General’s Report). The between oral health and general health and
Secretary charged the report to ”define, portrays the mouth and face as a mirror of
describe and evaluate the interactions be- general health and disease. It describes how
tween oral health and general health and oral health is promoted and maintained and
well-being (quality of life), through the life how oral diseases are prevented. The report
span, in the context of changes in society.’” also shows the oral health needs of the
During the next 3 years, under the direction community and lists the many and varied
of the Office of the Surgeon General and the opportunities that exist to enhance oral
National Institute of Dental and Craniofa- health in the future. In short, the Surgeon
cial Research, Project Director Caswell A. General’s Report symbolizes a stepping-off
Evans, D.D.S., M.P.H., coordinated the ef- point for the next millennium, bringing
forts of a highly qualified project team and a important oral health issues into focus, de-
cadre of contributing authors and content fining challenges for the future, and equip-
experts. By early 2000 the project team’s ping public health professionals and policy
dedication and determination paid off, and makers with the tools to effect change.
the first-ever Surgeon General’s Report on This chapter intends to fulfill a number of
Oral Health was completed. objectives. It provides a brief history of the
The Surgeon General’s Report represents U.S. Public Health Service, presents a chro-
a thorough review of the important issues nology of Surgeons General throughout
relating to oral and craniofacial health and time, and places the current Surgeon Gen-
disease. The report describes the craniofa- eral’s Report in the context of previous

37
38 DENTALCAREDELIVERY

reports. The chapter also summarizes the 1811, when the U.S. Navy created its own
Surgeon General’s Report and its important hospital ~ y s t e m . ~
messages to the American public. Although Local administration of the service left
the chapter provides a thorough synopsis, it administration of the hospitals subject to the
does not intend to provide a critical review whims of politicians and customs collectors.
of the Surgeon General’s Report. The During the next several decades, the Marine
breadth of such a critical review would be Hospital Fund health care system devolved
well beyond the scope of this chapter. Fi- into a disjointed, poorly functioning organi-
nally, the chapter places the Surgeon Gen- zation of hospital^.^ In 1849 the Marine
eral’s Report in the broader context of se- Hospital Fund appointed Drs. George Lor-
lected oral health initiatives at the national, ing and Thomas Edwards to lead a com-
state, and local levels. mission charged with evaluating the Fund
hospitals. Their report placed the Fund
hospitals and their local administrators in a
A BRIEF HISTORY less than favorable light. Loring and Ed-
OF THE U.S. PUBLIC wards were also the first to recommend a
HEALTH SERVICE “chief surgeon” to provide central leader-
ship to the Fund system. During the Civil
During our nation‘s early history, port cities War, the Marine Hospital Fund fell into
found themselves poorly equipped to han- further disarray, as some hospitals were
dle the health care needs of merchant sail- overrun by soldiers, and others were aban-
ors. On July 16, 1798, in an attempt to doned completely. In 1869 the Treasury Sec-
remedy the situation, President John Adams retary, then administrator of the Fund, com-
signed An Act for the Relief uf Sick and missioned Drs. Stewart and Billings to
Disabled Seamen, providing for ”the tempo- inspect and report on the hospitals. Again,
rary relief and maintenance of sick or dis- the hospital system was found to be in
abled seamen in the hospitals or other dismal shape.
proper institutions now established in the During the following year, in response to
several ports of the United States, or in ports the unfavorable report, the Secretary initi-
where no such institutions exist, then in ated some organizational change^.^ In 1871
such other manner as he (the Secretary of Dr. John Maynard Woodworth, General
the Treasury) shall direct” (1 Stat. L. 605).* Sherman’s chief medical officer during the
The Act called for a tax of 20 cents per Civil War, became the first Supervising Sur-
month against the wages of all American geon of the Marine Hospital Service (a
sailors. Funds were to be used to provide position later to be renamed Supervising
health care to merchant seaman in existing Surgeon General and then simply Surgeon
marine hospitals or to construct new hospi- General). Woodworth brought his experi-
tals, where necessary. The Act gave the ences with disciplined military service to
authority for local collection and adminis- the position and set in motion a series of
tration of a Marine Hospital Fund. In 1799 a reforms that would shape the Marine Hos-
new law granted that naval personnel pital Service to come. Dr. John B. Hamilton,
would also be beneficiaries of the Marine successor to Woodworth, wanted to make
Hospital Fund, a provision that lasted until Woodworth’s reforms permanent, and his
 THE SURGEON GENERAL'S REPORT ON ORAL HEALTH IN AMERICA 39

campaign to do so was successful when, on Changes in the Public Health Service

January 4,1889, President Cleveland signed took place at a dramatic rate after World
an Act to Regulate Appointments in the Marine War I. Between 1920 and 1936 the Public
Hospital Service of the United States (25 Stat. L. Health Service introduced the new fields of
639). The Act specified that the medical epidemiology and biostatistics to various
officers would thereafter be appointed by public health problems throughout the
the president, with the advice and consent ~ o u n t r yIn
. ~1939 President Roosevelt com-
of the Senate, after passing an examination. bined the Public Health Service with a num-
These reforms have remained in the Marine ber of other educational, health, and welfare
Hospital Service to the present. offices into the Federal Security Agency.' In
Over the next three decades, the Sur- 1942 the Public Health Service launched a
geons General orchestrated a broader scope campaign against malaria in military train-
for the Marine Hospital Service, which also ing camps called Malaria Control in War
resulted in two changes in name.5 During Areas (MCWA); in 1946 the MCWA pro-
the tenure of Surgeon General Wyman, for gram became a permanent agency of the
example, the budget for the Marine Hospi- Public Health Service and was renamed the
tal Service nearly tripled and the number of Communicable Disease Center, which later
staff physicians more than doubled. In 1902, became the Centers for Disease Control,
in an effort to reflect the new responsibili- and, finally, the Centers for Disease Control
ties of Marine Hospital Service physicians and Prevention (CDC). In 1948 Congress
in combating infectious disease, Wyman added the National Institutes of Dental Re-
guided the Congress to change the name of search (NIDR) to the National Institutes of
the Marine Hospital Service to the Public Health, and H. Trendley Dean was named
Health and Marine Hospital Service and the first director of the new dental institute.'
had the term Supervising eliminated from In 1953 additional agencies, hospitals, and
the Surgeon General title. the Office of Vital Statistics were combined
Between 1912 and 1920 the Public Health with the Federal Security Agency to create
and Marine Hospital Service gained greater the Department of Health, Education, and
notoriety and responsibility.6 During the Welfare (HEW). In 1955 the Public Health
tenure of Surgeon General Rupert Blue, Service took over the medical care of Amer-
Congress passed legislation that changed ican Indians from the Bureau of Indian
the name of the Public Health and Marine Affairs."
Hospital Service to the Public Health During the 1970s, prompted by a sweep-
Service. The charge of the newly named ing reorganization of HEW by Secretary
Service was to investigate diseases and Gardner (1965-1968), the Public Health
conditions that resulted from sanitation, Service evolved from a three-agency struc-
sewage, and pollution of U.S. streams and ture into a six-agency structure." In 1972
lakes. During Blue's period, as a result of the Public Health Service consisted of the
demands for health care personnel during newly arrived Federal Drug Administration
World War I, the Public Health Service (FDA), National Institutes of Health, and
allowed the commissioning of reserve offic- Health Services and Mental Health Admin-
ers, including pharmacists, sanitary engi- istration (HSMHA). The HSMHA consisted
neers, and dentists. of the Indian Health Service, National Cen-
40 DENTAL CARE DELIVERY

ter for Health St_atistics, CDC, Regional

Medical Program; Public Health Service
hospitals and health planning programs, Surgeons General of the U.S.
and other agencies. In 1973 the six agencies Public Health Service
included the CDC; Health Services Admin-
~~ ~~

istration (HSA); Health Resources Adminis- John M. Woodworth 1871-1879 (died)

John B. Hamilton 1879-1891
tration (HRA); Alcohol, Drug Abuse, and 1891-1911 (died)
Walter Wyman
Mental Health Administration (ADAMHA); Rupert Blue 1912-1920
and a combination of the FDA, National Hugh S. Cumming 1920-1936
Institutes of Health, and four new agencies Thomas Parran, Jr. 1936-1948
created by HSMHA. Leonard A. Scheele 1948-1956
Today, the Public Health Service is as Leroy E. Bumey 1956-1961
vital as ever, coordinating research, health Luther L. Terry 1961-1965
William H. Stewart 1965-1 969
care administration and financing, disease
Jesse L. Steinfeld 1969-1973
prevention and health promotion, and the S. Paul Ehrlich (acting) 1973-1977
investigation of infectious disease outbreaks Julius B. Richmond 1977-1981
throughout the United States and the world. C. Everett Koop 1981-1989
The Public Health Service has come a long Antonia C. Novello 1990-1993
way from its origins as the Marine Hospital M. Joycelyn Elders 1993-2994
Service. Its focus is vastly different today Audrey Manley (acting) 1995-1997
than it was more than 200 years ago, yet the J. Jarrett Clinton (acting) 1997-1998
David Satcher 1998-2002
Public Health Service maintains at its core Kenneth Moritsugu 2002-
the goal of bringing relief to those who are (acting)
ill. Much of this continuity in focus should
be credited to its long line of leaders-the
Surgeons General.

SURGEONS GENERAL was appointed by the Clinton administra-

OF THE U.S. PUBLIC HEALTH tion in 1998, became the first African-
SERVICE: A CHRONOLOGY American man to hold the office.
From 1871 until the present, the Surgeons
Including Surgeon General Satcher, 16 per- General have taken on a variety of respon-
sons have occupied the Office of Surgeon sibilities and have assumed various roles.
General since John Woodworth assumed the Before 1968, for example, the Office of the
position in 1871 (Box 2-1). Most of the Surgeon General assumed full responsibil-
Surgeons General have been men. The first ity for leading the Marine Hospital Service
woman to assume the position was Surgeon (and later the Public Health Service), includ-
General Novello, who served from 1990 ing program development, administration,
through 1993. Dr. Novello was also the first and financial management. In the position
Hispanic Surgeon General. In 1993 M. as head of the Marine Hospital Service or
Joycelyn Elders became the second woman Public Health Service, the Surgeon General
and the first African-American to assume reported directly to the president or his
the position. Surgeon General Satcher, who Cabinet. In 1968 President Johnson reorga-
 m SURGEON GENERAL‘SREPORT ON ORAL HEALTH IN AMERICA 41

nized the federal government and took mune deficiency, nutrition and health, child
mknagement of the Public Health Service abuse, physical activity, suicide, youth vio-
away from the Office of the Surgeon Gen- lence, mental health, responsible sexual be-
eral and placed it in the hands of the havior, and oral health. From the begin-
Assistant Secretary for Health (ASH). With ning, the reports of the Surgeons General
this reorganization, the Surgeon General have had a tremendous influence on health
was to become a principal deputy to the and health-related behaviors in the United
ASH, losing administrative responsibilities States.
and, instead, offering advice regarding pro- The first report (Smoking and Health: Re-
fessional medical issues. port of the Advisory Committee of the Surgeon
Since 1968 the relation between the Sur- General of the U S . Public Health Service),
geon General and the ASH has changed released in 1964 during Surgeon General
several times. In 1972 the Surgeon General Terry’s tenure, introduced the causal rela-
was again asked to report directly to the tion between cigarette smoking and lung
Secretary, rather than the ASH. In 1977 the cancer. The report took the nation by storm.
positions of Surgeon General and ASH were In January 1964, before a standing-room-
combined. In 1981 they again became sepa- only press conference, the Surgeon General
rate positions. In 1987 the Office of the announced the findings of his Advisory
Surgeon General was reestablished as a staff Committee on Smoking and Health. During
office within the Office of the Assistant the conference, Terry stated that ”cigarette
Secretary for Health, and the Surgeon Gen- smoking is causally related to smoking in
eral regained administrative authority of men,” and added, “the magnitude of the
the Commissioned Corps of the Public effect of cigarette smoking far outweighs all
Health Service. Finally, between 1998 and other factors. The data for women, though
2001, the positions of Surgeon General and less extensive, point in the same direc-
ASH were once again combined. tion.”” As a result of this report, the Federal
Trade Commission immediately called for
warning labels on cigarette packaging and
REPORTS OF THE SURGEONS Congress passed legislation requiring their
GENERAL THROUGHOUT use. The influence of the first Surgeon Gen-
HISTORY eral’s report on smoking and health was far
reaching. The report not only effected a
Beginning in the mid-1960s the Surgeon dramatic change in the way that the average
General of the US. Public Health Service citizen viewed smoking, but it established
had endeavored to educate the nation about prestige for the reports that would follow
important public health problems by releas- and secured a special place for the Surgeon
ing reports on a regular basis. To date, the General in the public’s eye.
Office of the Surgeon General has released In 1979 Surgeon General Richmond re-
more than 50 such reports. The vast majority leased Healthy People-The Surgeon General’s
of them have dealt with cigarette smoking Report on Health Promotion and Disease Pre-
and other tobacco-related health issues (Box vention.13 The document was important be-
2-2); however, beginning in the 1980s, other cause it defined, for the first time, national
reports have introduced such diverse topics health objectives against which progress
as disabilities among children, acquired im- during the following decade could be mea-
42 DENTAL CARE DELIVERY

Reports of the Surgeon General of the U S Public Health Service

2001 Surgeon General’s Call to Action to Promote Sexual Health and Responsible Sexual
Behavior
National Strategy for Suicide Prevention: Goals and Objectives for Action
Women and Smoking: A Report of the Surgeon General
Youth Violence: A Report of the Surgeon General
2000 Reducing Tobacco Use: A Report of the Surgeon General
Oral Health in America: A Report of the Surgeon General
1999 Mental Health: A Report of the Surgeon General
The Surgeon General’s Call to Action to Prevent Suicide
1998 Tobacco Use among US. Racial/Ethnic Minority Groups: A Report of the Surgeon
General
1996 Physical Activity and Health: A Report of the Surgeon General
1994 Preventing Tobacco Use Among Young People: A Report of the Surgeon General
Surgeon General’s Report for Kids about Smoking
1992 Surgeon General’s Report to the American Public on HIV Infection and AIDS
Smoking and Health in the Americas: A Report of the Surgeon General
1990 The Health Benefits of Smoking Cessation: A Report of the Surgeon General
1989 Reducing the Health Consequences of Smoking-25 Years of Progress: A Report of the
Surgeon General
1988 The Surgeon General’s Letter on Child Sexual Abuse
The Surgeon General’s Report on Nutrition and Health
The Health Consequences of Smoking-Nicotine Addiction: A Report of the Surgeon
General
1987 The Surgeon General’s Report on Acquired Immune Deficiency Syndrome
1986 Smoking and Health. A National Status Report: A Report to Congress
The Health Consequences of Involuntary Smoking: A Report of the Surgeon General
The Health Consequences of Using Smokeless Tohacco
1985 The Health Consequences of Smoking-Cancer and Chronic Lung Disease in the Work-
place: A Report of the Surgeon General

sured. This chapter discusses the oral health the proper use of condoms and other pro-
priority area for these ”Healthy People phylactics, and called for tolerance of those
1990” objectives, as well as the ”Healthy infected with the human immunodefi-
People 2000” and “Healthy People 2010” ciency virus (HIV). Although the report
objectives, in a later section. used explicit language and, to many, was
One of the most influential reports writ- controversial, it was also immensely popu-
ten during the 1980s was The Surgeon Gen- lar among public health professionals and
eral’s Report on Acquired Immune Deficiency the public. The Surgeon General’s report on
Syndrome, released by Surgeon General HIV, as well as the document that followed
K00p.l~This document, much of which was (Understanding AIDS), brought useful, accu-
written by Koop himself, described sex ed- rate, and nonjudgmental information to a
ucation in elementary schools, addressed nation that was frightened of a serious
 THE SURGEON GENERAL'S REPORT ON ORAL HEALTH IN AMERICA 43

Reports of the Surgeon General of the U.S. Public Health Service-cont'd

1984 The Health Consequences of Smoking-Chronic Obstructive Lung Disease: A Report of

the Surgeon General
Chronic Obstructive Lung Disease
1983 The Health Consequences of Smoking-Cardiovascular Disease: A Report of the
Surgeon General
1982 Report of the Surgeon General's Workshop on Children with Handicaps and Their
Families
The Health Consequences of Smoking-Cancer: A Report of the Surgeon General
1981 The Health Consequences of Smoking-The Changing Cigarette: A Report of the Sur-
geon General
1980 The Health Consequences of Smoking for Women: A Report of the Surgeon General
1979 Healthy People-The Surgeon General's Report on Health Promotion and Disease
Prevention
Smoking and Health
1977-78 The Health Consequences of Smoking
1976 The Health Consequences of Smoking: Selected Chapters from 1971 through 1975
Reports
1975 The Health Consequences of Smoking
1974 The Health Consequences of Smoking, 1974
1973 The Health Consequences of Smoking, 1973
1972 The Health Consequences of Smoking
1971 The Health Consequences of Smoking: A Report of the Surgeon General
1969 The Health Consequences of Smoking: 1969 Supplement to the 1967 Public Health Ser-
vice Review
1968 The Health Consequences of Smoking: 1968 Supplement to the 1967 Public Health Ser-
vice Review
1967 The Health Consequences of Smoking. A Public Health Service Review
1964 Smoking and Health: Report of the Advisory Committee of the Surgeon General of the
Public Health Service

public health problem of which they knew public that day, Surgeon General Satcher
1itt1e.l~ summarized key themes of the report and
On May 25, 2000, at Shepherd Elemen- placed the findings in a broader context of
tary School in Washington, D.C., Assistant general health and well-being. Dr. Satcher
Secretary for Health and Surgeon General stated that oral health meant much more
David Satcher released Oral Health in Amer- than healthy teeth; that oral health was
ica: A Report of the Surgeon Geneval.l6 The integral to general health; that safe and
document was the first-ever Surgeon Gen- effective disease prevention measures ex-
eral's report exclusively dedicated to oral isted that everyone could adopt to improve
health issues and was the fifty-first in a oral health and prevent disease; that pro-
series of Surgeon General's reports since found disparities in oral health existed in
1964. In his presentation to the American the United States; and that general health
Other documents randomly have
different content
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