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558417_fm.indd ii 11/9/09 11:00:28 AM
 CONCEPTS IN

Dental Public Health SECOND EDITION

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LWBK942-FM.qxd 6/25/11 8:45 AM Page x
 CONCEPTS IN
Dental Public Health
SECOND EDITION

Jill Mason, MPH, RDH

Associate Professor
Oregon Health & Science University
School of Dentistry
Portland, Oregon

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 Acquisitions Editor: Peter Sabatini
Product Manager: Matt Hauber
Marketing Manager: Allison Powell
Designer: Teresa Mallon
Compositor: Thomson Digital

Second Edition

Copyright © 2010 Lippincott Williams & Wilkins, a Wolters Kluwer business

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9 8 7 6 5 4 3 2 1

Library of Congress Cataloging-in-Publication Data

Concepts in dental public health / [edited by] Jill Mason. — 2nd ed.
p. ; cm.
Rev. ed. of: Concepts in dental public health / Jill Mason. c2005.
Includes bibliographical references and index.
ISBN 978-1-58255-841-7
1. Dental public health. 2. Health promotion. I. Mason, Jill (Jill Dee)
[DNLM: 1. Oral Health. 2. Community Health Planning. 3. Health Promotion. 4. Public
Health. WU 113 C744 2010]
RK52.M287 2010
362.19'76—dc22
2009043638
DISCLAIMER
Care has been taken to confirm the accuracy of the information present and to describe generally accepted practices.
However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from applica-
tion of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness,
or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional
responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and
universal recommendations.
The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text
are in accordance with the current recommendations and practice at the time of publication. However, in view of ongoing
research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions,
the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings
and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for
limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of
each drug or device planned for use in their clinical practice.

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558417_fm.indd iv 11/9/09 11:00:28 AM

 Preface
You are about to venture into an aspect of the oral health professions that may be a new realm to
you—one not previously considered as a career possibility. Enter with an open mind, and you can
find rewards also not previously considered. Did you enter the profession because you “want to work
with people” or “want to help people?” Here is the opportunity to explore new avenues for that per-
sonal goal.
This textbook provides an overview of dental public health in greater depth and breadth than the
traditional view of community dental hygiene. It builds a foundation in community education and
health promotion, but expands to provide a broader view of the core principles and competencies
expected at all levels of involvement in public health practice, from part-time volunteer work to a
professional career in public health practice.
As depicted on the cover of the text, dental public health involves many entities coming together
around a central focus—improving the public’s oral health. When each piece of the puzzle is inter-
connected, the infrastructure is strong and the benefit to the public is enhanced. This theme is car-
ried throughout the text and each chapter heading depicts pieces of the puzzle addressed in that
chapter.
Each chapter is written by a leader in the dental public health community. All have advanced edu-
cation and expertise in public health. Although primarily written for the dental hygiene student, it is
useful for all oral health care providers working in public health settings.
The modular format of the text is specifically designed to allow for flexibility in depth of content
or order of presentation for different curricula and teaching styles. Each module centers on a core
content area of public health. To accommodate different curricula, the modules can be used in a
different sequence than presented. The text also can be used for multiple courses, in the event that
public health content is presented in various courses (e.g., statistics, ethics, research, health educa-
tion, and community dental hygiene).
Key terms are listed at the beginning of each chapter to guide the learner’s study of core concepts.
The key terms are often used in public health practice and appear on National Board Examinations.
The competencies addressed in each chapter, and listed in Appendix 3, are from the American
Dental Education Association’s Competencies for Entry into the Profession of Dental Hygiene.
These competencies are not used verbatim in all dental hygiene programs for purposes of accredita-
tion; however, they are the guiding principles for assuring that students are competent for practice
and, therefore, remain a useful tool to guide the learner’s study and aid the instructor’s efforts toward
that end. Various learning activities are provided for groups or individuals to use inside or outside
the classroom. In addition, review questions and answers are provided to reinforce main ideas.
Resources, including web sites and search terms, are listed for use with the learning activities, or for
more in-depth study and reference. Highlighted at the beginning of each chapter are the stages in
the Dental Hygiene Process of Care that are addressed in that chapter as they relate to public health
practice.
v

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 vi PREFACE

Module 1: Introduction to Dental Public Health. This module is an introduction to the core prin-
ciples of public health, with a brief, historical overview of dental public health. This module also
highlights more recent trends and the many career opportunities in public health, together with a
global perspective of public health from various countries.
Module 2: Program Planning and Evaluation. This module is a primer of public health program
planning and evaluation. The module takes the familiar framework of assessment, diagnosis, plan-
ning, implementation, evaluation, and documentation and expands it from the patient care setting to
its application in public health settings.
Module 3: Health Promotion and Oral Health Education. This module describes the necessary
elements of health promotion and health education programs and model programs. In addition, the
module provides resources and instruction for creating culturally appropriate materials for use with
public programs.
Module 4: Epidemiology and Research. This module provides an overview of epidemiologic and
research principles, both for evaluating public programs and for critically reviewing the scientific
literature. It also describes the various forms of scientific communication and includes instruction
on how to prepare a written article, an oral presentation, and a poster session or table clinic. The
chapter on biostatistics uses specific dental examples and progresses from the fundamental concepts
of statistical terminology and central tendency to more advanced concepts, such as logistic regres-
sion. Sections of the chapter can be selected for study to meet the needs and depth of the individual
program curriculum.
Module 5: Ethics and the Law in Public Health Practice. Most ethics texts focus on individual
ethics and private practice implications. This module includes basic ethical concepts and terminol-
ogy and the process of how laws are developed. In addition, it expands the principles and provides
examples in the public health arena, to assist advocacy and social justice efforts for populations.
Module 6: National Board Preparation. This module presents a personalized system and check-
list to prepare for the Community Dental Hygiene section of the National Board Dental Hygiene
Examination (NBDHE). The module includes sample questions in the testlet format of the
NBDHE.

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 Acknowledgments
So many people…………

To the contributors, whose perseverance, dedication, and suggestions enhanced the outcome,
thank you. What an amazing group of people to work with!

Thank you to the crew at LWW, especially Matt. Your calm encouragement and guidance is
appreciated.

To Mom, Dad, and Marc, who always knew me better than I knew myself – I miss you – I know
you would be proud.

To Erin and Lauren – thanks for keeping the balance in life. Your support and artistic input
were invaluable.

RBJ - BFF

vii

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 Contributors
Editor Beverly A. Isman, MPH, RDH, ELS
Jill Mason, MPH, RDH Dental Public Health consultant
Associate Professor Davis, CA
Oregon Health & Science University
School of Dentistry Robert Isman, DDS, MPH
Portland, OR California Department of Health Services
Sacramento, CA
Contributors
Kathy Phipps, MPH, DrPH, RDH
Gail Aamodt, MS, RDH Dental Public Health Consultant
Clinical Education Coordinator Morro Bay, CA
Dental Health Science
Pacific University Rachel Badovinac Ramoni, DMD, ScD
Hillsboro, OR Acting Director, Dental Public Health Residency
Instructor in Developmental Biology
Phebe Blitz, MS, RDH Harvard School of Dental Medicine
Dental Hygiene Program Director Boston, MA
Mesa Community College
Mesa, AZ Kneka P. Smith, MPH, RDH
University of New England
Ann O. Dickinson, MS, RDH Associate Dean for Planning
Director, Dental Hygiene Program Portland, Maine
Department of Dental Hygiene
Remington College- Nashville Campus Pamela Zarkowski, BSDH, MPH, JD
Nashville, Tennessee Professor and Academic Vice President
University of Detroit Mercy
Ellen Grabarek, MPH, RDH, CHES, AP Detroit, MI
Project Director, Del E. Webb Dental Outreach
Program
Department of Dental Hygiene
Northern Arizona University
Flagstaff, AZ

Denise Muesch Helm, MA, RDH, EdD (Cand)

Associate Dean
College of Health & Human Services
Northern Arizona University
Flagstaff, AZ

viii

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 Contents
PREFACE / v

MODULE 1. INTRODUCTION TO DENTAL PUBLIC HEALTH

1 History and Principles of Dental Public Health / 2

Jill Mason
2 Trends in Dental Public Health / 15
Beverly A. Isman
Robert Isman
3 Global Perspectives in Oral Health Care / 31
Phebe Blitz
4 Professional Opportunities in Dental Public Health / 40
Jill Mason
Kneka P. Smith

MODULE 2. PROGRAM PLANNING AND EVALUATION

5 Effective Community Programs / 68

Ellen Grabarek
6 Planning for Community Programs / 81
Ellen Grabarek
7 Program Evaluation / 95
Ellen Grabarek

MODULE 3. HEALTH PROMOTION AND ORAL HEALTH EDUCATION

8 Oral Health Promotion / 108

Denise Muesch Helm
9 Community Oral Health Education / 131
Ann O. Dickinson
10 Developing Educational Materials / 151
Ann O. Dickinson

MODULE 4. EPIDEMIOLOGY AND RESEARCH

11 Concepts in Epidemiology / 178

Kathy Phipps

ix

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 x CONTENTS

12 Applying Epidemiology in Public Health

Practice: Oral Health Surveillance / 192
Kathy Phipps
13 Oral Disease Patterns in the United States / 204
Kathy Phipps
14 Biostatistics / 215
Rachel Badovinac Ramoni
15 Scientific Communication / 249
Jill Mason

MODULE 5. ETHICS AND THE LAW IN PUBLIC HEALTH PRACTICE

16 Ethical Principles / 266

Pamela Zarkowski
17 Legal Principles / 288
Pamela Zarkowski

MODULE 6. NATIONAL BOARD SUCCESS

18 National Board Success / 310

Gail Aamodt
Jill Mason

APPENDICES / 325

GLOSSARY / 336

INDEX / 351

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 MODULE

INTRODUCTION TO DENTAL
PUBLIC HEALTH
1

558417_Mason2e_ch01.indd 1 11/6/09 2:37:55 PM

 History and Principles of Dental
Public Health

Objectives Documentation
ASSESSMENT
Diagnosis
1
After studying this chapter and completing the study questions and
activities, the learner will be able to:
• Define dental public health.
• Define common public health terms.
• Describe three core functions of public health.
• Describe what constitutes a public health problem.
• Describe the four phases in the history of public health. Evaluation PLANNING
• Identify key organizations and events that have shaped dental public Implementation
health.
• Identify federal agencies involved in public health activities.

KEY TERMS

American Association of Public Canadian Association of Public National Center for Health Statistics
Health Dentistry Health Dentistry National Institute of Dental and
American Board of Dental Public Community Craniofacial Research
Health Core public health functions Pan American Health Organization
American Dental Hygienists’ Dental public health Public health
Association Health Social Security Act
American Public Health Association Healthy People Surgeon General’s Report on Oral
Association of State and Territorial Institute of Medicine Health
Dental Directors Maternal and Child Health World Health Organization

See Appendix 3 for the ADEA competencies addressed in this chapter.1

provide you with the skills and knowledge neces-

Introduction sary to be a valuable contributor in the commu-
As you begin to explore the public health aspects nity in which you practice.
of the oral health profession, you will find both It is essential all oral care providers, regardless
differences and similarities to your clinical expe- of practice location and mode, are aware of the
riences. This chapter highlights the history and unique problems in ensuring oral health for all
philosophy of dental public health, the structure members of society and participate in the solu-
of the profession, and the goals of public health. tions. This text is developed around the philosophy
You may find many of your clinical skills in treat- that all members of the oral health professions,
ment planning, problem solving, and critical and our allies from outside the profession, are all
thinking are valuable in identifying and solving pieces of a puzzle that, when complete, would
public health issues in the communities in which assure oral health for all members of society. You
you choose to practice. It is the aim of this text to will also discover that the puzzle is not complete
2

558417_Mason2e_ch01.indd 2 11/6/09 2:37:58 PM

 CHAPTER 1 / HISTORY AND PRINCIPLES OF DENTAL PUBLIC HEALTH 3

and there is much opportunity for providers of definition does not define what constitutes a
all types to help shape and complete the puzzle. healthy public so much as it provides a descrip-
It may seem that in comparing public health tion of the professional discipline of public
with private practice, they are separate from one health and the method used by that profession
another. In fact, they are all pieces of the same to attain or maintain public health. In 1955, J.W.
puzzle. Although private practice settings treat a Knutson5 also defined the discipline, reflect-
significant portion of the population, public health ing the community nature of public health as,
reaches out to many who may not have access to “Public health is people’s health. It is concerned
that mode of care. It requires everyone’s unique with the aggregate health of a group, a commu-
abilities working together to complete the puzzle. nity, a state, or a nation.” In 1988, the Institute
As you learn about public health, consider how of Medicine (IOM)6 defined the mission of
you, in the type of practice you eventually choose, public health as “… fulfilling society’s inter-
can help complete the puzzle. est in assuring conditions in which people can
be healthy.” Interestingly, this last definition
includes “society’s interest” as a component
WHAT IS DENTAL PUBLIC HEALTH? in the attainment of the public’s health. As you
will encounter throughout this text, the interest,
If someone were to ask you about your health, acceptance, and input from recipients of public
how would you respond? Great? Good? Poor? health interventions are important elements of
Lousy? Do you think only of your physical status public health practice.
and not your mental mindset? Over time, many If we add oral health to our exploration of the
people have attempted to define health. Webster definition of health, we next attempt to define
defines health as “physical and mental well-being; dental public health. Dental public health
freedom from disease.”2 This is an abbreviated is one of nine specialties of dentistry recog-
version of the often-used definition established nized by the American Dental Association. The
in 1948 by the World Health Organization definition of dental public health adopted by the
(WHO)3: “health is a state of complete physical, American Board of Dental Public Health
mental, and social well-being and is not merely (ABDPH), the governing body for the specialty,
the absence of disease or infirmity.” How does defines dental public health as:
one know when they have complete physical,
mental, and social well-being? What about the “The science and art of preventing and control-
multitude of people who live with chronic dis- ling dental diseases and promoting dental health
eases, such as diabetes or hypertension, and through organized community efforts. It is that
consider themselves healthy? Even given the form of dental practice that serves the commu-
availability of a definition by a preeminent health nity as a patient rather than the individual. It
organization like WHO, can one definition suf- is concerned with dental health education of the
fice for all of the nuances and individual percep- public, with applied dental research, and with
tions that surround health? Attempting to define the administration of group dental care pro-
health as a dichotomy when it is, in reality, a grams, as well as the prevention and control of
continuum continues to present difficulties. dental diseases on a community basis.”7
A similar difficulty is present when defining
The Canadian Association of Public
public health. If health is difficult to define,
Health Dentistry similarly defines public
how does one define public health? A defini-
health dentistry:
tion presented by Winslow4 in 1920 is still used
today. He defined public health as “the science “Dental public health is concerned with the diagno-
and art of preventing disease, prolonging life, sis, prevention, and control of dental diseases and
and promoting physical health and efficiency the promotion of oral health through organized
through organized community efforts.” The community efforts. Dental public health serves

558417_Mason2e_ch01.indd 3 11/6/09 2:37:58 PM

 4 MODULE 1 / INTRODUCTION TO DENTAL PUBLIC HEALTH

the community as the patient rather than the sions for the person in your chair are impacted
individual, through research, health promotion, by the larger community and the setting in
education, and group dental care programs.”8 which the person is treated, along with financ-
ing mechanisms. Dental public health positions
These definitions incorporate the concept of
require skills in assessing and diagnosing com-
the community as the patient, rather than the
munity oral health needs; planning, implement-
individual, a key concept of public health that
ing, and evaluating community-based oral health
you will encounter throughout this text. The defi-
programs; providing educational services; apply-
nitions also articulate the importance of public
ing research; using epidemiology; formulating
education, research, and program administration
policy; advocating; and understanding the orga-
to control disease on a community level; how-
nization of health care. The specific competen-
ever, they may fall short in addressing the impact
cies for community involvement stated in the
of societal changes and the role played by various
Competencies for Entry into the Profession of
models of health care. In addition, the ABDPH
Dental Hygiene (American Dental Education
definition was adopted prior to the increased
Association [ADEA])1 and the competencies for
acceptance of the term oral health rather than
dental public health practitioners7–9 express the
dental health, whereas the Canadian version
specific skills needed for practice or employment
uses the term oral health. This terminology has
in dental public health. These will be explored in
changed, replacing the term dental health with
more detail in Chapter 4. In addition, all of the
oral health to emphasize more than just teeth
dental hygienist roles described by the American
in the oral cavity. Professionals recognize that
Dental Hygienists’ Association (ADHA)10
oral cavity health extends beyond dental care of
(advocate, educator, clinician, researcher, and
the teeth and supporting structures. Lately, the
administrator/manager) illustrate the close align-
general public has begun also to make the con-
ment between dental hygiene and public health
nection beyond teeth and gums. With oral health
practice. It should not be overlooked that all
now known to be so influential in the general
dental professionals can and should become
health of the body and vice versa, it is time to
involved in community public health efforts. A
incorporate a broader scope for ensuring the
clear understanding of public health principles
public’s oral health. The term oral health also
is necessary for all oral health practitioners to
encourages other groups to readily join the effort
meet this challenge. It is the ethical responsibil-
in improving the public’s oral health when the
ity of all health care practitioners to work toward
effort is not so closely aligned with the term den-
improvement of the health of the community,
tistry. Unfortunately, dentistry is too often seen
especially for those who have limited access to
as an exclusive profession, keeping a distance
care or cannot advocate for themselves.
from the rest of the health care system. This
may be perceived as a barrier for other partners
outside the oral health professions who may join
in our efforts. Other groups interested in oral CORE PUBLIC HEALTH PRINCIPLES
health may include other health care provider
groups, citizen coalitions, philanthropic organiza- Public health is often an invisible infrastructure
tions, third-party payers, schools, faith organiza- until crisis occurs. The public health infra-
tions, and businesses. structure includes all governmental and non-
The most distinctive difference between pub- governmental entities that provide any public
lic health practice and private practice is the health services.11 From how many public health
concept of the community as the patient. In pri- measures have you personally benefited? Have
vate practice, the patient is the person currently you been immunized? Do you drink fluoridated
in the dental chair and care is provided based water? What other measures can you think of?
on the individual’s needs and desires. In public A recent trend in business and government is
health, even in a clinical setting, the care deci- increased accountability. For example, schools

558417_Mason2e_ch01.indd 4 11/6/09 2:37:58 PM

 CHAPTER 1 / HISTORY AND PRINCIPLES OF DENTAL PUBLIC HEALTH 5

are expected to be accountable to the public for AS

SE
the educational achievement of their students, SS
M
businesses must be more accountable to clients E
Evaluate Monitor

NT
and investors, and government entities must be Health
more accountable to the taxpayers who fund
their programs. In this era of demand for greater Assure
Competent Diagnose &
accountability, it is incumbent on schools, busi- Manage
Workforce em Investigate

ASSURANCE
nesses, and governments to develop methods to

me
t
Sys

nt
evaluate and ensure quality in their respective Research
Link to/ Inform,
endeavors. Dental public health practice is not Provide Educate,
without guidelines, competencies, goals, and Care Empower
expectations at all levels of practice. Several

POL
Mobilize
groups, such as the IOM, the American Public

ICY
Enforce Community
Health Association, and the Association of Laws Partnerships

DE
State and Territorial Dental Directors

V
Develop EL
(ASTDD), have developed frameworks to
OP
Policies ME
assess progress, quality, and success in public NT
health.6,12,13 These frameworks work well to eluci-
date the nature of public health practice. FIGURE 1-1 The government’s role in public health.12
In 1988, the IOM6 delineated the core func-
tions of public health agencies as assessment, All of these important public health func-
policy development, and assurance (Box 1-1). tions are interrelated and continuous and based
This landmark report prompted the public health on evidence provided by research to form a
community to look closely at services provided strong foundation for public health practice.
and develop a statement of core public health This interrelationship is illustrated in Figure 1-1
functions that are considered essential public by the diagram developed by the Public Health
health services (Box 1-2).12 Functions Steering Committee.12

BOX 1-1 The Role of the Government in Public Health—Core

Functions of Public Health Agencies

Assessment: Each public health agency regularly and systematically collects, assembles, analyzes,
and makes available information on the health of the community, including statistics on health
status, community health needs, and epidemiologic and other studies of health problems.
Policy Development: Each public health agency exercises its responsibility to serve the
public interest in the development of comprehensive pubic health policies by promoting use
of the scientific knowledge base in decision making and leading in the development of public
health policy.
Assurance: Public health agencies assure their constituents that services necessary to achieve
agreed upon goals are provided by encouraging actions by other entities, requiring such action
through regulation or providing services directly. Each public health agency involves key policy
makers and the general public in determining high-priority personal and community-wide health
services, which the government guarantees to every member of the community.
From The Future of Public Health. Institute of Medicine. National Academy of Sciences, 1988.6

558417_Mason2e_ch01.indd 5 11/6/09 2:37:58 PM

 6 MODULE 1 / INTRODUCTION TO DENTAL PUBLIC HEALTH

BOX 1-2 Essential Public Health Services

What Public Health Does (The Purpose of Public Health):

• Prevents epidemics and the spread of disease
• Protects against environmental hazards
• Prevents injuries
• Promotes and encourages healthy behaviors and mental health
• Responds to disasters and assists communities in recovery
• Assures the quality and accessibility of health services.
How Public Health Serves (The Practice of Public Health) (Essential Services):
• Monitors health status to identify and solve community health problems
• Diagnoses and investigates health problems and hazards in the community
• Informs, educates, and empowers people about health issues
• Mobilizes community partnerships and actions to identify and solve health problems
• Develops policies and plans that support individual and community health efforts
• Enforces laws and regulations that protect health and ensure safety
• Links people to needed personal health services and assures the provision of health care when
otherwise unavailable
• Assures a competent public and personal health care workforce
• Evaluates effectiveness, accessibility, and quality of personal and population-based health
services
• Researches for new insights and innovative solutions to health problems.
From Public Health in America, Fall 1994. Public Health Functions Steering Committee.12 Available at: www.health.gov/
phfunctions/public.htm. Accessed August 2008.

Following this report of essential public health public health workforce responded to all public
functions, the ASTDD further developed the list concerns regarding health, it would result in a
of services as it relates directly to dental public reactive, knee-jerk, inefficient, and ineffective
health services provided at the state level (Box response to society’s health needs.
1-3).13 These guidelines, used at national, state, The current criteria used to define a public
and local levels, provide a unified framework for health problem are (i) a condition or situation
all public health efforts, allowing all public health that is a widespread actual or potential cause of
programs to work toward common goals. The morbidity or mortality, and (ii) a perception on
common framework also allows for better col- the part of the public, the government, or public
laboration, sharing of information, and documen- health authorities that the condition is a public
tation of success among public health partners. health problem.14 This definition allows a broad
interpretation of a public health problem in
DEFINING A PUBLIC HEALTH PROBLEM that “widespread,” “potential,” and “perception”
can all be interpreted differently in different
After defining the role of public health and the situations with different threats to the public.
essential services that should be provided, what Bioterrorism, West Nile Virus, Severe Acute
constitutes a public health problem that warrants Respiratory Syndrome (SARS), natural disasters,
resources applied toward its solution? If the automobile safety, water purification, and oral

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 CHAPTER 1 / HISTORY AND PRINCIPLES OF DENTAL PUBLIC HEALTH 7

BOX 1-3 Essential State Dental Public Health Services

Assessment
Assess oral health status and needs
Analyze determinants of identified needs
Assess fluoridation status of water systems and other sources of fluorides
Implement oral health surveillance systems
Policy Development
Develop plans and policies through a collaborative process
Provide leadership to address oral health problems
Mobilize community partnerships
Assurance
Inform, educate, and empower the public
Promote and enforce laws
Link people to oral health services; assure availability, access, and acceptability
Support primary and secondary prevention programs
Assure the capacity and expertise of the public and personal health workforce
Evaluate effectiveness, accessibility, and quality of oral health services
Conduct research and support demonstration projects
From Guidelines for State and Territorial Oral Health Programs: Essential Public Health Services to Promote Oral Health
in the United States (2007 Revision). The Association of State and Territorial Dental Directors. Available at: http://www.
astdd.org. Accessed January 2009.13

disease may be seen as more or less a problem In the second phase (1880–1930), population-
depending on whom you ask. Later chapters will based prevention strategies were possible with
describe methods for identifying public health advances in bacteriology and immunizations,
problems and developing solutions. reducing the effects of infectious diseases.
Immunization programs were an outgrowth of
HISTORY OF PUBLIC HEALTH this phase.
Continued advancements in technology in a
Public health has traversed through three phases third phase (1930–1975) allowed a further shift
into a current, fourth phase that is centered on to the treatment of disease through increasingly
the current societal needs of the times and the complex medical treatments. Interventions in
progression of industrialization and technology this phase occurred increasingly in hospitals
in the world. During the first phase (1849–1900), rather than with community-based public health
public health activities were related to the elimi- measures. During this phase, many major infec-
nation and control of diseases that grew out of tious diseases, such as smallpox, were eradicated
rapid industrialization and crowded and poor and cures for many acute health problems were
living conditions. Many activities were aimed at developed.
reducing the morbidity and mortality of such dis- The current, or fourth, phase arises from the
eases as cholera, polio, and plague. Efforts, there- realization that technology may be strikingly
fore, were directed at basic sanitation methods. effective in the treatment or cure of acute health

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 8 MODULE 1 / INTRODUCTION TO DENTAL PUBLIC HEALTH

problems but ineffective in managing chronic and where we are going. Several key events have
lifestyle diseases and controlling the spiraling shaped the profession of dental public health to
cost of high technology health care. The value make it what it is today.
of technology is limited because of the lack of The dental hygiene profession originated in
availability to all members of the public and the 1906 as Dr. Alfred C. Fones began a course of
inability to correct the most prevalent diseases we study for his assistant, Irene Newman.15 This
now face, those that occur as a result of longer life early profession was centered in public health
expectancy gained from earlier phases of public practice. The dental hygienist was prepared to
health and lifestyle choices. This current phase provide education and treatment in the commu-
now emphasizes a broader approach to health. nity setting and to work as an advocate for dental
It goes beyond prevention of specific diseases care. The preventive nature of the dental hygiene
to encompass the concept of overall wellness. profession is still a perfect fit in the public health
Health promotion strategies are used to encour- arena as envisioned by Alfred Fones. Even today,
age healthy lifestyles, resulting in a reduced risk the mission of the ADHA is “to improve the pub-
of multiple problems. For example, choosing not lic’s total health.”16
to smoke or choosing to stop smoking can reduce Public health continues to be an arena in
the risk for lung cancer, hypertension, periodon- which oral health professionals work together
tal disease, heart disease, or emphysema. and with other groups to improve the oral health
Will terrorist actions, such as the events of of the communities in which they work and live.
September 11, 2001, and natural disasters, like It is sad to think that the original purpose of the
Hurricane Katrina and others, cause us to look dental hygiene profession has blurred because of
again at our public health infrastructure and our the fear that dental hygienists may be a threat to
ability to respond to new public health threats, dental practices and the public. This perception
such as bioterrorism? Will we enter a new phase has resulted in limitations put on dental hygiene
of public health? Will we strengthen the protec- licensure and practice through restrictive dental
tion from and rapid response to unknown or practice acts, which are only now starting to
undefined threats to health? The quick responses reverse, with more states allowing dental hygien-
and measures taken to stop the spread of the ists to practice in other than private settings and
SARS epidemic indicate how rapid information under less restrictive supervision requirements.
transfer and global cooperation can protect the State dental practice acts are also evolving to
public’s health and highlight how important allow dental hygienists to perform services not
cooperation and information sharing can be in permitted in the past. However, it will be some
preventing a world disaster. The effectiveness time before Fones’ vision is truly fulfilled.
of our response to major disasters teaches us A key public health event occurred in August
what pieces of the puzzle are missing and what 1935. The Social Security Act,17 passed by
improvements can be made. Congress, established unemployment compen-
sation and benefits for the elderly. In addi-
HISTORIC HIGHLIGHTS IN DENTAL tion, it provided aid to the individual states for
PUBLIC HEALTH health and welfare activities, including grants for
Maternal and Child Health (MCH). Because
oral health services were included in maternal
“Trying to plan for the future without a sense of
and child health block grants, many states estab-
the past is like trying to plant cut flowers”—
lished dental public health units within their
Daniel Boorstin
health department structure. The number of
No text would be complete without setting dental public health units grew so rapidly that,
the stage for what is to come by exploring the in 1937, a group of state dental administrators
path by which we have traveled. Knowing where founded the American Association of Public
we have been helps us understand where we are Health Dentists (AAPHD), which was changed

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 CHAPTER 1 / HISTORY AND PRINCIPLES OF DENTAL PUBLIC HEALTH 9

in 1983 to the American Association of Public

Health Dentistry, reflecting the expanded
BOX 1-4 Ten Great Public
membership that included dental hygienists, Health Achievements of the
health educators, and others. In 1977, the 20th Century
AAPHD voted to allow dental hygienists to be
voting members of the organization, becoming Vaccination
the first and only sponsoring organization of Motor vehicle safety
a dental specialty to allow full membership to Workplace safety
dental hygienists.18 Infectious disease control
The 1940s saw many dental public health Reduction in death from coronary heart
developments. During World War II (WWII), disease and stroke
the dental services of the armed forces expanded Safer and healthier food
considerably. This was a direct result of the poor Healthier mothers and babies
oral health status of the young recruits being Family planning
inducted, which shed light on the extensive Fluoridated drinking water
dental needs of the United States population.19 Recognition of tobacco use as a health
Dental services for the armed forces increased hazard
during WWII because of selective service rejec-
tions, resulting from about 10% of potential From Ten Great Public Health Achievements—United
recruits failing the military physical examination. States, 1900–1999. Centers for Disease Control and
Prevention. MMWR 1999;48(12):241–243.20
The recruits lacked the necessary six opposing
teeth in each arch to meet the military standard.19
To accommodate the manpower needs for the
war, selective service requirements were again
lowered twice before the end of the war. The In 1951, public health dentistry was rec-
growth in armed forces dental services and the ognized as the seventh of what are currently
need to treat large groups of people efficiently nine specialties in dentistry. The ADHA also is
and effectively became the seed for the concept developing special emphases in dental hygiene
of the community as the patient, which has practice, one of which would be public health.
remained a core concept for dental public health This is evidenced by the ADHA 2008 adoption
practice. The armed forces experience led to the of the Competencies for the Advanced Dental
development in 1948 of the National Institute of Hygiene Practitioner.21 This new practitioner is
Dental Research (NIDR) to address the national expected to provide a wide range of services in
dental problem.19 The NIDR was eventually public health, becoming another piece of the
changed to the National Institute of Dental public health framework.
and Craniofacial Research (NIDCR), reflect- In January 2000, the Department of Health
ing a broader perspective about oral growth and and Human Services launched Healthy People
development. 2010, a comprehensive, nationwide health pro-
In 1945, controlled clinical trials of water motion and disease prevention plan.22 It builds
fluoridation began in Grand Rapids, Michigan, on similar documents of 1990 and 2000 and con-
and Newburgh, New York. These trials forever tains 467 objectives designed to be a framework
changed the smiles of America and led to the for improving the health of the nation during
establishment of water fluoridation as a safe, the first decade of the 21st century. There are
effective means of preventing dental caries. 28 focus areas, each representing a public health
Indeed, water fluoridation, considered one of area, including oral health. The objectives serve
ten great public health achievements of the 20th as targets for the health of the nation for the
century,20 is supported by all major health profes- year 2010 and provide a basis for comparison
sional organizations (Box 1-4). and a focus for health agencies at all levels to

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 10 MODULE 1 / INTRODUCTION TO DENTAL PUBLIC HEALTH

participate in the goals of the nation. Tracking The dental public health network also appears
of progress is the responsibility of the National at all levels of society. Many local, national, and
Center for Health Statistics, which provides international governmental agencies include a
a centralized location for information and data dental public health component and opportuni-
related to the objectives. Healthy People 2020 ties for dental public health careers. Chapter 4
is the next step in the process and is planned for highlights many of these career opportunities in
release in 2010. greater detail.
The Surgeon General’s Report on Oral The United States Government will be used
Health was released in May 2000.23 This was the here to illustrate a public health and dental pub-
first Surgeon General’s Report on Oral Health lic health infrastructure. In the United States,
in the more than 50-year history of Surgeon the President’s Cabinet includes leading officials
General Reports. The report highlights the fact of the fifteen executive departments of the gov-
that oral health is better now than ever before ernment. Within these departments are many
in history. The report’s primary message is that agencies responsible for essential services in
oral health is essential to the general health and public health. Figure 1-2 highlights the depart-
well-being of all Americans and that it can be ments and agencies with significant dental public
achieved by all Americans. However, the report health functions. Many of these agencies work
also illustrates the profound disparities that exist together and in tandem with schools, community
in oral health in America—children, the elderly, organizations, philanthropic organizations, and
members of racial and ethnic groups, and those others to accomplish their goals. Similar infra-
with disabilities and complex health conditions structures also occur at local, state, provincial,
are at greater risk for oral disease. The report and international levels.
calls for a national partnership to provide oppor- Global health also affects the health of the
tunities for individuals, communities, and the local population. With the increased ability to
health professionals to work together to main- travel throughout the world, health concerns
tain and improve the nation’s oral health. It is can quickly transfer from one country or area of
too early to know the full impact of this report the world to another and become a global public
on oral health in America; however, public health problem. Infectious and life-threatening
health dentistry professionals are taking the diseases, such as SARS and HIV/AIDS, are a
charge seriously. leading concern. The effect of global move-
ment of people from one country to another
also affects the need for a strong oral health
PUBLIC HEALTH INFRASTRUCTURE infrastructure. Therefore, it behooves public
health professionals and agencies from various
The fabric of the public health infrastructure countries to work together to solve problems,
in the United States is an example of a broad, eradicate disease, and protect people from newly
sweeping network of many entities, working at developing threats. Certain, more notable, glob-
all levels of government and society to protect al entities involved in public health endeavors
the health of Americans. A constant challenge are the WHO and the Pan American Health
in public health is that efforts are occurring on Organization (PAHO).
so many fronts that coordination and collabora- The WHO headquarters is located in Geneva,
tion are often difficult. However, the Internet Switzerland. Their objective is attainment of the
and common goals and frameworks allow for highest possible level of health by all peoples.24
better communication and easier access to infor- WHO acts as the directing and coordinating
mation. This network is often invisible to the authority on international health work and pro-
beneficiaries of the efforts; however, all of these poses regulations and makes recommendations
protections and core functions of a public health about global public health practices. The World
infrastructure are part of our everyday lives. Oral Health Report 2003 states that oral diseases

558417_Mason2e_ch01.indd 10 11/6/09 2:37:59 PM

 President
Cabinet (Executive Departments)
Agriculture Commerce Housing and Urban Development Energy Transportation

558417_Mason2e_ch01.indd 11
Education
Labor Justice Defense State Treasury

Health & Veterans

Interior Human Affairs Homeland Security
Services

OSG

OPHS* USPHS Commissioned Corps

12 Core Public Health Offices

IHS* NIH* CDC* HRSA* AHRQ* SAMHSA* NCEH/ATSDR* AoA CMS ACF
Areas Institutes Centers Bureaus Centers Centers Divisions Centers Centers Offices
FDA*
Centers

Aberdeen NCI COGH BPHC CBER CDOM CSAT NCEH CPM CDHPC OHS
Alaska NEI COTPER BHPr CDRH CFACT CSAP EEHS CPO CMM OFA
Albuquerque NHLBI CCEHIP MCHB CDER COE CMHS EHHE CMSO OPA
Bemidji NHGRI NCEH/ATSDR HAB CFSAN CP3 DLS OPRE
Billings NIA NCIPC BCRS CVM CQuIPS ATSDR OCSE
California NIAAA CCHIS HSB NCTR DHAC ORR
Nashville NIAID NCHM DHS OCS
Navajo NIAMS NCHS DTEM OLAB
Oklahoma NIBIB NCPHI DRO ORO
Phoenix NICHD CCHP ADD
Portland NIDCD NCBDDD ANA
Tucson NIDCR NCCDPHP ACYF
NIDDK CCID
NIDA NCIRD *Denotes components of the U.S. Public Health Service
NIEHS NCZVED
NIGMS NCHHSTP
NIMH NCPDCID
NINDS NIOSH
NINR
NLM
CHAPTER 1 / HISTORY AND PRINCIPLES OF DENTAL PUBLIC HEALTH

7 Centers
FIGURE 1-2 United States—Federal Infrastructure of Health Services. (See Appendix 2 for a listing of the acronyms and their meanings).
11

11/6/09 2:37:59 PM
 12 MODULE 1 / INTRODUCTION TO DENTAL PUBLIC HEALTH

are a major public health problem and that of its mission, activities, budget, and role in
increased emphasis should be on developing the dental public health infrastructure.
global policies in oral health promotion and oral 4. Write a reflection paper discussing what con-
disease prevention.25 One priority is more effec- stitutes good oral health.
tive coordination with other WHO programs and 5. Choose a particular oral health problem in
external partners. your community and create a list of organiza-
The PAHO headquarters is located in tions or community groups in your community
Washington, DC. It is an international public that would be important partners in an oral
health agency, founded in 1902, that includes health coalition formed to address the prob-
all 35 countries in the Americas.26 Its mission is lem (e.g., early childhood caries, fluoridation
to strengthen national and local health systems of the community’s water supply, school fluo-
and to improve the health of the peoples of the ride rinse program).
Americas. PAHO collaborates with such entities 6. Write a reflection paper on the pros and
as Ministries of Health, governmental agencies, cons of the public health infrastructure being
nongovernmental organizations (NGOs), univer- “invisible.”
sities, social security agencies, and community 7. Identify a public health problem and describe
groups. why it constitutes a public health problem.
8. Choose a state, province, or a country other
than the United States and investigate the
Summary dental public health infrastructure of the cho-
sen area.
Much of public health, which has evolved with 9. Create a classroom game based on the abil-
time, is an invisible infrastructure that has been ity to link an acronym with a public agency
developed to protect the health of the public. and the role it has in public health. Include
Public health activities occur at all levels of the agency’s mission and location and other
government and society and include efforts to details.
improve the public’s oral health. Core functions
of public health entities and competencies for
public health professionals guide public health
practice. The dental public health profession Resources
has a rich history of working to improve the oral American Association of Public Health Dentistry
health of the public. In addition, the mission of (AAPHD) (listserve): http://www.aaphd.org
the dental hygiene profession and the profes- American Public Health Association Oral Health
sional roles of dental hygienists are a reflection Section: http://www.apha-oh.org
of the natural fit between dental hygiene and Association of State and Territorial Dental
public health, which was envisioned by Dr. Directors.: http://www.astdd.org
Alfred Fones as he prepared the first dental World Health Organization: http://www.who.
hygienist. int/en/
Pan American Health Organization.: http://
new.paho.org/hq/index/php?lang=en
U.S. Government official Web portal: http://
Learning Activities www.usa.gov
1. List public health services from which you Healthy People 2020: http://www.healthypeople.
have personally benefited. gov/HP2020
2. Develop your own definition of dental public American Dental Hygienists’ Association: http://
health. adha.org
3. Choose a governmental agency with oral Canadian Association of Public Health Dentistry:
health responsibilities and write a description http://www.caphd-acsdp.org

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 CHAPTER 1 / HISTORY AND PRINCIPLES OF DENTAL PUBLIC HEALTH 13

REFERENCES
Review Questions 1. American Dental Education Association. Competencies
for entry into the profession of dental hygiene. Exhibit 7.
1. The third phase of public health included all J Dent Educ 2004;68(7):745–749.
of the following EXCEPT the: 2. Webster’s New World Dictionary. Simon and Schuster,
a. treatment of disease with complex medical 1995.
treatment. 3. World Health Organization. Preamble to the Constitution
b. eradication of smallpox. Adopted by the International Health Conference, New
c. intervention through hospitalization rather York, June 19–22, 1946.
4. Winslow CEA. The untilled fields of public health.
than the community.
Modern Med 1920;2:183–191.
d. cure for acute health problems. 5 Knutson JW. What is public health? In: Pelton WJ,
e. effective management of chronic, lifestyle- Wisan JM, eds. Dentistry in Public Health, 2nd ed.
related diseases. Philadelphia, PA: W.B. Saunders, 1955.
6. The Future of Public Health. Institute of Medicine,
2. State dental public health units originally Committee for the Study of the Future of Public Health.
developed as a result of the: Washington, DC: National Academy Press, October 1988.
a. establishment of the American Association 7. American Association of Public Health Dentistry/
of Public Health Dentistry. American Board of Dental Public Health. Competency
b. need for recruits during WWII. statements for dental public health. J Public Health
c. Surgeon General’s Report. Dent 1998;58(Suppl. 1):119–122.
8. Canadian Association of Public Health Dentistry. Available
d. Maternal and Child Health grants to states.
at: http://www.caphd-acsdp.org. Accessed January 2009.
e. creation of the NIDR. 9. Core competencies for public health professionals. Council
3. The controlled clinical trials of water fluorida- on Linkages Between Academia and Public Health
Practice. Washington, DC: Public Health Foundation.
tion began in:
Available at: http://phf.org. Accessed August 2009.
a. 1937. 10. Types of dental hygiene careers. American Dental
b. 1942. Hygienists’ Association Online. Available at: http://
c. 1945. www.adha.org/careerinfo/dhcareers.htm. Accessed
d. 1948. January 2009.
e. 1953. 11. Chapter 23: Public Health Infrastructure. In: Healthy
People 2010 (Conference Edition; two volumes).
4. The primary reason for developing the NIDR Washington, DC: Department of Health and Human
was to: Services, January 2000.
a. provide a central agency to monitor state 12. Public Health in America. Fall 1994. Public Health
fluoridation efforts. Functions Steering Committee. Available at: http://
www.health.gov/phfunctions/public.htm. Accessed
b. address the national dental problems discov- January 2009.
ered through selective service rejections. 13. Guidelines for state and territorial oral health programs:
c. create educational opportunities for dental Essential public health services to promote oral health
public health professionals. in the United States (2007 Revision). The Association
d. make dentistry more visible at the National of State and Territorial Dental Directors. Available
Institutes of Health. at: http://www.astdd.org/docs/ASTDDGuidelines.pdf.
Accessed January 2009.
e. study the cost-effectiveness of community
14. The practice of dental public health. In: Burt BA, Eklund
water fluoridation. SA, eds. Dentistry, Dental Practice, and the Community.
5. Core functions of public health include: 6th ed. Philadelphia, PA: W.B. Saunders, 2005, p. 39.
15. Motley WE. History of the American Dental Hygienists’
a. assessment.
Association, 1923–1982. Chicago, IL: American Dental
b. policy development. Hygienists’ Association, 1983, p. 21.
c. assurance. 16. Profile of ADHA—Mission Statement. Available at:
d. funding of oral health programs. http://www.adha.org/aboutadha/profile.htm. Accessed
e. a, b, and c. January 2009.

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 14 MODULE 1 / INTRODUCTION TO DENTAL PUBLIC HEALTH

17. Social Security Act of 1935. Available at: http://www. 22. Healthy People 2010 (Conference Edition; two vol-
usconstitution.com/socialsecurityactof1935.htm. umes). Washington, DC: Department of Health and
Accessed January 2009. Human Services, January 2000.
18. Application for Continued Recognition of the Specialty 23. Oral Health in America: A Report of the Surgeon
of Dental Public Health. Submitted by the American General—Executive Summary. Rockville, MD: DHHS,
Association of Public Health Dentistry to the American National Institute of Dental and Craniofacial Research,
Dental Association, 1986. Available at: http://www. National Institutes of Health, 2000.
aaphd.org/default.asp?page=history.htm. Accessed 24. World Health Organization (WHO). About WHO.
January 2009. Available at: http://www.who.int/about/en/. Accessed
19. Harris RR. Dental Science in a New Age: A History of January 2009.
the National Institute of Dental Research. Rockville, 25. WHO Oral Health Report for 2003. Commun Dent
MD: Montrose Press, 1989, pp. 78–91. Oral Epidemiol 2003;31(Suppl. 1):3–23. Available at:
20. Ten Greatest Public Health Achievements—United http://www.who.int/oral_health/publications/report03/
States, 1900–1999. Centers for Disease Control and en/. Accessed January 2009.
Prevention. MMWR 1999;48(12):241–243. 26. Pan American Health Organization (PAHO). About
21. American Dental Hygienists’ Association. Competencies PAHO. Available at: http://www.paho.org/english/paho/
for the Advanced Dental Hygiene Practitioner. Adopted What-PAHO.htm. Accessed January 2009.
March 2008. Available at: http://www.adha.org/
downloads/competencies.pdf.

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 Trends in Dental Public Health

Objectives ASSESSMENT
Documentation
2
Diagnosis
After studying this chapter and completing the study questions and
activities, the learner will be able to:
• Discuss the reasons for oral health disparities and the lack of access
to care.
• Describe at least five public health strategies for reducing oral health
disparities and access problems.
• Discuss trends in financing for oral care and community-based public Evaluation Planning
health programs. Implementation
• Describe potential reasons for a fragile dental public health
infrastructure and current efforts to address the problems.
• Discuss challenges posed by ethnic and cultural discrepancies between the oral health workforce and the
general population.
• Give examples of multidisciplinary collaborations and public–private partnerships to address oral health
problems.
• Give examples of ways to integrate oral health with general health and public health.
• Discuss how advances in science and information technology influence the field of dental public health.
• Discuss a variety of health communication strategies.
• Discuss the goal of evidence-based practice and obstacles to implementing this approach in public health
settings.

KEY TERMS

Anticipatory guidance Health communication Patient navigators

Capitation Integration of oral health and Plain language
Children’s Health Insurance general health Public health care financing
Program Interdisciplinary programs
Community coalitions Leadership development Risk assessment
Community-based participatory Literacy Safety net dental clinics
research Loan forgiveness program Social marketing theory
Culturally relevant Managed care plans Systematic reviews
Dental Health Professional Media advocacy Teledentistry
Shortage Areas Medicaid Volunteerism
Dental home Medicare
Diffusion of innovations Mobile and portable dental
Evidence-based practice services
Gatekeeper Oral health disparities

See Appendix 3 for the ADEA competencies addressed in this chapter.1

15

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 16 MODULE 1 / INTRODUCTION TO DENTAL PUBLIC HEALTH

Introduction ORAL HEALTH DISPARITIES

“It was the best of times, it was the worst of times; Although oral health problems affect everyone,
it was the age of wisdom, it was the age of foolish- certain population subgroups, defined by demo-
ness; it was the epoch of belief, it was the epoch graphic factors such as age, sex, race or ethnicity,
of incredulity; it was the season of Light, it was socioeconomic status, primary language, geogra-
the season of Darkness; it was the spring of hope, phy, medical or disability status, and behavioral
it was the winter of despair; we had everything lifestyles, experience higher levels of oral disease.
before us, we had nothing before us . . .” They are said to have oral health disparities
Charles Dickens (1812–1870) in comparison with other groups. Non-Hispanic
Blacks, Hispanics, American Indians, and Alaska
This quotation from A Tale of Two Cities by Natives generally have the poorest oral health of
Charles Dickens captures the seemingly oppos- the racial and ethnic groups in the United States.2
ing perspectives that have characterized the field Limited knowledge of and access to preventive
of dental public health for the last few decades. It oral health measures and professional care have
reflects the vicissitudes of public health, as well contributed to these disparities. Box 2-1 sum-
as the importance of considering different per- marizes some statistics to highlight the extent of
spectives on an issue. Students who learn ideal the problem.3-7
public health practices while in school often do The U.S. population is aging, with the fast-
not realize how much the fields of public health est growing segment ages 85 years and older.
and dental public health fluctuate in response to The first baby boomers will turn 65 in 2011. By
overall societal, medical, economic, and political 2030, about 71 million Americans will be ages 65
changes. Traditional approaches that have been and older (about 20% of the population).8 There
previously successful may no longer be relevant. are pronounced geographic shifts in the U.S.
Dental professionals must be aware of trends population as well, with southern and western
that affect the public’s oral health and the way states increasing in population. Most older per-
that professional care is delivered and financed. sons remain in the community; in 2000, 4.5% of
Public health professionals who stay energized people ages 75 to 84 and 18.2% of those 85 and
by new challenges that arise on a daily basis may older lived in nursing homes.9 Many more reside
also be frustrated by ongoing budget fluctuations in assisted living facilities and on their own or
and bureaucratic processes that appear to be with relatives. The number of persons with dis-
inflexible and outdated. One day may be high- abilities living in the community, regardless of
lighted by a successful fluoridation campaign and age, continues to increase. Older Americans use
the next by a request to cut 20% from the oral more health services than previous generations.
health program budget due to an overall budget With improved oral care, these groups retain
deficit. Dental public health professionals face their teeth longer, increasing the demand for
an environment, therefore, in which they need comprehensive services that can be provided
to be flexible, proactive, up-to-date, creative, in different settings. This presents a challenge
and compassionate. Those who succeed have to planners, academic faculty, and clinicians,
learned the importance of maintaining a sense especially as geriatric dentistry or special care
of balance—between a career and personal/ dentistry are not yet one of the accredited dental
family interests, idealism and reality, personal specialties.
integrity and compromise, and innovation and More than one of four Americans is Black,
patience. This chapter addresses certain trends Hispanic, or Asian/other non-Hispanic; this pro-
in the United States that challenge dental public portion will increase to one of three Americans
health practice and certain ways that organiza- by 2020.2 More than one in 10 U.S. residents is
tions, communities, and professionals are meet- foreign-born, the majority of whom are Hispanic
ing these challenges. or Asian/Pacific Islander origin. Many arrive in

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 CHAPTER 2 / TRENDS IN DENTAL PUBLIC HEALTH 17

BOX 2-1 Oral Health Needs and Disparities

• Dental caries is the most common chronic childhood disease—five times more common than
asthma and seven times more common than hay fever.
• Poor children suffer twice as much dental decay as their more affluent peers and the disease
is more likely to be untreated; this trend continues into adolescence.
• Between 1988–1994 and 1999–2004, tooth decay in primary teeth of children ages 2 to 5 years
increased from 24% to 28% and untreated dental decay also increased.3
• American Indian/Alaska Native children ages 2 to 4 years have five times the rate of dental
decay of all U.S. children.
• Between 1988–1994 and 1999–2004, the use of dental sealants increased from 22% to 30%
among youths and from 18% to 38% among adolescents.3
• Uninsured children are 2.5 times less likely than insured children to receive dental care.
For each child without medical insurance, there are at least 2.6 children without dental
insurance.
• According to the 2004 Medical Expenditure Panel Survey, high-income children under age
21 were twice as likely to have a visit as poor children, and the percentage of children with no
dental coverage decreased from 1996 to 2004.5
• More than two out of every three children with Medicaid coverage did not receive any dental
services in Federal Fiscal Year 2006.6
• More than 51 million school hours are lost each year to dental-related illness; poor children
suffer nearly 12 times more restricted activity days than higher-income children.
• A greater percentage of non-Hispanic Blacks ages 18 years and older have missing teeth com-
pared with non-Hispanic Whites.
• American Indian/Alaska Native populations have much greater rates of dental caries and
periodontal disease in all age groups than the general U.S. population. The high prevalence of
diabetes is a contributing factor.
• Oral cancer accounts for a greater percentage of cases of cancer than ovarian, cervical, thyroid,
or brain cancer.7
• Of all oral cancer cases, 85% were among whites, 10% among blacks, and almost 5% among
Hispanics.7
• The 5- and 10-year relative survival rates for all stages of oral cancer are 59% and 44%, respec-
tively.7
• African American males have the highest incidence of oral and pharyngeal cancers in the
United States and their 5-year survival rates are lower than the rest of the population.
• Small-scale studies show that populations with mental retardation or other developmental dis-
abilities have higher rates of poor oral hygiene and have periodontal treatment needs greater
than the general population.
• Almost two thirds of community residential facilities for persons with disabilities report inad-
equate access to dental care for their residents.
• Sixty-five percent of child abuse cases involve head and oral–facial trauma.
• Oral clefts are more common among North American Indians (3.7 per 1,000 live births) and
more common among Whites than Blacks (1.7 versus 0.5 per 1,000 live births).
From Oral Health in America: A Report of the Surgeon General. Rockville, MD: DHHS, NIDCR, NIH, 2000,4 except
where indicated otherwise, with permission.

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 18 MODULE 1 / INTRODUCTION TO DENTAL PUBLIC HEALTH

the United States with significant unmet oral are using this framework to develop strategic
health needs, inadequate finances, and a limited plans and implement activities.
knowledge of the English language. When seek- 3. Lack of comparable or updated data at state
ing care, they find themselves in a cultural and and local levels hinders attempts to document
communication disconnect with a predominantly improvements in oral health, despite continu-
White and English-speaking dental and dental ing efforts to refine data collection and analy-
hygiene workforce and with limited resources to sis for oral health indicators. The National
pay for care. They may not receive timely care Oral Health Surveillance System (NOHSS),
or any care and are more likely to have negative developed jointly by the Association of State
health encounters. and Territorial Dental Directors (ASTDD)
In 2000, 45% of the adult U.S. population and the Centers for Disease Control and
read at an eighth grade level or lower. About Prevention (CDC), is one attempt to collect
45% of English-speaking adults are estimated and analyze comparable data. On the NOHSS
to have limited literacy skills that interfere with web site, data for the following eight oral
their ability to handle basic skills involved in health indicators can be displayed in tables,
seeking and receiving health care.10 Health lit- graphs, and maps for the nation and each
eracy is important for learning oral health knowl- state that submitted data: (i) dental visits,
edge, completing health applications and forms, (ii) teeth cleaning, (iii) complete tooth loss,
following health recommendations, purchasing (iv) fluoridation status, (v) dental caries expe-
oral health care products, promoting oral health rience, (vi) untreated dental caries, (vii) dental
to others, communicating with oral health care sealants, and (viii) cancer of the oral cavity and
providers, and navigating various aspects of an pharynx. Other indicators are under consider-
oral health care system. ation. These data can be used to advocate for
What is being done nationally to track and more resources to address oral health dispari-
address these disparities? ties and to track improvements in oral health.
More information on the NOHSS is included
1. Healthy People is a national health promotion in subsequent chapters.
and disease prevention initiative that includes 4. State and local health departments, dental
the goal of eliminating health disparities schools, and dental hygiene programs can
among different segments of the population. play a role in reducing oral health disparities
Oral Health, with 17 objectives, is a separate by conducting research using measures that
focus area in the Healthy People 2010 objec- yield comparable data. To increase resources
tives, but is also woven into many other focus as part of its Plan to Eliminate Craniofacial,
areas, such as maternal and child health, can- Oral, and Dental Health Disparities, the
cer, diabetes, access, and infrastructure.11 National Institute of Dental and Craniofacial
2. In April 2003, the Surgeon General issued Research (NIDCR) has funded two cycles
A National Call to Action, a framework for of grants for Centers for Research to
oral health action and strategies for collabora- Reduce Oral Health Disparities to encour-
tion to reduce disparities and improve oral age interdisciplinary research across com-
health.12 The report calls for action on the part ponents of academic health centers and
of individuals and groups in five areas: change with community-based agencies and orga-
perceptions of oral health; overcome barriers nizations.2 The focus is on community-
by replicating effective programs and proven based participatory research where the
efforts; build the science base and accelerate community is an equal partner in identifying
science transfer; increase oral health work- research priorities and in all phases of the
force diversity, capacity, and flexibility; and projects. Also as part of the Disparities Plan,
increase collaboration. National organizations NIDCR and CDC collaborated on the for-
as well as state and local oral health coalitions mation of the Dental, Oral, and Craniofacial

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 CHAPTER 2 / TRENDS IN DENTAL PUBLIC HEALTH 19

Data Resource Center to consolidate health states were continuing or proposing to offer
and disease data from multiple sources. CDC full or limited adult oral health benefits, and
also funds a network of Prevention Research the number of states offering no coverage had
Centers across the country, some of which increased to 16. In 2007, 16 states offered at least
are conducting interdisciplinary oral health some oral health benefits in all major service
research. categories, 13 states excluded at least one service
category, 16 states offered emergency services
only, and 6 states offered no adult services.16
FINANCING OF PUBLIC HEALTH AND ORAL These program descriptions illustrate the tradi-
HEALTH CARE tionally limited or fragmented coverage afforded
to oral health care by public programs. In 2006,
Unlike medical care, a large portion of oral state and federal public programs covered 6%
health care is financed privately, either as out- of oral health expenditures nationally, but 45%
of-pocket payments made directly to a dentist of all personal health care expenditures.13 State
or through employment-based dental insurance and federal governments convey an unfortunate
benefits. Since 1960, these two sources have message to the public about the importance of
financed more than 93% of all dental expendi- oral health by covering virtually no oral health
tures. Nationally, the public paid out-of-pocket services in Medicare and deeming the coverage
for 44% of dental expenditures, but for only 15% of adult oral health services optional for state
of all personal health care expenditures (includ- Medicaid programs. In contrast to medicine,
ing dental) in 2006.13 the relative scarcity of dental insurance and the
The two largest public health care financ- absence of managed care in existing dental plans
ing programs are Medicare and Medicaid. mean that those people who seek care always
In 2007, the Medicare program provided health have to assume at least some responsibility for
insurance coverage for more than 44 million their oral health care costs.
people who were ages 65 and older, certain The Children’s Health Insurance Program
people with disabilities, and persons with kidney (CHIP) is a jointly funded federal–state program
failure.14 Since its inception in 1965, with a few that provides health insurance coverage for chil-
minor exceptions, Medicare has never provided dren up to age 19 whose families do not qualify
coverage for oral health services. for Medicaid and whose incomes are generally
Medicaid is a jointly funded, federal–state less than twice the federal poverty level ($22,050
health insurance program for certain low- for a family of four in 2009). During Federal
income and needy people. It covers approxi- Fiscal Year 2008, 7.4 million children were
mately 42.1 million individuals, including enrolled in CHIP for at least part of the year.17
children, seniors, people who are blind or have Although oral health coverage is not a manda-
other disabilities, and people who are eligible tory component of CHIP (unless the program is
to receive federally assisted income mainte- an extension of the state’s Medicaid program),
nance payments.15 Oral health services under all states have elected to offer at least some oral
Medicaid are mandatory for children, but are health coverage to eligible children. However,
one of about 34 health and health-related ser- the extent of coverage is dependent on funding
vices that are considered optional for adults. In and, in difficult economic times, states often tend
difficult economic times, cash-strapped states to view oral health coverage as one of the more
may cut these optional benefits to save money expendable benefits.
and preserve other programs. In 2000, 31 state In addition to the major publicly financed
Medicaid programs offered full or limited oral oral health care programs noted above, the wide
health coverage for adults and seven states range of community-based programs—community
offered no coverage. By 2003, when only three clinics, school-based sealant programs, preschool
states were not facing budget deficits, only 15 fluoride programs, nursing home oral health

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 20 MODULE 1 / INTRODUCTION TO DENTAL PUBLIC HEALTH

programs—are funded through various sources, than 20% of all children had no dental coverage.
such as federal, state, and local governments; Approximately 103 million adults ages 21 to 64
corporate sponsors; foundations and other philan- (60%) had private dental coverage during that
thropic organizations; sliding fee schedules; and year, whereas only 5% had public coverage and
private donations. The one thing common to most 34% had no coverage.5
of these programs is that they are typically under- Health insurance plans can be broadly divided
funded relative to public need and demand. into two large categories: (i) indemnity plans
Insurance is a major determinant of oral (also referred to as reimbursement plans), and
health care utilization. Most full-time employ- (ii) managed care plans. With indemnity plans,
ees in medium-sized and large businesses are the insurer pays a specific amount for a specific
covered for at least some oral health care service or set of services; therefore, these plans
benefits, but fewer small businesses offer such are often referred to as fee-for-service plans.
benefits. Although more than 14% of children There are three basic types of managed
younger than 18 have no form of public or care plans: (i) health maintenance organizations
private medical insurance, more than twice as (HMOs), (ii) preferred provider organizations
many—23 million children—have no dental (PPOs), and (iii) point-of-service (POS) plans.
insurance.18 In 2006, although more than 15% See Box 2-2 for definitions of these plans. All
of persons ages 18 and older had no form of managed care plans involve an arrangement
medical insurance, 20% of nonelderly adults between the insurer and a selected network of
and 12% of children had no medical insurance.19 health care providers. All offer policyholders
In 2004, approximately 46 million children financial incentives to use the providers in that
(54%) had private dental coverage during the network. There are usually specific standards for
year, whereas about 26% of all children had selecting providers and formal steps to ensure
only public dental coverage and slightly less that quality care is delivered.

BOX 2-2 Basic Types of Managed Care Plans

Health Maintenance Organizations

HMOs, or their dental equivalents (dental maintenance organizations [DMOs] or dental health
maintenance organizations [DHMOs]), provide health care services on a prepaid basis, meaning
that HMO/DMO members pay a fixed monthly fee, regardless of how much care is needed in a
given month. In most cases, HMO/DMO members must receive their care from providers and
facilities within the HMO/DMO network.
Preferred Provider Organizations
PPOs are plans under which patients select a provider from a network or list of providers who
have agreed, by contract, to discount their fees. In PPOs that allow patients to receive treatment
from a nonparticipating provider, patients will be penalized with higher deductibles and copay-
ments. PPOs are usually less expensive than comparable indemnity plans.
Point-of-Service Plans
POS plans are arrangements in which patients with a managed care plan have the option of seek-
ing treatment from an “out-of-network” provider. The reimbursement for the patient is usually
based on a low table of allowances, with significantly reduced benefits than if the patient had
selected an “in-network” provider.

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 CHAPTER 2 / TRENDS IN DENTAL PUBLIC HEALTH 21

When managed care programs first began activities. Many federal, state and local dental
in the 1940s, an underlying principle was that public health programs are overextended, under-
providing and paying for preventive services funded and lack highly trained and experienced
would ultimately reduce the costs of health care. leadership. Twenty-four states have three or
Even today, many managed care plans are in the fewer employees working in state government
forefront of prevention and offer programs that oral health programs; eight states have more
traditional indemnity insurance plans may not than 50% of their state and local health jurisdic-
cover. tions with a population of over 250,000 with no
Managed care plans are typically paid a fixed dental programs.20 Differences in state oral health
amount per enrollee per month, regardless of programs are reflected in the annual ASTDD
whether that individual actually uses the services Synopses of State and Territorial Dental Public
the plan offers. This arrangement is referred to Health Programs. Numerous national organiza-
as capitation. Although the plans themselves tions and government agencies are trying to
are capitated, providers participating in the plans alleviate this situation by promoting leadership
may be reimbursed in several different ways development through already existing leader-
(e.g., they may receive a capitation fee, but they ship institutes, public policy fellowships, or by
may also be paid fee-for-service or be salaried by creating new opportunities for skill development
the plan). in public health, management, and informa-
In many managed care plans, a primary care tion technology. Tools to help states address
provider (e.g., pediatrician, family practitioner, infrastructure problems are available on CDC’s
general dentist, and, sometimes, pediatric den- Division of Oral Health web site. The Health
tist) controls referral to specialists (i.e., the Resources and Services Administration (HRSA)
patient cannot independently see a specialist). also has provided a number of funding opportu-
This is referred to as the gatekeeper function. nities to help states strengthen their oral health
infrastructure. Web sites that contain online
information related to the content of this chapter
ORAL HEALTH INFRASTRUCTURE AND are included in the Resources section.
WORKFORCE More than 90% of active dentists and dental
hygienists work in private practice. Many general
dentists and specialists do not participate in public
Programs
financed programs such as Medicaid or SCHIP,
As noted in the Surgeon General’s Report on placing a burden on community clinics and
Oral Health, “The public health infrastructure other programs that treat underserved popula-
for oral health is insufficient to address the needs tions. Continuing efforts through national groups
of disadvantaged groups, and the integration of such as the American Dental Association (Give
oral and general health programs is lacking.”4 Kids a Smile), Oral Health America, American
Infrastructure, as described in Chapter 1, refers Dental Hygienists’ Association, The National
to systems, people, relationships, and resources Foundation of Dentistry for the Handicapped,
needed to perform functions. A National Call and Special Olympics promote private sector
to Action reports that the lack of personnel with volunteerism to provide free or reduced-fee
oral health expertise at all levels in public health preventive services and oral health care to indi-
programs remains a serious problem. Public viduals who can’t afford private sector care,
health agencies in particular are experiencing a especially children, disabled individuals, and frail
void in the number of experienced dental public elders. This does not begin to solve the dental
health professionals who can fill management or access problem, however.
policy positions, especially due to retirements. In July 2008 an estimated 47.6 million peo-
State and local oral health programs vary in ple resided in 3,951 areas designated by the
funding sources, staffing patterns, and range of Department of Health and Human Services’

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 22 MODULE 1 / INTRODUCTION TO DENTAL PUBLIC HEALTH

Bureau of Primary Health Care (BPHC) as need and demand for care. The Safety Net
Dental Health Professional Shortage Areas Dental Clinic Manual is available online to help
(DHPSAs).21 To meet the 3,000:1 desired ratio communities make decisions about building or
of population to dental practitioners in these expanding safety net clinics.
DHPSAs, 9,321 dental professionals are needed. Another solution to the access problem is to
DHPSAs are geographic areas, special population take the services to where populations live, work,
groups (e.g., low-income or Medicaid popula- or spend a significant amount of time, such as to
tions), or facilities (e.g., correctional institutions) the schools. Many community-based programs
designated by the federal government as having a that use self-propelled mobile vans, mobile trail-
shortage of oral health personnel. This designa- ers that are parked at sites, and portable dental
tion qualifies these entities for various federal equipment that will fit into an automobile or
programs (e.g., community health centers and truck are providing services to underserved pop-
sites where health professionals may be able to ulations. These mobile and portable dental
practice and have all or a portion of their student services are particularly efficient for conduct-
loans forgiven). ing dental sealant programs. An online Mobile
The federal government supports Federally and Portable Dental Manual is available to help
Qualified Health Centers, community/migrant/ communities implement high-quality mobile and
homeless health center programs located in portable dental care systems.
medically or dentally underserved communities. To address the lack of/maldistribution of
In 2007 more than 1,000 health centers oper- dental services in rural or isolated areas, tele-
ated 6,000 service delivery sites in the United dentistry is helping (i) general practitioners seek
States, D.C. and the territories/jurisdictions.22 needed consultation from specialists for certain
To increase the proportion of centers that pro- patients, (ii) dental hygienists practice in areas
vide on-site oral health care, the BPHC began where a dentist is not always available for diag-
an initiative in 2002 that required new clinics nosis and consultation, (iii) delivery of continuing
or expansion of existing clinics to include oral education courses, and (iv) dentist–laboratory
health care to receive funding, so most of these communication, as well as reducing travel time
centers now include on-site oral health pro- and expenses for families. Teledentistry uses
grams, employing more than 6,800 oral health electronic information and communications
professionals to provide services including pri- technology to provide and support health care
mary and preventive oral health care and out- provided in distant locations. Digital radiography
reach. In 2007 more than 2.8 million patients and other computer and video applications, as
received dental services at health centers, twice well as Integrated Services Digital Network
as many as in 2001. lines, make this type of service possible.
Numerous community nonprofit and for- One potential solution to certain access
profit clinics have emerged to serve as addition- problems is to change restrictive state dental
al safety net dental clinics. The oral health practice acts that prevent dental hygienists
care safety net is where people go because from practicing without the supervision of a
(i) they do not have a regular source of care or dentist, that limit state licensure to practitioners
they choose it as their regular source of care, who have successfully passed a state clinical
(ii) they know there is a sliding fee scale or that board, and that prevent dental hygienists from
their Medicaid card will be accepted, (iii) they receiving direct reimbursement from third-
will not be turned away when they are in pain party payers, such as Medicaid or private dental
and cannot afford care, and (iv) the clinic is insurers. Recent legislation has expanded the
close to home, or for various other reasons. It role of dental hygienists in several states to pro-
helps people who otherwise fall through the mote better access to preventive services and to
cracks in oral health care. Unfortunately, there address these barriers. New models of service
are not enough clinics to meet the growing delivery are arising in some states and native

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 CHAPTER 2 / TRENDS IN DENTAL PUBLIC HEALTH 23

communities. This is addressed in more detail districts often find themselves working with chil-
in Chapter 4. dren and families that represent more than 240
different language groups. Although language
assistance for limited English proficient persons
Workforce
(including use of bilingual staff, interpreters,
The oral health workforce, like the general popu- and translation of written materials) has been
lation, is aging, and many professionals choose required for years for programs and health care
to work part-time. Some states project they will providers who receive federal funding (includ-
lose 30% to 50% of their oral health workforce ing Medicaid and Medicare), resources and
to retirement in the next decade. This situation monitoring are inadequate. Some programs are
is mirrored in public health and academic set- training members of the community to serve as
tings. Recruiting members of underrepresented patient navigators or community health work-
ethnic groups into oral health and allied health ers to help bridge the communication gap and
professions and into dental public health posi- to assure that people are aware of information,
tions has been difficult. For example, recruit- services and financial coverage, and know how to
ment continues to be a problem for the Indian access and use them.
Health Service and for tribal clinics that want Student indebtedness plays a major role in
to hire members of their own communities. The decisions to enter dental school and then to work
number of oral health professionals representing in private practice or in public health. In 2006,
minority groups in the United States is dispropor- the mean graduating debt of dental students was
tionate to the distribution of these groups in the $162,155 compared to $107,504 in 2002.24 More
population. In 2005, underrepresented minori- than 50% reported at least $150,000 in educa-
ties comprised 12.8% of applicants and 12.6% tional debt. About 33% of the graduating seniors
of first-year enrollees.23 Most of the increase has in 2007 reported use of Health Professions
been among Asian/Pacific Islander students. In a Student Loans and 7% received scholarships
2006 study of dental graduates, the least impor- from one of the uniformed services, the Indian
tant factor noted for going into dentistry was the Health Service, or the National Health Service
opportunity to serve vulnerable and low-income Corps. Twelve percent reported they would be
populations, although minority students rated participating in a federal or state loan forgive-
this and service to own race and ethnic group ness program and 4% received need-based
higher than white students.24 The field of dental federal grants or fellowships. Unfortunately,
hygiene is even less ethnically diverse. Relatively graduates who practice in the National Health
few faculty members in dental or dental hygiene Service Corps or the Indian Health Service to
schools are ethnic minorities. pay off student loans or scholarship obligations
These ethnic and cultural discrepancies often leave after their obligations are finished.
between the oral health workforce and the gen- Lower salaries for university faculty and public
eral population create a number of challenges. health positions have deterred some dental and
Adequate numbers of role models and mentors dental hygiene graduates from pursuing these
are lacking for students and graduates from eth- options, despite other benefits that they gain. In
nic minority groups who wish to work in dental 2006 there were 406 faculty vacancies overall and
public health settings. Designing effective com- 17 vacant positions in community dentistry/public
munity-based oral health promotion and disease health.25 Only about 6% of graduating students
prevention programs that are culturally relevant planned on entering government service imme-
to different groups (incorporating health beliefs, diately on graduation; slightly higher percentages
dietary considerations, and communication styles of ethnic minorities, especially American Indian/
from each group) is difficult. This will be cov- Alaska Native and Black/African American stu-
ered more in Chapter 10. Dental hygienists who dents, planned on doing so.24 When asked about
provide services in large metropolitan school long-term plans for practice, 1.3% indicated they

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 24 MODULE 1 / INTRODUCTION TO DENTAL PUBLIC HEALTH

would practice in government service and 1.7% coalitions, and volunteerism are now the primary
indicated teaching/administration or research. Only focus of many funding streams from foundations
0.3% of the seniors had applied for further educa- and government agencies. Staff of governmental
tion in the specialty of dental public health. As of oral health programs who are frustrated with the
December 31, 2007 there were a total of 218 liv- slowness of bureaucracy and an inability to advo-
ing dentists board certified in dental public health, cate directly with lawmakers are experiencing
157 of which were certified as active (J. Alderman, new successes when community groups advocate
personal communication, July 27, 2008). for improvements in oral health and leverage
Options for dental hygiene and dental assist- various resources to fund and implement pro-
ing graduates to pursue advanced education in grams. Oral health coalitions have helped initiate
dental public health are limited, although some significant changes in legislation, regulations
possess MPH or DrPH degrees. Many do not that impact dental hygiene practice and public
wish to enroll in a formal degree program but financing of care, and promotion of community-
would rather work part-time or full-time and based preventive programs. Efforts to develop
have the opportunity to obtain a specialty cer- and implement comprehensive or topic-focused
tificate or participate in a fellowship or residency state oral health action plans have been funded
program. As you will read in Chapter 4, more by the National Governors’ Association, HRSA,
online and other programs are being developed Maternal and Child Health Bureau (MCHB),
to help fill this gap, but specialty certification and and CDC. Recent communication efforts have
fellowships are not yet available. The American focused on increasing the general public’s knowl-
Dental Hygienists’ Association’s Public Health edge of oral health, including strategies to advo-
Council may partner with other organizations to cate with policymakers and legislators for public
create additional options and career tracks. policy changes and increased resources. Later
chapters will provide more information on coali-
MOBILIZING ASSETS THROUGH tion building.
COALITION BUILDING

The role of government in health care has always INTEGRATION OF ORAL HEALTH INTO
been a contentious issue and continues to be a GENERAL HEALTH AND PUBLIC HEALTH
focus of arguments on covering the uninsured,
prescription drug benefits, cutbacks in Medicaid The Surgeon General’s Report, Oral Health in
services, and laws/regulations governing the America, called for the integration of oral
health care industry. Many public health profes- health and general health—thinking of the
sionals and members of advocacy groups have mouth as an integral part of the whole body rather
turned to community-based solutions to solve than as separate territory that only dental profes-
health issues and access problems, applying sionals can enter. This concept is important for
practices from other cultures and countries to assuring the sustainability of community-based
arrive at new approaches. The concepts “Think oral health programs. Oral health concepts can
globally; act locally” and “It takes a village to raise be integrated into and funded by programs on
a child” are readily applicable to today’s crises in nutrition, cancer, HIV/AIDS, osteoporosis, birth
health care and oral health care. defects, diabetes, cardiovascular disease, tobacco
Communities are recognizing the need for cessation, prenatal counseling, school-readiness
broad and diverse input into promotion of oral initiatives, efforts to maintain the functional status
health and provision of oral health services, where of the elderly, and military readiness for action.
anyone can have a role. Coordination of health, Integrating primary medical care and oral
education, social, and other services is needed to health care to prevent oral disease in young
ensure healthy individuals and healthy commu- children has been and continues to be the focus
nities. Public/private partnerships, community of numerous collaborative projects and publica-

558417_Mason2e_ch02.indd 24 11/6/09 2:40:22 PM

 CHAPTER 2 / TRENDS IN DENTAL PUBLIC HEALTH 25

tions. In 1994, the National Center for Education professionals find it difficult to learn new elec-
in Maternal and Child Health published Bright tronic communication systems, putting them at a
Futures: Guidelines for Health Supervision of disadvantage for keeping professionally current.
Infants, Children, and Adolescents, a framework Rapid dissemination of information in various
for health professionals to provide developmen- formats through electronic media, particularly
tally appropriate health promotion and disease the Internet, is enabling people to learn about
prevention services to children and their fami- innovations in a timely manner and to share them
lies.26 Bright Futures in Practice: Oral Health with others. It also helps the public advocate for
followed in 1996 to help oral health and other programs and policies directly with legislators in
health care professionals address the oral health a rapid fashion. Health professionals and policy-
needs of children within this framework.27 A new makers often are in the difficult position of trying
edition of Bright Futures in 2008 includes a sep- to keep ahead of consumer knowledge levels,
arate chapter on oral health. The basis for these answer questions based on reliable information,
guidelines is (i) risk assessment—assessment and correct misperceptions due to inaccurate
of risk factors and protective factors for dental information online. People are more aware of
caries, periodontal disease, malocclusion, and their rights and responsibilities as health care
oral injury, and (ii) anticipatory guidance— consumers. People with difficulty in understand-
counseling families about their children’s current ing and navigating the health care system and
oral health status and what to expect at upcoming communicating with their providers now have
developmental stages. This approach now has more opportunities to find helpful resources and
been adopted by many groups and is becoming also communicate online. All of these factors are
the cornerstone of clinical and community-based changing the way policymakers, health profes-
infant and child oral care programs. sionals and consumers communicate.
Other models for integration include (i) teach-
ing general dentists the skills to treat young
Health Communication Strategies
children and recognize other childhood health
problems, (ii) promoting a child’s first oral health New health communication strategies are
assessment/dental visit by age one, (iii) assur- slowly being incorporated into public health
ing that each child has a “medical home” and a approaches to improving oral health. Health
“dental home”—a continuous, accessible source communication is the “study and use of commu-
of care, (iv) incorporating oral health screening/ nication strategies to inform and influence indi-
referral, education, and fluoride varnishes into vidual and community decisions that enhance
primary care and well child visits, and (v) increas- health.”11 Two health communication strategies
ing interprofessional education and communi- that are used in public health are (i) social mar-
cation via the Internet. Head Start is another keting theory, a technique used to increase
example of a national program that promotes public awareness of the relationship of behav-
integration of oral health with general health and iors to diseases and to influence people to take
school readiness. action,28 and (ii) media advocacy, the strategic
use of various media outlets and formats to
increase awareness and knowledge of issues.29
APPLICATION OF TECHNOLOGY AND These concepts are discussed in more depth in
SCIENTIFIC RESEARCH later chapters.
FrameWorks Institute has used these tech-
niques in research on oral health for almost a
Influence of Information Technology
decade, examining the public’s understanding of
Health professionals and policymakers today are oral health to help design strategies to engage and
inundated with information that affects health mobilize advocates to address this issue. Using
practices and policy development. Some older this research, funded by the Washington Dental

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 26 MODULE 1 / INTRODUCTION TO DENTAL PUBLIC HEALTH

Service and others, FrameWorks designed and their messages and approaches to different groups
managed a public campaign on oral health for to be culturally relevant. Evaluating effectiveness
children in the state of Washington, the “Watch and efficiency of interventions has assumed more
Your Mouth” campaign, which has now become importance so that oral health promotion efforts
a model for replication in other states and com- can be more evidence-based. Additional infor-
munities.30 mation on creating appropriate communication
Other strategies attempt to address the health tools will be presented in Chapter 10.
needs of people with limited English language
skills. The National Literacy Act of 1991 defined
Evidence-Based Practice
literacy as “. . . ability to read, write, and speak
in English and compute and solve problems at In the last decade, evidence-based health care
levels of proficiency necessary to function on the has served as a catalyst for new avenues for
job and in society, to achieve one’s goals, and health services research and a focus on health
develop one’s knowledge and potential.”31 One outcomes. The goal of evidence-based prac-
model for improving health literacy is to inte- tice is to facilitate timely translation of research
grate health concepts and skills into adult educa- findings into clinical and community practices
tion, General Educational Degree programs, and that result in improved oral health. This requires
English as a Second Language classes. Another a decision-making process based on integration
model is use of “plain language.”32 Although of new evidence for effectiveness with expert
there is no standard definition, it means that opinion, clinical and community experience, and
people who use documents written in plain lan- professional judgment. Various barriers exist,
guage can quickly and easily (i) find what they however, to prevent widespread use of this
need, (ii) understand what they find, and (iii) act approach in clinical or certain public health
on that understanding. settings (Box 2-3).
All of these strategies emphasize the impor- Research on diffusion of innovations
tance of identifying appropriate communication demonstrates that it takes at least 10 years for
and health promotion approaches for each audi- practitioners to adopt new materials or tech-
ence. Because the “one size fits all” approach does niques.34 Research on many new clinical and pre-
not work, programs must learn how to customize ventive techniques has not yet been translated

BOX 2-3 Barriers to Implementing Evidence-Based Dentistry

• Insufficient research or inconclusive evidence

• Poor quality research
• Inadequate or ineffective dissemination of evidence
• Faculty not basing their teaching on evidence-based approaches
• Clinicians not reading or hearing about new research or not wanting to learn the new skills
• Expecting clinicians to document and evaluate clinical oral health outcomes for their
patients
• Convincing third-party payers to reimburse based on new practice guidelines
• Implementing standard diagnostic codes.
Adapted from Mertz B, Manuel-Barkin C, Isman B, O’Neil E. Improving Oral Health Care Systems in California. San
Francisco, CA: UCSF Center for the Health Professions; 2000, with permission.33

558417_Mason2e_ch02.indd 26 11/6/09 2:40:22 PM

 CHAPTER 2 / TRENDS IN DENTAL PUBLIC HEALTH 27

to their use with various population groups in • New communication channels: learning to
private practice or public health settings. Before design and disseminate key messages to differ-
evidence-based practice can be fully imple- ent target audiences using new technologies.
mented in clinical and public health settings, • Outcome-based evaluation: looking at the
however, additional research is needed, espe- impact of programs on oral health rather than
cially to develop reliable and valid measures of just program logistics and numbers of people
oral health outcomes. The Cochrane Oral Health served.
Group, one of several groups that perform sys- • Management of young professionals: relating
tematic reviews, has completed a number of to a group that expects participatory deci-
oral health reviews. ASTDD has established sion making and has different communication
another type of review process for best practices skills and work styles, especially in relation to
that rates state and community practice submis- new information technology.
sions on five criteria: (i) impact/effectiveness, • Methods for imparting dental public health
(ii) efficiency, (iii) demonstrated sustainability, history and experience: making the lessons
(iv) collaboration/integration, and (v) objectives/ of the past relevant to the present and the
rationale. Reports about dental public health future.
“best practice” approaches to improve the infra-
structure can be accessed through the ASTDD
Best Practices web site. Additional information
about evidence-based oral health promotion pro-
Learning Activities
grams is found in Chapter 8. 1. Choose one of five actions cited in the
National Call to Action to Promote Oral
Health, and discuss ways that you or your
class can “answer the call.”
Summary 2. Find oral health statistics for your commu-
nity or state. Compare statistics from 10 or
Many trends in the field of dentistry, dental
20 years ago to more recent statistics. How
hygiene, and public health create challenges for
have they changed? What do you think con-
students and professionals who wish to work in
tributed to these changes?
the field of dental public health. Major chal-
3. Locate online resources about the principles
lenges include reducing oral health disparities,
of community-based participatory research
increasing access to preventive services and oral
and how they relate to cultural relevance.
health care, financing oral care, integrating oral
Locate and describe some funded projects
health into general health and public health
that are examples of this type of research
efforts, mobilizing assets through new col-
applied to oral health disparities.
laborations and community partnerships, and
4. Check the ASTDD web site to see if your
using new technologies and evidence-based
state has held a dental summit or Head Start
practices.
oral health forum. If so, review the reports,
New skills that are needed to meet future den-
action plans, and recommendations. What
tal public health challenges include the following:
barriers to care were identified and what
• Interdisciplinary teams: working with new were the recommended actions to address
partners such as social scientists, epidemiolo- the problems? Discuss roles that dental and
gists, evaluation specialists, and health com- dental hygiene students and practicing den-
munication specialists. tal professionals can play in implementing
• Community coalition building: increasing sup- the recommendations.
port and ownership for oral health programs, 5. Interview someone in the state Medicaid pro-
creating solutions to local issues, and assuring gram about how enrollment of families, enroll-
sustainability of programs. ment of dental providers, and coverage and

558417_Mason2e_ch02.indd 27 11/6/09 2:40:22 PM

 28 MODULE 1 / INTRODUCTION TO DENTAL PUBLIC HEALTH

reimbursement rates for various oral health HRSA Bureau of Primary Health Care: http://
services have changed in the past 5 years. bphc.hrsa.gov/
6. View the ASTDD Synopses of State Dental HRSA Bureau of Primary Health Care Dental
Public Health Programs and compare four Health Professional Shortage Areas: http://
states on such characteristics as population, bhpr.hrsa.gov/shortage
infrastructure, funding sources, and range of HRSA Maternal and Child Health Bureau: http://
programmatic activities. mchb.hrsa.gov/
7. Research what professional leadership insti- Indian Health Service: http://ihs.gov
tutes or programs are available for dental, Mobile and Portable Dental Manual: http://www.
dental hygiene, or public health professionals mobile-portabledentalmanual.com
in the United States, and compare them for National Foundation of Dentistry for the
length and cost, topics and projects, and out- Handicapped: http://www.nfdh.org
comes reported by alumni. National Maternal and Child Oral Health
8. Develop recruitment tools to interest under- Resource Center: http://mchoralhealth.org
represented ethnic groups in public health National Oral Health Surveillance System: http://
professions, especially dental public health. www.cdc.gov/nohss
9. Interview the state oral health program NIDCR Dental, Oral and Craniofacial Data
director, a member of the state staff, or a city Resource Center: http://drc.nidcr.nih.gov/
or county dental director to learn ways that Office of the Surgeon General: http://www.
oral health is integrated into other health surgeongeneral.gov
programs and activities. Oral Health America: http://www.oralhealthamer-
10. Interview a dental researcher or a member of ica.org
the dental hygiene faculty. Ask how advances Safety Net Dental Clinic Manual: http://www.
in science and technology have changed the dentalclinicmanual.com
way they do research, access information, Special Olympics Special Smiles: http://www.
and teach in the past 5 to 10 years. specialolympics.org

Resources Review Questions

American Association of Public Health Dentistry
1. Which of the following persons is least likely
(AAPHD): http://www.aaphd.org
to have difficulty accessing dental care?
American Public Health Association, Oral Health
a. A frail, elderly woman who is homebound
Section: http://www.apha.org/
b. A 20-year-old, male, Hispanic, migrant agri-
Association of State & Territorial Dental Directors
cultural worker
(ASTDD): http://www.astdd.org
c. A 40-year-old female American Indian in
CDC Oral Health Resources: http://www.cdc.
an isolated Alaskan village
gov/OralHealth
d. A 59-year-old state government worker
CDC Prevention Research Centers: http://www.
e. A 2-year-old who lives in a single-parent
cdc.gov/prc
family with his five brothers and is eligible
Cochrane Oral Health Group: http://www.ohg.
for but not enrolled in Medicaid
cochrane.org
Health Literacy Studies: http://www.hsph. 2. Which of the following is NOT a true state-
harvard.edu/healthliteracy ment?
Healthy People 2010 Resources: http://www. a. Dental caries is the single most common
healthypeople.gov chronic children’s disease.
HRSA Bureau of Health Professions: http:// b. Over 50% of child abuse cases involve head
bhpr.hrsa.gov/ and oral facial trauma.

558417_Mason2e_ch02.indd 28 11/6/09 2:40:22 PM

 CHAPTER 2 / TRENDS IN DENTAL PUBLIC HEALTH 29

c. Uninsured children are 2.5 times less likely e. The number of dental professionals apply-
than insured children to receive dental care. ing for government jobs has increased in
d. Less than 200 school hours are lost to the past few years.
dental-related illness each year.
6. All of the following are considered barriers to
e. African American males have the highest
implementing evidence-based dental public
incidence of oral and pharyngeal cancers
health practice EXCEPT:
in the United States and their 5-year sur-
a. the time it takes for practitioners to adopt
vival rates are lower than the rest of the
new research.
population.
b. the translation of techniques used success-
3. The Surgeon General’s Report, A National fully in private practice with individual
Call to Action to Promote Oral Health, covers patients to a community-based population
five actions. Which of the following is NOT approach.
one of the actions? c. not having enough scientists to review pre-
a. Change public perceptions of oral health vious studies.
b. Increase oral health workforce diversity, d. the lack of funded oral health research in
capacity, and flexibility community-based settings.
c. Build the science base and accelerate sci- e. convincing third-party payers to reimburse
ence transfer based on new practice guidelines.
d. Overcome barriers by replicating effective
programs and proven efforts REFERENCES
e. Promote more disciplinary rather than
interdisciplinary collaborations 1. American Dental Education Association. Competencies
for entry into the profession of dental hygiene. Exhibit 7.
4. All of the following trends may increase access J Dent Educ 2004;68(7):745–749.
to care EXCEPT: 2. National Institute of Dental and Craniofacial Research.
a. teledentistry. A Plan to Eliminate Craniofacial, Oral, and Dental
Health Disparities. Rockville, MD: DHHS, NIH,
b. mobile and portable dentistry.
NIDCR, 2002. Available at: http://www.nidcr.nih.
c. dental expansion of community health gov/NR/rdonlyres/932B8B7D-E114-4491-BE85-
centers. ABA6F29663AE/0/hdplan.pdf. Accessed July 2008.
d. more restrictive dental and dental hygiene 3. Dye BA, Tan S, Smith V, et al. Trends in oral health
state practice acts. status: United States, 1988–1994 and 1999–2004.
e. volunteerism. National Center for Health Statistics. Vital Health Stat
2007;11(248):1–104.
5. Which of the following is an accurate repre- 4. Oral Health in America: A Report of the Surgeon
sentation of a current dental public health General. Rockville, MD: Department of Health
workforce issue? & Human Services (DHHS), National Institute of
a. Ethnic representation in the dental public Dental and Craniofacial Research (NIDCR), National
Institutes of Health (NIH), 2000. Available at: http://
health workforce does not mirror represen- www.surgeongeneral.gov/library/oralhealth. Accessed
tation in the population served by public July 2008.
health programs. 5. Manski RJ, Brown E. Dental Use, Expenses, Private
b. Too many graduates are applying for dental Dental Coverage, and Changes, 1996 and 2004.
public health advanced education programs. Rockville, MD: Agency for Healthcare Research and
c. Salaries for dental public health positions Quality, 2007. MEPS Chartbook No.17. Available at:
http://www.meps.ahrq.gov/mepsweb/data_files/publica-
are not much different than salaries in pri-
tions/cb17/cb17.pdf. Accessed July 2008.
vate dental or dental hygiene practice. 6. Centers for Medicare & Medicaid Services
d. Currently, there are many options for dental National Data Files. Available at: http://www.cms.
hygienists to pursue advanced education or hhs.gov/MedicaidEarlyPeriodicScrn/Downloads/
credentialing in dental public health. National_1995_2006.zip. Accessed July 2008.

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 30 MODULE 1 / INTRODUCTION TO DENTAL PUBLIC HEALTH

7. U.S. Cancer Statistics Working Group. United States 19. Kaiser Family Foundation. Health Insurance Coverage
Cancer Statistics: 2004 Incidence and Mortality. of the Nonelderly Population, 2006. Available at: http://
Atlanta: U.S. Department of Health and Human facts.kff.org/results.aspx?view=slides&cbook=50.
Services, Centers for Disease Control and Prevention Accessed July 2008.
and National Cancer Institute, 2007. Available at: 20. Association of State and Territorial Dental Directors.
http://www.cdc.gov/cancer/npcr/npcrpdfs/US_Cancer_ Summary Report. Synopses of State Dental Public Health
Statistics_2004_Incidence_and_Mortality.pdf. Accessed Programs. Data for FY 2006–2007. Available at: http://
July 2008. www.astdd.org/docs/2008SynopsisReportSUMMARY.
8. Institute of Medicine. Retooling for an Aging America: pdf. Accessed July 2008.
Building the Health Care Workforce, 2008. Executive 21. Data provided by the HRSA BPHC Shortage Designation
Summary available at: http://www.nap.edu?catalog/12089. Branch. Available at: http://datawarehouse.hrsa.gov.
html. Accessed July 2008. Accessed July 2008.
9. Administration on Aging. A Profile of Older Americans: 22. Health Resources and Services Administration. Health
2006. Available at: http://www.aoa.gov/PROF/Statistics/ Centers: America’s Primary Care Safety Net. Reflections
profile/2006/2006profile.pdf. Accessed July 2008. on Success, 2002–2007. Available at: http://bphc.hrsa.
10. Scott BS. Low literacy: A health care quality issue. gov/success. Accessed July 2008.
Closing the Gap 2003;Jan/Feb:14–15. 23. Chmar JE, Weaver RG, Ramanna S, et al. U.S. dental
11. Healthy People 2010: Objectives for Improving Health. school applicants and enrollees, 2005 entering class. J
Washington, DC: U.S. Government Printing Office, Dental Educ 2007;71(8):1098–1123.
2001. Available at: http://www.healthypeople.gov. Accessed 24. Chmar JE, Harlow AH, Weaver RG, et al. Annual
July 2008. ADEA survey of dental school seniors, 2006 graduating
12. A National Call to Action to Promote Oral Health. class. J Dental Educ 2007;71(9):1228–1253.
Rockville, MD: DHHS, Public Health Service (PHS), 25. Chmar JE, Weaver RG, Valechovic RW. Dental school
NIH, NIDCR, Spring 2003. Available at: http://www. vacant budgeted faculty positions, academic years
surgeongeneral.gov/topics/oralhealth/nationalcalltoac- 2005-06 and 2006-07. J Dental Educ 2008;72(3):370–385.
tion.htm. Accessed July 2008. 26. Green M, ed. Bright Futures: Guidelines for Health
13. Catlin A, Cowan C, Hartman M, et al. National health Supervision of Infants, Children, and Adolescents.
spending in 2006: A year of change for prescription Arlington, VA: National Center for Education in
drugs. Health Affairs 2008;27(1):1–16. Maternal and Child Health, 1994.
14. Kaiser Family Foundation. Medicare Enrollment, 27. Casamassimo P. Bright Futures in Practice: Oral
by Eligibility Status, 2001–2007. Available at: http:// Health. Arlington, VA: National Center for Education
facts.kff.org/results.aspx?view=slides&topic=2. Accessed in Maternal and Child Health,1996.
July 2008. 28. Bolig R. Social marketing and health communications.
15. Kaiser Family Foundation. Medicaid Enrollment in 50 Am J Health Commun 1997;Spring:12–16.
States: December 2006 Update. Available at: http:// 29. Wallach L, Dorfman L. Media advocacy: A strategy for
www.kff.org/medicaid/7606.cfm. Accessed July 2008. advancing policy and promoting health. Health Educ Q
16. McGinn-Shapiro M. Medicaid coverage of adult dental 1996;23(3):293–317.
services. National Academy for State Health Policy 30. Watch Your Mouth Campaign. Available at: http://www.
Monitor, 2008. watchyourmouth.org. Accessed July 2008.
17. Kaiser Family Foundation. Estimated Number of 31. PL 1-2-73. The National Literacy Act of 1991. July 25,
Children Enrolled in CHIP with Family Income at 1991.
or Below 200% Federal Poverty Level (FPL) and 32. Locke J. The plain language movement. Am Med
Above 200% FPL, FY2008. Available at http:// Writers Assoc J 2003;18(1):5–8.
www.statehealthfacts.org/comparemaptable. 33. Mertz B, Manuel-Barkin C, Isman B, et al. Improving
jsp?ind=658&cat=4. Accessed September, 2009. Oral Health Care Systems in California. San Francisco,
18. Vargas CM, Isman RE, Crall JJ. Comparison of chil- CA: UCSF Center for the Health Professions, 2000.
dren’s medical and dental insurance coverage by socio- 34. Rogers EM. Diffusion of Innovations, 3rd ed. New York:
economic characteristics, United States, 1995. J Public The Free Press, 1983.
Health Dent 2002;62(1):38–44.

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 Global Perspectives in Oral
Health Care

Objectives Assessment
Documentation Diagnosis
3
After studying this chapter and completing the study questions
and activities, the learner will be able to:
• Identify and discuss three influences on an oral health care system.
• Discuss three barriers to access oral health care
• Describe the role and education of oral health care workers around the
world.
Evaluation PLANNING
Implementation

KEY TERMS

Aboriginal health workers Dental therapists International Federation of Dental

Atraumatic restorative technique Financial barriers Hygienists (IFDH)
(ART) Indian Health Service Personal/cultural barriers
Dental health aide therapists Interim therapeutic restoration Socioeconomic position
Dental nurses (ITR) Structural barriers

See Appendix 3 for the ADEA competencies addressed in this chapter.1

health research agenda, setting norms and stan-

Introduction dards, articulating evidence-based policy options,
Perspectives on oral health care are necessarily providing technical support to countries and
different in various countries. Perspectives are monitoring and assessing health trends.” In 2003
dependent on many factors including demograph- WHO indicated that because of the high preva-
ics, oral health needs, health care values/beliefs, lence and incidence in all regions of the world,
and educational and health care systems of deliv- oral disease is a major public health problem.2
ery. Each culture has its own way of meeting the This chapter describes factors influencing oral
oral health needs of its people. One chapter cannot health care systems and examples of the various
cover in detail all of the nuances of oral care around workforce provider groups involved in the care
the world. The goal of this chapter is to provide an process in different countries.
overview of health care providers and systems that
will expose the student to other oral health care
possibilities and encourage further study. INFLUENCING FACTORS ON ORAL HEALTH
By its own definition “The World Health CARE SYSTEMS
Organization (WHO) is the directing and coor-
dinating authority for health within the United The way each country finances health care plays
Nations system. It is responsible for providing a role in the type of oral health care provided
leadership on global health matters, shaping the and how it is delivered. Financing can come
31

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 32 MODULE 1 / INTRODUCTION TO DENTAL PUBLIC HEALTH

from general government revenues, insurance, pists practice. Dental assistants or dental nurses
or direct payment by individuals receiving care. are employed in most countries. Their education
Most countries have a combination of financial varies from university education to on-the-job
support. When supported by government funds, training.
treatment can be limited to specific types of The combination of all of these influences
treatment and/or specific treatments for specific on oral health care systems makes comparisons
populations. For instance in Russia, mainstream between oral health systems and outcomes in
patients pay for their own dentures; however, different countries difficult. However, with the
dentures may be funded by the government for blossoming of technology, it is becoming easier
vulnerable populations. Russia provides some to share information and compare effectiveness
dental care for all of its citizens. A national docu- of different systems.
ment is published in Russia each year, which
determines the services provided by the govern- BARRIERS TO CARE
ment revenue and those funded by the patient.
When a country like the United States uses a Barriers to oral health care can take many forms.
system predominately funded by direct payment The barriers may be structural, financial, and/or
from the one receiving care, access to care is personal/cultural. Structural barriers are relat-
limited for those in a lower socioeconomic ed to the number, type, concentration, location,
position. or organizational configuration of health care
Population age, location, and oral health sta- providers. Providers face barriers and economic
tus have an influence on the design of an oral challenges to developing practices in low-income
health care system. For instance, whether the areas. Many providers have large loan debts, and
country has more elderly or more children might the cost of establishing a practice in low-income
determine the location of care. Elderly care areas can be tremendous. Public programs and
might be more effective if provided in a nursing community health care facilities in the United
home, whereas many countries provide care for States are seeing rapidly increasing caseloads as
children in school clinics. If a large portion of the the result of the high cost of oral health care in
population lives in rural areas, it may be neces- the private practice sector, decreasing numbers
sary to deliver care from mobile clinics or use of providers accepting Medicaid, and a broader
alternative providers. If children in a particular definition of dental indigence.
country have a high caries rate and financial Restrictive laws that prohibit the use of dental
resources are limited, the focus of the system therapists and dental hygienists to provide ser-
might necessarily be on restoring the teeth, vices to special or rural populations are barriers
whereas if the caries rate was lower, the focus to access to care for those populations.
might be on prevention. Financial barriers limit access because of a
Health policy of each country is formulated patient’s inability to pay for a service, or provid-
by politicians using data on oral health needs of ers who choose not to provide care for those with
their particular population. The policy reflects limited finances. As described in Chapter 2, cur-
the health values and beliefs of the culture. Goals rently in the United States, millions of Americans
and objectives for actions are identified and are do not have dental insurance coverage, making
facilitated or restrained by available financial access to care more difficult.
support. Personal/cultural barriers inhibit patients
Oral health care providers and the educational from seeking care or following provider recom-
systems vary in each country. For instance, the mendations based on personal or cultural beliefs.
education of a dentist varies from a 2-year post- These beliefs include fear of providers of differ-
secondary training to 4-year postuniversity degree. ent cultural backgrounds and races, fear of the
There are over 40 countries where dental hygien- system, belief in their own healers, and culturally
ists practice and 50 countries where dental thera- accepted attitudes and beliefs.

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 CHAPTER 3 / GLOBAL PERSPECTIVES IN ORAL HEALTH CARE 33

ORAL HEALTH CARE WORKFORCE Dental Hygienists

Dental hygienists exist in 37 countries. The
Although there are many commonalities in oral
emphasis of service of a dental hygienist is to
health workforce in countries throughout the
empower the patient to maintain health in the oral
world, there is variation from country to country
environment. The focus is on prevention, primarily
as to how each particular role performs. The
of caries and periodontal disease. Dental hygien-
descriptions below are a general overview of each
ists assess a patient’s oral health status as well as
member of the oral health care workforce.
risk for disease, develop a plan of care, implement
the plan and evaluate the results of treatment.
Dentists
Although the focus of practice in most countries
Most countries have dentists who assess, diag- is similar, government regulations and other influ-
nose, and treat oral disease. As mentioned previ- ences tend to be different. In Holland, dental
ously, the education of dentists varies between hygienists can own their own dental hygiene prac-
countries. In most industrialized countries, the tice and many do. There, much of dental hygiene
length of formal education for a dentist is at least care is funded by the government. In Japan, den-
4 to 5 years in a university setting. Dentists may tal hygienists provide more educational services
own their own practice, work as an associate and often provide assistance to dentists.
dentist, or work in community health centers The education of dental hygienists in the
and government agencies depending on the oral United States ranges from 2 to 4 years. However,
health care system in the country. the European Union has decreed that beginning
in 2008, dental hygiene education will be at a
Dental Therapists bachelor degree level.3
Dental therapists are also referred to as expand- The International Federation of Dental
ed duty auxiliaries and previously referred to in Hygienists (IFDH) has 26 member countries. It
New Zealand as dental nurses and are employed provides a forum for sharing information regard-
in over 50 countries. In general, therapists are ing the practice and education of dental hygien-
employed by the government and work on chil- ists in its member countries. The web site (www.
dren in the school system. They assess, plan, and ifdh.org) lists the member countries and provides
treat children of school age providing preventive information on dental hygiene practice and how
and restorative care and extractions when neces- to qualify as a dental hygienist in each country.
sary. They work under general supervision of a
dental officer who is available for consultation Dental Assistants
and may visit a couple of times per year to do Dental assistants are used in varying degrees in
chart audits and other quality assurance tasks. most industrialized countries. Their roles range
The education of dental therapists tradition- from limited duties to highly sophisticated tasks.
ally has been 2 years in length and carried out In general, they provide support services for
in technical schools. Within the last decade both the patient and the dentist. An example would
Australia and New Zealand, which have a long be cleaning up and setting up the room, steril-
and successful history with dental therapists, izing instruments, and greeting and seating the
have combined the education of dental thera- patient. The education varies from on-the-job
pist and dental hygienist into a dually trained training to some university education.
Bachelor Degree in Oral Health. The education
is now more commonly in a University setting in
Dental Lab Technicians and Denturists
these two countries. Statutes are being changed
to allow the new oral health therapist to provide Dental lab technicians work in dental labora-
services for both children and adults in remote tories fabricating appliances and restorations
areas. from instructions and materials prescribed by a

558417_Mason2e_ch03.indd 33 11/6/09 2:40:41 PM

Other documents randomly have
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10 ANYHOW STORIES. [STORY a little picture on its face

and sometimes ticked away for nearly a week without stopping. The
baby's high chair stood in one corner, and in another there was a
cupboard hung up high against the wall, in which the mother kept all
manner of little surprises. The children often wondered how the
things that came out of that cupboard had got into it, for they
seldom saw them put there. " Dear children," the mother said one
afternoon late in the autumn, " it is very chilly for you to go to the
village, but you must walk quickly, and who knows but what you
may bring back a letter saying that dear father is already on his way
to England." Then Blue-Eyes and the Turkey made haste and were
soon ready to go. " Don't be long," the mother said, as she always
did before they started. "Go the nearest way and don't look at any
strangers you meet, and be sure you do not talk with them." " No,
mother," they answered; and then she kissed them and called them
dear good children, and they joyfully started on their way. The
village was gayer than usual, for there had been a fair the day
before, and the people who had made merry still hung about the
street as if reluctant to own that their holiday was over.
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THEN SHE KISSED THEM.— P. J

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ii.] THE NEW MOTHER. 11 " I wish we had come

yesterday," Blue-Eyes said to the Turkey ; " then we might have
seen something." " Look there," said the Turkey, and she pointed to
a stall covered with gingerbread; but the children had no money. At
the end of the street, close to the Blue Lion where the coaches
stopped, an old man sat on the ground with his back resting against
the wall of a house, and by him, with smart collars round their
necks, were two dogs. Evidently they were dancing dogs, the
children thought, and longed to see them perform, but they seemed
as tired as their master, and sat quite still beside him, looking as if
they had not even a single wag left in their tails. " Oh, I do wish we
had been here yesterday," Blue-Eyes said again as they went on to
the grocer's, which was also the post-office. The post -mistress was
very busy weighing out half-pounds of coffee, and when she had
time to attend to the children she only just said "No letter for you to-
day," and went on with what she was doing. Then Blue-Eyes and the
Turkey turned away to go home. They went back slowly down the
village street, past the man with the dogs again. One dog had
roused himself and sat up rather crookedly with his head a good
deal on one side, looking very melancholy and rather
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12 ANYHOW STORIES. [STORY ridiculous; but on the

children went towards the bridge and the fields that led to the
forest. They had left the village and walked some way, and then, just
before they reached the bridge, they noticed, resting against a pile
of stones by the wayside, a strange dark figure. At first they thought
it was some one asleep, then they thought it was a poor woman ill
and hungry, and then they saw that it was a strange wild-looking
girl, who seemed very unhappy, and they felt sure that something
was the matter. So they went and looked at her, and thought they
would ask her if they could do anything to help her, for they were
kind children and sorry indeed for any one in distress. The girl
seemed to be tall, and was about fifteen years old. She was dressed
in very ragged clothes. Round her shoulders there was an old brown
shawl, which was torn at the corner that hung down the middle of
her back She wore no bonnet, and an old yellow handkerchief which
she had tied round her head had fallen backwards and was all
huddled up round her neck. Her hair was coal black and hung down
uncombed and unfastened, just anyhow. It was not very long, but it
was very shiny, and it seemed to match her bright black eyes and
dark
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IT.] THE NEW MOTHER. 13 freckled skin. On her feet were

coarse gray stockings and thick shabby boots, which she had
evidently forgotten to lace up. She had something hidden away
under her shawl, but the children did not know what it was. At first
they thought it was a baby, but when, on seeing them coming
towards her, she carefully put it under her and sat upon it, they
thought they must be mistaken. She sat watching the children
approach, and did not move or stir till they were within a yard of her
; then she wiped her eyes just as if she had been crying bitterly, and
looked up. The children stood still in front of her for a moment,
staring at her and wondering what they ought to do. " Are you
crying ?" they asked shyly. To their surprise she said in a most
cheerful voice, " Oh dear, no ! quite the contrary. Are you ? " They
thought it rather rude of her to reply in this way, for any one could
see that they were not crying. They felt half in mind to walk away ;
but the girl looked at them so hard with her big black eyes, they did
not like to do so till they had said something else. "Perhaps you have
lost yourself?" they said gently.
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H ANYHOW STORIES. [STORY But the girl answered

promptly, " Certainly not. Why, you have just found me. Besides,"
she added, " I live in the village." The children were surprised at
this, for they had never seen her before, and -yet they thought they
knew all the village folk by sight. " We often go to the village," they
said, thinking it might interest her. " Indeed," she answered. That
was all ; and again they wondered what to do. Then the Turkey, who
had an inquiring mind, put a good straightforward question. " What
are you sitting on ? " she asked. " On a peardrum," the girl
answered, still speaking in a most cheerful voice, at which the
children wondered, for she looked very cold and uncomfortable. "
What is a peardrum ?" they asked. "I am surprised at your not
knowing," the girl answered. " Most people in good society have
one." And then she pulled it out and showed it to them. It was a
curious instrument, a good deal like a guitar in shape ; it had three
strings, but only two pegs by which to tune them. The third string
was never tuned at all, and thus added to the singular effect
produced by the village girl's music. And yet, oddly,
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•I "IT REALLY IS A MOST BEAUTIFUL THING IS A

PEARDRUM."— P. 15.
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ii.] THE NEW MOTHER. 15 the peardrum was not played by

touching its strings, but by turning a little handle cunningly hidden
on one side. But the strange thing about the peardrum was not the
music it made, or the strings, or the handle, but a little square box
attached to one side. The box had a little flat lid that appeared to
open by a spring. That was all the children could make out at first.
They were most anxious to see inside the box, or to know what it
contained, but they thought it might look curious to say so. "It really
is a most beautiful thing, is a peardrum," the girl said, looking at it,
and speaking in a voice that was almost affectionate. " Where did
you get it ?" the children asked. " I bought it," the girl answered. "
Didn't it cost a great deal of money?" they asked. "Yes," answered
the girl slowly, nodding her head, "it cost a great deal of money. I
am very rich," she added. And this the children thought a really
remarkable statement, for they had not supposed that rich people
dressed in old clothes, or went about without bonnets. She might at
least have done her hair, they thought ; but they did not like to say
so.
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16 ANYHOW STORIES. [STORY " You don't look rich," they

said slowly, and in as polite a voice as possible. " Perhaps not," the
girl answered cheerfully. At this the children gathered courage, and
ventured to remark, "You look rather shabby" — they did not like to
say ragged. "Indeed?" said the girl in the voice of one who had
heard a pleasant but surprising statement. " A little shabbiness is
very respectable," she added in a satisfied voice. " I must really tell
them this," she continued. And the children wondered what she
meant. She opened the little box by the side of the peardrum, and
said, just as if she were speaking to some one who could hear her,
"They say I look rather shabby ; it is quite lucky, isn't it ? " " Why,
you are not speaking to any one ! " they said, more surprised than
ever. " Oh dear, yes ! I am speaking to them both." " Both?" they
said, wondering. "Yes. I have here a little man dressed as a peasant,
and wearing a wide slouch hat with a large feather, and a little
woman to match, dressed in a red petticoat, and a white
handkerchief pinned across her bosom. I put them on the lid of the
box, and when I play they dance most beautifully. The little
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ii.] THE NEW MOTHER. 17 man takes off his hat and waves
it in the air, and the little woman holds up her petticoat a little bit on
one side with one hand, and with the other sends forward a kiss." "
Oh ! let us see ; do let us see ! " the children cried, both at once.
Then the village girl looked at them doubtfully. " Let you see!" she
said slowly. " Well, I am not sure that I can. Tell me, are you good?"
" Yes, yes," they answered eagerly, " we are very good!" "Then it's
quite impossible," she answered, and resolutely closed the lid of the
box. They stared at her in astonishment. " But we are good," they
cried, thinking she must have misunderstood them. "We are very
good. Mother always says we are." " So you remarked before," the
girl said, speaking in a tone of decision. Still the children did not
understand. "Then can't you let us see the little man and woman?"
they asked. " Oh dear, no !" the girl answered. " I only show them to
naughty children." c
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18 ANYHOW STORIES. [STORY "To naughty children !" they

exclaimed. " Yes, to naughty children," she answered ; " and the
worse the children the better do the man and woman dance." She
put the peardrum carefully under her ragged cloak, and prepared to
go on her way. " I really could not have believed that you were
good," she said, reproachfully, as if they had accused themselves of
some great crime. " Well, good day." " Oh, but do show us the little
man and woman," they cried. " Certainly not. Good day," she said
again. " Oh, but we will be naughty," they said in despair. " I am
afraid you couldn't," she answered, shaking her head. " It requires a
great deal of skill, especially to be naughty well. Good day," she said
for the third time. " Perhaps I shall see you in the village to-
morrow." And swiftly she walked away, while the children felt their
eyes fill with tears, and their hearts ache with disappointment. " If
we had only been naughty," they said, " we should have seen them
dance ; we should have seen the little woman holding her red
petticoat in her
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IL] THE NEW MOTHER. 19 hand, and the little man waving
his hat. Oh, what shall we do to make her let us see them ?" "
Suppose," said the Turkey, " we try to be naughty to-day ; perhaps
she would let us see them to-morrow." "But, oh!" said Blue-Eyes, "I
don't know how to be naughty ; no one ever taught me." The Turkey
thought for a few minutes in silence. " I think I can be naughty if I
try," she said. " I'll try to-night." And then poor Blue-Eyes burst into
tears. " Oh, don't be naughty without me ! " she cried. " It would be
so unkind of you. You know I want to see the little man and woman
just as much as you do. You are very, very unkind." And she sobbed
bitterly. And so, quarrelling and crying, they reached their home.
Now, when their mother saw them, she was greatly astonished, and,
fearing they were hurt, ran to meet them. " Oh, my children, oh, my
dear, dear children," she said ; "what is the matter?" But they did
not dare tell their mother about the village girl and the little man and
woman, so they answered, "Nothing is the matter; nothing at all is
the matter," and cried all the more.
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20 ANYHOW STORIES. [STORY "But why are you crying?"

she asked in surprise. " Surely we may cry if we like," they sobbed. "
We are very fond of crying." " Poor children ! " the mother said to
herself. " They are tired, and perhaps they are hungry ; after tea
they will be better." And she went back to the cottage, and made the
fire blaze, until its reflection danced about on the tin lids upon the
wall; and she put the kettle on to boil, and set the tea-things on the
table, and opened the window to let in the sweet fresh air, and made
all things look bright. Then she went to the little cupboard, hung up
high against the wall, and took out some bread and put it on the
table, and said in a loving voice, "Dear little children, come and have
your tea ; it is all quite ready for you. And see, there is the baby
waking up from her sleep ; we will put her in the high chair, and she
will crow at us while we eat." But the children made no answer to
the dear mother ; they only stood still by the window and said
nothing. " Come, children," the mother said again. " Come, Blue-
Eyes, and come, my Turkey ; here is nice sweet bread for tea."
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ii.] THE NEW MOTHER. 21 Then Blue-Eyes and the Turkey

looked round, and when they saw the tall loaf, baked crisp and
brown, and the cups all in a row, and the jug of milk, all waiting for
them, they went to the table and sat down and felt a little happier ;
and the mother did not put the baby in the high chair after all, but
took it on her knee, and danced it up and down, and sang little
snatches of songs to it, and laughed, and looked content, and
thought of the father far away at sea, and wondered what he would
say to them all when he came home again. Then suddenly she
looked up and saw that the Turkey's eyes were full of tears. " Turkey
!" she exclaimed, "my dear little Turkey ! what is the matter? Come
to mother, my sweet; come to own mother." And putting the baby
down on the rug, she held out her arms, and the Turkey, getting up
from her chair, ran swiftly into them. " Oh, mother," she sobbed, "
oh, dear mother ! I do so want to be naughty." " My dear child ! "
the mother exclaimed. " Yes, mother," the child sobbed, more and
more bitterly. " I do so want to be very, very naughty." And then
Blue-Eyes left her chair also, and, rubbing her face against the
mother's shoulder, cried
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22 ANYHOW STORIES. [STORY sadly. " And so do I,

mother. Oh, I'd give anything to be very, very naughty." " But, my
dear children," said the mother, in astonishment, " why do you want
to be naughty ? " " Because we do ; oh, what shall we do ? " they
cried together. "I should be very angry if you were naughty. But you
could not be, for you love me," the mother answered. " Why couldn't
we be naughty because we love you ? " they asked. " Because it
would make me very unhappy ; and if you love me you couldn't
make me unhappy." " Why couldn't we ? " they asked. Then the
mother thought a while before she answered ; and when she did so
they hardly understood, perhaps because she seemed to be
speaking rather to herself than to them. " Because if one loves well,"
she said gently, " one's love is stronger than all bad feelings in one,
and conquers them. And this is the test whether love be real or
false, unkindness and wickedness have no power over it." " We don't
know what you mean," they cried ; " and we do love you ; but we
want to be naughty."
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ii.] THE NEW MOTHER. 23 " Then I should know you did
not love me," the mother said. " And what should you do ?" asked
Bine-Eyes. " I cannot tell. I should try to make you better," " But if
you couldn't ? If we were very, very, very naughty, and wouldn't be
good, what then ?" "Then," said the mother sadly — and while she
spoke her eyes filled with tears, and a sob almost choked her — "
then," she said, " I should have to go away and leave you, and to
send home a new mother, with glass eyes and wooden tail." " You
couldn't," they cried. " Yes, I could," she answered in a low voice ; "
but it would make me very unhappy, and I will never do it unless
you are very, very naughty, and I am obliged." " We won't be
naughty," they cried ; " we will be good. We should hate a new
mother ; and she shall never come here." And they clung to their
own mother, and kissed her fondly. But when they went to bed they
sobbed bitterly, for they remembered the little man and woman, and
longed more than ever to see them ; but how could they bear to let
their own mother go away, and a new one take her place ?
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24 ANYHOW STORIES. [STORY II. " GOOD-DAY," said the

village girl, when she saw Blue-Eyes and the Turkey approach. She
was again sitting by the heap of stones, and under her shawl the
peardrum was hidden. She looked just as if she had not moved since
the day before. " Good day," she said, in the same cheerful voice in
which she had spoken yesterday ; " the weather is really charming."
"Are the little man and woman there?" the children asked, taking no
notice of her remark. " Yes ; thank you for inquiring after them," the
girl answered ; " they are both here and quite well. The little man is
learning how to rattle the money in his pocket, and the little woman
has heard a secret — she tells it while she dances." " Oh, do let us
see," they entreated. " Quite impossible, I assure you," the girl
answered promptly. " You see, you are good." " Oh !" said-Blue
Eyes, sadly ; "but mother says if we are naughty she will go away
and send home a new mother, with glass eyes and a wooden tail." "
Indeed," said the girl, still speaking in the same unconcerned voice,
" that is what they all say."
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IT.] THE NEW MOTHEK. 25 " What do you mean ? " asked
the Turkey. " They all threaten that kind of thing. Of course really
there are no mothers with glass eyes and wooden tails ; they would
be much too expensive to make." And the common sense of this
remark the children, especially the Turkey, saw at once, but they
merely said, half crying — " We think you might let us see the little
man and woman dance." " The kind of thing you would think,"
remarked the village girl. " But will you if we are naughty ? " they
asked in despair. " I fear you could not be naughty — that is, really
— even if you tried," she said scornfully. " Oh, but we will try ; we
will indeed," they cried ; " so do show them to us." " Certainly not
beforehand," answered the girl, getting up and preparing to walk
away. " But if we are very naughty to-night, will you let us see them
to-morrow ? " " Questions asked to-day are always best answered
to-morrow," the girl said, and turned round as if to walk on. " Good
day," she said blithely ; " I must really go and play a little to myself;
good
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26 ANYHOW STORIES. [STORY day," she repeated, and

then suddenly she began to sing— " Oh, sweet and fair 's the lady-
bird, And so's the bumble-bee, But I myself have long preferred The
gentle chimpanzee, The gentle chimpanzee-e-e, The gentle chim " "
I beg your pardon," she said, stopping, and looking over her
shoulder; "it's very rude to sing without leave before company. I
won't do it again." " Oh, do go on," the children said. " I'm going,"
she said, and walked away. " No, we meant go on singing," they
explained, "and do let us just hear you play," they entreated,
remembering that as yet they had not heard a single sound from the
peardrum. " Quite impossible," she called out as she went along. "
You are good, as I remarked before. The pleasure of goodness
centres in itself ; the pleasures of naughtiness are many and varied.
Good day," she shouted, for she was almost out of hearing. For a
few minutes the children stood still looking after her, then they broke
down and cried. " She might have let us see them," they sobbed.
The Turkey was the first to wipe away her tears.
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ii.] THE NEW MOTHER. 27 " Let us go home and be very

naughty," she said ; " then perhaps she will let us see them to-
morrow." " But what shall we do ? " asked Blue-Eyes, looking up.
Then together all the way home they planned how to begin being
naughty. And that afternoon the dear mother was sorely distressed,
for, instead of sitting at their tea as usual with smiling happy faces,
and then helping her to clear away and doing all she told them, they
broke their mugs and threw their bread and butter on the floor, and
when the mother told them to do one thing they carefully went and
did another, and as for helping her to put away, they left her to do it
all by herself, and only stamped their feet with rage when she told
them to go upstairs until they were good. " We won't be good," they
cried. " We hate being good, and we always mean to be naughty.
We like being naughty very much." " Do you remember what I told
you I should do if you were very very naughty ? " she asked sadly.
"Yes, we know, but it isn't true," they cried. " There is no mother
with a wooden tail and glass eyes, and if there were we should just
stick pins into her and send her away ; but there is none." Then the
mother became really angry at last, and
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28 ANYHOW STORIES. [STORY sent them off to bed, but

instead of crying and being sorry at her anger they laughed for joy,
and when they were in bed they sat up and sang merry songs at the
top of their voices. The next morning quite early, without asking
leave from the mother, the children got up and ran off as fast as
they could over the. fields towards the bridge to look for the village
girl. She was sitting as usual by the heap of stones with the
peardrum under her shawl. " Now please show us the little man and
woman," they cried, " and let us hear the peardrum. We were very
naughty last night." But the girl kept the peardrum carefully hidden.
" We were very naughty," the children cried again. " Indeed," she
said in precisely the same tone in which she had spoken yesterday. "
But we were," they repeated ; " we were indeed." "So you say," she
answered. "You were not half naughty enough." " Why, we were
sent to bed ! " " Just so," said the girl, putting the other corner of
the shawl over the peardrum. " If you had been really naughty you
wouldn't have gone ; but you
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THE NEW MOTHER. can't help it, you see. As I remarked

before, it requires a great deal of skill to be naughty well." " But we
broke our mugs, we threw our bread and butter on the floor, we did
everything we could to be tiresome." "Mere trifles," answered the
village girl scornfully. " Did you throw cold water on the fire, did you
break the clock, did you pull all the tins down from the walls, and
throw them on the floor ? " " No ! " exclaimed the children, aghast, "
we did not do that." " I thought not," the girl answered. " So many
people mistake a little noise and foolishness for real naughtiness ;
but, as I remarked before, it wants skill to do the thing properly.
Well, good day," and before they could say another word she had
vanished. " We'll be much worse," the children cried, in despair. "
We'll go and do all the things she says;" and then they went home
and did all these things. They threw water on the fire ; they pulled
down the baking-dish and the cake-tin, the fish-slice and the lid of
the saucepan they had never seen, and banged them on the floor ;
they broke the clock and danced on the butter; they turned
everything upside down ; and then they sat still and wondered if
they were
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30 ANYHOW STORIES. [STORY naughty enough. And when

the mother saw all that they had done she did not scold them as she
had the day before or send them to bed, but she just broke down
and cried, and then she looked at the children and said sadly — "
Unless you are good to-morrow, my poor BlueEyes and Turkey, I
shall indeed have to go away and come back no more, and the new
mother I told you of will come to you." They did not believe her ; yet
their hearts ached when they saw how unhappy she looked, and
they thought within themselves that when they once had seen the
little man and woman dance, they would be good to the dear
mother for ever afterwards; but they could not be good now till they
had heard the sound of the peardrum, seen the little man and
woman dance, and heard the secret told — then they would be
satisfied. The next morning, before the birds were stirring, before
the sun had climbed high enough to look in at their bedroom
window, or the flowers had wiped their eyes ready for the day, the
children got up and crept out of the cottage and ran across the
fields. They did not think the village girl would be up so very early,
but their hearts had ached so much at the
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