CHAPTER 1 DENTAL PUBLIC HEALTH: AN OVERVIEW
The goal of the dental profession is to protect and preserve the oral health of the public. Each dentist, dental hygienist, dental assistant, and dental laboratory technician is a member of a team of health care workers combating diseases that jeopardize the health of the public. As with any good team, each member has an important role to play for the team to be successful. The purpose of this chapter is to examine the discipline of dental public health and the contribution that dental public health practitioners make to protect and preserve the oral health of the public. Perhaps most importantly, this chapter seeks to emphasize the importance of teamwork among dental health professionals to achieve the goal of optimal oral health for the public and the importance of teamwork between them and other health professionals because dental public health is an integral component of public health and is directly affected by public health programs and policies.
“Public health is a coalition of professions united by their shared mission,” states the Institute of Medicine of the National Academy of Sciences.1 The phrase “coalition of professions” stresses that the achievement of better public health requires more than the participation of the various health professions. It includes contributions from engineers, educators, statisticians, political scientists, policy analysts, and administrators, among many others. So one distinguishing aspect of public health is individuals and groups banding together to achieve a common goal.
The next distinguishing characteristic of public health is the “shared mission” that this coalition of professions seeks to achieve. The public health mission statement developed by the Institute of Medicine is “fulfilling society’s interest in assuring conditions in which people can be healthy.”1 In 1995 a blue ribbon committee convened by the Public Health Service published both a vision and a mission statement for public health: “Vision: Healthy People in Healthy Communities” and “Mission: Promote Physical and Mental Health and Prevent Disease, Injury, and Disability.”2 These mission statements are similar to those of the American Dental Association (ADA) and American Dental Hygienists’ Association (ADHA). The “History and Mission Statement” of the ADA calls for the protection, enhancement, improvement, and promotion of the public’s oral and general health and well-being.3 The ADHA mission statement begins with, “To improve the public’s total health.”4
The primary public health mission, however, differs from those of the ADA and ADHA in that its primary focus is on “society’s interest.” Public health is concerned with communitywide concerns and the overall public interest, rather than the health interests of particular individuals or groups (which is not to negate the important part that individual health care concerns have in public health). Although the concerns of public health are broader than those of the many distinct and diverse professional disciplines, including those of dentistry and dental hygiene, these disciplines are necessary for the attainment of optimal public health.1 Public health can accomplish its mission only if partnerships can be fostered and nurtured among governmental and nongovernmental public health agencies, private organizations, and individuals.5,6
How public health is defined can provide insight into the complexity surrounding the use of the term. Defining the word health, for example, is not simple. The traditional dictionary definition of health is being free from pain or disease.7 This limited definition has proved insufficient to address issues of public health concern. In 1948 the World Health Organization (WHO) created a more encompassing definition of health in its constitution. WHO defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”8 The concept of a close relationship among mind, body, health, and society is not new. Aristotle espoused it in the third century BCE. He wrote that the “health of body and mind is so fundamental to the good life that if we believe men have any personal rights at all as human beings, then they have an absolute moral right to such measure of good health as society alone is able to give them.”9
Some believe that the WHO concept of health may be unrealistic in that freedom from disease, stress, frustration, and disability is actually incompatible with the process of living and aging. Rene Dubos, for example, wrote, “Complete and lasting freedom from disease is but a dream remembered from imaginings of a Garden of Eden designed for the welfare of man.”10 Pickett and Hanlon8 suggest considering health as a continuum under which a disease or injury may lead to an impairment, which may lead to a disability, which may lead to a dependency requiring external resources or aids to carry out activities of daily living. Health in this continuum then can be defined as “the absence of a disability.”8
The science and art of preventing disease, prolonging life, and promoting physical and mental efficiency through organized community effort for the sanitation of the environment, the control of communicable infections, the education of the individual in personal hygiene, the organization of medical and nursing services for the early diagnosis and preventive treatment of disease, and the development of the social machinery to insure everyone a standard of living adequate for the maintenance of health, so organizing these benefits as to enable every citizen to realize his birthright of health and longevity.11
This definition shows great understanding in that Winslow recognized the impact of social, educational, and economic factors on health. Although he did not include either health care services or mental health within his concept of public health, his definition was advanced for its time. Since then the focus of public health has continued to expand. It has moved from its earliest beginnings dealing with individual hygiene to include sanitary engineering, preventive physical and mental medical science, social behavioral aspects of personal and community medicine, and more recently the promotion and assurance of comprehensive health services for all.8
Public health now can be thought of as being concerned with four broad areas: (1) lifestyle and behavior, (2) the environment, (3) human biology, and (4) the organization of health programs and systems. Thus public health is concerned with keeping people as healthy as possible and controlling or limiting factors that impede health; it is the organization and application of public resources to prevent dependency that would otherwise result from disease or injury.
Public health, in essence, determines the health status of the community; identifies populations potentially affected or at risk for a particular problem; analyzes the dimensions of the problem through the use of epidemiologic methodology; and then plans, implements, and evaluates the appropriate interventions.12
The title of this book uses the term community dental health, whereas this chapter uses the term dental public health. Although both terms often are used interchangeably, a distinct difference exists between them. Both community and public mean a collection of people, a population, or a group of people having something in common.7 From that perspective the terms public health and community health can be considered equivalent. Current usage, however, tends to define public to mean a general collection of people without regard to a specific geographic area in which they live. Community is used to indicate a collection of people who are located in a defined geographic area such as a city, nation, or state. In this regard, a community is more commonly defined as a group or collection of people who live in a specified geographic area that is of a limited size.7 For example, although one can refer to the community of St. Louis, the home base of the publisher of this book, one would not refer to the public of St. Louis.
Another concept of community is a group or collection of people having similar attributes.7 For example, although one can refer to a community of dentists, dental hygienists, or dental assistants, one would not refer to a public of those professions. Another meaning of community is that of a particular location in which someone lives. For example, one might ask someone in which community she or he lives, but it would not make sense to ask someone in which public she or he lives.7
This book also has in its title the term dental health. The term oral health has recently come into greater prominence and is replacing in certain instances the term dental health. Although the terms dental and oral in regard to health still are being used interchangeably, use of the term dental is still more common. That may not be the case in the future. The use of the term oral will most likely continue to increase because the term dental, in the eyes of the public, is limited primarily to the teeth. The term oral, however, refers to not only the teeth and gingivae and their supporting tissues and bone but also the hard and soft palate, the lining of the mouth, the throat, the tongue, the lips, the salivary glands, the masticator muscles, the lower and upper jaws, and the temporomandibular joints.14
What much of the public, including many in the clinical health professions, does not realize is that public health has been primarily responsible for the most dramatic and significant improvements in the health of the U.S. population. Since 1900 the average life expectancy of persons in the United States has increased by more than 30 years, with 25 of those years (83%) being attributed to advances in public health. The Centers for Disease Control and Prevention (CDC) selected a public health “top 10 list” for the twentieth century. Fluoridation of drinking water, which was initiated in 1945, is on the list because it has played an important role in the reduction of tooth decay in children (40% to 70%) and of tooth loss in adults (40% to 60%) in the United States. The other nine are vaccinations, motor-vehicle safety, safer workplaces, control of infectious diseases, decline in deaths from coronary heart disease and stroke, safer and healthier foods, healthier mothers and babies, family planning, and recognition of tobacco use as a health hazard.15
Thus public health practitioners must face the reality that the public has a limited understanding of the role and function of public health. A major reason for this is that when public health is functioning optimally, it is invisible. For example, when a person eats at a restaurant in the United States and does not get sick, turns on the tap to get a drink of water and out comes uncontaminated water, walks outside and breathes the air and does not choke, walks into a building and does not become enveloped by secondhand smoke, he or she probably does not think of it, but the reality is that public health has been doing its job. The public takes for granted a safe water supply, that food is not contaminated, that garbage is collected, and that a system safely removes and treats human waste. When we eat at restaurants, we expect that someone has established food safety standards and that the restaurant has been inspected to ensure that those standards have been met. And we expect that a monitoring system is in place to detect outbreaks of disease in case of a breakdown in the established standards of hygiene.
In 1996 a poll conducted by Louis Harris and Associates found that few Americans have any real idea what the term public health means. When, however, its meaning was explained to them, “almost everyone believed it to be very important.”16
Although media coverage of public health issues has continually increased, the stories are rarely labeled as public health stories and most people do not recognize them as such. Even though the stories deal with obvious public health problems such as acquired immunodeficiency syndrome (AIDS), food-borne diseases, lead or mercury poisoning, harmful drug interactions, or polluted air, most people do not recognize them as public health stories because of the multidisciplinary nature of the field and the complex ethical and political issues that are inherently part of each story.17
Regardless of the definition of public health, a lack of understanding associated with it will continue. One way to more clearly explain public health and to describe its mission and purpose is by indicating that public health18
More specifically, public health is less food poisoning because of food inspection programs, less death and disability from car accidents because of requirements for seat belts and air bags, less lung cancer because of smoking cessation programs, less heart disease because of public education regarding diet and blood pressure screening, less childhood disease because of immunization programs, fewer infant deaths because of prenatal care programs, and fewer dental caries because of water fluoridation.
Dental public health is a field of study within the broader field of public health. Its philosophy and substance reflect public health and its focus on the community rather than on the individual patient. An early dental public health worker, J. W. Knutson, defined public health as follows:
Public health is people’s health. It is concerned with the aggregate health of a group, a community, a state, or a nation. Public health in accordance with this broad definition is not limited to the health of the poor, or to rendering health services or to the nature of the health problems. Nor is it defined by the method of payment for health services, or by the type of agency responsible for supplying those services. It is simply a concern for and activity directed toward the improvement and protection of the health of a population group in the aggregate.19
As applied to dentistry, this definition implies that dental public health is concerned only with the dental health of aggregate populations and not individuals. Now is a good time to reevaluate definitions such as these and amend them to more accurately reflect that individuals, as well as groups, are of concern to the activities and interests of public health. A modification of Knutson’s definition to include this concept would be the following: Dental public health is a concern for and activity directed toward the improvement and promotion of the dental health of the population as a whole, as well as of individuals within that population. This expanded concept of public health to include a focus on individuals recently has been gaining increasing acceptance with the emergence of the term the new public health, in which the traditional conception of public health is expanded to include “the health of the individual in addition to the health of populations.”9
As with the more general term public health, a better-understood explanation of dental public health may be best achieved by giving specific examples. Dental public health is less tooth decay because of fluoridated water and school fluoride programs, less periodontal disease because of public education programs, greater access to high-quality early diagnosis and treatment of dental disease because of dental care delivery programs and research, less tooth damage among athletes because of mouthguard programs, and less oral cancer because of tobacco cessation and cancer screening programs.
The ADA has recognized dental public health as one of nine specialties of dentistry. The American Board of Dental Public Health (ABDPH), which is the regulatory agency for the specialty, was established in 1954. Dental public health’s mission is set forth in the definition adopted by the ABDPH. It is a modification of the previously mentioned Winslow definition of public health.11 The ABDPH defined dental public health as
[T]he science and art of preventing and controlling dental disease and promoting dental health through organized community efforts. It is that form of dental practice that serves the community as a patient rather than the individual. It is concerned with the dental health education of the public, with research and the application of the findings of research, with the administration of programs of dental care for groups, and with the prevention and control of dental disease through a community approach.19a
Dental public health, like public health, recently has expanded its focus to include the dental care delivery system and its impact on oral health status. The reason for this is that the development of alternative delivery systems such as dental health maintenance organizations, independent practice associations, point-of-service organizations, and preferred-provider organizations are having an increasing impact on the public’s health. Public health’s interest in access to comprehensive and quality dental care for the American public requires that attention be paid to the increased role of third-party payers (e.g., insurance companies, managed care plans) and the increasing emphasis on cost control.
In today’s complex society, therefore, dental health issues cannot be the exclusive concern of any one sector of dentistry. In view of current economic, political, and social factors, which are increasingly influencing the health services delivery system in the United States, dental public health, organized dentistry, and dental hygiene will of necessity find it mutually beneficial to work together more closely because the overall mission of these groups is the same: optimal dental health for all Americans and universal access to comprehensive care.
Two themes determine public health practice: the scientific knowledge regarding the causes and control of disease and the belief of the public that the disease can be controlled and that doing so is a public responsibility.1 An early example in this country of the importance of both of these themes is Lemuel Shattuck’s Report on the Sanitary Conditions of Massachusetts. This report was published in 1850 and is considered one of the most important documents in the history of public health in the United States.1,8 The scientific basis in Shattuck’s report consisted of vital statistics that demonstrated differences in disease rates in different communities. Although he considered that individual behavior was responsible in part for these differences, he argued that because the larger community could be affected, as well as the individual, public action was necessary. It was not until after the Civil War that increased public acceptance of the government’s role developed, and Massachusetts established a state board of public health in 1869.1 The Great Depression in the 1930s was another event that affected public health by altering the beliefs of people. The great social and economic insecurity during that period led people to look more to government to intervene in the social and economic structure of their lives.
In 1988 the Institute of Medicine (IOM) published The Future of Public Health.1 The report stated that public health in this country has deteriorated “like a two-lane highway in the shadow of an interstate.” The landmark report declared the current system to be fragmented and rudderless to the point of “disarray” and exposed a litany of weaknesses, gaps, and challenges that threatened to overwhelm “this nation that has lost sight of its public health goals.”20 Part of the cause for the decline in public health has been that advances in technology and science over the past decades have led society to focus on diagnosis and cure of disease rather than a public health infrastructure that deals with community efforts aimed at the prevention of disease and promotion of health.
The major problems cited in the report that require public health action include the AIDS epidemic, pollution-related diseases, the surge in chronic diseases characteristic of an aging population, inadequate funding of public health agencies, and the growing health care needs of the indigent.
The IOM report identified three core public health functions: assessment, policy development, and assurance.1 The American Public Health Association, the national organization that addresses issues of public health concern, delineated these three core functions as follows21:
With the increasing public health focus on chronic diseases and injury prevention, the assurance function has taken on a more prominent role in recent years. As we enter the twenty-first century, heart disease, stroke, and cancer are the leading causes of death in the United States, whereas pneumonia and tuberculosis led the list at the beginning of the twentieth century. Currently, public health efforts seek to reduce cigarette smoking and improve diet. Workplace safety has become an increasing concern for many occupational groups, such as convenience store clerks who are at high risk for violent attacks. The leading cause of death among children under age 14 in industrialized countries is preventable injuries.23 Because automobile accidents are a major cause of death and injury, public health measures for “assuring conditions in which people can be healthy” include ensuring well-designed highways and cars and the use of seat belts.1
The IOM report, The Future of Public Health, served as a catalyst to wake up and bring together the public health community at the federal, state, and local levels, along with other members of society concerned with the health of the public, in the realization that all was not well with the country’s public health system. Arguably, the report’s most important contribution was the development of the previously mentioned three core public health functions of assessment, policy development, and assurance.
Since publication of the IOM report, a number of agencies and organizations have worked to respond to the problems and recommendations in the report. This section traces some of the responses devised by these groups. Immediately recognizing the value of these core functions, the CDC, a federal agency in the Department of Health and Human Services (DHHS), created the Public Health Practice Program Office (PHPPO) in 1989 for the purpose of further clarifying the role of public health agencies in addressing the core functions.
Soon after its formation, the PHPPO convened a meeting of representatives from the major public health organizations: the Association of State and Territorial Health Officials (ASTHO), American Public Health Association (APHA), National Association of County and City Health Officials (NACCHO), Association of Schools of Public Health (ASPH), U.S. Conference of Local Health Officials (USCLHO), and Health Resources and Services Administration (HRSA). Their task was to clarify and describe the local public health agency activities that are necessary to ensure that the three core functions of public health are implemented. The deliberations of these organizations led to the following set of 10 organizational practices, organized under the three core public health functions24,25:
A work group of dental public health leaders was convened by the CDC and the Association of State and Territorial Dental Directors (ASTDD) in 1993 to elaborate on the three core public health functions for dental health. The group developed the following functions26:
By 1993 public health leaders had realized that although the three core functions of public health were widely accepted in the public health community, they had failed to communicate public health’s role to elected officials, policy makers, and the public. To remedy that, public health officials decided that public health needed a list of essential public health services. In 1993 and 1994 the Public Health Service convened the Public Health Functions Steering Committee. The committee included representatives of federal, national, state, and local public health agencies. In 1995 the committee released a document, “Public Health in America,” that specified the following 10 essential public health services2,27:
In 1995 the IOM formed the Committee on Public Health to determine the progress made since the release of its 1988 report. To assist the committee, the IOM assembled a panel of people from government, academia, industry, and citizen and other private sector groups. After a 9-month period of study, the IOM published a report detailing the committee’s analysis of the progress made since the 1988 report was published.29 This report concluded that since 1988 a significant strengthening of public health practice in governmental public health agencies and in other settings had occurred. In addition, however, the committee “encountered evidence that many of the problems identified in the Future of Public Health were still with us.”29
In 1997 the IOM published Performance Monitoring to Improve Community Health, which promoted the use of performance measures, standards, and monitoring to help ensure that needed public health functions are provided.30,31
In that same year the Public Health Practice Program Office at the CDC, in partnership with the major national public health organizations, began a new initiative, the National Public Health Performance Standards Program. The purpose of this initiative was to advance the capacity of public health agencies to better address the public health weaknesses highlighted in the Future of Public Health report.32–34 The Standards Program will focus on the following goals: (1) improve quality and performance, (2) increase accountability, and (3) increase the science base for public health practice.32
In March 2001 a report prepared by the CDC for the U.S. Senate was released. The report found that the U.S. public health infrastructure is insufficient to protect Americans from emerging threats. The CDC proposed a major national initiative linking local, state, and federal agencies to address gaps in the public health workforce’s capacity and competency, information and data systems, and organizational capacities of local and state health departments and laboratories. The public health infrastructure is defined as the underlying foundation that supports the planning, delivery, and evaluation of public health activities.35
This report, in asserting that the nation’s current public health system could not protect Americans from emerging threats, was proved unfortunately to be prescient. This deterioration, which had been virtually overlooked by much of the country, was suddenly placed in the national spotlight on September 11, 2001. On that day, the United States was suddenly and deliberately attacked by terrorists who flew two airplanes into New York’s World Trade Center, resulting in the collapse of its Twin Towers, and another plane into the Pentagon in Washington, D.C.36
Unfortunately, it had to take September 11 and the subsequent days of public anxiety caused by the fear of future biological attacks for the state of the nation’s public health system to be questioned. It has become apparent that the system is not sound and lacks support. We must acknowledge the need of repair immediately. Only time will tell whether the impact of 9/11 will result in the revitalization of public health.36a
Leaders in the dental public health community recognized that the important pronouncements contained in the IOM report also applied to dental public health.1 As a result, an in-depth review of dental public health’s origins, scope of responsibilities, and future challenges and roles was included. The findings from this review were published in The Future of Dental Public Health Report. In response to the question “Where does dental public health stand today?” the report acknowledged that the current environment in which federal, state, and local dental health programs exist is conflicting, inconsistent, and infused with ambiguous policies. Although the oral health needs are documented with persistent and emerging oral health problems, oral health is given a low priority by health planners. The report states that the contributions of dental public health professionals are not well understood by either the dental profession or the broad field of public health. The report suggests that dental public health leadership “must strive to articulate the public’s oral health needs more clearly to dental, public health and health policy makers.”37 The following five interrelated goals are recommended for dental public health as a pathway to improved effectiveness37:
Public health successes include reductions in lead poisoning, traffic fatalities, smoking, and dental caries. Although much is still to be accomplished in regard to these successes, they are the result not of dental or medical technology but of social, behavioral, and environmental change. Issacs and Schroeder38 have suggested four elements responsible for successful public health programs: