Specialty recognition

Dental public health was established as a specialty in 1950, and is one of the nine specialties of dentistry currently recognized by the American Dental Association (ADA). In 1986, it was the first of the then eight specialties of dentistry to be reviewed and receive continued recognition as a specialty, and then was reviewed again in 1996. It is the only specialty that deals with population groups and is the second smallest in number of active board certified specialists, having only 155 active diplomates in 2006 . To become board certified a dentist must have a master’s degree in public health and have completed a dental public health residency or its educational equivalent, have 2 years of public health experience, and must pass the examination of the American Board of Dental Public Health.

In 2007, there were 38 accredited schools of public health and 13 dental public health residency training programs in the United States. There are approximately 2,032 dentists in the United States who work in public health and about 1,000 of these have at least 1 year of advanced education beyond dental school; over 600 have 2 years of advanced education beyond dental school . Dental hygiene does not have recognized specialization of any kind; however, some public health dental hygienists have advanced degrees in public health.

Scope and practice of dental public health

Dental public health expertise is needed wherever one is concerned about oral health and groups of people, or populations of concern. Education and training in such areas as epidemiology, biostatistics, policy, management, administration, and research, give the public health professional the tools to help a population achieve better oral health.

Core competencies: there are certain core competencies a dental public health professional must have to be effective in the practice of public health. In 1988, the 165 competency objectives covered the following four broad categories:

• •

  Health policy and program management

• •

  Research methods in dental public health

• •

  Oral health promotion and disease prevention

• •

  Oral health services and delivery

In 1997, the dental public health leadership narrowed these objectives to 10 competencies with an emphasis on skills, not just knowledge, as in earlier editions. The specialist trained in dental public health is expected to have skills in these 10 core competencies ( Box 1 ) .

This list includes competencies necessary for planning (I), implementing, monitoring, and evaluating oral health programs (V, VI) at the community level (III, VII). The interventions to control oral health disease and promote oral health (II) are based on needs (VI, IX, X). The competency requirements mandate that interventions should be based on scientifically proven, cost effective, and ethical standards (IV, II, IX). Other competency requirements include advocacy for oral health policy (VIII), sound management skills (III), and the ability to interpret and translate science to recommendations for action (IX). Other basic skills needed by dental public health professionals include knowledge of clinical dentistry, leadership, and communication skills, and the ability to work effectively with coalitions and constituency building. Thus, being a competent and effective dental public health professional requires many skills and competencies to be successful.

The US Department of Health and Human Services, the federal dental public health infrastructure and programs

The US Department of Health and Human Services (HHS) is the principal federal agency that administers public health programs in the United States. The HHS has a stated priority of protecting the health of all Americans and providing essential human services, especially for those least able to help themselves. The President’s budget for the HHS for fiscal year (FY) 2008 was $698 billion, and the HHS has approximately 66,890 full-time equivalent employees (FTEs) of personnel .

Dentistry’s recent history in the HHS

In the 1960s and 1970s dentistry had a significant role in the HHS, with over 300 personnel in the Division of Dentistry, and public health dentists in all ten public health service regional offices. This was the heyday of public health activity through the federal sector, with the development of many new public health programs such as Medicare, Medicaid, Head Start, Community and Migrant Health Centers, Community Action Programs, and the National Health Service Corps, to name a few, all with significant dental components, except Medicare. In the late 1970s and 1980s, there was a major decline in dentistry’s role in the HHS, as the Division of Dentistry decreased to a handful of personnel. The National Health Service Corps dental field strength dropped from 500 in 1982 to 50 in 1989, fluoridation activities were moved to the then Centers for Disease Control, the dental public health residency training grants were not reauthorized, and the support for training dental auxillaries and personnel in team practice was also discontinued in 1981, while support for training physician assistants and nurse practitioners continued. The 1989 Final Report to Congress on Oral Health Activities documented the diminished role of dentistry in the HHS .

After much activity by the dental public health community, in the 1990s oral health was included in the White House’s national health plan, the Secretary of the HHS began an Oral Health Initiative, and dental public health residencies were reauthorized by Congress. In 1992, a Chief Dental Officer was selected for the Health Resources and Services Administration (HRSA) and oral health was made a priority in this agency again. The Secretary’s Oral Health Initiative included workforce development, direct service, improving the dental public health infrastructure, and translating science into practice and policy. The Surgeon General’s Report on Oral Health, which was several years in the making, was released in 2000. In 2000, with the new administration, the HRSA Chief Dental Officer position was abolished, but reinstituted in 2007.

During the 1980s and 1990s, it was also very helpful to the public’s oral health that oral health was included in the 1990 National Health Objectives, as well as Healthy People 2000 and Healthy People 2010. Also beginning in the early 1970s, the then National Institute of Dental Research (NIDR), now the National Institute of Dental and Craniofacial Research (NIDCR), played a very significant role in community based prevention initiatives, such as community water fluoridation, school fluoridation, school fluoride programs, and pit and fissure sealants. NIDR also demonstrated that school-based plaque control programs did not prevent caries, but did help prevent gingivitis. In the 1990s, the funding of the Centers for Research to Reduce Oral Health Disparities was initiated.

The oral health activities undertaken by two federal offices and specific federal agencies are described in the following sections.

Office of the Surgeon General

The Surgeon General is the nation’s chief health educator, appointed by the President and confirmed by the Senate, and reports to the Secretary of Health and Human Services. In 2000, the first ever Surgeon General’s Report on Oral Health described the magnitude of oral diseases in the United States population and the actions necessary to address them . The Report is available at www.surgeongeneral.gov/library/oralhealth . Major findings of the report were:

• •

  Oral diseases and disorders in and of themselves affect health and well being throughout life.

• •

  Safe and effective measures exist to prevent the most common dental diseases—dental caries and periodontal diseases.

• •

  Lifestyle behaviors that affect general health, such as tobacco use, excessive alcohol use, and poor dietary choices affect oral and craniofacial health as well.

• •

  There are profound and consequential oral health disparities within the United States population.

• •

  More information is needed to improve America’s oral health and eliminate health disparities.

• •

  The mouth reflects general health and well being.

• •

  Oral diseases and conditions are associated with other health problems.

• •

  Scientific research is key to further reduction in the burden of diseases and disorders that affect the face, mouth, and teeth.

The Surgeon General’s Report on Oral Health and the National Call to Action to Promote Oral Health had a significant impact on raising the visibility of the silent epidemic of oral diseases. The Call to Action is available at http://www.surgeongeneral.gov/topics/oralhealth/nationalcalltoaction.htm .

Office of Disease Prevention and Health Promotion and Healthy People 2010

Healthy People 2010 is a set of health objectives for the nation to be achieved over the first decade of this century and administered by the Office of Disease Prevention and Health Promotion. Oral health is one of 28 priority areas, with 17 objectives and many subobjectives. The oral health objectives are for preventing and controlling oral and craniofacial diseases, conditions, and injuries, and improving access to related services . Goals 21 to 14 and 21 to 17 are related to increasing the proportion of oral health programs and dental public health personnel in federal, state, and local agencies. Healthy People 2010 is available at www.healthypeople.gov .

Indian Health Service

The IHS is the primary health care provider and health care advocate for American Indian and Alaska Native communities. The IHS employs approximately 15,550 people from a variety of professional backgrounds, with an expenditure of $2.2 billion in 2005 to serve a population of 2.5 million eligible Native Americans dispersed across 35 states in 557 different federally recognized tribes . The IHS has been actively involved in the development of programs to address the oral health needs of rural Alaska Natives who have great difficulty in accessing oral health services .

In FY 2006, the Division of Oral Health had a budget of $117.7 million and there were 489 full-time dentists and 147 full-time dental hygienists in the field . There are currently 148 dentist vacancies at the IHS, a vacancy rate of 33%, which is higher than for any other profession .

Centers for Disease Control and Prevention

The mission of Centers for Disease Control and Prevention (CDC) is to promote health and quality of life by preventing and controlling disease, injury, and disability. The President’s budget for the CDC for FY 2008 was $8.8 billion . The Division of Oral Health (DOH) is one of ten Divisions within the National Center for Chronic Disease Prevention and Health Promotion. There are ten dental public health personnel in the DOH. Its strategic priorities are:

• •

  Strengthening the capacity of state oral health programs

• •

  Improving the capacity to monitor the nation’s oral health

• •

  Building the evidence base to strengthen prevention strategies

• •

  Disseminating data, findings, and effective prevention practices

The budget for the DOH has increased from $3 million in FY 1998 to $11.6 million in FY 2007. The DOH helps states, territories, and other countries collect oral health data, apply new methods for oral health surveillance, monitor the status of community water fluoridation, and train state and local fluoridation engineers and state program leaders on fluoridation. The DOH also promotes and provides technical assistance on school-based and school-linked dental sealant programs, investigates outbreaks of infectious diseases in clinical dental settings, and provides infection control information for dental personnel and serves as a resource within CDC on oral health .

National Center for Health Statistics

The National Center for Health Statistics (NCHS) is the nation’s principal agency for providing health statistics and it is a part of the CDC. This information is used to develop policies and programs to improve health. Oral health-related activities at the NCHS are primarily concentrated in the Division of Health and Nutrition Examination Surveys, which is responsible for planning, implementing, conducting, and evaluating examination and nutrition surveys at NCHS.

National Institutes of Health

The National Institutes of Health (NIH) is the primary federal agency conducting and supporting medical research, with an annual budget of over $28 billion . The discoveries from these institutes have prevented diseases and improved the quality of people’s lives. This 100-year HHS agency achieves this by awarding competitive grants to researchers in its own laboratories, universities, medical and dental schools, and other research institutions. The NIH is made up of 27 different components, called institutes and centers, with specific research agendas, such as the National Cancer Institute, National Institute of Mental Health, and others.

National Institute of Dental and Craniofacial Research is one of the NIH Institutes. The organizational mission is accomplished by:

• •

  Performing and supporting basic and clinical research

• •

  Conducting and funding research training and career development programs to ensure an adequate number of talented, well-prepared, and diverse investigators

• •

  Coordinating and assisting relevant research and research-related activities among all sectors of the research community

• •

  Promoting the timely transfer of knowledge gained from research and implications for health to the public, health professionals, researchers, and policy-makers .

The NIDCR Division of Extramural Research plans, develops, and manages basic, translational, and clinical research supported by grants, cooperative agreements, and contracts in dental, oral, and craniofacial health and disease. Some of the areas into which research is being done include infectious diseases, health disparities, behavioral and social aspects of health and disease, temporomandibular joint dysfunction, developmental biology and mammalian genetics, AIDS and oral manifestations of immunosuppression, biomaterials, and tissue engineering and regenerative medicine . The NIDCR’s FY 2007 budget was $389.4 million .

Centers for Medicare and Medicaid Services

The Centers for Medicare and Medicaid Services (CMS) is the federal agency responsible for administering the Medicare, Medicaid, State Children’s Health Insurance (SCHIP), the Health Insurance Portability and Accountability Act, the Clinical Laboratory Improvement Amendments, and several other health-related programs. The total CMS expenditure (Medicaid, SCHIP, and Medicare) on all health services was $660 billion and spending for dental services was only $4.9 billion . National expenditures for dental care were over $86.6 billion in 2005, or 4.4% of total health care expenditures, a continuing decrease from 6.4% in 1970 . The percentage of the population without health insurance has been on the increase; in 2006 it was 15.8%, or about 47 million people, with the majority being ethnic minorities . In 2004, 34.6% of all Americans had no dental coverage, more than twice the number without medical insurance .

The dental public health workforce is often intimately involved on the national, state, and local level, helping to improve these CMS programs and to provide access to these resources for vulnerable populations. There are two public health dentists who work in the CMS.

Medicare is the federal government sponsored and funded health insurance program that covers people who are older than 65 years and people less than 65 years who have certain disabilities or end-stage renal disease. It is administered in Parts A, B, C, and D or hospital care, outpatient visits, and prescription drugs. About 41 million Americans are covered under Medicare at a cost of about $342 billion in 2005 . Dental benefits are not routinely covered under Medicare, except under certain conditions, such as oral cancer . In 2005 the Medicare expenditure for dental services was $92 million .

Medicaid is the federal and state funded program that offers care to eligible low-income individuals and families. As of 2004, about 58.5 million Americans were covered under Medicaid, with about 50% being children, at a total cost of about $310 billion, of which 57% is federal money and 43% state money. Many more are eligible for these programs, however they are not enrolled. The expenditure for dental services from Medicaid for 2005 was $4.2 billion, or 1.35% . Dental care is mandatory for children and optional for adults, being determined by the states. In most states, access to dental care is inadequate for children on Medicaid, with only 15.7% actually receiving treatment in 2004, primarily because dentists do not participate in the program .

State Child Health Insurance Program

SCHIP is jointly financed by the federal and state governments. In some states the program is a part of the state Medicaid program. The states are allowed flexibility within federal guidelines on the benefits covered. SCHIP builds on Medicaid coverage and provides additional access for up to 6 million low-income children. Dental benefits are covered by all states but one . However, given the amount of discretion allowed at the state level on benefits, it is not uncommon to have cuts in dental benefits. Total Medicaid SCHIP expansion and SCHIP expenses for 2005 was $7.6 billion, with dental expenses making up 7.3% or $563 million of the total .

Food and Drug Administration

The Food and Drug Administration (FDA) is responsible for protecting the public’s health by assuring the safety, efficacy, and security of human and veterinary drugs, biologic products, medical devices, our nation’s food supply, cosmetics, and products that emit radiation. The FDA currently employs five dental professionals.

Health Resources and Services Administration

The primary purpose of the Health Resources and Services Administration is to improve access to health care services for people who are uninsured, isolated, or medically vulnerable . HRSA grantees provide health care in all states to uninsured people, people living with HIV/AIDS, and pregnant women, mothers, and children. HRSA activities are managed centrally and through the ten public health service regions, some of which have dental consultants with mostly nondental responsibilities. The bureaus most active in oral health are HIV/AIDS, Maternal and Child Health, Primary Health Care, and Health Professions.

The HIV/AIDS Bureau provides clinical care and support for uninsured and underinsured individuals and families of individuals with HIV/AIDS. Through the Ryan White Care Act in FY 2006, 78,000 clients with 220,000 encounters received oral health services at a cost of $43 million in the Parts A, B, C, and D programs (HIV Bureau, Health Resources and Services Administration Department of Health and Human Services, personal communication, 2007).

The Maternal and Child Health Bureau (MCHB) is responsible for assuring that necessary services are made available to American mothers and children. Programs coordinated by the MCHB, which include oral health, have as their objective to support the development and implementation of comprehensive, culturally competent, coordinated systems of care for the estimated 18 million United States children who have or are at risk for chronic, physical, developmental, behavioral, or emotional conditions, and who also require health and related services of a type or amount beyond that required by children generally . Expenditures by the federal government on maternal and child health services were $628 million in 2005 . Dental expenditures were 2.1% or about $13 million.

Other efforts of the MCHB include the National Oral Health Policy Center, which provides information and support for national, state, and local (MCHB) programs; develops policy that advances oral health and dental care for (MCHB) populations and vulnerable and at-risk populations; and supports leadership development in oral health policy .

The National Maternal and Child Oral Health Resource Center aims to support health professionals, program administrators, educators, policymakers, and others with the goal of improving oral health services for pregnant women, infants, children, and adolescents, including those with special health care needs and their families . Activities of the Oral Health Resource Center include collecting programmatic materials, such as guidelines, curricula, policies, and reports; maintaining an online database of projects funded by the HRSA and MCHB; and responding to information requests on topics such as early childhood caries, dental sealants, fluoride varnish, and access to and reimbursement for oral health services .

The Bureau of Primary Health Care (BPHC) provides national leadership in assessing the nation’s health care needs of underserved populations and in assisting communities to provide primary health care services to the underserved to help eliminate health disparities. The BPHC provides support to community health centers that provide primary services to rural and medically underserved populations in spite of their ability to pay. They form a major component of the “safety net” system. In 2006, BPHC grantees had 6,250 FTE health professionals who provided 6,149,694 encounters for 2,557,003 patients . Community Health Centers that receive federal grant subsidy as a primary means of funding are referred to as federally qualified health centers (FQHC). All new FQHCs are required to assure access to oral health services .

Seventy-three percent of existing federally-funded health centers provided oral health services onsite, as compared with 34% in 1997. Others referred patients to contracted private providers. Dental visits constituted about 10% of all visits to the federally-funded health centers in 2005, a growth of 87% since 2000 .

The Migrant Health Program supports the delivery of migrant health services that includes dental services with other prevention-oriented and pediatric services. These programs serve over 650,000 migrant and seasonal farm workers. In 2002, 85.1% (103) of 121 Migrant Health Programs provided some type of dental care .

The Bureau of Health Professions (BHPr) coordinates, evaluates, and supports the development and use of the nation’s health personnel . The BHPr has defined the public health dental worker as the individual who “…plans, develops, implements and evaluates dental health programs to promote and maintain optimum oral health of the public” . Many of these individuals work in a public health program, such as community health centers where clinical services or dental treatment is provided to high risk or vulnerable populations. They may or may not have formal training in public health. This includes dental professionals, such as dentists, dental hygienists, dental assistants, dental technicians, and other personnel.

A Health Professional Shortage Area (HPSA) is a geographic area, population group, or health care facility that has been designated by the federal government as having a shortage of health professionals. Vulnerable population groups bear a disproportionately heavier burden of oral disease. The purpose of the HPSA designation is to reverse the unequal oral disease and access challenge.

There are three categories of HPSAs: primary care, dental, and mental health. HPSAs are designated using several criteria, including population-to-clinician ratios. This ratio is usually 3,500 to 1 for primary care, 5,000 to 1 for dental care, and 30,000 to 1 for mental health care. HPSAs are assigned a numerical score from 1 to 26 based on the level of need. The higher score has greater priority. The number of dental HPSAs (DHPSA) has steadily increased, from 805 in 1991 to 3,724 in 2007, affecting about 48 million people in these areas. The number of additional practitioners needed to remove a DHPSA designation is 6,701 dentists, and 9,318 are needed to meet target ratios. Thirty-four percent of these areas are in metropolitan areas and the rest are in nonmetropolitan areas .

National Health Service Corps

This HRSA program is managed through the BHPr and provides incentives to health professionals to work in communities that would otherwise be without health care. Some of the strategies adopted by the National Health Service Corps (NHSC) are forming partnerships with communities and organizations, student loan repayment, and recruiting culturally competent clinicians . The NHSC program has a field strength of more than 4,000 clinicians and health care professionals who provide care to over 4 million people nationwide. About half of these are in community health centers. The field strength for dentists in 2006 was 415, and 42 for dental hygienists . Currently, the NHSC uses loan repayment as the main incentive to attract professionals to work with underserved populations.

Other federal departments also have programs that provide oral health services; these include the US Departments of Defense, Transportation, and Veterans Affairs. The US Department of Agriculture administers the Women, Infants, and Children program that increasingly serves as a link for prevention, early detection, and referral of early childhood tooth decay in high-risk children .

State dental public health infrastructure and oral health programs

Each state’s Department of Health is very important for improving the oral health of the populations they serve. Most states have a dental director who coordinates efforts and helps ensure that necessary programs and services are provided. These may include, but are not limited to programs for the following :

• •

  Access to oral health services and workforce studies

• •

  Early Childhood Caries (formerly Baby Bottle Tooth Decay)

• •

  Fluoridation advocacy

• •

  School fluoride mouth rinse and dental sealants

• •

  Fluoride supplements and fluoride varnish

• •

  Mouth-guard and injury prevention

• •

  Clinical services and infection control

• •

  Dental screening, needs assessment, and oral health surveys

• •

  Oral health education and promotion

• •

  Smoke and spit tobacco cessation

• •

  Water fluoridation monitoring and private well fluoride testing

• •

  Prevent Abuse and Neglect through Dental Awareness (PANDA)

State dental directors may be full-time or part-time. There is considerable variation in the professional training and academic qualification of these directors. As of 2007, 44 states had a full-time state dental director position . Of the filled positions, there were 29 dentists and 9 dental hygienists. Of the 29 dentists, 21 had a Masters in Public Health (MPH) degree and one had a Juris Doctor degree. Three of the dental directors who are dental hygienists had an MPH degree and one had a doctorate. Seven states had vacant positions, yet to be filled. (Dean Perkins, DDS, MPH, Executive Director Association of States and Territorial Directors, personal communication, September, 2007). In 2002, the median number of FTEs in state dental programs was three and the range was 0 to 81 . The budget for dental activities in different states in 2001 and 2002 ranged from less $100,000 to over $1,000,000. In 2002, 5.9% of the states spent less than $100,000 and 35% of the states spent over $1,000,000 ( Table 1 ).

Table 1

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related

Related posts:

1. Oral Health Disparities in the United States
2. Financing Dental Care: Trends in Public and Private Expenditures for Dental Services
3. Understanding Measurement of Dental Diseases and Research Participation in Practice Set-Up
4. Fluorides in Dental Public Health Programs
5. Planning and Evaluating Community Oral Health Programs
6. Public Health Issues in Geriatric Dentistry in the United States

Stay updated, free dental videos. Join our Telegram channel

Join