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Comprehensive Notes: Dentistry & Dental Public Health – Chapter 1

Development of the Dental Profession

  • Dental diseases date back to pre-history; scientifically based care only emerged in the last few centuries.
  • 1728: Pierre Fauchard publishes Le Chirurgien Dentiste (>800 pages, 2 volumes) – considered the foundational Western text on dentistry.
  • Early training pathway: apprenticeship. Example: G.V. Black’s formal education lasted 20 months after only “a few weeks” with Dr. Speers (whose library was a single book).
  • 1840: Baltimore College of Dental Surgery (later University of Maryland) established – first U.S. dental school.
    • Curriculum: 16-week course following ≥1 yr apprenticeship.
    • First cohort: 5 enrolled, 2 graduated.
  • Mid-1800s: American Journal of Dental Science (first national dental journal) and American Society of Dental Surgeons (first national organization) founded – genesis of U.S. dental profession.
  • Proprietary (for-profit) schools proliferated, producing graduates of highly variable quality ➔ separated dentistry from medicine.
  • International contrasts:
    • English-speaking & Scandinavian countries: dentistry independent of medicine.
    • Central/Southern Europe: split between stomatologists (physicians) & second-tier dentists – ultimately abandoned.
  • 1929: Closure of last proprietary school soon after the Gies Report (advocated university-based, accredited programs).
  • 1945: First controlled community water-fluoridation trials – milestone for preventive dentistry.
  • 1948: National Institute of Dental Research (now NIDCR) founded – accelerates research.
  • 1950s “Golden Age” drivers:
    • High-speed air-turbine hand-piece (1957)
    • New restorative materials; economic boom.
  • 1963 Health Professions Educational Assistance Act (+ renewals 1971, 1976): federal funds for construction, student aid, per-capita support ➔ revitalized dental schools.
    • Physical plant reconstruction 1963–1978; new schools ➔ dental schools increased from 39 (1930) to 59 (1980).
  • Late 1970s–1990s: perceived oversupply of dentists (post-Vietnam downturn 1964–1975, caries decline) ➔ 7 school closures.
  • 1990s–2019: applications rebound; new schools in Arizona, Florida, Nevada; total 66 accredited U.S. schools by 2019.
  • Current/future influencers: aging & diverse population, oral–systemic links, genomics, social determinants, equity, student debt, inter-professional care, new technologies.

Models & Characteristics of a Profession

Competing Models of Professionalism

  • Commercial model – care as commodity; driven by patient’s ability/willingness to pay.
  • Guild model – dentist holds knowledge; patient passive; ethical trust to provide best care (historically dominant in U.S.).
  • Interactive model – practitioner & patient are partners; merges expertise with patient values (growing trend).

Essential Criteria (Box 1.1)

  • Continuously expanding, archived body of knowledge.
  • Academic preparation in specialized institutions.
  • Lifelong commitment to continuing education.
  • Privilege of self-regulation (admission, discipline).
  • Self-developed code of ethics.
  • Organized societies to advance mission & serve members.

Public Health Foundations

Defining Health

  • WHO (1946): “complete physical, mental & social well-being, not merely absence of disease” – aspirational.
  • Sociological: “state of optimum capacity for valued tasks” – pragmatic.

Defining Public Health

  • Winslow (1920): “science & art of preventing disease, prolonging life & promoting physical health & efficiency through organized community efforts.”
  • IOM (1988): society’s duty to assure conditions in which people can be healthy.

IOM Core Functions

  1. Assessment – continuous data collection & dissemination.
  2. Policy Development – use science to guide decisions.
  3. Assurance – ensure services meet agreed-upon goals (directly, via partners, or regulation).

Essential Public Health Services (Box 1.2)

  1. Monitor health.
  2. Diagnose & investigate.
  3. Inform, educate, empower.
  4. Mobilize partnerships.
  5. Develop policies & plans.
  6. Enforce laws.
  7. Link to / ensure care.
  8. Assure competent workforce.
  9. Evaluate services.
  10. Research innovative solutions.

Identifying a Public Health Problem

  • Classic criteria (Blackerby 1944):
    1. Widespread morbidity/mortality;
    2. Applicable body of knowledge exists;
    3. Knowledge not currently applied.
  • Modern broadened criteria:
    • Condition causes actual/potential widespread morbidity or mortality.
    • Perceived as a problem by public, government, or health authorities.
  • Examples:
    • Smoking identified post-Surgeon General report 1964 – meets both criteria.
    • HIV/AIDS recognition driven by public perception, media, and governmental mandate.
    • Road accident deaths (≈10× HIV deaths in 2016) illustrate disparity between perception & burden.

Dental Public Health (DPH) as a Specialty

  • ADA-recognized specialty since 1950 (one of nine).
  • Definition (adapted from Winslow): prevention & control of dental diseases & promotion of dental health through organized community efforts; community is the “patient.”

Core Functions (Box 1.3 – ASTDD)

I. Assessment – oral health status, determinants, public perceptions.
II. Policy – mobilize partners; develop supportive plans.
III. Assurance – laws, access, workforce, evaluation, research.

Competencies for DPH Specialists (Box 1.4 – 2018)

  1. Manage population oral-health programs.
  2. Ethical decision-making.
  3. Evaluate care systems.
  4. Design surveillance systems.
  5. Communicate on oral/public-health issues.
  6. Lead collaborations.
  7. Advocate for policy/legislation.
  8. Critically appraise evidence.
  9. Conduct research.
  10. Integrate social determinants.

Workforce Snapshot

  • <200 board-certified DPH specialists, yet broad influence.
  • Employment settings: federal/state/local health departments, Indian Health Service, academia, research institutes, insurance, NGOs, foundations.
  • Interdisciplinary collaboration with physicians, nurses, engineers, social workers, nutritionists, etc.

Illustrative Achievements

  • Epidemiologic proof & community roll-out of water fluoridation.
  • Clinical trials validating fluoride toothpaste, rinses, sealants.
  • Development of incremental & comprehensive care systems for large populations.
  • Demonstrated productivity gains via expanded dental team roles.

Clarifications (What DPH is not)

  • Not merely “dentistry for the poor,” Medicaid dentistry, socialized dentistry, or provider of last resort.
  • Encompasses infection control, tobacco control, workforce policy, disparities research, access initiatives, etc.

Personal vs Community (Population) Care

  • Philosophic Divide:
    • Private care: maximizes best individual outcome; resource use often unlimited.
    • Public health: minimizes worst population outcome; resource allocation constrained, socially negotiated.
  • Decision Context:
    • Private dentist: autonomous within legal/ethical bounds.
    • Public health professional: salaried, accountable to supervisors, boards, taxpayers; rarely acts unilaterally.
  • Target Groups: Public programs often serve culturally, linguistically, socio-economically distinct or marginalized populations – may not hold mainstream health behaviors (e.g., appointment keeping, routine visits).

Data Collection & Surveillance in Dental Public Health

Surveillance Defined

  • Ongoing, systematic collection, analysis & interpretation of outcome-specific data for planning, implementation & evaluation.
  • Emphasizes simplicity, speed, practicality over the exhaustive precision required in clinical trials – “some data are better than none.”

Data Sources

  • Vital statistics (births, deaths).
  • Reportable disease notifications (e.g., plague, cholera).
  • Registries: cancer (SEER), congenital anomalies.
  • Administrative datasets: hospital discharge records.

Passive vs Active Surveillance

  • Passive: clinicians/hospitals required to report; authorities do not actively solicit (risk of under-reporting).
  • Active: health department staff contact providers/facilities to obtain case data for a defined period (often outbreak investigations).

Dental-Specific Surveillance Evolution

  • Historically limited to periodic surveys, not continuous surveillance (exception: oral cancer & cleft registries).
  • National Health & Nutrition Examination Surveys (NHANES) – rich but expensive, delayed, not state-specific.
  • National Oral Health Surveillance System (NOHSS) (mid-1990s, CDC + ASTDD): first formal oral-health surveillance framework.
    • 8 key indicators
    • Adults: dental visit (past yr), professional cleaning, complete tooth loss, loss of ≥6 teeth.
    • Children: caries experience, untreated decay, sealant presence, water-fluoridation coverage.
    • Data sources include Behavioral Risk Factor Surveillance System (BRFSS) – state-tailored telephone survey.

Seven-Step ASTDD Model for State/Local Data

  1. Establish purpose & partners.
  2. Review existing information.
  3. Decide if new data are needed.
  4. Basic Screening Survey (BSS) protocol & training (quick clinical assessments).
  5. Data analysis.
  6. Dissemination.
  7. Program planning & evaluation.

WHO Pathfinder Method

  • Simplified, globally standardized sampling & data collection; feeds into Global Oral Data Bank.
  • Enables surveillance where no prior data existed; uses minimally trained personnel following protocol.

Limitations of National Surveys (Box 1.5)

  • Dependence on dentists for examinations – costly & time-consuming.
  • Caries-centric protocols less relevant as disease mix changes.
  • Surface-level data mismatch with person-level health-goal metrics.
  • Weak periodontal surveillance tools.
  • Declining public participation ➔ potential response bias.
  • Reports often lag years, diminishing timeliness for policy.

Planning Cycle (Fig. 1.1)

  1. Collection of information (surveillance, surveys, registries).
  2. Strategic planning ➔ long-term goals & specific objectives.
  3. Implementation of evidence-based programs.
  4. Evaluation ➔ feedback to refine objectives & programs.

Ethical, Social & Practical Implications

  • Public health successes (e.g., safe water, immunizations) become invisible, risking complacency & funding erosion.
  • U.S. spends most on healthcare yet ranks low on population health metrics – signals need to invest upstream (social determinants, prevention).
  • Individualism vs population responsibility tension influences policy debates (e.g., seat-belt laws, fluoridation, contraceptive access).
  • Professionalism entails balancing commercial viability with ethical obligation to serve community needs.

Numerical & Statistical Highlights

  • Proprietary school closures: 1929.
  • Federal construction/student-aid influx: 1963–1978 (15 yrs).
  • Dental school count: 39 ➔ 59 (1930–1980); 66 schools by 2019.
  • HIV vs road-accident mortality 2016: road deaths ≈ 10× HIV deaths.
  • U.S. infant-mortality ranking 2017: 56th globally.
  • Board-certified DPH specialists: <200$$.

Integrated Vision

  • Dentistry & dental public health share the overarching goal: “Healthy people in healthy communities.”
  • Mutual understanding and collaboration between private practitioners and public health professionals are essential for:
    • Achieving equitable access.
    • Incorporating prevention & population thinking into clinical care.
    • Sustaining innovations (e.g., fluoridation, sealants, tobacco cessation) that yield life-long benefits beyond what individual treatment alone can deliver.