Vol. 51, No. 2, Spring 1991
Dental Public Health: New Opportunities-New Responsibilities" Stephen Wotman, DDS Professor of Community Dentistry Case Western Reserve University School of Dentistry 2123 Abington Road Cleveland, OH 44106
Abstract Major changes affecting oral health in the United States have provided new leadership challenges for public health dentistry. Two new roles for dental public health are proposed: leadership in the incorporation of expanded public health skills into the education of every clinicaf dentist; and a broadening of the specialty in a manner similar to that of preventive medicine, involving the creation of subspecialties in public health dentistry, occupational environmental dentistry, and management policy dentistry. Thecurrent status of community dentistry departments in dental schools and programs of public health education for dental personnel in schools of public health are reviewed. Content is suggested for the incorporation of expanded public health skills into the education of every clinical dentist. Key Words: undergraduate dental education, public health dentistry, occupational dentistry, environmental dentistry, management dentistry, health policy dentistry.
The last decade of the 20th century provides the opportunity to look with pride on the accomplishments of dental public health in this century and to set the stage for accomplishments in the next (1). Successful preventive effortsfor dental caries in industrialized nations have caused a shift of emphasis for the dentist from the oral healthneedsof children to thoseof adultsand theelderly. New understanding of periodontal disease has enabled most people to believe they can keep their teeth for a lifetime (2). Improved technology and changing approaches to the provision of care have caused major changesin professional practice (3).These developments have caused reassessment of the activities of dental schools (4). At the same time, a change in emphasis for medical science from acute to chronic disease (51, a burgeoning base of scientific knowledge and technology, *Presented in part at the 1989 meeting of the American Public Health Association (Chicago). Manuscript received 3/15/90; returned to author for revision:5/23/90; accepted for publication:6/15/90.
and renewed concern over the equitable distribution of care, all provide the basis for further advances in our ability to protect and improve health in the 21st century. Those engaged in dental public health should consider two new roles. First is the provision of leadership to incorporate broadly defined public health skills into the education of every clinical dentist (6). Second is the expansion of the already broadened perspective of public health in dental public health to create opportunities for expanded residency training analogous to that available in preventive medicine. What Is the Situation Now? The last survey of education of dental personnel in public health was conducted in 1985 (7). Lotzkar reviewed the programs to prepare dentists for careers in public health and estimated the number of individuals within dentistry who had formal public health backgrounds. He found increased interest, by the federal services, in dentists with training in prevention and administration. He analyzed the reasons for and against seeking diplomate status and estimated that a significant number of dentists are engaged in public health activities without completing qualificationas a specialist. His survey did not concern itself with the public health background and experience of the clinical dentist. Dental Schools. The education of the clinical dentist is currently undergoing major reassessment. Virtually all dental schools are experiencing a painful reexamination of their mission and goals. This reassessment is most often stimulated by a fiscal imperative resulting from reduced enrollment and reduced state support. It is complicated by the demand that dental school programs adapt quickly to the changing characteristics of the profession and the demands of universities for faculty to meet high scholastic criteria as well as have outstanding clinical expertise (3). Dental schools are experimenting with new programs, especially in the area of orientation to medical problems, attention to populations at risk for dental disease, and public health skills. As a result, dental schools are taking measures to
operate more effectively and efficiently. General trends include the consolidationof departments; stresson facult y scholarship; revised missions to more closely ally the goals of dental schools with changing demands for oral health care; less isolation of faculty and students, allowing dental education programs to draw on, and contribute to, the intellectual base of the university; and the emergence of severe faculty resistance to change at some institutions. Departments of Community Dentistry. Departments of community dentistry in dental schools provide a wide variety of functions. The 1987-88 update of the Dental Educators Database provided by the American Association of Dental Schools reported 42 dental schools with one or more departments titled: Community Dentistry, Public Health, Behavioral Science, Preventive Dentistry, Health Ecology, Statistics, or Nutrition (8). Thirteen schools had no department that included one of these titles. Informal discussions with a few chairpersons suggest that the functions of these departments include: community service projects, advanced general dentistry programs, behavioral science teaching, epidemiology and biostatisticsof dental disease, ethics, introduction to dentistry, practice management, and individual programs in the theory and practice of caring for specific populations at risk (e.g., the handicapped, the elderly). These individuals also characterizecommunity dentistry departments as at risk in a contracting environment, but with a few centers of excellence remaining around the country. Schools of Public Health. Programs for dental personnel in schools of public health require a core of skills and then follow two general patterns. Of the 23 schools of public health, seven offer a public health dentistry/community dentistry curriculum. These programs supervise the MPH and doctoral training of dental personnel and emphasize the incidence and prevalence of dental disease. The approach is often heavily weighted toward traditional epidemiology in an infectious disease context. Most schoolsof public health have no distinct program of dental public health and the dentist or dental hygienist seeking public health education in these schools secures core skills in public health before adding a specialized interest in one of the basic or newly applied areas of public health. These areas include: epidemiology; biostatistics; health administration, planning, and policy; environmental science; sociomedical science; tropical medicine (international health); geriatrics and gerontology; population and family health; and nutrition. Basic science departments are usually available either in the school of public health or in an associated school of medicine. Many schools of public health, departments of preventive medicine (in medical schools), health departments, and federal organizations sponsor preventive medicine residencies. This specialty includes standards for
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residency programs in public health, preventive medicine, occupational medicine, and aerospace medicine. A school, health department, or federal organization (e.g., NIDR, 1%) may also sponsor a residency in dental public health. Arguments for a Closer Relationship between Public Health and Clinical Dentistry Many major problems of clinical practice require the use of public health skills for solution. The traditional division between public health concerns and clinical practice has narrowed so that the application of public health skills is at the cutting edge of change in clinical dentistry as well as medicine. The average clinical practitioner has only meager knowledge of public health skills and is therefore at a loss when called upon to analyze and act on problems concerning groups, populations, and communities as part of daily practice.
"Dentists are introduced to the profession through a micro view, bypassing the problems of health and dealing immediately with events at the cellular level."
Examples of some of the new problems faced by the practitioner include: the identification of populations at risk for dental disease to maintain the individual practitioner's market share; an understanding of the rationale of insurance review and the role that quality assurance might play in qualification for insurance payment, as well as in marketing efforts; implementation of occupational health surveillanceand regulation concerning exposure to noxious substances; utilization of new practice forms that allow the dentist to be competitive with bulk providers of care; objective evaluation of the numerous schemes being put forward in the states for universal health insurance; the evaluation of new dental technology by analyzing the effect on the dentist's own practice, utilizing the practice computer; and an understanding of the expected outcome of specific restorative techniques in the individual's practice, also utilizing the computer (9). What Kinds of Programs Are Possible? Dentists are introduced to the profession through a micro view, bypassing the problems of health and dealing immediately with events at the cellular level. The missing element is a global or macro view of the field of dentistry as it relates to the health of individuals and the society. The health professions make up one of the few educational areas that do not go from the general to the specific. Skills and knowledge necessary to gain a macro view enabling the practitioner to function in situations
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dealing with groups, populations, and communities include: Epidemiology and Biostatistics. These subjects need to be presented in a more relevant form, utilizing illustrations drawn from marketing, planning, and individual practice analysis, as well as classical methodology. Health Care Systems. A view of the role of dentistry in the total health care system is needed. Management, planning and policy development techniques, and applications in dentistry should be stressed. Current practice administration topics can be used to illustrate and apply skills in a relevant manner. Environmental Science. The role of noxious substances in chronic disease and measures needed to minimize risk should be underscored. The interaction of regulation and the dentist’s responsibility to patients and personnel also needs to be emphasized. Social Sciences (medical economics, anthropology, medical sociology, social psychology, and political science).These skills extend the dentist’s understanding of behavior of patients, practitioners, and society. Emphasis should be on utilizing this knowledge in oral health advocacy through influence on individual patients, the dental health care system, and populations at risk for dental disease. Clinical Exercises. The object is to utilize dental school clinics and public agencies to provide experience in the diagnosis and management of oral health problems of groups, populations, and communities. Course material including these core skills should be included in the DDS curriculum. Building on this knowledge, part-time master‘s degree programs, continuing education programs, can also be developed for practitioners in concert with other health professions schools. In addition to the current full-time programs in the dental specialties, continuing education programs should be in the areas of needs of special populations (e.g., geriatric),management, and advanced clinical practice. How Expanded Emphasis on Public Health Skills for Clinical Dentists Affects Public Health Practitioners Board certification for public health dentists currently requires formal academic training (the MPH); formal residency experience; and satisfaction of an evaluation board concerned with knowledge, experience, and competence. Substantial additional knowledge and experience is required for a dentist to meet these criteria. The additional teaching suggested above for the DDS curriculum does not provide sufficient knowledge to direct more complex publicly, or privately, sponsored programs for which public health dentists are most commonly utilized. The changing compact with the society and the changing expectations of the public from the health profes-
sional (lo), however, provide new opportunities for public health in dentistry. Like our colleagues in medicine, we need to assess how additional public health skills can be developed in depth so that individuals make contributions to the public’s health in areas previously considered as only a part of the specialists’ training. We need to develop additional residency training opportunities in several important areas expanding the specialty. Criteria for expansion must be the utilization of skills to improve the public health, the ability to certify competence in the area, and both the need for and the possibility of career development for individuals with additional qualifications. In addition to the present well-thought-out residency programs in dental public health, residency opportunities can be developed in: Preventive Dentistry. A number of dental practitioners have declared themselves to be specialists in preventive dentistry. The qualifications of these practitioners range from well-experienced senior investigators to health faddists of questionable competency. The field of preventive dentistry has matured as a public health discipline. Indeed, the ability to define effective preventive measures in dentistry has far outstripped comparable efforts in other branches of medicine. Residency experiences in preventive dentistry can focus on preventive techniques for individuals (e.g., sealants, fluoride treatment for children and the elderly, behavioral changes needed to make flossing and brushing effective); the application, monitoring, promotion, and evaluation of preventive dental programs for groups and communities (e.g., water fluoridation, educational programs for children, adults and the elderly, school dental health, community sealant programs); and the development and application of new preventive methodologies as knowledge of the basic science of dental disease continues to expand (eg., injury prevention, public health approaches for periodontal disease, birth defect prevention, prediction of the effect of health promotion campaigns ill]). Occupational/Environmental Dentistry. Linking industrial pollutants to severe chronicdisease (e.g., cancer) underscores the importance of the occupational health physician. Since many pollutants are detectable in teeth or saliva, the participation of the dentist in the monitoring of the work place is appropriate and potentially useful. The efforts of occupational health dentists should be concerned with the detection of environmental pollutants in teeth and saliva; the detection and control of noxious substances utilized in dental practice; and research into the effect of noxious substances on patients, dentists, and other personnel. Tracing of environmental insults during pregnancy or early childhood revealed by abnormalities in structure or function (12,13)can also be accomplished (in some cases) through examination of tooth structure (14).
PolicyAVanagement Dentistry. The practice of dentistry, like the practice of medicine, has seen an increase in the number of practices involving multiple practitioners. In addition, the proliferation of practice forms, methods of raising capital, and varieties of practice organization that have affected the rest of the health professions are apparent in dentistry. Managers in the United States deal mostly with immediate problems. A business school education is oriented toward profit and loss and the "bottom line." Health care organization managers, on the other hand, need an understanding of the dynamics of disease and populations. Without this understanding, it is impossible for health care organizations to plan for the future. Planning in the private sector is an important aspect of health care management and marketing. Planningin the public sector is the development of healthcare policy. Specialists are needed who have both public health and business skills.
"I suggest that public health dentistry be redefined as a specialty, that its base be maintained through established training in public health dentistry and new criteria added for the areas of preventive dentistry, occupationallenvironmental dentistry, and policyhanagement dentistry."
The dentist/manager has become an important figure in many practices, as well as a reviewer and policy maker for insurance companies and governmental agencies. Minimum credentials for this position should include perspective and methodology related to groups, populations, and communities (public health), together with management skills. This combination is commonly provided as an MPH in health administration, sometimes combined with an MBA degree. The MBA alone does not provide sufficient background to understand the dynamics of disease and to manage and plan a health care enterprise. Residencies in management and policy can be designed and implemented. I suggest public health dentistry be redefined as a specialty, that its base be maintained through established training in public health dentistry and new criteria added for the areas of preventive dentistry, occupational /environmental dentistry, and policy/management dentistry. Just as the specialty of preventive medicine includes public health, preventive medicine, occupational medicine, and aerospace medicine, so can public health dentistry construct a series of subdisciplines to recognize the broadened activities of public health professionals in the work place. An orderly process needs to be devised for the development of these areas. Universities, health
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departments,or others may wish to set up demonstration residency programs with the advice of the American Board of Dental Public Health. All candidates would continue to earn the MPH degree as a basic requirement. Exploring this approach can alleviate a number of problems. At a recent meeting of the American Public Health Association in Chicago, 1 was challenged by the question: Are there jobs for public health dentists? The expansion of the definition of the public health dentist will expand career opportunities for public health specialists,increase the number of those who qualify, and foster additional recognition of the specialty by the profession and public at large. Successful Leadership Provides Opportunity Success with the further integration of public health skills into the lexicon of the clinical dentist and an expansion of the specialty based on rigorous criteria should bring additional talent to bear on research of importance to oral health. Increased sophistication will enhance the quality and quantity of research into such areas as: marketing as an extension of epidemiology;the effectiveness of therapeutic techniques and practice forms; the effects of advocacy; quality assurance; the effect of proposals for the rationalization of health care on the oral health of the population; the importance of environmental factors and population trends to oral health; as well as the evaluation of new programs, materials, and therapeutic approaches (clinical trials). More effective demonstration projects, problem analysis, and model building can also be expected. Dangers of Inactivity-Failure to Seize the Moment The last year has seen the beginning of a major effort to reexamine and restructure the health care system. This effort has resulted in proposals for change in at least 19 states, as well as new discussion at the federal level. The inclusion or exclusion of dentistry in these discussions will depend on the availability of leaders in the profession who understand problems of dental care not only in the context of individual patients, but also in terms of oral health for groups, populations, and communities. If the additional expertise and orientation needed to address the oral health concerns of groups, populations, and communities cannot be added to the armamentarium of the dentist, the response of the profession to proposals for change will be uninformed. As a result, the profession may push itself into an inflexible stance, forcing basic decisions concerning oral health and the future of the profession to be made without sufficient dental input (15). Dental schools must deal with the new problems of integration with medicine illustrated by the additional medical knowledge needed to deal with the chronically ill elderly. They must teach dentists how to assimilate new technology while controlling the cost of care. They
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need to provide additional skills and a broadened outlook for dentists through a base of public health skillsand knowledge. Failure to accomplish these aims in a rapidly changing health care system may result in a worst-case scenario for dentistry. We may see developed a relationship similar to that between the optometrist and the ophthalmologist for the dentist and physician. The dentist will make prosthetic devices while diagnosis, prescription, and treatment for most disease and malformation will be accomplished by medical and surgicai colleagues expanding existing specialty areas. Specialists in dental public health are uniquely qualified to foster the integration of public health skills into the clinical practice of dentistry. At the same time, they can expand the role of dental public health practitioners by establishing criteria for an expanded specialty. As a result, dental public health will enhance and expand its ability to influencechanges needed to improve the public health. Leadership provided by specialists in public health dentistry through programs for dental students, clinical dentists, and an expanded specialty can enhance the opportunity to maintain dentistry as a vibrant, exciting, intellectual enterprise dedicated to finding and applying new and established methods to the prevention of disease and the promotion of health.
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