Christine French Beatty - Community Oral Health Practice For The Dental Hygienist (2017) - 2
Christine French Beatty - Community Oral Health Practice For The Dental Hygienist (2017) - 2
Christine French Beatty - Community Oral Health Practice For The Dental Hygienist (2017) - 2
FOURTH EDITION
Cover image
Title Page
Copyright
Dedication
Contributors
Reviewers
Preface
Acknowledgments
Summary
Community Case
References
Additional Resources
Summary
Community Case
References
Additional Resources
Determinants of Health
Summary
Community Case
References
Additional Resources
Chapter 4 Measuring Oral Health Status and Progress
Opening Statement: Healthy People 2020 Leading Health Indicators (LHI) and Targets 1
Healthy People
Types of Measurements
Summary
Community Case
References
Additional Resources
Part Two: Access to Oral HealthCare and Dental Public Health Systems
Future Directions
Summary
Community Case
References
Chapter 6 Oral Health Programs in the Community
Opening Statements
Head Start
Financing Programs
Summary
Community Case
References
Additional Resources
Research Designs
Research Methodology
Summary
Community Case
References
Additional Resources
Health Promotion
Summary
Community Case
References
Additional Resources
A System in Crisis
Leadership
Domestic Violence
Summary
Community Case
References
Additional Resources
Considering Culture
Cultural Competence
Health Literacy
Summary
Community Case
References
Additional Resources
Chapter 11 Service-Learning
Opening Statements: Highlights of Service-Learning Research in Higher Education: Dental Hygiene
Student Comments
Introduction
Stages of Service-Learning
Summary
Applying Your Knowledge
Community Case
References
Additional Resources
References
Glossary
Index
Copyright
This book and the individual contributions contained in it are protected under
copyright by the Publisher (other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research
and experience broaden our understanding, changes in research methods,
professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and
knowledge in evaluating and using any information, methods, compounds, or
experiments described herein. In using such information or methods they should be
mindful of their own safety and the safety of others, including parties for whom
they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised
to check the most current information provided (i) on procedures featured or (ii) by
the manufacturer of each product to be administered, to verify the recommended
dose or formula, the method and duration of administration, and contraindications.
It is the responsibility of practitioners, relying on their own experience and
knowledge of their patients, to make diagnoses, to determine dosages and the best
treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors,
or editors, assume any liability for any injury and/or damage to persons or property
as a matter of products liability, negligence or otherwise, or from any use or
operation of any methods, products, instructions, or ideas contained in the material
herein.
Dental hygiene science content must include oral health education and
preventive counseling, health promotion, patient management, clinical
dental hygiene, provision of services for and management of patients with
special needs, community dental/oral health, medical and dental
emergencies, legal and ethical aspects of dental hygiene practice, infection
and hazard control management, and the provision of oral health care
services to patients with bloodborne infectious diseases.
The American Dental Education Association (ADEA) Section on Dental Hygiene
Education, Competency Development Committee developed dental hygiene
competencies to assist dental hygiene schools in meeting the accreditation standards.
The competency statements serve as guidelines for individual programs in defining
the abilities they want their graduates to possess. These competency statements are
presented in the following five domains: Core Competencies, Health Promotion and
Disease Prevention, Community Involvement, Patient Care, and Professional
Growth and Development. The current Community Involvement (CM) competencies
as revised and approved by the ADEA House of Delegates in 2011 are as follows:
CM.1 Assess the oral health needs and services of the community to determine
action plans and availability of resources to meet the health care needs.
CM.2 Provide screening, referral, and educational services that allow patients to
access the resources of the health care system.
CM.3 Provide community oral health services in a variety of settings.
CM.4 Facilitate patient access to oral health services by influencing individuals or
organizations for the provision of oral health care.
CM.5 Evaluate reimbursement mechanisms and their impact on the patient's access
to oral health care.
CM.6 Evaluate the outcomes of community-based programs and plan for future
activities.
CM.7 Advocate for effective oral health care for underserved populations.
At the end of each chapter in the textbook, competencies are listed from all
domains that are relevant to the chapter content. The complete document of revised
competencies for entry into the profession of dental hygiene can be found in
Appendix B. Therefore the instructor and student can apply the information within
Community Oral Health Practice for the Dental Hygienist to the goal of developing
competencies in the profession of dental hygiene.
Chapter 1 defines community oral health for students through examples of public
health problems and solutions. The core public health functions and essential public
health services are defined, and the role of the government in community oral
health is discussed. Chapter 2, on careers in public health, enables students to
envision the future use of the information they are learning in this textbook and in
the Community Oral Health course. It describes the various alternative dental
hygiene career roles and options, and features profiles of dental hygienists who
practice in alternative settings and roles related to community oral health.
Reviewing these featured career choices allows students to comprehend the
relevance of the content in the forthcoming chapters.
Chapter 3, on assessment, and Chapter 4, on measuring oral health, emphasize the
importance of these crucial steps in planning and evaluating community oral health
programs and in oral health surveillance at the national and state levels. Dental
hygienists involved in public health need to be knowledgeable about and proficient
in using the tools of assessment and measurement of oral health, including common
dental indexes. Chapter 5, on the burden of oral disease in the population, will help
students become well informed about the current level of various oral diseases and
conditions in the population to be able to prioritize the needs of different
community target groups. This chapter also describes the status of various issues
that affect access to care, including workforce and financing of oral care. A
discussion of the Healthy People 2020 oral health objectives and tracking of
progress in relation to the objectives is threaded throughout these three chapters as
an important framework for assessment and development of community oral health
programs.
Chapters 3, 4, and 5 are appropriately placed within the book as a preparation for
Chapter 6, on community oral health programs, which discusses the planning,
implementation, and evaluation phases of program development as well as the
funding of community oral health programs. Successful community oral health
programs at the local, state, and national levels are featured in relation to various
priority populations. Internet websites, resources, and updates on state oral health
programs are incorporated. Also included is a description of the steps needed to set
up a community program, which can assist students in developing community oral
health projects for the Community Oral Health course, the American Dental
Hygienists' Association (ADHA) student organization, or other service-learning
activities. These steps will also be useful after graduation when working or
volunteering in the community through ADHA or other means.
Chapter 7 covers the research process and statistics in a relevant, organized
format, with application to community oral health. Criteria for reviewing oral
health literature are included, as is a discussion of the use of research results for
evidence-based decision making in dental hygiene practice. Chapter 8 explains
theories of health promotion and identifies strategies for developing and delivering
oral health information to the public. Chapter 9 addresses the social responsibility
of oral health providers and the role of government with respect to improving
access to care for underserved populations and achieving health equity in the
population. The importance of communication and leadership are discussed in
relation to these social responsibilities.
In Chapter 10, cultural competence is discussed in relation to the cultural diversity
of our nation and the importance of reducing oral health disparities. Also described
are the development of cultural competence and models of ways to incorporate
cultural competence into interactions with patients and in our community oral health
promotion efforts. Chapter 11, on service-learning, defines the importance of the
interface between the needs of the community and student learning. The benefits of
service-learning, especially in relation to interprofessional collaboration, are
discussed and ways are suggested to integrate service-learning into the student's
community oral health experience.
Chapter 12 provides the student with practice in answering community oral health
test questions similar to those on the National Board Dental Hygiene Examination
(NBDHE). These community cases test the student's understanding of content in the
textbook in relation to real-world community situations. The practice test also can
assist the student in successfully answering this type of question on the NBDHE and
potentially result in improved scores on the NBDHE in the area of community oral
health.
Listings of knowledge-application activities can be found at the end of each
chapter. These are suggestions for classroom activities and/or outside assignments
that can bring the chapter content to life for greater overall understanding of
community oral health. Instructors can assign the activities, or students can elect to
pursue them on their own for enrichment.
Also at the end of each chapter are sample community cases with test questions. A
second set of cases for each chapter is available on the Student section of the Evolve
website (http://evolve.elsevier.com/Beatty/community/), which also contains
supplemental information and learning activities related to Community Oral Health
Practice for the Dental Hygienist. These cases are designed to assist students in their
mastery of the material in each chapter and provide extra practice in answering
case-type questions similar to those on the NBDHE. The answers/rationales to these
cases are on the Student section of the Evolve website as well. In addition, a third set
of cases with test questions and answers/rationales for each chapter are available on
the Faculty section of the Evolve website, which can be used by instructors for
testing or shared with the students for further practice/application.
Supplementary materials are located at the end of the textbook. Appendixes A and
D contain community organization and government websites for oral health
resources, respectively. Appendix B lists the dental hygiene competencies, and
Appendixes C and D include valuable information for forming community
partnerships and performing community health assessments, respectively. Appendix
E provides ideas for topics to address in community oral health programming, and
Appendix F describes common dental indexes for use in assessment, program
evaluation, and research. Because a vocabulary of terms is unique to community
oral health practice, a Glossary is included for reference; key terms are bolded
throughout the book and included in the Glossary.
I humbly submit this textbook to the profession with the goal of providing
students with the information they need to begin their profession with a positive
attitude toward community oral health and a willingness to contribute to the oral
health of all persons in their community. The future of community oral health rests
with the upcoming leaders who are currently studying and experiencing it as
students. I hope the textbook can help to spark and/or cultivate a passion that will
result in the same fulfillment from community oral health practice that I have
experienced in my 52 years in the profession.
Acknowledgments
Over the course of preparing this textbook for publication, many people have
provided their support, guidance, and assistance. I want to acknowledge with sincere
appreciation the following colleagues for their contributions and time, which went
far beyond the scope of their chapters in providing assistance with moral support,
project planning, research, content review, and manuscript preparation:
Charlene B. Dickinson, RDH, BSDH, MS, Texas Woman's University Department
of Dental Hygiene
Amanda M. Hinson-Enslin, RDH, CHES, MPH, PhD(c), University of Texas at
Dallas Department of Interdisciplinary Studies and Texas Woman's University
Department of Health Studies
The many students who have shared my enthusiasm for community oral health
during my 40 years of teaching have inspired me, and I thank them for their
commitment to the oral health of the public.
I especially appreciate family and friends who have supported this professional
endeavor with their understanding, love, sacrifice, and prayers. I particularly want
to recognize the following family members:
Husband Richard; our son Justin, his wife Connie, and our grandchildren
Grace, Josiah, and Piper; and our son Allen.
Christine French Beatty
C H AP T E R 1
People's Health
An Introduction
Christine French Beatty RDH, MS, PhD
OBJECTIVES
1. Define and relate the terms health, public health, dental public health,
community health, and population health.
2. Identify public health problems within a community.
3. Identify public health measures or solutions; relate them to public health
problems.
4. Define dental disease as a chronic public health problem with public health
solutions.
5. Compare the components of private practice and public health practice.
6. Explain the role of the government in public health practice.
7. Identify core functions of public health and the essential public health services;
relate the essential services to the core functions.
8. Identify the current issues and limitations of dental public health.
9. Describe the future potential and challenges of dental public health.
Opening Statements: What Is Public Health?
• Influenza immunizations prevent epidemics, saving lives and money.
• Vaccine research of the human immunodeficiency virus (HIV) is a top priority to
end the epidemic.
• Community water fluoridation is listed as one of the 10 greatest public health
achievements of the twentieth century.
• Evidence links dental disease to life-threatening systemic diseases such as heart
disease, respiratory ailments, and diabetes.
• The website of the world's largest tobacco company acknowledges that smoking
tobacco causes serious health risks.
• Improved water sanitation reduces an environmental hazard to control infectious
diseases.
• The Occupational Safety and Health Administration (OSHA) prevents work-related
injuries by enforcing laws and providing education and training.
• Bioterrorism has put public health officials on alert for unusual diseases.
• The American Dental Hygienists' Association (ADHA) has proposed the creation
of a dental hygiene–based dental therapist/midlevel oral health provider to address
the problem of inadequate access to oral health care for underserved groups.
• U.S. Public Health Service (USPHS) officers were sent to assist with recovery after
the 9/11 attack on the United States (U.S.).
• Public health officials and health practitioners encourage healthy eating to prevent
obesity, a condition that reduces almost all aspects of health and increases the risk
of several incapacitating, deadly diseases such as diabetes, heart disease, and some
cancers.
• The Affordable Care Act (ACA) has increased dental coverage for children of
low-income families.
Health, Public Health, and Dental Public
Health
The Opening Statements demonstrate the importance of people's health. These
specific examples of people's health illustrate what is meant by the topics of health,
public health, dental public health, community health, and population health. They
also help to show the wide range of activities involved in public health. A review of
the more formal definitions of these terms is also necessary for complete
understanding of these concepts. Although various definitions exist, the following
should suffice for use within the scope of community oral health practice for the
dental hygienist.
Health has been described as follows by the World Health Organization (WHO)
in their most recent Constitution: “Health is a state of complete physical, mental, and
social well-being and not merely the absence of disease.”1
Public health is defined by the CDC Foundation as the “science of protecting and
improving the health of families and communities through promotion of healthy
lifestyles, research for disease and injury prevention, and detection and control of
infectious diseases. Overall, public health is concerned with protecting the health of
entire populations. These populations can be as small as a local neighborhood, or as
big as an entire country or region of the world.”2 According to the American Public
Health Association, public health “promotes and protects the health of people and
the communities where they live, learn, work and play.”3 It is concerned with
prevention, health education, recommending policies, administering services,
conducting research, and limiting health disparities by promoting healthcare
equity, quality, and accessibility.2
Dental public health has been defined by the American Association of Public
Health Dentistry as “the science and art of preventing and controlling dental
diseases and promoting dental health through organized community efforts. It is the
form of dental practice that serves the community as a patient rather than the
individual. It is concerned with dental education of the public, with applied research,
and with the administration of group dental care programs as well as the prevention
and control of dental diseases on a community basis.”4 In addition, the American
Dental Association (ADA) describes dental public health as “that part of dentistry
providing leadership and expertise in population-based dentistry, oral health
surveillance, policy development, community-based disease prevention and health
promotion, and the maintenance of the dental safety net”5 (see Chapter 2 for a
discussion of the safety net). In many cases the term community oral health is used
interchangeably with the term dental public health.
Community health has traditionally referred to the health status of a defined
group within the population and the actions and conditions that improve and protect
the health of the community.6 In this text, the terms public health and community
health are used synonymously. The connection between people's health and
community oral health will become apparent throughout the text.
Population health has been defined as “the health outcomes of a group of
individuals, including the distribution of such outcomes within the group.”7 This
definition focuses on the implicit goal of improving health outcomes in the concept
of population health. In addition, outcomes can be interpreted broadly. The health
status of a population is only one aspect. Additional aspects of population health are
environmental and individual factors that influence health, disparities and inequities,
determinants of health, and shared responsibility for diffuse accountability.
The term population health is a newer one that emphasizes the varied extent of
factors that affect the health of the public. Addressing these factors requires
collaboration of community partners to improve outcomes. Thus an epidemiologic
approach is important to managing population health, making measurement a
fundamental aspect of the population health viewpoint. In practice, the terms
population health, community health, and public health are used interchangeably.
These topics and their correlations are discussed further in the book in various
chapters.
G ui di ng Pri nci pl es
Criteria for Identifying Public Health Problems
• Socioeconomic impact
• Communicability
• International requirements
2. Ability to prevent, control, or treat the health problem:
• Preventability
• Speed of response
• Economics
• Availability of resources
G ui di ng Pri nci pl es
Seven Characteristics of Public Health Solutions
The DHHS has 11 operating divisions, including eight agencies in the Public
Health Service and three human services agencies (Figure 1-1).21 Many of these
federal agencies encompass oral health programs (Box 1-1). The primary
involvement of the federal government in public health is to provide an
infrastructure, research, surveillance, and funding for programs that are carried out
at the state and local levels.
FIG 1-1 Departments and agencies of the federal government.
ox 1-1
B
Federal Governmental A g enci es of Interest i n
Communi ty Oral H eal th
Administration for Children and Families (ACF; www.acf.hhs.gov/)—manages the
Head Start program that funds local Head Start programs that prepare qualified
preschool age children for entry into school.
Agency for Healthcare Research and Quality (AHRQ; www.ahrq.gov/)—
responsible for supporting research designed to improve the quality of health care,
reduce its costs, address patient safety and medical errors, and increase access to
essential services.
Centers for Disease Control and Prevention (CDC; www.cdc.gov/)—the nation's
disease prevention and wellness promotion agency, addressing a wide range of
health threats including oral diseases. CDC works to protect people's health and
safety, provide credible information to enhance health decisions, and improve
health through strong partnerships. The agency provides expertise, information,
tools, and community collaboration to assist agencies with community
programming; administers funding for state and local health departments and
community-based organizations for many varied public health programs, including
oral health programs; provides surveillance data (e.g., water fluoridation);
provides leadership and direction in the prevention and control of diseases and
other preventable conditions; coordinates and implements national health policy on
the state and local levels; responds to public health emergencies; and cooperates
with other nations on health projects.
Centers for Medicare and Medicaid Services (CMS; www.cms.gov/)—provides
oversight for Medicare, the federal portion of the Medicaid program and the
Children's Health Insurance Program (CHIP), the Health Insurance Marketplace,
and related quality assurance activities.
Department of Agriculture (USDA; www.usda.gov/wps/portal/usda/usdahome)—
administers the Women, Infants, and Children (WIC) program through the Food
and Nutrition Service. Local WIC programs provide nutritional foods, education,
screening, and referrals, including dental care and education for eligible women
who are pregnant, are breastfeeding, or have young children under age 5.
Department of Defense (DoD; www.defense.gov/) and Veterans Administration
(VA; http://www.va.gov/)—provide direct care for specific armed services and
veteran populations.
Food and Drug Administration (FDA; www.fda.gov/)—enforces laws to ensure
the safety and effectiveness of drugs, biologic products, and medical devices.
Health Resources and Services Administration (HRSA; www.hrsa.gov/)—is the
primary federal agency for improving access to healthcare services for people who
are uninsured, isolated, or medically vulnerable through various means, including
funding community and school-based health centers. The HRSA improves access
by strengthening the healthcare workforce, building healthy communities, and
achieving health equity.
Indian Health Service (IHS; www.ihs.gov/)—provides direct comprehensive
patient care and community health programming for Native American and Alaska
Native populations, with opportunity for maximum tribal involvement in
developing and managing the programs.
National Institutes of Health (NIH; www.nih.gov/)—conducts and funds
epidemiologic, medical, and biomedical research, provides science transfer, trains
promising young researchers, and promotes acquisition and distribution of medical
knowledge. Several institutes are relevant to oral health, such as National Institute
of Dental and Craniofacial Research (NIDCR), National Cancer Institute (NCI), and
National Institute on Aging (NIA).
Public Health Service (USPHS; www.usphs.gov/)—the principal operating
division of the U.S. Department of Health and Human Services; responsible for
protecting, promoting, and advancing the health and safety of the American
population. The PHS provides rapid and effective response to public health crisis
situations, leadership and excellence in public health practices, and activities to
advance public health science. Goals are carried out by the Commissioned Core of
Health Officers, led by the Surgeon General, who staff various federal agencies
and clinics and respond to national emergencies.
Other federal government agencies also have a role in oral health for specific
populations. The related functions of the Department of Defense, the Veterans Health
Administration, the Department of Agriculture, and the Indian Health Service are
also described in Box 1-1.
At the state level, public health agencies have been charged with the task of
developing and coordinating oral health programs within their states. These
programs increase the awareness of oral health issues, promote sound oral health
policy development, and support initiatives for the prevention and control of oral
disease. At the local level, educational, preventive, and patient care oral health
programs vary throughout the nation. These local programs are implemented
through local government, nonprofit, faith-based, or other agencies or
organizations. For example, local community health centers provide services for
low-income families, and school-based programs provide oral health education and
oral disease prevention services to children (see Chapter 6). As a result of a decline
in funding at all levels, there has been less involvement at the local level in recent
years, and fewer data have been collected to document oral health status and
determine needs.22
ox 1-2
B
Si g ni fi cant N ati onal Oral H eal th Ini ti ati ves
Key Points of the Surgeon General's Report Oral Health in America
(2000)
• Oral health is more than just healthy teeth
• Oral health is essential to the general health and well-being of all Americans
• General health factors (e.g., tobacco use, poor diet, obesity, diabetes) affect oral
and craniofacial health
Strategies:
• The Office of Head Start is partnering with the American Academy of Pediatric
Dentistry to develop a national infrastructure focused on recruiting and
supporting public and private pediatric and general dentists to serve as dental
homes for young, racially and ethnically diverse children at high risk for dental
disease. Strategies include recruiting and training private sector dentists in
optimal oral healthcare practices for working with high-risk populations;
assisting Head Start programs in obtaining comprehensive oral health services
for Head Start children; providing parents, caregivers, and Head Start staff with
the latest evidence-based information on prevention of tooth decay, acquisition of
healthy habits, importance of oral health to children's overall health and
development, and value of establishing a dental home; and helping to secure
dental homes for Head Start children.
• The Centers for Medicare and Medicaid Services is identifying state Medicaid
dental programs that have implemented innovative strategies resulting in
increased access to dental care. This information of best practices will be shared
with other states to improve the overall delivery of dental services throughout all
Medicaid programs for the purpose of increasing access to dental care.
• The Secretary of the DHHS and the Administrator of the Health Resources and
Services Administration will consider implementing an oral health initiative
consisting of messages and a strategy to increase the visibility of existing DHHS
oral health activities and improve awareness of oral health services available to
the public. A strategic plan and a way to evaluate and support the initiative will be
included. This initiative will be based on a comprehensive report to be developed
by the National Academy of Science and the Institute of Medicine's Board on
Healthcare Services and Board on Children, Youth and Families. (This report has
been completed; see Advancing Oral Health in America later.)
• The National Research Council and the Institute of Medicine will collaborate with
the Board on Children, Youth and Families and the Board on Health Care
Services to develop an “access” report of the oral healthcare system in the nation
with particular focus on issues that disproportionately impact the underserved
who are most vulnerable to oral disease and the public and private safety net
providers intended to serve them. (This report has been completed; see Improving
Access to Oral Health Care for Vulnerable and Underserved Populations later.)
• The Indian Health Service's Division of Oral Health will finalize implementation
and expansion of an Early Childhood Caries Initiative to promote prevention and
early intervention of dental caries in young children through an interdisciplinary
approach. Components of the program include early oral health assessments by
community partners such as Head Start, the Women, Infants, and Children
Program, and medical personnel in community clinics; fluoride varnish
application by these community partners and dental teams; dental sealants on
primary teeth at an early age; the use of interim therapeutic restorations to reduce
dental treatment in the operating room; and the establishment of a national oral
health surveillance system to measure the impact of this initiative.
• The Office of Minority Health (OMH) will launch a new Cultural Competency E-
Learning Oral Health Continuing Education Program for the purpose of targeting
oral health disparities. This web-based project will be evidence-based and will
include needs assessment focus groups, extensive literature reviews, and input
from experts in the field (See Chapter 10.).
• The Office on Women's Health (OWH) will set out to change the perception of
oral health's impact on overall health by incorporating accurate oral health
information into existing OWH online and offline educational programs for
health professionals and the public. OWH also will work with regional programs
to highlight oral health activities.
• Changes need to be made in laws and regulations such as scope of practice laws
ox 1-3
B
Core Functi ons of Publ i c H eal th A g enci es at A l l
Level s of Government
Assessment
• Every 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. Not every agency is large enough to
conduct these activities directly; intergovernmental and interagency cooperation
is essential. Nevertheless, each agency bears the responsibility for seeing that the
assessment function is fulfilled. This basic function of public health cannot be
delegated.
Policy Development
• Every public health agency exercises its responsibility to serve the public interest
in the development of comprehensive public health policies by promoting use of
the scientific knowledge base in decision making about public health and by
leading in developing public health policy. Agencies must take a strategic
approach, developed on a base of positive appreciation for the democratic
political process.
Assurance
• Public health agencies assure their constituents that services necessary to achieve
agreed upon goals are provided, either by encouraging actions by other entities
(private or public sector), by requiring such action through regulation, or by
providing services directly.
• Each public health agency involves key policymakers and the general public in
determining a set of high-priority personal and community-wide health services
that governments will guarantee to every member of the community. This
guarantee should include subsidization or direct provision of high-priority
personal health services for people unable to afford them.
Reprinted with permission from National Academy of Science. The Future of the Public's Health in the 21st
Century. Washington, DC: National Academies Press; 2002.
Ten essential public health services have been identified to represent the
activities that all communities should undertake (Table 1-2). These services are
considered vital to achievement of healthy people in healthy communities and are an
integral part of public health practice.29 Figure 1-2 demonstrates the relationship of
the essential public health services to the core public health functions, also
providing further understanding of the core functions.30 Basically, the essential
services operationalize the core functions. Successful provision of these services
requires collaboration among members of the healthcare system, which consists of
all public, private, and voluntary entities that contribute to the delivery of essential
public health services within a jurisdiction, as well as across various levels of
government.11,23,31
TABLE 1-2
Essential Public Health Services to Promote Health and Oral Health in the
U.S. Organized around the Core Public Health Functions
10 Esse ntial Public He alth Se rvic e s (CDC) 10 Esse ntial Public He alth Se rvic e s to Promote Oral He alth (ASTDD)
Asse ssme nt Asse ssme nt
1. Monitor health status to identify and solve community health 1. Assess oral health status and implement an oral health surveillance system
problems
2. Diagnose and investigate health problems and health haz ards in the 2. Analyz e determinants of oral health and respond to health haz ards in the
community community
3. Inform, educate, and empower people about health issues* 3. Assess public perceptions about oral health issues and educate/empower them to
achieve and maintain optimal oral health
Polic y De ve lopme nt Polic y De ve lopme nt
4. Mobiliz e community partnerships and action to identify and solve 4. Mobiliz e community partners to leverage resources and advocate for/act on oral
health problems health issues
5. Develop policies and plans that support individual and community 5. Develop and implement policies and systematic plans that support state and
health efforts community oral health efforts
Assuranc e Assuranc e
6. Enforce laws and regulations that protect health and ensure safety 6. Review, educate about, and enforce laws and regulations that promote oral health
and ensure safe oral health practices
7. Link people to needed personal health services and assure the 7. Reduce barriers to care and assure utiliz ation of personal and population-based
provision of health care when otherwise unavailable oral health services
8. Assure competent public and personal healthcare workforce 8. Assure an adequate and competent public and private oral health workforce
9. Evaluate effectiveness, accessibility, and quality of personal and 9. Evaluate effectiveness, accessibility, and quality of personal and population-based
population-based health services oral health promotion activities and oral health services
10. Research for new insights and innovative solutions to health 10. Conduct and review research for new insights
problems
*
This essential service is listed under Assurance by the CDC (Figure 1-2) and was moved under
Assessment by the ASTDD to correspond to the equivalent essential service for oral health, which reflects
Assurance rather than Policy Development.
FIG 1-2 Core public health functions and essential public health services.
Building on the framework of the core public health functions and the essential
public health services, the Association of State & Territorial Dental Directors
(ASTDD) developed essential public health services to promote oral health that
correspond to the essential public health services (see Table 1-2).31 These essential
public health services to promote oral health provide guidelines for oral health
programs within state health departments (see Chapter 6). The core public health
functions, the essential public health services, and the essential public health services
to promote oral health provide direction for all dental public health professionals
working at national, state, and local levels. These core functions and essential
services are reflected in the national oral health initiatives previously discussed and
in the future plans for dental public health discussed in the next section.
Future of Dental Public Health
What Needs to Be Done
Over the years the number of dental public health programs at federal, state, and
local levels has declined as a result of tight budgets and diminishing resources.22
Dental disease persists as a public health problem that can be alleviated and possibly
eliminated.11,24-26 The knowledge exists, but because of restraints and a lack of
resources, this knowledge is not being applied toward the goal of freeing
communities from dental disease.25 The Pew Charitable Trusts Dental Policy reports
that the latest data from 2013 indicate that dental care is one of the greatest unmet
needs among children in the U.S. To solve this problem, Pew advocates for the
following: 1) ensuring that coverage from Medicaid and the CHIP leads to real
care,32 2) increasing the number of oral health professionals who can provide high-
quality dental care to low-income children,32 and 3) authorizing dental therapists to
extend dental care to underserved populations.33
The ongoing need to emphasize the importance of oral health has never been
stronger. It is the responsibility of oral health professionals to emphasize the
connection of oral health to people's overall health to the policymakers of our
nation19,34 (see Chapter 9). Recent public health reports24-26 continue to stress the
importance of increasing the priority given to oral health by health planners. The
reports also emphasize goals that need to be met to advance oral health in the future
(Box 1-2).
Impacting oral health will require greater interprofessional collaboration to
address the multifactorial nature of oral diseases.24 Developing alliances with other
healthcare professionals can influence oral health in two ways.35 Dental
professionals can impact the lives of their patients from a total health perspective. In
addition, other healthcare professionals can become aware of the effect of oral
health on the systemic conditions they are treating and vice versa. Interprofessional
partnerships have the potential to change the perception of oral health and overcome
barriers to optimize preventive care.
An example of interprofessional collaboration at the organizational level is a new
program: “Be Part of the Change” campaign.36 The ADHA and the Oral Cancer
Foundation have partnered in an effort to spread awareness of oral cancer to help
early detection by dental and medical practitioners. At a professional level the
American Association of Public Health Dentistry has recommended actions to
consolidate the inclusion of oral health into the health-related home model as an
integrated approach to medical and dental homes.37 This approach has been
implemented successfully in community-based clinics for low-income patients.38 In
addition, the Health Resources and Services Administration (HRSA) has
recommended expanding the oral health clinical competency of primary care
medical clinicians to lead to improved oral health.39 Interprofessional dental
hygiene education has been suggested as necessary to assure success of
interprofessional practice for dental hygienists.40 (See Chapter 2 for further
discussion of interprofessional collaborative practice [ICP].)
The ACA, commonly referred to as Obamacare, that passed in 2010 will have
significant effects on health care, including dental care and dental public health. An
estimated 11 million to 24 million children and nonelderly adults will gain access to
dental coverage by 2018, many of them through Medicaid.41 This will challenge the
capacity of the current dental workforce and require innovative, effective, and
efficient ways to increase the workforce so that the necessary dental care can be
provided.42 Oral health professionals will need to collaborate with other interest
groups to identify cost-effective solutions that are agreeable to all communities of
interest.43
The increase in the number of individuals with dental coverage will also
challenge the budget and require cost-cutting measures. One of the suggested ways
to reduce the expense of dental care is to reduce the number of dental-related
hospital emergency room visits for dental treatment that could be provided in dental
offices.44 Estimates are that using a triage system to refer these patients to
emergency dental clinics could save $1.7 billion per year.
The increase in the number of people with Medicaid dental coverage combined
with the further development of midlevel dental providers will necessitate that more
states implement policies to allow dental hygienists to be directly reimbursed by
Medicaid. In 2014 only 16 states provided for direct Medicaid reimbursement of
dental hygienists.45
Even though the ACA has increased dental coverage, gaps remain for low-
income adults.46 It is important to continue to seek new ways to increase access to
dental care for groups that will not benefit from the ACA.
Changes will continue to be needed to address the following provisions of the
ACA that are aimed at improving the dental public health infrastructure:41
• Increased funding for public health infrastructure, including CDC oral health
programs and national oral health surveillance programs
• Additional funding for school-based health centers (Figure 1-3)
FIG 1-3 School-based programs provide greater opportunity for children to learn
about oral health and have increased access to care. (© iStock.com.)
ox 1-4
B
Ini ti ati ves of A DA 's A cti on for Dental H eal th
Prog ram
Lead Collaborations to Achieve and Exceed the Healthy People 2020
goals
• Dedicate resources to collaborations, public/private partnerships, and community-
based interventions defined locally
• Increase access to care in dental offices and clinics for patients requiring
emergency treatment to solve the underlying patient problems
• Offer dental treatment to children in need and establish dental homes for continuity
of care
• Reduce barriers to access and increase capacity of the community health center
dental programs and private dental practices
• Establish the ADA sponsored site MouthHealthy.org as the most respected and
trusted online resource for oral health information
The ADA began the Long-Term Care Dental Campaign in 2014 as one of the
initiatives of the ADH program.60 This community-based project was designed to
assist state dental associations to create successful initiatives and to train more
dentists to serve at long-term care facilities as care providers, advisors, and dental
directors. The campaign consisted of a training session for state dental society
representatives to enable them to take a leadership role in long-term care policy and
advocacy in their states. The project also includes development of online continuing
education designed to help oral health professionals become more comfortable
providing care in long-term care settings and to create successful and sustainable
oral health delivery programs that serve nursing home residents.61
The ASTDD is a vital component of dental public health. This organization
sustains policy development and disease prevention programs through its support of
oral health surveillance. It also collaborates with a broad base of national, state, and
local partners to advocate for policies and programs. In 2012 the ASTDD addressed
changes to be made to enhance the state oral health infrastructure and capacity with
the goal of improving states' ability to improve the oral health of their
populations.62
The American Dental Education Association (ADEA) is a driving force in change
within dentistry and dental hygiene. In 2011 ADEA cosponsored an initiative to
develop core competencies for ICP to prepare all health professionals to be able to
function successfully in a collaborative model.63 These competencies can be used to
further develop interprofessional education in dental schools and dental hygiene
programs to prepare oral health professionals to participate in ICP (see Chapter 2).
The ADHA has a long history of advocating for increased access to oral health
care.48,64 In 2004 ADHA became the first national oral health organization to
propose a new oral health provider, the Advanced Dental Hygiene Practitioner
(ADHP), in an attempt to reach underserved populations.65 The ADHP is a midlevel
oral healthcare practitioner based on the nurse practitioner model.66 The role of the
midlevel provider and its development in dentistry is discussed further in Chapter 2.
The ADHA recently reaffirmed its support for improving access to care by
increasing the utilization of dental hygienists and midlevel dental practitioners.67
Dental hygienists are taking an active role in assessing and prioritizing oral
health needs in the community in various ways such as participating in the ADA
Access to Care Summit, providing leadership for ASTDD initiatives, and forging
careers in community oral health (see Chapter 2). They have a responsibility to
participate in the activities that will list community oral health practice as an
important achievement in the twenty-first century.19 Social responsibility and the
dental hygienist's commitment to the community are discussed further in Chapter 9.
Significant changes in workforce models are taking place to address the access to
care problem (see Chapter 2). The number of states that allow the public to have
direct access to the oral healthcare services of a dental hygienist in at least one
practice setting increased from 28 states in 2008 to 37 states in 2014.68 In 2009
Minnesota became the first state to approve the licensing of a dental therapist, the
dental equivalent of a nurse practitioner. Minnesota's law created a dental-based
dental therapist who will work with a dentist onsite and a dental hygiene–based
advanced dental therapist based on ADHA's model for the ADHP, who will work
under a collaborative practice agreement with an off-site dentist.69 Maine authorized
the practice of dental hygiene therapy in 2014, following a model similar to the
advanced dental therapist in Minnesota.70 More states, including Washington, New
Mexico, Kansas, and Vermont, are currently deliberating dental hygiene–based
midlevel workforce proposals. Additional states, including New Hampshire and
North Dakota, are studying other alternative workforce models.67
Challenges and successes of these new workforce initiatives have been reported
to assist other states in making the necessary changes to pursue new workforce
models.47 Also, studies have been conducted to identify the characteristics of
individuals drawn to these workforce models and challenges of their employment
situations to facilitate recruitment and retention.71,72
The ADHA in 2005 adopted an updated version of the six roles of the dental
hygienist originally established in the 1980s. The most important change included
positioning the role of public health as an integral component of the other roles of
clinician, educator, researcher, advocate, and administrator/manager 73 (see Chapter
2).
In 2013 ADHA, the ADHA Institute of Oral Health, and the Santa Fe Group
collaborated to hold the symposium Transforming Dental Hygiene Education: Proud
Past, Unlimited Future.40 The purpose of this conference was to analyze the
strengths and weaknesses of the current dental hygiene educational process and
curriculum to identify necessary changes that can improve dental hygienists' success
in meeting the oral health needs of the American public. The outcomes of the
conference highlighted the need for change and the need for dental hygiene to be
integrated into the overall healthcare system to be able to meet the changing needs
of society—in other words, ICP.74 Based on the results of this forum, the ADHA has
developed a strategic plan to address the dental hygiene curriculum changes needed
to prepare future dental hygienists for the expanded roles that are being created
within ICP.75
Common Goals
The goals of dental public health are optimal oral health for all citizens and
universal access to comprehensive dental care. With these goals in mind, both
dentists and dental hygienists have entered the field of public health by accepting
employment within programs that include health promotion, community disease
prevention, and provision of dental care to selected groups of people. Oral health
professionals and public health officials share a vision to improve the oral health of
underserved populations. For the nation to make significant progress toward this
goal, the commitment of a broad group of collaborative stakeholders is needed to
promote new initiatives that all communities of interest can support.11,23,57,76
The DHHS has recommended specialty public health training for oral health
professionals who direct dental public health programs.25 Dentists become
recognized specialists in the field of dental public health through specialty
certification with the American Board of Dental Public Health. In most states dental
hygienists have no required formal or specialty education required to work in the
community, although some have pursued advanced degrees or certification in public
health or community health.
Competencies for graduate education for dental hygienists were developed jointly
by the ADHA and ADEA. These proficiencies are based on the recognition that
further education prepares the dental hygienist to meet the challenges of working
with underserved populations that continually face barriers to health care, such as
inadequate geographic and financial access and complex medical conditions.76 In
addition, advanced education has been suggested for dental hygienists filling the
expanded roles of alternative workforce models77 and is required by most states that
have advanced certification for dental hygienists.65 Dental hygienists in expanded
roles have identified educational deficiencies that will need to be addressed by
future dental hygiene programs as the profession evolves and dental hygienists
accept more responsibility.78
Summary
An understanding of people's health includes learning the basic terminology to
define health, public health, dental public health, community health, and population
health. People's health is the health of the public living within a community, state, or
nation. Identifying public health problems and solutions provides dental hygienists
with the knowledge to explore this field of health further and a means by which they
might become involved. The government's role in people's health is mentioned
briefly as an introduction to the programs to be discussed in more detail in future
chapters. Comparison of private practice to community oral health practice
demonstrates the similarities and prepares dental hygienists for the assessment,
planning, implementation, and evaluation phases that constitute public health
programs. National oral health initiatives and nationally developed core oral health
functions and essential public health services are introduced. As healthcare
providers, with many roles and responsibilities, dental hygienists have a calling and
an ethical duty to serve the communities in which they live. Oral health
professionals who have chosen careers in public health contribute to the
advancement of dental public health, but much more needs to be accomplished by all
members of the dental hygiene and dental professions. Continued collaboration of
all stakeholders will be required to develop creative solutions to the significant
problems in our nation of widespread oral diseases and unmet dental needs, oral
health disparities, and lack of access to oral health care.
Applying Your Knowledge
1. Bring articles to class from the daily news or current magazines that present a
public health issue and discuss what the problem is and how it is being addressed.
(Use the criteria for identifying public health problems and the characteristics of
public health solutions described in this chapter to evaluate the issue.)
2. Choose a government public health program and further investigate its purpose
and success in accomplishing this purpose.
3. Identify a local community oral health program and analyze how it reflects the
vision, goals, and objectives of the national oral health initiatives.
4. Read and report on one of the national oral health initiatives described in the
chapter.
5. Research and report on the creation of the midlevel provider. Select a state and
report on the practice act that allows for improved access to oral health care for
underserved populations.
6. Search online for the Oral Health Atlas, and report on dental disease as a
worldwide public health problem (use maps and charts in this atlas for comparison).
Dental Hygiene Competencies
Reading the material within this chapter and participating in the activities of
Applying Your Knowledge will contribute to your ability to demonstrate the
following competencies:
HP.4
Identify individual and population risk factors, and develop strategies that promote
health-related quality of life.
Community Involvement
CM.1
Assess the oral health needs and services of the community to determine action
plans and availability of resources to meet the healthcare needs.
CM.7
Advocate for effective oral health care for underserved populations.
Community Case
In your new position as the Oral Health Program Coordinator at the State Health
Department, you are asked to conduct a statewide screening project to determine the
oral health status of school-age children. After you collect and analyze the data
from the statewide survey, you are to determine what oral health programs you
would like to plan that will address the needs of children in your state. Once
programs are selected and prioritized, you will be involved in planning the
programs for local implementation.
1. Which core public health function is addressed through the initial phase of this
project?
a. Assurance
b. Assessment
c. Policy development
d. Planning
2. All of the following essential public health services to promote oral health
EXCEPT one would apply to this situation. Which one is the EXCEPTION?
a. Assess oral health status and implement an oral health surveillance system
b. Develop and implement policies and systematic plans that support state and
community oral health efforts
c. Reduce barriers to care and assure utilization of personal and population-based
oral health services
d. Review, educate about, and enforce laws and regulations that promote oral
health and ensure safe oral health practices
3. Which one of the major agencies within the DHHS would have the most
possibilities for funding the programs you select to conduct?
a. PHS (Public Health Service)
b. ACF (Administration for Children and Families)
c. CMS (Centers for Medicare & Medicaid Services)
d. WIC (Women, Infants, and Children)
4. The initial phase of the project you are assigned relates to which private practice
function?
a. Diagnosis
b. Treatment
c. Examination
d. Evaluation
5. If the programs you select are to be effective public health solutions, they will
need to have all EXCEPT one of the following characteristics. Which one is the
EXCEPTION?
a. Not hazardous to life or function
b. Easily and efficiently implemented
c. Attainable by those who can afford it
d. Effective immediately upon application
References
1. Constitution of the World Health Organization. 45th ed. World Health
Organization: Geneva; 2006 [Available at]
www.who.int/governance/eb/who_constitution_en.pdf [Accessed January
19, 2015].
2. What is Public Health? CDC Foundation: Atlanta, GA; 2015 [Available at]
http://www.cdcfoundation.org/content/what-public-health [Accessed
January 19, 2015].
3. What is Public Health? American Public Health Association: Washington,
DC; 2014 [Available at] https://www.apha.org/what-is-public-health
[Accessed January 19, 2015].
4. Competency Statements for Dental Public Health. American Association of
Public Health Dentistry: Springfield, IL; 2014 [PDF available at]
https://aaphd.memberclicks.net/assets/Education/competency%20statements-
dental%20public%20health%201.pdf [Accessed September 17, 2015].
5. Dental Public Health Module. American Dental Association: Chicago, IL;
2012 [PDF available at] http://www.ada.org/en/member-center/oral-health-
topics/dental-public-health [Accessed January 19, 2015].
6. Community Health. Dictionary.com. [Available at]
http://dictionary.reference.com/browse/community+health; 2014 [Accessed
January 19, 2015].
7. Stoto MA. Population Health in the Affordable Care Act Era. Academy
Health; 2013 [Available at]
www.academyhealth.org/files/AH2013pophealth.pdf [Accessed January 19,
2015].
8. CDC Looks Ahead: 13 Public Health Issues in 2013. Centers for Disease
Control and Prevention: Atlanta, GA; 2013 [Available at]
http://blogs.cdc.gov/cdcworksforyou24-7/2013/01/cdc-looks-ahead-13-
public-health-issues-in-2013/ [Accessed January 19, 2015].
9. The State of Aging & Health in America 2013. Centers for Disease Control
and Prevention: Atlanta, GA; 2013 [Available at]
www.cdc.gov/aging/pdf/state-aging-health-in-america-2013.pdf [Accessed
January 19, 2015].
10. Community Water Fluoridation. Centers for Disease Control and
Prevention: Atlanta, GA; 2015 [Available at]
http://www.cdc.gov/fluoridation/pdf/communitywaterfluoridationfactsheet.pdf
[Accessed September 18, 2015].
11. Institute of Medicine of the National Academies, Committee on an Oral
Health Initiative. Advancing Oral Health in America. National Academies
Press: Washington, DC; 2011 [Available at]
http://www.hrsa.gov/publichealth/clinical/oralhealth/advancingoralhealth.pdf
[Accessed January 28, 2015].
12. Dental Caries (Tooth Decay) in Children (Age 2 to 11). National Institute of
Dental and Craniofacial Research: Bethesda, MD; 2014 [Available at]
http://www.nidcr.nih.gov/DataStatistics/FindDataByTopic/DentalCariesChildren2to11.
[Accessed January 20, 2015].
13. Adult Oral Health. Centers for Disease Control and Prevention Division of
Oral Health: Atlanta, GA; 2013 [Available at]
http://www.cdc.gov/oralhealth/publications/factsheets/adult_oral_health/adults.htm
[Accessed January 20, 2015].
14. Oral Health for Older Americans. Centers for Disease Control and
Prevention, Division of Oral Health: Atlanta, GA; 2013 [Available at]
http://www.cdc.gov/oralhealth/publications/factsheets/adult_oral_health/adult_older.h
[Accessed January 20, 2015].
15. Griffin SO, Jones JA, Brunson J, et al. Burden of oral disease among older
adults and implications for public health priorities. Am J Public Health.
2012;102:411; 10.2105/AJPH.2011.300362.
16. Oral Health in America. A Report of the Surgeon General. U.S. Department
of Health and Human Services, US Public Health Service, National
Institutes of Health, National Institute of Dental and Craniofacial Research:
Bethesda, MD; 2000 [Available at]
http://www.nidcr.nih.gov/DataStatistics/SurgeonGeneral/ [Accessed
January 23, 2015].
17. Competencies for Entry into the Profession of Dental Hygiene. American
Dental Education Association: Washington, DC; 2011 [Available at]
http://www.adea.org/gSearch.aspx?q=dental%20hygiene%20competencies
[Accessed January 21, 2015].
18. Building the Foundation: Leadership and Structure. Healthy People Oral
Health Toolkit. National Institute of Dental and Craniofacial Research:
Bethesda, MD; 2014 [Available at]
http://www.nidcr.nih.gov/EducationalResources/DentalHealthProf/HealthyPeople2010
[Accessed January 21, 2015].
19. Code of Ethics for Dental Hygienists. American Dental Hygienists'
Association: Chicago, IL; 2014 [Available at] http://www.adha.org/bylaws-
ethics [Accessed January 21, 2015].
20. HHS Strategic Plan and Secretary's Strategic Initiatives. Department of
Health and Human Services: Washington, DC; 2014 [Available at]
http://www.hhs.gov/strategic-plan/priorities.html [Accessed January 21,
2015].
21. HHS Agencies & Offices. Department of Health and Human Services:
Washington, DC; 2015 [Available at]
http://www.hhs.gov/about/agencies/hhs-agencies-and-offices/index.html
[Accessed December 12, 2015].
22. Thiess R. What Do Current Federal Funding Levels in the Wake of
Sequestration Mean for State Budgets?. Economic Policy Institute:
Washington, DC; 2013 [Available at] http://www.epi.org/publication/ib363-
sequestration-and-state-budgets/ [Accessed January 21, 2015].
23. A National Call to Action to Promote Oral Health. NIH Publication No. 03-
5303. U.S. Department of Health and Human Services, Public Health
Service, Centers for Disease Control and Prevention and the National
Institutes of Health, National Institute of Dental and Craniofacial Research:
Bethesda, MD; 2003 [Available at]
http://www.nidcr.nih.gov/DataStatistics/SurgeonGeneral/NationalCalltoAction/
[Accessed January 22, 2015].
24. Institute of Medicine, National Research Council. Improving Access to Oral
Health Care for Vulnerable and Underserved Populations. National
Academies Press: Washington, DC; 2011 [Available at]
http://iom.edu/Reports/2011/Improving-Access-to-Oral-Health-Care-for-
Vulnerable-and-Underserved-Populations.aspx [Accessed January 23,
2015].
25. Healthy People 2020. Department of Health and Human Services, Office of
Disease Prevention and Health Promotion: Rockville, MD; 2015 [Available
at] https://www.healthypeople.gov/ [Accessed January 23, 2015].
26. Promoting and Enhancing the Oral Health of the Public: HHS Oral Health
Initiative 2010. Department of Health and Human Resources: Washington,
DC; 2010 [Available at]
http://www.hrsa.gov/publichealth/clinical/oralhealth/hhsinitiative.html
[Accessed January 21, 2015].
27. Institute of Medicine, Committee of the National Academies, Committee on
Assuring the Health of the Public in the 21st Century. The Future of the
Public's Health in the 21st Century. National Academies Press: Washington,
DC; 2003 [Available at] http://www.nap.edu/openbook.php?
isbn=030908704X [Accessed January 26, 2015].
28. Centers for Disease Control and Prevention, Office for State, Tribal, Local
and Territorial Support. United States Public Health 101 (Power Point
Presentation). Author: Atlanta, GA; 2013 [Available at]
http://www.cdc.gov/nphpsp/essentialservices.html [Accessed January 23,
2015].
29. Centers for Disease Control and Prevention, Office for State, Tribal, Local
and Territorial Support. The 10 Essential Public Health Services: An
Overview (Power Point presentation). Author: Atlanta, GA; 2014 [Available
at] http://www.cdc.gov/nphpsp/essentialservices.html [Accessed January 23,
2015].
30. The Public Health System and the 10 Essential Public Health Services.
Centers for Disease Control and Prevention: Atlanta, GA; 2014 [Available
at] http://www.cdc.gov/nphpsp/essentialservices.html [Accessed January 23,
2015].
31. Essential Public Health Services to Promote Health and Oral Health in the
United States. Association of State & Territorial Dental Directors: Reno,
NV; 2014 [Available at] http://www.astdd.org/prevention-and-control-of-
early-childhood-tooth-decay/ [Accessed January 23, 2014].
32. Dental Policy Overview. Pew Charitable Trusts: Philadelphia, PA; 2014
[Available at] http://www.pewtrusts.org/en/projects/childrens-dental-policy
[Accessed January 24, 2015].
33. Working with Midlevel Providers: Dentists' Perspectives. Pew Charitable
Trusts: Philadelphia, PA; 2014 [Available at]
http://www.pewtrusts.org/en/about/news-room/news/2014/10/02/working-
with-midlevel-providers-dentists-perspectives [Accessed January 24, 2015].
34. Principles of Ethics and Code of Professional Conduct. American Dental
Association: Chicago, IL; 2012 [Available at] http://www.ada.org/en/about-
the-ada/principles-of-ethics-code-of-professional-conduct [Accessed
January 25, 2015].
35. Mallonee LF. The need for inter-professional collaboration. J Dent Hyg.
2012;86:56.
36. OCF - RDH “Be Part of the Change™” Campaign. The Oral Cancer
Foundation; 2015 [Available at]
http://www.oralcancerfoundation.org/support-ocf/rdh/ [Accessed January
29, 2015].
37. Toward a Comprehensive Health Home: Integrating the Mouth to the Body
(policy statement). American Association of Public Health Dentistry; 2012
[PDF available at] http://www.aaphd.org/assets/resolution-
statements/aaphd%20final%20health%20home%20resolution%20-
%20last%20revision%20oct%202011.pdf [Accessed January 29, 2015].
38. Oral Health Integration in the Patient-Centered Medical Home (PCMH)
Environment: Case Studies from Community Health Centers. Qualis Health;
2012 [Available at]
http://dentaquestfoundation.org/sites/default/files/resources/Oral%20Health%20Integ
Centered%20Medical%20Home,%202012.pdf [Accessed January 29, 2015].
39. Integration of Oral Health and Primary Care Practice. U.S. Department of
Health and Human Services, Health Resources and Services
Administration; 2014 [Available at]
http://www.hrsa.gov/publichealth/clinical/oralhealth/primarycare/integrationoforalhe
[Accessed January 29, 2015].
40. Transforming Dental Hygiene Education: Proud Past, Unlimited Future.
Santa Fe Group; 2013 [Available at] http://santafegroup.org/transforming-
dental-hygiene-education-proud-past-unlimited-future/ [Accessed January
30, 2015].
41. Palmer C. Potential effects of the Affordable Care Act. ADA News. 2012
[Available at] http://www.ada.org/en/publications/ada-news/2012-
archive/october/potential-effects-of-the-affordable-care-act [Accessed
January 25, 2015].
42. Oral Health Provisions Contained in House and Senate Health Reform
Legislation. American Dental Hygienists' Association: Chicago, IL; 2009
[Available at] www.adha.org/resources [Accessed January 26, 2015].
43. Gwozdek AE, Tetrick R, Shaefer HL. The origins of Minnesota's mid-level
dental practitioner: Alignment of problem, political and policy streams. J
Dent Hyg. 2014;88:292.
44. Wall T, Nasseh K, Vujicic M. Majority of dental-related emergency
department visits lack urgency and can be diverted to dental offices.
American Dental Association Health Policy Institute; 2014 [Available at]
http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_0
[Accessed January 29, 2015].
45. Direct Medicaid Reimbursement Map 2014. American Dental Hygienists'
Association: Chicago, IL; 2014 [Available at]
http://www.adha.org/reimbursement [Accessed January 25, 2015].
46. Nasseh K, Vujicic M, O'Dell A. Affordable Care Act Expands Dental Benefits
for Children but Does Not Address Critical Access to Dental Care Issues.
American Dental Association Health Policy Institute: Chicago, IL; 2013
[Available at]
http://www.ada.org/sections/professionalResources/pdfs/HPRCBrief_0413_3.pdf
[Accessed January 29, 2015].
47. Dollins HE, Bray KK, Gadbury-Amyot CC. A qualitative case study of the
legislative process of the hygienist-therapist bill in a large midwestern
state. J Dent Hyg. 2013;87:275.
48. George MC. Public policy and legislation for oral health: A convergence of
opportunities. J Dent Hyg. 2013;87(Spec Comm Iss):50 [Special Commem].
49. Ten Great Public Health Achievements in the 20th Century. Centers for
Disease Control and Prevention: Atlanta, GA; 2013 [Available at]
http://www.cdc.gov/about/history/tengpha.htm [Accessed January 15,
2015].
50. Centers for Disease Control and Prevention. Ten great public health
achievements, United States, 2001-2010. MMWR. 2011;60:619 [Available at]
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6019a5.htm [Accessed
January 24, 2015].
51. Solana K. ADA, leading health groups urge MLB Players Association to ban
tobacco use at ballparks. ADA News. 2014 [Available at]
http://www.ada.org/en/publications/ada-news/2014-archive/june/leading-
health-groups [Accessed January 24, 2015].
52. Coan L, Windsor LJ, Romito LM. Increasing tobacco intervention strategies
by oral health practitioners in Indiana. J Dent Hyg. 2015;89(3):190–201.
53. Employer Obligations after Exposure Incidents OSHA: Introduction: A
Guide to Employer Obligations. American Dental Association: Chicago,
IL; 2014 [Available at] http://www.ada.org/en/science-research/osha-
standard-of-occupational-exposure-to-bloodbor [Accessed January 24,
2015].
54. Kelsch NB. Five moments of hand hygiene in dentistry. RDH. 2013;33(10)
[online; Available at] http://www.rdhmag.com/articles/print/volume-
33/issue-10/columns/five-moments-of-hand-hygiene-in-dentistry.html
[Accessed September 17, 2015].
55. Williams J. ADA joins AHA, CDC and other health organizations in Million
Hearts initiative. ADA News. 2012 [Available at]
http://www.ada.org/en/publications/ada-news/2012-archive/august/ada-
joins-aha-cdc-and-other-health-organizations-in-million-hearts-initiative
[Accessed January 24, 2015].
56. Pera M. Oral Health-Total Health: Know the Connection (ADHA Fact Sheet).
American Dental Hygienists' Association: Chicago, IL; 2015 [n.d. Available
at] https://www.adha.org/resources-docs/7228_Oral_Health_Total.pdf
[Accessed January 24].
57. Access to Dental Care Summit Proceedings. American Dental Association:
Chicago, IL; 2009 [Available at] http://www.ada.org/en/public-
programs/action-for-dental-health/access-to-care/2009-access-to-dental-
care-summit [Accessed January 24, 2015].
58. Action for Dental Health Fact Sheet. American Dental Association: Chicago,
IL; 2013 [Available at]
http://www.ada.org/~/media/ADA/Public%20Programs/Files/Fact_Sheet__Action_for
[Accessed January 24, 2015].
59. Palmer C. ADA delivers Action for Dental Health report to Congress. ADA
News. 2014 [Available at] http://www.ada.org/en/publications/ada-
news/2014-archive/may/ada-delivers-action-for-dental-health-report-to-
congress [Accessed January 24, 2015].
60. Crozier S. ADA Long-term Care Dental Campaign aims to reduce barriers
to care. ADA News. 2014 [Available at]
http://www.ada.org/en/publications/ada-news/2014-archive/november/ada-
long-term-dental-campaign-aims-to-reduce-barriers-to-care [Accessed
January 24, 2015].
61. Dentistry in Long-Term Care Course. American Dental Association, ADA
Center for Professional Success: Chicago, IL; 2014 [Available at]
http://success.ada.org/en/dentistry-in-long-term-care-course?
nav=ltc_rotator [Accessed January 24, 2015].
62. State Oral Health Infrastructure and Capacity: Reflecting on Progress and
Charting the Future. Association of State and Territorial Dental Directors;
2012 [Available at] http://www.astdd.org/publications/ [(Infrastructure
Enhancement Project). Accessed January 29, 2015].
63. Interprofessional Education Collaborative Expert Panel. Core Competencies
for Interprofessional Collaborative Practice: Report of an Expert Panel.
Interprofessional Education Collaborative: Washington, DC; 2011
[Available at] http://www.aacn.nche.edu/education-resources/ipecreport.pdf
[Accessed February 7, 2015].
64. Access to Care Position Paper. American Dental Hygienists' Association:
Chicago, IL; 2001 [Available at] http://www.adha.org/ [Accessed January
24, 2015].
65. Dental Hygiene Workforce Models. Chicago, IL: American Dental
Hygienists' Association; n.d. Available at :
<http://www.adha.org/workforce-models-adhp>; [Accessed January 25,
2015].
66. Lyle DM, Malvitz DM, Nathe C. Processes and perspectives: The work of
ADHA's Task Force on the Advanced Dental Hygiene Practitioner (ADHP).
J Dent Hyg. 2009;83(1):45.
67. American Dental Hygienists' Association Supports Increased Access to
Care, Use of Dental Hygienists and Mid-Level Providers to Help Deliver
Dental Services (press release). American Dental Hygienists' Association:
Chicago, IL; 2014 [Available at] http://www.adha.org/adha-press-releases/
[Accessed January 24, 2015].
68. Direct Access (Chart & Maps). American Dental Hygienists' Association:
Chicago, IL; 2014 [Available at] http://www.adha.org/direct-access
[Accessed January 24, 2015].
69. The Minnesota Story: How Advocates Secured the First State Law of Its
Kind Expanding Children's Access to Dental Care. The Pew Charitable
Trusts: Philadelphia, PA; 2010 [Available at]
http://www.pewtrusts.org/en/research-and-analysis/reports/2010/09/20/the-
minnesota-story-how-advocates-secured-the-first-state-law-of-its-kind-
expanding-childrens-access-to-dental-care [Accessed January 24, 2015].
70. Pew Commends Maine for Authorizing Dental Hygiene Therapists. Pew
Charitable Trusts: Philadelphia, PA; 2014 [Available at]
http://www.pewtrusts.org/en/about/news-room/press-
releases/2014/04/29/pew-commends-maine-for-authorizing-dental-
hygiene-therapists [Accessed January 25, 2015].
71. Delinger J, Gadbury-Amyot CC, Mitchell TV, et al. A qualitative study of
extended care permit dental hygienists in Kansas. J Dent Hyg. 2014;88:160.
72. Myers JB, Gadbury-Amyot CC, VanNess C, et al. Perceptions of Kansas
extended care permit dental hygienists' impact on dental care. J Dent Hyg.
2014;88:364.
73. Professional Roles of the Dental Hygienist. American Dental Hygienists'
Association, doc 73213. [Available at] www.adha.org [Accessed January 25,
2015].
74. U.S. Department of Health and Human Services, Health Resources and
Services Administration, Transforming Dental Hygiene Education, Proud
Past, Unlimited Future: Proceedings of a Symposium. U.S. Department of
Health and Human Services: Washington, DC; 2014 [Available at]
http://www.hrsa.gov/publichealth/clinical/oralhealth/transformingdentalhygiene.pdf
[Accessed January 28, 2015].
75. One Year Later, Symposium Outcomes Continue to Drive Change in Dental
Hygiene Profession (press release). American Dental Hygienists'
Association: Chicago, IL; 2014 [Available at] http://www.adha.org/adha-
press-releases [Accessed January 28, 2015].
76. Core Competencies for Graduate Dental Hygiene Education. American
Dental Education Association; 2011 [Available at] www.adea.org [Accessed
January 25, 2015].
77. Stolberg RL, Brickle CM, Darby MM. Development and status of the
advanced dental hygiene practitioner. J Dent Hyg. 2011;85(2):83.
78. Vannah CE, McComas M, Taverna M, et al. Educational deficiencies
recognized by independent practice dental hygienists and their suggestions
for change. J Dent Hyg. 2014;88:373.
Additional Resources
Association of State & Territorial Dental Directors.
www.astdd.org.
Department of Health and Human Services.
www.hhs.gov.
Office of the Surgeon General.
www.surgeongeneral.gov/library.
C H AP T E R 2
Careers in Public Health for the Dental
Hygienist
Christine French Beatty RDH, MS, PhD, Charlene B. Dickinson RDH, BSDH, MS
OBJECTIVES
1. List and explain public health career options for dental hygienists.
2. Discuss public health careers as a means of addressing the problem of access to
oral health care.
3. Compare and contrast various alternative oral health careers in alternative
practice settings.
4. Discuss levels of supervision and reimbursement regulatory changes in
alternative practice settings.
5. Identify and describe various careers to do with alternative workforce models,
as well as define educational requirements for each.
6. Discuss the concept of interprofessional collaborative practice (ICP) in public
health practice and provide examples.
7. Discuss the disconnect between oral health care and overall health care; discuss
the future of ICP in oral health care.
8. Identify and describe specific careers categorized by the American Dental
Hygienists' Association's (ADHA) designated roles of the dental hygienist;
describe the relation of public health to the ADHA's designated roles of the dental
hygienist.
Opening Statements: Career Possibilities
• Public health hygienist at a local health department
• Statewide coordinator for a school-based fluoride varnish program
• Dental hygienist at a Veterans Affairs hospital
• Dental hygienist working with a state migrant farm worker program
• Dental hygienist at a state correctional facility
• State dental director in a state health department
• Dental hygienist coordinating oral health programs with a university community
outreach department
• Dental health educator with a school system
• Dental hygienist managing a dental sealant team operated by a nonprofit
organization
• Dental hygienist as an administrator of a U.S. Department of Health and Human
Services (DHHS) federal health program
• Dental hygienist contracting for service in a nursing home
• Consultant to a Head Start program
• Dental hygienist U.S. Public Health Service (USPHS) officer with an Indian Health
Service (IHS) clinic
• Dental clinic director in a community-based health center
• Advanced dental therapist with a rural dental public health mobile clinic
• Coordinator of a children's oral health coalition operated by a metropolitan
children's hospital
• Chief officer of a nonprofit dental organization
• Coordinator of a community-based program operated by a for-profit corporation
Community Oral Health Practice as a Career
Dr. Alfred C. Fones is credited with initiating the development of the profession of
dental hygiene and establishing the original public health focus of the profession. In
1906 he trained the first dental hygienist, Irene Newman, and in 1913, he started the
Fones School of Dental Hygiene in Bridgeport, Connecticut. Dr. Fones developed a
curriculum for dental hygienists who began work within the Bridgeport Public
School system (Figure 2-1). The first dental hygienists were trained to work in the
community (Figure 2-2), providing education and preventive services in their role
as an advocate for dental public health.1 In reporting outcomes of the utilization of
dental hygienists in the Connecticut public schools, Dr. Fones also spoke of a
connection of oral health to systemic health and the dental hygienist's role in
addressing systemic conditions of the schoolchildren by implementing oral health
preventive programs.2
FIG 2-1 The first dental hygienists provided oral health education in public schools.
Pictured here are dental hygiene students teaching brushing to children who were
seated at their desks in the classroom. The dental hygiene student at the front of the
classroom demonstrated while other students circulated to provide hands-on
assistance as the children practiced the correct brushing technique. (Photograph
courtesy University of Bridgeport, Fones School of Dental Hygiene.)
FIG 2-2 The first dental hygienists provided dental hygiene services in community
settings. (Copyright University of Rochester Libraries. All Rights Reserved.)
Public health careers for dental hygienists now run the gamut from high-level
administrative posts to providing oral hygiene care for older adult residents in a
nursing home or providing oral health education for school-age children.3 These
positions are located in a variety of settings from federal government programs to
local community programs or entrepreneurial positions self-created to provide
programs to underserved populations. Some dental hygienists in public health have
an associate's degree or certificate, or a bachelor's, a master's, or a doctoral
degree.4 Many dental hygienists with advanced degrees working in public health
began their public health careers with the minimum level of education. They chose
to continue their education as their interests developed, their challenges expanded,
and their desire grew to do more for the oral health of their community. A career in
community oral health practice offers a variety of rewarding experiences that tend
to feed the desire to make a difference in the oral health of all people and provide
job satisfaction for dental hygienists.5
This career chapter has been placed in the beginning of the textbook to allow you
to make a connection with the role you might play in performing the functions
discussed in the successive chapters. In private practice the individual patient is your
focus; in public health the community is your patient. Your responsibilities will
advance beyond individual clinical care, although in many positions individual care
still remains a very important function. Public health takes you into the realm of
program development, implementation, and evaluation; presents a chance to work
with various populations, other professionals, agencies, financing mechanisms, and
rules and regulations; provides a variety of day-to-day activities that reflect the
diverse roles of the dental hygienist; and offers an opportunity for career
advancement to higher level administrative and management positions.3
Future Trends for Dental Hygienists in
Public Health
Potential of the Dental Hygienist to Address the
Access to Oral Health Care Problem
Chapter 1 introduced the issues of continuing high prevalence of oral diseases in the
population, inadequate access to oral health care, profound disparities among
specific population groups in oral health status and access to oral health care, and
the problem of dental disease as a chronic problem among low-income populations.
Also presented were ways that federal agencies, state governments, and oral health
professional organizations are addressing these gaps in access to oral health care
through legislation, policy development, and refocusing of programs.
Some of the actions resulting from these processes relate to dental hygiene
careers, thus laying a foundation for this chapter (see Guiding Principles). Several
of these achievements are concerned with expanding and creating new roles for the
dental hygienist in the oral health workforce. This includes the new concept of a
midlevel provider in dentistry.6 Future initiatives such as those described in Chapter
1 and associated follow-up strategies and action plans are expected to increase the
demand for dental hygienists working in community oral health practice.
G ui di ng Pri nci pl es
Summary of Actions Resulting from Recent Government and
Professional Oral Health Initiatives
• Extending educational loans and loan forgiveness for oral health professionals
• Creating tax credits for providers
ADHA has advocated for issues related to dental public health7 (Box 2-1). Among
them are several issues that involve the increased utilization of dental hygienists in
public health practice to address the unmet needs of underserved populations. These
groups include low-income children, pregnant women, older adults, and persons
who are developmentally, physically, mentally, or medically compromised. Dental
hygienists have demonstrated their ability to reach these disenfranchised groups.8
Research has demonstrated that fully utilizing dental hygienists by expanding their
professional practice environment and reducing supervision requirements improves
access to oral health services, utilization of oral health services, and oral health
outcomes.8
ox 2-1
B
Publ i c H eal th Issues A dvocated for by the
A DH A
• Inclusion of oral health content in existing programs to prevent disease, promote
health, and solve health problems among underserved groups such as low-
income children, pregnant women, elders, and persons who are developmentally,
physically, mentally, or medically challenged
• Development of community-based comprehensive oral health programs
FIG 2-3 A dental hygienist can provide dental hygiene treatment to homebound
patients in their homes. (Photograph courtesy Charlene Dickinson.)
FIG 2-4 A, A mobile dental van operated by GreeneHealth in partnership with
Columbia Memorial Hospital provides primary preventive services as well as dental
examinations and x-rays, restorations, and simple extractions to children in dentally
underserved rural school districts in Columbia and Greene Counties in New York.
(Photograph courtesy Columbia Memorial Health.) B, The inside treatment area of a
mobile dental van designed for screening. Dental vans used for comprehensive
dental treatment are outfitted with a full dental unit, x-ray machine, and other
necessary equipment. (Courtesy Colgate Oral Pharmaceuticals.)
FIG 2-5 A dental hygiene student applies fluoride varnish to a preschool age child
in a school-based fluoride varnish program. (Photograph courtesy Christine French Beatty.)
There are different stages of prevention reflected in the various services provided
by oral health practitioners (Table 2-1).10 Services at the primary prevention stage
are more effective, less costly, and involve less technology than those at the stages
of secondary prevention and tertiary prevention. Often primary prevention
strategies do not require a dentist,11 thus allowing the dental hygienist to work
directly (unsupervised) with underserved populations to provide these primary
preventive services. Primary preventive services and screening, classified as
secondary prevention, are typically provided by dental hygienists in public health
programs in alternative settings.
TABLE 2-1
Stages of Prevention
Stag e of
De sc ription Oral He alth Example s
Pre ve ntion
Primary Prevents the disease before it occurs; includes health education, disease prevention, Dental prophylaxis, sealants, fluoride varnish
and health protection application, water fluoridation, oral health education
Secondary Eliminates or reduces diseases in the early stages; includes screening to detect and treat Restorations such as composites, glass ionomer,
changes before onset of symptoms to control disease progression; requires more amalgam, interim therapeutic restorations, crowns,
technology and is more costly than primary prevention nonsurgical periodontal therapy, extractions, radiation
or chemotherapy, dental and oral cancer screening
Tertiary Seeks to reduce the impact caused by a disease on the patient's function, longevity, Dentures, implants, bridge work, prostheses,
and quality of life after the disease has been treated in its acute clinical phase; limits reconstructive surgery
disability from disease in later stages and includes rehabilitation; most costly stage
and requires highly trained professionals to treat the disease
Supe rvision
De sc ription
Le ve l
Direct The dentist needs to be present, examines the patient to authoriz e the work to be performed, and checks it after.
Indirect The dentist needs to be present, generally authoriz es the work to be performed, examines the patient, either before or after work is performed,
and is available for consultation during the patient visit.
Ge ne ral The dentist needs to authoriz e the work to be completed before services but does not need to be present during treatment; the patient must be
one of record.
Direct Access The dental hygienist can provide services as he or she determines appropriate without specific authoriz ation, referred to as unsupe rvise d
prac tic e .
The ADHA defines direct access as a dental hygienist's “right to initiate treatment
based on his or her assessment of a patient's needs without the specific authorization
of a dentist, to treat the patient without the presence of a dentist, and to maintain a
provider-patient relationship.”15 Currently, 71% of states allow the public to have
direct access to the oral healthcare services of a dental hygienist, which represents a
25% increase in the last 7 years.15 Various states have different forms of direct
access, some in only certain public health settings and some for only certain
services (see Table 2-3).
TABLE 2-3
New Oral Healthcare Workforce Models in the U.S.—Current and
Proposed
Minne sota
Alaska De ntal
Advanc e d De ntal Maine De ntal Community
De ntal The rapist
Hyg ie ne Hyg ie ne De ntal He alth Midle ve l Oral He alth Prac titione r
He alth Aide (DT) 2/Advanc e d
Prac titione r
The rapist
The rapist Coordinator (MLOHP) 1
1 De ntal
(ADHP) (DHT) 1 (CDHC) 2
(DHAT) 2 The rapist
(ADT) 3
De ve lope d/Propose d Proposed by Developed by Developed by Developed by Developed by Proposed by ADHA
by American Dental Alaska Native Minnesota state Maine state American Dental
Hygienists' Tribal Health statute and rules statutes and Association
Association (ADHA) Consortium rules (ADA)
(ANTHC)
Stag e of Approved by ADHA Began to First licensed in Signed into Launched pilot in Concept applied in various models called
De ve lopme nt in 2004; educational practice in 2011 law in 2014 2009 in selected by several names in different states such
competencies Alaska in dental HPSAs in 3 as
finaliz ed in 2008; 2004 states; later Collaborative/Affiliated/Alternative/Public
first ADT expanded to 8 Health (PH)/Extended Care Practice of
educational program states; ADA focus Dental Hygiene (DH)
based on ADHP to expand to
competencies began dental HPSAs
in fall 2009 nationwide
Educ ation/Training Master's level 24-month DT—bachelor's Advanced DHT 18-month Licensed dental hygienist with various
education for training degree in DT training after training program years or hours of clinical experience in
currently licensed program through 2013; DH licensure; piloted at selected different states; bachelor's degree in some
dental hygienists administered 28-month bachelor's dental schools; states; additional education/training in
who have a by ANTHC in training program degree in DH comes from the some states
bachelor's degree partnership after 2013 (can be community, thus
with ADT—master's completed understands and is
institutions of degree in ADT; concurrently accepted by the
higher 2000 hours with DHT community
education; supervised clinical training);
comes from practice as DT 2000 hours
the supervised DT
community to clinical practice
be able to
address social
barriers to
dental care
Re g ulation/Lic e nsure Envisioned to be Certified and DT—State DT State DHT Envisioned to be Various certifications in different states
state licensed and regulated by license license certified; no
regulated, in addition the ANTHC ADT—State DT formal state
to existing DH license Community license and ADT licensure
Health Aide certification; can
Program be dually licensed
(CHAP) to practice DH as
well
Prac tic e Se tting s Community and PH Community Primarily settings Schools; Piloted in PH Private dental practice or clinic; various
settings, possibly health center that serve low- healthcare clinics in PH facilities, programs, and settings that
private practice clinics in income, facilities; underserved rural, serve low-income, uninsured, and
remote, rural uninsured, and clinical urban, and Native underserved patients
Alaskan underserved facilities and American
villages patients, or are various PH communities;
located in programs that currently in PH
designated public serve clinics in dental
health or private underserved HPSAs; can be
sector dental patients and adapted to other
HPSAs clients settings
Supe rvision Collaborative Remote DT—General or Direct Onsite or general Unsupervised; must have on file with the
arrangement general indirect supervision; supervision, state dental board a collaborative
envisioned with supervision; supervision written practice depending on agreement with a dentist for consultation,
strong dentist depending on agreement with service referral, and emergencies; in some states
communication and presence not service; dentist dentist patient must have a current referral from
referral networks; required; use presence required required, a dentist or physician
presence of a dentist of teledentistry for complicated including
not required; use of to partner procedures but not standing orders
teledentistry to with dentist, for preventive
partner with a dentist including real- ADT—Presence
time video and of a dentist not
radiologic required for DT
oversight services; general
remote
supervision with
teledentistry for
others
Collaborative
management
agreement with
dentist required
for both DT and
ADT
Pre ve ntive Sc ope of Oral health and Oral health DT: Assessments Oral health and Traditional scope of DH practice
Prac tic e nutrition and Oral health and Radiographs nutrition authoriz ed in that state
education nutrition nutrition Full range of education
Full range of education education preventive Sealant
preventive Sealant Sealant placement services placement
services, including placement Fluoride within scope Fluoride
complete Fluoride varnishes of DH treatments
prophylaxis, treatments Coronal polishing practice Coronal
sealant placement, Coronal Oral cancer polishing
fluoride polishing screenings Scaling for type I
treatments, caries Prophylaxis Caries risk periodontal
risk assessment, Expose assessment patients
oral cancer radiographs Expose Collection of
screenings radiographs diagnostic data
Radiographs ADT:
Advanced disease DT scope without
prevention and onsite
management supervision
therapies (e.g.,
chemotherapeutics)
Pe riodontal Sc ope of Nonsurgical N/A DT: N/A Traditional N/A Traditional scope of DH practice
Prac tic e periodontal therapy ADT: N/A scope of DH authoriz ed in the state
practice
authoriz ed in
the state
Re storative Sc ope of Preparation and Placement of DT: Cavity Palliative Scope of DH practice authoriz ed in the
Prac tic e restoration of restorations Restorations of preparations temporiz ation state
primary and in primary primary and and (with hand
permanent teeth and permanent teeth restorations instrumentation
Placement of permanent Placement of Simple only)
temporary teeth preformed extractions Placement of
restorations Placement of crowns Stainless steel temporary
Placement of preformed Placement of and aesthetic restorations
preformed crowns crowns temporary anterior
Temporary Pulpotomies crowns crowns
recementation of Direct/indirect Space
restorations pulp capping maintainers
Pulp capping in Pulpotomies on
primary and primary teeth
permanent teeth Atraumatic
Pulpotomies on restorative
primary teeth therapy
Simple repairs and ADT:
adjustments on DT scope without
removable onsite
prosthetic supervision
appliances
Additional Sc ope of Uncomplicated Nonsurgical DT: Local Advocacy role to Scope of DH practice authoriz ed in the
Prac tic e extractions of extractions Extractions of anesthesia address social, state
primary and of primary primary teeth and nitrous environmental, Dental referrals for care beyond the scope
permanent teeth and Limited oxide and health of the practice
Place and remove permanent medication Management literacy barriers
sutures teeth prescriptions of dental to dental
Dental referrals for Dental ADT: trauma utiliz ation
care beyond the referrals for DT scope without Suturing Interviewing and
scope of the ADHP care beyond onsite Nonsurgical counseling to
the scope of supervision extractions enroll clients in
the DHAT Oral evaluation of primary government-
and assessment and funded dental
Treatment plan permanent programs and
formulation teeth provide social
Nonsurgical Limited support
extraction of medication
periodontally prescriptions
involved, Supervise
mobile dental
permanent teeth assistants
and dental
hygienists
Dental
referrals for
care beyond
the scope of
the DHT
1
Dental hygiene–based dental therapist/midlevel provider
2
Nondental hygiene–based dental therapist/midlevel provider
3
Dental hygiene–based and nondental hygiene–based dental therapist/midlevel provider
Specific examples of changes in state regulations around the scope of practice for
dental hygienists can help you understand the variety of direct access arrangements
and the impact of direct access. In New Mexico dental hygienists are allowed to
practice in certain settings without the oversight of a dentist through a collaborative
practice agreement with a dentist or group of consulting dentists. In Washington
state dental hygienists may practice unsupervised in hospitals, nursing homes, home
health agencies, group homes, state institutions, and public health facilities provided
the hygienist refers to the dentist for treatment and meets a requirement of clinical
experience. Colorado is one of the states that allows dental hygienists to practice
without supervision in all settings and allows licensed dental hygienists to own a
dental hygiene practice.
For the purpose of funding for public health programs, the Health Resources
and Services Administration (HRSA) defines a dental health professional
shortage area (dental HPSA) based on the following: 1) The available workforce
of dental professionals and of community health departments and clinics is
inadequate in relation to the population size; 2) the population group has access
barriers that prevent their use of the area's dental providers; or 3) the federal or
state correctional, public health, or nonprofit private facility has inadequate capacity
to meet the needs of the area or population served16 (see Chapter 5). Because of the
shortage of dentists in these areas, dental HPSAs are particularly in need of
regulatory changes that allow dental hygienists and dental therapists to have direct
access. Thus, the call to relax supervision regulations to help alleviate the access to
care problem is coming from public health professional organizations, government
agencies, and the dental hygiene profession. In a written statement to the
Commission on Dental Accreditation, the Federal Trade Commission declared that
the ability of qualified nondentist oral healthcare providers “to work without a
dentist on the premises is critical to their ability to increase the availability of dental
care in areas where dentists are scarce or unavailable.”17
Inadequate access to health care caused by professional shortages and geographic
and financial barriers prevents people from attaining improved health status and
improved quality of life. Realizing the need for reaching these underserved
populations, the dental profession is initiating preventive programs conducted by
dental hygienists in many states. These programs also require regulatory changes to
allow dental hygienists' direct access.
Some dental hygienists initially volunteer to provide services in alternative
settings. However, more and more have found creative ways to be reimbursed for
working in these settings. Writing grants, seeking school board funds, collecting
Medicaid payments through an accepted provider, or contracting with a facility in
states that allow it are a few of the innovative reimbursement plans currently being
used. With less restrictive dental hygiene supervision and an increased number of
dental hygienists seeking public health careers, changes are being made in
restrictive regulations that prevent dental hygienists from receiving direct
reimbursement from third-party payers such as Medicaid or private dental
insurers.18 ADHA also has advocated for these changes and has provided dental
hygienists with resources to pursue direct insurance reimbursement.19,20 Currently
16 states allow dental hygienists to receive direct Medicaid reimbursement.18
These data for states that have achieved regulatory changes for dental hygiene
supervision and direct reimbursement change continually as more states experience
related changes to the laws and regulatory policies. For current information by state
on direct access, supervision levels for specific dental hygiene services, and
Medicaid reimbursement, view the ADHA websites http://www.adha.org/practice-
issues and http://www.adha.org/reimbursement.
Dental Therapist
More than 50 countries worldwide have developed dental therapist programs to
meet the dental needs of the people in their countries.23 In 1921 a dental therapist
program was first introduced in New Zealand. At that time the dental therapist was
called the dental nurse.24
Services provided by the dental therapist vary by country. The scope of practice
in New Zealand for children and adolescents up to age 18 includes assessment,
diagnosis, primary preventive procedures including scaling and polishing, taking of
impressions for constructing and fitting mouthguards, local anesthesia, preparing
teeth for and placing basic restorative procedures and stainless steel crowns,
pulpotomies, extraction of primary teeth, oral health education and promotion, and
referrals as needed, all under the remote general supervision of collaborating
dentists.25 For adults age 18 and over, dental therapists provide similar services in a
team situation under direct supervision.25 Dental therapists in New Zealand are
required to complete a bachelor's degree in an approved oral health major and a
dental therapy training program that results in certification; additional credentials
are required for dental therapists working with adults age 18 and older.26
Alaska.
The dental health aide therapist (DHAT) was the first dental therapist model in the
U.S., implemented in 2004 by the Alaska Native Tribal Health Consortium
(ANTHC).27 The DHAT is authorized by the Alaska tribal government rather than
the state government, so they can provide dental care only for the Alaska native
population on tribal lands. Table 2-3 provides a complete description of the scope
of practice, required education and/or training, certification or licensure,
supervision, and practice settings for the DHAT 28 and other workforce models.
DHATs provide services to the most isolated rural regions of Alaska, in which
little to no care was previously provided. To improve access to care in these rural
communities, candidates with strong ties to rural areas of Alaska are selected for the
DHAT program.28 Nearly 80% of DHATs return to their home regions to practice,
and the program has an 81% retention rate.28 Over the 10 years of existence of the
programs, DHATs have increased access to preventive and restorative oral health
care for over 40,000 citizens of Alaska's remote, rural communities.28 The DHAT
program has proven to be economically viable and sustainable,28 and a 2-year
intensive evaluation by the W.K. Kellogg Foundation demonstrated that Alaska's
DHATs provide safe, competent, and appropriate dental care.29
Minnesota.
Providers similar to the DHAT are now legally allowed to practice in Minnesota and
Maine, and 15 other states are pursuing comparable models.30 In 2011 Minnesota
began to license two levels of dental therapy practice: the dental therapist (DT) and
the advanced dental therapist (ADT),31 both presented in detail in Table 2-3.
The DT has a bachelor's or master's degree in dental therapy, and the ADT has a
master's degree in advanced dental therapy.31 Patterned after the Advanced Dental
Hygiene Practitioner (ADHP) model (see later section), the first ADT master's
program (MSADT) required a bachelor's degree in dental hygiene for entry to the
program.32 This MSADT curriculum had a focus on team-based healthcare delivery,
clinical practice, leadership, and inter-professional education and practice.33 A
newer Master of Dental Therapy program does not require an active dental hygiene
license33 and allows entry with any Bachelor of Science or Bachelor of Arts.34
Both DTs and ADTs have a license to practice as dental therapists with a scope of
practice similar to the Alaska DHAT—providing basic preventive services, limited
restorative services, extractions of primary teeth, and limited medication
prescriptions. In addition, the ADT can evaluate, assess, and plan treatment; perform
nonsurgical extractions of periodontally involved, mobile permanent teeth; and
administer all services of a DT without the requirement of onsite supervision.31
DTs and ADTs are required to enter into a collaborative management agreement
with a dentist, which governs the delegation of duties. The ADT collaborative
management agreement must include additional specific written protocols to direct
situations in which the ADT encounters a patient who requires treatment that exceeds
the authorized scope of practice of the ADT.35
By law, Minnesota dental therapists primarily provide care in settings serving
predominantly low-income, uninsured, and underserved patients, or in areas
designated as dental HPSAs.31 In 2014 the Minnesota Board of Dentistry presented a
favorable report to the legislature after conducting an evaluation of the impact of
dental therapists on the delivery of and access to dental services in Minnesota31 (Box
2-2).
ox 2-2
B
Resul ts of an Eval uati on of Dental T herapi sts'
Impact i n Mi nnesota
1. The dental therapy workforce is growing and appears to be fulfilling statutory
intent by serving predominantly low-income, uninsured, and underserved
patients.
3. Clinics employing dental therapists are seeing more new patients, and most of
these patients are public program enrollees or from underserved communities.
4. Dental therapists have made it possible for clinics to decrease travel time and wait
times for some patients, thus increasing access.
6. Savings from the lower costs of dental therapists are making it more possible for
clinics to expand capacity to see public program and underserved patients.
8. Most clinics employing dental therapists for at least a year are considering hiring
additional dental therapists.
9. Dental therapists offer potential for reducing unnecessary emergency room visits
for noninjury dental conditions.
Maine.
The newest dental therapist is the dental hygiene therapist (DHT) in Maine, signed
into law in 201336 (see Table 2-3). The DHT is licensed as a dental hygiene therapist
and as a dental hygienist. The DHT differs from other dental therapists in that a
license to practice dental hygiene is required before training as a dental therapist. A
bachelor's degree in dental hygiene is required, which, if necessary, can be
completed concurrently with the DHT training.37 The DHT scope of practice is
similar to the Alaska DHAT and Minnesota DT, which is added to the dental hygiene
scope of practice. The dental therapy functions are practiced under direct
supervision and require a written practice agreement with a dentist, including
standing orders.
Table 2-3 highlights the practice settings and supervision for these various dental
therapists, showing that they work in several different circumstances. One is under
remote general supervision in community settings where there is no dentist
available, taking dental care to an otherwise unserved population. Another is in
public health and community-based dental clinics as a member of the dental team
alongside the dentist. Dental therapists also work in private dental offices as a way
to expand the capacity of the private practice of dentistry, which is the backbone of
dental services delivery in this country. An evaluation of the impact of dental
therapists revealed that, in rural private dental practices, the addition of a dental
therapist increased new patients by up to 38%, and the share of Medicaid patients
was increased by up to 50%.30
G ui di ng Pri nci pl es
Examples of Interprofessional Collaborative Practice
• A dental hygienist with an IHS community health clinic collaborates with the
medical staff to develop a tobacco cessation program that links oral health and
overall health effects of using tobacco.
• A dental hygienist and public health nutritionist in a local health department work
together to develop a nutritional education program that links dietary choices to
oral health issues and obesity for use with at-risk patients.
• A public health hygienist works with other staff in a local health department to
develop programs and educational materials for individuals served in the well-
baby clinic and Women, Infants, and Children (WIC) program.
Interprofessional resources have been developed to assist with ICP. One example
is the Bright Futures Project, a national health promotion initiative launched by
HRSA's Maternal and Child Health Bureau. This online program provides
comprehensive health information and resources, including oral health guidelines
from pregnancy to adolescence, that can be used by public health teams to achieve
optimal health for these priority populations.54 Another example is a collaborative
federal and state level initiative, Oral Health Resources for Health Professionals,
that has made available oral health information geared to clinical medical
practitioners. This project provides downloadable oral health educational materials
in various formats, patient education materials, and reference materials with palm
application for easy access.55 One more example is Smiles for Life, an online source
of educational information for health professionals produced by the Society of
Teachers for Family Medicine “to ensure the integration of oral health and primary
care.”56 This resource includes a curriculum that consists of eight modules covering
core areas of oral health relevant to medical and oral health professionals and
including assessments of user competencies for free continuing education credit.
FIG 2-6 Dental hygiene and medical students collaborate during Basic Screening
Survey oral exams and follow-up referrals as part of a school-based
interprofessional education project in a culturally diverse school; the project also
involves nursing, speech, and audiology students. (Photograph courtesy Schelli Stedke.)
In 2013 over 100 oral health stakeholders gathered to consider the future of the
dental hygiene profession in the healthcare system. ADHA was a major sponsor of,
and participant in, this collaborative conference, Transforming Dental Hygiene
Education: Proud Past, Unlimited Future, which called for a transformation of the
dental hygiene profession in light of the Affordable Care Act passed in 2010 and the
resulting changes to the healthcare system.65 Key concepts addressed by the
conference included the need to do the following:
• Increase access to oral health care
• Continue emphasizing the oral-systemic link
• Use an ICP approach to oral healthcare delivery
• Make changes in the dental hygiene curriculum relative to ICP and the skills
necessary to fill the dental hygiene professional roles in addition to clinician
• Adopt innovative collaboration models for dental hygiene practice
• Partner with multiple stakeholders to achieve desired goals
ADHA followed up after the conference by redirecting the association's strategic
plan based on a change in core ideology focused on “lead[ing] the transformation
of the dental hygiene profession to improve the public's oral and overall health.”66
The resulting new vision of ADHA is “to integrate dental hygienists into the
healthcare delivery system as essential primary care providers to expand access to
oral health care.” ADHA is advocating for an IPE approach to dental hygiene
education to drive the shift toward ICP and is leading an effort to establish pilot IPE
dental hygiene educational programs.
These various activities have resulted in an increasing interest in ICP among
primary medical care providers, oral health practitioners, and healthcare
management professionals in the private and nonprofit sectors. Some examples of
results of this interest include the following:
• In many states medical personnel in pediatric offices and clinics apply fluoride
varnish to their infant and toddler patients' teeth on a routine basis.65
• Administrators of nonprofit and government entities have contrasted different
versions of medical-dental integration in healthcare delivery to determine the most
effective model.67
• A pilot project in Colorado located a dental hygienist in the pediatrician's office to
add an oral health component to well-baby visits.65
• A dental hygienist who was highlighted in Access magazine is employed in a
private medical practice, partnering with the physician to address the oral-systemic
link with patients.68
It is anticipated that the expected growth of ICP will result in improved oral health
care. In addition, this increased emphasis on ICP is projected to bring about changes
in the educational and practice delivery systems for oral healthcare practitioners.
These changes will require, and result in, a greater incorporation of public health
principles, practices, and priorities into the practice of dentistry and dental hygiene
in the private and nonprofit sectors.
Careers in Public Health
Public health is integrated at some level into all dental hygiene careers.69 The ADHA
has described various career options for dental hygienists, some of which are public
health careers and some of which are not.70 Regardless of the career option public
health is embedded because all dental hygiene careers relate to improving the oral
health of the public. This relationship of public health to the various careers
presented by ADHA is described in Table 2-4. The dental hygienist who has a
concern for improving and protecting the oral health of the public can make a
difference regardless of the dental hygiene career selected.
TABLE 2-4
Relationship of Public Health to Various Dental Hygiene Careers
Care e r De sc ription Re late d to De ntal Public He alth Example s of Public He alth–Re late d Ac tivitie s
Administrator/Manager Creates and directs dental public health programs • Directs the oral health unit of a state health
department
• Coordinates a sealant program in the local school
district sponsored by a faith-based community
clinic
• Coordinates a community oral health program for
a for-profit corporation
Advocate Supports, recommends, and/or campaigns for a specific cause or policy to • Participates in a community water fluoridation
improve the oral health of the public campaign
• Participates in lobbying efforts to change the state
dental practice act to authoriz e the practice of
dental hygiene therapy in the state
Clinician Provides clinical care in a variety of settings, in line with public health • Provides clinical services in a dental clinic that is
priorities, objectives, recommendations, and best practices integrated into a community health center in a
dental HPSA
• Delivers clinical services to Medicaid patients in a
private practice
Corporate Supports the oral health industry through the sale of products and services • Presents educational programs on fluorides and
and the education of oral health professionals regarding those products and other preventive and therapeutic products to
services with the end goal of improving the health of the public student and practicing dental hygienists to enhance
their use in dental public health programs
• Contributes financially to dental public health
programs; underwrites or donates supplies to a
specific public health project
Educator • Educates about and promotes oral health to patients and various target • Educates patients in a diabetes program in a
groups to improve the oral health of the public community health center about the association of
• Educates dental hygiene students and practicing dental hygienists about oral health and diabetes
dental public health topics • Conducts oral health educational programs in the
community on topics that are relevant to the
specific population
• Dental hygiene program professor teaching
Community Oral Health (COH) and coordinating
COH service learning
Entrepreneur Uses imagination and creativity to initiate or finance commercial enterprises • Establishes a business to take dental hygiene care
that will provide oral health services or programming for underserved to rural schools
populations • Starts a nonprofit to build a new dental clinic in
the community that will serve low-income,
uninsured, and underserved clients
Researcher Conducts research related to health and disease within a population, • Conducts a comprehensive oral health community
preventive procedures, dental utiliz ation, public health infrastructure, needs assessment to be able to plan relevant
assessment of population needs, program evaluation, workforce models, programs
public health outcomes, and other dental public health topics • Collects data on best practices for program
planning
• Collects data on program outcomes to evaluate the
success of a school-based sealant program
Dental hygienists who pursue a public health career will be associated with one of
a variety of settings that is geared to the population that is unable to access dental
care through private dental offices. These various settings make up what is
commonly referred to in public health circles as the safety net system of providers
that deliver care for people with no or limited insurance.71 Dental safety net
providers are the clinics and facilities that deliver a significant level of oral health
care to uninsured, Medicaid, and other vulnerable populations. This includes private
facilities that offer pro bono services, dental and dental hygiene school clinics, and
hospital emergency rooms that won't turn away Medicaid beneficiaries and patients
who are in pain and can't afford care. Because this default system is a patchwork of
institutions, clinics, and oral healthcare providers supported by a variety of
sometimes dissimilar financing options, it is not uniform from one community to
another and is not always financially secure. It is affected by the general political
environment, the number of uninsured people, and the types of oral healthcare
institutions in the area.71 Dental hygienists working in public health settings are part
of this dental safety net system.
Regardless of the setting, dental hygienists in public health positions use a variety
of skills to positively impact their communities. The ADHA has presented these
skills in relation to professional roles, with public health as a common thread
through all of them (Figure 2-7).72 In this section, these roles of the dental hygienist
are described as they apply to public health. Most public health positions require a
combination of skills defined in these multiple roles. Positions held by dental
hygienists in alternative practice settings are included to illustrate the variety of
career possibilities and inspire the reader.
FIG 2-7 American Dental Hygienists' Association's (ADHA) Roles of the Dental
Hygienist.
To seek employment in a public health setting, a dental hygienist can research
available positions with federal agencies, state and local health departments,
nonprofit organizations, hospitals, and corporations. Much of this search can be
accomplished on the web. In addition, networking with other oral health
professionals in public health positions can be beneficial. Common sources of
available public health positions with government agencies are USAJOBS at
www.usajobs.gov for federal postings and Government Jobs at
www.governmentjobs.com for government jobs at all levels. Positions in federally
funded community health centers are posted at the local and state levels where the
centers are located. Table 2-5 presents some of the primary federal agencies and
programs that are significant employers of dental hygienists.
TABLE 2-5
Selected Public Health Career Opportunities for Dental Hygienists in
Federal Agencies and Programs
Clinician
In the familiar role of clinician, the public health dental hygienist provides
evidence-based clinical services to priority populations, including assessment of
oral health conditions; delivery of preventive, periodontal, and restorative care
within the regulated scope of practice for the state; and evaluation of treatment
outcomes. The characteristics, values, and prevalent oral diseases of lower
socioeconomic status (SES) groups that seek care in public health clinics can
influence the utilization of dental services offered in these clinics. Additional skills
needed by the public health–oriented clinician include the ability to assess the
perceived dental needs of the patient and to recognize the social and economic
barriers to successful oral health outcomes (see Chapter 4). Immigrant families new
to a community present language challenges and the need for cultural competency
skills (see Chapters 8 and 10).
A public health clinician may treat many types of patients during a given week,
providing care to infants, children, adults, and older adults. For example, a dental
hygienist may place varnish on infants' teeth during a nutrition clinic one day. On
another day he or she may provide periodontal treatment to pregnant women
coming to the health department for prenatal care visits. Another day the hygienist
may go to a local elementary school to participate in a survey as part of an ongoing
assessment of the prevalence of dental disease in the state, and follow up with the
required referral component of the screening. Another part of the clinician's job
may be to visit a long-term care facility on a monthly basis to provide clinical care
to bedridden residents.
Clinicians in public health learn to be flexible with their dental environment.
Clinical facilities may be in local health departments, in stationary school dental
trailers, or in mobile dental vans that can be moved to multiple locations within a
geographic area. Also, a clinical facility may consist of portable dental equipment
moved from one school or facility to another. Clinical dental hygiene positions are
available in many community settings; for example, health department clinics,
community health centers, hospitals, nursing homes, residential facilities for older
adults, and prison facilities. Because these facilities also provide medical care,
interprofessional practice is characteristic of the clinician role in public health.
Some locations offer the additional challenges of complex medical histories and
patients with physical or mental disabilities.
Federal and state agencies have established clinical dental hygiene positions (e.g.,
the IHS, the National Health Service Corps, Community and Migrant Health
Programs, the USPHS, military bases, or state health departments). In addition, local
clinical care programs may be supported by nonprofit volunteer or faith-based
organizations. Many of these positions involve interprofessional collaboration by
nature of the setting. As the economy fluctuates the number of public health dental
programs and clinics will vary. In nonprofit and publicly funded programs
clinicians must be accountable with the most cost-effective means of providing
quality dental services to the most people.
Educational requirements for a public health clinical position may vary from an
associate's degree with 1 year of experience to a bachelor's degree, depending on
the requirements of the agency. Some positions require course work in business and
public health. Additional certification may be required, depending on the workforce
models authorized in the state. If the public health job requires more administrative
or management skills (see later section), an employer may require a master's
degree.
The clinician role in public health can require a variety of skills depending on the
specific expectations of the position and the population served. For example,
specialized skills may be required in assessment, treating periodontal cases,
preventive procedures, specific diseases that are prevalent in the population served,
and managing complex medically compromised patients and other special
populations.
Experience as a clinician and in various aspects of public health may be required,
depending on the position. ICP experience may be required as well.
Educator
Dental Hygiene Faculty
A dental hygienist in a faculty role may focus his or her career on teaching
community dental health/public health courses and supervising dental hygiene
students in community projects, rotations, and practicums. This educator can help
students understand how public health is integrated into all aspects of dental hygiene
practice, become aware of the segment of society that does not have access to oral
health care, and become knowledgeable of disparities in dental disease and dental
utilization and how to help solve these problems. Incorporating community
involvement and service learning (see Chapter 11) into the dental hygiene student's
experience will promote civic engagement, reinforce humanitarian ideals, build
skills in cultural competence, and influence the student's interest after graduation in
treating low-income patients in clinical practice, volunteering with community oral
health projects, or pursuing a full-time career in dental public health.
Educational requirements for dental hygiene faculty are a bachelor's or master's
degree, depending on the college and the teaching responsibilities and clinical
dental hygiene experience. Dental hygiene educators need knowledge of curriculum
development, program development, and evaluation and also need effective human
relations and communication skills. Professional practice experience in public
health would be beneficial for an educator responsible for community courses and
coordinating students' community experiences.
Corporate Educator
A third educator role is as a corporate educator (see Table 2-4). In this role the
dental hygienist is employed by industry to educate oral health professionals on the
science and appropriate use of their oral health products. Many larger companies
also have corporate educators who focus on academic relations, making
presentations to students and faculty.
Educational requirements for corporate educators vary. Usually a bachelor's or
graduate degree is required, depending on the job responsibilities. Professional
experience and other requirements will also vary according to the specific job
requirements and may parallel those of a dental hygiene educator or an
administrator/manager.
Advocate
The consumer advocate sees problems related to achieving optimal oral health and
attempts to develop a solution. As an oral health professional, the dental hygienist
can be a leader for the consumer and can be asked to be a vocal advocate for oral
health. The role of advocate may not be a full-time position but may be part of any
other professional role in the dental hygiene profession. Advocacy can take several
forms, depending on the needs of the community.
Dental hygienists will become aware of individuals or groups in the local
community that have oral health disparities and lack access to oral health care (see
Chapter 9). For example, older adults in long-term care facilities and senior living
communities may have difficulty accessing dental care because of problems with
mobility and transportation (Figure 2-8). The dental hygienist can advocate for these
individuals by representing them in seeking community resources and in
developing special programs to meet their needs. Also, by bringing such consumer
issues to the attention of local media or powerful citizens, the dental hygienist is
able to influence changes that might lead to resolution of the access problems,
ultimately improving their oral health.
FIG 2-8 Dental hygienists can advocate for community groups with special needs,
which can take several forms, depending on the needs of the community. (©
iStock.com.)
FIG 2-9 Dental hygiene students attend the state dental hygiene association lobby
day at the state capitol to experience political advocacy first-hand. (Photograph
courtesy Christine French Beatty.)
Researcher
As a researcher a dental hygienist uses scientific methods and knowledge to
identify and pursue a specific area of interest (see Chapter 7 for a discussion of the
scientific method used in research). Dental hygienists employed in the research
arena work in various settings such as state health departments, universities, dental
schools, hospitals, other government agencies, and private industry.
In a state health department dental program, the epidemiology of dental diseases
is a likely area of interest. As an example, the public health dental hygienist might
coordinate a statewide needs assessment. Knowledge of research methods and
assessment tools, including dental indices, is required to survey the prevalence of
oral diseases; biostatistics skills are important for analyzing data; and critical
thinking is necessary for interpretation and application of research results. In
addition, because much public health research is conducted in the field, it is
important to be able to work with representatives and administrators of various
community and government organizations, such as school districts and other
government agencies.
The role of researcher is involved in the required accountability for public funds
used by public health programs at all levels. Oral health data must be continually
gathered to evaluate and demonstrate the effectiveness of public health programs in
improving oral health and reducing barriers to oral health care. Epidemiologic
research is crucial in maintaining existing oral health programs or initiating new
ones.
For example, a dental hygienist could be hired in a research position at a dental
school to participate in a periodontal research project to study the effectiveness of a
new antimicrobial product. Another example of a research associate position is with
a microbiology department of a university, conducting research on the microbial
etiology of periodontal disease. A dental hygienist on the faculty of a dental hygiene
program could be involved in a variety of research projects as part of the faculty
position expectations. A dental hygienist employed at a Veterans Affairs hospital
might study therapeutic procedures for patients with head and neck cancer, and
another on staff with a dental clinic associated with a children's hospital could study
pediatric patient management techniques. A dental hygienist with HRSA could be
involved in research related to the adequacy and effectiveness of the dental
workforce nationwide.
Dental product companies have ongoing research to scientifically determine the
effectiveness of new methods and products to prevent and treat oral diseases. A
dental hygienist has an appropriate background in basic sciences and dental sciences
to join a research team in industry.
As evident from these examples, the role of researcher is frequently part of
another professional role. In many positions the dental hygienist may work part-
time as a researcher, with the remainder of the job description being one of the
other professional roles discussed in this section.
Educational requirements for researcher positions include a bachelor's degree
with several years of relevant experience, a master's degree, or a doctoral degree,
depending on the type of research position and the job responsibilities. The
researcher role requires the sharing of research results with other oral health
professionals and the public, which requires strong writing and oral presentation
skills. Also of value are knowledge of research methodology and computing and
interpersonal skills.
Certification by the Research Administrators Certification Council has value for
the researcher who is developing and administering projects; it will increase
credibility and improve employment and advancement opportunities. A researcher
involved in epidemiologic research will benefit from certification through the
Association for Professionals in Infection Control and Epidemiology. A researcher
who is conducting clinical trials will find it helpful to have knowledge of computer
programming, medical terminology, and medical procedures. A research scientist
designs research studies and analyzes results, requiring knowledge of survey
design, analysis, modeling, sampling, standard statistical software packages, and
project cost estimation.
Administrator/Manager
The expanded coordination of community-wide oral health programs creates the
need for a dental hygienist to be an administrator or manager. In this role the
hygienist initiates, develops, organizes, and manages oral health programs to meet
the needs of targeted groups of people. Public health program planning occurs at
the local, state, and federal levels. If the oral health program is implemented for a
large population or within a large geographic area, supervision of other
professional and technical staff may be required.
Dental hygienists fill administrator/manager positions at various levels. The
type of oral health program managed depends on the needs of the population.
Following are some examples of public health administrator/manager positions
held by dental hygienists:
• Coordinator of a regional oral health coalition
• Director of a hospital dental clinic
• Executive director of a nonprofit dental organization
• Manager of the oral health unit of a state public health department
• Coordinator of a statewide Head Start school-based fluoride varnish program
• Manager of a dental hygiene program in a state prison system
• President and owner of a mobile nursing home practice
• Assistant administrator of a DHHS operating division
• Manager of an oral health program with a federal agency such as the Centers for
Disease Control and Prevention (CDC) or the Office of the Assistant Secretary of
Health
• Coordinator of a community-based program sponsored by a for-profit
corporation
Most of these programs are in government or nonprofit settings. Some are in for-
profit healthcare settings such as hospitals or nursing homes. In addition, some
corporations also focus on community oral health programs and employ dental
hygienists to coordinate these programs. For example, Colgate Oral
Pharmaceuticals, a for-profit company leading the oral care market with both over-
the-counter and therapeutic professional products, has a presence in the community
by supporting and coordinating community oral health programs. Through their
Bright Smiles, Bright Futures® program, Colgate provides free dental screening
and oral health education globally. In the U.S. a fleet of mobile dental vans travel to
underserved rural and urban communities, reaching over 1000 towns and more than
10 million children each year. Their award-winning oral health education
curriculum is used in schools. In the U.S. it has reached nearly 90% of kindergarten
students each year, 3.5 million children in all 50 states, and over 750,000 preschool
children through a partnership with Head Start.76 Dental hygienists are employed by
Colgate to coordinate these community programs (Figure 2-10).
FIG 2-10 The Colgate Bright Smiles, Bright Futures® dental van is used to provide
free dental screening and oral health education to children globally. (Courtesy Colgate
Oral Pharmaceuticals.)
Name:
Christy Jo Fogarty, RDH, ADT, BSDH, MSOHP
Position and Place of Employment:
Licensed dental hygienist (RDH) and advanced dental therapist (ADT), Children's
Dental Services, Minneapolis, Minnesota
Description of Organization:
Children's Dental Services (CDS) is a not-for-profit organization that has provided
dental services to children for nearly 100 years through a community-based clinic
that focuses on a diverse population of children under the age of 21. The main
clinic is in the inner city of Minneapolis, and CDS also serves several schools with
onsite school-based clinics and mobile outreach programs in Minneapolis and St.
Paul. In addition, CDS has outreach mobile clinics in rural areas throughout the
state. ADTs and RDHs travel from the main clinic to these rural sites to treat
children using mobile equipment, providing services that include examination,
radiographs, prophylaxis, sealants, and fluoride.
Duties Performed in This Position:
As ADT: Perform examinations, all types of restorations, stainless steel crowns on
permanent and primary teeth, extraction of primary teeth and permanent teeth with
Class III or IV mobility
As RDH: Perform prophylaxis and scaling/root planing (not allowed with just
ADT license), radiographs, sealants, and fluoride
Required Qualifications and Experience:
Bachelor's degree with both RDH and ADT licenses; Oral Hygiene Practitioner
master's degree
Personal Comment:
I began my career as a dental hygienist employed in private practice in
Minneapolis. About 20% of our clients were on public assistance, so I spent much
of my time working with that population. I also worked closely with and gave care
to teens at a drug treatment facility. After that, I spent 7 years doing independent
contracting in the Minneapolis/St. Paul area. When I got the opportunity to expand
my dental knowledge and scope of practice to serve those who could not gain
access to care, I knew I had found my lifelong calling. I started in the first ADT
class even before the legislation passed, taking a leap of faith in relation to the
amazing success of dental therapy in Minnesota.
Being the first ADT in this organization, I faced various challenges and had to
overcome numerous trials. Many dentists held latent feelings of mistrust created by
the ADA and the Minnesota Dental Association. Thus, I had to prove my knowledge
and skills to several dentists that I worked with. In the meantime, CDS was faced
with the logistics of how to incorporate the ADT position into the office. Also, we
had to educate everyone on both my scope of practice and my supervision level.
Even setting up billing was challenging as many insurers weren't sure in what
“category” of provider the ADT should be entered because midlevel providers
were new to dentistry.
As I transitioned from dental hygiene into more of a dental therapy scope of
practice, I worked closer with the dentists, and they came to realize the strong
restorative skills that I had. Today, I practice in a very fluid and seamless way with
the dentists and other dental therapists in my office. The staff is well versed in the
ADT scope of practice and the level of supervision needed. I collaborate on
treatment continually with my supervising dentist, but rarely at the same site. We
communicate regularly, and I can utilize her knowledge and skills remotely
whenever necessary. I am treated as a valuable member of the team, and most of the
dentists can no longer imagine working without a dental therapist.
In addition, I have functioned in the role of advocate for legislative proposals
related to dental hygienists as midlevel providers in other states. I have talked with
dozens of legislators across the nation about how dental therapy is effectively and
efficiently benefiting the citizens of Minnesota in terms of increased access to
dental care and improved oral health. In May of 2014, Maine became the second
state to codify a midlevel dental practitioner, and several other states have proposed
similar legislation.
Advice to Future Dental Hygienists:
Spend time honing your clinical skills and practicing in public health. It is hard
work and will challenge you on many levels, but it has huge payoffs as well. Also,
if you would like to provide more for your patients as a clinician, consider
continuing your training by becoming an ADT as well. Not many jobs allow one to
get paid in both money and hugs . . . mine does!
Name:
Terri Chandler, RDH, EFDA, CDA
Position and Place of Employment:
Founder/CEO/Executive Director of Future Smiles, Las Vegas, Nevada
Description of Organization:
Established in 2009, Future Smiles is a nonprofit organization that has the mission
to provide the essential resources and infrastructure to increase access to oral
health care for underserved populations and also generating public health
opportunities for dental hygienists. Through school-based care, Future Smiles
applies a systems approach to remove common barriers of cost, transportation, lost
income resulting from time off work, and lost school time for learning. The
ultimate goal is to change the way children and their families think and act
regarding their personal oral health and at the same time instilling positive oral
health behaviors that can last a lifetime.
Future Smiles delivers school-based services in the Clark County School District
with two types of operational delivery modes: set locations and mobile school
locations. These school-based settings are referred to as Education and Prevention
of Oral Disease (EPOD) programs. An EPOD is a hybrid of a traditional dental
sealant program that includes additional dental hygiene services. Typically, an
EPOD operates in a school-based health center but is sometimes set up in a
classroom, nurse's office, lunch room, modular building, or other available space.
The Clark County School District provides the space at no cost for five EPODs,
three of which operate year round and two that operate only during the school year.
In this mobile school-based program, dental hygiene teams “carry-in-and-carry-
out” portable dental units that are easily transported, weigh 50 pounds or less, fold
into suitcase containers, and are on wheels for easy transport. The dental hygiene
teams spend an average of 2 to 3 weeks at each of the mobile school locations.
Using a positive consent form signed by a parent or guardian, Future Smiles
offers dental hygiene services to all at-risk students enrolled in the school. These
services include screening, oral health education, prophylaxis, sealants, fluoride
varnish, digital x-rays (at limited locations), and case management through a
referral system for restorative dentistry. Children are referred to community-based
clinics, the local dental school clinic, and area dentists through a network of
dentists who either are Medicaid providers or have offered pro bono dental care to
the students with untreated dental caries. Further impact is achieved through oral
health education presentations, “brush at lunch” presentations, health fairs, and
program services provided at various community health clinics.
Duties Performed in This Position:
My role is primarily management, which involves financial planning, public
relations, program development, grant writing, public health advocacy, oral health
consulting, and, whenever possible, going into the schools to provide clinical
dental hygiene treatment to at-risk students in the school community. I still really
love being able to provide clinical dental hygiene treatment! In addition, I provide
leadership for a staff of 14 dental hygienists to set the tone and establish a culture of
collaborative teamwork in this community oral health program.
Required Qualifications and Experience:
Personal qualities that made it possible to create this nonprofit were my passion,
determination, enthusiasm, careful planning, strong sense of possibility, and
profound belief that we can make a difference. Eight years with the Nevada State
Health Division's Oral Health Program as the statewide sealant coordinator and the
oral health coalition coordinator provided in-depth knowledge of oral health issues
in Nevada and innovative solutions to foster long-term change.
Personal Comment:
While practicing clinically, I came to a cross-road in my life, at which point I
clearly saw a way to impact the oral health of disadvantaged youth through my
personal life experience. One might ask why I left private practice in a great dental
office that offered financial security and respect to form a nonprofit to address
dental wellness for the underserved. It's simple: to make a difference in the lives of
others! I was at a point in my life when the reward and challenge of developing a
dental hygiene–based program was possible for me, and I took the opportunity and
ran with it.
In mid-2009, I left private practice employment and devoted my time and energy
to developing Future Smiles. My goal was to increase access to dental hygiene
services for at-risk children and their families with a school-based program.
Today, I continue to provide clinical care (school-based and private practice) while
also serving as the executive director of my nonprofit organization.
As an oral health professional for over 30 years, I had never been in business for
myself. Thus, forming this nonprofit organization required a lot of learning, for
example, about insurance, financial planning, state/local licenses, and the Internal
Revenue Service (IRS) application process for a nonprofit. After 5 years many of
these new business elements are now part of our standard operating procedures,
and we have learned to embrace annual audits, renewal dates, and financial reviews.
As a public health entity Future Smiles was under the scrutiny of the dental
community. They had many questions concerning what Future Smiles was offering
the public and how that “fit into” the business culture of private dental practices.
Fortunately, Future Smiles had a solid business plan that allowed our school-based
services to operate under the Nevada State Board of Dental Examiners Public
Health Dental Hygiene endorsement. The dental hygienists who work with Future
Smiles are contracted as Medicaid providers as well.
I believe it is important for all dental hygienists to be acknowledged as registered
professionals with the National Plan & Provider Enumeration System (NPPES) at
https://nppes.cms.hhs.gov. Through NPPES a dental hygienist is registered as a
dental health professional and will receive a National Provider Identification
number (NPI). The NPI is attached to all dental hygiene licenses and can be used as
an identifier for Medicaid and insurance contracting.
The best part of my work with Future Smiles is going into a school to serve the
students. It is also gratifying to hear stories from the dental hygiene team about
their positive and rewarding experiences serving the children and making a
difference within the profession.
Advice to Future Dental Hygienists:
As dental hygienists we often think that what we do only involves clinical treatment.
However, with a nonprofit like Future Smiles, we become a collective group with
many talents and the ability to make a long-term impact on the oral health of the
population we serve. The work of the nonprofit is exponential, touching many lives
and continuing beyond its individual founders. Future Smiles is so much more than
a job and source of professional income. The real joy of working with a nonprofit
is the hope and compassion that result, providing the inspiration that serves as the
true essence of a nonprofit.
Name:
Diann Bomkamp, RDH, BSDH, CDHC
Position and Place of Employment:
Clinical dental hygienist in private practice for 45 years; part-time consultant for
the Missouri Department of Health and Senior Services (MDHSS); and various
leadership and public health advocacy positions in the Missouri Dental Hygienists'
Association (MDHA) and the ADHA.
Description of Organization:
The ADHA is the professional organization that represents the professional
interests of registered dental hygienists. ADHA's mission is to “advance the art and
science of dental hygiene” with the ultimate purpose of improving the public's oral
and general health. This is accomplished through efforts aimed at “ensuring access
to quality oral health care; increasing awareness of the cost-effective benefits of
prevention; promoting the highest standards of dental hygiene education, licensure,
practice, and research; and representing and promoting the interests of dental
hygienists” (www.adha.org). The MDHA is the Missouri state constituent of ADHA.
The MDHSS is the Missouri state health department that serves the citizens of the
state; the oral health program is one of a variety of health programs within the
MDHSS.
Duties Performed in This Position:
I research issues, communicate with others, educate policymakers, advocate for
public health and dental hygiene issues, and function as a public health policy
strategist.
Qualifications and Experience Required for This Position:
Advocating for access to improved oral health for the public requires strong
dedication to the cause, tenacious energy and stamina (thick skin), the skill of being
a consensus and relationship builder, and the ability to be flexible and shift gears
quickly. In addition, an advocate must develop an in-depth understanding of both
dental hygiene and public health, know how to interpret research and translate it
into understandable information for policymakers and the public, understand how
public policy evolves, be familiar with the dental hygiene accreditation standards
and practice acts, and comprehend how they affect the delivery of oral health care
in the context of today's public health issues.
Personal Comment:
My interest in dental hygiene was triggered after working for my uncle, a dentist in
St. Louis, when I was 16 years old. I have practiced as a dental hygienist more than
45 years since earning my bachelor's degree in dental hygiene from Marquette
University in Milwaukee, Wisconsin. Initially, I worked in general practice but have
spent most of my years as a clinical dental hygienist in a periodontal practice.
Additionally, I was a dental hygiene educator, serving as a clinic coordinator and
lead preclinical instructor, and an examiner for the Western Regional Examining
Board and the Central Regional Dental Testing Service.
My advocacy role began in the early 1980s through involvement with the MDHA
as the public health chairperson. Eventually I served as President of both the
Greater St. Louis Dental Hygienists' Association and the MDHA and also edited the
MDHA newsletter. I was legislative chair of MDHA for more than 20 years, which
gave me a perspective on how public policy is made and the importance of
advocacy. My legislative activities led to more involvement in politics, resulting in
MDHA forming a political action committee, which I chaired. I served as a
delegate/alternate delegate to ADHA for many years, as ADHA District VIII Trustee
in 1998 to 2002, and ultimately as ADHA President in 2008–2009.
Because of my interest in public health and improving access to oral health care,
I earned a Community Dental Health Certificate (CDHC) at Northeast Wisconsin
Technical College in 2006. More recently, I worked with the MDHSS as an oral
health consultant with four other dental hygienists to implement the Preventive
Services Program (PSP), a state oral health program to screen, educate, apply
fluoride varnish, and refer children to a dentist (http://health.mo.gov/blogs/psp/). In
that position I also helped to create a K-12 oral health educational curriculum,
along with several other educational programs
(http://health.mo.gov/living/families/oralhealth/oralhealtheducation.php).
After recognizing the strong need for the dental profession to be involved in the
political arena, I decided to run for Missouri state representative in 2002 and 2004,
but lost by a very slim margin. During my year as president of ADHA, I had
tremendous opportunities to work on the access to oral healthcare agenda,
including the implementation of the ADHP. I also worked on dental hygiene's
involvement in healthcare reform and had the chance to promote the utilization of
dental hygienists to positively affect the public health infrastructure.
I have recently participated as part of a working group to update the Missouri
Oral Health Plan. Also, as the MDHA Legislative Co-Chairperson, I am working
for better utilization of dental hygienists in Missouri by promoting an extended
oral healthcare access bill. In addition, we are working on a teledentistry initiative
to increase dental hygienists' ability to serve populations that do not have access to
care. I also am a member of the Executive Board of the Missouri Coalition for Oral
Health, a group of many different state oral health advocates who are pursuing
better policies on water fluoridation, adult dental benefits for those on Medicaid,
and other relevant oral health activities.
All of these experiences along my career path have provided a broad perspective
of dental hygiene. They also portray the positive impact that a clinical dental
hygienist can have in promoting better oral health in his or her own state and at the
national level through active involvement in our professional organization and its
related public health initiatives. The experiences and contacts resulting from my
active involvement in ADHA/MDHA have opened many doors to serve in various
ways as an advocate for oral health for the public.
Advice to Future Dental Hygienists:
Beginning hygienists should become aware of the many options that they have in
their career path if they work through ADHA and other oral health coalitions to
make positive changes in the oral health arena. By helping others at the systems and
organizational level and at the individual patient or client level, I know you can find
great fulfillment in your professional lives, as I have in mine.
Name:
Tammy L. Allen
Position and Place of Employment:
Co-owner, LifeCycle Dental Resource, Inc., Fort Worth, Texas
Description of Organization:
LifeCycle Dental is a privately owned, mobile provider of dental and dental
hygiene services to older adult residents of long-term care facilities, a population
that continues to be underserved. The mission of LifeCycle Dental is, “We believe
that everyone deserves excellence in dental service throughout all phases of life.
We are committed to caring for oral health, self-esteem, and dignity in geriatric
dental care” (www.lifecycledental.com). Based on a genuine belief that prevention
is the key to maintaining oral health, the organization was established in 2002 to
implement a preventive dental model for this population. LifeCycle Dental began
by taking their mobile clinics to three long-term care facilities and has expanded to
over 55 facilities in the North Texas area in 13 years.
Duties Performed in This Position:
I deliver clinical dental hygiene services to the residents of long-term care
facilities. As co-owner, I am in an administrator role as well. In that capacity I train
and supervise a large clinical and office staff, do billing and insurance, and deal
with the day-to-day operations of the business.
Required Qualifications and Experience:
Personal qualities that were essential to establish this business were having a
passion for the provision of oral health care for older adults, being willing to
sacrifice the time necessary to learn what was needed to launch the business, and
exhibiting determination and focus. Extensive knowledge and experience in
providing oral care for older adults were necessary. Also, knowledge of
regulations related to caring for this population and advocacy skills were vital.
Some of this was acquired through developing the business.
Personal Comment:
Oral health remains a tremendous concern for residents of long-term facilities and
their families. Though most mobile dental companies work on the basis of
emergency pain referrals, I believe that optimum dental care should focus on
prevention, not alleviation of pain. My professional journey has been guided by my
love of older people and by way of following my desire to care for this population
that lacks the level of dental hygiene care needed for optimal health. While serving
on the Texas State Board of Dental Examiners, I became aware of Texas's critical
need for a preventive oral health model for long-term care facilities, and I was
instrumental in changing Texas law to allow dental hygienists to provide treatment
in these facilities.
I have faced many challenges along the way, mostly with time commitments, as it
takes a tremendous amount of time to set up and operate an organization to serve
this segment of the population. For a time, I eliminated all extracurricular activities
to focus all my energy on learning how to care for, and deliver care to, residents of
long-term care facilities.
Another challenge that must be overcome to provide this type of service is the
fact that no regulations exist to require that long-term residents have a dental
examination or professional dental hygiene services, at least in this state. In
addition, daily oral care is still viewed as relatively unimportant in long-term
facilities, ranking last on the priority list of daily care, even below hair
appointments and nail polishing.
Finally, there continues to be a dearth of knowledge among most long-term care
facility staff concerning the significance of oral care in relation to the health,
comfort, and quality of life of long-term care residents. Our team of dentists and
dental hygienists face these challenges daily, with seemingly little momentum
gained.
Advice to Future Dental Hygienists:
Learn about and, as needed, get involved in changing the laws and regulations
related to oral health care in your state before pursuing an entrepreneurial
endeavor to provide dental and/or dental hygiene care to the specific population
you are passionate about. For example, until regulations are changed, I believe
there is little hope of dental hygienists having a significant impact in daily care for
the geriatric residents in long-term care facilities.
Name:
Joyce Bartle Flieger, BSDH, MPH, RDH, EFDH
Position and Place of Employment:
Oral Health Professional, First Smiles Program, University of Arizona College of
Agriculture and Life Sciences Cooperative Extension, Tucson, Arizona
Description of Organization:
As an outreach arm of The University of Arizona and the College of Agriculture
and Life Sciences, the office of the Arizona Cooperative Extension is a statewide
not-for-profit nonformal education network that provides a link between the
university and the citizens of Arizona, “bringing research-based information into
communities to help people improve their lives” (https://extension.arizona.edu).
Their vision is to be “a vital national leader in creating and applying knowledge to
help people build thriving, sustainable lives, communities, and economies.” Their
mission is “to engage with people through applied research and education to
improve lives, families, communities, environment, and economies in Arizona and
beyond.” The First Smiles program operated by the Cooperative Extension serves
the oral health needs of at-risk children and their families in a rural Arizona county
on the Mexican border. This county has medical and dental healthcare shortages,
and in some parts of the county, a 1- to 3-hour drive is required to access a dental
or medical provider. This grant-funded program provides oral health education to
parents and their children and delivers preventive services to infants, children, and
pregnant women.
Duties Performed in This Position:
I provide oral health assessments, preventive services such as fluoride varnish, and
dental referrals as needed for children age 0 to 5 and pregnant women. In addition,
oral health education is provided for these groups and their families and child care
providers.
Required Qualifications and Experience:
Licensure as a dental hygienist and Affiliated Practice Dental Hygienist (APDH)
certification were required for this position. In addition, working with this
population requires experience managing young children who have never had any
type of dental service or assessment. Also, to competently refer children,
knowledge is required of the following: oral pathology/abnormalities in young
children and infants; how these abnormalities can affect breast feeding, speech, and
success later in life; when and to which health professionals to refer for a workup
of these conditions; and the health professionals available for referral in the rural
community. The oral health professional must be able to do it all in a rural
community where there are limited funds and other resources. This position
requires skills in clinical procedures, data gathering, data recording, and data
storage. In addition, confidentiality, creativity, and especially trustworthiness are
required.
Personal Comment:
The journey to my current position has taken many different turns. Upon
graduation with honors in 1973 from the University of Southern California Dental
Hygiene program, I took a position in public health with the Los Angeles County
Health Department and worked on a community water fluoridation campaign for
the city of Los Angeles. As a dental hygienist, I practiced in community health
centers and parochial schools, providing dental hygiene services to children and
pregnant women, and in an American Indian health center. My experiences as a
public health dental hygienist prompted me to pursue a Master of Public Health
degree from the University of Michigan.
After graduate school, I also pursued an academic career as a professor, clinic
coordinater, dental hygiene program director, and department chair. Throughout
my years as a dental hygiene educator, I continued to satisfy my love for clinical
dental hygiene with part-time clinical practice. I also supported my local dental
hygiene associations and encouraged students to participate in community service
activities.
When I moved to Arizona I became certified as an Expanded Function Dental
Hygienist (EFDH) in California to qualify for local anesthesia. More recently, I
served the State of Arizona as the Office Chief with the Arizona Department of
Health Services, Office of Oral Health. This position allowed me to participate in
many new state-level initiatives, including being part of the new landscape for the
APDH in Arizona. I personally earned the APDH certification so I could organize
dental sealant programs in the schools for state and county health departments
without dentist supervision. Also, I worked on state projects to provide dental
services for rural communities and other underserved populations and to procure
grant funding to pilot teledentistry in Arizona.
Currently I administer the Future Smiles program, for which I helped with the
groundwork at the state level. This qualified me to apply for the county-level
position when the funding became available. Thus, I have experienced the “boots-
on-the-ground” work of this state initiative, learning what works and what doesn't.
As a result I have concluded that it is important to get out of the office after
developing a project to experience the strengths and weaknesses of the new
program.
The barriers I have encountered in the Future Smiles program were more
entrenched in the community than I had imagined. False doctrines were abundant,
such as “children do not need to see a dentist till age 2 or 3,” “fluoride is not
healthy,” and “tooth decay in primary teeth is fine because those teeth come out
anyway.” The First Smiles project started with a strong educational program that
met the needs of the rural community I was serving and helped dispel these myths. I
developed age-appropriate messages about oral health for the children, and I
learned quickly that these messages were successful as well to educate the adults
that were present during the children's education.
A tight-knit rural community can be a difficult place to affect change in
behaviors. Every interaction matters! Developing trust among community members
is important to the success of any program. Providing a model professional oral
health program that truly benefits the community is important to establish trust.
Advice to Future Dental Hygienists:
Learn as much as you can about the research evidence that will support your
program and what will make it an effective program. Knowing how to collect data
and how to apply that data in a grant report is invaluable when it comes to
successfully acquiring continuation of program funding. Know how to advocate
for change and make evidenced-based decisions.
Name:
Annette Wolfe, RDH, BS
Position and Place of Employment:
Academic Manager, Southwest Colgate
Oral Pharmaceuticals
New York, New York
Description of Organization:
Colgate-Palmolive is a leading global consumer products company, tightly focused
on oral care, personal care, home care, and pet nutrition, with business in over 200
countries and territories around the world. As part of Colgate-Palmolive, Colgate
Oral Pharmaceuticals is a leader in the oral care market with both over-the-counter
and therapeutic professional dental products. At Colgate we are committed to doing
business with integrity and respect for all people and for the world around us. Our
three fundamental values—Caring, Global Teamwork, and Continuous
Improvement—are part of everything we do. We demonstrate our Caring value by
supporting community programs around the world including our own flagship
program, Colgate Bright Smiles, Bright Futures®. Colgate Bright Smiles, Bright
Futures® is among the most far-reaching, successful children's oral health
initiatives in the world. With long-standing partnerships with governments, schools,
and communities, Colgate Bright Smiles, Bright Futures® has reached more than
half a billion children and their families across 80 countries with free dental
screenings and oral health education.
Duties Performed in This Position:
I present scientific technology and product lectures and seminars at dental colleges
and dental hygiene programs; deliver continuing education programs to practicing
oral health professionals; assist in developing various presentations; and
participate as a vendor and educational representative in continuing education
events, dental and dental hygiene conventions, and other professional meetings.
Also, I assist in training field representatives. In relation to community oral health,
my team and I participate in Bright Smiles, Bright Futures® initiatives (see earlier),
as well as partnering with dental hygiene education programs and dental hygiene
professional associations to help implement community-based programs that serve
underserved population groups.
Required Qualifications and Experience:
Necessary qualifications include: Registered Dental Hygienist with a minimum of 2
to 5 years' experience in an academic setting or visiting academic institutions.
Master's degree and/or equivalent experience is required. Strong interpersonal,
organizational, and communication skills are a must.
Personal Comment:
In 1978 I received my Associate of Science degree and was licensed as a dental
hygienist in Florida for 8 years. After moving to Texas I completed a Bachelor of
Science degree in Dental Hygiene through the degree completion program at Texas
Woman's University, minoring in business. Before graduating I responded to a
newspaper advertisement that read, “Wanted: Dental Hygienist to sell dental
equipment” and was hired by EMS/Electro Medical Systems, manufacturer of the
Piezon ultrasonic scaler.
During my time with EMS, I gained experience in many areas including training,
program development, marketing, internal auditing, and sales. It was during this
time that I got my first opportunity to be a presenter and learned to overcome my
fear of public speaking, which was one of my biggest career challenges. The
networking opportunities here paved the way for my further professional
development.
After my stint at EMS, Dentsply presented an opportunity to be a clinical
educator. I developed and managed an 11-state territory and continued to develop
my presentation skills. After that I spent 2 years as Professional Services Specialist
and trainer for D4D Technologies, a manufacturer of chairside CAD/CAM systems.
This was another great learning experience and networking opportunity. Finally, in
2009 I was hired by Colgate Oral Pharmaceuticals in my current position.
My clinical experience has been invaluable to me in my current and past
corporate positions. This hands-on experience makes training students and dental
personnel more efficient and practical. As a result of my experience, I understand
patient care, motivation, and the possible challenges involved in both. In addition, it
provides me with credibility in the field.
Advice to Future Dental Hygienists:
Get as much clinical experience as possible, as that is the foundation of a dental
hygiene career in other roles. Make sure to maintain your membership in ADHA
and network, network, network! To seek a corporate position within the dental
industry, whether in sales, as an educational representative, or another aspect, attend
meetings, talk to dental company representatives, introduce yourself to speakers at
continuing education programs, have a business card to pass out, develop computer
skills, and get trained in public speaking. Pursuing a career in education can
simultaneously enhance your dental hygiene knowledge and speaking skills.
Finally, never say “never,” don't try to predict what life will bring your way, and
work hard to follow your dream.
Name:
Lieutenant Cynthia Chennault, RDH, BSDH
Position and Place of Employment:
Advanced Clinical Dental Hygienist, USPHS, and IHS, Catawba Service Unit, Rock
Hill, South Carolina
Description of Organization:
The IHS provides a comprehensive health service delivery system for
approximately 1.9 million American Indians and Alaska Natives who belong to 566
federally recognized tribes in 35 states. The IHS is the principal federal healthcare
provider and health advocate for this underserved population, and its goal is to
raise their “health status to the highest level” (www.ihs.gov). Care is provided
through community-based clinics on the reservations, which are staffed by a
combination of USPHS Commissioned Core officers, Federal Civil Service
employees, and direct tribal hires. The first two options provide excellent benefits
as federal employees, and direct hire employment benefits are comparable to those
offered through the civil service or the USPHS Commissioned Corps.
Overseen by the Surgeon General, the USPHS Commissioned Corps is a diverse
team of more than 6500 highly qualified public health professionals. Driven by a
passion to serve the underserved, these men and women fill essential public health
leadership and clinical service roles with the nation's federal government agencies.
Dental hygienists serve as commissioned officers in this uniformed, although not
armed, service. They have the opportunity to be employed in a variety of federal
agencies, including IHS health service centers, federal prisons, and the CDC. After
20 years they qualify for retirement that is on a par with retirement from military
service.
Duties Performed in This Position:
As an RDH and oral health promotion/disease prevention coordinator in this IHS
dental clinic, I serve a user population of 1800 patients. My responsibilities include
all aspects of direct patient dental hygiene care, assessing community oral health
needs, and establishing community oral health programs, including the planning,
implementation, and evaluation of these programs. Additionally, I have collateral
duties that include instructing dental team members on the proper techniques of
sterilization and infection control, and numerous interagency collaborative health
projects.
Required Qualifications and Experience:
A dental hygienist can follow one of the following three routes to work for the IHS:
2. USPHS Commissioned Corps Health Service Officer status requires U.S. native or
naturalized citizenship, less than 44 years of age (may be adjusted upward for
current or prior active duty), and meeting current medical and security
conditions. Also required is a qualified bachelor's degree from an accredited
program, usually approved by American Universities and Colleges. Dental
hygienists must have graduated from a dental hygiene program accredited by the
Commission on Dental Accreditation of the ADA, and must have a current,
unrestricted, and valid dental hygiene license to practice in one of the 50 states,
Washington DC, the Commonwealth of Puerto Rico, the U.S. Virgin Islands, or
Guam.
3. Direct Tribal Hire is not part of the federal personnel system. Most tribes require
a license to practice dental hygiene in the state of the assignment. Potential
applicants need to reach out to the specific tribe(s) to learn their requirements
because they vary. The tribal application process is handled through the local
Human Resources office for the tribe. Therefore compensation, benefits, and
advancement are negotiated directly with the tribal HR department.
2. Research all available dental resources in your community for older adults who
are unable to afford or travel to private dental offices. Consider whom you would
contact to find out the location of these dental services. Write a job description for a
position to treat older adult residents unable to have access to care in private offices.
3. Research dental supervision laws in several states including your own; and
compare and contrast your state's supervision regulations to other states to
determine whether there is a need for change in your state. Which populations might
benefit from a change? How might you be involved in initiating a change? Report
your findings in class.
5. Read the law in your or another state concerning a dental hygiene–based oral
health midlevel provider, and interview someone who is one. Determine how he or
she is addressing the oral health needs of the underserved. Consider if this career
option would appeal to you. Report this to your class.
6. Read the report Transforming Dental Hygiene Education: Proud Past, Unlimited
Future, and report on it in class. What thoughts do you have about the future of the
profession? How do public health and the future of dental hygiene interrelate?
Present this in class.
Dental Hygiene Competencies
Reading the material in this chapter and participating in the activities of Applying
Your Knowledge will contribute to the student's ability to demonstrate the following
competencies:
Core Competencies
C.8
Promote the values of the dental hygiene profession through service-based
activities, positive community affiliations, and active involvement in local
organizations.
Community Involvement
CM.3
Provide community oral health services in a variety of settings.
CM.4
Facilitate patient access to oral health services by influencing individuals or
organizations for the provision of oral health care.
CM.7
Advocate for effective oral health care for underserved populations.
OBJECTIVES
1. Discuss the mission of public health and how the collaborative efforts of many
organizations have worked together to enhance the recognition and validity of
public health professions.
2. Explain the importance of assessment as a core public health function.
3. Describe the roles of public health professionals in assessment.
4. Discuss the basic terms and concepts of epidemiology.
5. Describe the conceptual models that illustrate the determinants of health.
6. Identify the determinants of health that affect the health of individuals and
communities, especially in public health.
7. Identify the specific stages of a planning cycle.
8. Discuss a community oral health improvement process.
9. Describe the main steps followed and key activities undertaken in a community
oral health assessment, and compare and contrast the different methods of data
collection that can be used in community health assessments.
Opening Statement: Example of a
Community Profile
• Population of 87,214 with 36,431 households
• Sex: 48.2% male; 51.8% female
• Race/ethnicity: 56% Hispanic; 21% white; 15% African American; 5% Asian; 3%
other
• Median resident age: 28.3 years
• Geography: 62% rural and 38% urban; 789 square miles of land
• Industry: tobacco farming area; large proportion of population is migrant farm
workers
• Median household income level: $57,000; range of $18,000 to $82,000 for farmers
and farm workers
• Education level of people age 25 and older: 22% completed college; 33%
completed some college; 32% only completed high school; 8% did not complete
9th grade
• Language: 65% Spanish speaking
• Environment:
G ui di ng Pri nci pl es
Subject Areas Represented on the CPH National Certification
Examination
Core Areas:
1. Biostatistics
3. Epidemiology
3. Leadership
6. Program planning
7. Systems thinking
FIG 3-3 Example of an oral health coalition. (Data from Michigan Oral Health Coalition;
n.d. Available at http://www.mohc.org/. Accessed April 2015.)
Assessment: a Core Public Health Function
Three core functions of public health have been identified that shape the basic
practice of public health at the federal, state, and local levels.19 Health agencies and
departments must perform these functions to protect and promote health, wellness,
and quality of life and to prevent disease, injury, disability, and death. The three
functions (see Chapter 1) are 1) assessment, 2) policy development, and 3)
assurance.19 This chapter emphasizes the core public health function of assessment
in the community.
Public health agencies promote, facilitate, and—when necessary and appropriate
—perform community health assessments, as well as monitoring change in key
measures to evaluate performance. Assessment is defined as the regular and
systematic collection, assemblage, and analysis of data and communication
regarding the health of the community.20,21 Assessment, also referred to as a needs
assessment, includes statistics on health status, community health needs, and
epidemiologic and other studies of health problems, determinants of health, and
related factors.20, 21 Continual assessment of needs is considered surveillance, which
is discussed in Chapter 4. Chapter 5 explains the outcomes of surveillance,
presenting the status and trends of oral health and related factors for the U.S.
population based on Healthy People 2020 objectives, which provides useful data for
a community health assessment.
G ui di ng Pri nci pl es
Essential Public Health Services for Oral Health Related to
Assessment and Evaluation
• Assess oral health status and needs so that problems can be identified and
addressed.
• Assess the fluoridation status of water systems and other sources of fluoride.
• Conduct research and support demonstration projects to gain new insights and
applications of innovative solutions to oral health problems.
Dental hygienists working within the public, private, or nonprofit sectors must
have skills to assess community oral health problems and to evaluate outcomes of
oral health population-based and personal oral health services. Dental hygienists
working in community settings generally participate in a variety of assessment and
evaluation activities. Examples of some of these roles and potential activities are
shown in Box 3-1.
ox 3-1
B
Ex ampl es of Rol es of Publ i c H eal th Dental
H y g i eni sts i n A ssessment
• A public health dental hygienist serves on a committee with the state oral health
coalition. The committee collaborates with the state oral health program to
develop a comprehensive document describing the burden of oral disease in the
state. The report includes chapters on the prevalence of disease and unmet needs,
oral health disparities, and the societal impact of oral disease.
• An oral health program director evaluates the State Oral Health Plan by assessing
the attainment of goals and specific objectives related to oral health promotion,
disease prevention and control, and specific risk factors.
• An oral health policy analyst determines the number and geographic distribution
of dentists statewide who participate in the Medicaid and state Children's Health
Insurance Program (CHIP) programs and provide oral health care to children in
infancy, early childhood, middle childhood, and adolescence.
• An oral health program administrator with a city health department assesses the
oral health assets, needs, and resources of a metropolitan area.
• A public health dental hygienist from a county health department assesses dental
sealants in third-grade children in schools throughout the county.
• An oral health program manager evaluates the quality and outcomes of clinical
preventive services in a school-based oral health program.
• A dental hygienist appointed to a state oral health advisory committee evaluates the
performance measures in a work plan to implement state-level programs for
community water fluoridation and school-based dental sealants.
Overview of Epidemiology: Population-
Based Study of Health
Public health dental hygienists involved in assessment and evaluation should
become well versed in the basic concepts of epidemiology, which is a core science
of community health. This section provides a broad overview of epidemiology.
Table 3-1 presents the definitions of terms used in epidemiology and community
health assessments.
TABLE 3-1
Common Terms Used in Epidemiology
Te rm De finition
Acute Referring to a health effect; brief exposure of high intensity, in contrast to chronic.
Basic screening A rapid assessment accomplished in a short time by visual detection and providing information about gross dental and oral lesions.
Calibration The standardiz ation of examiners or instruments as they apply or are used for epidemiologic measurements.
Case control Epidemiologic study that compares persons with a disease or condition (cases) with another group of people from the same population
study without the disease or condition (controls). The study is used to identify risks and trends and suggest some possible causes for disease or for
particular outcomes.
Chronic Referring to a health-related state that lasts a long time, in contrast to acute.
Cohort study The method of epidemiologic study in which subsets of a defined population can be identified and observed for a sufficient number of
person-years to generate reliable incidence or mortality rates in the population subsets; usually a large population, a study lasting for a
prolonged period (years), or both. (Synonym: concurrent, follow-up, incidence, longitudinal, prospective study)
Cross-sectional A study that examines the relationship between diseases (or other health-related characteristics) and other variables of interest as they exist
study in a defined cross-section (sample) of the population at one particular time; requires a large sample siz e.
Determinants Factors or events that are capable of bringing about a change in health; the various factors that make up the multifactorial approach to a
disease or health condition.
Dichotomous A measurement scale that arranges items into either of two mutually exclusive categories.
scale
Ecoepidemiology Conceptual approach that unifies molecular, social, and population-based epidemiology in a multilevel application of methods aimed at
identifying causes, categoriz ing risks, and controlling public health problems.
Ecologic study Epidemiologic study in which the units of analysis are populations or groups of people rather than individuals.
Endemic disease The constant, normal presence of a disease or infectious agent within a given geographic area or population group.
Epidemic Occurrence in a community or region of cases of an illness, specific health-related behavior, or other health-related events clearly in excess
of normal expectancy. (From Greek epi [upon], demos [people])
Epidemiologic A visual/tactile examination accomplished with dental instruments and a light source; provides more detailed information than basic
examination screening.
Epidemiology The study of the frequency and distribution of disease, disability, and death in the population, including the nature, cause, control, and
determinants of health and disease, as well as related factors.
Eradication (of Termination of all transmission of infection by extermination of the infectious agent through surveillance and containment.
disease)
Etiology Science of causes, causality; in common use, cause.
Incidence The rate of instances of illness commencing, or of persons falling ill, during a given period in a specified population; more generally, the
rate of new events (e.g., new cases of a disease in a defined population) within a specified period of time. (Synonym: incident number)
Index In epidemiology and related sciences, usually refers to a rating scale or a set of numbers derived from a series of observations of specified
variables (e.g., health status index, scoring systems for severity or stage of cancer, heart murmurs, mental retardation, and dental indexes).
Monitoring Systematic examination of public health program coverage and delivery for the purpose of assuring the program is proceeding as planned
and to provide opportunity to respond by adjusting the program as needed; includes systematic assessment of the extent to which a program
is consistent with its design and implementation plan, is reaching its intended target population, and can be justified in terms of a cost-
benefit analysis; closely related to program evaluation.
Morbidity Any departure, subjective or objective, from a state of physiologic or psychological well-being; in this sense, sickness, illness, and morbid
condition are similarly defined and synonymous.
Mortality Related to death.
Multifactorial Referring to the concept that a given disease or other outcome may have more than one cause; a combination of causes or alternative
approach combinations of causes may be required to produce the effect.
Occurrence In epidemiology, a general term describing the frequency of a disease or other attribute or event in a population without distinguishing
between incidence and prevalence.
Pandemic An epidemic occurring over a very wide area (e.g., multiple continents or worldwide) and usually affecting a large proportion of the
population.
Prevalence Proportion of instances of a given disease or other condition in a given population at a designated time; when used without qualification,
term usually refers to the situation at a specified point in time (point prevalence).
Proportion Any expression of the amount of disease or health condition, presented as a fraction in relation to the siz e of the population; the numerator
is part of the denominator; can be expressed as a percentage.
Prospective A research design that observes or follows a cohort over a long period forward in time.
Rate The expression of disease in a population using a standardiz ed denominator and including a time dimension; allows for valid comparisons.
Ratio The expression of the magnitude of one occurrence of disease exposure in relation to another, which can be written as a fraction (4/3), with
a colon (4 : 3), or with the word “ to” (4 to 3); in contrast to a proportion, there is not necessarily a relationship between the two values.
Retrospective A research design that uses a review of past events, such as medical history or lifestyle.
Sensitivity Proportion of truly diseased persons as identified by the screening test; the measure of the probability of a correct diagnosis or the
probability that any given case will be identified by the test. (Synonym: true-positive rate)
Specificity Proportion of truly nondiseased persons identified by the screening test; a measure of the probability of correctly identifying a nondiseased
person with a screening test. (Synonym: true-negative rate)
Surveillance Ongoing systematic collection, analysis, and interpretation of health data with the aim of timely dissemination of the health information to
responsible parties who plan, implement, and evaluate public health practices and programs to prevent and control diseases and conditions;
uses methods distinguished by their practicability, uniformity, and rapidity; an essential feature of epidemiology.
Surveillance Functional capacity for data collection, analysis, and dissemination linked to public health programs.
system
Trend A long-term movement in an ordered series; an essential feature is that the movement, although possibly irregular in the short term, shows
movement consistently in the same direction over a long term.
Adapted from Porta M (ed.). A Dictionary of Epidemiology. 5th ed. (online version). New York: Oxford
University Press; 2014. Available at
http://www.oxfordreference.com/view/10.1093/acref/9780195314496.001.0001/acref-9780195314496.
Accessed April 2015.
Epidemiologic Triangle
Epidemiology is based on a multifactorial perspective, with consideration given to
the interacting relationships among host factors, agent factors, and environmental
factors.23 The epidemiologic triangle depicts disease as the outcome of these factors.
For example, the development and progression of dental caries are attributed to
multiple factors.20,21,23 Figure 3-5 portrays the epidemiologic triangle with dental
caries shown as a multifactorial disease influenced by host, agent, and
environmental factors.
Host Factors
The host may be a person, an animal, or a plant. Host factors (see Figure 3-5)
relate primarily to susceptibility and resistance to disease through biologic
immunity, knowledge and cognition, behavior modification, screening, and
personal power. Age, gender, socioeconomic status, race, ethnicity, culture, genetic
endowment, behavior, physiologic and nutritional state, previous exposure, and
other factors influence susceptibility and resistance.23
Agent Factors
Agent factors (see Figure 3-5) are the biologic or mechanical means of causing
disease, illness, injury, or disability, such as microbial, parasitic, viral, or bacterial
pathogens or vectors; physical or mechanical irritants; chemicals; drugs; trauma;
and radiation. Biology, marketing, engineering, regulations, and legislation can
influence agent factors.23
Environmental Factors
Environmental factors (see Figure 3-5) include physical, sociocultural,
sociopolitical, and economic components. The media, beliefs, occupation, food
sources, geography, climate, housing, social roles, technology, and other factors
can influence environmental conditions.23
Uses of Epidemiology
Health represents a general balance among host, agent, and environmental factors;
health problems occur when the balance is threatened by changes in host, agent, or
environment.23 Prevention is concerned with maintaining or initiating a balance of
these factors. Disease or health status depends on multiple factors such as exposure
to a specific agent, strength of the agent, susceptibility of the host, and
environmental conditions.23
Epidemiology can be used to provide different types of data and information.23
Epidemiologists in public health agencies are responsible for surveillance,
investigation, analysis, and evaluation.20,21,23 The various uses of epidemiology are
illustrated in Box 3-2.
ox 3-2
B
Uses of Epi demi ol og y
• Describe patterns among groups.
• Test hypotheses for prevention and control of diseases, injuries, disabilities, and
deaths through special studies in populations.
• Measure the distribution of health status, diseases, injuries, disabilities, births, and
deaths in populations.
• Identify determinants (e.g., protective and risk factors, social factors, policies) for
death or acquiring diseases, injuries, and disabilities.
ox 3-3
B
Trends Shapi ng the Concepti ons of H eal th i n
the 20th and 21st Centuri es
• Changes in social conditions and mores, professional ethos, and social institutions
Many factors have been identified as influences on the health of individuals and
populations.20,21,24 Several of these risk factors are generally recognized as broader
determinants of health (e.g., employment; education; environment; income; shelter;
food; social justice and equity; family, friends, and social supports; peace and
safety; culture and race relations). Other factors (e.g., language, learning,
meaningful work, recreation, self-esteem, personal control) are considered
contributors to well-being. These factors may also be classified as follows:20,21,23
2. Acquired determinants, which influence health and are obtained after birth and
throughout life, include multiple factors such as infections, trauma, cultural
characteristics, and spiritual values.
There has been a broadening of the concepts of health promotion and disease
prevention from an individual focus toward a human ecological approach.20,21
Health has become much more than just the absence of disability and disease. In
1948 the World Health Organization (WHO) Constitution defined health as “a state
of complete physical, social and mental well-being, and not merely the absence of
disease or infirmity”.25 This definition is still considered a principle by the WHO
today.25 The fundamental conditions and resources for health that were first
described in 1986 by the WHO Ottawa Charter for Health Promotion are still
considered the foundational components of improving health today and are
reflected in the multifactorial approach to health26 (Figure 3-6).
FIG 3-6 Prerequisites for health, Ottawa Charter for Health Promotion. (Data from
Health Promotion: The Ottawa Charter for Health Promotion. Geneva: World Health Organization;
2015. Available at http://www.who.int/healthpromotion/conferences/previous/ottawa/en/. Accessed
March 2015.)
Health promotion was discussed in the Ottawa Charter as the process of enabling
people to increase control over and to improve their health.26 To reach a state of
complete physical, mental, and social well-being, an individual or group must be
able to identify and realize aspirations, satisfy needs, and change or cope with the
environment. Health was therefore seen as a resource for everyday life rather than
the objective of living. Health was a positive concept emphasizing social and
personal resources and physical capacities.26 These principles of health promotion
are still accepted today; therefore health promotion is not just the responsibility of
the health sector but goes beyond healthy lifestyles to well-being.
Determinants of Health
Many models describing the multiple factors that influence the broader dimensions
of health in individuals and populations were developed in the second half of the
twentieth century as multicausal perspectives of health and disease began to take
precedence over monocausal models.20,21,23 The concept of a “web of causation”
emerged as multifactorial perspectives grew, with attention focused on the various
determinants of chronic diseases, disabilities, and injuries. Health status and
differences in health status were shown to be affected by genetic, environmental,
social, and economic factors related to personal and family circumstances, income,
education, where people live and work, and health services.
A broader and more comprehensive view of health is now recognized, with
increased importance placed on the determinants of health in relation to improving
health of individuals and populations. Determinants of health are described as
having comprehensive influence on collective and personal well-being with a
profound effect on the health of individuals, families, communities, nations, and the
world.27–29 Factors such as where people live, the state of environment, genetics,
income, educational levels, and relationships with friends and family all have a
considerable impact on health.30 In other words, whether people are healthy or not is
determined largely by circumstances and environment, and the context of people's
lives influences their health. Also, individuals are unlikely to be able to directly
control many of the determinants of health.
According to Healthy People 2020, health determinants are embedded in the
broad range of personal, social, physical, economic, and environmental factors that
determine the health status of individuals and populations.27 Definitions and
examples of the categories of determinants of health according to Healthy People
2020 are presented in Box 3-4. To improve health in the future, plans, policies, and
programs should be directed toward these health determinants.
ox 3-4
B
Determi nants of H eal th, Healthy People 2020
Policymaking:
Definition: Local, state, and federal level laws and regulations that affect individual
and population health.
Examples:
• State law requires that seatbelts be worn in cars to protect people in the event of a
car accident.
Social:
Definition: Also known as social and physical determinants; the social factors and
physical conditions in the environment in which people are born, live, learn, play,
work, and age; they impact a wide range of health, functioning, and quality of life
outcomes.
Examples:
Health Services:
Definition: Access to health services and the quality of health services.
Examples:
• Access to healthcare providers who speak the same language as the patient.
Individual Behavior:
Definition: Actions of individuals that influence their personal health.
Examples:
• Quitting smoking, resulting in reduction of risk for cancer and other conditions,
including periodontal disease.
• Changing one's diet to improve overall health and reduce the risk of developing
dental caries.
• Age
• Sex
• Birth defects (e.g., physical and mental disabilities, cleft lip, cleft palate)
Data from Determinants of Health, Healthy People 2020. Rockville, MD: Office of Disease Prevention and
Health Promotion; 2015. Available at http://www.healthypeople.gov/2020/about/foundation-health-
measures/Determinants-of-Health. Accessed May 2015.
G ui di ng Pri nci pl es
The Healthy People 2020 Approach to Social Determinants of Health
One goal of Healthy People 2020 is to create social and physical environments that
promote health for all through a “place-based” organizing framework that reflects
five key areas of social determinants of health, referred to as determinant areas.
The five determinant areas are listed subsequently along with the critical
components that were used in establishing the Healthy People 2020 objectives.
1. Economic stability
• Poverty
• Employment
• Food security
• Housing stability
2. Education
• Social cohesion
• Civic participation
• Incarceration/institutionalization
4. Health and health care
• Health literacy
5. Neighborhood and built environment
• Access to healthy foods
• Quality of housing
• Environmental conditions
ox 3-5
B
Scenari os of H eal th Determi nants Impacti ng
Oral H eal th
Scenario 1:
Max is a 27-year-old male and has three part-time jobs. He lives in a small house
located in a rural area with his wife and four children. Because of his work status,
Max does not have vacation time, paid time off, or health benefits. Max and his
wife's financial situation limits their food choices to purchasing processed foods
that are heavily laden with carbohydrates and sugar. They cannot afford dental care,
and two of their children have untreated dental caries. Their children qualify for
Medicaid but the closest oral healthcare facility that accepts Medicaid is more than
40 miles away from their house.
Scenario 2:
Jose is a 29-year-old male with a full-time job. He lives in a rental home in an
urban area with his wife and four children. Jose has vacation time, paid time off,
and health benefits but no employer-sponsored dental benefits for his children. His
wife works as well but has no benefits. They share a car. To balance their budget on
their limited income, Jose and his wife purchase processed foods that have high
contents of carbohydrates and sugar. They cannot afford dental care, and all of their
children have untreated dental caries. The children qualify for CHIP, and the closest
dentist who accepts CHIP is five miles away from where they live.
Can you identify the determinants of health in Scenario 1 and Scenario 2?
Explain how the determinants of health differ between the two scenarios.
ox 3-6
B
Communi ty Case Il l ustrati ng the Impact of
H eal th Determi nants on Oral H eal th Inequi ti es
In a community of 152,783 residents reports indicate about 33% of children and
adolescents live at and below 133% of the federal poverty level (FPL). About 26%
of the population lives in rural areas. The water system in the area is not
fluoridated. There are school-based oral health programs that provide sealants,
fluoride varnish, and oral health instructions. According to a report, 29.4% of
children and adolescents have untreated decay, and 33.5% of children and
adolescents have at least one sealant placed. There is a community-based clinic with
an oral health component located in the center of town. The clinic is several miles
away from the neighborhoods where many citizens who qualify reside. Public
transportation is available, but the trip takes one to two hours each way. There are
44 dentists in the area; only two dentists in the area accept Medicaid and CHIP as a
form of insurance. This situation has overloaded the two dental offices that accept
Medicaid and CHIP, and they are unable to accept the numbers of patients that
qualify.
No single formula exists for conducting a community oral health assessment. The
Association of State & Territorial Dental Directors (ASTDD) has published
Assessing Oral Health Needs: ASTDD Seven-Step Model, commonly referred to as
the ASTDD Seven-Step Model. This resource is a community oral health
assessment guide that describes the specific steps required in the process (Figure 3-
10).46 This model is concentrated on the oral health status of a community, and it can
be used to focus on an entire community or a specific segment of the population
within a community.46 Examples of other community health assessment models are
provided in Box 3-7. Alhough all models share common characteristics, discussion
of the community assessment process in this chapter will center on the ASTDD
Seven-Step Model. Limitations of space allow only for a summary of the highlights
of the process. A comprehensive discussion of the model can be referred to if
needed (see References and Additional Resources).
FIG 3-10 ASTDD Seven-Step Assessment Model. (Data from Kuthy RA, Siegal MD,
Phipps K. Assessing Oral Health Needs: ASTDD Seven-Step Model; 2003. Located at Data
Collection, Assessment and Surveillance, ASTDD website. Reno, NV: Association of State and
Territorial Dental Directors; n.d. Available at http://www.astdd.org/oral-health-assessment-7-step-
model/. Accessed May 2015.)
ox 3-7
B
Ex ampl es of Communi ty H eal th A ssessment
Model s
• Mobilizing for Action through Planning and Partnerships (MAPP) developed by
the National Association of County and City Health Officials in collaboration
with the Centers for Disease Control and Prevention (CDC)36
G ui di ng Pri nci pl es
Factors to Use in Understanding and Describing a Community
Types of data.
Regardless of whether the data are secondary or primary, different types of
information are necessary to ensure that a complete assessment accurately describes
the factors influencing oral health in the community.20,21 Which specific forms to
collect will depend on the purposes of the assessment and the desired outcomes. For
example, the assessment could be designed to evaluate determinants of health in the
community, assess the needs and assets, and/or quantify disparities and inequities
among population groups, all of which would require different types of data and
measurement methods.20,21
The following two main classes of data can be used to describe a community and
to characterize dimensions of health within the community:48
1. Quantitative data refer to information that is objective and measurable. The data
can be expressed as a quantity or amount, numerically representing the size of a
problem. Quantitative data can be used to calculate statistical significance when
necessary (see Chapter 7). Examples are demographic information, vital statistics
such as numbers of births or deaths, incidence or prevalence rates of disease,
number of schools in a county, and employment statistics.
The community partners determine and prioritize information needs and evaluate
alternative methods of data collection.46 One option might be to integrate specific
measures into ongoing surveys and assessments.
FIG 3-12 Assessment data can be compared with other data from various
sources.
ox 3-8
B
Key Steps to Determi ne and Pri ori ti ze
Communi ty Oral H eal th Issues
1. Develop a prioritization process; community input is vital.
3. Determine the community's capacity to address oral health priorities. Consider the
assets and resources that were identified during the assessment process. How can
the wide array of community assets and resources be expanded and maximized to
address the oral health issues?
4. Consider how amenable each oral health priority is to change. What realistic
degree of change can the community achieve in a specific time period?
5. Assess the economic, social, and political issues that influence the community's
ability to address the priority oral health issues. When formulating oral health
improvement strategies to address public health priorities, be cognizant of
economic, social, and political factors that can affect plans and strategies.
ox 3-9
B
Ex ampl es of Informati on for a Communi ty
Profi l e
Physical and Spatial Characteristics
Geographic boundaries, geographic size, population size, population density,
community type, physical condition of neighborhoods, community assets,
community layout, transportation, environmental conditions, water supply, water
quality, community infrastructure, education resources and facilities, public
commons and informal gathering places, number of places of worship, religious
denominations, and signs of development or decay in the community.
Community Inventory
History of the community, community traditions, dominant values, beliefs, social
norms, attitudes, political system, political and government structure, prominent
political figures, formal and informal community leadership, community support
systems through networks, support and community members, gatekeepers,
communication channels, community organizations and associations, and
capacities and inventories of community members and groups.
Sociodemographic Characteristics
Community Demographic Data
Population distribution by age, gender and gender ratios, race, ethnicity, social
class, economic status, education levels, occupations, marital status, employment
status, value of housing, household living conditions, religions, nationality, cultural
characteristics, migration, immigration trends, and trends of change in size and
composition.
Social Demographic Data
Social attributes, social structures, community stability, social cohesiveness, civic
engagement, the functioning of social networks, families and households, family
values, individual beliefs, attitudes, social norms, attitudes, opinions, cultural
forces, religious beliefs, vulnerable population groups in the community, quality of
life, and enrollment in government and public assistance programs such as
Medicaid, Children's Health Insurance Program (CHIP), Women, Infants, and
Children (WIC) program, Head Start, and child care support.
Vital Events
Birth rates, fertility rates, life expectancy, mortality rates, morbidity rates, cause-
specific related morbidity and mortality rates, marriages, and divorces.
4. Select three Healthy People 2020 oral health objectives. For each one, if you
wanted to retrieve primary data for your local area population, what measures
would you use to do that? How would you assess it in the coming year in the
following situations: a) in an urban inner-city community for one objective, b) in a
suburban community for another objective, and c) in a rural county for the final
objective? Share your results with your class.
Dental Hygiene Competencies
Reading the material in this chapter and participating in the activities of Applying
Your Knowledge will contribute to the student's ability to demonstrate the following
competencies:
HP.5
Evaluate factors that can be used to promote patient adherence to disease prevention
or health maintenance strategies.
Community Involvement
CM.1
Assess the oral health needs and services of the community to determine action
plans and availability of resources to meet the healthcare needs.
CM.6
Evaluate the outcomes of community-based programs, and plan for future activities.
Community Case
You are a dental hygienist serving on a health team at a community-based healthcare
facility. The executive director has called a meeting about the need to plan a
community health assessment in the surrounding neighborhood served by the
community health center. This community health assessment is an essential
component of the center's application to receive continued grant funding. Your role
as a member of the planning committee is to provide input on the components of the
community health assessment.
1. What is the first step the committee should take for the community health
assessment?
a. Collect data from existing resources.
b. Identify critical health issues and select health priorities.
c. Mobilize the community by forming key partnerships and recruiting
participants to collaborate in the community health assessment.
d. Plan and collect primary health data in the community.
2. During the data collection phase of the community health assessment, all of the
following are government resources for health data that the committee could use
EXCEPT one. Which one is the EXCEPTION?
a. Population surveys from the Bureau of the Census
b. State health surveys
c. Health and dental records from a private hospital
d. CDC Cancer Registry
3. What is the name used for the comprehensive description of the community that
includes comprehensive, detailed community data?
a. Community asset map
b. Community profile
c. Primary data collection
d. Plan for the community assessment
4. The data collection method that would be the most costly and time-consuming
would be which of the following?
a. Windshield tour
b. Mailed survey
c. Person-to-person interview
d. Telephone interview
5. Both primary and secondary data can be either qualitative or quantitative in
describing a community. Qualitative data are expressed as a quantity or amount.
a. The first statement is true, and the second statement is false.
b. The second statement is true, and the first statement is false.
c. Both statements are true.
d. Both statements are false.
References
1. Goldsteen R, Goldsteen K, Graham D. Introduction to Public Health [e-
book]. Springer: New York; 2011 [Available from: eBook Collection
(EBSCOhost), Ipswich, MA; Accessed February 17, 2015].
2. Holsinger J. Contemporary Public Health: Principles, Practice, and Policy
[e-book]. University Press of Kentucky; 2012 [Available from: Book
Review Digest Plus (H.W. Wilson), Ipswich, MA; Accessed February 17,
2015].
3. What is Public Health? American Public Health Association: Washington,
DC; 2014 [Available at] https://www.apha.org/what-is-public-health
[Accessed January 19, 2015].
4. Caron R, Hiller M, Wyman W. Public health system partnerships: Role for
local boards of health in preparing the future public health workforce. J
Community Health [serial online]. 2014;39(1):29–34 [Available from:
CINAHL Complete, Ipswich, MA; Accessed February 17, 2015].
5. Montes JH, Webb SC. The Affordable Care Act's implications for a public
health workforce agenda: Taxonomy, enumeration, and the standard
occupational classification system. J Public Health Manag Pract.
2015;21(1):69–79.
6. About NBPHE. National Board of Public Health Examiners: Washington,
DC; 2015 [Available at] https://www.nbphe.org/aboutnbphe.cfm [Accessed
February 2015].
7. History. National Board of Public Health Examiners: Washington, DC; 2015
[Available at] https://www.nbphe.org/history.cfm [Accessed February
2015].
8. Exam Info. National Board of Public Health Examiners: Washington, DC;
2015 [Available at] https://www.nbphe.org/examinfo.cfm [Accessed
February 2015].
9. Hernandez B. Foundation Concepts of Global Community Health Promotion
and Education. Jones & Bartlett Learning: Sudbury, MA; 2015.
10. Areas of Responsibilities, Competencies, and Sub-Competencies for the
Health Education Specialists 2010. National Commission for Health
Education Credentialing, Inc.: Whitehall, PA; 2010 [Available at]
http://www.nchec.org/assets/2251/areas_of_responsibilities_and_competencies.pdf
[Accessed April 2015].
11. Core Competencies for Public Health Professionals. The Council on
Linkages Between Academia and Public Health Practice, Public Health
Foundation: Washington, DC; 2014 [Available at]
http://www.phf.org/resourcestools/Documents/Core_Competencies_for_Public_Healt
[Accessed February 2015].
12. Accreditation Standards for Advanced Specialty Education Programs in
Dental Public Health. Commission on Dental Accreditation: Chicago, IL;
2013 [Available at] http://www.ada.org/~/media/CODA/Files/dph.ashx
[Accessed April 2015].
13. Competencies for the New General Dentist. American Dental Education
Association: Washington, DC; 2008 [Available at]
http://www.adea.org/about_adea/governance/Pages/Competencies-for-the-
New-General-Dentist.aspx [Accessed April 2015].
14. Accreditation Standards for Dental Education Programs. Commission on
Dental Accreditation: Chicago, IL; 2010 [Available at]
http://www.ada.org/~/media/CODA/Files/predoc.ashx [Accessed April
2015].
15. Accreditation Standards for Dental Hygiene Education Programs.
Commission on Dental Accreditation: Chicago, IL; 2013 [Available at]
http://www.ada.org/~/media/CODA/Files/dh.ashx [Accessed March 2015].
16. ADEA Core Competencies for Graduate Dental Hygiene Education.
American Dental Education Association: Washington, DC; 2011 [Available
at]
http://www.adea.org/uploadedFiles/ADEA/Content_Conversion_Final/about_adea/go
[Accessed April 2015].
17. Mabery M, Gibbs-Scharf L, Bara D. Communities of practice foster
collaboration across public health. EJKM [serial online]. 2013;17(2):226–
236 [Available from: PsycINFO, Ipswich, MA; Accessed February 17,
2015].
18. Michigan Oral Health Coalition. Lansing, MI; 2015 [n.d. Available at]
http://www.mohc.org/ [Accessed April].
19. Core Functions of Public Health and How They Relate to the 10 Essential
Services. Centers for Disease Control and Prevention: Atlanta, GA; 2011
[Available at] http://www.cdc.gov/nceh/ehs/ephli/core_ess.htm [Accessed
February 2015].
20. McKenzie JF, Neiger BL, Thackeray R. Planning, Implementing &
Evaluating: Health Promotion Program—A Primer. 6th ed. Pearson
Education, Inc: Glenview, IL; 2013.
21. Issel LM. Health Program Planning and Evaluation: A Practical, Systematic
Approach for Community Health. 3rd ed. Jones & Bartlett Learning:
Burlington, MA; 2014.
22. Policy and Position Statements: Oral Health Position Statement. Association
of State and Territorial Health Officials: Arlington, VA; 2012 [Available at]
http://www.astho.org/Policy-and-Position-Statements/Position-Statement-
on-Oral-Health/?terms=dental+hygienist [Accessed March 2015].
23. Rothman KJ. Epidemiology: An Introduction. Oxford University Press, Inc.:
New York; 2012.
24. Health and Development. World Health Organization: Geneva; 2015
[Available at] http://www.who.int/hdp/en/ [Accessed April 2015].
25. Constitution of the World Health Organization (Preamble). Basic
Documents. World Health Organization: Geneva; 2014 [Available at]
http://apps.who.int/gb/bd/PDF/bd48/basic-documents-48th-edition-
en.pdf#page=7 [Accessed December 2015].
26. Health Promotion: The Ottawa Charter for Health Promotion. First
International Conference on Health Promotion, Ottawa: November 21, 1986.
World Health Organization: Geneva; 2015 [Available at]
http://www.who.int/healthpromotion/conferences/previous/ottawa/en/
[Accessed March 2015].
27. Determinants of Health, Healthy People 2020. Office of Disease Prevention
and Health Promotion: Rockville, MD; 2015 [Available at]
http://www.healthypeople.gov/2020/about/foundation-health-
measures/Determinants-of-Health [Accessed May 2015].
28. Social Determinants of Health. Centers for Disease Control and Prevention:
Atlanta, GA; 2014 [Available at]
http://www.cdc.gov/socialdeterminants/Definitions.html [Accessed April
2015].
29. Social Determinants of Health: Commission on Social Determinants of
Health, 2005–2008. World Health Organization: Geneva; 2015 [Available
at] http://www.who.int/social_determinants/thecommission/en/ [Accessed
March 2015].
30. Health Impact Assessment. World Health Organization: Geneva; 2014
[Available at] http://www.who.int/hia/evidence/doh/en/ [Accessed April
2015].
31. Social Determinants of Health, Healthy People 2020. Office of Disease
Prevention and Health Promotion: Rockville, MD; 2015 [Available at]
http://www.healthypeople.gov/2020/topics-objectives/topic/social-
determinants-health [Accessed May 2015].
32. Health Equity. Centers for Disease Control and Prevention: Atlanta, GA;
2015 [Available at] http://www.cdc.gov/chronicdisease/healthequity/
[Accessed May 2015].
33. Melbye M, Huebner CE, Chi DL, et al. A first look: Determinants of dental
care for children in foster care. Spec Care Dentist. 2013;33(1):13–19;
10.1111/j.1754-4505.2012.00312.x.
34. Sangaré AD, Samba M, Bourgeois D. Illness-related behaviour and
sociodemographic determinants of oral health care use in Dabou, Côte
d'Ivoire. Community Dent Health. 2012;29(1):78–84.
35. Sistani MMN, Yazdani R, Virtanen J, et al. Determinants of oral health: Does
oral health literacy matter? Article ID 249591. ISRN Dent 2013:6e.
[Available at] http://www.hindawi.com/journals/isrn/2013/249591/
[Accessed May 2015].
36. Vakili M, Rahaei Z, Nadrian H, et al. Determinants of oral health behaviors
among high school students in Shahrekord, Iran based on health promotion
model. J Dent Hyg. 2011;85(1):39–48 [Available at]
http://www.researchgate.net/publication/50374476_Determinants_of_oral_health_beh
[Accessed May 2015].
37. Van den Branden S, Van den Branden S, Leroy R, et al. Effects of time and
socio-economic status on the determinants of oral health-related
behaviours of parents of preschool children. Eur J Oral Sci.
2012;120(2):153–160; 10.1111/j.1600-0722.2012.00951.x.
38. Watt RG. Social determinants of oral health inequalities: Implications for
action. Community Dent Oral Epidemiol. 2012;40(Suppl2):44–48;
10.1111/j.1600-0528.2012.00719.x.
39. Zenthöfer A, Rammelsberg P, Cabrera T, et al. Determinants of oral health-
related quality of life of the institutionalized elderly. Psychogeriatrics.
2014;14(4):247–254; 10.1111/psyg.12077.
40. Tellez M, Zini A, Estupiñan-Day S. Social determinants and oral health: An
update. Curr Oral Health Rep. 2014;1:148–152 [Available at]
http://link.springer.com/article/10.1007%2Fs40496-014-0019-6#page-1
[Accessed May 2015].
41. Shareck M, Frohlich KL, Poland B. Reducing social inequities in health
through settings-related interventions—A conceptual framework. Glob
Health Promot. 2013;20(2):39–52.
42. Milestones in health promotion: Statements from global conference. World
Health Organization: Geneva; 2013 [Available at]
http://www.who.int/healthpromotion/Milestones_Health_Promotion_05022010.pdf?
ua=1 [Accessed March 2015].
43. Raingruber B. Contemporary Health Promotion in Nursing Practice. Jones &
Bartlett Learning, Inc.: Burlington, MA; 2014.
44. The Community Guide: Program Planning Resource. U.S. Department of
Health and Human Services: Washington, DC; 2014 [Available at]
http://www.thecommunityguide.org/uses/program_planning.html
[Accessed April 2015].
45. Infrastructure Development Tools. Centers for Disease Control and
Prevention, Division of Oral Health: Atlanta, GA; 2013 [Available at]
http://www.cdc.gov/oralhealth/state_programs/infrastructure/ [Accessed
March 2015].
46. Kuthy RA, Siegal MD, Phipps K. Assessing Oral Health Needs: ASTDD
Seven-Step Model; 2003. Located at Data Collection, Assessment and
Surveillance, ASTDD website. Association of State and Territorial Dental
Directors: Reno, NV; 2015 [n.d. Available at] http://www.astdd.org/oral-
health-assessment-7-step-model/ [Accessed May 2015].
47. Community Tool Box. Lawrence, KS: KU work group for community health
and development. University of Kansas; 2014 [Available]
http://ctb.ku.edu/en [Accessed January 2015].
48. Leedy PD, Ormrod JE. Practical Research: Planning and Design. Pearson
Education, Inc.: Upper Saddle River, NJ; 2013.
49. Creswell J. Research Design: Qualitative, Quantitative and Mixed Methods
Approaches. 4th ed. SAGE Publications: Thousand Oaks, CA; 2014.
Additional Resources
American Association for Community Dental Programs (AACDP):.
A Model Framework for Community Oral Health Programs Based upon the
Ten Essential Public Health Services.
A Guide for Developing and Enhancing Community Oral Health Programs.
www.aacdp.com/index.html.
American Public Health Association.
www.apha.org.
Association for Community Health Improvement.
www.communityhlth.org/.
Association of State & Territorial Dental Directors:.
Assessing Oral Health Needs: ASTDD Seven-Step Model.
Proven and Promising Best Practices for State and Community Oral Health
Programs.
Best Practices Approaches.
www.astdd.org.
CDC Division of Oral Health.
http://www.cdc.gov/oralhealth/.
CDC Healthy Communities Program.
www.cdc.gov/HealthyCommunitiesProgram/.
CDC National Center for Chronic Disease, Prevention and Health Promotion
(NCCDPHP).
www.cdc.gov/chronicdisease/about/index.htm.
CDC Office of the Director, Office of Chief of Public Health Practice
(OCPHP).
http://cdc.gov/od/ocphp/.
Community Toolbox.
http://ctb.ukans.edu.
Dental, Oral, and Craniofacial Data Resource Center (DRC) [cosponsored by
the NIDCR and CDC Division of Oral Health].
http://drc.hhs.gov/.
Health Resources and Services Administration.
www.hrsa.gov/.
HRSA Data Warehouse.
http://datawarehouse.hrsa.gov/.
Healthy Cities and Healthy Cities Resources:.
Healthy Communities Institute.
www.healthycommunitiesinstitute.com/index.html.
International Healthy Cities Foundation.
www.healthycommunitiesinstitute.com/ihcf.html.
Healthy City.
www.healthycities.org.
National Association of County and City Health Officials.
www.naccho.org.
Mobilizing for Action through Planning and Partnerships (MAPP) (Part of the
Assessment Protocol for Excellence in Public Health [APEXPH] project).
www.naccho.org/topics/infrastructure/MAPP/index.cfm.
National Institute of Dental and Craniofacial Research (NIDCR).
www.nidcr.nih.gov.
National Maternal and Child Oral Health Resource Center.
www.mchoralhealth.org/.
National Oral Health Surveillance Systems (NOHSS) [cosponsored by CDC
and ASTDD].
www.cdc.gov/nohss/.
National Public Health Performance Standards Program (NPHPSP).
http://www.cdc.gov/nphpsp/.
Office of Disease Prevention and Health Promotion, U.S. Department of
Health and Human Services: Healthy People 2020.
http://www.healthypeople.gov/2020/topicsobjectives2020/default.
Oral Health Infrastructure Development Tools and State Oral Health Plans.
www.cdc.gov/OralHealth/state_programs/infrastructure/index.htm.
www.cdc.gov/OralHealth/state_programs/OH_plans/index.htm.
Public Health Foundation.
www.phf.org/.
World Dental Federation (FDI).
www.fdiworldental.org/.
World Health Organization (WHO), Oral Health.
www.who.int/oral_health/en/.
C H AP T E R 4
Measuring Oral Health Status and
Progress
Charlene Dickinson RDH, BSDH, MS, Christine French Beatty RDH, MS, PhD
OBJECTIVES
1. Discuss the national Healthy People initiative and its significance; relate it to
surveillance.
2. Recognize the Healthy People 2020 national oral health objectives.
3. Identify and discuss the Leading Health Indicators (LHI) and their progress.
4. Describe the use of surveillance in relation to oral health.
5. Compare and contrast the procedures and methods used in oral health surveys.
6. Discuss measures used to assess oral diseases, oral conditions, and related
factors in populations for the purposes of surveillance; relate them to tracking
progress on Healthy People 2020 objectives and oral health indicators.
7. Identify and utilize sources of oral health surveillance data for program
planning purposes and discuss the future considerations for oral health
surveillance.
Opening Statement: Healthy People 2020
Leading Health Indicators (LHI) and Targets1
LHI Topic Are a LHI and Targ e t for 2020
Access to Health Services • Increase proportion of persons with medical insurance—100%
• Increase proportion of persons with a usual primary care provider—83.9%
Clinical Preventive Services • Increase proportion of adults who receive a colorectal cancer screening based on the most recent guidelines—70.5%
• Increase proportion of adults with hypertension whose blood pressure is under control—61.2%
• Reduce proportion of persons with diagnosed diabetes whose A1c value is greater than 9—16.1%
• Increase proportion of children (19–35 months) who are fully immuniz ed—80%
Environmental Quality • Reduce number of days that Air Quality Index (AQI) exceeds 100—1,980,000,000 AQI-weighted people days
• Reduce proportion of children (3–11 years) exposed to secondhand smoke—47%
Injury and Violence • Reduce number of fatal injuries—53.7 per 100,000 population
• Reduce number of homicides—5.5 per 100,000 population
Maternal, Infant, and Child Health • Reduce number of all infant deaths—6 per 1000 live births within a year
• Reduce proportion of preterm live births—11.4%
Mental Health • Reduce suicide rate—10.2 suicides per 100,000 population
• Reduce proportion of adolescents (12–17 years) who experience major depressive episodes—7.5%
Nutrition, Physical Activity, and • Increase proportion of adults who meet the objectives for aerobic physical activity and for muscle-strengthening
Obesity activity—20.1%
• Reduce proportion of adults (20 years and older) who are obese—30.5%
• Reduce proportion of children and adolescents (2–19 years) who are considered obese—14.5%
• Increase total vegetable intake for all persons (2 years and older)—1.14 cup equivalent per 1000 calories
Oral Health • Increase proportion of children, adolescents, and adults who used the oral healthcare system in the past year—49%
Reproductive and Sexual Health • Increase proportion of sexually active females (15–44 years) who received reproductive health services in the past 12
months—86.5%
• Increase proportion of persons living with human immunodeficiency virus (HIV) who know their serostatus—90%
Social Determinants • Increase proportion of students who graduate with a regular diploma 4 years after starting ninth grade—82.4%
Substance Abuse • Reduce proportion of adolescents reporting use of alcohol and any illicit drugs during the past 30 days—16.5%
• Reduce proportion of adults (18 years and older) who engaged in binge drinking during the past 30 days—24.4%
Tobacco • Reduce proportion of adults who are current cigarette smokers—12%
• Reduce proportion of adolescents who smoked cigarettes in past 30 days—16%
1
Data from Healthy People: Leading Health Indicators. Rockville, MD: Office of Disease Prevention and
Health Promotion; 2015. Available at http://www.healthypeople.gov/2020/Leading-Health-Indicators.
Accessed March 2015.
Health Assessment: Essential in Monitoring
Community Health
The focus of the previous chapter was assessment in relation to community
profiling and program planning for improvement of the health of the community.
On the other hand, the emphasis of this chapter is assessment for the purpose of
surveillance. Both chapters highlight the protection, promotion, and improvement
of the health of communities with an emphasis on different relevant processes.
Because of the oral-systemic link, oral health surveillance efforts build on
overall health surveillance. The focus of this chapter is surveillance of oral health
of the population. Oral health surveillance is important in relation to various
population groups, such as children, elderly, and other vulnerable populations.1,2
Assessment for surveillance can be accomplished for various common oral and
craniofacial diseases and conditions, as listed in Appendix E.
Multiple determinants influence oral health in populations1,3 (see Chapter 3).
Health and oral health disparities exist across the United States (U.S.) population,
and these disparities affect all ethnicities within all age groups.2 Oral health
problems or dental visits result in employed adults losing more than 164 million
hours of work each year.1 Oral diseases can have an effect on economic efficiency
and compromise an individual's ability to perform well at home, school, or on the
job.1,4 Oral diseases ranging from dental caries to oral cancer involve a multiplicity
of relationships among social, cultural, behavioral, environmental, and biologic
dimensions.1,3 These factors reflect the determinants of oral health and contribute to
the development and progression of oral diseases, conditions, and injuries.1,3
In addition, various factors affect the access of population groups to community
preventive services (e.g., community water fluoridation) and clinical dental services.
Community preventive services can prevent oral diseases at a community level and
improve population oral health. Clinical preventive dental services can prevent oral
problems among individuals with access to dental clinics or dental offices. Also,
oral health practices and healthy behaviors by individuals can affect oral health
outcomes. When conducting population surveillance, it is important to evaluate key
determinants that influence oral health status and access to services. The national
oral health objectives outlined in Healthy People 2020 provide an important
framework for the development of oral health assessments at the state and local
levels for the purpose of surveillance.5
The U.S. faces a crisis with the burden of chronic diseases, including oral
diseases and conditions.4 Agencies and organizations, such as the National Institute
of Health (NIH), the Centers for Disease Control and Prevention (CDC), National
Institute of Dental and Craniofacial Research (NIDCR), and the Association of
State & Territorial Dental Directors (ASTDD), are committed to improving the
oral health of the nation by expanding and improving community-wide oral health
surveillance.1,6
Healthy People
Health promotion and disease prevention are important concepts in the U.S.
Therefore, the nation has developed plans for the prevention of diseases and the
promotion of health embodied in the initiative known as Healthy People.7 These
national health objectives shape the health agenda in the U.S. and guide health
improvements. Each decade since 1980 the U.S. Department of Health and Human
Services (DHHS) has released a comprehensive set of national public health
objectives.7,8 Healthy People provides national 10-year health targets aimed at
improving the health of all Americans. It is grounded in the notion that establishing
objectives and providing benchmarks to track and monitor progress over time can
motivate, guide, and focus action.
The Healthy People initiative has been the nation's blueprint for disease
prevention and health promotion since its beginning in the 1980s.7 The initiative
originated in a 1979 report by the Surgeon General that established the precedent
for setting national health objectives and monitoring progress over an interval of a
decade.7,8 Healthy People 2000 and Healthy People 2010 set measurable national
targets to be achieved by the years 2000 and 2010, respectively.7,8 Healthy People
2020, the fourth generation of national benchmarks, was launched in 2010 and
established national objectives to be reached by the year 2020.7
ox 4-1
B
Healthy People 2020 Framew ork
Vision
A society in which all people live long, healthy lives
Mission
Healthy People 2020 objectives strive to accomplish the following:
• Provide measurable objectives and goals that are applicable at the national, state,
and local levels.
Overarching Goals
• Attain high quality, longer lives free of preventable disease, disability, injury, and
premature death.
• Achieve health equity, eliminate disparities, and improve the health of all groups.
• Create social and physical environments that promote good health for all.
• Promote quality of life, healthy development, and healthy behaviors across all life
stages.
Data from Objective Development and Selection Process. Healthy People 2020 Framework. Washington, DC:
Office of Disease Prevention and Health Promotion; 2014. Available at
http://www.healthypeople.gov/sites/default/files/HP2020Framework.pdf. Accessed January 2015; Objective
Development and Selection Process. 2020 Topics & Objectives – Objectives A-Z. Washington, DC: Office of
Disease Prevention and Health Promotion; 2014. Available at
http://www.healthypeople.gov/2020/topicsobjectives2020/default. Accessed January 2015.
FIG 4-1 Action model to achieve Healthy People 2020 overarching goals.
The outermost circle represents broad social, economic, cultural, health, and
environmental conditions and policies at the global, national, state, and local levels.
Social conditions include economic inequality, urbanization, mobility, cultural
values, attitudes, and policies related to discrimination and intolerance on the basis
of race, gender, and other differences. Other conditions at the national level include
major sociopolitical shifts, such as recession, war, and governmental collapse.
The figure also shows a feedback loop of interventions, outcomes, assessment,
monitoring, evaluation, and dissemination to enable achievement of the Healthy
People 2020 overarching goals.9 The placement of interventions (e.g., policies,
programs, and information) on this feedback loop demonstrates the impact of
interventions on the determinants of health over the course of life.7,9 In addition, the
outcomes of such interventions are demonstrated through assessment, monitoring,
evaluation, and dissemination. Through application of evidence-based practices, the
findings can be used to inform intervention planning and implementation of
effective strategies.
The general public usually understands the term health disparities to mean any
differences in health. However, in the public health community and as defined by the
Advisory Committee, the term refers to a particular type of health difference
between individuals or groups that is unfair because it is caused by social or
economic disadvantage.7 Thus, a health disparity is a particular type of health
difference that is closely linked with social or economic disadvantage. As depicted
in Figure 4-2, health disparities adversely affect groups of people who have
systematically experienced greater social or economic obstacles to health.7
Health equity is a desirable goal and standard that entails special efforts to
improve the health of those who have experienced social or economic
disadvantage.7 Health equity is oriented toward achieving the highest level of health
possible for all groups.7 According to the Advisory Committee, and as illustrated in
Figure 4-2, specific requirements are needed for health equity.7 Thus, the Advisory
Committee based their recommendations on the following short- and long-term
actions to achieve health equity:7
• Particular attention to groups that have experienced major obstacles to health
associated with being socially or economically disadvantaged
• Promotion of equal opportunities for all people to be healthy and to seek the
highest level of health possible
• Distribution of the social and economic resources needed to be healthy in a
manner that progressively reduces health disparities and improves health for all
• Attention to the root causes of health disparities, specifically health determinants, a
principal focus of Healthy People 2020
ox 4-2
B
Healthy People 2020 Topi c A reas
• Access to Health Services
• Adolescent Health*
• Cancer
• Diabetes
• Environmental Health
• Family Planning
• Food Safety
• Genomics*
• Global Health*
• Older Adults*
• Oral Health
• Physical Activity
• Preparedness*
• Respiratory Diseases
• Sexually Transmitted Diseases
• Sleep Health*
• Substance Abuse
• Tobacco Use
• Vision
Data from Healthy People 2020 Topics & Objectives – Objectives A-Z. Atlanta, GA: Centers for Disease
Control and Prevention; 2015. Available at http://www.healthypeople.gov/2020/topicsobjectives2020/default.
Accessed April 2015.
The national health objectives have served as a basis for the development of state
and community plans to improve health for over three decades.7 Many states and
localities have used the Healthy People framework, objectives, tools, and resources
to guide the development of health improvement plans and performance standards.5
Several resources based on the national health objectives have been developed to
guide these planning initiatives (see Additional Resources in Chapters 3, 4, and 5).
Healthy People 2020 oral health goal: Prevent and control oral and craniofacial diseases, conditions, and injuries, and improve access to preventive services
and dental care.
Oral He alth of Childre n and Adole sc e nts
• Reduce the proportion of children and adolescents who have dental caries experience in their primary or permanent teeth (NHANES, CDC/National Center
for Health Statistics [CHS])
• Reduce the proportion of children and adolescents with untreated dental decay (NHANES, CDC/NCHS)
Oral He alth of Adults
• Reduce the proportion of adults with untreated dental decay (NHANES,CDC/ NCHS)
• Reduce the proportion of adults who have ever had a permanent tooth extracted (partial and complete tooth loss) because of dental caries or periodontal
disease (NHANES, CDC/NCHS)
• Reduce the proportion of adults aged 45–74 years with moderate or severe periodontitis (NHANES, CDC/NCHS)
• Increase the proportion of oral and pharyngeal cancers detected at the earliest stage (National Program of Cancer Registries; National Center for
Chronic Disease Prevention and Health Promotion [NCCDPHP]; Surveillance, Epidemiology, and End Results [SEER] Program; NIH/National
Cancer Institute)
Ac c e ss to Pre ve ntive Se rvic e s
• Increase the proportion of children, adolescents, and adults who used the oral healthcare system in the past year (Medical Expenditure Panel Survey
[MEPS], Agency for Healthcare Research and Quality [AHRQ])*
• Increase the proportion of low-income children and adolescents who received any preventive dental service during the past year (MEPS, AHRQ)
• Increase the proportion of school-based health centers with an oral health component: provision of sealants, dental care, and topical fluoride (School-
Based Health Care Census [SBHCC], National Assembly on School-Based Health Care [NASBHC])
• Increase the proportion of local health departments and Federally Qualified Health Centers (FQHCs) that have an oral health program (Uniform Data
Systems [UDS], Health Resources and Services Administration [HRSA]/Bureau of Primary Health Care [BPHC])
• Increase the proportion of patients who receive oral health services at FQHCs each year (UDS, HRSA/BPHC)
Oral He alth Inte rve ntions
• Increase the proportion of children and adolescents who have received dental sealants on their primary and permanent molar teeth (NHANES, CDC/NCHS)
• Increase the proportion of the U.S. population served by community water systems with optimally fluoridated water (Water Fluoridation Reporting
System [WFRS], CDC/NCCDPHP)
• (Developmental) Increase the proportion of adults who receive preventive interventions in dental offices: counseling on reduction of tobacco use or cessation,
screening for oral and pharyngeal cancers, and testing or referral for glycemic control (NHANES, CDC/NCHS)
Monitoring , Surve illanc e Syste ms
• (Developmental) Increase the number of states (including the District of Columbia) that have systems for recording and for referring infants and children
with cleft lips and cleft palates to craniofacial anomaly rehabilitative teams (Annual Synopses of State and Territorial Dental Public Health Programs
[ASTDD Synopses], Association of State & Territorial Dental Directors [ASTDD])
• Increase the number of states that have an oral and craniofacial health surveillance system (ASTDD Synopses, ASTDD)
Public He alth Infrastruc ture
• Increase the proportion of state and local health agencies and programs that have a dental public health program directed by a dental professional with
public health training (ASTDD Synopses, ASTDD)
• Increase the number of tribal health agencies and programs that have a dental public health program directed by a dental professional with public health
training (Indian Health Services, CDC Division of Oral Health)
*
Leading Health Indicator (LHI)
Data from Healthy People 2020 Oral Health Objectives. Rockville, MD: Office of Disease Prevention and
Health Promotion; 2015. Available at https://www.healthypeople.gov/2020/topics-objectives/topic/oral-
health. Accessed April 2015.
TABLE 4-2
Healthy People 2020: Selected Health Objectives That Relate to Oral
Health
Data from Healthy People 2020 Topics and Objectives – Objectives A-Z. Rockville, MD: Office of Disease
Prevention and Health Promotion; 2014. Available at
https://www.healthypeople.gov/2020/topicsobjectives2020/default. Accessed January 2015.
The Healthy People 2020 oral health objectives are based on the latest research
and scientific evidence related to oral health.5 They combine current information
with contemporary public health principles to benefit the largest number of people
in the U.S. The oral health objectives inform decision making and resource
allocation by driving action at national, state, and local levels toward the
achievement of common oral health improvement goals.5 States, territories, tribes,
and localities can use the framework to guide health plans for oral health
improvements. The oral health objectives can shape the development and
implementation of policies, interventions, programs, and practices tailored for
specific population groups. The objectives identify significant opportunities to
improve oral health for all Americans by providing a focus for efforts in the public,
private, and nonprofit sectors.5 In addition, these objectives provide a framework
for measuring oral health indicators and progress toward achievement of targets.5
Additional information about measures used to monitor Healthy People 2020
objectives and the key data sources can be found in the Additional Resources and
References at the end of this chapter.
Oral Health Surveillance Systems
Public health surveillance is the ongoing systematic collection, analysis, and
interpretation of outcome-specific health-related data needed for the planning,
implementation, and evaluation of public health practice.13 The purpose is to
provide information necessary for public health decision making.14 Surveillance can
be used to monitor and clarify the epidemiology of health problems, to allow
priorities to be set, and to inform public health policy and strategies.13 An effective
public health surveillance system routinely collects data on health outcomes, risk
factors, and intervention strategies for the whole population or representative
samples of the population.14
A comprehensive public health surveillance system integrates oral health and is
essential for programmatic activities to improve oral health. Several agencies and
national organizations have stressed the importance of oral health surveillance
systems to routinely collect data on oral health outcomes, risk factors, and
intervention strategies for the population.15,16 The CDC recommends surveillance if
a health-related event, such as an oral disease or condition affects many people,
requires large expenditures of resources, is largely preventable, and is of public
health importance.16
Oral health surveillance systems are not only oral health data collection systems.
Oral health surveillance also involves timely communication of oral health findings
to responsible parties and the public, and using oral health data to initiate and
evaluate public health measures to prevent and control oral diseases.16 An oral
health surveillance system should contain at a minimum a core set of oral health
measures that describe the status of important oral health conditions to serve as
benchmarks for assessing progress in achieving oral health improvements.16,17
Historically, the oral health surveillance system has been under the control of the
federal government. Even though a few states have collected data over the years, a
comprehensive oral health surveillance system at the state level has not existed.16
Steps have been taken in the U.S. at the national, state, and local levels to
formulate a systematic approach for oral health data collection and reporting.16 The
focus of these collaborative efforts among organizations and agencies has been to
promote oral health assessment and monitoring that could be applied in a wide
range of environments. These efforts also have stressed the importance of oral
health program evaluation in light of contemporary public health principles. An
important aim of these efforts has been the dissemination of procedures for
collecting comparable data to assess oral health. A long-term goal includes an
approach for continuous monitoring of oral health at the national, state, and
community levels, as well as an expansion of indicators in oral health surveillance
systems. Results of these endeavors include the development of standard ways to
monitor the national oral health objectives, creation of an oral health needs
assessment model, and documentation of uniform methods to measure community
oral health.15,16
The ASTDD is a national nonprofit organization that represents state and
territorial public health agency programs for oral health. The organization has
developed and updated several resources that provide guidance on oral health
surveillance, including a best practices report that provides a review of oral health
assessment measures, methods, and standards (Box 4-3).16
ox 4-3
B
Best Practi ce Cri teri a for a State-Based Oral
H eal th Survei l l ance Sy stem, A ST DD
1. Impact/Effectiveness:
• Data and findings from the surveillance system are used for
public health actions.
2. Efficiency:
TABLE 4-3
Basic Screening Survey Screening Indicators
Data from Basic Screening Surveys: An Approach to Monitoring Community Oral Health: Preschool &
School Children. Association of State and Territorial Dental Directors; 2008. Available at
http://www.azdhs.gov/phs/owch/oral-health/documents/infant-youth/ASTDD-BSS-manual.pdf. Accessed
February 2015; Basic Screening Surveys: An Approach to Monitoring Community Oral Health: Older Adults.
Association of State and Territorial Dental Directors; 2010. Available at http://www.prevmed.org/wp-
content/uploads/2013/11/BSS-SeniorsManual.pdf. Accessed March 2015.
For all age groups, observations of oral health status are made by dentists, dental
hygienists, or other appropriate healthcare workers in accordance with state law.18,19
Questionnaires can be administered by nondental personnel. When the BSS is used
with an older adult population that has limited cognitive function, the ASTDD
suggests that the BSS be limited to an in-mouth screening with an option of
obtaining some information from the resident, resident's guardian, or staff.19
TABLE 4-5
Oral Health Indicators in National Oral Health Surveillance System
(NOHSS), 2010
Data from National Oral Health Surveillance System. Atlanta, GA: Centers for Disease Control and
Prevention; 2010. Available at http://www.cdc.gov/nohss/index.htm. Accessed April 2015.
TABLE 4-6
New 2012 NOHSS Oral Health Indicators Approved by the Council of
State andTerritorial Epidemiologists (CSTE), and Accompanying Data
Sources
Data from Proposed New and Revised Indicators for the National Oral Health Surveillance System. Council
of State and Territorial Epidemiologists; 2012. Available at
http://c.ymcdn.com/sites/www.cste.org/resource/resmgr/PS/12-CD-01FINALCORRECTEDOCT201.pdf.
Accessed April 2015.
A major data source for assessment and surveillance data is the National Health
and Nutrition Examination Survey (NHANES), an initiative of the CDC.22 The
NHANES is a program of studies designed to provide a comprehensive assessment
of the health and nutritional status of adults and children in the U.S. The survey is
unique in that it combines interviews and physical examinations (Figure 4-4). Oral
health is a component of this survey, providing comprehensive data for surveillance
and assessment for program planning. Two other important health surveillance
surveys in the U.S. that include questions related to oral health are the National
Health Interview Survey (NHIS) and the Behavioral Risk Factor Surveillance
System (BRFSS).20
FIG 4-4 The NHANES is unique in that it includes interviewing by an examiner in
addition to an oral examination. (© iStock.com.)
A review of these and other data sources for the NOHSS oral health indicators
presented in Table 4-6 and Appendix D will bring about an understanding of the
breadth of oral health–related data that is available. These data sources are useful
during the data gathering stage of assessment for program planning (see Chapter 3)
and for surveillance. Data are available in various forms from these sources,
including charts, graphs, and interactive web-based oral health maps. Data are
presented for the nation and by state and county. Several resources have been
developed to provide guidance to national, state, territorial, tribal, and local oral
health programs in planning and implementing oral health surveillance systems (see
Additional Resources and References at the end of this chapter).
Measuring Oral Health and Its Determinants
in Populations
This chapter focuses on measurements of oral health used in population-based oral
health surveillance systems and oral health surveys. The text highlights common
measures used to assess population oral health, specifies oral health indicators
included in Healthy People 2020 and the NOHSS and provides an overview of
clinical and nonclinical data collection measures of oral health and related factors.
Measures and methods used for assessment of individual patients in clinical settings
or in clinical studies (including clinical trials) are not emphasized in this chapter.
Other books review clinical evaluation techniques or clinical research methods.23,24
Selection of data collection methods and measures for community oral health
assessment should be based on the following:
TABLE 4-7
Attributes of an Effective Dental Index
Attribute Explanation
Validity Index accurately measures what is intended
Reliability Index measures consistently at different times; results of measures are reproducible and stable
Utility Criteria are clear, simple, objective, and easy to understand
Sensitivity Small degrees of differences in the variable can be detected by the index
Acceptability Application of the index is not unnecessarily painful, time demanding, or demeaning to participants, and use of the index has minimal
expense and hassle
Quantifiability Statistics can be applied to data collected with the index
Clinical Index criteria are clinically meaningful
significance
Data from Lo E. Caries Process and Prevention Strategies: Epidemiology, CE course No. 368.
Dentalcare.com; 2014. Available at http://www.dentalcare.com/en-US/dental-education/continuing-
education/ce368/ce368.aspx?ModuleName=introduction&PartID=-1&SectionID=-1. Accessed April 2015.
The DMF index has been modified to the dmf, df, and def indexes for use with
primary teeth in children.24 The lower case letters signify the use of the index on
primary teeth, in contrast to the upper case letters (e.g., DMFT) denoting the index
for permanent teeth. In general, the dmf, df, and def are used and interpreted in the
same way as the DMF. However, adjustments have been made in their scoring to
compensate for the exfoliation of teeth in children. The scoring criteria for the dmf,
df, and def can be found also in Appendix F.
The BSS discussed earlier uses a basic screening approach to assess untreated
dental caries and dental caries experience on a per-person basis.18,19 See Box 4-5 for
an explanation of the scoring of dental caries with the BSS. Population measures are
formulated to indicate the proportion of the population that has caries experience
versus being caries-free. These terms are used commonly to describe the dental
caries status of population groups, which can be determined with the BSS or the
DMF index (Figure 4-5).
ox 4-5
B
Use of the BSS to Measure Dental Cari es i n a
Popul ati on
• Treated and untreated dental caries are scored.*
• Dichotomous measures (yes or no) are used on a per-person basis to score the
absence or presence of untreated decay and caries experience.
• A tooth is considered to have untreated decay when the screener can readily
observe breakdown of the enamel surface; only cavitated lesions in pits and
fissures and on smooth tooth surfaces are scored.
• Dental caries experience is defined as at least one decayed tooth, restored tooth, or
missing tooth resulting from prior exposure to tooth decay.
Data from Basic Screening Surveys: An Approach to Monitoring Community Oral Health: Preschool & School
Children. Association of State and Territorial Dental Directors; 2008. Available at
http://www.azdhs.gov/phs/owch/oral-health/documents/infant-youth/ASTDD-BSS-manual.pdf. Accessed
February 2015; Basic Screening Surveys: An Approach to Monitoring Community Oral Health: Older Adults.
Association of State & Territorial Dental Directors; 2010. Available at http://www.prevmed.org/wp-
content/uploads/2013/11/BSS-SeniorsManual.pdf. Accessed March 2015.
FIG 4-5 Caries experience and caries-free (Data from Basic Screening Surveys: An
Approach to Monitoring Community Oral Health: Preschool & School Children. Association of State
and Territorial Dental Directors; 2008. Available at http://www.azdhs.gov/phs/owch/oral-
health/documents/infant-youth/ASTDD-BSS-manual.pdf. Accessed February 2015; Basic Screening
Surveys: An Approach to Monitoring Community Oral Health: Older Adults. Association of State &
Territorial Dental Directors; 2010. Available at http://www.prevmed.org/wp-
content/uploads/2013/11/BSS-SeniorsManual.pdf. Accessed March 2015.)
ox 4-6
B
Compari son of Treatment N eed Cl assi fi cati on
Sy stems
BSS, WHO, NHANES
BSS 19 WHO 25 NHANES 22
• Urgent need for dental care, as soon 0—No treatment needed 1—Should see a dentist immediately
as possible 1—Preventive or routine treatment needed 2—Should see a dentist within 2 weeks
• Early dental care needed, within 2—Prompt treatment including scaling needed 3—Should see a dentist at earliest
several weeks 3—Immediate (urgent) treatment needed because of pain or infection of convenience
• No obvious problems, next regular dental or oral origin 4—Should continue with regular routine
checkup 4—Referred for comprehensive evaluation of medical/dental treatment dental care
(systemic conditions)
FIG 4-6 A young child is screened for sealants in a school-based oral health
program. (Photograph courtesy Terri Patrick.)
ox 4-7
B
Measurement of Seal ants w i th the BSS
• A dichotomous measure (yes or no) is used to assess for the presence of dental
sealants on a per-person basis.*
• Children are coded as having sealants if they have at least one sealant in the mouth.
• On a primary molar in 3- to 5-year-olds
*Some states elect to adapt the scoring by counting the number of sealed permanent molars in each survey
participant's mouth.
Data from Basic Screening Surveys: An Approach to Monitoring Community Oral Health: Preschool & School
Children. Association of State and Territorial Dental Directors; 2008. Available at
http://www.azdhs.gov/phs/owch/oral-health/documents/infant-youth/ASTDD-BSS-manual.pdf. Accessed
February 2015.
Sometimes oral health survey protocols limit measurements for dental sealants to
selected tooth surfaces or teeth (e.g., permanent molars).15,18 Also, the survey
protocol can limit sealant measurement to specific age groups. For example, in the
U.S., the use of the NHANES to monitor the NOHSS oral health indicator of dental
sealants is limited to specific teeth in the age groups represented in the Healthy
People 2020 objective (primary molars in children aged 3 to 5 years and permanent
molars in children aged 6 to 9 years and 13 to 15 years).22,32,36
The criteria for the BSS exclude the measurement of sealants in preschool
children.18 However, the Healthy People 2020 dental sealant objective includes a
target for sealants in primary molars of children aged 3 to 5.32 As a result the
NHANES has added the measurement of dental sealants on primary molars in this
age group as a means of tracking progress on this objective.22,36
Periodontitis
Periodontitis is manifested by the loss of the connective tissue and bone that support
the teeth.37 Unless appropriate treatment commences, periodontitis is likely to
progress to advanced stages of bone destruction, placing the individual at risk for
eventual tooth loss.37 Of great public health concern is the association of periodontal
disease with the four leading chronic diseases—cardiovascular disease, cancer,
chronic respiratory disease, and diabetes.24
Measurement of periodontal disease is complicated by the complexity of the
disease process.24 The disease may occur differently around different teeth and
around different sites of the periodontium surrounding the same tooth. Also, the
different rates of disease progression, its varied pathophysiologic profile, and its
range of presentation add to the difficulty of accurate measurement.24
Various scaled indexes have been used in the past to assess periodontitis, but these
were composite indexes that scored gingivitis and periodontitis on the same scale.
Composite indices are now considered invalid and thus have been discarded.38
Contemporary measurements of the health of periodontal tissues in population-
based surveys reflect current theories of the pathogenesis of periodontal diseases.38
According to the American Academy of Periodontology (AAP), CAL, a measure
of accumulated past disease at a site rather than current activity, remains a
diagnostic “gold standard” for periodontitis.38 Therefore, a disaggregated approach
is taken to evaluate and record clinical signs and accumulated destructive results of
past disease. This disaggregated measurement method has been used in the
NHANES since 1988 to monitor changes in periodontal disease status and trends
and to track achievement of targets for the Healthy People national oral health
objectives related to periodontal disease.24,32 The WHO also uses this manner of
measuring periodontal disease, which allows for comparison of the status and
trends of periodontal disease from one population to another.25,35
Historically, clinical periodontal examination has been included in the NHANES
national health surveys in the U.S. and in the WHO surveys in other countries.22,25
Explicit protocols and criteria are outlined for assessments of periodontal status as
part of the oral epidemiologic examination procedures of these surveys, including
the measurement of specific parameters to assess periodontal status (Figure 4-7).22,25
Clinical attachment loss is defined as recession combined with pocket formation,
measured with a periodontal probe.22,25
FIG 4-7 Parameters to assess periodontal status (Data from National Health and
Nutrition Examination Survey [NHANES]: Oral Health Dental Examiners Manual. Atlanta, GA: Centers
for Disease Control and Prevention; 2013. Available at
http://www.cdc.gov/nchs/data/nhanes/nhanes_13_14/Oral_Health_Examiners.pdf. Accessed
February 2015; Oral Health Surveys: Basic Methods. 5th ed. Geneva: World Health Organization;
2013. Available at http://apps.who.int/iris/bitstream/10665/97035/1/9789241548649_eng.pdf.
Accessed February 2015.)
Bleeding is included as one of the parameters for periodontal status because of its
relationship to the progression of periodontitis.22 Substantial oral debris is included
on the BSS as an optional indicator. It is defined as “an abundance of soft or hard
matter covering more than 2/3 of any tooth surface” and measured on a
dichotomous scale. Calculus was measured as part of the NHANES periodontal
assessment at one time, but it is no longer included in epidemiologic assessment
because it is not considered a predictor of future disease.22,24,38 Mobility is measured
on the BSS on a per-person basis using a dichotomous scale.19
Before 2009 the NHANES measured periodontitis using a partial-mouth scoring
approach rather than full-mouth examinations.22,36 Two quadrants (one upper and
one lower) were randomly selected for probing of two or three sites per tooth.22,36
More recent NHANES surveys have included a full-mouth probing examination to
test validity of measurement procedures.22
Periodontitis has been measured in the poppulation on adults and not older adults
in the past,8 based on the age range of the Healthy People 2010 objective related to
periodontitis in adults (35- to 44-year-olds). This practice has potentially led to
underestimating the prevalence of periodontal disease in the U.S. population.24 As a
result the Healthy People 2020 periodontal disease objective has been focused on a
more representative age range of adults (46- to 74-year-olds), and the new
NHANES surveys have been adjusted to assess periodontitis in this same age
group.32
The WHO CPI that was described earlier for measurement of bleeding is also
used to assess recession, pocket depth, and CAL, according to the WHO Oral Health
Surveys: Basic Methods manual.25 The WHO developed the CPI by modifying their
Community Periodontal Index of Treatment Needs index. The treatment need codes
for observed conditions were eliminated because they no longer reflected
contemporary theories of periodontal disease.24 The CPI allows for a rapid
assessment of periodontal status of a population according to various grades of
periodontal health (see Appendix F). The CPI was also the basis for the development
of the Periodontal Screening Record (PSR) by the American Dental Association for
screening in the clinical setting.27
Sometimes, to increase efficiency, lower cost, and decrease time spent on the
epidemiologic examination, partial-mouth periodontal measurements are made to
assess periodontal status.24 For example, the CPI identifies specific index teeth for
different age groups,25 although it can be applied to whole mouth scoring as well.
Also, as described earlier, the NHANES has used partial-mouth scoring in the past.
Historically, the Periodontal Disease Index (PDI) included specific teeth to be
measured, which presumably represented the whole mouth; these teeth are referred
to as the “Ramfjord teeth,” named after Dr. Ramfjord, who created the index.24
Although the index is no longer useful because it too no longer reflects
contemporary theories of periodontal disease, the Ramfjord teeth (Box 4-8)
continue to be used for partial-mouth scoring of dental indices in assessment,
surveillance, and clinical research studies.24
ox 4-8
B
Ramfjord Teeth
• Tooth #3: Right maxillary first molar
Data from Chattopadhyay A. Oral Health Epidemiology: Principles and Practice. Sudbury, MA: Jones and
Bartlett; 2011.
Q2. Overall, how would you rate the health of your teeth and gums?
Q3. Have you ever had treatment for gum disease, such as scaling and root planing,
sometimes called deep cleaning?
Q4. Have you ever had any teeth become loose on their own without injury?
Q5. Have you ever been told by a dental professional that you have lost bone around
your teeth?
Q6. During the past 3 months, have you noticed a tooth that doesn't look right?
Q7. Aside from brushing your teeth with a toothbrush, in the last 7 days, how many
days did you use dental floss or any other device to clean between your teeth?
Q8. Aside from brushing your teeth with a toothbrush, in the last 7 days, how many
days did you use mouthwash or other dental rinse product that you use to treat
dental disease or dental problems?
Data from National Health and Nutrition Examination Survey: Oral Health Questionnaire. Hyattsville, MD:
National Center for Health Statistics, Centers for Disease Control and Prevention; 2013–2014. Available at
http://www.cdc.gov/nchs/data/nhanes/nhanes_13_14/OHQ_H.pdf. Accessed February 2015.
Other outcomes of the workgroup will also impact the future of surveillance of
periodontitis in the U.S. The workgroup produced standard case definitions of
periodontitis for application to surveillance and research; these definitions are now
widely recognized and applied in population studies and research,40 including the
NHANES tracking of Healthy People 2020 objectives32 (Figure 4-8). These
definitions can standardize future surveillance efforts. The workgroup will continue
to explore ways to improve periodontal disease surveillance in the U.S.40
FIG 4-8 Healthy People 2020 case definitions of moderate and severe
periodontitis (From Healthy People 2020: Oral Health. Rockville, MD: Office of Disease Prevention
and Health Promotion; 2015. Available at https://www.healthypeople.gov/2020/topics-
objectives/topic/oral-health. Accessed February 2015.)
ox 4-10
B
Sel f-Report Questi ons Rel ated to Tooth Loss
BRFSS, 2014
• How many of your permanent teeth have been removed because of tooth decay or
gum disease? Include teeth lost to infection, but do not include teeth lost for other
reasons, such as injury or orthodontics. Note: If wisdom teeth are removed
because of tooth decay or gum disease, they should be included in the count for
lost teeth.
NHIS, 2014
• Have you lost all of your upper and lower natural (permanent) teeth?
Data from 2014 Behavioral Risk Factor Surveillance System (BRFSS) Questionnaire. Atlanta, GA: Centers for
Disease Control and Prevention; 2013. Available at http://www.cdc.gov/brfss/questionnaires/pdf-
ques/2014_BRFSS.pdf. Accessed February 2015; National Health Interview Survey: Questionnaires, Datasets,
and Related Documentation: 1997 to the Present: 2014 NHIS & 2015 NHIS. Available at
http://www.cdc.gov/nchs/nhis/quest_data_related_1997_forward.htm. Accessed May 2015.
ox 4-11
B
Questi ons to A ssess Recei pt of Oral Cancer
Ex ami nati on, 2013–2014, N H A N ES and BSS
NHANES
Q1. In the past 12 months, did a dentist, hygienist, or other dental professional have
a direct conversation with you about the importance of examining your mouth for
oral cancer?
Q2. Have you ever had an examination for oral cancer in which the doctor or dentist
pulls on your tongue, sometimes with gauze wrapped around it, and feels under
the tongue and inside the cheeks?
Q3. Have you ever had an examination for oral cancer in which the doctor, dentist,
or other health professional feels your neck?
Q4. When did you have your most recent oral or mouth cancer examination? Was it
within the past year, between 1 and 3 years ago, or over 3 years ago?
Q5. What type of healthcare professional performed your most recent oral cancer
examination?
BSS
Q1. Have you ever had a check for oral cancer in which the doctor or dentist pulls
on your tongue, sometimes with gauze wrapped around it, and feels under the
tongue and inside the cheeks?
Data from 2013-2014 National Health and Nutrition Examination Survey (NHANES): Oral Health Questionnaire.
Atlanta, GA: Centers for Disease Control and Prevention; 2015. Available at
http://www.cdc.gov/nchs/data/nhanes/nhanes_13_14/OHQ_H.pdf. Accessed April 2015; Basic Screening Surveys:
An Approach to Monitoring Community Oral Health: Older Adults. Association of State & Territorial Dental
Directors; 2010. Available at http://www.prevmed.org/wp-content/uploads/2013/11/BSS-SeniorsManual.pdf.
Accessed March 2015.
ox 4-12
B
Components of the W H O Gl obal Tobacco
Survei l l ance Sy stem (GT SS)
• Global Youth Tobacco Survey (GYTS)—survey for youth aged 13–15 years
conducted in schools
• Access to cigarettes
• Demographics
• Exposure to media
• Economics
Craniofacial Anomalies
Orofacial clefts have a significant impact on the healthcare system and are
candidates for public health surveillance32 (see Chapter 5). In the U.S. craniofacial
anomalies (including cleft lip and palate) are usually expressed as a proportion or
rate based on recordings of congenital anomalies on birth certificates.32 However,
recordings of craniofacial anomalies and oral clefts on birth certificates is not
universal. This inadequacy of surveillance related to oral and craniofacial
anomalies has been addressed by public health officials.32
A Healthy People 2020 oral health objective is to increase the number of states
(including the District of Columbia) that have a system for recording clefts at birth,
as well as referring infants and children with cleft lip and cleft palate to craniofacial
anomaly rehabilitative teams.32 Healthy People 2020 also has an objective that
focuses on increasing the number of states and the District of Columbia that have an
oral and craniofacial health surveillance system. Both objectives will be measured
through the Annual Synopses of State and Territorial Dental Public Health
Programs routinely prepared by the ASTDD.32
Malocclusion
Malocclusion can be assessed during a population-based oral health survey through
evaluation of occlusal characteristics. The WHO has incorporated an epidemiologic
examination of dental aesthetics in the protocol for a basic oral health survey. In this
assessment an individual's social and psychological well-being is considered to be
the main benefit of orthodontic treatment. It includes objective measurements of
aesthetic acceptability according to social norms.25
The BSS includes the measurement of posterior functional contacts as an optional
indicator on the older adult survey to determine whether teeth oppose each other and
can function properly while the individual is eating.19 A dichotomous measure
(yes/no) is used to indicate if any functional contacts exist on each side of the mouth.
At various times function, aesthetics, and occlusal contacts have been measured by
NHANES, although not since 2008 when functional contacts were measured. Current
NHANES versions do not focus on these measurements.36
Dry Mouth
With the increasing average age of the U.S. population and the greater use of
medications that produce xerostomia, there has been interest in tracking this
condition in the population. The older adult BSS includes severe dry mouth as an
optional indicator on the oral examination.19 Several NHANES surveys in the early
2000s included questions concerning dry mouth and problems with chewing food.36
Denture Use
The use of dentures can be assessed in epidemiologic surveys with interview
questions regarding denture wear. NHANES has routinely included questions about
the use of partial and full dentures during the last 14 years.36 The BSS includes a
question asked of participants during screening about whether they have an upper
and/or a lower denture and whether or not they wear their dentures while they eat.19
Data from Chattopadhyay A. Oral Health Epidemiology: Principles and Practice. Sudbury, MA: Jones and
Bartlett; 2011; National Health and Nutrition Examination Survey (NHANES): Oral Health Dental Examiners
Manual. Atlanta, GA: Centers for Disease Control and Prevention; 2013. Available at
http://www.cdc.gov/nchs/data/nhanes/nhanes_13_14/Oral_Health_Examiners.pdf. Accessed February
2015.
Oral examination for fluorosis was included in the 2013–2014 NHANES survey
and has been assessed regularly during the previous 14 years to establish a trend for
the prevalence of fluorosis.22,36 According to the DHHS, the need to continue
surveillance of fluorosis will continue to monitor the effect of the new
recommendation for the optimal fluoride content of the water in relation to
fluoridation (see discussion under next section, Measurement of Access to Water
Fluoridation).52 On the 2013–2014 NHANES, imaging of teeth was accomplished
with fluorescence and white light. These images will be read remotely by experts
and analyzed with the epidemiologic dental fluorosis examination to enhance long-
term efforts at estimating prevalence of dental fluorosis in the U.S. population
within the operational scope of the NHANES.36
ox 4-13
B
Concl usi ons and Recommendati on of the
Federal Panel on Communi ty Water
Fl uori dati on of the DH H S
New Water Fluoridation Recommendation, 2015
Conclusions
1. Community water fluoridation remains an effective public health strategy for
delivering fluoride to prevent tooth decay and is the most feasible and cost-
effective strategy for reaching entire communities.
3. Caries preventive benefits can be achieved and the risk of dental fluorosis
reduced at a fluoride level of 0.7 mg/L for water fluoridation.
4. Recent data do not show a convincing relationship between water intake and
outdoor air temperature.
Recommendation
For community water systems that add fluoride to their water, the U.S. Public Health
Service (PHS) recommends a fluoride concentration of 0.7 mg/L (parts per million
[ppm]) to maintain caries prevention benefits and reduce the risk of dental
fluorosis.
Data from U.S. Department of Health and Human Services Federal Panel on Community Water Fluoridation. U.S.
Public Health Service recommendation for fluoride concentration in drinking water for the prevention of dental
caries. Public Health Rep 2015;130(July–August):14p/e. Available at
http://www.publichealthreports.org/documents/PHS_2015_Fluoride_Guidelines.pdf. Accessed May 2015.
A Healthy People 2020 objective in the topic area Access to Health Services
addresses the need to increase coverage of dental insurance.10
Survey questions through interviews and questionnaires have been used to collect
data relative to this indicator.19,25 The Medical Expenditure Panel Survey (MEPS)
and other national surveys, such as the NHANES, NHIS, and BRFSS, include
specific questions that are used to measure progress on this Healthy People 2020
objective.36,41,42,55 In addition, the BSS manuals Basic Screening Surveys: An
Approach to Monitoring Community Oral Health: Older Adults19 and Basic
Screening Surveys: An Approach to Monitoring Community Oral Health: Preschool
& School Children18 list examples of questions about access to oral health care.
These and other validated questions can be selected for inclusion in self-
administered questionnaires and interviewer-administered surveys conducted by
states and local communities.15,16 Box 4-14 outlines questions relative to access to
oral healthcare services that were included in the 2014 BRFSS and the BSS. The
BRFSS questions are part of a survey questionnaire that is completed by adult
participants and parents of children participating in school-based oral health
surveys.41 The BBS questions are used in national, state, and local surveys of older
adults.19
ox 4-14
B
Questi ons to Eval uate the Use of the Oral
H eal thcare Sy stem
Adults
• During the past 12 months, was there any time when you needed dental care
(including checkups) but didn't get it because you couldn't afford it? (yes, no)
• What is the main reason you have not visited the dentist in the past year? (don't
know, fear, apprehension, nervousness, pain, dislike going, cost, do not have or
know a dentist, cannot get to the office or clinic [too far away], no transportation,
no appointments available, no reason to go [no problems, no teeth], other
priorities, have not thought of it, other)
Dental Insurance
• Do you have any kind of insurance coverage that pays for some or all of your
routine dental care, including dental insurance, prepaid plans such as HMOs, or
government plans such as Medicaid? (yes, no, don't know)
• Do you have insurance that helps pay for any routine dental care including
cleaning, x-rays, and examinations? (yes, no, don't know)
The CDC conducts the biennial National Study of Long-Term Care Providers
(NSLTCP) in which data are collected from administrators of residential care
communities and directors of adult day services centers relative to various services
provided for clients, including dental care.56 One of the purposes of the NSLTCP is
to offer reliable, accurate, relevant, and timely statistical information to support and
inform long-term care services policy, research, and practice, which could impact
the future of dental care provision for this vulnerable population.56 In 2014 both
questionnaires used for this study, the Residential Care Community Questionnaire
and the Adult Day Services Centers Questionnaire, included the following question
related to access to oral healthcare services:56
• Question: Mark if this residential care community provides routine and emergency
dental services by a licensed dentist.
• Responses: By (1) paid residential care community/center employees, (2)
arranging for and paying outside vendors, (3) arranging for outside vendors paid
by others, (4) referral, or (5) none of these apply/not provided.
The need to measure OHRQOL at the individual and population level has been
discussed extensively.24,57,59,61,62,63 Multiple OHRQOL survey instruments have been
developed, with the Geriatric Oral Health Assessment Instrument (GOHAI), the Oral
Health Impact Profile (OHIP), and the Child Perceptions Questionnaire (CPQ) being
among the ones most commonly used.24,61,63 A better understanding of the multiple
dimensions of OHRQOL can demonstrate the significance of oral health conditions
for individuals and for society as a whole. This increased understanding can
contribute to oral health efforts at both the individual and community level to
improve OHRQOL.59,62
Measuring the various aspects of OHRQOL during an assessment contributes to
the identification of population subgroups and oral diseases that need to be
prioritized for health promotion and disease prevention efforts.1,2,3,24 Including
OHRQOL in survey research adds a powerful dimension to the planning and
development of health promotion programs. Identifying groups who are vulnerable
for low OHRQOL, for example, children, pregnant women, and older adults, makes
it possible to target efforts aimed at improving oral health and elevating
OHRQOL.62 To accomplish this, integration of OHRQOL into routine overall
healthcare programs has been suggested, for example, in nursing homes, Head Start
facilities, federally funded health centers for indigent or homeless adults, and local
Women, Infants, and Children (WIC) programs.57
Measurement of OHRQOL is also fundamental in relation to the evaluation of
outcomes of initiatives. At the population level, this can enrich the data available to
track progress, make decisions, create accountability, improve the quality of future
initiatives and efforts, and market successful efforts.24 At an individual level, a focus
on OHRQOL can help to ensure that treatments provided result in health gains that
enhance not only the individual's clinical status but also his or her QOL.24,63
Epidemiologic survey research can be used to examine trends in OHRQOL, identify
individual and environmental characteristics that affect OHRQOL, such as income
and education, aid in needs assessment and oral health planning for population-
based policy initiatives, and determine the success of such initiatives.57
The link between OHRQOL and oral health status is not straightforward and is
influenced by various individual and socioenvironmental factors. Therefore,
assessment of OHRQOL for dental public health purposes should be accomplished
for each country or community rather than globally.62 In the evaluation of outcomes,
the economic, social, and psychological consequences of oral diseases, conditions,
and injuries should be considered.62
Perceived health status and general assessment of oral health are common
measurements used in population-based oral health surveys. The WHO Oral Health
Surveys: Basic Methods manual includes suggested survey questions to assess
OHRQOL25 (Box 4-15). These questions have been included in national and
international health surveys and can be used for state and local assessments.
NHANES and NHIS have included similar questions during various survey cycles
over the last few years for the purpose of surveillance.36,42
ox 4-15
B
Oral H eal th–Rel ated Qual i ty of Li fe Questi ons,
W H O Oral H eal th Survey
Basic Methods Adult Questionnaire, 2013
Q1. During the past 12 months, did your teeth or mouth cause any pain or
discomfort? (yes, no, don't know)
Q2. Because of the state of your teeth or mouth, how often have you experienced
any of the following problems during the past 12 months? (very often, fairly
often, sometimes, not at all, don't know)
• Dry mouth
2. As a member of the board of your state dental hygiene association, you are
appointed to a task force to partner with the state dental association to explore ways
to strengthen the oral health program in your state. What principles of infrastructure
and capacity will guide your efforts on this initiative? What information about the
infrastructure and capacity of the current state oral health program do you need, and
where can you find that information? Where would you find other information to
help you meet the objectives of the task force? What resources could you use? Who
could you contact for further information?
3. Your local community water supply has been fluoridated for over 25 years. In
response to the new PHS recommendations, the city council is reconsidering water
fluoridation for the community. As a dental hygienist practicing in the community,
you would like to meet with city council members to provide current, evidence-
based information to help them make the decision to continue fluoridating the
community water supply. Describe how you would prepare to meet with them. What
information would you need? Where could you get the information? How else
could you assist the city council with this important decision?
5. Your mother lives in a residential facility for older adults in your community.
The director of the facility asks for your assistance as a dental hygienist to develop
a comprehensive oral health program for the residents of the facility. What general
information about access to oral health care and oral health quality of life specific
to this population in our nation would you need to learn? What resources could you
use to acquire this information? What steps could you take to identify the oral health
needs and the oral health quality of life of the residents of the facility? How could
you find out what resources are available for oral health care for this population in
your community? Who could you contact?
Dental Hygiene Competencies
Reading the material in this chapter and participating in the activities of Applying
Your Knowledge will contribute to the student's ability to demonstrate the following
competencies:
HP.5
Evaluate factors that can be used to promote patient adherence to disease prevention
or health maintenance strategies.
Community Involvement
CM.1
Assess the oral health needs and services of the community to determine action
plans and availability of resources to meet the healthcare needs.
CM.6
Evaluate the outcomes of community-based programs, and plan for future activities.
Community Case
In your position as the State Dental Director, you have received a request from the
State Health Officer for the State Department of Public Health that the State Health
Surveillance System be reorganized and changed based on the Healthy People 2020
health objectives. You are asked to develop a plan to integrate an updated oral health
component for this State Health Surveillance System.
1. All of the following resources should be reviewed during the early planning of
the oral health component for the State Health Surveillance System EXCEPT one.
Which one is this EXCEPTION?
a. National Healthy People 2020 oral health objectives
b. National Oral Health Surveillance System (NOHSS)
c. The Dental, Oral, and Craniofacial Data Resource Center (DRC)
d. The Oral Health Impact Profile (OHIP)
2. What measure would be used to assess untreated tooth decay?
a. Percentage of persons with a CPI score of ≥ 1
b. Percentage of persons with ≥ 1 dft or DMFT
c. Percentage of persons with ≥ 1 dt or DT
d. Percentage of edentulous persons
3. In designing a survey to evaluate access to dental care, all of the following
EXCEPT one is most often collected with the use of a questionnaire. Which one is
the EXCEPTION?
a. Last oral cancer examination
b. Usual source of dental care
c. Annual dental visit
d. Reason for not having a dental visit in the past year
4. Which survey method would you select to replicate in the state to assess the
presence of dental sealants among third-grade students?
a. National Health Interview Survey (NHIS)
b. Association for State & Territorial Dental Directors (ASTDD) Basic Screening
Survey (BSS)
c. Behavioral Risk Factor Surveillance Survey (BRFSS)
d. National Vital Statistics System
5. An important goal of an Oral Health Surveillance System is to assess disparities
among different segments of a population. All of the following factors EXCEPT
one are important to include in a State Oral Health Surveillance System to track
oral health disparities. Which one is the EXCEPTION?
a. Geographic location
b. Age
c. Occupation
d. Racial and ethnic background
References
1. Oral Health in America: A Report of the Surgeon General. U.S. Department
of Health and Human Services, National Institute of Dental and Craniofacial
Research, National Institutes of Health: Rockville, MD; 2000 [Available at]
http://silk.nih.gov/public/hck1ocv.@www.surgeon.fullrpt.pdf [Accessed
January 2015].
2. Improving Access to Oral Health Care for Vulnerable and Underserved
Populations. National Academy of Sciences, Institute of Medicine of the
National Academies: Washington, DC; 2011 [Available at]
https://www.iom.edu/~/media/Files/Report%20Files/2011/Improving-
Access-to-Oral-Health-Care-for-Vulnerable-and-Underserved-
Populations/oralhealthaccess2011reportbrief.pdf [Accessed April 2015].
3. Institute of Medicine of the National Academies, Committee on an Oral
Health Initiative. Advancing Oral Health in America. National Academies
Press: Washington, DC; 2011 [Available at]
http://www.hrsa.gov/publichealth/clinical/oralhealth/advancingoralhealth.pdf
[Accessed January 2015].
4. Dental Crisis in America: The Need to Expand: A Report from Chairman
Bernard Sanders. Subcommittee on Primary Health and Aging, U.S. Senate
Committee on Health, Education, Labor & Pensions: Washington, DC; 2012
[Available at]
http://www.sanders.senate.gov/imo/media/doc/DENTALCRISIS.REPORT.pdf
[Accessed April 2015].
5. About Healthy People, Healthy People 2020. Office of Disease Prevention
and Health Promotion: Rockville, MD; 2015 [Available at]
http://www.healthypeople.gov/2020/About-Healthy-People [Accessed April
2015].
6. A National Call to Action to Promote Oral Health. U.S. Department of
Health and Human Services, Public Health Service, Centers for Disease
Control and Prevention and the National Institutes of Health, National
Institute of Dental and Craniofacial Research: Rockville, MD; 2003
[Available at]
http://www.nidcr.nih.gov/DataStatistics/SurgeonGeneral/NationalCalltoAction/Docum
[Accessed January 2015].
7. History & Development of Healthy People, Healthy People 2020. Office of
Disease Prevention and Health Promotion: Rockville, MD; 2015 [Available
at] https://www.healthypeople.gov/2020/about/History-and-Development-
of-Healthy-People [Accessed January 2015].
8. Healthy People 2010 Final Review. National Center for Health Statistics:
Hyattsville, MD; 2012 [Available at]
http://www.cdc.gov/nchs/data/hpdata2010/hp2010_final_review.pdf
[Accessed January 2015].
9. Healthy People 2020 Framework, Healthy People 2020. Office of Disease
Prevention and Health Promotion: Rockville, MD; 2014 [Available at]
http://www.healthypeople.gov/sites/default/files/HP2020Framework.pdf
[Accessed January 2015].
10. 2020 Topics & Objectives – Objectives A-Z, Healthy People 2020. Office of
Disease Prevention and Health Promotion: Rockville, MD; 2015 [Available
at] https://www.healthypeople.gov/2020/topicsobjectives2020/default
[Accessed May 2015].
11. Leading Health Indicators, Healthy People 2020. Office of Disease
Prevention and Health Promotion: Rockville, MD; 2015 [Available at]
http://www.healthypeople.gov/2020/Leading-Health-Indicators [Accessed
January 2015].
12. Healthy People 2020 Leading Health Indicators: Progress Update. Office of
Disease Prevention and Health Promotion: Rockville, MD; 2015 [Available
at] https://www.healthypeople.gov/2020/leading-health-indicators/Healthy-
People-2020-Leading-Health-Indicators%3A-Progress-Update [Accessed
January 2015].
13. Public Health Surveillance. World Health Organization: Geneva; 2015
[Available at] http://www.who.int/topics/public_health_surveillance/en/
[Accessed April 2015].
14. Best Practice Approach State-Based Oral Health Surveillance System, Best
Practice Approaches for State and Community Oral Health Programs.
Association of State & Territorial Dental Directors: Reno, NV; 2011
[Available at] http://www.astdd.org/docs/BPASurveillanceSystem.pdf
[Accessed April 2015].
15. Texas Oral Health Surveillance Plan. Department of State Health Services,
Family and Community Health Services Division, Oral Health Branch:
Austin, TX; 2012 [Available at] http://www.dshs.state.tx.us/dental/TOHSS-
page-DOC.doc [Accessed January 2015].
16. Phipps K, Kuthy R, Marianos D, et al. State-Based Oral Health Surveillance
Systems: Conceptual Framework and Operational Definition. Association
of State & Territorial Dental Directors: Reno, NV; 2013 [Available at]
http://www.astdd.org/docs/state-based-oral-health-surveillance-systems-
cste-whitepaper-oct-2013.pdf [Accessed January 2015].
17. The Basic Screening Survey: A Tool For Oral Health Surveillance, Not
Research. Association of State & Territorial Dental Directors: Reno, NV;
2011 [Available at] http://www.astdd.org/docs/bss-what-is-oral-health-
surveillance-4-26-2011.pdf [Accessed January 2015].
18. Basic Screening Surveys: An Approach to Monitoring Community Oral
Health: Preschool & School Children. Association of State & Territorial
Dental Directors: Reno, NV; 2008 [Available at]
http://www.azdhs.gov/phs/owch/oral-health/documents/infant-
youth/ASTDD-BSS-manual.pdf [Accessed February 2015].
19. Basic Screening Surveys: An Approach to Monitoring Community Oral
Health: Older Adults. Association of State & Territorial Dental Directors:
Reno, NV; 2010 [Available at] http://www.prevmed.org/wp-
content/uploads/2013/11/BSS-SeniorsManual.pdf [Accessed March 2015].
20. National Oral Health Surveillance System. Centers for Disease Control and
Prevention: Atlanta, GA; 2010 [Available at]
http://www.cdc.gov/nohss/index.htm [Accessed April 2015].
21. Reed GM, Duffy R. Proposed New and Revised Indicators for the National
Oral Health Surveillance System. Council of State and Territorial
Epidemiologists: Atlanta, GA; 2012 [Available at]
http://c.ymcdn.com/sites/www.cste.org/resource/resmgr/PS/12-CD-
01FINALCORRECTEDOCT201.pdf [Accessed April 2015].
22. National Health and Nutrition Examination Survey (NHANES): Oral Health
Dental Examiners Manual. Centers for Disease Control and Prevention:
Atlanta, GA; 2013 [Available at]
http://www.cdc.gov/nchs/data/nhanes/nhanes_13_14/Oral_Health_Examiners.pdf
[Accessed February 2015].
23. Giannobile WV, Burt BA, Genco RJ. Clinical Research in Oral Health.
Wiley-Blackwell: Ames, IA; 2010.
24. Chattopadhyay A. Oral Health Epidemiology: Principles and Practice. Jones
and Bartlett: Sudbury, MA; 2011.
25. Oral Health Surveys: Basic Methods. 5th ed. World Health Organization:
Geneva; 2013 [Available at]
http://apps.who.int/iris/bitstream/10665/97035/1/9789241548649_eng.pdf
[Accessed February 2015].
26. Morgenstern H, Sohn W. Observational studies in oral health research.
Giannobile WV, Burt BA, Genco RJ. Clinical Research in Oral Health.
Wiley-Blackwell: Ames, IA; 2010.
27. Wyche CJ. Indices and scoring methods. Clinical Practice of the Dental
Hygienist. 11th ed. Lippincott Williams & Wilkins: Philadelphia, PA; 2013.
28. Nathe CN, McKinney BE, Beatty CF. Research approaches and designs.
Nathe CN. Dental Public Health & Research. 3rd ed. Pearson: Upper Saddle
River, NJ; 2011.
29. Niendorff WJ. Carious lesions. Norman OH, Garcia-Gody F, Nathe CN.
Primary Preventive Dentistry. 8th ed. 2014 [Upper Saddle River, NJ;
Pearson].
30. Lo E. Caries Process and Prevention Strategies: Epidemiology, CE course
No. 368. Dentalcare.com. [December; Available at]
http://www.dentalcare.com/en-US/dental-education/continuing-
education/ce368/ce368.aspx?
ModuleName=introduction&PartID=-1&SectionID=-1; 2014 [Accessed
April 2015].
31. Drury TF, Winn DM, Snowden CB, et al. An overview of the oral health
component of the 1988–1991 National Health and Nutrition Examination
Survey (NHANES III, Phase 1) (special issue). J Dent Res. 1996;75:620–
630.
32. Oral Health, Healthy People 2020. Office of Disease Prevention and Health
Promotion: Rockville, MD; 2015 [Available at]
https://www.healthypeople.gov/2020/topics-objectives/topic/oral-health
[Accessed February 2015].
33. Pizanis VG. Technological advances in primary dental care. Norman OH,
Garcia-Gody F, Nathe CN. Primary Preventive Dentistry. 8th ed. Pearson:
Upper Saddle River, NJ; 2014.
34. International Caries Detection and Assessment System Coordinating
Committee. Rationale and Evidence for the International Caries Detection
and Assessment System (ICDASII). ICDAS Foundation; 2011 [Available at]
https://www.icdas.org/uploads/Rationale%20and%20Evidence%20ICDAS%20II%20S
1.pdf [Accessed February 2015].
35. Oral Health: Periodontal Country Profiles. World Health Organization:
Geneva; 2015 [Available at]
http://www.who.int/oral_health/databases/niigata/en/ [Accessed April
2015].
36. National Health and Nutrition Examination Survey: Questionnaires,
Datasets, and Related Documentation. Centers for Disease Control &
Prevention: Atlanta, GA; 2014 [Available at]
http://www.cdc.gov/nchs/nhanes/nhanes_questionnaires.htm [Accessed May
2015].
37. Wilkins EM. Clinical Practice of the Dental Hygienist. 11th ed. Lippincott,
Williams & Wilkins: Philadelphia, PA; 2012.
38. American Academy of Periodontology. Position paper—Epidemiology of
periodontal diseases. J Periodontol. 2005;76:1406–1419.
39. Eke PI, Dye FA, Wei L, et al. Self-reported measures for surveillance of
periodontitis. J Dent Res. 2013;92:1041–1047; 10.1177/0022034513505621.
40. Eke PI, Thornton-Evans G, Dye B, et al. Advances in surveillance of
periodontitis: The Centers for Disease Control and Prevention Periodontal
Disease Surveillance Project. J Periodontol. 2012;83:1337–1342;
10.1902/jop.2012.110676 [Available at]
http://www.joponline.org/doi/abs/10.1902/jop.2012.110676?
journalCode=jop [Accessed April 2015].
41. Behavioral Risk Factor Surveillance System. Centers for Disease Control
and Prevention: Atlanta, GA; 2015 [Available at] http://www.cdc.gov/brfss/
[Accessed January 2015].
42. National Health Interview Survey: Questionnaires, Datasets, and Related
Documentation 1997 to the Present. Centers for Disease Control &
Prevention: Atlanta, GA; 2015 [Available at]
http://www.cdc.gov/nchs/nhis/quest_data_related_1997_forward.htm
[Accessed May 2015].
43. National Program of Cancer Registries (NPCR): About the Program.
Centers for Disease Control and Prevention: Atlanta, GA; 2013 [Available
at] http://www.cdc.gov/cancer/npcr/about.htm [Accessed May 2015].
44. Overview of the SEER Program. National Institutes of Health, National
Cancer Institute, Surveillance, Epidemiology, and End Results Program:
Bethesda, MD; 2015 [n.d. Available at]
http://seer.cancer.gov/about/overview.html [Accessed December].
45. National Oral Health Surveillance System: Data Sources. Centers for
Disease Control & Prevention: Atlanta, GA; 2010 [Available at]
http://www.cdc.gov/nohss/DSMain.htm [Accessed April 2015].
46. International Classification of Diseases (ICD). World Health Organization:
Geneva; 2015 [Available at] http://www.who.int/classifications/icd/en/
[Accessed May 2015].
47. Huber MA, Sankar V. It's not just an “oral cancer” exam. Tex Dent J.
2013;130:426–434 23923464.
48. Freeman T, Roche AM, Williamson P, et al. What factors need to be
addressed to support dental hygienists to assist their patients to quit
smoking? Nicotine Tob Res. 2012;14:1040–1047; 10.1093/ntr/ntr329 [Epub
2012 Feb 17].
49. Walsh MM, Belek M, Prakash P, et al. The effect of training on the use of
tobacco-use cessation guidelines in dental settings. J Am Dent Assoc.
2012;143(6):602–613 22653940.
50. Tobacco Free Initiative (TFI): Surveillance and monitoring. World Health
Organization: Geneva; 2015 [Available at]
http://www.who.int/tobacco/surveillance/en/ [Accessed May 2015].
51. Funmilayo ASM, Mojirade AD. Dental fluorosis and its indices, what's new?
IOSR-JDMS. 2014;13(7) [Ver.III:55–60. e-ISSN: 2279-0853, p-ISSN: 2279-
0861; Available at] http://www.iosrjournals.org/iosr-jdms/papers/Vol13-
issue7/Version-3/M013735560.pdf [Accessed April 2015].
52. U.S. Department of Health and Human Services Federal Panel on
Community Water Fluoridation. U.S. Public Health Service
recommendation for fluoride concentration in drinking water for the
prevention of dental caries. Public Health Rep. 2015;130(July–
August):14p/e [Available at]
http://www.publichealthreports.org/documents/PHS_2015_Fluoride_Guidelines.pdf
[Accessed May 2015].
53. 2012 Water Fluoridation Statistics. Centers for Disease Control &
Prevention: Atlanta, GA; 2013 [Available at]
http://www.cdc.gov/fluoridation/statistics/2012stats.htm [Accessed
September 2015].
54. Water Fluoridation Reporting System (WFRS) Fact Sheet. Centers for
Disease Control & Prevention: Atlanta, GA; 2014 [Available at]
http://www.cdc.gov/fluoridation/factsheets/engineering/wfrs_factsheet.htm
[Accessed February 2015].
55. MEPS Topics: Dental Visits/Use/Events and Expenditures. Medical
Expenditure Panel Survey. Agency for Healthcare Research and Quality:
Rockville, MD; 2009 [Available at]
http://meps.ahrq.gov/mepsweb/data_stats/MEPS_topics.jsp?topicid=47Z-1
[Accessed March 2015].
56. National Study of Long-Term Care Providers. Centers for Disease Control
& Prevention: Atlanta, GA; 2015 [Available at]
http://www.cdc.gov/nchs/nsltcp.htm [Accessed April 2015].
57. Sischo L, Broder HL. Oral health-related quality of life: What, why, how,
and future implications. J Dent Res. 2011;90:1264–1270;
10.1177/0022034511399918 [Available at]
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3318061/ [Accessed April
2015].
58. Constitution of the World Health Organization. 45th ed. World Health
Organization: Geneva; 2006 [Available at]
www.who.int/governance/eb/who_constitution_en.pdf [Accessed January
2015].
59. Bennadi D, Reddy CVK. Oral health related quality of life. J Int Soc Prev
Community Dent. 2013;3(1):1–6 [Available at]
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3894098/ [Accessed March
2015].
60. Health-Related Quality of Life & Well-Being, Healthy People 2020. Office
of Disease Prevention and Health Promotion: Rockville, MD; 2015
[Available at] http://www.healthypeople.gov/2020/topics-
objectives/topic/health-related-quality-of-life-well-being [Accessed May
2015].
61. Gilchrist F, Rodd H, Deery C, et al. Assessment of the quality of measures of
child oral health-related quality of life. BMC Oral Health. 2014;14:40e;
10.1186/1472-6831-14-40 [Available at]
http://www.biomedcentral.com/1472-6831/14/40 [Accessed May 2015].
62. Krisdapong S, Prasertsom P, Rattanarangsima K, et al. Using associations
between oral diseases and oral health-related quality of life in a nationally
representative sample to propose oral health goals for 12-year-old children
in Thailand. Int Dent J. 2012;62:320–330; 10.1111/j.1875-
595x.2012.00130.x.
63. de la Fuente Hernández J, del Carmen Aguilar Díaz F, del Carmen
Villanueva Vilchis M. Oral Health Related Quality of Life. Singh Virdi M.
Emerging Trends in Oral Health Sciences and Dentistry. InTech Europe:
Rijeka; 2015 [Available at]
http://dx.doi.org/10.5772/59262 http://cdn.intechopen.com/pdfs-
wm/47896.pdf [Accessed May 2015].
64. State Oral Health Infrastructure and Capacity: Reflecting on Progress and
Charting the Future: State Oral Health Program (SOHP) Infrastructure
Elements. Association of State & Territorial Dental Directors: Reno, NV;
2012 [Available at] http://www.astdd.org/docs/infrastructure-enhancement-
project-feb-2012.pdf [Accessed March 2015].
65. Strategic Plan: 2015–2016. Association of State & Territorial Dental
Directors: Reno, NV; 2015 [Available at] http://www.astdd.org/about-us/
[Accessed April 2015].
66. Dye BA, Li X, Lewis BG, et al. Overview and quality assurance for the oral
health component of the National Health and Nutrition Examination Survey
(NHANES), 2009–2010. J Public Health Dent. 2014;74:248–256.
Additional Resources
National Maternal & Child Oral Health Resource Center.
http://www.mchoralhealth.org/data.html.
NIDCR/CDC Dental, Oral and Craniofacial Data Resource Data Center.
http://www.nidcr.nih.gov/research/ToolsforResearchers/NIDCRData/.
ASTDD Oral Health Surveillance System.
http://www.astdd.org/state-based-oral-health-surveillance-system/.
ASTDD Basic Screening Surveys.
http://www.astdd.org/basic-screening-survey-tool/.
CDC Surveillance Resource Center.
http://www.cdc.gov/surveillancepractice/index.html.
My Water's Fluoride.
https://nccd.cdc.gov/DOH_MWF/Default/Default.aspx.
The State of Aging and Health in America.
http://www.cdc.gov/aging/pdf/state-aging-health-in-america-2013.pdf.
Oral Health for Independent Older Adults (ADEA Resource Guide).
http://www.adea.org/publications/Pages/OralHealthforIndependentOlderAdults.aspx
C H AP T E R 5
Population Health
Amanda M. Hinson-Enslin RDH, CHES, MPH, PhD(c), Christine French Beatty RDH, MS, PhD, Sharon C.
Stull BSDH, MS
OBJECTIVES
1. Describe the burden of oral disease globally and in the United States.
2. Identify indicators for oral health included in the Healthy People 2020 national
oral health objectives.
3. Describe the social effects of oral disease.
4. Discuss the oral health status and trends in the United States.
5. Explain the oral health disparities and inequities among population groups.
6. Describe the methods of financing dental services in the United States and issues
related to these financing mechanisms that enhance or detract from oral health
care.
7. Explain the issues related to the adequacy of the oral health workforce, as well
as the future outlook and recommendations.
8. Describe how teledentistry can be used to enhance workforce capacity and
improve access to oral health care.
9. Describe the infrastructure and capacity of dental public health programs and
future outlook.
10. Discuss the factors that influence oral health in populations and the future
changes recommended to improve access to oral health care.
Opening Statement: The Burden of Oral
Diseases in the United States
• Although evidence suggests that oral health has been improving in most of the
United States (U.S.) population, many subgroups are experiencing disparities and
not faring well.1
• Children 3 to 5 years old have the highest rate of untreated decay compared with
other age groups.2
• About 92% of dentate adults 20 to 64 years of age and 93% of dentate older adults
65 years of age and older have experienced dental caries.3
• About 74% of the U.S. population were served by community water systems and
received optimally fluoridated water in 2012.4
• Nearly 50% of adults surveyed in 2009 to 2010 had periodontitis in the U.S.5
• About 15% of American adults aged 65 to 74 and 22% of adults aged 75+ were
edentulous in 2009 to 2010.2
• Non-Hispanic white status and higher socioeconomic status (SES) account for
higher rates of dental sealants in children.2
Part One: Oral Health Status and Trends
Global Burden of Oral Diseases
Oral health has a profound effect on general health and is an important indicator of
quality of life. Oral health problems still persist in countries around the globe
despite great improvements in the oral health of some populations. Significant oral
disease burdens exist among different age groups, especially for people with lower
incomes and educational levels and for certain racial and ethnic groups in
developing and developed countries.6,7
Of the 291 diseases studied in the international collaborative Global Burden of
Disease Study in 1990 to 2010, untreated dental caries was the most common
condition.6 Between 60% and 90% of school children and nearly 100% of adults had
dental caries,6,7 between 15% and 20% of 35- to 44-year-olds had severe
periodontitis,7 and 30% of adults ages 65 to 74 had lost all their natural teeth.6 Oral
cancer was the eighth most common cancer globally.6 Of all the genetic birth
defects, 25% were craniofacial malformations.6 Ninety percent of children with
noma (see Box 5-1) did not receive proper care and had poor chances of survival.6
According to one study, “Oral conditions remained highly prevalent in 2010,
collectively affecting 3.9 billion people.”11 There was a 20.8% increase in the global
burden of oral conditions, which was attributed to population growth and aging.11
Also, inadequate alignment of oral health professionals remains a core issue
globally, leading to the absence of concentrated action and advocacy in the various
governments worldwide.12
ox 5-1
B
N oma
Noma, also known as cancrum oris and gangrenous stomatitis, is a painful form of
gangrene that destroys mucous membranes.8,9 Noma primarily occurs in young
children 2 to 5 years old who are malnourished and in locations that lack sanitation,
although it can be seen also in older children.8 Often the children who experience
noma have had another illness such as measles or malaria or an
immunodeficiency.8 Thus it is a condition that is more common in underdeveloped
nations.8 Worldwide, the annual incidence is 20 cases per 100,000 population and
has increased in recent years because of the human immunodeficiency
virus/acquired immunodeficiency syndrome (HIV/AIDS) pandemic. Noma occurs
in 39 of the 46 countries of the African region where approximately 90% of
children with noma die without receiving any care.8,10
From Baratti-Mayer D, Pittet B, Montandon D, et al for the Geneva Study Group on Noma
[GESNOMA]: Noma: an infectious disease of unknown aetiology, Lancet Infect Dis 3:419–431,
2003.
Research suggests that the possible cause is a fusospirochetal bacterium and that
noma may be a severe stage of the disease process of necrotizing ulcerative
gingivitis.8,10 Noma causes tissue destruction of the gingiva and buccal mucosa that
spreads to the lips and cheeks.8,10 The infection can lead to the development of
draining ulcers, result in tissue death, and if left untreated, end in an agonizing
death.8,9 Noma is treated with a regimen of antibiotics, debridement, and proper
nutrition. In cases of disfigurement, plastic surgery is necessary to remove dead
tissue and reconstruct facial tissues to improve function of the mouth and jaw and
to improve appearance.8 This condition may heal without treatment, but it can still
cause disfigurement, which may be extreme.8 Proper nutrition, cleanliness, and
sanitation are measures that can prevent noma from occurring.8
FIG B Percentage of at Least One Dental Sealant in a Permanent Tooth among
Children and Adolescents in New Mexico, 2013–2014 School Year.
G ui di ng Pri nci pl es
Healthy People 2010 Objectives That Experienced Regression
• Decrease in proportion of children, adolescents, and adults who used the oral
healthcare system in the past year
TABLE 5-1
Healthy People (HP) 2020 Oral Health Objectives: Targets and Progress,
and Relationship to Healthy People (HP) 2010
HP 2010
Pe rc e ntag e of HP 2020 HP Chang e
Ag e Pe rc e ntag e
Numbe r HP 2020 Oral He alth Obje c tive Targ e t Ac hie ve d, Base line 2020 Sinc e HP
(Ye ars) Chang e , Base line
2000–2010 Data Targ e t 1 2020 Launc h
to Final
OH-1 Reduce the proportion of children and adolescents who have dental caries experience in their primary or permanent teeth
1.1 Young children (primary teeth) 3–5 33.3% ↑ ☹2 33.3% 30% No data
1.2 Children (primary and permanent teeth) 6–9 1.9% ↑ ☹2 54.4% 49% No data
1.3 Adolescents (permanent teeth) 13–15 8.2% ↓ 50% 53.7% 48.3% No data
☺2
OH-2 Reduce the proportion of children and adolescents with untreated dental decay
2.1 Young children (primary teeth) 3–5 18.8% ↑ ☹2 23.8% 21.4% Improved
2.2 Children (primary or permanent teeth) 6–9 3.6% ↑ ☹2 28.8% 25.9% Improved
2.3 Adolescents (permanent teeth) 13–15 10.0% ↓ 40% 17.0% 15.3% Improved
☺2
OH-3 Reduce the proportion of adults with untreated dental decay
3.1 Adults with untreated dental decay 35–44 3.7% ↑ ☹2 27.8% 25% No data
3.2 Adults with untreated coronal caries 65–74 DNA3 DNA3 17.1% 15.4% No data
3.3 Adults with untreated root surface caries 75+ DNA3 DNA3 37.9% 34.1% No data
OH-4 Reduce the proportion of adults who have ever had a permanent tooth extracted because of dental caries or periodontal disease
4.1 Had a tooth extracted because of dental caries or 45–64 4 26.7% ↓ 80% 76.4% 68.8% Worsened
periodontal disease ☺2
4.2 Lost all natural teeth 65–74 17.2% ↓ 71.4% 24.0% 21.6% Improved
☺2
OH-5 Reduce the proportion of adults with moderate or severe periodontitis5
Adults with severe or moderate periodontitis5 45–74 5 27.3% ↓ 75.0% 12.8% 11.5% No data
☺2
OH-6 Increase the proportion of oral and pharyngeal cancers detected at the earliest stage
Proportion of oral and pharyngeal cancers detected at All 8.3% ↓ ☹2 32.5% 35.8% Worsened
earliest stage
OH-7 Increase the proportion of children, adolescents, and adults who used the oral healthcare system in the past year
Children, adolescents, and adult dental attendance 2 and 2.3% ↓ ☹2 44.5% 49% Worsened
older
OH-8 Increase the proportion of low-income children and adolescents who received any preventive dental service during the past year
Children and adolescents who received preventive 2–18 6 24% ↑ 14.6% 30.2% 33.2% Improved
service ☺2
OH-9 Increase the proportion of school-based health centers with an oral health component
9.1 Proportion of school-based health centers with K–12 100% ↑ 400% 24.1% 26.5% No data
an oral health component that includes dental *2
sealants
9.2 Proportion of school-based health centers with K–12 11.1% ↑ 50% 10.1% 11.1% No data
an oral health component that includes dental care ☺2
9.3 Proportion of school-based health centers with K–12 DNA3 DNA3 29.2% 32.1% No data
an oral health component that includes topical
fluoride
OH-10 Increase the proportion of local health departments and Federally Qualified Health Centers (FQHCs) that have an oral healthcare program
10.1 Proportion of FQHCs that have an oral health All 44% ↑ 100% 75% 83% Improved
care program *2
10.2 Proportion of local health departments that All DNA3 DNA3 25.8% 28.4% No data
have oral health prevention or care programs
OH-11 Increase the proportion of patients who receive oral health services at FQHCs each year
Patients who received care at FQHCs All DNA3 DNA3 17.5% 33.3% Improved
OH-12 Increase the proportion of children and adolescents who have received dental sealants on their molar teeth
12.1 Young children (primary teeth) 3–5 DNA3 DNA3 1.4% 1.5% No data
12.2 Children (permanent teeth) 6–9 7 39.1% ↑ 33.3% 25.5% 28.1% Improved
☺2
12.3 Adolescents (permanent teeth) 13–15 7 40.0% ↑ 17.1% 19.9% 21.9% Improved
☺2
OH-13 Increase the proportion of the U.S. population served by community water systems with optimally fluoridated water
Communities with optimally fluoridated water All 16.1% ↑ 76.9% 72.4% 79.6% No data
☺2
OH-14 (Developmental) Increase the proportion of adults who received preventive interventions in dental offices from a dentist or dental hygienist in the
past year
14.1 Received information focused on reducing Adults DNA3 DNA3 N/A9 N/A9 No data
tobacco use or smoking cessation
14.2 Received an oral/pharyngeal cancer screening8 Adults 38.5% ↑ 71.4% N/A9 N/A9 No data
☺2
14.3 Tested or referred for glycemic control Adults DNA3 DNA3 N/A9 N/A9 No data
OH-15 (Developmental) Increase the number of states (including the District of Columbia) that have a system for recording and referring infants and
children with cleft lips and cleft palates to craniofacial anomaly rehabilitative teams
15.1 System for recording cleft lips and cleft All 106.3% ↑ 48.6% No data No data No data
palates10 ☺2
15.2 System for referral for cleft lips and cleft All DNA3 DNA3 N/A9 N/A9 No data
palates to rehabilitative teams
OH-16 Increase the number of states (including the District of Columbia) that have an oral and craniofacial health surveillance system
Number of states All Not reported 84.3% 32 51 (50 No data
☺2 states
and
D.C.)
OH-17 Increase health agencies that have a dental public health program directed by a dental professional with public health training
17.1 Proportion of states (including D.C.) and local All 38.5% ↑ 750% 23.4% 25.7% No data
health agencies serving jurisdictions of 250,000 or *2
more persons
17.2 Number of Indian Health Service Areas and All 11.1 ↑ Met at baseline 11 12 No data
Tribal Health Programs serving jurisdictions of *2
30,000 or more persons
1
Target setting method was 10% improvement for most HP 2020 goals (OH-11 and OH-16 were
exceptions)
2
☹ = Moved away from target; ☺ = moved toward target; * = met or exceeded target
3
DNA = Data not available; these are new goals for HP 2020
4
This goal for HP 2010 was for ages 35 to 44 years rather than the age range of 45 to 64 years in the HP
2020 goal
5
This goal for HP 2010 was to reduce destructive periodontitis in adults ages 35 to 44
6
HP 2010 objective was for <19 years old
7
HP 2010 used ages 8 and 14 rather than these age ranges
8
HP 2010 goal was a subgoal of another goal and did not specify in a dental office
9
N/A = Not applicable: Baseline data and targets are not set for developmental goals
10
HP 2010 goal existed for this subgoal without the other subgoal of this HP 2020 goal; baseline data for HP
2020 not reported
Data from Healthy People 2010 Final Review. Hyattsville, MD: National Center for Health Statistics; 2012.
Available at http://www.cdc.gov/nchs/data/hpdata2010/hp2010_final_review.pdf. Accessed April 2015;
Department of Health and Human Services. Healthy People 2020: Oral Health. Available at
https://www.healthypeople.gov/2020/topics-objectives/topic/oral-health/objectives. Accessed December
2014.
Healthy People 2020 provides the national health objectives for the current
decade, 2010–2020.17 Table 5-1 presents the Healthy People 2020 oral health
objectives as well. The column labeled “HP 2020 Baseline Data” presents the
baseline that was used to determine the target for each objective and will be used to
evaluate progress. The column labeled “HP 2020 Target” shows the anticipated end-
of-decade data for each objective, or the goal for improvement. The column labeled
“Change Since HP 2020 Launch” indicates any movement toward or away from the
target (improved or worsened) for some objectives, based on data sources that have
become available since the launch of Healthy People 2020.17 These objectives and
targets serve as a guide for adopting policies and implementing preventive
measures, programs, and other initiatives by the nation, local communities,
individuals, and professionals to ensure marked improvements of oral health in the
future.17
ox 5-2
B
Soci al Impact of Oral Di seases and Condi ti ons
on Chi l dren and A dul ts
Children
• Experience delayed growth and development
• Avoid talking
• Have poor school performance
• Miss school
• Avoid smiling
Adults
• Experience impaired oral functions
• Suffer disfigurement
Dental Caries
Although coronal and root surface dental caries rates are higher in other countries,
even the U.S. has a high rate of untreated and treated caries. Untreated dental caries
can lead to pain, abscesses, extensive dental treatment, extractions of teeth, and
costly dental care.
FIG 5-2 Percentage of Untreated Decay Among U.S. Children by Poverty Levels,
2009–2010. (Data from Dye BA, Li X, Thornton-Evans G. Oral health disparities as determined by
selected Healthy People 2020 oral health objectives for the United States, 2009–2010 [Internet].
NCHS Data Brief 2012 Aug;(104):1–8. Available at
http://www.cdc.gov/nchs/data/databriefs/db104.pdf. Accessed December 2014.)
In addition, the rate of caries experience was measured in third graders in each
state as part of the NOHSS from 1998 to 2011 with the following results:25
• Between 40.6% and 75% in all states had either treated or untreated caries.
• Caries experience rates varied by state, with the lowest in Connecticut and the
highest in Arizona.
• Between 14.9% and 40.4% had untreated decay.
• Untreated decay also varied by state, with the highest in Arizona and the lowest in
the state of Washington.
These increases in rates of dental caries and untreated decay in the last decade
also were documented in very young children17 (Table 5-1). Early childhood caries
affects the primary teeth of infants and young children 1 to 5 years of age.
Sometimes referred to as baby bottle tooth decay or nursing caries, it can be a
devastating condition, often requiring thousands of dollars and a hospital visit with
general anesthesia during treatment. Substantial pain, psychological stress, health
risks, and expense are associated with restorative care for children affected by early
childhood caries. Infant feeding practices, in which children are put to bed with
formula or other sweetened drinks and fall asleep while feeding, have been
associated with this condition.26
Healthy People 2020 includes objectives to reduce dental caries and untreated
decay in all age groups of children and adolescents17 (Table 5-1). On a positive note,
tracking data for Healthy People 2020 are somewhat promising, indicating some
improvement in the rates of untreated decay for all age groups of children and
adolescents17 (Table 5-1). This is likely to be related to the increasing numbers of
children with access to dental care as a result of the Patient Protection and
Affordable Care Act, also called simply the Affordable Care Act (ACA), and the
Medicaid expansion (see later in chapter).
TABLE 5-2
Mean Number of Decayed, Missing, and Filled Teeth (DMFT) in
Adults by Various Factors, NHANES 1999–2004
Data from National Institute of Dental and Craniofacial Research. Dental Caries (Tooth Decay)
in Adults (Age 20 to 64); 2014. Available at
http://www.nidcr.nih.gov/DataStatistics/FindDataByTopic/DentalCaries/DentalCariesAdults20to64.htm.
Accessed December 2014; National Institute of Dental and Craniofacial Research. Dental Caries
(Tooth Decay) in Seniors (Age 65 and Over); 2014. Available at
http://www.nidcr.nih.gov/DataStatistics/FindDataByTopic/DentalCaries/DentalCariesSeniors65older.htm.
Accessed December 2014.
TABLE 5-3
Mean Number of Decayed, Missing, or Filled Teeth (DMFT) in Adults by
Age, NHANES 1999–2004
De c aye d Pe rmane nt Missing Pe rmane nt Fille d Pe rmane nt Total De c aye d, Missing , or Fille d Pe rmane nt
Ag e Group
Te e th (DT) Te e th (MT) Te e th (FT) Te e th (DMFT)
20–34 years 0.93 0.62 4.61 6.16
35–49 years 0.75 2.39 7.78 10.91
50–64 years 0.55 5.3 9.2 15.05
65–74 years 0.39 8.32 8.96 17.68
75 years or 0.47 9.41 8.42 18.3
more
Data from National Institute of Dental and Craniofacial Research. Dental Caries (Tooth Decay) in Adults
(Age 20 to 64); 2014. Available at
http://www.nidcr.nih.gov/DataStatistics/FindDataByTopic/DentalCaries/DentalCariesAdults20to64.htm.
Accessed December 2014; National Institute of Dental and Craniofacial Research. Dental Caries (Tooth
Decay) in Seniors (Age 65 and Over); 2014. Available at
http://www.nidcr.nih.gov/DataStatistics/FindDataByTopic/DentalCaries/DentalCariesSeniors65older.htm.
Accessed December 2014.
As the trends in aging continue, adults will lose fewer teeth as they age but will
have more teeth that are at risk for dental caries throughout life. The most current
research results from the National Health and Nutrition Examination Survey
(NHANES) indicated that there was a decrease in the prevalence of root caries
among adults between the time periods 1988 to 1999 and 1999 to 2004.24 Yet, the
data from these two NHANES reports suggest that root caries continues to be a
problem for older adults. Also, the data demonstrated an increase in root caries
experience with age, as follows:24
• 21.6% of adults aged 50 to 64 years had unrestored root caries
• 31.7% of adults aged 65 to 74 years had unrestored root caries
• 42.3% of adults 75 years and older had unrestored or restored root caries
Because of the increasing numbers of older adults, Healthy People 2020 has new
objectives to reduce untreated coronal and root caries in older adults in addition to
continuing the objective of decreasing untreated decay in adults 35 to 44 years old17
(Table 5-1).
FIG 5-3 Percentage of Children with at Least One Dental Sealant Placed, 2009–
2010. Data from Dye BA, Li X, Thornton-Evans G. Oral health disparities as determined by selected
Healthy People 2020 oral health objectives for the United States, 2009–2010 [Internet]. NCHS Data
Brief 2012;Aug(104):1–8. Available at http://www.cdc.gov/nchs/data/databriefs/db104.pdf. Accessed
December 2014.)
Periodontal Diseases
In previous NHANES studies, a partial periodontal examination was used to assess
the periodontal status of the nation.35 This method of partial periodontal
examination was caused by lack of funding and understanding of the true burden of
periodontitis and resulted in deflated estimates of periodontitis in the U.S.35 Thus,
the protocols were updated, and in the 2009–2010 NHANES researchers used the
gold standard of a full-mouth periodontal probing to ensure accurate assessments of
periodontal diseases among the U.S. population.5
Results of the 2009–2010 NHANES revealed that 47.2% of the representative adult
sample, ages 30 to 65+, had periodontitis with a breakdown by classification of
8.7% mild periodontitis, 30% moderate periodontitis, and 8.5% severe
periodontitis.5 Periodontitis was highest among men, Mexican Americans, adults
with less than a high school education, adults below 100% of the federal poverty
level (FPL), widowed individuals, and current smokers.5 Details of analysis of the
distribution of periodontitis by demographic factors and smoking status are
presented in Table 5-4. A 27.3% reduction of destructive periodontitis was reported
in adults ages 35 to 44 during the last decade16 (Table 5-1). A Healthy People 2020
objective is to reduce moderate or severe periodontitis in 45- to 74-year-old
adults.17
TABLE 5-4
Percentage of U.S. Adults with Periodontal Disease (PD), NHANES 2009–
2010
Data from Eke PI, Dye BA, Wei L, Thorton-Evans GO, Genco RJ. Prevalence of periodontitis in adults in
the United States: 2009 and 2010. J Dent Res 2012;91:914–920. CINAHL Complete. Web,
http://jdr.sagepub.com/content/91/10/914. Accessed January 2015.
The most recent NHANES data reflected only periodontitis; gingivitis was not
assessed by the 2009–2010 NHANES.5 The latest gingivitis data are from the
NHANES III conducted from 1988 to 1994. Those data indicated that nearly half
(48%) of adults 35 to 44 years of age had gingivitis.36 This represented an increase
from the 41% of young adults with gingivitis in the NHANES conducted from 1985
to 1986.37
Tooth Loss
Fewer adults are undergoing tooth extraction caused by dental caries or periodontal
disease. The percentage of people who have lost all their natural teeth declined
during the second half of the past century.19 In addition, rates of edentulism (the loss
of all natural teeth) and partial tooth loss decreased during the past decade16 (Table
5-1). On the other hand, data that have become available since the launch of Healthy
People 2020 indicate a possible reversal resulting in an increase of partial tooth loss
along with a continuing decrease in complete tooth loss.17 It is interesting to
consider a possible relationship of the this increase in partial tooth loss to the
decrease in untreated decay in adults described earlier.
The U.S. Department of Health and Human Services (DHHS) surveyed the U.S.
population for the prevalence of complete tooth loss and tooth retention among
adults in 2009 to 2010.2 Excluding third molars from the analysis, results showed
that, in general, edentulism increased and complete tooth retention decreased with
age. Also, poverty level status significantly impacted tooth loss and tooth retention.
For example, complete tooth retention was more than twice as high for adults aged
45 to 64 who lived above the FPL compared with the same age group living below
the FPL. Also, edentulism was more than two and a half times higher among 65- to
74-year-olds living below the FPL compared with the same age group who lived
above the FPL. Edentulism rates differed for the various ethnic groups as well.
Details of tooth retention and edentulism by age, poverty level status, and ethnic
group membership can be viewed in Figures 5-4 and 5-5.
FIG 5-4 Prevalence of Complete Tooth Retention Among U.S. Adults, 2009–
2010. (Data from Dye BA, Li X, Thornton-Evans G. Oral health disparities as determined by
selected Healthy People 2020 oral health objectives for the United States, 2009–2010 [Internet].
NCHS Data Brief 2012;Aug(104):1–8. Available at
http://www.cdc.gov/nchs/data/databriefs/db104.pdf. Accessed December 2014.)
FIG 5-5 Prevalence of Edentulism Among Older U.S. Adults, 2009–2010. (Data from
Dye BA, Li X, Thornton-Evans G. Oral health disparities as determined by selected Healthy People
2020 oral health objectives for the United States, 2009–2010 [Internet]. NCHS Data Brief
2012;Aug(104):1–8. Available at http://www.cdc.gov/nchs/data/databriefs/db104.pdf. Accessed
December 2014.)
Data from Howlader N, Noone AM, Krapcho M, Garshell J, Neyman N, Altekruse SF, Kosary CL, Yu M, Ruhl
J, Tatalovich Z, Cho H, Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (ed.). SEER Cancer Statistics
Review, 1975-2011. Bethesda, MD: National Cancer Institute; based on November 2013 SEER data
submission, posted to SEER website April 2014. Available at http://seer.cancer.gov/csr/1975_2011/.
Accessed January 2015.
Known risk factors for oral cancer include the use of all forms of smoked and
smokeless tobacco products and excessive consumption of alcohol.38 Combinations
of tobacco and alcohol represent a substantially greater risk than either substance
consumed alone. Also, the chewing of betel quid and gutka, a practice that is
common in southeast Asia, is a risk factor for developing oral and pharyngeal
cancer. Another risk factor is contracting an HPV infection although only a small
percentage of HPV infections develop into oropharyngeal cancer.38
Malocclusion
No current national data are available for malocclusion. The latest data were results
of the NHANES III published in the 1990s.47 At that time the following findings were
reported:
• Severe crowding of anterior incisors was found in 9% of persons aged 8 to 50
years; 25% had no crowding.48
• Approximately 9% had a posterior crossbite, most commonly identified in
whites.48
• Severe overbite was present in 8%; a similar percentage had severe overjet.48
• Fewer than 5% of whites had an open bite.48
• Children and adults had different rates and types of malocclusions that could
benefit from orthodontic care.49
Craniofacial Injuries
Injuries to the head, face, and teeth are common, and the most common causes of
craniofacial injuries are accidents and sports-related injuries.23, 50,51 Approximately
one third of all dental injuries and 19% of head and face injuries are sports related
according to some epidemiologic surveys.51,52 The majority of sport-related dental
and orofacial injuries affect the upper lip, maxilla, and maxillary incisors, with 50%
to 90% of dental injuries involving the maxillary incisors.53 Dentoalveolar trauma
resulting from these injuries can produce significant costs over the individual's
lifetime for restorative, endodontic, prosthodontic, implant, or surgical treatment.53
Traumatic dental injuries have additional indirect costs, including children's time
lost from school and parents' time lost from work.53 These consequences are
especially significant for lower income, minority, and noninsured children.53
The latest national data for craniofacial injuries were collected by the NHANES
from 1999 to 2004, with a focus on incisal trauma23 (Table 5-6). Incisal trauma is
defined as a traumatic injury affecting either an upper or lower permanent incisor.
More widespread use of effective population-based interventions could help reduce
the morbidity, mortality, and economic burden associated with craniofacial injuries.
Community-based interventions, professional practices, and personal behaviors that
increase the use of passenger restraints, air bags, helmets, protective gear, and
mouth guards are recommended to prevent orofacial injuries.53
TABLE 5-6
Prevalence of Incisal Trauma among Children by Age Group and Gender,
NHANES 1999–2004
Data from Dye BA, Tan S, Smith V, Lewis BD, Barker LK, Thorton-Evans GO, et al. Trends in Oral Health
Status, United States, 1988–1994 and 1999–2004. National Center for Health Statistics; 2007. Vital Health
Stat, Series 11, Number 248. Available at http://www.cdc.gov/nchs/data/series/sr_11/sr11_248.pdf.
Accessed December 2014.
Healthy People 2020 has an objective concerned with orofacial injuries, which is
to increase the number of states with an oral and craniofacial health surveillance
system to be able to track data for this oral condition17 (Table 5-1). Efforts in
relation to this same objective in Healthy People 2010 resulted in an increase in the
number of states with an oral and craniofacial health surveillance system; by 2010,
the number reached 84.3% of the target for the Healthy People 2010 objective16
(Table 5-1).
Dental Fluorosis
The results of the NHANES from 1999 to 2004 revealed the following distribution
of prevalence of fluorosis in each of the categories for the 4- to 49-year-olds that
were surveyed:54
• 16.5% were categorized as having questionable fluorosis,
• 16% had very mild fluorosis,
• 4.8% had mild fluorosis,
• 2.0% had moderate fluorosis,
• less than 1% had severe fluorosis, and
• 60.6% had no fluorosis.
In addition, it was found that adolescents ages 12 to 15 had the highest prevalence
of dental fluorosis (40.6%).54 Figure 5-6 compares the rate of fluorosis among
various age groups.
FIG 5-6 Prevalence of Dental Fluorosis in the U.S., NHANES, 1999–2004. (Data
from Dye BA, Li X, Thornton-Evans G. Oral health disparities as determined by selected Healthy
People 2020 oral health objectives for the United States, 2009–2010 [Internet]. NCHS Data Brief
2012;Aug(104):1–8. Available at http://www.cdc.gov/nchs/data/databriefs/db104.pdf. Accessed
December 2014.)
The prevalence of dental fluorosis within the nation has increased in the milder
categories although the severity has not increased.54 The 1999 to 2004 fluorosis data
were compared with previous 1986–1987 NHANES fluorosis data to evaluate any
change in the prevalence of fluorosis in the population.55 The analysis revealed an
increase in fluorosis in adolescents (ages 12 to 15) from 22.6% in 1986–1987 to
40.7% in 1999–2004.55 The public health officials who conducted this analysis
concluded that because of the increase in prevalence of enamel fluorosis in cohorts
born since 1980, the “increase should be evaluated in the context of total fluoride
exposure.”55 They recommended that surveillance tools were needed to monitor
multiple sources of fluoride.55 It was this increase in fluorosis in the younger age
groups that caused concern and was partially the impetus for reducing the
recommended optimal level of fluoride in the community water to 0.7 ppm.56,57
Part Two: Access to Oral HealthCare and
Dental Public Health Systems
Access to the Oral Healthcare System
Tomar and Cohen identified attributes of an ideal oral healthcare system that are
important to assure consistency with the key principles recommended by leading
public health authorities.58 They proposed that an ideal oral healthcare system
should include the following attributes: integration with the rest of the healthcare
system, emphasis on health promotion and disease prevention, monitoring of
population oral health status and needs, evidence-based, effective, cost-effective,
sustainable, equitable, universal, comprehensive, ethical, linked with continuous
quality assessment and assurance, culturally competent, and empowers communities
and individuals to create conditions conducive to health.58
Over the past decade leaders from various groups of the healthcare system have
called for greater prevention of oral diseases, elimination of oral health disparities,
and changes that needed to be instituted to ensure access to oral health services for
children and adults. Much of this has been prompted by decreases in access to care
for specific populations.1 Vulnerable population groups that often lack access to
oral health care include the following:1,19,59-67
• low-income individuals,
• older adults,
• pregnant women,
• prisoners,
• recent immigrants,
• individuals with human immunodeficiency virus (HIV) and other special
healthcare needs,
• homeless persons,
• homebound individuals,
• migrant and seasonal farm workers,
• persons with disabilities,
• individuals living in rural areas, and
• infants and young children.
The increased concern for the inadequacies of the current oral healthcare system
has been made apparent through the trends and lack of access to oral health care.
The changes to the healthcare system through the ACA also have impacted the
evolution of the oral healthcare system.68,69 The ACA aims to improve the oral
health of Americans through the multiple mechanisms that are discussed in Chapters
1, 6, and 9.
Several other changes are needed to support the initiatives of the ACA to be able
to result in improved oral health status of Americans. Some of these
transformations are expansion of the oral healthcare workforce, increase in the
number of oral healthcare professionals in the public sector, greater collaboration
between oral healthcare and other healthcare professionals, more dental insurance
coverage for individuals who are uninsured or underinsured, increased funding and
grants to support the initiatives, and comprehensive public education focused on
oral health prevention and coordinated at the national level.1,18,59,68,69 These are
discussed in Chapters 1, 6, and 9.
The current primary model for oral health care is the private practice delivery
model. In addition, a safety net exists for those who do not access the private sector
of dentistry.1,59 With the private practice model, dentists are located in areas that can
support them.1 For this reason, there are more dentists practicing in high-income
areas than in low-income areas. This practice pattern limits access to oral care to
those few Americans who can afford to pay for it. The safety net, generally
comprised of an array of providers, including Federally Qualified Health Centers
(FQHCs), FQHC look-alikes, non-FQHC community health centers, dental and
dental hygiene schools, school-based clinics, state and local health departments, and
not-for-profit and public hospitals, does not have the capacity to serve the 80 to 100
million people in need.1 The goal of recent changes is that the oral healthcare
system will continue to evolve to a proactive model that enables access to oral
health care for all.
ox 5-3
B
Key Barri ers to A ccessi ng Oral H eal th Care
• Lack of availability of providers
• Financial cost
• Lack of perceptions about need for regular dental care by both individuals and
health professionals
• Age
• Language
• Habits
• Lack of education
• Lack of access
• Attitudes
• Belief in invulnerability
• Denial of diagnosis
• Illiteracy
• Lack of transportation
• Provider conflicts
ox 5-4
B
Dental A ttendance of Chi l dren, A dol escents,
and A dul ts, N H A N ES 1999–2004 and MEPS
2011
• 23% of 2- to 11-year-olds had never visited a dentist.
• Approximately 50% of adults 65 and older had not visited a dentist within a year.
• 12% of 20- to 64-year-old adults had not visited a dentist within 5 years.
• 23% of adults 65 and older had not visited a dentist within 5 years.
• More than 52% of children ages 2 to 17 were offered advice by a medical doctor
about needing routine dental visits.
• Children and adolescents of minority families and families with low incomes were
less likely to have had a dental visit.
• Adult and older adult minorities with lower incomes were less likely to have had a
dental visit.
The Healthy People 2020 target is 49% for the objective to increase the
proportion of the population that used the oral healthcare system in the past year 17
(Table 5-1). The movement away from the target is discouraging.17 On the other
hand, dental attendance has increased among very young children because of the
emphasis on improving children's access to dental care in Medicaid.74 It is expected
to continue to increase through 2018 because of changes made by the ACA74 (see
later in the chapter).
Another Healthy People 2020 objective related to dental attendance is to increase
the proportion of low-income children and adolescents who received preventive
dental services during the past year.17 Data for this objective are encouraging. From
2000 to 2010 preventive dental services for low-income children and adolescents
increased by 24%16 (Table 5-1). Furthermore, data sources since the launch of
Healthy People 2020 seem to indicate a continuation of this trend during this
decade.17 Two similar new objectives relate to increasing preventive interventions
for adults in dental offices, specifically in relation to the oral-systemic link (Table
5-1). One relates to dentists and dental hygienists providing information on
reducing tobacco use or smoking cessation. The other is testing or referral by a
dentist or dental hygienist for glycemic control.17
Timely and consistent regular dental visits vary significantly according to social
and demographic factors, including age, gender, race and ethnicity, level of
education, family income, family structure, place of residence (urban, rural),
geographic location in the U.S., cultural values and belief systems, health insurance
status, disability status, dentition status, current health status, and
institutionalization.1,18,19,59-67 In general, utilization rates are greater in whites and
individuals with higher educational attainment. Rates are lower for individuals from
families with lower income levels and who have various physical, mental, and
medical disabilities. This pattern may be impacted in the future by the fact that 52.9%
of states now have policies to increase access to dental care for nursing home
residents, and 58.8% have similar policies for developmentally disabled adults.75
TABLE 5-7
Types of Dental Insurance
Insuranc e
Pe rsons Elig ible Cove rag e of Plan Funding
Type
Private • Obtained primarily through employer-sponsored group Dental coverage and cost vary depending on plan and Privately funded by
plans provider individuals or
• Occasionally obtained through private purchase employers
Medicaid • Required for ages 0–18 for family income up to 133% of • Relief of pain and infections Federal and state
the federal poverty level (FPL) • Restoration of teeth funded; percentage
• Half of the states (26, including D.C.) cover children in • Preventive services (e.g., prophylaxis, fluoride, sealants) of each varies by
families with incomes up to at least 250% of the FPL; • State Medicaid programs are generally required to cover state
states have the option to expand coverage above the Early and Periodic Screening, Diagnosis, and Treatment
federal minimum (EPSDT) for children 19 and younger
• Some states also cover pregnant women, older adults, and • In some states, dental services are limited to emergency
individuals with disabilities living at or below 133% of services
the FPL • Each state is required to develop a dental periodicity
schedule in consultation with recogniz ed dental
organiz ations involved in child health
Children's For uninsured children ages 0–18 with family income too • Required to include coverage for dental services needed Federal and state
Health high for Medicaid (varies by state) to prevent disease and promote oral health, restore oral funded, and
Insurance structures to health and function, and treat emergency percentage of each
Program conditions varies by state
(CHIP) • States are required to post a listing of all participating
Medicaid and CHIP dental providers and benefit
packages
Data from The PEW Charitable Trusts. Medicaid Expansion and Everything You Need to Know; 2013.
Available at http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2013/06/11/medicaid-
expansion-and-everything-you-need-to-know. Accessed March 2015; The Henry J. Kaiser Family
Foundation. Where are States Today? Medicaid and CHIP Eligibility Levels for Children and Non-Disabled
Adults; 2013. Available at https://kaiserfamilyfoundation.files.wordpress.com/2013/04/7993-03.pdf.
Accessed March 2015; U.S. Department of Health and Human Services. Medicaid.gov: Dental Care.
Available at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Dental-
Care.html. Accessed March 2015.
FIG 5-7 Percentage of Dental Insurance Coverage Among Americans, 2010 and
2012. (Nasseh K, Vujicic M. Dental benefits expanded for children, young adults in 2012. Health
Policy Institute Research Brief. American Dental Association. October 2014. Available from
http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_1014_.ashx.
Accessed January 2015.)
Private dental insurance plans are received most often through employment,
although they are purchased occasionally by individuals.78,79 Public programs
covering dental care include Medicaid and Children's Health Insurance Program
(CHIP).80 Medicare is a source of health insurance coverage for older adults in the
U.S. but not a source of dental insurance.80 Medicare covers only extremely limited
hospital-based oral surgery needed in conjunction with medical treatment.80 A few
Medicare Advantage plans have included modest dental benefits of primary and
secondary services.80
Financing of dental care is further complicated by the varied types of dental
benefits plans (Table 5-8), some of which are fee-for-service and some of which
possess various characteristics of managed care, and the numerous payment
mechanisms used (Table 5-9). Managed care is a term used to describe health
insurance that uses techniques to control the cost of providing benefits, including
contracts with providers to provide care at reduced costs, financial incentives for
beneficiaries to use these providers, and control of services provided; the approved
providers make up what is referred to as the plan's network. The use of various
types of financing to fund oral health programs is described in Chapter 6.
TABLE 5-8
Dental Insurance (Benefits) Plans
Source: The Advantages of Offering a Dental Benefits Plan. Chicago, IL: American Dental Association; n.d.
Available at http://www.ada.org/en/public-programs/dental-benefit-information-for-employers/insurance-
and-financing. Accessed October 2015.
TABLE 5-9
Mechanisms of Payment for Oral Health Care
Me c hanism De sc ription
Individual Payme nt Me thods
Fee-for-service Traditional two-party arrangement in which a fee is set for a service and the patient is charged for the service performed; declining method of
payment as third-party payment becomes more prevalent
Barter system The provider and client negotiate payment by exchanging goods or services without using money; still evident in some rural areas and
developing countries
Encounter fee A set fee each time a patient has a treatment encounter, regardless of the services provided; sometimes used by community programs as a
discounted fee for clients with no dental insurance
Sliding fee A range of fees that varies according to the patient's ability to pay; sometimes used by community programs as a discounted fee for clients
scale with no dental insurance
Third-Party Payme nt Me thods
Usual, Third-party payment based on an average of fees usually charged in the area for a similar service; varies by geographic area and population
customary, siz e, and from carrier to carrier; most commonly used payment method
and reasonable
fee
Discounted fee Third-party system in which fees lower than the area UCR are agreed to by a provider for members of a specifically identified group (e.g.,
students, older adults) or participants in a prepaid group; becoming more common
Fee schedule List of charges set by the third-party payer and agreed to by the provider who enrolls as a provider; provider is reimbursed by the third-party
payer and cannot charge more; system used by Medicaid/CHIP
Table of List of covered services with an assigned dollar amount set by the third-party payer; providers are reimbursed by the third party payer and
allowances can charge patients the difference between their fees and the fees set by the table of allowances
Capitation A form of contracted care in which a provider receives a fixed payment from a third-party payer in exchange for all or most care needed by a
group of patients during the contract period; method used by HMOs; payment is made to the provider regardless of use by enrollees; designed
to increase preventive care, but effectiveness is in question; uncommon
Direct Beneficiaries (clients or patients) are reimbursed by the employer or benefits administrator (e.g., insurance company) for a specified
reimbursement percentage of dental expenses upon presentation of evidence of expenses
Cost-Sharing Me thods Use d in Third-Party Payme nt to Control Costs
Copayment Patient pays a fixed amount at each visit, and the remainder of the fee is covered by the third-party; designed to discourage overuse
Coinsurance Similar to copayment but a percentage rather than a fixed amount; used by most dental insurance plans
Deductible A required amount that must be paid by the patient annually as an out-of-pocket expense before the insurance plan will pay
Annual limits A specific dollar limit that the insurance plan will pay each year
(maximum
coverage)
Waiting period A specified length of time that the patient must wait before coverage begins
Source: Beatty CF, Beatty CE, Dickinson CB. Community Oral Health Planning and Practice. In: Blue CM,
editor. Darby's Comprehensive Review of Dental Hygiene. 8th ed. St Louis: Elsevier; 2016.
Expenditures
Private dental insurance differs from private health insurance in the amount of
premiums, cost sharing by plan enrollees (deductibles, copayments, and
coinsurance), and maximum annual benefits.81 Although premiums for dental plans
are much smaller than for health plans, enrollees of dental plans are required to pay
greater out-of-pocket individual contributions for the cost of services compared
with health plans.81 Dental care fees are usually charged by procedure and
traditionally have been paid on a fee-for-service basis.81 Additionally, many dental
plans cap the amount paid out annually.82 The differences between health and dental
coverage are attributable to different assumptions about risk underlying each type
of plan and how the risk is shared among plan enrollees.81 The risk-sharing
propositions of the different types of plans have been shown to have an impact on
utilization and premium rates with differentials in costs and cost sharing by
beneficiaries.81 Because of the low level of dental insurance coverage and the
structure of dental benefits, out-of-pocket expenses account for a much larger
percentage of total dental care spending for individuals in comparison to out-of-
pocket costs for general health care paid by individuals.83
The societal costs of dental care are substantial in the U.S.83,84 (Box 5-5). The total
national dental expenditures in 2012 were similar to 2011 when adjusting for
inflation.76 People's out-of-pocket expenditures for dental care were more than three
times higher than their out-of-pocket expenditures for all other health expenditures.
This provides an indication of the financial burden for dental care carried by the
population and offers an explanation for why so many are unable to access dental
care.
ox 5-5
B
Dental Care Ex pendi tures, U.S., 2010–2012
• The national dental care expenditures were about $111 billion in 2012.
• The average annual expense for dental care per person was $666 in 2010.
• In 2010 out-of-pocket expenditures for dental care were 47.5% compared with
14.2% out-of-pocket expenditures for overall health care.
Data from Rohde, F. Dental Expenditures in the 10 Largest States, 2010. Statistical Brief #415. Rockville, MD:
Agency for Healthcare Research and Quality; 2013. Available at
http://www.meps.ahrq.gov/mepsweb/data_files/publications/st415/stat415.pdf. Accessed April 2015; Wall T,
Nasseh K, Vujicic M. Financial Barriers to Dental Care Declining after a Decade of Steady Increase. Health
Policy Institute Research Brief. Chicago, IL: American Dental Association; 2013. Retrieved at
http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_1013_1.ashx. Accessed
April 2015.
Dental care expenditures vary by state of residence. In 2010 California and Texas
had a lower percentage of people with dental expenditures than the national average,
whereas Illinois and Michigan had a higher percentage of people with dental
expenditures than the national average.83 Persons residing in California and
Michigan had a higher average of dental expenses than the national average. On the
other hand, New York, Ohio, and Georgia had a lower average of dental expenses
compared with the national average.83 Also, according to research reports, from
2000 to 2011, the number of people with private dental insurance or adult dental
state Medicaid benefits decreased, placing a greater burden on the individuals to pay
for dental care out-of-pocket.76,85
The ACA is expected to increase dental insurance coverage for children and
adults.74 This increase is because of the expansion of coverage with Medicaid and
CHIP (see later in the chapter), as well as with private dental benefits.74 By 2018,
through the ACA expansion, it is estimated that there will be an increase in the
number of sources of dental benefits for children and adults.74 For adults, it is
estimated that sources of dental benefits will increase from 113.8 million to 131.5
million.74 This would result in an approximate 15% increase of dental benefits for
children and adults in 2018.74
Medicaid.
Since its enactment in 1965 as a publicly funded program, Medicaid (Title XVIV of
the Social Security Act) has increased access to care for low-income people,
functioned as the main payer of nursing home and other long-term care, and
partially supported the safety net of providers that serve low-income and uninsured
people.89 Today Medicaid provides health care to low-income people who qualify
and also provides various levels of dental coverage. Federal law has required that
states offer Medicaid to all people in explicit groups and according to specified
income thresholds (Table 5-7). Also, states have broad authority to expand Medicaid
beyond these federal minimum standards and they have done so to varying
degrees.90,91
In 2013 Medicaid covered health and long-term care services for 62 million low-
income Americans, including children and parents, people with disabilities, and
older adults.90 Most children and parents covered by Medicaid are in working
families, and without Medicaid, the vast majority of its enrollees would be
uninsured.90 In 2013 37% of children were covered by Medicaid and CHIP.87
The federal government and the states jointly finance Medicaid, and the states
administer the program within broad federal guidelines.90 The federal share of
Medicaid spending is at least 50% in every state,90 and it varies based on state per
capita income relative to the national average.90,91 Medicaid covers a wide range of
benefits to meet the complex needs of the diverse populations served.90-92 States also
can receive federal matching funds for many optional services, including
prescription drugs, prosthetic devices, hearing aids, and dental care for adults.90-92 A
list of dental services provided by Medicaid is in Table 5-7.
All states provide dental benefits for children up to age 19 who are enrolled in
Medicaid via the mandatory Early and Periodic Screening, Diagnostic, and
Treatment (EPSDT) benefit. According to federal law, states are required to cover
comprehensive preventive care, diagnostic services, and dental treatment through
this EPSDT benefit.91,93 Dental benefits include preventive dental care, all dental care
that is medically necessary to restore teeth and maintain dental health (including
orthodontics), and assistance in arranging for covered services such as scheduling
and transportation.91,93 A distinctive focus of EPSDT is an orientation toward
prevention that maximizes health and development of children and that diverts the
health implications and financial expenses of long-term treatment and disability.91
Although state Medicaid programs are required by federal rules to cover
comprehensive oral health services for children, coverage for adult dental services
is considered optional.94 States often choose to offer adults a more limited set of
covered services than children, or offer no coverage at all.91,94 Each state has
flexibility to determine what dental benefits are provided by Medicaid for adults.93 In
2012 less than 30% of the states offered some form of dental coverage to adults
through Medicaid.94 There are no minimum requirements for adult dental coverage.
Most states provide at least emergency dental services for adults, but less than half
of the states have provided comprehensive dental care. Approximately 10.2% of
Americans age 65 and older have dental coverage through Medicaid, and 63.9% do
not have any form of dental coverage.95 Because of the ACA expansion, Medicaid
benefits for adults are increasing,95 and it is predicted that dental benefits through
Medicaid for adults will increase by 16.9 million persons by 2018.74
Medicare.
According to Title XVIII of the Social Security Act, Medicare is a federal health
insurance program enacted in 1965 and administered by the Social Security
Administration to provide health care for adults ages 65 and older.98 In 2012 over 41
million older adults enrolled in Medicare.99 Traditional Medicare is not a source of
dental insurance because it does not pay for any general oral health care.80 Medicare
pays only for dental care when it is medically necessary for another medical
procedure, such as organ transplantation.80
TABLE 5-10
Oral Health Workforce, 2012 and Projected Oral Health Workforce, 2025
Workforc e Role Estimate d Numbe r, 2012 Proje c te d Numbe r, 2025 Proje c te d De mand, 2025 Proje c te d Shortag e or Surplus, 2025
Dentists 190,800 202,600 218,200 Shortage of 15,600
Dental Hygienists 153,600 197,200 169,100 Surplus of 28,100
Data from U.S. Department of Health and Human Services, Health Resources and Services
Administration, National Center for Health Workforce Analysis. National and State-Level Projections of
Dentists and Dental Hygienists in the U.S., 2012–2025. Rockville, MD: Author; 2015. Available at
http://bhpr.hrsa.gov/healthworkforce/supplydemand/dentistry/nationalstatelevelprojectionsdentists.pdf.
Accessed April 2015.
Of the nation's professionally active dentists, 92% provide dental care in the
private sector of the oral healthcare system.105 The safety-net dental delivery system
is under pressure and in short supply of dental workforce.1 Greater numbers of
dentists, especially general dentists, pediatric dentists, and public health dentists are
needed in the public sector because of the use of the safety net oral healthcare
system.1 According to the American Dental Education Association, approximately
80% of all dentists practice general dentistry, and the remaining 20% practice in one
of the nine recognized specialty areas (endodontics, oral and maxillofacial surgery,
oral pathology, oral and maxillofacial radiology, orthodontics, pediatric dentistry,
periodontics, prosthodontics, and public health dentistry).1,106
In previous years the dentist-to-population ratio has stayed consistent at
approximately 60 dentists per 10,000 people, but this ratio is expected to decline in
the future because of the growth of the population.1 As the number of general
dentists decreases, it is predicted to have a negative impact on the supply of dentists,
especially in rural areas. The allied oral health workforce and new workforce
models are central to meeting the increasing needs and demands for dental care (see
Chapters 1 and 2).
About 192,800 dental hygienists and 303,200 dental assistants were in the U.S.
workforce from 2012 to 2013.107,108 Both dental hygiene and dental assisting have an
expected growth of over 25% through 2022 and are among the fastest growing
occupations in the country.107,108 In the late 1980s there were more dental graduates
than dental hygiene graduates, a trend that changed in 1991.109 Since 1991 there has
been a larger number of dental hygiene graduates than dental graduates, with an
increasingly greater difference each year 109 (Figures 5-9 and 5-10). In 2012 there
were 38% more dental hygiene graduates than dental graduates (7097 dental hygiene
graduates and 5100 dental graduates).109 As previsouly stated, this trend is expected
to continue and result in a surplus of dental hygienists by 2025, compared with a
shortage of dentists104 (Table 5-10). It has been suggested that this surplus of dental
hygienists can be used to fill the gap resulting from the shortage of dentists by
expanding the roles of dental hygienists and more effectively integrating them into
the dental care delivery system.104
FIG 5-10 Number of Dental (DDS) and Dental Hygiene (RDH) Graduates, ADHA,
1988–2012. (Data from American Dental Hygienists' Association. Dental Hygiene Education:
Curricula, Program, Enrollment and Graduate Information; 2014. Available at
https://www.adha.org/resources-docs/72611_Dental_Hygiene_Education_Fact_Sheet.pdf.
Accessed April 2015.)
TABLE 5-11
Number of Oral Health Workforce Programs
Data Sources:
1
American Dental Education Association. Number and Type of Allied Dental Education Programs
Accredited by CODA, 1970–2013. Available at
http://www.adea.org/publications/tde/Pages/EducattionalInstitutions.aspx. Accessed January 2015.
2
American Dental Education Association. List of all United States and Canadian Dental Schools, 2014.
Available at http://www.adea.org/publications/tde/Pages/EducattionalInstitutions.aspx. Accessed January
2015.
3
American Dental Education Association. Advanced Dental Students. Number of Accredited Advanced
Dental Education Programs, 2004–2005 to 2010–2012. Available at
http://www.adea.org/publications/tde/Pages/Students/advanced-dental-students.aspx. Accessed January
2015.
Diversity is increasing within the oral health professions in the U.S. (Figure 5-11).
The greatest gains in diversification of dental school enrollment have been an
expansion in the representation of females, which increased by nearly 37% between
2000 and 2013.1,111 Representation by underrepresented minorities has been low
traditionally among predoctoral dental students enrolled in dental schools although
it has improved in recent years112 (Figure 5-12). Based on current dental school
enrollment trends and on the increase in the diversity of the population by race and
ethnicity, the future dental workforce will remain unrepresentative of the population
to be served in the U.S.112 This imbalance will be further exacerbated by the
significant changes in racial and ethnic composition of the U.S. population
anticipated over the coming years.
FIG 5-11 A culturally diverse oral health workforce is needed to meet the demands
of a culturally diverse population. (Photograph courtesy Faizan Kabani and Charlene
Dickinson.)
FIG 5-12 Approximate Distribution of Dental Students by Race, ADEA, 2013. (Data
from American Dental Education Association. Enrollees by Race and Ethnicity in U.S. Dental
Schools, 2000–2013. Available at http://www.adea.org/PreDocDentAppStudents/. Accessed January
2015.)
ox 5-6
B
Dental H eal th Professi onal Shortag e A rea
(Dental H PSA ) Desi g nati on Requi rements
Geographic Areas Must:
• Be rational areas for the delivery of dental services
• Have access barriers that prevent the population group from using the area's dental
providers
• Have a ratio of the number of persons in the population group to the number of
dentists practicing in the area and serving the population group of at least 4000 : 1
Facilities Must:
• Be either federal or state correctional institutions or public or nonprofit medical
facilities
• Have a ratio of the number of internees per year to the number of FTE dentists
serving the institution of at least 1500 : 1
• Have insufficient capacity to meet the dental care needs of that area or population
group
Where a geographic area does not meet the shortage criteria, but a population
group within the area has access barriers, a population group designation may be
possible.118 In some cases, facilities may be designated as HPSAs.118 This applies to
correctional facilities and state mental hospitals. In addition, public and nonprofit
private facilities located outside designated HPSAs may receive facility HPSA
designation if they are accessible to and serving a designated geographic area or
population group HPSA.
Dental HPSA designation is used for a variety of purposes by federal programs,
including evaluation of the eligibility of a given area or population for a number of
federal and state programs to expand the oral health workforce.1,119 These programs
include the National Health Service Corps (NHSC), federal and state loan repayment
programs, Community Health Center programs, and several Title VII Health
Professions Programs.
In June 2014 there were 4900 dental HPSAs.119 The number of dental HPSAs
designated by the HRSA has grown exponentially from 792 in 1993 to 3527 in 2006
to 4230 in 2009 to 4900 in 2014.119,120 Dental HPSAs are based on a dentist to
population ratio of 1 : 5000.117 This means that, when there is only one dentist for
every 5000 or more people, an area is eligible to be designated as a dental HPSA.
Based on this and the current number of dentists in the U.S., approximately 7300
additional dentists are needed nationwide to eliminate the current dental HPSA
designations. Thus, dental HPSAs not only reflect the maldistribution of dentists, but
also indicate the inadequate supply of dental manpower in the nation.
Innovative strategies are needed to recruit and retain dental professionals who
will seek careers in oral health and public health today and in the future.1 In addition,
strategies must be implemented to ensure that the dental workforce is culturally
competent to provide oral health services to increasingly diverse individuals and
communities.1 As demands for oral health services increase both nationally and
through programs for specific, vulnerable populations, groups, or communities,
collaboration among state and local oral health programs and key stakeholders is
essential to enhance development of the dental workforce.
With the current oral health disparities and expected population growth, creative
measures are crucial to improve oral health, including developments in education,
research, and health promotion and expansion of clinical care within the private,
public, and nonprofit sectors. Such methods of increasing access to oral health care
were addressed by the ACA in 2010. The nation has an opportunity to expand quality
dental care for children and adults who are not receiving needed services. In
relation to the oral health workforce, the ACA has the following provisions:121-123
• Expand the dental health aide therapist model for tribal lands
• Increase grants and contracts for provider education: dental; residency and
advanced education in general, pediatric, and public health dentistry; and dental
hygiene
• Increase funds for loan repayment programs for provider education
• Create new primary care residency programs
• Authorize a demonstration grant for new workforce models
• Increase funds for community health centers and school-based health centers
FIG 5-13 Oral health professionals can provide leadership to assure universal
access to effective oral health services. (© iStock.com.)
History of Teledentistry.
Teledentistry began in 1924 with a physician seeing patients over the radio using a
television screen.139 The initial concept of teledentistry developed as part of the
blueprint for dental informatics established by the Westinghouse Electronic System
Group in Baltimore.139 The birthplace of teledentistry as a subspecialty field of
telemedicine can be linked to a 1994 U.S. Army project known as the Total Dental
Access Project, which aimed to improve patient care, dental education, and
communication between dentists and dental laboratories.139-142 It was used also by the
Army to provide medical consultation to people more than 100 miles away.139
Since that time, public health facilities, remote rural clinics, and other
organizations have implemented teledentistry with varying degrees of success. A
recent systematic review of clinical outcomes, healthcare utilization, and cost
determination associated with teledentistry provided some promising foundational
data regarding positive clinical outcomes for access to care in rural and urban
settings.134
ox 5-7
B
Successful Ex ampl es of Tel edenti stry
Alaska Dental Health Aide Therapist Program
Alaska Dental Health Aide Therapists (DHAT) provide dental services to the
residents of the most isolated rural regions of Alaska, where there are no dentists.
They function as part of an integrated team of dental care providers, through
village health clinics of the Alaska Tribal Health System (ATHS) that serve the
Alaskan native people.143 According to Dr. Mary Williard, the dentist who directs
the Alaska Dental Health Aide Therapist training program, DHATs, and nearly all
healthcare providers in the ATHS use telehealth technology, which is provided by
the Alaska Federal Health Care Access Network (AFHCAN).138 As a nonprofit
organization operated by the Alaska Native Tribal Health Consortium, AFHCAN
aided all village clinics in acquiring the tele-healthcare technology.138 During the 10
years from 2003, when the program was initiated, to 2013, DHATs increased access
to preventive and restorative oral health care for more than 40,000 citizens of
Alaska's remote rural communities through the use of teledentistry.143
Apple Tree Dental, Minnesota
Apple Tree Dental is a nonprofit dental practice that operates five regional dental
access programs in urban and rural areas of Minnesota. Special care dental
professionals are linked via telehealth technologies with onsite dental clinics at
schools, Head Start centers, group homes, assisted-living centers, nursing facilities,
and other community sites for people facing physical, financial, and geographic
barriers to care. Dental hygienists who are working under collaborative
agreements with dentists are connected to them for consultation and diagnosis.
Approximately 70% of the children treated in Head Start centers need only
preventive services provided by the dental hygienist. A dentist treats the other 30%
who require additional care during onsite visits, using portable equipment.138,144
The Pacific Center for Special Care, California
The Pacific Center for Special Care at the University of the Pacific Arthur A.
Dugoni School of Dentistry in San Francisco created a “Virtual Dental Home” to
take dental care to underserved populations in the community through schools,
nursing homes, community centers, and Head Start centers. The mobile telehealth
technology system consists of a collapsible dental chair, laptop computer, digital
camera, supplies to do temporary fillings, an Internet-based dental record system,
and a handheld x-ray machine. Teams of registered dental hygienists in alternative
practice, registered dental hygienists, and registered dental assistants, led by
geographically distant dentists, collaborate to provide triage, case management,
preventive procedures, and early intervention therapeutic services.144 Via telehealth
technology, medical histories and dental images are uploaded to a website where a
dentist reviews them, creates a treatment plan, and provides patient referrals to
local dentists when more complex treatment is required.138,145
ox 5-8
B
Top 10 Infrastructure and Capaci ty El ements
for State Oral H eal th Prog rams (SOH P),
A ST DD 2000
Assessment
• Establish and maintain a state-based oral health surveillance system for ongoing
monitoring, timely communication of findings, and the use of data to initiate and
evaluate interventions.
Policy Development
• Provide leadership to address oral health problems with a full-time state dental
director and an adequately staffed oral health unit with competence to perform
public health functions.
• Develop and maintain a state oral health improvement plan and, through a
collaborative process, select appropriate strategies for target populations,
establish integrated interventions, and set priorities.
• Develop and promote policies for better oral health and to improve health systems.
Assurance
• Provide oral health communications and education to policymakers and the public
to increase awareness of oral health issues.
• Build linkages with partners interested in reducing the burden of oral diseases by
establishing a state oral health advisory committee, community coalitions, and
governmental workgroups.
• Develop health systems interventions to facilitate quality dental care services for
the general public and vulnerable populations.
ox 5-9
B
Key Factors A ssoci ated w i th Success of State
Oral H eal th Prog rams (SOH P)
• Diversified funding that includes funding for local programs.
• A current (within the past 5 years) and comprehensive state oral health plan with a
practical evaluation component
• Strong, evidence-based local programs with quality guidance from the state. Local
level evidence-based programs such as dental sealants and fluorides targeted to
high-risk populations are essential, and states with local programming limited to
oral health education have not seen improvements in children's oral health.
Based on the work of the ASTDD, the Healthy People initiative has addressed the
need to strengthen the infrastructure and increase the capacity of SOHPs. The
proportion of school-based health centers with an oral health component that
includes dental sealants increased by 100% in the last decade, and the proportion
increased by 11.1% for the inclusion of dental care16 (Table 5-1). Healthy People
2020 includes continuing both these objectives, as well as adding a new objective to
increase topical fluoride programs in school-based health centers17 (Table 5-1). The
proportion of FQHCs with an oral health component increased by 44% last
decade;16 the Healthy People 2020 includes continuing this objective and adding a
new objective to increase the proportion of local health departments that have an
oral health component17 (Table 5-1). Another new objective in Healthy People 2020
is to increase the proportion of patients who receive oral health services at FQHCs
each year.17 A Healthy People 2020 objective related to capacity is to increase health
agencies that have a dental public health program directed by a dental professional
with public health training, both in local health agencies serving jurisdictions of
250,000 or more persons and in Indian Health Service Areas and Tribal Health
Programs serving jurisdictions of 30,000 or more persons17 (Table 5-1).
3. Providing optimally fluoridated water to at least 75% of residents who are served
by community water systems
5. Paying dentists who serve Medicaid-enrolled children at least the 2008 national
average (60.5%) of dentists' median retail fees
6. Reimbursing medical care providers through its state Medicaid program for
preventive dental services
8. Submitting basic screening data to the national database that tracks oral health
status
G ui di ng Pri nci pl es
Key Elements Necessary to Achieve Improved Oral Health in the
Future
• Infrastructure and capacity that are necessary to plan, implement, and evaluate oral
health policies, practices, and programs that are sustainable in the future.
• Health systems interventions that ensure access to oral health care for adults,
children, and vulnerable, underserved population groups.
2. Prepare a presentation to make in class describing how you would use the
information found on the selected oral health indicator to plan, implement, and
evaluate an oral health program in your role as one of the following:
4. Read The Virtual Dental Home: Improving the Oral Health of Vulnerable
Populations Using Geographically Distributed Telehealth-Enabled Teams available
at www.healthycal.org/archives/10842. Make a presentation in class to share the
information.
5. Go to the Healthy People 2020 website to review the progress of the oral health
objectives. Prepare a presentation to share the information in class.
Dental Hygiene Competencies
Reading the material in this chapter and participating in the activities of Applying
Your Knowledge will contribute to the student's ability to demonstrate the following
competencies:
Community Involvement
CM.1
Assess the oral health needs and services of the community to determine action
plans and availability of resources to meet the healthcare needs.
CM.4
Facilitate patient access to oral health services by influencing individuals or
organizations for the provision of oral health care.
CM.5
Evaluate reimbursement mechanisms and their impact on the patient's access to oral
health care.
CM.6
Evaluate the outcomes of community-based programs, and plan for future activities.
Community Case
As the State Dental Director of the state of New Mexico, you are working with a
state oral health coalition to develop a statewide oral health plan for the state. You
review the current status of key oral health indicators from data for the states of the
Southwest region of the U.S. (Table A), the state (Figure B), and the nation as
reflected in Healthy People 2020 (Table 5-1). Census data indicate that
approximately 33% of children and adolescents in New Mexico are in families that
live at and below 133% of the FPL, and nearly 24% of the population lives in rural
areas. There are a total of 70 community-based clinics within New Mexico, and less
than a third has an oral health component.
TABLE A
Percentage of Third-Grade Students with Untreated Tooth Decay in the
Southwestern States
1. Which oral health program has the lowest priority for this state?
a. A statewide school-based dental sealant program
b. A statewide school-based fluoride varnish program
c. A statewide school-based dental treatment program
d. Brushing and flossing presentations at schools across the state
2. Where are you most likely to find information on how the oral health status and
trends of this state compare to that of the nation?
a. Healthy People 2010
b. Healthy People 2020
c. NHANES
d. NOHSS
3. Which is the most likely mechanism for payment of dental services for this
population?
a. CHIP and Medicaid
b. Head Start
c. Medicare
d. Private insurance
4. How do the state-level oral health data compare with the Healthy People 2020
national baseline data?
Statement 1: New Mexico has a higher rate of untreated dental caries among
children and adolescents compared with the national average.
Statement 2: New Mexico has a higher rate of at-risk children and adolescents who
have at least one dental sealant in a permanent tooth compared with the national
average.
a. The first statement is true, and the second statement is false.
b. The first statement is false, and the second statement is true.
c. Both statements are true.
d. Both statements are false.
5. Which of following initiatives related to workforce capacity and infrastructure
would be the lowest priority for this state?
a. Advocate for a midlevel workforce model
b. Increase the number of community-based clinics with an oral health component
c. Increase the number of community-based clinics
d. Seek funding for a statewide teledentistry program
References
1. Institute of Medicine of the National Academies. Advancing Oral Health in
America. The National Academies Press: Washington, DC; 2011 [Available
at]
http://www.hrsa.gov/publichealth/clinical/oralhealth/advancingoralhealth.pdf
[Accessed April 2015].
2. Dye BA, Li X, Thornton-Evans G. Oral health disparities as determined by
selected Healthy People 2020 oral health objectives for the United States,
2009–2010 [Internet]. NCHS Data Brief. 2012;104:1–8 [Available at]
http://www.cdc.gov/nchs/data/databriefs/db104.pdf [Accessed December
2014].
3. Dental Caries (Tooth Decay) in Adults (Age 20 to 64). National Institute of
Dental and Craniofacial Research: Bethesda, MD; 2014 [Available at]
http://www.nidcr.nih.gov/DataStatistics/FindDataByTopic/DentalCaries/DentalCariesA
[Accessed December 2014].
4. 2012 Water Fluoridation Statistics. Centers for Disease Control and
Prevention: Atlanta, GA; 2013 [Available at]
http://www.cdc.gov/fluoridation/statistics/2012stats.htm [Accessed
December 2014].
5. Eke PI, Dye BA, Thorton-Evans GO, et al. Prevalence of periodontitis in
adults in the United States, 2009 and 2010. J Dent Res. 2012;91:914–920.
6. Oral Health Worldwide. A Report of the FDI World Dental Federation. The
FDI World Dental Federation: Geneva; 2014 [Available at]
http://www.worldoralhealthday.com/wp-
content/uploads/2014/03/FDIWhitePaper_OralHealthWorldwide.pdf
[Accessed December 2014].
7. Oral Health. Fact Sheet 318. World Health Organization: Geneva; 2012
[Available at] http://www.who.int/mediacentre/factsheets/fs318/en/
[Accessed December 2014].
8. Noma. National Institutues of Health, U.S. National Library of Medicine:
Bethesda, MD; 2013 [Available at]
http://www.nlm.nih.gov/medlineplus/ency/article/001342.htm [Accessed
March 2015].
9. Heiner DC, Ivie EL, Lovell T. Medical terms used by saints in Nauvoo and
Winter Quarters, 1839-48. Relig Educ. 2009;10(3):151–162 [Available at
Brigham Young University Religious Studies Center website at]
http://rsc.byu.edu/archived/volume-10-number-3-2009/medical-terms-
used-saints-nauvoo-and-winter-quarters-1839-48 [Accessed March 2015].
10. Oral Health and Noma. [Geneva: World Health Organization; n.d.; Retrieved
at]
http://www.aho.afro.who.int/profiles_information/index.php/AFRO:Oral_health_and_
[Accessed March 2015].
11. Marcenes W, Kassebaum NJ, Bernabé E, et al. Global burden of oral
conditions in 1990-2010: A systematic analysis. J Dent Res.
2013;92(7):592–597; 10.1177/0022034513490168 [Available at]
http://jdr.sagepub.com/content/early/2013/05/23/0022034513490168.abstract
[Accessed April 2015].
12. Benzian HHM, Holmgren C, Yee R, et al. Political priority of global oral
health: An analysis of reasons for international neglect. Int Dent J.
2011;61(3):124–130.
13. Benzian H, Bergman M, Cohen LK, et al. The UN high-level meeting on
prevention and control of non-communicable diseases and its significance
for oral health worldwide. J Public Health Dent. 2012;72(2):91–93.
14. Oral Health. The objectives of the WHO Global Oral Health Programme
(ORH). World Health Organization: Geneva; 2015 [Available at]
http://www.who.int/oral_health/objectives/en/ [Accessed December 2014].
15. Oral Health Country/Area Profile Programme. World Health Organization:
Geneva; 2015 [Available at]
http://www.who.int/oral_health/databases/malmo/en/ [Accessed December
2014].
16. Healthy People 2010 Final Review. National Center for Health Statistics:
Hyattsville, MD; 2012 [Available at]
http://www.cdc.gov/nchs/data/hpdata2010/hp2010_final_review.pdf
[Accessed April 2015].
17. Healthy People 2020. Oral Health. Department of Health and Human
Services, Office of Disease Prevention and Health Promotion: Washington,
DC; 2015 [Available at] https://www.healthypeople.gov/2020/topics-
objectives/topic/oral-health/objectives [Accessed December 2014].
18. Institute of Medicine, National Research Council. Improving Access to Oral
Health Care for Vulnerable and Underserved Populations. National
Academies Press: Washington, DC; 2011 [Available at]
http://iom.edu/Reports/2011/Improving-Access-to-Oral-Health-Care-for-
Vulnerable-and-Underserved-Populations.aspx [Accessed January 23,
2015].
19. Oral Health in America. A Report of the Surgeon General. Department of
Health and Human Services, Public Health Service: Rockville, MD; 2000
[Available at] http://silk.nih.gov/public/hck1ocv.@www.surgeon.fullrpt.pdf
[Accessed April 2015].
20. Acharya S, Pentapati KC. Work stress and oral health-related quality of life
among Indian information technology workers: An exploratory study. Int
Dent J. 2012;62:132–136 [Accessed January 2015; Available at MEDLINE,
Ipswich, MA].
21. Jackson SL, Vann WF, Kotch JB, et al. Impact of poor oral health on
children's school attendance and performance. Am J Public Health.
2011;101:1900–1906; 10.2105/AJPH.2010.200915.
22. Shah N, Arruda A, Inglehart M. Pediatric patients' orthodontic treatment
need, quality of life, and smiling patterns—An analysis of patient, parent,
and provider responses. J Public Health Dent [serial online].
2011;71(1):62–70 [Accessed January 2015].
23. Healthy People 2020 Leading Health Indicators. Progress Update, Executive
Summary. Department of Health and Human Services, Office of Disease
Prevention and Health Promotion: Washington, DC; 2014 [Available at]
http://www.healthypeople.gov/sites/default/files/LHI-ProgressReport-
ExecSum_0.pdf [Accessed January 2015].
24. Dye BA, Tan S, Smith V, et al. Trends in oral health status: United States,
1988-1994 and 1999-2004. Vital Health Stat. 2007;11(248):1–92 [Available
at] http://www.cdc.gov/nchs/data/series/sr_11/sr11_248.pdf [Accessed April
2015].
25. National Oral Health Surveillance System. Oral Health Indicators. Centers
for Disease Control and Prevention: Atlanta, GA; 2010 [Available at]
http://www.cdc.gov/nohss/ [Accessed December 2014].
26. American Academy of Pediatric Dentistry, American Academy of
Pediatrics, American Academy of Pediatric Dentistry Council on Clinical
Affairs. Policy on Early Childhood Caries (ECC). Classifications,
Consequences, and Preventive Strategies. Pediatr Dent. 2005;27(7):31
[Available at]
http://www.aapd.org/media/Policies_Guidelines/P_ECCClassifications.pdf
[Accessed March 2015].
27. Davies RM, Blinkhorn AS. Preventing dental caries: Part 1. The scientific
rationale for preventive advice. Dent Update. 2013;40:719–726 [Available
at] http://www.actml.com.au/professional-development/actml-events-
calendar/oral-health-promotion-brushing-up-on-oral-health/prereading-
preventing-dental-caries-part-1_20150212123802.pdf [Accessed April
2015].
28. Govindaiah S, Bhoopathi V. Dentists' levels of evidence-based clinical
knowledge and attitudes about using pit-and-fissure sealants. J Am Dent
Assoc. 2014;145:849–855.
29. Clovis JB, Horowitz AM, Kleinman DV, et al. Maryland dental hygienists'
knowledge, opinions and practices regarding dental caries prevention and
early detection. J Dent Hyg. 2012;86:292–305 [Epub 2012 Nov 7; Available
from: Health Source: Nursing/Academic Edition, Ipswich, MA. Accessed
January 7, 2015].
30. Horowitz AM, Kleinman DV, Wang MQ. What Maryland adults with young
children know and do about preventing dental caries. Am J Public Health.
2013;103(6):e69–76; 10.2105/AJPH.2012.301038 [Epub 2013 Apr 18;
Available from: MEDLINE, Ipswich, MA. Accessed January 7, 2015].
31. Truman BI, Gooch BF, Evans CA Jr. (ed.). The guide to community
preventive services: Interventions to prevent dental caries, oral and
pharyngeal cancers, and sports-related craniofacial injuries. Am J Prev
Med. 2002;23(1 Suppl.):21.
32. Bailey W, Duchon K, Barker L, et al. Populations receiving optimally
fluoridated public drinking water—United States, 1992–2006. MMWR Morb
Mortal Wkly Rep. 2008;57:737.
33. Griffin SO, Gooch BF, Lockwood SA, et al. Quantifying the diffused benefit
from water fluoridation in the United States. Community Dent Oral
Epidemiol. 2001;29:120–129 11300171.
34. Water Fluoridation Status of the 50 Largest Cities in the United States.
Wisconsin Dental Association: West Allis, WI; 2012 [Available at]
http://www.wda.org/wp-content/uploads/2012/05/US-Cities-
Fluoridation.pdf [Accessed April 2015].
35. Eke P, Thornton-Evans G, Dye B, et al. Advances in surveillance of
periodontitis: The Centers for Disease Control and Prevention periodontal
disease surveillance project. J Periodontol [serial online]. 2012;83:1337–
1342 [Available at CINAHL Complete, Ipswich, MA. Accessed February
2015].
36. Healthy People 2010 Data: What is Data2010? Centers for Disease Control
and Prevention: Atlanta, GA; 2011 [Available at]
http://www.cdc.gov/nchs/healthy_people/hp2010/data2010.htm [Accessed
April 2015].
37. Healthy People 2000 Final Review. Public Health Service, National Center
for Health Statistics: Hyattsville, MD; 2001 [Available at]
http://www.cdc.gov/nchs/data/hp2000/hp2k01.pdf [Accessed April 2015].
38. Detailed Guide: Oral Cavity and Oropharyngeal Cancer. American Cancer
Society: Atlanta, GA; 2015 [Available at]
http://www.cancer.org/cancer/oralcavityandoropharyngealcancer/index
[Accessed April 2015].
39. Howlader N, Noone AM, Krapcho M, et al. SEER Cancer Statistics Review,
1975–2011. National Cancer Institute: Bethesda, MD; 2014 [based on
November 2013 SEER data submission, posted to SEER website; updated
December; Available at] http://seer.cancer.gov/csr/1975_2011/ [Accessed
April 2015].
40. Ibsen OAC, Phelan JA. Oral Pathology for the Dental Hygienist. 6th ed.
Elsevier Saunders: St Louis; 2014.
41. Oral Cancer Facts. Oral Cancer Foundation: Newport Beach, CA; 2015
[Retrieved at] http://www.oralcancerfoundation.org/facts/ [Accessed April
2015].
42. Facts about Cleft Lip and Cleft Palate. Centers for Disease Control &
Prevention: Atlanta, GA; 2014 [Available at]
http://www.cdc.gov/ncbddd/birthdefects/cleftlip.html [Accessed April
2015].
43. The Health Consequences of Smoking—50 Years of Progress: A Report of
the Surgeon General. Department of Health and Human Services, Centers
for Disease Control and Prevention, National Center for Chronic Disease
Prevention and Health Promotion, Office on Smoking and Health: Atlanta,
GA; 2014 [Available at]
http://www.surgeongeneral.gov/library/reports/50-years-of-
progress/index.html#fullreport [Accessed January 2015].
44. Craniofacial Birth Defects. National Institute of Dental and Craniofacial
Research: Bethesda, MD; 2014 [Available at]
http://www.nidcr.nih.gov/DataStatistics/FindDataByTopic/CraniofacialBirthDefects/
[Accessed December 2014].
45. Mastroiacovo P, IPDTOC Working Group. Prevalence at birth of cleft lip
with or without cleft palate: Data from the International Perinatal Database
of Typical Oral Clefts (IPDTOC). Cleft Palate Craniofac J. 2011;48(1):66–
81; 10.1597/09-217 [Available at]
http://connection.ebscohost.com/c/articles/57956249/prevalence-birth-
cleft-lip-without-cleft-palate-data-from-international-perinatal-database-
typical-oral-clefts-ipdtoc [Accessed January 2015].
46. Tanaka SA, Mahabir RC, Jupiter DC, et al. Updating the epidemiology of
cleft lip with or without cleft palate. Plast Reconstr Surg. 2012;129(3):511e–
518e; 10.1097/PRS.0b013e3182402dd1.
47. Proffit W, Jackson T, Turvey T. Changes in the pattern of patients receiving
surgical-orthodontic treatment. Am J Orthod Dentofacial Orthop [serial
online]. 2013;143(6):793–798 [Available at MEDLINE, Ipswich, MA.
Accessed February 2015].
48. Brunelle JA, Bhat M, Lipton JA. Prevalence and distribution of selected
occlusal characteristics in the U.S. population, 1988–1991. J Dent Res.
1996;75(special issue):706–713. ISSN 0022-0345. .
49. Proffit WR, Fields HW Jr, Moray LJ. Malocclusion prevalence and
orthodontic treatment need in the United States: Estimates from the
NHANES III survey. Int J Adult Orthodon Orthognath Surg. 1998;13:97–
106 9743642.
50. Traumatic Dental Injuries. [Chicago, IL: American Association of
Endodontists; n.d.; Available at] http://www.aae.org/patients/treatments-
and-procedures/traumatic-dental-injuries.aspx [Accessed January 2015].
51. Burt CW, Overpeck MD. Emergency visits for sports-related injuries. Ann
Emerg Med. 2001;37:301–308 [Available at]
http://www.sciencedirect.com/science/article/pii/S0196064401811161
[Available at Science Direct at April 2015].
52. Bourguignon C, Sigurdsson A. Preventive strategies for traumatic dental
injuries. Dent Clin North Am. 2009;53:729–749.
53. American Academy of Pediatric Dentistry. Policy on prevention of sports-
related orofacial injuries. Oral Health Policies Reference Manual.
2013;35(6):67–71 [Available at]
http://www.aapd.org/media/Policies_Guidelines/P_Sports.pdf [Accessed
March 2015].
54. Beltrán-Aguilar ED, Barker L, Dye BA. National Center for Health
Statistics: Hyattsville, MD; 2010. Prevalence and severity of dental fluorosis
in the United States, 1999–2004. vol. no. 53 [NCHS Data Brief; Available
at] http://www.cdc.gov/nchs/data/databriefs/db53.pdf [Accessed April
2015].
55. Beltrán-Aguilar ED, Barker LK, Canto MT, et al. Surveillance for dental
caries, dental sealants, tooth retention, edentulism, and enamel fluorosis—
United States, 1988-1994 and 1999-2002. MMWR. 2005;54(3):1–44
[Retrieved at] http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5403a1.htm
[Accessed April 2015].
56. Optimal Fluoride Level Recommendations. Community Water Fluoridation.
[Madison, WI: Wisconsin Department of Health Services; n.d.; Retrieved at]
https://www.dhs.wisconsin.gov/publications/p0/p00457.pdf [Accessed April
2015].
57. Community Water Fluoridation. Centers for Disease Control and
Prevention: Atlanta, GA; 2013 [Available at]
http://www.cdc.gov/fluoridation/faqs/ [Accessed March 2015].
58. Tomar S, Cohen L. Developing a new paradigm for the dental delivery
system. J Public Health Dent. 2010;70(Suppl. 1):S6–14; 10.1111/j.1752-
7325.2010.00185.x.
59. Helgeson M, Glassman P. Oral health delivery systems for older adults and
people with disabilities. Spec Care Dentist. 2013;33(4):177–189;
10.1111/scd.12038.
60. Schrimshaw EW, Siegel K, Wolfson NH, et al. Insurance-related barriers to
accessing dental care among African American adults with oral health
symptoms in Harlem, New York City. Am J Public Health. 2011;101:1420–
1428; 10.2105/AJPH.2010.300076.
61. Lai B, Milano M, Roberts M, et al. Unmet dental needs and barriers to dental
care among children with autism spectrum disorders. J Autism Dev Disord.
2012;42:1294–1303; 10.1007/s10803-011-1362-2.
62. Vujicic M, Yarbrough C, Nasseh K. The effect of the Affordable Care Act's
expanded coverage policy on access to dental care. Med Care. 2014;52:715–
719; 10.1097/MLR.0000000000000168.
63. Karolynn S, Eric WS, Carol K, et al. Types of dental fear as barriers to
dental care among African American adults with oral health symptoms in
Harlem. J Health Care Poor Underserved [serial online]. 2012;23:1294–
1309 [Available at CINAHL Complete, Ipswich, MA. Accessed February
2015].
64. Rouleau T, Harrington A, Brennan M, et al. Receipt of dental care and
barriers encountered by persons with disabilities. Spec Care Dentist [serial
online]. 2011;31(2):63–67 [Available at CINAHL Complete, Ipswich, MA.
Accessed February 2015].
65. Dodd V, Logan H, Brown C, et al. Perceptions of oral health, preventive
care, and care-seeking behaviors among rural adolescents. J School Health
[serial online]. 2014;84:802–809 [Available at SPORTDiscus with Full
Text, Ipswich, MA. Accessed February 2015].
66. Cohen LA, Bonito AJ, Eicheldinger C, et al. Behavioral and socioeconomic
correlates of dental problem experience and patterns of health care-seeking.
J Am Dent Assoc [serial online]. 2011;142(2):137–149 [Available at
CINAHL Complete, Ipswich, MA. Accessed February 2015].
67. Kelesidis N. A Racial comparison of sociocultural factors and oral health
perceptions. J Dent Hyg. 2014;88(2):173–182.
68. Williams S. The Affordable Care Act: Implications for America's oral health
care system. Access. 2013;27(7):13–15.
69. Glassman P. Interprofessional practice in the era of accountability. J Calif
Dent Assoc. 2014;42:645–651 25265731.
70. Treatment Needs. National Institute of Dental and Craniofacial Research:
Bethesda, MD; 2014 [Available at]
http://www.nidcr.nih.gov/DataStatistics/FindDataByTopic/TreatmentNeeds/
[Accessed January 2015].
71. Soni A. Children's Dental Care: Advice and Visits, Ages 2–17,
2011.Statistical Brief #432. Agency for Healthcare Research and Quality:
Rockville, MD; 2014 [Available at]
http://meps.ahrq.gov/mepsweb/data_files/publications/st432/stat432.pdf
[Accessed January 2015].
72. Health, United States, 2010. With Special Feature on Death and Dying. DHHS
Pub. No. 2011-1232. National Center for Health Statistics: Hyattville, MD;
2011 [Available at] http://www.cdc.gov/nchs/data/hus/hus10_InBrief.pdf
[Accessed January 2015].
73. Oral and Dental Health. Centers for Disease Control and Prevention: Atlanta,
GA; 2014 [Available at] http://www.cdc.gov/nchs/fastats/dental.htm
[Accessed March 2015].
74. Nasseh K, Vujicic M, O'Dell A. Affordable Care Act Expands Dental Benefits
for Children but Does Not Address Critical Access to Dental Care Issues.
Health Policy Institute Research Brief. American Dental Association:
Chicago, IL; 2013 [Available at]
http://www.ada.org/sections/professionalResources/pdfs/HPRCBrief_0413_3.pdf
[Accessed January 2015].
75. Summary Report. Synopses of State Dental Public Health Programs: Data
for FY 2012-2013. Association of State and Territorial Dental Directors:
Reno, NV; 2014 [Retrieved at] http://www.astdd.org/docs/synopsis-of-state-
programs-summary-report-2014.pdf [Accessed April 2015].
76. Wall T, Nasseh K, Vujicic M. Financial Barriers to Dental Care Declining
after a Decade of Steady Increase. Health Policy Institute Research Brief.
American Dental Association: Chicago, IL; 2013 [Retrieved at]
http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_1
[Accessed April 2015].
77. Manski RJ, Brown E. Dental Use, Expenses, Dental Coverage, and Changes,
1996 and 2004, MEPS Chartbook No.17. Agency for Healthcare Research
and Quality: Rockville MD; 2007 [Available at]
http://meps.ahrq.gov/data_files/publications/cb17/cb17.pdf [Accessed April
2015].
78. Wiatrowski W. Employment-Based Health Benefits in Small and Large
Private Establishments. Department of Labor, Bureau of Labor Statistics:
Washington, DC; 2013 [Available at] http://www.bls.gov/opub/btn/volume-
2/employment-based-health-benefits-in-small-and-large-private-
establishments.htm [Accessed January 2015].
79. Rice T, Rosenau P, Unruh LY, et al. United States of America: Health system
review. Health Syst Transit. 2013;15(3):1–431 [Available at]
http://www.euro.who.int/en/about-
us/partners/observatory/publications/health-system-reviews-hits/countries-
and-subregions/united-states-of-america-hit-2013 [Accessed April 2015].
80. Medicare Dental Coverage. Centers for Medicare & Medicaid Services:
Baltimore, MD; 2013 [Available at]
http://www.cms.gov/Medicare/Coverage/MedicareDentalCoverage/index.html?
redirect=/MedicareDentalcoverage/ [Accessed January 2015].
81. A Guide to Dental Benefits Plans. [Chicago, IL: American Association of
Endodontists; n.d.; Available at]
https://www.aae.org/uploadedfiles/practice_management/dental_benefits_and_coding
[Accessed March 2015].
82. The Advantages of Offering a Dental Benefits Plan. American Dental
Association: Chicago, IL; 2015 [Available at]
http://www.ada.org/en/public-programs/dental-benefit-information-for-
employers/insurance-and-financing [Accessed March 2015].
83. Rohde F. Dental Expenditures in the 10 Largest States, 2010. Statistical Brief
#415. Agency for Healthcare Research and Quality: Rockville, MD; 2013
[Available at]
http://www.meps.ahrq.gov/mepsweb/data_files/publications/st415/stat415.pdf
[Accessed April 2015].
84. Vujicic M, Goodell S, Nasseh K. Dental Benefits to Expand for Children,
Likely Decrease for Adults in Coming Years. Health Policy Institute
Research Brief. American Dental Association: Chicago, IL; 2013 [Available
at]
http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_0
[Accessed April 2015].
85. Nasseh K, Vujicic M. The effect of growing income disparities on U.S.
adults' dental care utilization. J Am Dent Assoc. 2014;145:435–442;
10.14219/jada.2014.1.
86. Children and Oral Health. Assessing Needs, Coverage, and Access. Kaiser
Commission on Medicaid and the Uninsured Policy Brief. Henry J. Kaiser
Family Foundation: Menlo Park, CA; 2012 [Available at]
https://kaiserfamilyfoundation.files.wordpress.com/2013/01/7681-04.pdf
[Accessed January 2015].
87. Rudowitz R, Artiga S, Arguello R. Children's Health Coverage: Medicaid,
CHIP and the ACA. Henry J. Kaiser Family Foundation: Menlo Park, CA;
2014 [Available at] http://kff.org/health-reform/issue-brief/childrens-
health-coverage-medicaid-chip-and-the-aca/ [Accessed January 2015].
88. Shane DM, Padmaja A. Spillover Effects of the Affordable Care Act?
Exploring the Impact on Young Adult Dental Insurance Coverage. Health
Serv Res. 2014; 10.1111/1475-6773.12266 [Available at]
http://onlinelibrary.wiley.com/doi/10.1111/1475-6773.12266/suppinfo
[Accessed April 2015; (online version)].
89. Medicaid: A Timeline of Key Developments (1965-2015). Henry J. Kaiser
Family Foundation: Menlo Park, CA; 2015 [Available at]
http://kff.org/medicaid/timeline/medicaid-a-timeline-of-key-developments/
[Accessed January 2015].
90. Medicaid, a Primer—Key Information on the Nation's Health Coverage
Program for Low-Income People. Henry J. Kaiser Family Foundation,
Kaiser Commission on Medicaid and the Uninsured: Menlo, CA; 2013
[Available at] http://kff.org/medicaid/issue-brief/medicaid-a-primer/
[Accessed April 2015].
91. Early and Periodic Screening, Diagnostic, and Treatment. [Baltimore, MD:
Centers for Medicare & Medicaid Services; n.d.; Available at]
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-
Topics/Benefits/Early-and-Periodic-Screening-Diagnostic-and-
Treatment.html [Accessed January 2015].
92. The Uninsured and the Difference Health Insurance Makes. The Kaiser
Commission on Medicaid and the Uninsured, Henry J. Kaiser Family
Foundation: Menlo Park, CA; 2012 [Available at] http://kff.org/health-
reform/fact-sheet/the-uninsured-and-the-difference-health-insurance/
[Accessed April 2015].
93. Dental Care. [Baltimore, MD: Centers for Medicare & Medicaid Services;
n.d.; Available at] http://www.medicaid.gov/Medicaid-CHIP-Program-
Information/By-Topics/Benefits/Dental-Care.html [Accessed December
2014].
94. Medicaid Benefits: Dental Services. Henry J. Kaiser Family Foundation:
Menlo Park, CA; 2012 [Available at] http://kff.org/medicaid/state-
indicator/dental-services/ [Accessed March 2015].
95. Nasseh K, Vujicic M. Dental Benefits Expanded for Children, Young Adults
in 2012. Health Policy Institute Research Brief. American Dental
Association: Chicago, IL; 2014 [Available at]
http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_1
[Accessed January 2015].
96. CHIP Tips. Children's Oral Health Benefits. Henry J. Kaiser Family
Foundation Kaiser Commission on Medicaid and the Uninsured,
Georgetown University's Center for Children and Families: Menlo Park,
CA; 2010 [Available at] https://www.cdhp.org/resources/246-chip-tips-
children-s-oral-health-benefits-kaiser-family-foundation [Accessed April
2015].
97. Paradise J, Garfield R. What is Medicaid's Impact on Access to Care, Health
Outcomes, and Quality of Care? Setting the Record Straight on the
Evidence. Henry J. Kaiser Family Foundation: Menlo Park, CA; 2013
[Available at] http://kff.org/report-section/what-is-medicaids-impact-on-
access-to-care-health-outcomes-and-quality-of-care-setting-the-record-
straight-on-the-evidence-issue-brief/ [Accessed January 2015].
98. Compilation of Social Security Laws. Title XVIII—Health Insurance for the
Aged and Disabled. [Woodlawn, MD: Social Security Administration; n.d.;
Available at] http://www.ssa.gov/OP_Home/ssact/title18/1800.htm
[Accessed March 2015].
99. Medicare Enrollment—Aged Beneficiaries: As of July 1, 2012. Medicare
Enrollment Reports. Centers for Medicare & Medicaid Services: Baltimore,
MD; 2014 [Available at] https://www.cms.gov/Research-Statistics-Data-
and-Systems/Statistics-Trends-and-Reports/MedicareEnrpts/index.html?
redirect=/medicareenrpts/ [Accessed January 2015].
100. Affordable Care Act, Dental Benefits Examined. American Dental
Association: Chicago, IL; 2013 [Available at]
http://www.ada.org/en/publications/ada-news/2013-
archive/august/affordable-care-act-dental-benefits-examined [Accessed
January 2015].
101. Total U.S. Dental School Graduates, 1960-2013 (table). Predoctoral Dental
Students. [Washington, DC: American Dental Education Association; n.d.;
Available at] http://www.adea.org/PreDocDentAppStudents/ [Accessed
January 2015].
102. Graduates of Advanced Dental Education Programs, 2010-11 (table).
Advanced Dental Students. [Washington, DC: American Dental Education
Association; n.d.; Available at]
http://www.adea.org/publications/tde/Pages/Students/advanced-dental-
students.aspx [Accessed January 2015].
103. Guthrie D, Valachovic R, Brown LJ. The impact of new dental schools on
the dental workforce through 2022. J Dent Ed. 2009;73:1353 20007489.
104. National and State-Level Projections of Dentists and Dental Hygienists in
the U.S., 2012-2025. Department of Health and Human Services, Health
Resources and Services Administration, National Center for Health
Workforce Analysis: Rockville, MD; 2015 [Available at]
http://bhpr.hrsa.gov/healthworkforce/supplydemand/dentistry/nationalstatelevelprojec
[Accessed April 2015].
105. Distribution of Public and Private U.S. Dental Schools with 2013 Entering
Classes (map). [Washington, DC: American Dental Education Association;
n.d.; Available at]
http://www.adea.org/uploadedFiles/ADEA/Content_Conversion/publications/Trendsin
[Accessed January 2015].
106. After Dental School. [Washington, DC: American Dental Education
Association; n.d.; Available at]
http://www.adea.org/dental_education_pathways/Pages/AfterDentalSchool.aspx
[Accessed January 2015].
107. Occupational Outlook Handbook, 2014-15 Edition, Dental Hygienists.
Department of Labor, Bureau of Labor Statistics: Washington, DC; 2014
[Available at] http://www.bls.gov/ooh/healthcare/dental-hygienists.htm
[Accessed January 2015].
108. Occupational Outlook Handbook, 2014-15 Edition, Dental Assistants.
Department of Labor, Bureau of Labor Statistics: Washington, DC; 2014
[Available at] http://www.bls.gov/ooh/healthcare/dental-assistants.htm
[Accessed January 2015].
109. Dental Hygiene Education: Curricula, Program, Enrollment and Graduate
Information. American Dental Hygienists' Association: Chicago, IL; 2014
[Available at] https://www.adha.org/resources-
docs/72611_Dental_Hygiene_Education_Fact_Sheet.pdf [Accessed April
2015].
110. Direct Medicaid Reimbursement (map). American Dental Hygienists'
Association: Chicago, IL; 2014 [Available at]
http://www.adha.org/resources-docs/7526_Medicaid_Map.pdf [Accessed
April 2015].
111. Dental School First-Time Enrollees by Gender, 2000-2013 (table).
[Washington, DC: American Dental Education Association; n.d.; Available
at] http://www.adea.org/PreDocDentAppStudents/ [Accessed January 2015].
112. Formicola AJ, D'Abreu KC, Tedesco LA. Underrepresented minority dental
student recruitment and enrollment programs: An overview from the Dental
Pipeline Program. J Dent Educ. 2010;74(10):S67–73.
113. Pourat N, Choi MK. Trends in the supply of dentists in California. Health
Policy Brief, PB2014-2. UCLA Center for Health Policy Research: Los
Angeles, CA; 2014 [Available at]
http://healthpolicy.ucla.edu/publications/Documents/PDF/2014/dentistspb-
mar2014.pdf [Accessed April 2015].
114. Knoerl E, Haleem M, Wistar C. New York State dental workforce resources
and incentive programs. NY State Dent J. 2012;78(6):20–24 [Available at
New York State dental workforce resources and incentive programs.
Accessed April 2015].
115. Improving access to oral health care in Florida. Today's FDA.
2012;24(4):29–40 [Available at]
http://www.ncbi.nlm.nih.gov/pubmed/22856273 [Accessed April 2014].
116. Supply of Dentists in the U.S.: 2001–2013 (XLSX). Supply of Dentists.
American Dental Association: Chicago, IL; 2015 [Available at]
http://www.ada.org/en/science-research/health-policy-institute/data-
center/supply-of-dentists/ [Accessed April 2015].
117. Dental HPSA Designation Overview. Health Professional Shortage Areas
(HPSAs). [Rockville, MD: Health Resources and Services Administration
Health Workforce; n.d.; Available at]
http://bhpr.hrsa.gov/shortage/hpsas/designationcriteria/dentalhpsaoverview.html
[Accessed April 2015].
118. Guidelines for Primary Medical Care/Dental HPSA Designation. [Rockville,
MD: Health Resources and Services Administration; n.d.; Available at]
http://bhpr.hrsa.gov/shortage/hpsas/designationcriteria/medicaldentalhpsaguidelines.h
[Accessed April 2015].
119. Shortage Designation: Health Professional Shortage Areas & Medically
Underserved Areas/Populations. [Rockville, MD: Health Resources and
Service Administration; n.d.; Available at] http://www.hrsa.gov/shortage/
[Accessed January 2015].
120. Swift JQ. Statement of the American Dental Education Association (ADEA),
Presented before the U.S. Senate Committee on Health Education Labor and
Pensions Hearing “Addressing Health Care Workforce Issues.”. American
Dental Education Association: Washington, DC; 2008 [Available at]
http://www.allhealth.org/briefingmaterials/adea-helptestimony-1268.pdf
[Accessed March 2015].
121. The Affordable Care Act and Health Centers. [Rockville, MD: Health
Resources and Services Administration; n.d.; Available at]
http://bphc.hrsa.gov/about/healthcenterfactsheet.pdf [Accessed January
2015].
122. School-Based Health Care Centers. [Rockville, MD: Health Resources and
Services Administration; n.d.; Available at]
http://www.bphc.hrsa.gov/about/schoolbased/index.html [Accessed January
2015].
123. Palmer C. Potential effects of the Affordable Care Act. ADA News, October
9, 2012. American Dental Association: Chicago, IL; 2012 [Available at]
http://www.ada.org/en/publications/ada-news/2012-
archive/october/potential-effects-of-the-affordable-care-act [Accessed
January 2015].
124. Oral Health Workforce. [Rockville, MD: Health Resources and Services
Administration; n.d.; Available at]
http://www.hrsa.gov/publichealth/clinical/oralhealth/workforce.html
[Accessed January 2015].
125. Integration of Oral Health and Primary Care Practice. Health Resources and
Services Administration: Rockville, MD; 2014 [Available at]
http://www.hrsa.gov/publichealth/clinical/oralhealth/primarycare/index.html
[Accessed April 2015].
126. Gehshan S, Mijic M. Getting help for children: The need to expand the
dental workforce. J Calif Dent Assoc. 2011;39(7):481–490 [Available at
MEDLINE, Ipswich, MA. Accessed January 2015].
127. Tsai C, Wides C, Mertz E. Dental workforce capacity and California's
expanding pediatric Medicaid population. J Calif Dent Assoc.
2014;42(11):757–764 [Available at MEDLINE, Ipswich, MA]
http://europepmc.org/abstract/med/25417534 [Accessed January 2015].
128. Diringer J, Phipps K. California's state oral health infrastructure:
Opportunities for improvement and funding. J Calif Dent Assoc [serial
online]. 2012;40(1):31–37 [Available at MEDLINE, Ipswich, MA. Accessed
January 2015].
129. Projections Show a Slower Growing, Older, More Diverse Nation a Half
Century from Now. US Census Bureau: Washington, DC; 2012 [Available
at] https://www.census.gov/newsroom/releases/archives/population/cb12-
243.html [Accessed January 2015].
130. Bailit H, Beazoglou T, Demby N, et al. Dental safety net: Current capacity
and potential for expansion. J Am Dent Assoc. 2006;137(6):807–
815 16803811.
131. Haley J, Kenney G, Pelletier J. Access to Affordable Dental Care: Gaps for
Low Income Adults. The Henry J. Kaiser Family Foundation, The Kaiser
Commission on Medicaid and the Uninsured: Menlo Park, CA; 2008
[Available at]
http://www.centerfororalhealth.org/images/lib_PDF/kaiser%20low%20income%20co
[Accessed April 2015].
132. Kenney GM, Haley JM, Pelletier JE. Covering Kids & Families Evaluations:
Health Care for the Uninsured: Low-Income Parents' Perceptions of Access
and Quality. Urban Institute: Washington, DC; 2009 [Available at]
http://www.rwjf.org/content/dam/farm/reports/evaluations/2009/rwjf56063
[Accessed April 2015].
133. Mertz E, O'Neil E. The growing challenge of providing oral health care
services to all Americans. Health Aff. 2002;21(5):65–77 [Available at]
http://content.healthaffairs.org/content/21/5/65.full.pdf [Accessed April
2015].
134. Daniel S, Wu L, Kumar S. Teledentistry: A systemic review of clinical
outcomes, utilization and cost. J Dent Hyg. 2013;87(6):345–352.
135. Glassman P, Subar P. Creating and maintaining oral health for dependent
people in institutional settings. J Public Health Dent. 2010;70(Suppl.
1):S40–8.
136. Kopycka-Kedzierawski DT, Billings RJ, McConnochie KM. Dental
screening of preschool children using teledentistry: A feasibility study.
Pediatr Dent. 2007;29:209–213.
137. Sanchez-Dils E, Lefebvre C, Abeyta K. Teledentistry in the United States: A
new horizon of dental care. Int J Dent Hyg. 2004;2:161–164.
138. Moore T, Rover J. Digital revolution. Dimens Dent Hyg. 2013;11(11):50–54.
139. Sanjeev M, Shushant GK. Teledentistry a new trend in oral health. Int J Clin
Cases Investig. 2011;2(6):49–53.
140. Jampani ND, Nutalapati R, Dontula BSK, et al. Applications of teledentistry:
A literature review and update. J Int Soc Prev Community Dent.
2011;1(2):37–44.
141. Williams KT. The use of teledentistry to provide dental hygiene care to
rural populations. Access. 2011 [Available at]
http://www.thefreelibrary.com/The+use+of+teledentistry+to+provide+dental+hygiene
a0275853707 [Accessed April 2015; (electr)].
142. Skillman SM, Doescher MP, Mouradian WE, et al. The challenge to
delivering oral health services in rural America. J Pub Health Dent.
2010;70(Suppl. 1):S49–57.
143. Alaska Native Tribal Health Consortium. Alaska dental health aide
therapists mark 10 years in practice; Provided expanded access to 40,000
Alaska Native people. Native Health News Alliance (electr); 2014 [Available
at] http://www.nativehealthnews.com/alaska-dental-health-aide-therapists-
mark-10-years-in-practice-provided-expanded-access-to-40000-alaska-
native-people/ [Accessed February 2015].
144. Glassman P, Helgeson M, Kanteles J. Using telehealth technologies to
improve oral health for vulnerable and underserved populations. J Calif
Dent Assoc. 2012;40:579–585.
145. Graebner L. Virtual dental homes care for vulnerable populations. Calif
Health Rep. 2013 [Available at] http://www.healthycal.org/virtual-dental-
homes-care-for-vulnerable-populations/ [Accessed April 2015; (electr)].
146. State Oral Health Infrastructure and Capacity: Reflecting on Progress and
Charting the Future. Association of State & Territorial Dental Directors:
Jefferson City, MO; 2012 [Available at]
http://www.astdd.org/docs/infrastructure-enhancement-project-feb-
2012.pdf [Accessed April 2015].
147. Maternal and Child Health. MCH Programs Overview. [Rockville, MD:
Health Resources and Service Administration; n.d.; Available at]
http://mchb.hrsa.gov/programs/ [Accessed January 2015].
148. Building Infrastructure and Capacity in State and Territorial Oral Health
Programs. Association of State and Territorial Dental Directors: Reno, NV;
2000 [Available at] http://www.astdd.org/docs/Infrastructure.pdf [Accessed
April 2015].
149. Tomar SL. An assessment of the dental public health infrastructure in the
United States. J Public Health Dent. 2006;66(1):5–16 [Available at]
http://www.ncbi.nlm.nih.gov/pubmed/16570745 [Accessed April 2015].
150. Competencies for State Oral Health Programs. Association of State and
Territorial Dental Directors: Reno, NV; 2009 [Available at]
http://www.astdd.org/docs/CompetenciesandLevelsforStateOralHealthProgramsfinal.p
[Accessed April 2015].
151. Funding (web search). [Association of State and Territorial Dental
Directors; n.d.; Retrieved at] www.astdd.org/ [Accessed April 2015].
152. Operations Manual for Health Center Oral Health Programs. Chapter One:
Health Center Fundamentals, Version 1.1. National Network for Oral
Health Access: Denver, CO; 2010 [Available at]
http://www.nnoha.org/nnoha-
content/uploads/2013/08/OpManualChapter1.pdf [Accessed April 2015].
153. Pew Children's Dental Campaign. The State of Children's Dental Health:
Making Coverage Matter. Pew Charitable Trusts: Philadelphia, PA; 2011
[Available at]
http://www.pewtrusts.org/~/media/legacy/uploadedfiles/wwwpewtrustsorg/reports/sta
[Accessed April 2015].
154. National Funders. Health Affair. 2014;33:1098–1099;
10.1377/hlthaff.2014.0420.
C H AP T E R 6
Oral Health Programs in the
Community
Christine French Beatty RDH, MS, PhD, Charlene B. Dickinson RDH, BSDH, MS, Amanda M. Hinson-Enslin
RDH, CHES, MPH, PhD(c), Magda A. de la Torre RDH, MPH
OBJECTIVES
1. Describe oral health in the community and identify oral health programs at the
national, state, and local levels.
2. Describe the five steps of the community program planning process that are
necessary to organize an effective community oral health program.
3. Explain how program goals and objectives are used in program planning,
implementation, and evaluation; develop specific, measurable objectives for
community oral health programs using SMART + C objectives.
4. Explain water fluoridation in terms of its history, effectiveness, mechanisms of
action, safety, recommendations, cost, optimal level, and approaches
recommended for a fluoridation campaign to be able to defeat antifluoridationists.
5. Discuss the benefits of primary prevention programs, including various
fluoride modalities, sealants, and oral health education, and recommendations for
conducting these programs.
6. Describe the goals, mission, and oral health component of Head Start, and
explain the potential for the dental hygienist in a Head Start program.
7. Discuss secondary and tertiary oral health programs.
8. Identify the various funding streams, programs, initiatives, and structures to
finance oral health services through public health systems.
Opening Statements
• Dental caries is a transmissible, chronic disease that can be prevented.
• School-based pit and fissure sealant programs have been shown to reduce dental
caries by up to 60%.
• Community water fluoridation decreases tooth decay by 29% to 51% in children
and adolescents.
• Fluoride varnish applied every 6 months is effective in preventing dental caries in
the primary and permanent teeth of children and adolescents who are at moderate
to high risk for caries.
• Integrating oral health into school-based health programs increases access to care
for this vulnerable population.
• Head Start (HS) programs promote school readiness through the provision of
educational, health and oral health, nutritional, social, and other services to
enrolled children and families.
• By the year 2050 there will be 89 million older adults in America, indicating a
need for greater coordination of oral health services and programs for this
segment of the population.
• The increasing complexity of public financing of oral health care is enhancing
opportunities for community oral health programs.
Improving Oral Health in the Community
The mission of public health is to fulfill society's interest in assuring “conditions in
which people can be healthy.”1 This is accomplished through oral health programs
in the community. Without public health, including an emphasis on oral diseases and
conditions, society as a whole suffers. The social impact of oral diseases in specific
segments of the population is substantial.2,3 Results of untreated oral diseases
include lost productivity, increased healthcare costs, decreased quality of life, and
decreased learning among school-age children because of oral health–related
absences and inability to attend to learning.3 In some cases, even death can stem
from untreated oral disease such as tooth decay.2
Community oral health programs should reflect an emphasis on Healthy People
2020 health objectives. The following overarching goals of Healthy People 2020,
which relate to all aspects of health, including oral health, at all stages of life,
provide direction for oral health programs:4
• Attain high quality, longer lives free of preventable disease, disability, injury, and
premature death.
• Achieve health equity, eliminate disparities, and improve the health of all groups.
• Create social and physical environments that promote good health for all.
• Promote quality of life, healthy development, and healthy behaviors across all life
stages.
Community oral health programs extend the role of the dental hygienist from the
traditional private practice to the community as a whole. This chapter discusses
community oral health programs as opportunities to address the prevention of oral
diseases and problems of access to oral health care for children and adults in
relation to these Healthy People 2020 goals. The Association of State & Territorial
Dental Directors (ASTDD), Centers for Disease Control & Prevention (CDC), and
other organizations and agencies have applied best practice approaches to oral
health programs to promote health equity and quality of life, eliminate oral health
disparities, and achieve improved oral health and consequently overall health for all
populations. The ASTDD defines a best practice approach as “a public health
strategy that is supported by evidence for its impact and effectiveness.”5 According
to ASTDD, “Through proven and promising best practices, effective programs will
be better able to help achieve the Healthy People 2020 oral health objectives and to
meet the National Call to Action to Promote Oral Health.”5
National, State, and Local Programs: Role of
the Health Department
National Level
National, state, and local dental public health programs have similar roles but
widely varying organizational schemes. Nationally, several governmental programs
are involved in oral health promotion and disease prevention.
Among these programs are the multiple public health operating divisions of the
U.S. Department of Health and Human Services (DHHS), which is the federal
government's principal agency for protecting the health of all Americans and
providing essential services, especially for people who are least able to help
themselves.6 DHHS is the largest grant-making agency in the federal government.6
In 2015 DHHS awarded approximately 48,000 grants for a total of about $300
trillion.6 DHHS works with state and local governments to fund services at the local
level through state or county agencies, nonprofit organizations, educational
institutions, and private sector grantees. DHHS also provides regulatory oversight
and monitoring of the expenditures made by grantees. Refer to Figure 1-1 and Box
1-1 in Chapter 1 to review the operating divisions of the DHHS that are involved in
advancing the health, safety, and well-being of the American people.
State Level
State oral health programs (SOHP) exist in all states in the nation; these programs
are a major source of planning, funding, implementing, and coordinating of oral
health promotion programs for the states' residents.7 SOHP vary in their scope of
services and organization across the U.S., offering a variety of different services
and programs. Table 6-1 provides information on the percent of SOHP that offered
specific oral health services and programs from 2013 to 2014, according to the
ASTDD 2015 Summary Report: Synopses of State Dental Public Health Programs.7
TABLE 6-1
Percent of State Oral Health Programs That Offer Specific Oral Health
Services, 2013–2014*
State dental directors provide leadership and guidance for the SOHP.
Approximately 88% of state dental directors are full-time, representing a significant
increase in the number of states with full-time dental directors in the last decade.7 In
addition to the state dental directors, SOHP employ regional dental directors, public
health educators, clinical dentists, dental hygienists, and dental assistants who
provide oral health services to underserved populations.7 These dental public health
professionals also promote oral health through educational programs in public and
private schools and through collaborative efforts and partnerships with dental and
dental hygiene schools; HS centers; Women, Infant, and Children (WIC) programs;
county and city health departments; community-based organizations; faith-based
organizations; civic groups; and local dental providers and dental hygienists.
SOHP are funded by state general revenues and national sources of funding from
various DHHS operating divisions and offices.8 Consistently funded SOHP through
diversified funding sources are able to provide stronger programming and have
greater sustainability of programs.8,9 A focus of Healthy People 2020, various
federal national government agencies, and ASTDD is to build the infrastructure and
capacity of SOHP to enhance their ability to improve oral health of the
population.8,10 Additional information about SOHP is provided in Chapters 4 and 5.
Role of Essential Public Health Services to Promote Oral
Health
As discussed in Chapter 1 and presented in Table 1-2, the core public health
functions (i.e., assessment, policy development, and assurance) and the essential
public health services to promote oral health developed by ASTDD shape the basic
practice of dental public health.11 To further guide SOHP, the ASTDD has also
identified roles of SOHP in line with the essential services. These roles serve as
guidelines to SOHP in carrying out activities to meet the essential services. The
ASTDD document Guidelines for State and Territorial Oral Health Programs: PART
II State Roles, Activities and Resources: Guidelines Matrix presents these roles and
provides examples of activities for the various roles.11 See the References and
Additional Resources at the end of this chapter for this and other ASTDD resources
to assist with these activities.
Many states have developed programs that include the essential services for oral
health. For example, in the state of Washington, the Smile Survey was initiated to
provide statewide screenings for children to assess the status of their oral health and
identify gaps in access to oral health care. This survey is conducted every 5 years as
a state surveillance system.12 Based on ongoing assessment results, preventive
programs such as school-based sealants, fluoride varnish, and oral health education
have been developed, and program guidelines have been updated as needed.12,13 In
addition, the Washington State Collaborative Oral Health Improvement Plan 2009-
2014 was developed with input from more than 100 key partners and stakeholders,
as well as hundreds of individuals from the public and all health professions.14 The
oral health plan established guiding principles and defined strategic areas, goals,
and objectives to reflect Healthy People oral health objectives.
ox 6-1
B
Importance of Oral H eal th Coal i ti ons
• Provide an avenue for recruiting participants from diverse constituencies, such as
political, business, human service, social and religious groups, grassroots
groups, and individuals.
• Exploit new resources in changing situations to expand the potential scope and
range of services that can be accomplished.
• Demonstrate and develop widespread public support for issues, actions, or unmet
needs.
• Maximize the power of individuals and groups through joint action, increasing the
“critical mass” behind a community effort, providing a comprehensive approach
to programming, and enhancing competence and clout in advocacy and resource
development.
• Minimize duplication of services and fill gaps in service delivery, at the same time
improving trust and communication among groups that would normally compete
with one another.
Adapted from State Oral Health Coalitions and Collaborative Partnerships. Best Practice Approaches for State
and Community Oral Health Programs. Reno, NV: Association of State and Territorial Dental Directors.
Available at http://www.astdd.org/bestpractices-bpastatecoalitions.pdf. Accessed June 2015.
State oral health coalitions also provide resources to assist in developing and
enhancing the building blocks of a coalition. For example, the WOHC developed a
document, which is available on their website, for oral health professionals
interested in forming an oral health coalition for their own state or community.17
The Coalition Building Toolkit provides best practices information in relation to
being part of a coalition, steps to building a successful coalition, and effective team-
building activities.17
Local Level
Local programs also carry out the public health activities reflected in the core
public health functions and essential public health services with assistance from
SOHP through consultation and funding. The ASTDD guidelines and other
resources on the ASTDD website also serve to guide local programs.11 Individual
county and city health departments across the nation have recognized the need
within their communities to provide oral health services to various members of
their populations. Many of these clinics are federally funded, offering services on a
sliding scale fee schedule and accepting clients who receive public assistance
through Medicaid. Hours of clinic operation are tailored to best meet the needs of
the population they serve. The clinics provide diagnostic, preventive, and restorative
oral health services to older adults, the indigent population, and the working poor.
In addition, some of these clinics operate sealant, oral health education, and other
preventive programs in local schools.
Nonprofit and faith-based organizations also establish community-based clinics
that are funded through a variety of sources, including government, United Way,
and foundation grants; donations; sale of goods and services; special events; fund
raisers; and other sources. These clinics employ public health dentists and dental
hygienists and sometimes have supplemental clinical coverage provided by local
volunteer oral health professionals. Such community-based dental clinics can be
part of a comprehensive health center or free-standing community dental programs.
Two examples are described here.
CCA's revenue and support contributions come largely from resale merchandise
and donated goods and services. Other sources of funding are foundation grants,
special events, government grants, and the United Way. CCA also relies on financial
and other support of local businesses, civic chambers and organizations, churches,
community groups, restaurants, and interested individuals.18
The focus of CCA is to help people in need become self-sufficient by “offering a
hand-up instead of a hand out.”18 Thus other related services are provided such as
financial planning assistance, a food pantry, affordable housing, spiritual care and
counseling, vocational services (job-search support), case management services,
child care services, and seasonal programs—for example, a holiday meal program.
“CCA's comprehensive approach from rescue to transition helps each client
improve his or her financial situation, health, education, and spiritual well-being
through loving, Christ-centered case management and mutual accountability.”18
Dental Health Arlington
Another example of a local program is Dental Health Arlington (DHA), a nonprofit
organization that operates a dental clinic serving Southeast Tarrant County, Texas,
since 1993, providing dental access for low-income residents.19 Dentists, dental
hygienists, dental assistants, dental hygiene students from three dental hygiene
programs in the area, and predental students donate a total of 2400 volunteer hours a
year in the dental clinic to address the need for accessible, affordable dental care.
Routine preventive restorative services are provided in the clinic, and a pro-bono
dental referral program is available for more complex services.
In addition, DHA operates a mobile dental sealant program called SMILES that
annually benefits 9000 children in 31 local Title 1 schools. This program provides
oral health education to children in grades 1 through 3, as well as screenings,
sealants, and fluoride varnish to second- and third-grade children. Each year
approximately 4000 sealants are placed for 1400 children, and fluoride varnish is
provided to 3100 children, for a total value of $407,000.19 Children with severe
decay are referred to the DHA clinic for free dental treatment.
DHA is funded through a variety of sources, including an endowment; grants
from the United Way, Texas Department of Health, and local foundations,
businesses, and organizations; individual donations; and fund-raising events such as
a fun run and dental continuing education seminars. DHA also collaborates with
Texas Health Steps (THSteps) and Communities in Schools. DHA has received
numerous federal, regional, and local awards including the President's Service
Award from Points of Light in Washington, DC, and recognition from the Pew
Partnership, American Dental Association (ADA), Texas Dental Association, and
Texas Oral Health Coalition.19
Local Coalitions
In addition, coalitions can function at the regional or community level.15 These
coalitions can be developed through local jurisdictions, hospitals, or other local
organizations, and they collaborate with a state coalition to address and support
local issues and programs. An example is the Children's Oral Health Coalition
(COHC) of Tarrant County, Texas, developed and supported by the Cook Children's
Health Care System of Fort Worth Community Health Outreach Department.20
The COHC collaborates with various community partners to work to improve the
oral health of children from birth to third grade in the county with a special focus
on underserved children.20 Activities include legislative advocacy for children's oral
health issues, including access to care; train-the-trainer programs for health
professionals in the community; distribution of oral health/oral hygiene kits to low-
income children and families through community partners; and targeted oral health
education programs through local schools that serve low-income children.
Program Planning Process
With increased emphasis on improving public access to oral health care, the
responsibilities of the dental hygienist to promote oral health in the community take
on renewed importance. An organized program planning process is critical to
effective community oral health programs.21-23 Therefore it is important that the
dental hygienist understand the basic concepts and steps involved in planning and
conducting oral health programs in the community.
The program planning process is a model commonly used in public health
practice.24 The model provides a continuous cycle of basic steps to assess, plan,
implement, and evaluate a community program. These components can be reviewed
in the program planning process flowchart in Figure 3-8 in Chapter 3. They are
listed again here and explained in detail in the following sections of this chapter.
3. Select and plan effective health interventions to help achieve the objectives.
5. Evaluate the selected interventions based on the objectives and use the
information to improve the program.
Drawing a parallel of the steps used in planning and conducting community oral
health programs to the steps involved in the dental hygiene process of care can
facilitate understanding (Table 6-2). Although the community program planning
process has five steps and the dental hygiene process of care has six steps, they
correspond to each other as illustrated in the table. For example, the community
survey conducted to identify the community's primary health issues is comparable
to the patient's examination and interview for assessment. In this step, reviewing
secondary data in the community setting can be compared to reviewing data
previously recorded in a patient's chart or prior radiographs. Critically analyzing
community data in this step is similar to using decision making skills to analyze
patient data and reach conclusions about the patient's treatment needs in diagnosis.
Developing program goals and objectives is analogous to establishing treatment
goals and outcomes for the patient. Planning interventions and implementation of
the program are equivalent to the treatment plan and treatment of the patient.
Evaluation and review of the program can be compared to evaluating the patient's
treatment. A formal report of the program outcomes in the evaluation step of
community program planning is similar to documentation of patient care and
outcomes.
TABLE 6-2
Comparison of the Program Planning Process to the Dental Hygiene
Process of Care for Individual Patients
Five Ste ps of Prog ram Planning Proc e ss Six Ste ps of De ntal Hyg ie ne Proc e ss of Individual
Community Is the Patie nt Care Is the Patie nt
1. Ide ntify the Primary He alth Issue s 1. Asse ssme nt
Example: Data collected via community survey and review of existing data (secondary data Example: Data collected via visual inspection of gingiva,
previously collected); data critically analyz ed to conclude that high rates of tooth decay exist measurement of probe depths, radiographs, patient interview,
in the community and to identify associated risk factors and other assessment procedures; review of previous dental
records and history
2. Diag nosis
Example: Data critically analyz ed to conclude an indication
of moderate periodontitis
2. De ve lop a Me asurable Proc e ss and Outc ome Obje c tive s to Asse ss Prog re ss 3. Planning
in Addre ssing the He alth Issue s Example: Establishment of realistic goals and treatment
Example: Program will improve oral health; decay rates will be reduced by 20% in 2 years outcomes; development of treatment plan to address the
3. Se le c t and Plan Effe c tive He alth Inte rve ntions to He lp Ac hie ve the patient's moderate periodontitis such as nonsurgical
Obje c tive s periodontal therapy and self-care education
Example: Determination that a fluoride varnish program and comprehensive parent
education combined are the best interventions for this population group and these specific
circumstances
4. Imple me nt the Inte rve ntions 4. Imple me ntation
Example: Fluoride varnish program and a parent education program conducted for 5 years Example: Carry out the treatment plan to treat the patient
5. Evaluate the Se le c te d Inte rve ntions Base d on the Obje c tive s and Use the 5. Evaluation
Information to Improve the Prog ram Example: Evaluation of the outcomes of treatment at the
Example: Impact and outcome objectives evaluated to determine a change in tooth decay rates recommended intervals by comparing assessment and
and a change in risk behaviors addressed in education program; formal report developed to evaluation data to determine success of treatment, and
share with stakeholders, including program description, processes, and outcomes, as well as determination of need for further treatment or maintenance
recommendations to continue, improve, or make changes in the fluoride varnish and of periodontal condition
education programs 6. Doc ume ntation
Example: Recording of data, treatment steps and
information, recommendations, and treatment outcomes in
the patient chart
G ui di ng Pri nci pl es
Establishing Health Priorities
• How many people are affected (one person, small community, or entire country)?
Compounding the problem of establishing the priorities of health needs is the fact
that each community is unique, with its own values and ideas. If a community's basic
needs for food and security are not being met, dental needs assume a low priority.
An issue that often arises is the idea that if a community's perception of needs is
adhered to exclusively, actual clinical health problems may go untreated because the
people are not knowledgeable about many areas of health care. The solution to this
dilemma involves striking a delicate balance between negligence and
overzealousness. Although it is unethical to impose one's own perceptions on a
community, it is the professional's responsibility to inform people of existing
problems and their consequences.21-23
A community needs assessment can identify problems related to health status, as
well as access to and utilization of health care. The assessment also provides
information about the community itself and the priority populations within the
community. During the needs assessment, it is essential to involve the community
and form collaborations with community partners (see Appendix C) to gain support
from the community and maximize the use of community resources. The data
collected can be used to develop a community profile that will assist in identifying
appropriate solutions.
Use of dental survey data that have been collected previously by other
organizations (secondary sources of data) can make the assessment process easier.
For example, dental surveys are conducted by professionals at dental schools, local
and state health departments, and community health centers. Collaboration with
other agencies and organizations to know what has been accomplished can prevent
duplication of services.21-23 Data can be obtained and analyzed by various methods.
Further details about this assessment process can be reviewed in Chapter 3.
Appendix D provides additional information that can be helpful in conducting an
assessment.
Goals
Goals are broadly based ambitious statements of the impact of the interventions,
from which specific objectives are developed.25 An example of a goal statement is to
improve the oral health of school-age children in a community.
Objectives
Objectives are more specific than goals, aligning with the overarching program
goals and describing in a specific, measurable way the desired end results of
program activities. Objectives should clearly communicate the expected outcomes
of a community oral health program. This can be achieved by carefully constructing
the objectives. A common format for effective objectives is referred to as SMART
+ C objectives, which possess several common characteristics,21,25 listed and
explained in Box 6-2. In addition, examples of SMART + C objectives are presented
in Box 6-3 to illustrate these characteristics.
ox 6-2
B
Characteri sti cs of SMA RT + C Objecti ves
• Specific, telling how much (e.g., 40%) of what is to be achieved (e.g., what
behavior or what outcome) by whom (e.g., the individuals that will achieve it),
where it will be achieved (e.g., the community or priority group), and by when
(e.g., by 2016)
• Achievable in the sense that the objectives themselves are possible and that the
organization, agency, community, or priority group is capable of attaining them
• Timed, indicating a time line by which the objectives will be achieved, a portion of
which is made clear in the objectives
• Challenging, stretching the group to set its aims on significant improvements that
are important to members of the community
ox 6-3
B
Ex ampl es of SMA RT + C Objecti ves
Goal:
To promote use of fluoride mouthrinses
Objective 1:
Upon completion of today's six-step demonstration of how to rinse with a fluoride
mouthrinse and given an opportunity to practice, 75% of the adolescent participants
will demonstrate the six steps without error (compared with 20% baseline before
the program) by rinsing at a sink in the classroom.
Action Verb:
Demonstrate
SMART + C Characteristics:
• Specific: The specifics are who will be evaluated (the adolescent participants),
what will be evaluated (demonstrating the six steps), how well they must perform
the action to demonstrate achievement (75% will perform the skill without error),
where they will perform the action (at the sink in the classroom), and when they
must perform it (after the demonstration and practice).
• Measurable: 75% of the participants will have to successfully demonstrate all six
steps without error, and there are baseline data available for comparison.
• Achievable: There is a margin of error in that 25% can make errors, and it is
based on the activity that will teach the adolescent participants.
• Realistic: It is realistic because it aligns with the goal, reflects a realistic number
of participants to complete the task compared with the baseline, and the
participants have the necessary foundational abilities and maturity to perform the
skill.
• Time oriented: It will be measured after the demonstration and on the same day of
the demonstration.
• Challenging: Given that only 20% of the participants were familiar with the
correct process of rinsing before the program, it provides a challenge to achieve
75% of them demonstrating all six steps without error.
Objective 2:
One week after implementation of the program, 30% of adolescent participants will
self-report that they are rinsing twice a day at home (compared with 10% doing so
before the program) with the fluoride mouthrinse that was provided to them to take
home.
Action Verb:
Will self-report
SMART + C Characteristics:
• Specific: It is specific who will provide the self-report (adolescent participants),
what will be evaluated (self-report of using a fluoride mouthrinse), how much
they must perform the expected action (twice a day rinsing), where they will
perform it (rinse at home), and when it will be evaluated (1 week after the
program).
• Measurable: 30% of the adolescent participants will report that they are using a
mouthrinse two times a day, and there are baseline data available for comparison.
• Achievable: Participants have the skills and necessary supplies to comply based on
the activities planned.
• Time oriented: It is time oriented because it states that the program objective will
be achieved by measuring compliance 1 week after completion of the program.
ox 6-4
B
Sampl e Performance Verbs A ppropri ate for
Wri ti ng Objecti ves
Adjust
Adopt
Analyze
Apply
Arrange
Assemble
Attempt
Brush
Calculate
Categorize
Characterize
Choose
Classify
Compare
Complete
Conclude
Contrast
Copy
Count
Create
Debate
Define
Demonstrate
Describe
Design
Develop
Diagnose
Differentiate
Discuss
Distinguish
Estimate
Examine
Explain
Express
Find
Floss
Follow
Form
Gather
Group
Hypothesize
Identify
Illustrate
Implement
Increase
Interpret
Integrate
Invent
Join
Keep
Label
List
Locate
Map
Match
Measure
Modify
Observe
Organize
Palpate
Perform
Plan
Practice
Predict
Prepare
Produce
Prove
Rank
Rate
Recognize
Record
Reduce
Repeat
Report
Schedule
Select
Show
Solve
Sort
Spell
State
Summarize
Support
Test
Try
Unite
Weigh
Write
Question: What?
• What activities are required to achieve the objective?
Question: Who?
• Who is responsible for each action step of an activity or initiative?
Question: When?
• What is the necessary chronologic sequence of action steps?
Question: How?
• What materials, media, methods, techniques, etc., are needed?
For ease in addressing these questions, many community oral health programs
begin on a small scale. Using a smaller population with the intent to expand later is
called pilot testing. For example, a pilot test for a school-based dental sealant
program could involve only one school the first year with the goal of expanding the
program to include additional schools the next year. This implementation strategy
allows an opportunity for formative evaluation of the program operation and
provides ease in control and monitoring of the program activities. A pilot program
provides useful information and enables decisions to be made about the future of the
program.21
Evaluating the Selected Interventions Based on the
Objectives and Using the Information to Improve
the Program
Evaluation is a judgment of the effectiveness and efficiency of the program after it
has been in operation. It is designed to determine whether a fully operational
program is meeting the goals and objectives for which it was developed.21-23
Referred to as summative evaluation or outcome evaluation, this step involves
measuring the results or outcomes of the program against the objectives developed
during the early planning stages. Thus, the first step in evaluation is to review the
program goals and specific, measurable objectives. Also, program evaluation
occurs at various times in relation to program operation according to the time
frame of the objectives (intermediate or long term).
To evaluate the effectiveness of health interventions, specific measurement
instruments must be set up to collect data related to attaining each program
objective.21-23 The data that are obtained by measuring the objectives are called
measurable outcomes. These data are compared with baseline data to determine
success. Each objective should be reviewed to determine how well it meets the
program goals. The bottom line in evaluation is accountability—to consumers,
providers, involved agencies, and all other stakeholders. Through evaluation it can
be determined whether the program accomplishes what it was designed to
accomplish (e.g., Were the objectives of the program successfully met? If not, why
not?). Summarizing what went well and what did not, or drawing conclusions based
on intuition, is not adequate; the objectives themselves must be specifically
addressed, and data-driven outcomes must be analyzed.21-23
After the evaluation has been completed, the results should be reported. Reports
can consist of journal articles, summary reports, or a detailed report for
stakeholders, an advisory committee, or the community at large. Reporting
evaluation results to the community and stakeholders can increase community
support and assist in gaining future funding and support from other organizations to
be able to continue the program.21-23 According to the American Dental Hygienists'
Association (ADHA), sharing the results with other professionals is important also
to meet the ethical responsibility to “contribute knowledge that is valid and useful to
our clients and society.”28
Inherent in program evaluation is the possibility of attaining a negative outcome,
that is, the conclusion that the objectives have not been met. At the same time,
however, this does not mean that the program has been a failure. If a program is
evaluated properly so that negative outcomes become learning experiences and
indicators of future programming and research, in some sense it has been a
success.21-23 Formative evaluation during the implementation process can point out
problems and identify opportunities to correct program deficiencies early on. With
ongoing evaluation and change, the summative evaluation (end result) may in fact
measure a program with initial problems as successful.21-23
Program evaluation is an example of applied research. Basic research is the
“systematic study to gain knowledge or understanding of the fundamental aspects of
phenomena and of observable facts without specific applications toward processes
or products in mind.”29 Applied research is concerned with the application of this
knowledge to “determining the means by which a recognized and specific need may
be met,”29 or in other words, developing solutions to problems. For example, a
basic researcher would be concerned with the uptake of fluoride by the teeth from
various concentrations of fluoride varnish; a program evaluator would be
concerned with the success of the fluoride varnish program operation, including
cost effectiveness, acceptability, and meeting the program objectives. The
fundamental purpose of program evaluation is to assist in decision making about
the effectiveness of the program in its entirety, and to reassess the program and
make necessary changes to make the program more effective or efficient.21-23
Dental hygienists play a role in assessing the community, identifying the primary
health issues, and planning, implementing, evaluating, and reporting the outcomes
of community oral health programs. The dental hygienists who have chosen careers
as state dental directors, public health educators, or promoters have played an
important role in the advancement of dental public health, but there is much more
that can be accomplished by the dental hygiene profession as a whole. Many dental
hygienists implement community oral health programs as volunteers in their own
communities or as active members of ADHA and its local component societies. By
knowing how to organize an effective community oral health program and
becoming involved in its implementation, dental hygienists can have an impact in
reaching the goal of optimal oral health care for all people. See Additional
Resources at the end of this chapter and Chapter 8 for resources that can assist with
the steps of the Program Planning Process.
Primary Prevention Programs: Fluorides,
Sealants, Oral Health Education
Primary prevention is a major focus of community oral health programs. Programs
are selected based on the needs of the community. Multiple, varied primary
prevention programs are required to achieve the long-term outcome of optimal oral
health in a population.
ox 6-6
B
Popul ati on Served by Water Fl uori dati on i n the
U.S., 2012
Total U.S. population 313,914,040
Total U.S. population on public water systems 282,534,910
Total U.S. population on fluoridated drinking water systems 210,655,401
% of U.S. population on public water systems receiving fluoridated water 74.6%
Adapted from 2012 Fluoridation Statistics. Centers for Disease Control; 2013. Available at
http://www.cdc.gov/fluoridation/statistics/2012stats.htm. Accessed September 2013.
TABLE 6-3
Number of States with Various Proportions of the Population Having
Access to Community Water Fluoridation, 2012
Data from 2012 Water Fluoridation Statistics. Centers for Disease Control and Prevention; 2013. Available
at http://www.cdc.gov/fluoridation/statistics/2012stats.htm. Accessed June 2015.
TABLE 6-4
Estimated Annual Per Capita Cost for Community Water Fluoridation,
1992 and 2015*
Antifluoridationists
Antifluoridationists are opponents of community water fluoridation. Their reasons
include individual rights, safety, government mistrust, and religious freedom. The
arguments against fluoridation do not have any merit based on scientific knowledge.
The economic and health benefits of fluoridation for millions of Americans have
been confirmed over the years in numerous studies by renowned scientists.30-
32,34,35,37,38
ox 6-7
B
Effecti veness of Vari ous Fl uori de Modal i ti es
• Community water fluoridation: Early studies demonstrated a 50% to 70%
reduction in caries; more recent studies indicated a 20% to 40% reduction in
adults and 8% to 37% reduction in children as the result of additional availability
of other fluoride sources.*
• Fluoride mouthrinses: Studies in the 1970s and 1980s demonstrated a reduction in
caries ranging from 20% to 50%.*
• Dietary fluoride supplements: Controlled trials in the U.S. in the 1970s indicated
approximately a 20% to 28% reduction.*
*Milgram P, Reisine S. Oral health in the United States: The post-fluoride generation. Annu Rev Public Health
2000;21:403–436. doi:10.1146/annurev.publhealth.21.1.403.
†Marinho VCC, Worthington HV, Walsh T, Clarkson JE. Fluoride varnishes for preventing dental caries in
children and adolescents. Cochrane Libraries (Web); 2013. doi:10.1002/14651858. CD002279.pub2.
Available at http://www.cochrane.org/CD002279/ORAL_fluoride-varnishes-for-preventing-dental-caries-
in-children-and-adolescents. Accessed March 2015.
Fluoride Varnish
Developed in Europe during the 1960s, the use of fluoride varnish was introduced
to the U.S. in 1994 and remains in wide use in Europe and Canada. The varnish is
applied by an operator, with a recommended twice-yearly reapplication for optimal
benefit. The varnish is not intended to be permanent, like a sealant, but to hold the
fluoride in contact with the tooth for a period of time.
Varnish offers easy applicability of fluoride for infants, toddlers, and young
children; disabled individuals; hospitalized patients; and people with severe gag
reflexes that cannot tolerate tray application of gels and foams.50 Fluoride varnish
should be the only professionally applied fluoride for children younger than age
6.50 Studies in Europe have demonstrated their efficacy historically.37 Recent studies
in the U.S. have found fluoride varnish to be an effective evidenced-based approach
to prevent caries in primary and permanent teeth of children and adults, including
root surface caries in adults with gingival recession.51
Public health fluoride varnish programs are common today for high-risk
children in clinical sites, HS centers, and WIC sites.52 These programs have value
especially in addressing the increased incidence of dental caries in young children.
One example of such a program is a community fluoride varnish program
implemented by the Virginia Department of Health, Dental Health Program.53 The
primary focus of the program is to train dental and medical providers to use an oral
health risk assessment tool and place fluoride varnish on the teeth of children aged 3
years and younger. The Health Resources and Services Administration (HRSA) and
other grant funds supported the development of the program and the creation of
educational materials targeting the Medicaid eligible population. Other partners
collaborating on the grant included the Division of WIC and Community Nutrition
Services, EHS, Virginia's Department of Education, University of Virginia School
of Medicine, Department of Medical Assistance Services, and Virginia
Commonwealth University School of Dentistry.53
School-based fluoride varnish programs are implemented easily in elementary
schools and HS and similar preschool programs.52 These programs can be operated
by state and municipal health departments, local school districts, and dental hygiene
programs. For cost effectiveness, such programs should follow a targeted approach
versus universal application, be based on the presence of at least two population
versus individual high-risk factors to target moderate to high-risk populations (Box
6-8), and include applications at a minimum of 6-month intervals over at least a 2-
year period.52
ox 6-8
B
Popul ati on Ri sk Factors to Consi der i n
Targ eti ng Cari es Preventi on Prog rams
Proportion of the population who possess the following:
• Limited education
Adapted from Washington State School-Based Sealant and Fluoride Varnish Program Guidelines. Olympia, WA:
Washington State Department of Health, Oral Health Program; 2012. Available at
http://here.doh.wa.gov/materials/sealant-fluoride-varnish-guidelines/15_OHsealguid_E12L.pdf. Accessed June
2015.
TABLE 6-5
Dietary Fluoride Supplement Schedule, 2010
Prevention of Fluorosis
With all the additional sources of fluoride available today, the prevalence of caries
has decreased, but the prevalence of dental fluorosis has increased in both
fluoridated and nonfluoridated communities.32 Healthcare professionals, such as
dentists, dental hygienists, and physicians, are important sources of information for
patients regarding the use of fluoride-containing products and should provide
education and recommendations on the appropriate use of these products to help
reduce the prevalence of enamel fluorosis60 (Box 6-9). Dental hygienists can be a
valuable resource to the community by providing public education on fluorides and
consultation with primary care medical providers on water fluoridation and other
sources of fluoride.
ox 6-9
B
Centers for Di sease Control and Preventi on
Recommendati ons to Prevent Fl uorosi s
• Counsel parents and caregivers about the use of fluoride toothpaste by young
children (<2 years old, no fluoride toothpaste; ages 2-6 years, no more than a
pea-sized amount of fluoride toothpaste)
• Use an alternative source of water for children ≤8 years old whose primary
drinking water has a fluoride level >2 mg/L
Adapted from FAQs for Dental Fluorosis. Atlanta, GA: Centers for Disease Control and Prevention; 2013.
Available at http://www.cdc.gov/fluoridation/safety/dental_fluorosis.htm. Accessed June 2015.
Dental Sealants
Along with water fluoridation and fluoride toothpastes, dental sealants are a
cornerstone of individual and community practice to prevent and control dental
caries.50 Although the percentage of school-age children with sealants has risen in
recent years as the public and private sectors have been using the procedure, as
dental insurance has paid for sealants, and as parents have requested sealants for
their children, little increase has occurred among children in low-income
populations. One goal of Healthy People 2020 is to increase the number of children
with dental sealants on their primary and permanent molars10 (Table 6-6). The focus
on sealing primary teeth is a new subobjective in this latest version of Healthy
People oral health objectives and is based on the need to address the rise in early
childhood caries in the last decade.10
TABLE 6-6
Healthy People 2020 Oral Health Objective Relative to Dental Sealants
Objective: Increase the Proportion of Children and Adolescents Who Have Received Dental Sealants on Their Molar Teeth
Subobje c tive s 2010 Base line 2020 Targ e t
Children aged 3-5 years who have received dental sealants on one or more of their primary molar teeth 1.4% 1.5%
Children aged 6-9 years who have received dental sealants on one or more of their permanent first molar teeth 25.5% 28.1%
Adolescents aged 13-15 years who have received dental sealants on one or more of their permanent second molar teeth 19.9% 21.9%
Data from Healthy People 2020: Oral Health. Washington, DC: Department of Health and Human Services,
Office of Disease Prevention and Health Promotion; 2015. Available at
https://www.healthypeople.gov/2020/topics-objectives/topic/oral-health/objectives. Accessed May 2015.
To address the Healthy People goal over the past few decades, many states have
instituted school-based sealant programs (SBSP). In some programs mobile dental
vans are sent to schools and the sealants are applied in the van. In other programs,
portable equipment is transported from school to school and set up in available
spaces such as a gym, lunchroom, or extra classroom. Students are then brought to
the designated room for the procedure.
SBSP generally have focused on 6- to 8-year-olds and 12- to 14-year-olds
because the first and second molars usually erupt during these years. Placing
sealants on these teeth shortly after their eruption protects them from development
of pit and fissure caries. About 90% of decay occurs in the pits and fissures of
permanent posterior teeth with the molars being at highest risk.63
The CDC reports that SBSP reduce dental caries as much as 60%.64 If sealants
were applied routinely to susceptible tooth surfaces in conjunction with the
appropriate use of fluorides, most tooth decay in children could be prevented.
Because the effectiveness of sealants has been established, program administrators
should concentrate evaluation efforts on the quality of sealant placement, as well as
the acceptability and cost effectiveness of the program.53
As an example, the Ohio Department of Health's (ODH) School-Based Oral
Health Program provides grants to support local SBSP that target schools with 40%
or more students from low-income families based on their enrollment in the state's
free and reduced meals program.65 The grant funds originate from Ohio's federal
Maternal and Child Health Block Grant. In addition, an HRSA grant supported
expansion of the SBSP in the state. Grantee agencies include local health
departments, school systems, private not-for-profit agencies, and hospitals.66 In
2010 just over 50% of all Ohio third graders had at least one or more sealants on
their permanent molar teeth, meeting the Healthy People 2010 objective regardless
of racial group or income.66 In 2012 18 of the state's 21 SBSP were funded by the
ODH and provided sealants to 25,321 schoolchildren.66 In 2013, the ODH began
implementing a pilot collaboration between two safety net dental care programs and
SBSP in Northeast Ohio to provide follow-up care to students identified as needing
dental treatment.66 Currently, 17 SBSP are funded to place sealants through this
program.65
Table 6-7 provides the 2009 CDC recommendations for SBSP, which were
prepared by an appointed CDC-expert workgroup. These recommendations and the
accompanying report by Gooch and colleagues published in the Journal of the
American Dental Association continue to serve as an evidence-based guide for
SBSP.64
Table 6-7
CDC Recommendations for School-Based Sealant Programs
Data from Gooch BF, Griffin SO, Gray SK, et al. Preventing dental caries through school-based sealant
programs. J Am Dent Assoc 2009;140(11):1356–1365. Available at http://jada.ada.org/article/S0002-
8177%2814%2964584-0/fulltext. Accessed June 2015.
ox 6-10
B
Oral H eal th Educati on Lesson Pl an Templ ate
Title: Identify a title that reflects the topic of your lesson.
Concept/Topic to Teach: Clearly identify the topic of the lesson.
Goal: What is the purpose of the lesson? Record the general goal of your lesson.
Objectives: Begin with the end in mind. What do you want the students to learn
from this lesson? Write no more than three specific objectives for the lesson.
Vocabulary: Create a key vocabulary list that you will add to as you develop
your lesson plan. You will make sure the students understand these terms as they
work through the lesson.
Materials: Create a materials list and add to this as you develop your lesson.
This will help you prepare what you need for your lesson, such as audio/visual
(A/V) equipment, number of copies, and teaching supplies.
Introduction: Plan your introduction, such as a simple oral explanation for the
lesson, an introductory worksheet, or an interactive activity.
Teaching Method: Select the teaching strategy you will use, such as lecture,
group discussion, an activity, or a combination.
Content Outline: Write out supporting content information as notes.
Instructions: Write out step-by-step instructions for the practice skills for the
lesson.
Review: Create an end-of-lesson review of the most salient points of the lesson.
Evaluation Plan: Complete detailed assessments to determine the learning
outcomes; tie the evaluation plan to the objectives.
Accommodations: Plan any necessary accommodations for English as a second
language (ESL) or special education audience participants.
Adapted from Teaching Guide: Writing Lesson Plans. Fort Collins, CO: Colorado State University; n.d. Available
at http://writing.colostate.edu/guides/teaching/lesson_plans/. Accessed September 2015.
Health education theory (see Chapter 8) and the steps of the community program
planning process (see earlier in this chapter) should be incorporated into all oral
health education efforts. Selection of teaching strategies and materials for oral
health lessons should be based on the needs of the audience and with consideration
given to the advantages and disadvantages of the different methods (Box 6-11).
Various teaching techniques are more suitable for different topics and for different
audiences based on age, educational background, oral health literacy, and other
factors. In general, more effective methods are those that involve active audience
participation, utilize multiple senses, and combine teaching techniques to meet the
needs of various learning styles and maintain audience interest.69 Dental Health
Education: Lesson Planning & Implementation provides a comprehensive resource
for planning oral health education and community outreach programs.69
ox 6-11
B
Teachi ng Methods for Oral H eal th
Presentati ons
Advantag e s Disadvantag e s
Lecture—Informative Talk, Pre pare d Be fore hand and Give n to a Group; Use ful to Introduc e Ne w Topic s, Arouse Inte re st in a Subje c t,
or Re vie w Conc e pts
• Present many facts/ideas in short period • No active participation by the learner
• Convey information to large audience • Encourages one-way communication
• Prepare before presentation • Stifles creativity
• Instructor determines aims, content, organiz ation, pace, and direction • Requires effective writing, speaking, and modeling skills; poor presentation
• Integrate diverse materials and present various ideas/concepts in an technique is a barrier to learning
orderly fashion • Difficult to monitor student learning
• Can incorporate media
• Builds on foundation knowledge
• Can gradually develop difficult concepts
Lecture-Demonstration—Informative Talk; Pre se nts Information Supple me nte d by a De monstration to Re inforc e Le arning ; Can Be Use d
to Introduc e Information and to De monstrate Skills or Te c hnique s to Supple me nt Information; Fie ld Trips Can Be Use d for the
De monstration Portion
• Illustrates information visually • Without appropriate technology, difficult for large groups to see demonstration
• Presents information in a complete format • Requires careful preparation for success
• Allows for concentration of attention and economical use of time • Requires adequate equipment and facilities
• Useful for reinforcing material • Can be a passive approach
• Can use models, computer-generated slides, videotapes, and other
tools
• Technology (e.g., computer monitors) allows viewing by more
participants
Discussion—Group Ac tivity in Whic h the Stude nt and Te ac he r De fine a Proble m and Se e k a Solution; Inte rac tion Be twe e n Te ac he r and
Stude nts to Promote Dive rg e nt Thinking Whe re Closure Is Not Expe c te d; Promote s Unde rstanding and Clarific ation of Conc e pts,
Ide as, and Fe e ling s; Inc lude s Use of Que stions by the Le ade r to Stimulate Inte rac tion
Discovery Learning—Use s a Le ss Dire c t Que stioning Format to Prod the Le arne r into Using Log ic or Common Se nse to Disc ove r Ide as
or Conc e pts; Use ful to Build on Foundational Knowle dg e and to Introduc e Ne w Conc e pts
• Promotes learner involvement • May be interpreted as guessing
• Requires application of knowledge (higher level learning) • Learner needs to be guided so that correct information is concluded
• Promotes critical thinking • Requires foundational knowledge
• Motivates student to discover the “ right answer”
• Promotes divergent thinking; useful when multiple answers are
plausible
Brainstorming—Fre e Sharing of Ide as Ge ne rate d by Unstruc ture d Group Inte rac tion; May Have a We ll-De fine d, Cle arly State d
Proble m to Addre ss; Ide as Re c orde d for Future Disc ussion but Ne ve r Analyz e d for Me rit during Se ssion; Use ful for Group
Ide ntific ation of an Issue or Proble m
• Useful for youth and adult groups • Group dynamic may be influenced by stronger personalities of some students
• Encourages creativity • Requires careful management to maintain the purpose of the exercise
• Encourages application of knowledge • Not useful to share information, only for problem identification or issue
• Encourages contribution by all participants with no fear of a “ wrong clarification
answer” • Difficult to manage with children
• Encourages people to build on others' ideas
Web-Based Learning—Use of Compute r to Pre se nt Information in a Way That Can Be Inte rac tive ; Inc lude s Use of the Monitor to
Pre se nt Photos, Animation, Vide o, Print, and Sound for Le c ture -De monstration, Case s, Disc ussion Groups, Simulation, Te sting , and
Othe r Online Te ac hing Me thods
• Provides an alternative medium to present information • Useful for youth and adult groups
• Accessible at all times if learner has access to a computer • Some individuals may not have computer skills or access to appropriate
• Can be updated technology
• Provides enhanced printed material • Cost of equipment and linkages
• Provides ready access to wealth of resources on the web
• Can be used for virtual field trips
Cooperative and Collaborative Learning Activities—Oc c ur both Inside and Outside the Classroom or Le arning Environme nt; for Example ,
Group Ac tivitie s, Proje c ts, De bate s, and Expe rime nts
• Encourages critical thinking • Can be difficult to manage
• Promotes social environment for learning • Requires maturity of the students
• Students can learn from each other
School-Based Oral Health Programs
A comprehensive school-based oral health program includes multiple primary
prevention programs, oral health education (Figure 6-6), and a dental treatment
component. The comprehensive oral health promotion model focuses on the
assessment, prevention, and oral health education needs of children and their
families.
FIG 6-6 A dental hygiene student helps a first-grade child practice oral hygiene
skills. (Photograph courtesy Nichole Salazar.)
FIG 6-8 Head Start children will benefit from fluoride varnish programs. (Photograph
courtesy Christine French Beatty.)
FIG 6-9 Very young children can benefit form Early Head Start oral health
programs that put them on the road to healthy teeth and gingiva starting with “the
first tooth.” (Photograph courtesy Anabel Ruiz.)
TABLE 6-8
Head Start Program Statistics, 2014
Having served more than 32 million children since 1965, HS aids our nation's
most vulnerable children in community centers, schools, or family child-care
homes in urban, suburban, and rural communities.73 HS and EHS programs are
administered by the DHHS Office of the Administration for Children & Families
(ACF) Office of Head Start (OHS). Based on specific criteria, HS grants are
awarded directly to public agencies, private nonprofit or for-profit organizations,
tribal governments, and school systems for the purpose of operating HS programs
in local communities.73 HS agencies receive grant funding directly from ACF
(rather than from the state) and may directly operate the HS program, delegate
operations to another agency, or use a combination of these means of operating the
program.73 In 2014 the federal HS program was funded almost $8.6 billion by
Congress to serve almost one million children and pregnant women, and 1622
organizations received HS grants to operate local HS programs.73 In accordance
with a Congressional mandate, HS and EHS programs are monitored every 3 years
to ensure compliance with performance standards.73
Health Services
HS health services focus on prevention and early intervention, encompassing
medical, nutrition, oral health, and mental health services. The HS staff is required
to work in partnership with parents to ensure that the following occur:74
• Each child has a medical and dental home and medical and dental health insurance.
• Each child is up-to-date on a schedule of primary and preventive medical, dental,
and mental health care, including all necessary immunizations.
• The processes mentioned earlier take place within 90 calendar days of the child's
entry into the program.
• Referrals are made for further diagnosis, evaluation, and treatment in the event that
a potential health concern is identified during screening or the required well-child
visit.
• Children receive needed services and parents understand the services received.
• Transportation is provided to medical or dental appointments and child care as
needed.
HS programs are required to meet government standards for serving meals that
are high in nutrients and low in sugar, fat, and salt.74 Health education for both
children and parents is a critical requirement of HS.74 Children are taught healthy
behaviors, such as handwashing and toothbrushing, and can learn about injury
prevention, physical activity, and making healthy food choices. Parents participate in
health education workshops or receive health education services in the home.
HS programs are required to establish and maintain a Health Services Advisory
Committee (HSAC) comprised of local healthcare professionals, HS staff, and
parents.74 The HSAC can be instrumental in identifying community resources,
assisting programs in developing and implementing policies and procedures,
keeping the program informed of emerging research and practice guidelines, and
providing education to program staff and parents. Participation on the HSAC is an
opportunity for dental hygienists to get involved in local HS programs to assist with
the oral health component.
ox 6-12
B
Requi rements for Local H ead Start Prog rams
Rel ated to Oral H eal th
• Within the first 90 days of enrollment, determine whether each child has an
ongoing source of continuous accessible care (dental home) and if child is up-to-
date on age appropriate preventive and primary dental care.
• Establish and implement policies and procedures for rapid response to dental
emergencies with which all staff are familiar and trained.
• Provide oral health education programs for program staff, parents, and families.
• Provide parents with the opportunity to learn the principles of preventive oral
health, including the need for early dental treatment during pregnancy.
• Provide organizational structure and support for staff to manage dental services.
Adapted from Head Start Performance Standards and Other Regulations. Washington, DC: Office of the
Administration for Children & Families, Early Childhood Learning & Knowledge Center; 2015. Available at
http://eclkc.ohs.acf.hhs.gov/hslc/standards/hspps. Accessed June 2015.
FIG 6-10 Pre-school children learn important healthy lifestyle behaviors, such as
toothbrushing, when they practice them at school. (Photograph courtesy Christine French
Beatty.)
In the early years of HS, basic primary and secondary preventive oral health and
dental services were often provided by volunteer dentists. Over the years, HS
programs have faced many challenges in meeting the oral health performance
standard requirements for dental treatment. Current challenges with meeting these
standards are multifactorial and affect three different groups:75
1. HS directors and staff report that finding a dentist that will treat young children,
accept Medicaid, and have extended hours is one of their biggest challenges.
2. Dentists and their staff report that they do not feel comfortable treating young
children, parents cancel or do not keep appointments, and Medicaid reimbursement
is inadequate. In addition, they perceive that oral health is not important to HS
parents.
3. HS parents report problems with dental office staff not being friendly or
welcoming, language barriers, not understanding explanations and instructions,
transportation, and missed work hours for dental appointments. Also some parents
are reluctant to seek dental care for their children because of their own negative
dental experiences, or because they do not understand the importance of oral health,
believing that “baby teeth just fall out.”
FIG 6-11 Dental hygiene students screen homeless and indigent individuals at a
faith-based soup kitchen as part of a community program designed to provide oral
health education and referral to local community clinics for treatment. Courtesy Our
Daily Bread, Denton, TX.)
ox 6-13
B
Dental Servi ces Provi ded T hroug h the Tex as
H eal th Steps Prog ram
Preventive Services
• Dental examinations (initial and periodic)
• Cleaning (prophylaxis)
• Topical fluoride application
• Dental sealants
• Maintenance of space
Treatment Services
• Restorative treatment (e.g., fillings and crowns)
• Periodontal treatment
Emergency Services
• Procedures necessary to control bleeding, relieve pain, and eliminate acute
infection
• Crossbite therapy
Older adults are living longer and are more health conscious than their
counterparts of past generations. As a result, they are retaining more of their natural
dentition and have an increased need for access to dental care. Because their
incomes decline with retirement and only 2% of retirees have dental coverage
through a prior employer, they are also in need of a means to pay for dental
services.90,91 Medicare does not cover dental services except in relation to a medical
condition and never covers the cost of dentures.92 Only 11 states provide adult dental
benefits through Medicaid,93 and changes in dental coverage mandated by ACA also
do not include older adults.90,93 It has been suggested that oral health care needs to be
provided through Medicare.94 Even though this would be a burden to the nation's
economy, failing to provide oral health services to the growing older adult
population could be costly in the long run. In the role of advocate, dental hygienists
can support legislation and programs that will improve access to dental care for this
vulnerable population.
An example of a program to increase access to dental care for older adults is
Apple Tree Dental, a nonprofit dental organization that brings dental care to older
adults via mobile equipment at a reduced fee.95 Services provided include primary
preventive services, secondary restorative treatment, and tertiary services such as
dentures for residents of long-term care facilities. This program began in
Minnesota in 1986, when a few dental professionals recognized the problems of
access to dental care experienced by many older adults. The program has since
expanded to include patients with special needs, children with disabilities, and
indigent families, and the organization has grown to consist of 95 locations in
multiple states.95 They work with state and local authorities to establish mobile
delivery sites. Funding sources include individual donors, foundation grants, and
corporate sponsors.95
Apple Tree Dental provides a model that can be replicated to treat older adult
populations in other communities where similar programs are needed to provide
for the oral healthcare needs of this population. Such programs should be based on
an established need through assessment using standard data collection such as the
ASTDD Basic Screening Survey for older adults (see Chapter 4) and taking into
consideration the social, demographic, health, and economic characteristics of
today's older adult population.90
Financing Programs
The financing of dental public health is complex, with a combination of public and
private monies supporting programs, the availability of which varies according to
the national economy. Federal publicly financed initiatives cut across multiple
agencies, have multiple federal and state funding streams, and are only as strong as
the government policies that support them. These factors can make financing of oral
health programs challenging and sometimes risky in terms of depending on future
financing.94
Public funding is insufficient to address all the oral health needs in the nation,
making it impossible for some states to implement oral health programs that have
been identified as a priority. At present the majority of public health funding
addresses the health and well-being of pregnant women and children and is
accomplished through numerous federal initiatives. Funding for oral health care for
other population groups is limited.94 Current healthcare reform has increased access
to oral health services for children and other limited population groups; however, it
has been suggested that a more comprehensive health financing system is needed to
improve oral health for other vulnerable groups as well.94 Major current public
financing programs for oral health care are defined in Table 6-9.
TABLE 6-9
Public Financing of Oral Health Care
Block Grants
Maternal and Child Health Services block grants (Title V grants) provide funding
to states for the provision of prenatal care for women, primary and preventive care
for children, and health and supportive services for children with special healthcare
needs. This program is the nation's oldest federal-state partnership, and today most
state oral health programs are funded by these grants.94 Examples of state oral health
programs where the federal government had a significant impact in the community
include community water fluoridation, school-based sealant programs, safety net
programs, and development of state oral health plans based on Healthy People 2020
oral health objectives.94
Medicaid
Medicaid, or Title XIX, is a joint state-federal financed program that is
administered by the states to provide comprehensive medical and dental coverage
for children of low-income families. Dental coverage is required for all child
enrollees as part of a comprehensive set of EPSDT benefits.99 States have flexibility
to determine what dental benefits are provided to adult Medicaid enrollees.100
Although most states provide at least emergency dental services for adults, less than
half currently provide comprehensive dental care. In 2015 nearly 70 million people
were reported to be enrolled in Medicaid and CHIP nationwide.101 With the passage
of the ACA some states have expanded Medicaid coverage for children through
their state CHIP program.102 In many states the Medicaid program has ventured into
the managed care health arena for both medical and dental services in an effort to
reduce healthcare expenditures and also maximize preventive health measures.
State-specific information about Medicaid and CHIP is available at
http://www.insurekidsnow.gov/.
2. Have a classroom debate on fluoridation. Appoint people to take pro and con
positions, and research your position before the debate. Research the changes made
related to the CDC recommendation for the optimum level of fluoride in the
community water supply, and what brought about the changes. Have a mock city
council decide the outcome.
3. Develop a community oral health program. Describe the use of all five steps of
the community program planning process in your program, including a goal and
specific, measurable objectives, and identify potential resources for funding of the
program.
4. Discuss how you, as a private practice dental hygienist, might help implement the
core essential public health functions and oral health services in your community.
Core Competencies
C.3
Use critical thinking skills and comprehensive problem-solving to identify oral
healthcare strategies that promote patient health and wellness.
C.8
Promote the values of the dental hygiene profession through service-based
activities, positive community affiliations, and active involvement in local
organizations.
Community Involvement
CM.1
Assess the oral health needs and services of the community to determine action
plans and availability of resources to meet the healthcare needs.
CM.2
Provide screening, referral, and educational services that allow patients to access
the resources of the healthcare system.
CM.3
Provide community oral health services in a variety of settings.
CM.4
Facilitate patient access to oral health services by influencing individuals or
organizations for the provision of oral health care.
CM.5
Evaluate reimbursement mechanisms and their impact on the patient's access to oral
health care.
CM.6
Evaluate the outcomes of community-based programs, and plan for future activities.
CM.7
Advocate for effective oral health care for underserved populations.
Community Case
The dental hygiene school in your community has received a 3-year federal grant
from the U.S. Public Health Service to establish a pilot school-based
interprofessional collaborative health center in a Title I elementary school that also
has an Head Start program. The community is classified as a medical and dental
health professional shortage area by HRSA and is not fluoridated. The program
includes oral health education, primary oral disease prevention services, and dental
treatment. As the newly employed dental hygienist at the school, you will supervise
dental hygiene students on-site at the elementary school and in the clinic.
1. All of the following are components of establishing this oral health initiative
EXCEPT one. Which one is the EXCEPTION?
a. Assessment
b. Planning
c. Assurance
d. Evaluation
e. Implementation
2. The program goal is to improve the oral health of the school-age children. Which
instructional objective that you have written for the second-grade class's
educational component is specific and measurable?
a. The students will completely understand the connection of oral health to
general health.
b. The students will label the parts of the tooth accurately on a diagram.
c. The students will know how to brush and floss.
d. The students will remember the cause of tooth decay.
3. Which preventive program would have the most benefit for all of the school-age
children in this community?
a. School fluoride mouthrinse program
b. Fluoride varnish program
c. Sealant program
d. Community water fluoridation
4. Which program would be able to provide funding for dental treatment in the
school clinic?
a. Medicaid
b. Medicare
c. Head Start
d. Women, Infants, and Children
5. Which dental hygiene service provided by the dental hygiene students is
considered the most effective best practice for the prevention of dental caries?
a. A parent educational session at the parent-teacher association (PTA)
b. The development of brochures on good oral health practices
c. The application of fluoride varnish on the teeth of the children
d. The referral of children to the dental clinic for treatment
6. You could use all of the following EXCEPT one as resources to help establish
dental homes for individuals in this population. Which one is the EXCEPTION?
a. ASTDD
b. FQHC
c. SOHP
d. ACF
References
1. What is the Public Health System?. [Washington, DC: U.S. Department of
Health & Human Services; Available at]
http://www.hhs.gov/ash/initiatives/quality/system/ [Accessed June 2015].
2. Institute of Medicine, National Research Council. Improving Access to Oral
Health Care for Vulnerable and Underserved Populations. National
Academies Press: Washington, DC; 2011 [Available at]
http://iom.edu/Reports/2011/Improving-Access-to-Oral-Health-Care-for-
Vulnerable-and-Underserved-Populations.aspx [Accessed June 2015].
3. Dental Care in America: The Need to Expand Access. A Report from
Chairman Bernard Sanders, U.S. Senate Committee on Health, Education,
Labor & Pensions, Subcommittee on Primary Health and Aging; 2012.
4. Healthy People 2020, About Healthy People. Department of Health &
Human Services, Office of Disease Prevention and Health Promotion:
Rockville, MD; 2015 [Available at]
http://www.healthypeople.gov/2020/About-Healthy-People [Accessed June
2015].
5. Best Practice Approaches. [Reno, NV: Association of State and Territorial
Dental Directors; Available at] http://www.astdd.org/best-practices/
[Accessed July 2015].
6. U.S. Department of Health & Human Services. [Washington, DC; Available
at] www.hhs.gov [Accessed June 2015].
7. Summary Report: 2015 Synopses of State Dental Public Health Programs:
Data for FY 2013-2014. Association of State and Territorial Dental
Directors: Reno, NV; 2015 [Retrieved at]
http://www.astdd.org/docs/synopsis-of-state-programs-summary-report-
2015.pdf [Accessed June 2015].
8. State Oral Health Infrastructure and Capacity: Reflecting on Progress and
Charting the Future. Association of State & Territorial Dental Directors:
Reno, NV; 2012 [Available at] http://www.astdd.org/docs/infrastructure-
enhancement-project-feb-2012.pdf [Accessed April 2015].
9. Building Infrastructure and Capacity in State and Territorial Oral Health
Programs. Association of State and Territorial Dental Directors: Reno, NV;
2000 [Retrieved at] http://www.astdd.org/docs/Infrastructure.pdf [Accessed
April 2015].
10. Healthy People 2020: Oral Health. Department of Health & Human Services,
Office of Disease Prevention and Health Promotion: Rockville, MD; 2015
[Available at] https://www.healthypeople.gov/2020/topics-
objectives/topic/oral-health/objectives [Accessed May 2015].
11. Guidelines for State and Territorial Oral Health Programs: PART II State
Roles, Activities and Resources. Association of State & Territorial Dental
Directors: Reno, NV; 2013 [Available at] http://www.astdd.org/docs/astdd-
guidelines-section-ii-matrix-for-state-roles-examples-andresources-4-
2013-revisions.pdf [Accessed June 2015].
12. Smile Survey 2010: The Oral Health of Washington's Children. Washington
State Department of Health, Oral Health Program: Olympia, WA; 2011
[Available at] http://www.doh.wa.gov/Portals/1/Documents/Pubs/160-
099_SmileSurvey2010.pdf [Accessed June 2015].
13. Washington State School-Based Sealant and Fluoride Varnish Program
Guidelines. Washington State Department of Health, Oral Health Program:
Olympia, WA; 2012 [Available at] http://here.doh.wa.gov/materials/sealant-
fluoride-varnish-guidelines/15_OHsealguid_E12L.pdf [Accessed June
2015].
14. Washington State Oral Health Plan. Washington State Oral Health Coalition:
Olympia, WA; 2009 [Available at] http://www.ws-ohc.org/plan/waplan.pdf
[Accessed June 2015].
15. State Oral Health Coalitions and Collaborative Partnerships. Best Practice
Approaches for State and Community Oral Health Programs. [Reno, NV:
Association of State and Territorial Dental Directors; Available at]
http://www.astdd.org/bestpractices-bpastatecoalitions.pdf [Accessed June
2015].
16. Children's Health Alliance of Wisconsin. [West Allis, WI; Available at]
https://www.chawisconsin.org/ [Accessed June 2015].
17. Coalition Building Toolkit. [West Allis, WI: Wisconsin Oral Health
Coalition; Available at]
https://www.chawisconsin.org/documents/OH6Toolkit.pdf [Accessed June
2015].
18. Children's Oral Health Coalition. Cook Children's Health Care System: Fort
Worth, TX; 2014 [Available at]
https://www.centerforchildrenshealth.org/en-
us/Counties/tarrantcounty/ChildrensOralHealthCoalition/Pages/default.aspx
[Accessed June 2015].
19. Christian Community Action. 2015 [Lewisville, TX; Available at]
http://ccahelps.org/about-us/ [Accessed June 2015].
20. Dental Health Arlington. [Arlington, TX; Available at]
http://www.dentalhealtharlington.org/index.html [Accessed June 2015].
21. Community Tool Box. Work Group for Community Health and
Development, University of Kansas: Lawrence, KS; 2014 [Available at]
http://ctb.ku.edu/en [Accessed June 2015].
22. McKenzie JF, Neiger BL, Thackeray R. Planning, Implementing &
Evaluating: Health Promotion Programs: A Primer. 6th ed. Pearson
Education, Inc.: Glenview, IL; 2013.
23. Issel LM. Health Program Planning and Evaluation: A Practical, Systematic
Approach for Community Health. 3rd ed. Jones & Bartlett Learning:
Burlington, MA; 2014.
24. The Community Guide: Program Planning Resource. U.S. Department of
Health and Human Services: Washington, DC; 2014 [Available at]
http://www.thecommunityguide.org/uses/program_planning.html
[Accessed June 2015].
25. Goals and Objectives. University of California San Francisco Medical
Center, STD/HIV Prevention Training Center: San Francisco, CA; 2014
[Available at] https://www.stdhivtraining.org/YSMT_goals.html [Accessed
July 2015].
26. Glossary. New York State Department of Health; 2012 [Available at]
https://www.health.ny.gov/statistics/chac/glossary.htm#O [Accessed July
2015].
27. MAPP Framework. National Association of County & City Health Officials:
Washington, DC; 2015 [Available at]
http://www.naccho.org/topics/infrastructure/mapp/framework/index.cfm
[Accessed July 2015].
28. Code of Ethics for Dental Hygienists. American Dental Hygienists'
Association: Chicago, IL; 2014 [Available at]
https://www.adha.org/resources-
docs/7611_Bylaws_and_Code_of_Ethics.pdf [Accessed July 2015].
29. Definitions of Research and Development: An Annotated Compilation of
Official Source. [Arlington, VA: National Science Foundation; n.d.;
Available at] http://www.nsf.gov/statistics/randdef/fedgov.cfm [Accessed
July 2015].
30. 2012 Water Fluoridation Statistics. Centers for Disease Control and
Prevention: Atlanta, GA; 2013 [Available at]
http://www.cdc.gov/fluoridation/statistics/2012stats.htm [Accessed
September 2015].
31. Pollick HF. Community Water Fluoridation. Harris NO, Garcia-Godoy F,
Nathe CN. Primary Preventive Dentistry. 8th ed. Pearson: Boston, MA;
2014.
32. U.S. Department of Health & Human Services Federal Panel on Community
Water Fluoridation. U.S. Public Health Service recommendation for
fluoride concentration in drinking water for the prevention of dental caries.
Public Health Rep. 2015;130(July–Aug):14e [Available at]
http://www.publichealthreports.org/documents/PHS_2015_Fluoride_Guidelines.pdf
[Accessed June 2015].
33. Community Water Fluoridation (Fact Sheet). [Atlanta, GA: Centers for
Disease Control and Prevention; Available at]
http://www.cdc.gov/fluoridation/pdf/communitywaterfluoridationfactsheet.pdf
[Accessed June 2015].
34. Centers for Disease Control and Prevention. Achievements in public health,
1900–1999: Fluoridation of drinking water to prevent dental caries. MMWR
Morb Mortal Wkly Rep. 1999;48(41):933–940 [Available at]
www.cdc.gov/mmwr/preview/mmwrhtml/mm4841a1.htm [Accessed June
2015].
35. Community Preventive Services Task Force. Preventing Dental Caries:
Community Water Fluoridation: Task Force Finding and Rationale
Statement. The Guide to Community Preventive Services; 2013 [Available
at]
http://www.thecommunityguide.org/oral/supportingmaterials/RRfluoridation.html
[Accessed June 2015].
36. Burt BA, Eklund SA. Dentistry, Dental Practice, and the Community. 6th ed.
Elsevier: St Louis; 2005.
37. Centers for Disease Control and Prevention, Fluoride Recommendations
Work Group. Recommendations for using fluoride to prevent and control
dental caries in the United States. MMWR. 2001;50(RR14):1–42 [Available
at] http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm [Accessed
December 2014].
38. Best Practice Approach Reports. Use of Fluoride: Community Water
Fluoridation. Association of State & Territorial Dental Directors: Reno,
NV; 2001–2009 [Available at] http://www.astdd.org/use-of-fluoride-
community-water-fluoridation/ [Accessed June 2015].
39. Community and other approaches to promote oral health and prevent
diseases. Oral Health in America: A Report of the Surgeon General.
Department of Health & Human Services, U.S. Public Health Service,
National Institute of Dental and Craniofacial Research: Rockville, MD;
2000 [Available at]
http://silk.nih.gov/public/hck1ocv.@www.surgeon.fullrpt.pdf [Accessed
June 2015].
40. Heller KW, Sohn W, Burt BA, et al. Water consumption in the United States
in 1994–96 and indications for water fluoridation policy. J Public Health
Dent. 1999;59(1):3–11.
41. Questions and Answers on Fluoride. Environmental Protection Agency:
Washington, DC; 2011 [(document # EPA 815-F-11-001); Available at]
http://www.epa.gov/sites/production/files/2015-
10/documents/2011_fluoride_questionsanswers.pdf [Accessed December
2015].
42. Water Fluoridation Program: Program Overview. [Indianapolis, IN: Indiana
State Department of Health; Available at] www.in.gov/isdh/23287.htm
[Accessed June 2015].
43. Indiana's Community Water Fluoridation Program. Association of State &
Territorial Dental Directors: Reno, NV; 2011 [Available at]
http://www.astdd.org/state-activities-descriptive-summaries/?id=36
[Accessed June 2015].
44. Stocks M, Pollick H. The CDA Foundation model to fluoridate communities.
J Calif Dent Assoc. 2012;40(8):648–655.
45. Crozier S. Resolution OKs social media campaign for fluoridation. ADA
News: Chicago, IL; 2014 [Available at]
http://www.ada.org/en/publications/ada-news/2014-
archive/december/resolution-oks-social-media-campaign-for-fluoridation
[Accessed June 2015].
46. Kliff S. A brief history of America's fluoride wars. The Washington Post:
Washington, DC; 2013 [Available at]
http://www.washingtonpost.com/blogs/wonkblog/wp/2013/05/21/a-brief-
history-of-americas-fluoride-wars/ [Accessed June 2015].
47. Community Water Fluoridation Brief: Highlights and Lessons Learned from
2014. DentaQuest Foundation; 2015 [Available at]
http://www.astdd.org/docs/community-water-fluoridation-lessons-learned-
2015.pdf [Accessed June 2015].
48. School-Based Fluoride Mouthrinse Programs Policy Statement. Association
of State & Territorial Dental Directors: Reno, NV; 2011 [Available at]
http://www.nj.gov/health/fhs/oral/documents/astdd_school_fmr_policy_statement.pdf
[Accessed June 2015].
49. Best Practice Approach: Use of Fluoride: School-Based Fluoride
Mouthrinse and Supplement Programs. Association of State & Territorial
Dental Directors: Reno, NV; 2003 [Available at]
http://www.astdd.org/bestpractices/BPAFluorideMouthrinseSupplement.pdf
[Accessed June 2015].
50. Fluoride Varnish: An Evidence-Based Approach: Research Brief.
Association of State & Territorial Dental Directors: Reno, NV; 2014
[Available at] http://www.astdd.org/docs/fl-varnish-issue-brief-9-10-14.pdf
[Accessed June 2015].
51. Topical Fluoride for Caries Prevention: Full Report of the Updated Clinical
Recommendations and Supporting Systematic Review. ADA Center for
Evidence-Based Dentistry, Council on Scientific Affairs: Chicago, IL; 2013
[Available at]
http://ebd.ada.org/~/media/EBD/Files/Topical_fluoride_for_caries_prevention_2013_
[Accessed June 2015].
52. Washington State School-Based Sealant and Varnish Program Guidelines.
3rd ed. Washington State Department of Health Oral Health Program:
Olympia, WA; 2012 [Available at] http://here.doh.wa.gov/materials/sealant-
fluoride-varnish-guidelines/15_OHsealguid_E12L.pdf [Accessed June
2015].
53. Bright Smiles for Babies. [Richmond, VA: Virginia Department of Health,
Dental Health Program; Available at]
http://www.vdh.virginia.gov/ofhs/childandfamily/dental/mecoh/brightsmiles/
[Accessed June 2015].
54. Denton Christian Preschool Ensures Success for At-Risk Children. United
Way of Denton County; 2012 [Available at]
http://www.unitedwaydenton.org/news/denton-christian-preschool-ensures-
success-risk-children [Accessed June 2015].
55. Beatty CE, Beatty CF, Marshall D. Small Steps for Big Smiles: A Community
Fluoride Varnish Pilot Program (poster). National Oral Health Conference:
Portland, Oregon; 2009.
56. Fluoride Mouthrinse Program. Ohio Department of Health: Columbus, OH;
2015 [Available at]
https://www.odh.ohio.gov/en/odhprograms/ohs/oral/oralprev/mouthrinse.aspx
[Accessed June 2015].
57. Michigan Department of Community Health Oral Health Program and Best
Practices Guide for Conducting a School Based Fluoride Mouthrinse
Program. Public Health-Muskegon County: Muskegon, MI; 2012 [Available
at]
http://www.muskegonhealth.net/programs/educational/fluoride_rinse_manual.pdf
[Accessed June 2015].
58. School-Based Fluoride Mouthrinse Manual. Wisconsin Department of
Health Services Division of Public Health Oral Health Program: Madison,
WI; 2012 [Available at]
https://www.dhs.wisconsin.gov/publications/p0/p00309.pdf [Accessed June
2015].
59. Guideline on Fluoride Therapy. American Academy of Pediatric Dentistry:
Chicago, IL; 2012 [Available at] http://www.aapd.org/ [Accessed June
2015].
60. FAQs for Dental Fluorosis. Centers for Disease Control and Prevention:
Atlanta, GA; 2013 [Available at]
http://www.cdc.gov/fluoridation/safety/dental_fluorosis.htm [Accessed
June 2015].
61. Fluoride Supplements. American Dental Association: Chicago, IL; 2015
[Available at] http://www.ada.org/en/member-center/oral-health-
topics/fluoride-supplements#dosage [Accessed June 2015].
62. Fluoride Information. [Cumberland, PA: West Shore School District;
Available at]
http://www.wssd.k12.pa.us/webpages/HealthServices/resources.cfm?
subpage=66792 [Accessed June 2015].
63. Best Practice Approach: School-Based Dental Sealant Programs.
Association of State & Territorial Dental Directors: Reno, NV; 2015
[updated; Available] http://www.astdd.org/docs/bpar-selants-update-03-
2015.pdf [Accessed June 2015].
64. Gooch BF, Griffin SO, Gray SK, et al. Preventing dental caries through
school-based sealant programs. J Am Dent Assoc. 2009;140(11):1356–1365
[Available at] http://jada.ada.org/article/S0002-8177%2814%2964584-
0/fulltext [Accessed June 2015].
65. Dental Sealants. [Columbus, OH: Ohio Department of Health; Available at]
https://www.odh.ohio.gov/odhprograms/ohs/oral/oralfeatures/dentsealants.aspx
[Accessed June 2015].
66. Dental Public Health Activity Descriptive Report: The Ohio Department of
Health School-Based Dental Sealant Program. Association of State &
Territorial Dental Directors: Reno, NV; 2014 [updated; Available at]
http://www.astdd.org/bestpractices/DES38002OHsealantprogram_1_2014.pdf
[Accessed June 2015].
67. Coordinated School Oral Health Policy Statement. Association of State &
Territorial Dental Directors: Reno, NV; 2011 [Available at]
http://www.astdd.org/docs/coordinated-school-oral-health-policy-april-5-
2011.pdf [Accessed June 2015].
68. Integrating Oral Health Education into Health Education Curricula in
Schools Policy Statement. Association of State and Territorial Dental
Directors: Reno, NV; 2013 [Available at] http://www.astdd.org/school-and-
adolescent-oral-health-committee/ [Accessed June 2015].
69. Gagliardi L. Dental Health Education: Lesson Planning & Implementation.
2nd ed. Waveland Press: Long Grove, IL; 2007 [reissued 2014].
70. Miles of Smiles—Laredo. University of Texas Health Science Center San
Antonio Dental School; 2013 [Available at]
http://milesofsmiles.uthscsa.edu/LaredoMilesofSmiles.php [Accessed June
2015].
71. Components of Coordinated School Health. Centers for Disease Control and
Prevention, Adolescent and School Health: Atlanta, GA; 2015 [Available at]
http://www.cdc.gov/healthyyouth/cshp/components.htm [Accessed June
2015].
72. Garvin KM. It's Been 7 Years Since the 2007 Head Start Reauthorization. NC
Head Start Collaboration Office, Office of Early Learning; 2014 [Available
at] http://www.naehcy.org/sites/default/files/dl/conf-2014/h/c3/garvin-
head-start.pdf [Accessed June 2015].
73. Head Start Program Facts Fiscal Year 2014. Office of the Administration for
Children and Families: Early Childhood Learning & Knowledge Center:
Washington, DC; 2015 [Available at]
http://eclkc.ohs.acf.hhs.gov/hslc/data/factsheets/2014-hs-program-
factsheet.html [Accessed June 2015].
74. Head Start Program Performance Standards. Office of the Administration
for Children and Families: Early Childhood Learning & Knowledge
Center; 2015 [Available at]
http://eclkc.ohs.acf.hhs.gov/hslc/standards/hspps/1304/1304.20%20Child%20health%2
[Accessed June 2015].
75. Louie R, Goodman H, Isman B. Getting a Head Start on Oral Health: An
Overview of Oral Health Requirements and Programs. University of
California San Francisco Dental Public Health Seminar; 2013 [Available at]
http://www.astdd.org/head-start-oral-health-project/ [Accessed June 2015].
76. Healthy Smiles, Happy Children: A Dentist for Every Child. Pennsylvania
Head Start Association: Harrisburg, PA; 2015 [Available at]
http://paheadstart.org/index.php/oral-health/ [Accessed June 2015].
77. Dental Home Online Resource Center. American Academy of Pediatric
Dentistry. [Available at] http://www.aapd.org/advocacy/dentalhome/
[Accessed June 2015].
78. Direct Access. American Dental Hygienists' Association; 2014 [Available at]
http://www.adha.org/direct-access [Accessed June 2015].
79. Oral and Dental Health FastStats. Centers for Disease Control and
Prevention: Atlanta, GA; 2015 [Available at]
http://www.cdc.gov/nchs/fastats/dental.htm [Accessed June 2015].
80. Breaking Down Barriers. American Dental Association, Action for Dental
Health; 2015 [Available at] http://www.ada.org/en/public-programs/action-
for-dental-health/breaking-down-barriers [Accessed June 2015].
81. About Us. National Denturist Association: Poulsbo, WA; 2015 [Available at]
http://nationaldenturist.com/aboutus [Accessed June 2015].
82. Newkirk S, Slim LH. The laggards of dental hygiene. RDH. 2014;34(10):e
[Available at] http://www.rdhmag.com/articles/print/volume-34/issue-
10/features/the-laggards-of-dental-hygiene.html [Accessed June 2015].
83. Mobile and Portable Dental Services in Preschool and School Settings:
Complex Issues. Association of State & Territorial Dental Directors: Reno,
NV; 2011 [Available at] http://www.astdd.org/docs/mobile-portable-astdd-
issue-brief-final-02-29-2011.pdf [Accessed June 2015].
84. First Dental Home. Texas Department of State Health Services: Austin, TX;
2015 [Available at] www.dshs.state.tx.us/dental/FDH.shtm [Accessed June
2015].
85. Buchanan J. Interprofessional Education: Why Dentistry and Why Now?.
American Dental Education Association: Washington, DC; 2013 [Available
at] http://www.adea.org/Blog.aspx?id=21386&blogid=20741 [Accessed
June 2015].
86. National Center for Interprofessional Education. University of Minnesota:
Minneapolis, MN; 2013 [Available at] https://nexusipe.org/ [Accessed June
2015].
87. Achieving Bright Futures: Implementation of the ACA Pediatric Preventive
Services Provision. [Elk Grove Village, IL: American Academy of
Pediatrics] https://www.aap.org/en-us/professional-resources/practice-
support/Pages/achieving-bright.aspx [Accessed June 2015].
88. Step into a Healthy Future with Texas Health Steps!. Texas Department of
State Health Services; 2014 [updated; Available at]
http://www.dshs.state.tx.us/thsteps/default.shtm [Accessed June 2015].
89. The State of Aging & Health in America 2013. Centers for Disease Control
and Prevention, National Center for Chronic Disease Prevention and Health
Promotion: Atlanta, GA; 2013 [Available at]
http://www.cdc.gov/aging/pdf/state-aging-health-in-america-2013.pdf
[Accessed June 2015].
90. Healthy People 2020: Older Adults. Department of Health & Human
Services, Office of Disease Prevention and Health Promotion: Rockville,
MD; 2015 [Available at] http://www.healthypeople.gov/2020/topics-
objectives/topic/older-adults [Accessed June 2015].
91. Choosing a Dental Plan under ACA. American Dental Association: Chicago,
IL; 2014 [Available at] http://www.mouthhealthy.org/en/dental-care-
concerns/affordable-care-act-checklist/ [Accessed June 2015].
92. Medicare Dental Coverage. DHHS Center for Medicare & Medicaid
Services: Washington, DC; 2013 [Available at]
www.cms.gov/medicare/Coverage/MedicareDentalCoverage/index.html?
redirect=/MedicareDentalCoverage [Accessed June 2015].
93. Affordable Care Act, dental benefits examined. ADA News; 2013 [Available
at] http://www.ada.org/en/publications/ada-news/2013-
archive/august/affordable-care-act-dental-benefits-examined [Accessed
June 2015; American Dental Association].
94. Apple Tree Dental. 2015 [Minneapolis, MN; Available at]
http://www.appletreedental.org [Accessed June 2015].
95. Summary of the Fifth Leadership Colloquium: Financing Models for Oral
Health. U.S. National Oral Health Alliance; 2013 [Available at]
http://usalliancefororalhealth.org/sites/default/files/static/FifthColloquiumSummaryU
[Accessed June 2015].
96. Women, Infants, and Children (WIC). [Alexandria, VA: U.S. Department of
Agriculture, Food and Nutrition Service; Available at]
http://www.fns.usda.gov/wic/women-infants-and-children-wic [Accessed
June 2015].
97. WIC Nutrition Services Standards. U.S. Department of Agriculture, Food
and Nutrition Service: Alexandria, VA; 2013 [Available at]
http://www.nal.usda.gov/wicworks/Topics/WICnutStand.pdf [Accessed June
2015].
98. Medicare Access and CHIP Reauthorization Act of 2015: Summary of Key
Provisions Impacting Children. Georgetown University Health Policy
Institute Center for Children and Families: Washington, DC; 2015
[Available at] http://ccf.georgetown.edu/wp-
content/uploads/2015/05/MACRA-Kids-Brief.pdf [Accessed June 2015].
99. Early and Periodic Screening, Diagnostic, and Treatment. [Baltimore, MD:
Department of Health & Human Services, Centers for Medicare &
Medicaid Services; Available at] http://medicaid.gov/Medicaid-CHIP-
Program-Information/By-Topics/Benefits/Early-and-Periodic-Screening-
Diagnostic-and-Treatment.html [Accessed June 2015].
100. Dental Care. [Baltimore, MD: DHHS Centers for Medicare and Medicaid;
Available at] http://www.medicaid.gov/Medicaid-CHIP-Program-
Information/By-Topics/Benefits/Dental-Care.html [Accessed July 2015].
101. Medicaid & CHIP: January 2015 Monthly Applications, Eligibility
Determinations and Enrollment Report. Department HHS Centers for
Medicare and Medicaid Services: Baltimore, MD; 2015 [Available at]
http://www.medicaid.gov/medicaid-chip-program-information/program-
information/downloads/medicaid-and-chip-january-2015-application-
eligibility-and-enrollment-data.pdf [Accessed June 2015].
102. VanLandeghem K, Bronstein J, Brach C. The Role of Medical Care Use and
Dentist Participation. Department of Health & Human Services, Agency for
Healthcare Research and Quality: Rockville, MD; 2014 [Available at]
http://www.ahrq.gov/cpi/initiatives/chiri/briefs/brief2/index.html [Accessed
June 2015].
103. Head Start Program Facts FY 2014. Office of the Administration for
Children & Families, Head Start Early Childhood Learning & Knowledge
Center (ECLKC): Washington, DC; 2015 [Available at]
http://eclkc.ohs.acf.hhs.gov/hslc/data/factsheets/2014-hs-program-
factsheet.html [Accessed June 2015].
104. ACF FY 2015 Budget. Department of Health & Human Services,
Administration for Children & Families: Washington, DC; 2015 [Available
at] https://www.acf.hhs.gov/about/budget [Accessed June 2015].
105. Temporary Assistance for Needy Families (TANF). DDHS ACF Office of
Family Assistance: Washington, DC; 2015 [Available at]
http://www.acf.hhs.gov/programs/ofa/programs/tanf [Accessed July 2015].
106. Healthy Smiles for All. Samaritan Health Services: Corvallis, OR; 2015
[Available at] http://www.samhealth.org/communitysupport/Pages/Healthy-
Smiles.aspx [Accessed July 2015].
107. What are Federally Qualified Health Centers (FQHCS)?. [Washington, DC:
Department of Health & Human Services; Rockville, MD: Health Resources
and Services Administration; Available at]
http://www.hrsa.gov/healthit/toolbox/RuralHealthITtoolbox/Introduction/qualified.htm
[Accessed June 2015].
108. America's Health Centers (Fact Sheet). National Association of Community
Health Centers: Bethesda, MD; 2014 [Available at]
http://www.nachc.com/client/documents/Americas_CHCs1014.pdf
[Accessed June 2015].
109. HHS FY2016 Budget in Brief. Department of Health & Human Services:
Washington, DC; 2015 [Available at]
http://www.hhs.gov/about/budget/budget-in-brief/index.html [Accessed
June 2015].
110. Sealants Across Texas. Texas Dental Hygienists' Association; 2015
[Available at] http://everythingbelton.com/events-2/texas-dental-hygienists-
association-free-sealants-for-children-7-to-17-february-28th/ [Accessed
July 2015].
111. Give Kids a Smile. American Dental Association Foundation: Chicago, IL;
2014 [Available at] http://www.adafoundation.org/en/give-kids-a-smile
[Accessed July 2015].
112. About Us/Our Programs. Dental Lifeline Network: Denver, CO; 2015
[Available at] http://dentallifeline.org/about-us/ [Accessed June 2015].
Additional Resources
Guidelines for State and Territorial Oral Health Programs: PART II State
Roles, Activities and Resources: Guidelines Matrix, ASTDD.
http://www.astdd.org/docs/astdd-guidelines-section-ii-matrix-for-state-roles-
examples-andresources-4-2013-revisions.pdf.
Fluoride Mouthrinse Program, Manual. Ohio Department of Health Bureau of
Community Health Services & Patient-Centered Primary Care Oral Health
Section.
https://www.odh.ohio.gov/~/media/ODH/ASSETS/Files/ohs/oral%20health/FINAL%20M
2012%20Revisions.pdf.
Campaign for Dental Health (fluoridation), American Academy of Pediatrics.
http://ilikemyteeth.org/.
CDC Division on Oral Health.
http://www.cdc.gov/oralhealth/index.htm.
Fluoride Varnish Manual, Texas Department of State Health Services Oral
Health Program.
https://www.dshs.state.tx.us/dental/.
Seal America: The Prevention Invention. 2nd ed, revised.
http://mchoralhealth.org/seal/index.html.
Guidelines for Providing Dental Services in Skilled Nursing Facilities.
http://www.centerfororalhealth.org/images/lib_PDF/Skilled_Nursing_Facility_Dental_S
National Spit Tobacco Education Program (NSTEP).
https://oralhealthamerica.org/programs/nstep.
National Maternal & Child Oral Health Resource Center.
http://mchoralhealth.org/about/index.html.
MouthHealthy Oral Health Curriculum, American Dental Association.
http://www.mouthhealthy.org/en/.
Colgate Bright Smiles, Bright Futures.
http://www.colgate.com/app/BrightSmilesBrightFutures/US/EN/HomePage.cvsp
Crest + Oral B.
http://www.dentalcare.com/en-US/home.aspx.
Cavity Free Kids.
http://cavityfreekids.org/.
Tooth Tutor: A Simplified Oral Health Curriculum for Pre-K to Grade 12.
http://here.doh.wa.gov/materials/tooth-tutor/15_ToothTutor_E11L.pdf.
Safety Net Dental Clinic Manual.
http://dentalclinicmanual.com/.
Mobile-Portable Dental Manual.
http://www.mobile-portabledentalmanual.com.
Resource Highlights: Focus on Mobile and Portable Services, National
Maternal & Child Oral Health Resource Center.
http://mchoralhealth.org/highlights/mobileportable.html.
Oral Health Resources for Head Start.
http://eclkc.ohs.acf.hhs.gov/hslc/tta-system/health/oral-health.
ACF Office of Head Start National Center on Health, ASTDD.
http://www.astdd.org/head-start-oral-health-project/.
WIC: Early Entry in Dental Care Guidebook.
http://www.centerfororalhealth.org/images/lib_PDF/wic_dental_guidebook.pdf
Achieving Bright Futures, American Academy of Pediatrics.
https://www.aap.org/en-us/professional-resources/practice-
support/Periodicity/AllVisits.pdf.
C H AP T E R 7
Applied Research
Christine French Beatty RDH, MS, PhD, Amanda M. Hinson-Enslin RDH, CHES, MPH, PhD(c)
OBJECTIVES
1. Explain the importance of research in relation to dental hygiene practice.
2. Describe evidence-based decision making (EBDM), explain the levels of
evidence used for EBDM, and relate EBDM and the levels of evidence to research.
3. Explain the importance and the use of the scientific method in researching
questions related to dental hygiene practice.
4. Differentiate between the research hypothesis and the null hypothesis of a
research study.
5. Contrast qualitative and quantitative research and describe the use of each in
relation to dental hygiene.
6. Recognize various research designs and explain the characteristics and uses of
each one.
7. Explain sampling, describe sampling techniques and their uses, and explain the
importance of sample size.
8. Describe the groups used in experimental, quasi-experimental, and
observational studies and describe the use of randomization and matching to form
groups.
9. Explain variables: compare and contrast the independent and dependent
variables; explain the significance and relationship of relevant and extraneous
variables.
10. Explain research procedures that control errors and bias in research in
relation to blinding, length of study, sampling, collection of data, treatment of
data, and other important considerations.
11. Explain validity, reliability, and associated terms relative to data collection and
generalization; describe how to control them.
12. Explain the standards of ethically conducting research.
13. Explain the types of data and measurement scales and the significance of each.
14. Do the following in relation to the presentation of data and data analysis:
a. Compute and use the mean, median, and mode to
summarize data; compute and use measures of dispersion
to define distribution curves.
b. Discuss the uses of and interpret the results of various
statistical techniques: correlation, percentiles, and
inferential statistics.
c. Develop and use different types of chart displays to
present data; determine which type of graph to use with
different types of data.
d. Determine when it is appropriate to use parametric versus
nonparametric statistics.
e. Explain the percentiles (68%, 95%, and 99%) of the
normal distribution.
f. Contrast the use of different inferential statistical tests: t-
test, Analysis of Variance (ANOVA), confidence
intervals, chi-square, Wilcoxon signed-rank test, and
Mann-Whitney U test.
g. Explain probability, statistical significance, power, and
the role of sample size in relation to power and statistical
significance.
h. Explain the p value required for statistical significance
and its relationship to inferential statistical tests.
i. Explain the statistical conclusion.
j. Explain the difference between and how to prevent type I
and type II errors.
15. Express the importance of and the criteria for evaluating dental literature;
review a research report related to dentistry or dental hygiene; and explain the
differences between clinical significance and statistical significance.
Opening Statement: Questions in Research
• How does a public health team decide that community water fluoridation is needed
in their specific community and plan ways to promote it?
• What does a dental hygienist say to a patient who asks if a particular mouth rinse
really reduces dental plaque biofilm buildup as claimed in advertising?
• How does a dental hygienist advocate with public officials for a change in
regulations that would allow older adults direct access to dental hygienists in
extended-care facilities?
• How do communities decide what diseases/conditions or target groups to focus on
when allocating public health funds for dental public health programs?
• How does a dental hygienist answer a question about the best brand of toothpaste
posed by a member of the audience of a community oral health presentation?
• What health communication channels, formats, and materials are most effective
for patients served by a specific community health clinic?
• What is the most effective school-based caries prevention program?
• How does a dental hygienist answer patients' questions about the results of
nonsurgical periodontal therapy compared with surgical treatment of
periodontitis?
• What are the benefits to the public's oral health of utilizing a midlevel provider
workforce model?
• How does a hygienist explain the relative advantages of floss, water flosser, and
other interproximal oral hygiene aids?
Using Research to Answer Questions
Dental hygienists must seek answers to the questions in the Opening Statements and
others that relate to the various roles of dental hygiene practice. Even though
students may commonly learn answers to such questions from instructors or
colleagues, they must learn where and how to find reliable answers independently,
which requires an understanding of the research process. Research via the scientific
method is the basis by which answers are produced, and evidence-based decision
making (EBDM) is critical to the process of applying these answers to different
practice situations.
The profession of dental hygiene has a research agenda adopted by the American
Dental Hygienists' Association (ADHA)1 (see Guiding Principles). The breadth of
this research agenda demonstrates the importance of research to dental hygiene
practice, no matter what area of practice the dental hygienist selects. All the
questions presented in this chapter relate to this research agenda.
G ui di ng Pri nci pl es
Broad Categories of the National Dental Hygiene Research Agenda
FIG 7-2 Ranking of evidence for evidence-based decision making. The gold
standard of evidence (best clinical evidence available) is at least one published
systematic review of multiple, well-designed studies of the type that is best to
answer the research question. (From Beatty CF, Beatty CE, Dickinson CB. Community Oral
Health Planning and Practice. In Blue CM, Darby's Comprehensive Review of Dental Hygiene, 8th
ed. St Louis: Elsevier; 2017.)
The traditional narrative review that is commonly found in some dental hygiene
journals is actually at the lower end of the hierarchy of evidence so students must
learn to find, recognize, and read other types of research reports. The systematic
review, especially with a meta-analysis, is the highest ranked evidence for EBDM.
Between are various types of individual original research studies, which will be
explained throughout the chapter. The systematic review and meta-analysis are
described here.
In a systematic review, all previously published research studies that fit
prespecified eligibility criteria are examined and combined to answer a precise
research question. Explicit, systematic methods are used to minimize bias, and these
methods are communicated to the reader to provide transparency. Applying the
following key methods to a systematic review will result in an unbiased,
comprehensive answer to the research question:
• Use of clearly stated objectives with predefined eligibility criteria for studies
included in the review
• An unequivocal, reproducible methodology
• A systematic search for all studies that would meet the eligibility criteria
• Assessment of the validity of the findings of the included studies by evaluating the
research methodology and risk of bias
• A systematic presentation and synthesis of the features and findings of the included
studies5
The addition of meta-analysis to a systematic review provides a higher level of
evidence because statistical methods are applied to combine the results of all
relevant, independent studies, resulting in new information. Use of meta-analysis
has the following advantages:6
• Greater power is derived when more data are available for the statistical analysis
by combing the data from individual studies; this can result in statistical
significance where none was found with the smaller study samples of the
individual studies.
• Research results are more valid when they are based on more data.
• New research questions can be answered by identifying consistency of evidence
and differences across studies.
• Controversies resulting from apparently conflicting studies can be settled by
formally assessing the conflict, statistically analyzing the combined data, and
exploring and quantifying reasons for different results of individual studies.
• New hypotheses can be generated as a result of clarifying previous research
results.
A major source of reputable systematic reviews with meta-analysis related to oral
health and other healthcare topics is the Cochrane Collaboration. This is an
international, not-for-profit, independent organization dedicated to making up-to-
date, accurate information related to health care readily available worldwide.2 The
Cochrane Collaboration produces and disseminates systematic reviews with meta-
analysis through their Cochrane Database of Systematic Reviews, available at the
online Cochrane Library. At this site hundreds of reviews are available on various
relevant health topics, including many that are cataloged under the topics of
dentistry and oral health, and public health.
Primary literature.
Primary literature sources are original reports of new information, representing
original thinking and reporting a discovery.7 A research report is a primary source.
This is a report written by the researcher(s) to relate the findings of an original
research study, including presentation of data and interpretation of the statistical
results. Because a systematic review with meta-analysis reinterprets the results of
previous studies with additional statistical analysis and answers new research
questions, it too is considered a primary source.
Secondary literature.
Secondary literature sources are interpretations and evaluations of primary
sources that offer a commentary on, and discussion of, the evidence previously
reported, rather than contributing new evidence.7 A critical literature review is a
secondary source, as are many dental sciences textbooks, in that they refer to
primary sources. A systematic review without meta-analysis can be thought of as a
secondary source but it is still a higher level of evidence than individual primary
research reports. This is because it is a critical, comprehensive review of all
available studies on the topic, and its transparency avoids the limitations of other
secondary sources.
Tertiary literature.
Tertiary literature sources summarize primary and secondary sources.7
Dictionaries, encyclopedias, fact books, manuals, some textbooks, abstracts, and
indexes used to locate primary and secondary sources are all tertiary sources.
Although they do not provide evidence for EBDM, they are sometimes suitable in a
literature review for certain purposes. For example, use of a medical or dental
dictionary might be appropriate to define terminology.
The Scientific Method and Development of a
Research Question
Understanding the basics of research entails gaining an appreciation for the
components of a good research study, that is, understanding how a research idea is
formulated, how a study is designed and executed, and how the resulting data are
critically evaluated so that one can infer appropriate conclusions from the results.
Research can be thought of as a search for truth and the knowledge gained from this
search. A true definition of research is a systematic inquiry that uses orderly
scientific methods to answer questions or solve problems.8,9
Dental hygiene research involves an organized search for knowledge about
issues that relate to the professional practice of dental hygiene. To increase the
chance that research will be valid, reliable, and relevant, the scientific method—a
series of logical steps starting with the formulation of a problem—is employed.
These steps are listed and illustrated in relation to ECC in Figure 7-3. The
discoveries provided by research may lead to new knowledge or to the revision of
existing knowledge. Box 7-1 describes the evolution of a research problem,
research question, and ensuing clinical trials that led to revising existing
knowledge, a process that occurred over more than a decade. This methodical
search for knowledge impacted our current standard of practice in relation to the
use of fluoride varnish for prevention of dental caries, having a significant effect on
the oral health of young children in the United States (U.S.).
FIG 7-3 Steps of the scientific method.
ox 7-1
B
A ppl i cati on of the Research Process to a
Current Topi c of Interest
Fluoride Varnish
Research is a continual process that starts with a research problem and ends with
answers to research questions, frequently along with identifying the need for
additional research. The application of fluoride varnish for dental caries prevention
can be used to illustrate this process in relation to a current topic of interest. The
review and evaluation of this preventive procedure and its acceptance as a standard
of care to prevent caries is an ideal example of applying the scientific method to the
research process and using the results for evidence-based decision making
(EBDM).
In the 1990s, the Centers for Disease Control and Prevention (CDC) established a
group to develop recommendations for using fluorides to prevent dental caries.
The recommendations of this group were based on critical analysis of all available
evidence regarding the efficacy and effectiveness of various fluoride modalities.
The group critically reviewed studies from Canada and Europe related to the use of
fluorides and the effectiveness of fluoride varnish in preventing dental caries. At
that time the use of fluoride varnish in the U.S. was limited to the treatment of
dentin hypersensitivity. In 2001 the CDC released guidelines on the use of fluorides
to prevent caries based on this review of the evidence available at that time. These
guidelines included the statement that “a prescribing practitioner can use fluoride
varnish for caries prevention as an off-label use, based on professional
judgment.”31
In 2002, the Cochrane Collaboration published a systematic review with meta-
analysis of fluoride varnish studies published up to that time. The conclusion of this
review was that fluoride varnish substantially inhibited caries in both the permanent
and the deciduous dentitions. However, the authors noted that most studies were of
poor quality and included little information concerning acceptability of treatment
or possible side effects. Furthermore the authors recommended that further clinical
trials be conducted and that they be of high quality and include assessment of
potential adverse effects.32
After this review clinical trials were conducted in this country to test the
effectiveness of fluoride varnish in preventing dental caries for the purpose of
building a stronger body of research on the topic. Based on the results of this
research, in 2007 the Association of State & Territorial Dental Directors published
a research brief supporting the use of fluoride varnish and promoting its greater
effectiveness compared with other professionally applied topical fluorides.33 The
next year the American Association of Public Health Dentistry passed a resolution
recommending the use of fluoride varnish for caries prevention.34
In 2013, Cochrane Collaboration published a second systematic review with
meta-analysis, updating their first systematic review of 2002. Conclusions of the
2013 review “suggested substantial caries-inhibiting effect of fluoride varnish in
both permanent and primary teeth using fluoride varnish.”35 Also in 2013 the
American Dental Association (ADA) adopted evidence-based clinical guidelines on
the use of fluoride varnish in dental and dental hygiene practice, supported by a
systematic review conducted by the ADA Center for Evidence-Based Dentistry.36
The American Association of Pediatric Dentistry reiterated their support of the use
of fluoride varnish to prevent dental caries in their 2014 updated guidelines.37
Currently, the clinical procedure is used regularly in private and community-based
practice to prevent caries and treat dentin hypersensitivity.37
In sum the use of fluoride varnish to prevent dental caries was questioned,
evaluated, researched, supported, and finally implemented into private and
community-based practice. Through this process of applying the scientific method
to EBDM, more research questions have risen that need to be answered to improve
utilization of this superior topical fluoride modality. For example, questions about
acceptance of the procedure by patients, parents, and oral health professionals are
important to address so we can develop a plan of action aimed at speeding up the
diffusion of this effective innovation as a dental caries preventive measure,
especially in high-risk children who are experiencing higher caries rates today
compared with two decades ago.
G ui di ng Pri nci pl es
Research Problems and Research Questions
Example s of a Re se arc h
Example s of a Corre sponding Re se arc h Que stion
Proble m
Greater difficulty probing various Which quadrant in the human dentition is least accurately probed by second-year dental hygiene students at University X
areas of the mouth when using the Periodontal Screening Record (PSR) method of probing?
Effects of diet on oral health What is the carbohydrate content of the diet of patients in an Indian Health Service (IHS) community clinic who exhibit
moderate periodontitis compared with the diet of those who exhibit no signs of periodontal disease?
Level of difficulty maintaining What effect does modifying the brushing techniques of disabled patients in long-term care facilities have on their gingival
oral health for different people health?
Development of a Hypothesis
After a research question is formulated, a hypothesis is developed. This is a
statement that provides a proposed answer to the research question. The research
hypothesis is stated in positive terms that represent the researcher's prediction or
opinion. An example of a hypothesis for the first research question in the Guiding
Principles (Which quadrant in the human dentition is least accurately probed by
second-year dental hygiene students at University X when using the PSR method of
probing?) would be as follows: Second-year dental hygiene students at University X
using the PSR method are most inaccurate when probing the distal lingual surface of
teeth in the upper right quadrant of the human mouth.
The hypothesis is often expressed as a null hypothesis, which assumes that there
is no statistically significant difference between the groups being studied. Thus the
null hypothesis is a negative statement of the researcher's prediction or opinion. It is
actually the null hypothesis that is tested statistically. An example of a null
hypothesis for the preceding question would be as follows: Second-year dental
hygiene students at University X show no difference in the accuracy of probing any
tooth in the human mouth when using the PSR method.
General Methods of Research
Three major categories of research are qualitative, quantitative, and mixed methods.
Qualitative research methods require the use of language to answer the research
question, whereas with quantitative research, numbers are used to answer the
research question. Mixed-methods research involves a combination of qualitative
and quantitative methods within one research project. The words provide a clue to
help you remember the difference between qualitative and quantitative.
Qualitative = Language
Quantitative = Numbers
The type of research question determines which method of research is required to
be used in a research project.9
Qualitative Research
Qualitative research methods rely on language to answer the research question. If a
researcher cannot explain a particular concept with numbers then qualitative
research is needed. For example, a researcher may be looking for the perceived
barriers of parents who fail to acquire dental sealants for their children. To gather
data, the researcher could interview parents within that population and analyze the
interview manuscripts to discover a common theme. The analysis phase of a
qualitative research study is lengthier than that of a quantitative study because the
researcher is required to review responses individually. Qualitative data can be
collected via documented narratives, interviews, documented observations, or
manuscripts. Qualitative research reports are written narratives that include multiple
quotes.8 Qualitative research methods are used for community needs assessment and
preliminary research done for the purpose of identifying research questions and
hypotheses10 (see Table 7-1).
TABLE 7-1
Qualitative Versus Quantitative Research Methods
From Creswell J. Research Design: Qualitative, Quantitative and Mixed Methods Approaches. 4th ed.
Thousand Oaks, CA: SAGE Publications; 2014; Leedy PD, Ormrod JE. Practical Research: Planning and
Design. Upper Saddle River, NJ: Pearson Education, Inc.; 2013; Punch KF. Social Research: Quantitative
and Qualitative Approaches. Thousand Oaks, CA: SAGE Publications, Inc.; 2014.
Quantitative Research
Quantitative research methods rely on numbers to answer the research question.
For example, a researcher may want to determine whether a relationship exists
between the number of sports drinks consumed by athletes and their caries
experience. The researcher could measure the number of sports drinks consumed by
athletes in a particular population and the number of decayed, missing, and filled
teeth or surfaces (DMF) in the same participants. Such quantitative data can be
collected using a clinical examination, survey, observation, or patients' charts.
Quantitative data are analyzed by applying statistics and communicated with
numerical values, charts, and graphs.11 This chapter focuses on the methods used to
conduct and analyze quantitative research. Aids for conducing qualitative research
are provided in the references and resources at the end of this chapter. Table 7-1
contrasts qualitative and quantitative research methods for greater understanding.
Mixed-Methods Research
Mixed-methods research combines quantitative and qualitative research methods to
answer the research question. Data collection and reports of outcomes consist of a
combination of techniques used for quantitative and qualitative studies.8 For
example, a researcher may want to investigate the effectiveness of an oral cancer
presentation to an older adult community group. The researcher could evaluate their
knowledge increase with a posttest (quantitative) and their perception of the
personal relevance of the program on a scale of 1 to 5 (qualitative data that is coded
quantitatively) along with a brief narrative about how the information related to
their own situation and individual changes they plan to make (qualitative).
Research Designs
There are three main types of research designs used for oral health research:
observational, quasi-experimental, and experimental.10,12 See Table 7-2 for a
summary of these designs and examples of research questions for the different
designs. Selection of a design is based on the purpose and hypothesis of the study.
Reviewing the literature for previous studies on a topic can guide the choice of a
research design for a new study. The selected design can emulate accepted research
designs that have been validated previously by others and reported in the literature.
TABLE 7-2
Various Research Designs
Observational Research
In an observational research design, the researcher strictly observes participants'
behaviors, actions, or other exposures to disease-related factors in relation to the
presence of disease.12 There is no treatment applied or manipulated and no
randomization of participants; rather individuals are observed in the natural
progression of events. For this reason, observational research is below the
experimental approach on the ranking of evidence for EBDM (Figure 7-2).
Observational studies establish prevalence and incidence. Prevalence is the
proportion of existing cases of a disease or health condition in a population
measured at some designated time.10 Incidence is the rate of new disease or other
condition in a population during a designated period (number of new cases divided
by the total population at risk over a time period multiplied by a multiplier, e.g.,
100,000).10
Observational research is sometimes referred to as developmental and can be
descriptive or analytic. Descriptive studies define characteristics of a population,
for example, case reports, case series, and simple cross-sectional surveys. Analytic
studies provide information about association of risk attributes with an outcome
such as disease and are aimed at helping to establish risk for developing the
outcome and estimate causality. Examples are case-control studies, cohort studies,
and ecological studies. Cross-sectional studies are also analytic if factors are
measured to associate with the variable of interest. Cohort, case-control, and some
ecological studies are longitudinal in nature, meaning that multiple observations
occur over time.10 This is in contrast to cross-sectional, which indicates that data
describing exposures to suspected risk or protective factors and disease outcomes
data are collected at the same time.12 Case-control studies are retrospective,
indicating that the study looks backward to identify prior exposures in relation to an
outcome that is established at the start of the study.10 On the other hand, cohort and
longitudinal ecological studies are prospective in that outcomes, such as
development of a disease, are observed forward in time and related to other
factors.10 Table 7-2 provides more information and examples of these various types
of observational studies.
Experimental Research
An experimental study design has the greatest control; thus, it provides the highest
level of evidence of all the study designs3 (Figure 7-2). The aim of experimental
research is to discover the effects of a treatment in a controlled setting. An
experimental research design is used to discover if there is a benefit to receiving
treatment compared with not receiving treatment.8 A critical element of control in
experimental studies is the randomization of participants to assure the groups are
equivalent.
A specific example of experimental research is a clinical trial, a type of study that
tests the safety, efficacy, and effectiveness of new procedures, therapies, drugs, or
other interventions to prevent, screen for, diagnose, or treat disease in humans.10
Clinical trials are conducted on volunteer participants and include a control group
to compare the new treatment to a control. These studies are particularly valuable in
EBDM.
Various experimental design variations can be applied to clinical trials. Several
common to oral health research are described here.
Pretest-Posttest Design
In this design, the dependent variable is measured before (called the baseline
measure) and after the treatment intervention is introduced. The aim is to compare
the groups to determine whether the treatment produces a change in the dependent
variable.10 For example, a study could be carried out to test the effectiveness of a
water flosser compared with floss in reducing gingivitis. A baseline measure of the
dependent variable, gingivitis, is recorded as a pretest before introducing the
intervention (the two types of interdental cleaning procedures). After the study
participants use the water flosser and floss for the designated period, gingivitis is
measured a second time, called the posttest, for comparison to the pretest. The
pretest-posttest study design is classic and can be combined with other
experimental designs described here.
Repeated Measures Design
Sometimes the dependent variable is measured several times, usually at posttest, to
ascertain if the effect of the independent variable on the dependent variable will hold
over time. For example, in the study comparing the water flosser to floss, gingivitis
could be measured several times as posttest measures (3 months, 6 months, 9
months, 12 months) to be certain that any improvement in gingivitis is not
temporary. The repeated measures design is sometimes referred to as a time series
design.11
Crossover Design
Study participants can be given a sequence of different treatments with a period of
time between, during which no treatment is applied. All groups in a crossover study
design receive the same treatments, just in a different order. After using the first
treatment for the designated period, participants are switched (crossed over) to the
opposite treatment after an appropriate washout period intended to prevent any
carryover effects from the first treatment to the next.12 This design helps to control
any differences between experimental and control group members in that both
groups are made up of the same people, namely all the study participants.
An example of this design is to have one group use the water flosser and have the
other group use the floss for 3 months. At the end of the 3 months, the two groups
cease using their interdental cleaning for a month (the washout period). Then the
groups switch to use the other interdental cleaning product for 3 months. In this way,
both groups will have used both products with a washout period between.
Factorial Design
When the researcher is interested in studying two or more independent variables
within the same study, a factorial study is used.12 This design allows the
simultaneous assessment of multiple factors on the dependent variable and how the
factors interact with each other. The number of factors can be many. An example of
this design is a study to investigate the effects of combining various dental caries
prevention therapies on the incidence of caries in high-risk children. Multiple
groups would be formed with various combinations of factors, such as fluoride
varnish applied at different frequencies, use of xylitol gum, and rinsing with an
antimicrobial agent. These designs are identified by the number of factors and the
levels being examined. Table 7-3 provides an illustration of a 3×2 factorial study
(three factors and two levels of each factor, resulting in six groups).
TABLE 7-3
Combination of Factors for Six Groups of a 3 × 2 Factorial Design
Group 1: Group 2:
○ Varnish application 2 times a year ○ Varnish application 4 times a year
○ Use of xylitol chewing gum ○ Use of xylitol chewing gum
○ Use of antimicrobial ○ Use of antimicrobial
Group 3: Group 4:
○ Varnish application 2 times a year ○ Varnish application 4 times a year
○ No xylitol chewing gum ○ No xylitol chewing gum
○ Use of antimicrobial ○ Use of antimicrobial
Group 5: Group 6:
○ Varnish application 2 times a year ○ Varnish application 4 times a year
○ Use of xylitol chewing gum ○ Use of xylitol chewing gum
○ No antimicrobial ○ No antimicrobial
Quasi-Experimental Research
A quasi-experimental research design is similar to an experimental design. The
purpose is the same, and the design is experimental in nature in that there is
manipulation of a treatment in the study. The experimental design variations can be
used in quasi-experimental studies as well. The difference is that the participants are
not randomized; thus group equivalency is uncertain.8 Also called nonrandomized
research designs, quasi-experimental designs are used when randomization is not
practical or is impossible.12 The concept of randomization will be discussed in more
detail later in the chapter.
One type of quasi-experimental study is a community trial, in which a
community, rather than a group of individuals, receives the intervention. Such trials
can be used to evaluate policies, programs, or preventive treatments at the
community level.10 By their nature community trials cannot be randomized because
intact community groups are used. Even though community trials have less control
than clinical trials, they are useful to assess the effect of a community intervention
on the incidence of disease within that community. Community water fluoridation
trials are an example. Another example is to compare the benefits of smoke-free
community policies on health outcomes at the community level. A final example of
a community trial is an evaluation of a tobacco education program implemented in
one high school, compared with a different program or no program in another high
school.
Research Methodology
When a research question and hypothesis are identified, a plan is developed to
conduct the study. This plan consists of selecting a research design (see previous
section) and then identifying groups to be involved in the study, methods for data
collection, procedures to manipulate the treatment being tested, and statistics and
tests to summarize and analyze the data collected. Following a well-thought-out
research plan with appropriate research methods is important to control errors and
bias in a study.10 This is critical to generate valid research results that provide
legitimate evidence for EBDM. Ways to avoid sources of error and bias are
summarized in Box 7-2.
ox 7-2
B
Way s to Avoi d Sources of Error and Bi as i n
Cl i ni cal Tri al s
• Have a researchable hypothesis
From Beatty CF. Oral Epidemiology. In Nathe CN, Dental Public Health & Research: Contemporary Practice for
the Dental Hygienist. 3rd ed. Upper Saddle River, NJ: Pearson; 2011.
Population
In research the population is the entire group or whole unit of individuals having
similar characteristics to which the results of an investigation can be inferred.13 The
term parameter is used to refer to numeric characteristics of the population.
Populations can be large or small, depending on the topic to be studied. For
example, in the second research question in the Guiding Principles (What is the
carbohydrate content of the diet of patients in an IHS community clinic who exhibit
moderate periodontitis compared with the diet of those who exhibit no signs of
periodontal disease?), the population consists of all patients who have been treated
in the IHS clinic and have a diagnosis of moderate periodontitis. This population
might be difficult to access if it is a large clinic that treats patients from a large
geographic area. On the other hand, the population of the first research question in
the Guiding Principles (Which quadrant in the human dentition is least accurately
probed by second-year dental hygiene students at University X when using the
Periodontal Screening Record (PSR) method of probing?) is likely small and easily
accessed, making data collection from the entire population realistic.
Sampling
Taking a representative portion of the population is known as sampling. A sample is
a part or subset of the population that, if properly selected, can represent the
population and provide meaningful information about the entire population.13 The
term statistic is used to refer to numeric characteristics of samples.
Samples too can be large or small and are chosen to reflect the research design
most appropriately. Large representative samples are especially important for
descriptive surveys. Smaller samples are used frequently for clinical trials. A small
sample is typically utilized in a pilot study, which is a trial run done in preparation
for a major study. A pilot study cannot be employed to test a hypothesis; thus it does
not provide evidence for EBDM.14
The importance of using a sample can be illustrated in relation to our research
question (What is the carbohydrate content of the diet of patients in an IHS
community clinic who exhibit moderate periodontitis compared with the diet of those
who exhibit no signs of periodontal disease?). Although it might be optimal to
collect data from all patients in the IHS clinic with moderate periodontitis to arrive
at the answer, this may not be realistic. Because of time constraints, lack of
resources, or financial issues it may be decided that selecting a sample from within
the population can make it possible to conduct the study.
If it is decided that a sample of the population is to be utilized, different sampling
techniques can be employed. Each type of sample has its uses, advantages, and
disadvantages.13 Several common types of sampling, namely random sampling,
stratified random sampling, systematic sampling, convenience sampling, and
judgmental or purposive sampling, are presented in Table 7-4. In addition, an
example of each type of sample is provided in relation to the same research
question.
TABLE 7-4
Types of Samples
Type of
De finition Re sult Example *
Sample
Random Study participants are chosen Increases external validity by controlling Sample is randomly selected from a list of patient
independently of each other, with known differences in study participants; decreases numbers in the computeriz ed patient records who have
opportunity or probability for inclusion; possibility of selection bias; allows for the diagnosis of moderate periodontitis; if 50 clinic
each member of a population has an equal valid generaliz ation of results to the patients have the diagnosis of moderate periodontitis,
chance of being included; table of random population; yields a representative sample and a 50% sample is desired, 25 patients can be
numbers can be used for selection only when drawn from a homogeneous randomly selected
population
Stratified Study participants are randomly selected Results in a sample that proportionately Sample can be stratified for gender by randomly
random from two or more subdivided groups and accurately represents the subgroups selecting in a manner that results in a sample that
(strata) in the population that have (strata) in the population; yields the most represents the percentage of males and females in the
similar characteristics; strata used to representative sample for a heterogeneous population; if 60% of the 50 patients with moderate
stratify are according to any relevant population; controls for effects of periodontitis are male, and 40% are female, 60% of the
(confounding) variables that could affect confounding variables to prevent sample will also be male and 40% female (30 males
the study outcome extraneous variables and 20 females)
Systematic Selection of every nth member of the Not strictly a random sample; it is From the computeriz ed list of patient numbers with the
population from a list or file of the total considered to be random when the list or diagnosis of moderate periodontitis, a 50% systematic
population; the n depends on the siz e of file of members of the population is in sample can be generated by randomly selecting the first
the sample desired in relation to the random order and the first member of the patient and then selecting every second patient
population, for example, 10% is every sample is selected randomly
tenth member of the population
Convenience Study participants are chosen on the basis Introduces bias, which reduces validity of Sample consisting of the first 25 patients with a
of availability; used when access to the the sample and limits the generaliz ability diagnosis of moderate periodontitis who volunteer to
total population is not feasible for random of study results participate after a call for volunteers is posted in the
sample selection clinic and on social media
Judgmental Selection, through personal judgment, of Introduces bias, which reduces validity of Sample selection by the dental hygienist who has
or purposive study participants who would be most the sample and limits the generaliz ability treated the patients, is aware of their disease levels and
representative of the population and meet of study results; appropriate to use when potential for cooperation and compliance, and is aware
the specific required disease levels and/or very specific criteria are required such as of the purpose of the study and the participant
characteristics; selected by the researcher certain disease levels or exclusion criteria qualifications needed
or someone else with knowledge of the for drug or treatment trials
population
*
Examples relate to the research question: What is the carbohydrate content of the diet of patients in an
Indian Health Service (IHS) community clinic who exhibit moderate periodontitis compared with the diet of
those who exhibit no signs of periodontal disease?
Study Groups
Experimental, quasi-experimental, and some analytic research types use groups.
These groups are compared in order to answer the research question.
Variables
A variable is a characteristic or concept that varies within the population under
study. Several terms are used to refer to the different types of variables in an
experimental study. Understanding these terms can help you appreciate the
importance of using appropriate research designs, data collection methods, data
analysis, and interpretation of research results.
The experimental treatment or intervention that is imposed on the experimental
group of an experimental or quasi-experimental study is called the independent
variable.12 The independent variable is manipulated by the researcher and is
believed to cause or influence the dependent variable. The dependent variable is the
variable that is thought to depend on or to be caused by the independent variable. It
is the outcome variable of interest, is always measured during the course of an
experimental study, and is sometimes referred to as the outcome or measurement
variable.12
A relevant variable, also called a confounding variable, is any variable that
should be controlled because it can influence how the independent variable affects
the dependent variable. An extraneous variable is any confounding variable that is
not controlled in a study. Thus extraneous variables can influence the relationship
between the independent and dependent variables and potentially be sources of error
in relation to any observed effects in the study outcomes. In this way, extraneous
variables reduce the internal validity of an experimental study (see explanation later
in chapter). To increase internal validity it is critical to deal with relevant variables
by controlling them through either the research design or statistical procedures.15
Confounding variables must be controlled also in analytic studies to prevent their
interference in establishing relationships among study variables.
These variables can be explained further by using the example presented in the
previous section of an experimental study to test the effectiveness of a new
antimicrobial mouth rinse in controlling gingivitis in moderate periodontitis
patients. The independent variable is the mouth rinse, and the dependent variable is
gingivitis. Age and gender are relevant variables because they are associated with
periodontal disease. Both are controlled by using randomized matching to form the
study groups. Oral hygiene is also a confounding variable for gingivitis and can be
controlled by keeping it constant via training and monitoring of oral hygiene
throughout the study. If it is not controlled it becomes an extraneous variable that
can be a source of error for interpretation of results, thus reducing the internal
validity of the study. In other words, if the groups have different levels of daily self-
care (oral hygiene), the observed effect of the mouth rinse on gingivitis could be a
result of that difference in oral hygiene rather than the mouth rinse being tested.
Blinding (Masking)
One way to control bias is to use a blind study, which uses a procedure called
blinding or masking.10 Typically in a single-blind study, the examiners are unaware
of the group assignment; hence, they are not aware which group is receiving the
treatment and which is the control. In a double-blind study, the study participants, as
well as the researchers and examiners who interact with the study participants, are
unaware of group assignment. Masking the study participants prevents any possible
difference in their behavior that could result from their knowledge of group
assignment. Masking the researchers can control for any bias in the way study
participants are treated. Blinding the examiners prevents any influence of bias, even
subconscious bias, in observations or measurement of the dependent variable.
Using blind study procedures, especially masking the examiners, is critical and
should be done whenever possible. In some cases, it is not possible to mask study
participants even though examiners can be masked. For instance, in the previous
example of a study to compare the water flosser to flossing, it would be impossible
for study participants not to know which device they are using.
Length of Study
The appropriate length of a study depends on the variables being studied and the
type of study. For example, survey research that requires measurement of the
variables only one time will take less time to complete than an experimental study
that requires multiple measures of the dependent variable. Also the nature of the
dependent variable will affect the ideal length of a clinical trial. The study must be
long enough to allow detection of new disease and extension of current disease.
General recommendations are 2 to 3 years for caries studies, 8 to 21 days for
plaque-inhibiting studies, 90 days for supragingival calculus-inhibition studies,
longer for subgingival calculus-prevention studies, and 6 months for gingivitis-
reduction studies.16
Collecting Data
Many different techniques can be used to collect data (see Chapters 3 and 4). The
research design determines the appropriate method of data collection. During data
collection, it is important to use calibrated instruments (e.g., indexes, surveys, tests,
actual dental instruments used in examination such as a probe or explorer, and
equipment such as an x-ray machine). Calibration of instruments means to test them
for accuracy and consistency. When examiners are involved in data collection, it is
imperative that they too be calibrated (i.e., monitored to assure they are in
agreement with a set standard of performance for the data collection).12 For
example, if two dental hygienists conduct examinations in a school-based screening
program, both should be trained and monitored on the use of the various dental
indexes so their results will accurately and consistently reflect the criteria of the
indexes. Review Appendix F for the common dental indexes used to measure oral
health variables.
Two important concepts relate to data collection: validity and reliability.12
Validity is accuracy, and the term is used to refer to the accuracy of data and to the
accuracy of the methods and instruments used to collect the data. In essence, it
means that the outcomes of data collection accurately represent the presence or
absence of the variable being measured.17 Calibration, discussed in the previous
paragraph, affects validity.
The term validity is used also to refer to the validity of a study, meaning that the
study correctly answers the question that it asks.12 Two types of validity exist in
relation to research results. The first, internal validity, refers to how well a study is
conducted and depends on the controls placed during the conduct of the research
study. For example, if a study concludes that one therapeutic technique is superior to
another, how confident we can be that it actually is superior is a function of how
well the study design controlled for any sources of error. In other words, internal
validity refers to the fact that the therapeutic technique being tested is responsible
for the observed effects and that these effects are not caused by some other
uncontrolled factor. All sources of error related to data collection must be
controlled to ensure internal validity, for example, use of valid and calibrated
instruments, calibrated examiners, control of variables (see earlier discussion),
careful planning and supervision of study procedures, and use of appropriate
statistical procedures12 (Box 7-2).
Procedures used during data collection affect the internal validity of the study.12
For example, if dental caries is measured with the DMF index (see Appendix F), the
resulting data must accurately identify the presence or absence of caries on those
teeth. The examiners must evaluate the correct surfaces and accurately apply the
criteria for measurement of caries; and the instruments used must be capable of
accurately identifying the presence and absence of caries.
To assure validity of data and thus contribute to the internal validity of the study,
standard instruments and dental indexes with documented validity should be used
(Appendix F). If new surveys, instruments, or indexes are developed for a study,
they must be validated to ensure validity of measures.
The second form of study validity is external validity, which refers to the extent
to which study results can be generalized accurately to other situations and people.
External validity is affected by how well the sample represents the population.10 In
other words, when a sample is strongly representative of the population, the results
can be generalized to other members of the population. This denotes high external
validity.
The term reliability refers to the consistency and stability of the data.17 Reliability
of data is critical to assure valid research results. Instrument selection and methods
of data collection affect the reliability of measurements. For data to be reliable,
examiners, also called raters, must be calibrated (see earlier) to assure that their
measurements are consistent and can be reproduced. For example, if multiple raters
examine a child during a screening, they should detect the same carious lesions in
the child (Figure 7-4). This is referred to as interrater reliability. Also, if one of
the raters inspects the same child on multiple occasions, he or she should detect the
same lesions each time. This is called intrarater reliability.
FIG 7-4 Calibration of examiners is critical during oral health surveys to assure
reliability of data. (Photograph courtesy Schelli Stedke.)
G ui di ng Pri nci pl es
Standards of Ethical Conduct of Research with Human Participants
• Respect and Dignity. Human participants should be treated with respect and dignity.
• Informed Consent. Informed consent is required, including full disclosure of the
research plan and a description of the risks and benefits of participation.
Data
A discussion of data analysis must begin with an understanding of data itself. Pieces
of information, such as numbers collected from measurements, counts obtained
during the course of a research study, and responses to surveys and interviews, are
known as data. Although the concept of data itself may seem fairly straightforward,
there are different types of data, and the type of data determines how they are
handled during statistical analysis and graphic representation.13 Categorical data,
dichotomous data, discrete data, and continuous data are explained and
illustrated in Table 7-5.
TABLE 7-5
Types of Data
2. Ordinal scale—Consists of categories of variables that have rank order, but there
is no equal or defined value between the ranks. For example, cancer staging for
tumors is grouped into five stages: 0, I, II, III, and IV. In general, stage 0 is
carcinoma in situ, whereas stage IV represents cancers that have metastasized to
distant tissues or organs. Stage I, II, and III cancers represent advancing levels of
increased tumor size and/or spread of the cancer to adjacent tissues or organs,
nearby lymph nodes, or both. Although the higher stages represent more extensive
disease, differences from one stage to another are inexact, and each type of cancer
is staged a little differently, making it difficult to define differences between stages
precisely.20 Other examples of ordinal scale data are periodontal classification,
socioeconomic status, and rating or ranking scales such as satisfaction and pre-
ferences. Many dental indexes are ordinal scaled (see Appendix F).
3. Interval scale—Has an equal distance between measures along the continuum, but
there is no true zero point (e.g., temperature). Oral health variables are not typically
interval scale.
4. Ratio scale—Has equal intervals between the measures along a continuum, plus
there is a meaningful absolute zero point determined by nature, meaning there can
be absence of the variable being measured. Examples are height and weight, number
of teeth or sealants, and blood pressure.
Statistics
Statistics is a science used to describe, summarize, and analyze the data for the
purpose of making an inference about a population based on the sample data.13 Two
broad categories of relevant statistics are as follows:13
1. Descriptive statistics are used to describe and summarize data. Their objective is
to communicate results without generalizing beyond the sample to any population.
Some ways in which data are described or summarized are with measures of central
tendency, measures of dispersion, frequency counts and percentages, charts,
percentiles, and correlation statistics.
2. Inferential statistics are used to analyze sample data to make inferences about
the larger population from the sample data. In other words, although descriptive
statistics tell us something about the sample, inferential statistics tell us something
about the population that the sample comes from.
Descriptive and inferential statistics are contrasted in Table 7-6. Different types of
questions are answered by descriptive and inferential statistics. Descriptive statistics
answer questions about the status and relationship of variables in a group (e.g., rates
of caries, number of sealants placed, oral hygiene status). Inferential statistics
answer questions about differences and probability (e.g., effectiveness of methods to
prevent or control disease, differences in rates of disease, improvement in dental
utilization over time; see Guiding Principles).
G ui di ng Pri nci pl es
Different Research Results Derived by Using Descriptive Versus
Inferential Statistics
• The regular use of dental floss can help prevent periodontal disease.
Type s of
Use s/Charac te ristic s Me asure me nts/Statistic al Te c hnique s
Statistic s
Descriptive • Describe and summariz e data in sample • Measures of central tendency (mean, median, mode)
• Not generaliz ed to another group • Measures of dispersion (range, variance, standard deviation)
• Show relationships among variables (correlation) • Frequency counts and percentages
• Tables and graphs
• Percentiles
• Correlation
Inferential • Generaliz e or apply information from the sample to the • Parametric: t-test, analysis of variance (ANOVA)
population • Nonparametric: chi-square, Wilcoxon signed-rank test, Mann-
• Includes categories of parametric and nonparametric Whitney U test
• Confidence intervals
Descriptive Statistics
TABLE 7-7
Measures of Central Tendency
The mean is the arithmetic average of the data distribution. It is statistically noted
as and is calculated by adding all the values and dividing by the number (n) of
items according to the following formula:
The positive aspect of the mean is that it includes the value of each score; the
negative aspect is that it can be distorted by extreme scores in the distribution and
thus may not give a true picture of the central tendency. For example, if a test is
administered in a class of 12 people and 10 people in the class score an 85 and 2
people score a 30, the class average is 75.83. This is not a true representation of the
distribution of class scores because the vast majority scored 85. The use of the mean
requires ratio data, although it is common practice to use it with rating scales that
have a large number of values, including dental indexes.22 An advantage to the mean
is that it is amenable to further mathematical calculation and hence is used in many
statistical tests. Thus it is the measure used most often.
The median represents the exact middle score or value in an ordered distribution
of scores; it is the point above and below which 50% of the scores lie. When the
total number of scores is even, the median is computed by adding the two middle
scores and dividing by 2. The median can be used with ratio, interval, and ordinal
data. However, because it is not used in many statistical tests, it is sometimes not
useful.
Unlike the mean, the median has the advantage that it is not distorted by outliers
(extremely high or low scores) or skewed data. In the previous example described
in the Mean section earlier, the median score would be 85. However, it is not
difficult to imagine what would happen if scores were not evenly distributed and the
median were used to communicate the central tendency with no further information.
In this case the information provided also may not demonstrate a true midpoint for
the test scores. Communicating both the mean and the median might provide a
clearer representation of the central tendency of the data distribution.
The mode is the score or value that occurs most frequently in a distribution of
scores. Once again, the mode for the preceding example would be 85. The
distribution of scores may be unimodal, bimodal, or multimodal, or there may even
be no mode. The greatest usefulness of the mode is to communicate the central
tendency of categorical or nominal data.
Figure 7-5 presents the mean, median, and mode of a group of test scores. The
curve of the distribution represented by the line graph varies slightly from a
symmetric bell-shaped curve so the mean is a slightly higher value than the median
and mode. Figure 7-6 illustrates the relationship of the mean, median, and mode in
different types of distributions. In the symmetric distribution of a bell-shaped curve
(A), the mean, median, and mode are the same value. In a positively skewed curve
(B), the mean is to the right (higher score in the distribution) of the median and
mode. In a negatively skewed curve, the mean is to the left (lower score in the
distribution) of the median and mode. Note that in a skewed distribution, the median
is always between the mode and the mean because it is the midpoint of the
distribution, and the mean is toward the tail of the curve. This illustrates that if one
knows the mean, median, and mode of a distribution, one can tell if the distribution
is normal or skewed and, if skewed, the direction of the skew.
FIG 7-5 Graph of student test scores.
FIG 7-6 Graphing measures of central tendency for different types of curves.
Measures of dispersion.
In addition to the measures of central tendency (mean, median, and mode), measures
of dispersion (also known as measures of variation) are used to describe data.
Measures of dispersion (Table 7-8) communicate how much individual scores differ
or vary from the mean.11 For example, to provide a clearer picture of the
distribution of scores, a measure of dispersion would help to communicate the
effect of the extreme scores in the previous sample application of the mean to
provide a clearer picture of the distribution.
TABLE 7-8
Measures of Dispersion
ox 7-3
B
Frequency Di stri buti on, Rang e, Vari ance, and
Standard Devi ati on of Student Test Scores
Frequency Distribution of Student Test Scores
Te st Sc ore Numbe r of Stude nts Pe rc e ntag e of Stude nts
30 3 10
45 4 13.3
50 5 16.7
60 6 20
90 5 16.7
95 4 13.3
100 3 10
Total 30 100
The steps to calculate the variance and SD are as follows (Box 7-3):
It makes sense, then, that the farther away the data points on the distribution are
from the mean, the greater the variance and SD. A large SD value in relation to the
value of the mean indicates a large spread of scores. For the data in Box 7-3, the SD
of 23.7 in relation to the mean of 67 represents the large spread of scores presented
in the frequency distribution. Also, the SD of two distributions can be compared to
determine whether the variance of scores around the mean is similar or different,
and if different, which distribution has the larger spread of scores.
As another example, Box 7-4 demonstrates the data calculations for pretest scores
that were collected in a community research project involving 12 unwed teenaged
mothers and their knowledge of early childhood caries. In the case of this
distribution, although the mean, median, and mode are close in value, the mean is
slightly higher than the median and mode (the distribution is slightly positively
skewed) because of several higher scores. In addition, the large SD of 14 in relation
to the mean of 48 communicates the large spread of scores (range of 25 to 70) in
this distribution.
ox 7-4
B
Stati sti cal Cal cul ati ons of Mothers' Scores on
Test over Earl y Chi l dhood Cari es
Mothe r Pe rc e ntag e Sc ore
1 45
2 45
3 45
4 30 Mean = 48
5 35 Median = 45
6 25 Mode = 45
7 40
8 50 Range = 70 − 25 = 45
9 60
10 65
11 70 Variance = 210
12 70
Correlation.
The relationship or association of one variable to another is demonstrated with a
correlation statistic.22 For example, height and weight often show a strong
correlation because taller people usually have a higher weight than shorter people.
As another example, age and periodontal disease are correlated because periodontal
disease is associated with age (older adults have a higher incidence of periodontal
disease than young adults).
Various correlation statistics are available for use with different types of data
(categorical, discrete, and continuous) and measurement scales (nominal, ordinal,
interval, and ratio). Regardless of the type and scale of data, the correlation
coefficient is interpreted the same way.
The results of the calculation for correlation always have a range between +1 and
−1. The sign (+ or −) indicates either a positive or negative (inverse) relationship.
The relationship is positive (+ value of the coefficient) when the value of one
variable increases as the value of the other also increases. An example is the
relationship between heart disease and periodontal disease; the values increase and
decrease together. In contrast a negative correlation shows a negative or inverse
relationship between variables (Table 7-9). For example, oral hygiene practices are
negatively associated with gingivitis; as oral hygiene practices increase, gingivitis
decreases, and vice versa: as oral hygiene practices decrease, gingivitis increases.
TABLE 7-9
Interpretation of Correlation Coefficient: Direction and Strength
Adapted from Munro BH. Statistical Methods for Health Care Research. 6th ed. Philadelphia, PA: Lippincott;
2013.
Continuing with the sample study described earlier, using the sample pretest data
in Box 7-4, the presentation of this data in Table 7-10 shows that as the amount of
time educating the mothers increased, the mothers' differential between pretest and
posttest scores also increased. The scattergram in Figure 7-7 depicts a graphic
display of this same positive relationship between the two variables (the diagonal of
the line shows that as one variable increases in value, the other increases also). The
greater the incline of the diagonal line in a scattergram, the stronger the
relationship. However, without a correlation coefficient, it is impossible to know the
strength of the relationship. Suppose the correlation coefficient for the data for
these two variables was +0.85. This would provide a numeric value that can be
interpreted to determine the strength of the association.
TABLE 7-10
Summary of Mothers' Pretest and Posttest Knowledge Scores and Hours
of Education
Group Numbe r Group Type and Pre te st Sc ore s Hours of Educ ation Ave rag e % Inc re ase from Pre te st to Postte st
1 Four mothers with an average pretest score of 50 2 60
2 Four mothers with an average pretest score of 50 4 70
3 Four mothers with an average pretest score of 50 6 80
4 Four mothers with an average pretest score of 50 8 90
Table 7-9 also provides a guide to interpreting the value of the correlation
coefficient in representing the strength of the relationship. Using this guide, +0.85
would be considered a high correlation. However, in each study the nature of the
variables and the numbers involved in the analysis must also be considered along
with the correlation coefficient to determine what a noteworthy relationship is.22 In
all cases, the closer the relationship is to +1 or −1, the stronger the relationship.22
As an example of a negative correlation, Figure 7-8 is a scattergram showing a
negative relationship between a diet that includes fruits and vegetables each day and
the occurrence of certain cancers. In this case, as the intake of fruits and vegetables
increases, the incidence of cancer decreases, and vice versa: as the intake of fruits
and vegetables decreases, the incidence of cancer increases. The diagonal line of a
negative relationship on a scattergram is in the opposite direction, compared with
its position in a positive relationship (compare with Figure 7-7). The value of the
correlation coefficient for an inverse relationship is interpreted the same way as the
value of a positive correlation. Supposing that the correlation coefficient was −0.91
in this case, it would indicate a very high correlation.
FIG 7-8 Number of fruit and vegetable servings per day related to percent
incidence of cancer (negative correlation).
Percentiles.
A percentile is a statistical measure that represents the value below which a specific
percentage of observations fall in a distribution of values. Percentiles are often
used to report scores on a norm-referenced test. For example, if a score is in the
90th percentile, it is higher than 90% of the other scores. Another common use is
the assessment of infants' and children's weight and height compared with national
averages and percentiles found in growth charts. Similarly, body mass charts used
to identify obesity are based on percentiles. Quartiles and deciles, which split data
into 25% and 10% groups, respectively, are specific percentiles used in some cases.
Percentiles are important to us because they are used by many dental insurers to
determine the highest fees that they will reimburse (e.g., usual, customary, and
reasonable [UCR] fees; see Chapter 5).23
Bar graph.
A simple bar graph, in which bars do not touch, is used to display frequencies of
nominal or ordinal data (categorical data) or the value of different but comparable
items. The bars are of equal width and are separated to show the discrete nature of
the categories. An example of a bar graph is Figure 7-9 showing the pretest score of
each participant in the study of teenaged mothers and early childhood caries,
previously presented in Box 7-4.
Histogram.
A histogram is similar in appearance to a bar graph, except that the bars are
adjacent to each other (touching) to indicate that the frequency data in the graph are
on a continuum (Figure 7-10). Thus histograms are used to depict frequencies of
continuous data (interval or ratio scaled variables).
Frequency polygon.
A frequency polygon is a line graph also used to portray continuous data. A
histogram is easily converted into a frequency polygon by connecting the top center
point of each bar to create a line that pictorially presents the same frequency
distribution with a line instead of with bars. Figure 7-11 is a frequency polygon that
displays how many times per week the mothers in a study brush their children's
teeth. This data could be presented easily as a histogram instead. An advantage of
using a frequency polygon rather than a histogram is that several data distributions
can be presented in the same graph for a clear comparison. For example, a study
could be conducted to test the effectiveness of social media on the frequency of
mothers' brushing their children's teeth. A frequency polygon could be used to show
two distributions of data (two lines) portraying mothers' brushing of their children's
teeth: one for the experimental group and the second for the control group.
FIG 7-11 Number of times per week participants brush their children's teeth as
shown in a frequency polygon.
FIG 7-13 Time series line graph comparing the mean DI-S of children in two Head
Start programs over the school year.
Scattergram.
A scattergram or scatter plot is used to visually depict the relationship between
variables that is communicated statistically with the correlation coefficient (see
previous section). For each study participant, the value of one variable is plotted on
the x axis against the value of the second variable on the y axis (see Figures 7-7 and
7-8, which were previously used to illustrate the direction of relationship in
correlation).
Pie chart.
A pie chart is a circular graphic that illustrates numerical proportion by dividing
the whole circle or pie into sections (Figure 7-14). Simply, it presents parts of a
whole. For clarity in communicating the numerical proportions, each section of the
circle should be labeled with a percentage of the whole. Pie charts are commonly
used in lay presentations and mass media. However, they have been criticized and
are not recommended by experts for scientific literature. Employing a bar graph is
recommended instead.
FIG 7-14 Pie chart of the ethnic group representation of children in a Head Start
program.
Some of these graphs are used for frequency data, and some are not. When a table
or graph presents frequencies, the data can be presented as individual data points or
in groups. These groupings are referred to as intervals and must be of equal sizes
for accurate presentation and interpretation. A grouped frequency distribution can
be converted to a histogram or frequency polygon in the same way that an
ungrouped frequency distribution is changed over. For example, the test scores in
Box 7-4 are presented as individual data points. In Figure 7-15, these same data are
presented in a grouped frequency distribution table and a frequency polygon
showing frequencies and percentages of scores within specified intervals or ranges
of test scores.
FIG 7-15 Frequency distribution table and histogram of grouped frequency data.
Although tables and graphs may be incorporated into a written report with text,
the data in these charts should be understandable even without complementary text.
To communicate data accurately, it is important that proper technique be used to
construct effective tables and graphs. Box 7-5 presents the characteristics of
effective tables and graphs and ways to achieve those characteristics.
Box 7-5
Characteri sti cs of Effecti ve Tabl es and Graphs
and H ow to A ttai n T hem
1. Accuracy.
Enter data carefully. Follow basic principles for construction of tables and graphs.
Select the type of table or graph considering the type of data being presented.
Construct graphs that will not be misleading or open to misinterpretation. Begin the
vertical axis at zero with a break drawn in, if necessitated by a high frequency of
scores. Make the height of the vertical axis one half to three fourths of the
horizontal width of the graph.
2. Simplicity.
Present data in a straightforward manner. Highlight only the major points of
information. Minimize the use of grid lines, tics, unusual fonts, and showy patterns.
3. Clarity.
Make data easy to understand and self-explanatory. Use brief but clear titles and
headings, and label all axes and variables including type of frequency (count,
percent, cumulative). Carefully choose intervals. Include information on when and
where data were collected, if appropriate, and the size of the groups. Communicate
exclusions of observations from the data set including the reasons and criteria for
their exclusion. Include the basis for the measurement of rates. Use textbooks on
statistics and graphing, scientific writing style manuals, and samples of tables and
graphs in journal articles to guide your construction.
4. Appearance.
Pay attention to the construction so that the final result is neat and appealing.
5. Well-Designed Structure.
Emphasize the important points visually. Use dark bars and light grid lines and
horizontal lettering when possible.
From Beatty CF. Biostatistics. In Nathe CN, Dental Public Health & Research: Contemporary Practice for the
Dental Hygienist. 3rd ed. Upper Saddle River, NJ: Pearson; 2011.
Inferential Statistics
Inferential statistics are utilized to test hypotheses and generalize results from the
sample studied to the actual population that the sample was drawn from and
represents.11 Computing inferential statistics is a more complex process than other
statistical procedures that have been discussed in the chapter up to this point. Such
computations and interpretation of results of inferential statistical analyses require a
more sophisticated understanding of statistics. Thus the use of computers for
computation and consultation with a statistician are advised.
Two broad categories of inferential statistics to test a hypothesis are parametric
and nonparametric. The selection of parametric or nonparametric statistics is based
on characteristics of the data.
There are numerous parametric statistical tests. This chapter will present only a
few that are commonly used in oral health research. Others can be found in statistics
reference books, some of which are included in the references listed for this
chapter.
t-test.
One of the most common parametric statistics is the t-test, which is applied to
analyze the difference between the means of two data sets.22 It provides the
researcher with a statistical analysis of the difference between two groups, each
receiving a different treatment or control, or a change in one group resulting from
a treatment. Each of these two situations requires the use of a different version of the
t-test.
When the t-test is applied to a single group to compare pretreatment and
posttreatment scores, the t-test for dependent samples (also called paired samples,
matched samples, or repeated measures t-test) is used. This analysis is required
when only one group is studied, such as in a cohort study. To illustrate, a researcher
may want to examine the difference in blood glucose levels of diabetic patients
before and after treatment with a new diet. Assuming that all patients in the study
have similar characteristics, such as age and degree of disease present, the t-test for
dependent samples can be used to test the difference between pretreatment and
posttreatment glucose levels.
The independent t-test, also known as the Student's t-test and sometimes referred
to as the two sample t-test, is employed to determine the significance of differences
between the means of two independent groups such as an experimental group
compared with a control group. For example, a study might investigate the effect of
a new toothbrushing method on gingivitis. Patients with gingivitis are randomized
into two groups: (1) an experimental group asked to practice a new method of
toothbrushing and (2) a control group receiving no instruction and asked to brush
with their usual method. Gingivitis is measured with appropriate indexes at the
beginning of the study and again 3 months later. The hypothesis is that the new
method of toothbrushing will decrease gingivitis. The hypothesis is tested by
applying the Student t-test to compare the mean gingivitis improvement of the two
groups.
Analysis of variance.
Another commonly used parametric test is analysis of variance (ANOVA). This test
allows for comparison among three or more sample means by analyzing
interactions between and among the variances of the multiple groups.22
An example of the application of ANOVA is the comparison of five brands of
desensitizing toothpaste that claim relief of tooth sensitivity. Volunteers are
recruited, and each one is given a different brand of toothpaste disguised in a plain
white tube. Each study participant is asked to use this tube until it is finished. When
the tube is empty, each patient is given a different brand of toothpaste in an
unmarked tube to use until it too is emptied. This is repeated until all five patients
exhaust all five brands of sensitivity-relief toothpaste. Patients are asked to rate their
tooth sensitivity on a numeric scale of 1 to 10 each day for each tube of toothpaste.
The data for the mean sensitivity ratings for each of the five toothpaste brands for
each patient would look something like the data in Table 7-11.
TABLE 7-11
Sensitivity Rating Data Used in Analysis of Variance (ANOVA) Test
TP—Toothpaste brands 1 to 5.
Key: 1–10 = Sensitivity rating scale (10 is maximum).
ANOVA allows the dental hygienist to compare the mean sensitivity score of each
brand of toothpaste used in the study. It also allows a comparison of the different
responses from each participant for each toothpaste brand. ANOVA will yield
information about which brands actually reduce sensitivity, as well as how each
brand compares with the other brands. In essence, ANOVA compares differences
within groups (within each brand of toothpaste) and between groups (between the
different brands). If a difference is found to be significant, a follow-up statistic is
applied to determine where the significant difference lies, in other words, which
brand produced a statistically significant lower mean sensitivity rating.
Confidence intervals.
Another inferential statistic is a confidence intervals by which researchers estimate
the accuracy of a sample statistic such as the sample mean.10 It consists of two parts:
an interval and a percentage level of confidence. For example, with the mean of 48
for the test scores in Box 7-4, the confidence interval is 48 ± 7.94 (interval of 40.06
to 55.94) at a 95% level of confidence. The interpretation is that if the test were
repeated on multiple different samples from the same population, the calculated
confidence interval of 48 ± 7.94 would encompass the true population mean 95% of
the time. Researchers usually use a 95% or 99% level of confidence. Increasing the
confidence level to 99% would necessitate increasing the interval of values as well.
Thus increasing the confidence interval also decreases the specificity of the data,
and vice versa.
Power analysis.
Determining how many study participants are needed to provide significance is
called a power analysis.12 This analysis is calculated according to a specific
statistical formula. The power of a study, or its ability to detect differences among
groups and relationships among variables, is directly and positively related to
sample size and the precision with which the study is planned and conducted.11,12
Thus, sample size is important. Using too small or too large a sample can
influence the statistical significance. Generally, when applying parametric statistics,
the use of less than 30 in a sample or 25 in a study group will provide too little
information to make generalizations about the populations and demonstrate
statistical significance of results. With too large a sample, statistical significance can
occur more easily, possibly indicating statistical significance in error.17 With
nonparametric statistics the appropriate test must be selected for the sample size to
assure accurate interpretation of statistical significance.
The true importance of determining statistical significance is that the greater the
statistical significance, the more chance that any differences between or among
groups are real and not caused by chance. Thus there is added assurance that results
can be generalized to the population from whom the sample was taken.
p values.
Researchers use a p value to determine statistical significance.17 Whatever the
inferential statistic used to test the hypothesis, a p value is found for the statistical
result. The p value is the probability that the statistical result could be a false
scientific conclusion. The p value is affected by the sample size, the difference
between the means of the control and experimental group, and the SD of the
distribution.
Normally, an acceptable p value is 0.05 or less.12 This means that results with a p
value of 0.05 or less (p ≤ 0.05) are generally considered statistically significant and
provide the basis for rejection of the null hypothesis. A p of 0.05 means that the
results can be caused by chance 5 times in 100. Another way to say this is that there
is a 5% chance that the observed results or differences are due purely to chance and
not a true difference caused by the independent variable. Lower p values (e.g., 0.01,
0.001, or less) are more statistically significant. Thus the smaller the p value, the
more significant the findings of the study are considered.
TABLE 7-12
Errors Related to the Statistical Decision about the Null Hypothesis
Null hypothesis is
Null Hypothe sis Is Ac tually Ac c e pte d Not Ac c e pte d
True No error Type I α (alpha) error
False Type II β (beta) error No error
When the researcher rejects the null hypothesis based on the statistical results, but
the null is actually true, this is referred to as a Type I alpha (α) error. In this case
the statistical conclusion states that a difference exists when in actuality it does not.
With a significance level of 0.05 (p = 0.05), there is a 1 in 20 chance that a
conclusion will state that a difference exists when there is no difference. The Type I
error rate can be reduced by lowering the p value, for example, to 0.01 or 0.001.
On the other hand, when the opposite occurs, in other words, when the null
hypothesis is accepted although it is actually false, this is called a Type II beta (β)
error. In this case the statistical conclusion states that no relationship exists when
one actually does exist.
Analysis of the Literature
A thorough review of the literature is the first step of the research process and is
critical to every stage of the research process: synthesizing the research problem,
developing the research question, selecting the research design, formulating the
research plan including data collection, and interpreting the results. Additionally,
regularly reviewing and critically analyzing the literature is a professional
responsibility that is necessary regardless of the professional role of the dental
hygienist.25
Familiarity with the literature is important in relation to being informed and up-
to-date on dental hygiene topics that affect our practice, such as theories, methods,
therapies, and products. This assimilation of information requires more than
listening to colleagues with clinical expertise or attending continuing education
programs and professional conferences, which are at the lower end of the hierarchy
of evidence for EBDM (see Figure 7-2). Regular review of published literature,
whether in print or on the web, is an important step in remaining current in the
discipline. Meeting this professional responsibility18, 25 provides information that
enables the dental hygienist to answer questions posed by patients, intradisciplinary
and interdisciplinary colleagues, and community partners; to maintain competency;
and to be identified as an exceptional oral health professional.3
Every dental hygienist needs to have access to regular subscriptions of scientific
journals and Internet services to be able to conduct his or her own research on
various topics related to dental hygiene practice (Figure 7-17). Sometimes this can
be achieved via access to a library with a scientific collection associated with a
nearby university or college health sciences program, dental school, or medical
school. Also, these may have research librarians who can help with finding
literature on a scientific topic.
FIG 7-17 Practicing dental hygienists discuss scientific articles for evidence-
based decision making during a lunch break. (Photography courtesy Christine French
Beatty and Charlene Dickinson.)
Selection of Literature
Various factors must be considered when selecting journal articles for a literature
review.26 This section will discuss the selection of the appropriate journal, the
author, and the date of publication of the articles. In addition, use of web sources of
information is discussed.
Selecting a Journal
To begin a literature review, the dental hygienist or researcher must select
appropriate journals. The scientific writing to be reviewed should be
comprehensible to the average dental hygienist who is knowledgeable about the
topic area. Selecting literature that is pertinent to the field of dental hygiene will
allow the researcher to obtain a complete understanding of the research topic while
focusing the research on issues of importance to dental hygiene. For example,
because of the technicality and intricate scientific detail of its topics, the Journal of
Biochemical Research may not be the ideal place to start looking for information on
periodontal host factors, but the Journal of Periodontology might be preferable.
Although both journals publish in-depth scientific literature, the material in the
second is tailored to dentistry and dental hygiene, thus making it relevant and
understandable to the average oral health researcher.
Equally important is the selection of a reputable journal. Several aspects lend
credibility to a journal, including an editorial review board that evaluates each
contributed article for accuracy and reflection of current knowledge, relevancy of
content, and issues involving appropriate scientific style and method of writing.
This process is known as peer review, and the journal that uses peer review is
referred to as a refereed journal or a peer-reviewed journal. Individuals who are
considered experts on the content of a manuscript review it to make
recommendations concerning its publication. A reputable journal is commonly
affiliated with a professional group or society, a specialty group, or a reputable
scientific publisher. Sometimes professional groups will have a political stance or
agenda, which should be considered in selecting literature on some topics.
Popular magazines and periodicals published by commercial firms are not
considered reliable sources of scientific information. Examples of poor choices for
scientific literature are any of the typical newsstand health and recreation journals
and glamour and beauty magazines. Also, although many attractively presented
dental and dental hygiene publications exist, some are simply glorified advertising
brochures and do not represent an acceptable source of scientific material.
Authors
When selecting a journal article the reader should be careful to note that the author
has the appropriate qualifications. Authors should possess credentials and have
experience in or a current relationship with the field about which they are writing. If
the written work is a research study, there should also be information about the
research facilities where the research was conducted and information about
financial support for the project.
Date of Publication
Most often readers need to depend on the most current information although older
information may be considered classic or have historical significance and therefore
may be useful occasionally in conducting a review. One classic study often
mentioned in scientific writing is the Vipeholm study, conducted by Gustafsson and
colleagues in Sweden in the 1950s to investigate dental caries in relation to sugar
intake.27 Another example is Dr. Harold Löe's classic study of the role of plaque
bacteria on gingivitis, published in 1965.28
Although these are foundational studies, it is important to review current studies
that provide the newest information because newer research can change our
understanding of a disease and its prevention or control. Additionally, the most
recent literature on a topic is necessary to identify the current prevalence of oral
diseases in the population and up-to-date national oral health priorities and
strategies to address the problems. Information usually is considered current if it
has been published within the last 3 to 5 years. However, it is important to be
persistent in our research efforts to find the most current information, which may be
even more recent.
Also, when reading a research article, references cited in the journal article
should be carefully screened to validate their relevancy and age. Sometimes only a
limited amount of information is available on a given topic, which is reflected in the
article. For example, there is still a scarcity of true research involving herbal or
alternative dental therapies.
Box 7-6
Cri teri a to Eval uate Web Sources of Li terature
Authority
• Who is the author?
• Has the author published articles or books other than web pages?
Accuracy
• Are there clues to tell you that the information on the page is true?
• Does the author list sources? Is there a bibliography of citations on the page to
show where the data are coming from?
Currency
• Are the copyright dates and time period of the page current?
• Are the links current or are there any dead links on the page?
Coverage
• Is the page a complete document or an abstract/summary?
• Does the author adequately cover the topic? Is important information left out?
• Does the page contain information that is pertinent to your research topic? Does it
contain enough information to be useful? How can you use this information?
• Are there good links to additional coverage? Are the links appropriate to the
topic?
• Does the page have the required level of scholarship for scientific information?
Intended Audience
• For whom was the page written, readers of scientific or professional information
or the general public?
Biased Opinion
• Does the page or author reflect a particular bias or viewpoint? Does research done
on the author indicate a bias?
• Why was this page written? Is the page trying to sell readers a product or service
or persuade them to a particular position (biased), or is it reporting on
information (unbiased)?
• Is there advertising on the page? Can it be differentiated from the informational
content?
Adapted from Web Page Evaluation. Binghamton University Libraries, State University of New York; 2013.
Available at http://www.binghamton.edu/libraries/research/guides/web-page-checklist.html. Accessed March
2015.
ox 7-7
B
Rel i abl e Web Sources of Li terature
• Professional organizations (e.g., ADHA, AAP, ADA) = .org
• Scientific sites (e.g., American Council of Science and Health, Mayo Clinic) =
.org, .net
Note: .org and .net have been used recently by less reliable sites; care should be
taken to evaluate sites with these extensions.
Adapted from Web Page Evaluation. Binghamton University Libraries, State University of New York; 2013.
Available at http://www.binghamton.edu/libraries/research/guides/web-page-checklist.html. Accessed March
2015.
ox 7-8
B
Eval uati on of a Pri mary Research Report
Journal
• Use of peer review (refereed)
Author(s)
• Credentials and qualifications
• Scholarly experience; previously published
• Professional affiliation
Date of Publication
• Within 3 to 5 years, except for classic studies or historical perspective
Abstract
• Approximately 200 words
• Clear profile of article with brief description of the type of research, population
and sample, methods, overview of statistics, results, and conclusions
Introduction
• Review of the background, supporting literature
Results
• Appropriate treatment of data
Discussion/Conclusions
• Interpretation of results
References
• Valid sources
• Current references
Components of a Primary Research Report
Inclusion of primary research is critical when conducting a literature review. A
primary research report describes original research and includes the methods,
materials, results, discussion of interpretation, and conclusions of the study. The
contents of a published research report go by the following outline; each
component of the report should be evaluated.
Abstract
An abstract is a brief description of the published work and appears at the
beginning of a research report to provide the reader with an overview of the study.
This helps the reader determine whether the research report is relevant to the topic
being reviewed. An abstract of a research report usually is confined to
approximately 200 words and concisely defines the study's purpose, methods,
materials, results, and conclusions. The abstract does not present a complete picture
of the study nor the results; therefore it should not be relied on exclusively. The
only way to evaluate a scientific article and assess its usefulness as a source of
reliable information is to read the details within the full-text article.
Introduction
A primary research article begins with a review of the relevant current literature to
introduce the study. An accurate and complete description of the research problem is
provided, and the purpose or objective of the study is clearly explained. The
research question or hypothesis should be clear.
Results
This section includes a summary of the data, a description of the statistical analysis,
justification of the statistical tests used, results of the statistical analysis, and a
statement of the statistical decision. Data should be described and visually presented
in tables and graphs, which should be clear and understandable to the reader. How
the hypothesis of the study was tested should be described. Statistical tests should be
designated and should be appropriate for the data collected in the study.
Discussion
In this section the author interprets the statistical results and links them to the
relevant literature discussed in the introduction. Frequently, additional literature is
introduced in this section in relation to interpreting and applying the results. This
section also should include an account of any complications observed during the
research and a description of the study's strengths and weaknesses. The author
should especially focus the reader on any limitations of the study that could affect
interpretation and generalization of results.
A discussion of the conclusions and the inferences drawn from the results of the
research are presented in this section as well. These conclusions should
communicate clearly the statistical decisions to reject or accept the null hypotheses
and define outcomes of the research study. Conclusions are based on the facts
derived from the research, directly reflecting the findings of the study. It is never
appropriate to make statements that are not based on fact or that are not derived
from study results. However, the author can speculate on the meaning of the results.
Although speculation may be appropriate, it should be stated as such. When
applicable, the researcher also should discuss the clinical significance of the
research results. Based on the conclusions, the researcher may mention further
research necessary to obtain additional information or clarify questions identified
by the results of the study.
a. Population
b. Sample
c. Experimental group
d. Control group
e. Independent variable
f. Dependent variable
3. Using data that you have reviewed or collected, determine the mean, median, and
mode, and develop a table and graphs to present the data.
4. Give five examples of positive and negative correlations using variables related
to dental hygiene or to data from articles you have read.
5. Using one of the research studies from your literature review, describe the
statistical analysis. Evaluate appropriateness of the statistical techniques used and the
charts to display the data.
6. Evaluate a primary research report that you read as part of your literature review.
7. Design and complete a research study or community project following the steps
of the scientific method; present a poster on the results of the study or project.
Core Competencies
C.4
Use evidence-based decision making to evaluate emerging technology and treatment
modalities to integrate into patient dental hygiene care plans to achieve high-quality,
cost-effective care.
C.7
Integrate accepted scientific theories and research into educational, preventive, and
therapeutic oral health services.
Community Involvement
CM.1
Assess the oral health needs and services of the community to determine action
plans and availability of resources to meet the healthcare needs.
CM.6
Evaluate the outcomes of community-based programs, and plan for future activities.
Community Case
Allison is a registered dental hygienist practicing in a periodontist's office that treats
clients referred from several different dental practices in town. Most of the clients
present with moderate to severe periodontal disease with cementum exposure and
accompanying dentin hypersensitivity. She currently treats her patients with a
fluoride gel. Based on her reading of journal articles about the treatment of dentin
hypersensitivity with fluoride and the superior performance of fluoride varnish
compared with other fluoride products, Allison decides to evaluate if fluoride
varnish would work better for her own patients than the fluoride gel she has been
using. She plans to pursue a change in the office's treatment protocol for dentin
hypersensitivity if the varnish is more effective. After clearing the idea with her
employer and gaining regulatory approval for her project, Allison recruits 100 of
her own patients to participate in her study, all of whom are diagnosed with
moderate to severe dentin hypersensitivity as recorded in their patient records. She
randomly assigns half of them to a group to be treated with fluoride gel and the
other half to a group to be treated with fluoride varnish. Before starting each patient
on the assigned treatment, Allison records the patient’s self-assessment of the
severity of his or her hypersensitivity the day before the appointment. The self-
assessment is based on a scale of 0 for little to no dentin hypersensitivity
experienced during the day to 10 for severe dentin hypersensitivity experienced
during the day. Allison hypothesizes that the group treated with fluoride varnish will
experience less severe dentin sensitivity than those treated with fluoride gel. The
patients will be followed over the next 2 months and assessed once a month with the
same self-assessment of the level of dentin hypersensitivity experienced during the
full previous day, using the same rating scale. At the end of the 2-month period, she
will compare the patients' pretrial responses with the 1-month and 2-month
responses. If the results support rejection of the null hypothesis, Allison believes she
will be able to generalize the results to other patients in her practice and will
recommend a change in the treatment protocol to use fluoride varnish to treat for
dentin hypersensitivity.
1. The experimental group in this study is which of the following?
a. All the volunteers that Allison enrolls in the study
b. The patients who receive the fluoride gel treatment
c. The patients who receive the fluoride varnish treatment
d. The patients who don't complete the study
e. All the patients in Allison's practice who have moderate to severe periodontitis
and dentin hypersensitivity
2. The data that Allison collects for this study are which of the following types of
data?
a. Discrete data
b. Ordinal scale data
c. Categorical data
d. Ratio scale data
e. Continuous data
3. Which of the following descriptive statistics should be used to summarize the
data?
a. Parametric
b. Chi-square
c. Correlation coefficient
d. Counts and percentages
e. Means and standard deviations
4. Which two of the following methods used in this study are potential sources of
error in relation to internal validity?
a. Self-report measure of the dependent variable
b. Lack of a control group
c. Potential lack of interrater reliability
d. Use of a convenience sample
e. Potential examiner bias
5. Which of the following graphs is the best method for Allison to present the final
study outcome data to her employer to recommend a new protocol for the office?
a. Bar graph
b. Frequency polygon
c. Histogram
d. Pie chart
e. Scattergram
6. Which two of the following describe the type of study used by Allison?
a. Quasi-experimental
b. Repeated measures
c. Pretest-posttest
d. Observational
e. Blind (masked)
References
1. American Dental Hygienists' Association. National Dental Hygiene
Research Agenda; 2007 [Available at] https://www.adha.org/resources-
docs/7111_National_Dental_Hygiene_Research_Agenda.pdf [Accessed
February 2015].
2. UNC Health Science Library. Evidence Based Dentistry; 2015 [Available at]
http://guides.lib.unc.edu/c.php?g=8433&p=43431 [Accessed March 2015].
3. Forrest JL, Overman P. Keeping current: A commitment to patient care
excellence through evidence based practice. J Dent Hyg. 2013;87(Suppl.
1):33–40 [Available at]
http://jdh.adha.org/content/87/suppl_1/33.full.pdf+html [Accessed February
2015].
4. Marshall T, Straub-Morarend CL, Qian F, et al. Perceptions and practices of
dental school faculty regarding evidence-based dentistry. J Dent Educ.
2013;77:146–151 [Available at]
http://www.jdentaled.org/content/77/2/146.full [Accessed February 2015].
5. Green S, Higgins JPT, Alderson P, et al. What is a systematic review?. [Part
1, Chapter 1, Section 1.2.2, in Higgins JPT, Green S] Cochrane Handbook
for Systematic Reviews of Interventions; 2011 [Available at]
http://handbook.cochrane.org/ [Accessed March 2015].
6. Deeks JJ, Higgins JPT, Altman DG. Why perform a meta-analysis in a
review?. [Part 2, Chapter 9, Section 9.1.3, in Higgins JPT, Green S]
Cochrane Handbook for Systematic Reviews of Interventions; 2011
[Available at] http://handbook.cochrane.org/ [Accessed March 2015].
7. University of Maryland Libraries. Primary, Secondary, and Tertiary
Sources; 2014 [Available at] http://www.lib.umd.edu/tl/guides/primary-
sources [Accessed March 2015].
8. Creswell J. Research Design: Qualitative, Quantitative and Mixed Methods
Approaches. 4th ed. SAGE Publications: Thousand Oaks, CA; 2014.
9. Leedy PD, Ormrod JE. Practical Research: Planning and Design. Pearson
Education, Inc.: Upper Saddle River, NJ; 2013.
10. Friis RH, Sellers TA. Epidemiology for Public Health Practice. 5th ed. Jones
& Bartlett Learning: Burlington, MA; 2014.
11. Welkowitz J, Cohen BH, Lea RB. Introductory Statistics for the Behavioral
Sciences. 7th ed. John Wiley & Sons: Chichester; 2011 [Available at eBook
Collection (EBSCOhost). Web, Accessed December 2014].
12. Chattopadhyay A. Oral Health Epidemiology: Principles and Practice. Jones
& Barlett: Sudbury, MA; 2011.
13. Rosenthal JA. Statistics and Data Interpretation for Social Work. Springer
Publishing Company, LLC: New York; 2012.
14. Leon AC, Davis LL, Kraemer HC. The role and interpretation of pilot
studies in clinical research. J Psychiatr Res. 2011;45(5):626–629.
15. Keele R. Nursing Research and Evidence-Based Practice: Ten Steps to
Success. Jones & Bartlett Learning: Sudbury, MA; 2011.
16. Beatty CF. Biostatistics. Nathe CN. Dental Public Health & Research:
Contemporary Practice for the Dental Hygienist. 3rd ed. Pearson: Upper
Saddle River, NJ; 2011.
17. Katz DL, Wild D, Elmore JG, et al. Jekel's Epidemiology, Biostatistics,
Preventive Medicine, and Public Health. 4th ed. Elsevier Saunders:
Philadelphia, PA; 2014.
18. American Dental Hygienists' Association. Code of Ethics; 2014 [Available
at] http://www.adha.org/resources-
docs/7611_Bylaws_and_Code_of_Ethics.pdf [Accessed March 2015].
19. National Institutes of Health, Office of Extramural Research. Protecting
Human Research Participants (tutorial); 2011 [Available at]
https://phrp.nihtraining.com/index.php [Accessed March 2015].
20. National Institutes of Health, National Cancer Institute. Cancer Staging; 2015
[Available at]
http://www.cancer.gov/cancertopics/factsheet/detection/staging [Accessed
March 2015].
21. Centers for Disease Control and Prevention. Principles of Epidemiology in
Public Health Practice: An Introduction to Applied Epidemiology and
Biostatistics. 3rd ed. 2012 [updated; Available at]
http://www.cdc.gov/ophss/csels/dsepd/SS1978/SS1978.pdf [Accessed
March 2015].
22. Munro BH. Statistical Methods for Health Care Research. 6th ed. Lippincott:
Philadelphia, PA; 2013.
23. Fair Health Consumer Cost Look Up. Using the FH Medical Cost Lookup
and the FH Dental Cost Lookup; 2014 [Available at]
http://fairhealthconsumer.org/faq.php [Accessed March 2015].
24. Lozovsky V. Table vs. Graph. [Available on Information Builders website at]
http://www.informationbuilders.com/new/newsletter/9-2/05_lozovsky;
2008 [Accessed March 2015].
25. Forrest JL, Miller SA. Evidence-based decision making. Darby M, Walsh M.
Dental Hygiene: Theory and Practice. 4th ed. Elsevier Saunders: St Louis;
2015.
26. Houser J. Nursing Research: Reading, Using and Creating Evidence. Jones &
Bartlett Learning: Sudbury, MA; 2013.
27. Ng A. Vipeholm study. Cariology (Web); 2009 [Available at]
http://cariology.wikifoundry.com/page/Vipeholm+Study [Accessed March
2015].
28. Löe H, Theilade E, Jensen SB. Experimental gingivitis in man. J
Periodontol. 1965;36:177–187 [Available at]
http://www.researchgate.net/publication/9287160_EXPERIMENTAL_GINGIVITIS_IN
[Accessed March 2015].
29. Binghamton University Libraries, State University of New York. Web Page
Evaluation; 2013 [Available at]
http://www.binghamton.edu/libraries/research/guides/web-page-
checklist.html [Accessed March 2015].
30. Duke University Medical Center Library, University of North Carolina at
Chapel Hill Health Sciences Library. Introduction to Evidence-Based
Practice (tutorial); 2015 [Available at]
http://guides.mclibrary.duke.edu/c.php?g=158201&p=1036002 [Accessed
March 2015].
31. Centers for Disease Control and Prevention, Fluoride Recommendations
Work Group. Recommendations for using fluoride to prevent and control
dental caries in the United States. MMWR. 2001;50(RR14):1–42 [Available
at] http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm [Accessed
December 2014].
32. Marinho VC, Higgins JP, Logan S, et al. Fluoride varnishes for preventing
dental caries in children and adolescents. Cochrane Database Syst Rev.
2002;(3) [CD002279; Available at]
http://www.ncbi.nlm.nih.gov/pubmed/12137653 [Accessed March 2015;
(Abstract)].
33. Association of State and Territorial Dental Directors, Fluorides Committee.
Fluoride Varnish: An Evidence-Based Approach: Research Brief; 2007
[Available at]
http://www.astdd.org/docs/Sept2007FINALFlvarnishpaper.pdf [Accessed
March 2015].
34. American Association of Public Health Dentistry. AAPHD Resolution on
Fluoride Varnish for Caries Prevention; 2008 [Adopted January; Available
at] https://www.google.com/?gws_rd=ssl#q=fluoride+varnish+aaphd
[Accessed March 2015].
35. Marinho VCC, Worthington HV, Walsh T, et al. Fluoride varnishes for
preventing dental caries in children and adolescents. Cochrane Libraries
(Web). 2013; 10.1002/14651858 [CD002279.pub2; Available at]
http://www.cochrane.org/CD002279/ORAL_fluoride-varnishes-for-
preventing-dental-caries-in-children-and-adolescents [Accessed March
2015].
36. ADA Center for Evidence-Based Dentistry, Council on Scientific Affairs.
Topical Fluoride for Caries Prevention: Full Report of the Updated Clinical
Recommendations and Supporting Systematic Review; 2013 [Available at]
http://ebd.ada.org/~/media/EBD/Files/Topical_fluoride_for_caries_prevention_2013_
[Accessed March 2015].
37. American Academy of Pediatric Dentistry. Guideline on Fluoride Therapy.
Clinical Guidelines. 2014 [Available at]
http://www.aapd.org/media/Policies_Guidelines/G_fluoridetherapy.pdf
[Accessed March 2015].
Additional Resources
Centre for Evidence Based Dentistry.
http://www.cebd.org/.
American University literature review tutorial.
http://subjectguides.library.american.edu/litreview.
Guidelines for reading/reviewing scientific research papers.
http://www.unm.edu/~lkravitz/UNM%20Pages/readingreseach.html.
Journal of Dental Hygiene online articles.
http://oberon.ingentaconnect.com/vl=949594/cl=25/nw=1/rpsv/cw/www/adha/15530205
National Dental Hygiene Research Agenda.
https://www.adha.org/resources-
docs/7111_National_Dental_Hygiene_Research_Agenda.pdf.
Research Center, American Dental Hygienists' Association.
http://www.adha.org/research-center.
DHNet National Center for Dental Hygiene Research & Practice.
https://dent-web10.usc.edu/dhnet/.
Qualitative Research Methods: A Data Collector's Field Guide.
http://www.fhi360.org/sites/default/files/media/documents/Qualitative%20Research%20
%20A%20Data%20Collector%27s%20Field%20Guide.pdf.
Cochrane Library.
http://www.cochranelibrary.com/.
American Dental Association Research Agenda.
http://www.ada.org/en/about-the-ada/ada-positions-policies-and-
statements/research-agenda.
C H AP T E R 8
Health Promotion and Health
Communication
Beverly Isman RDH, MPH, ELS
OBJECTIVES
1. Discuss the scope of health promotion and the wide range of activities involved.
2. Apply various health promotion strategies, theories, and models to situations
for promotion of oral health.
3. Discuss ways to assess needs of diverse populations before designing health
promotion and health communication strategies.
4. Describe health communication in relation to health information technology, as
well as how to appropriately frame health messages using the four P's of
marketing.
5. Identify strategies for delivering health information to consumer groups by
using materials, activities, communication pathways, and evaluation methods that
are based on needs and characteristics of the target populations.
6. Follow a sequence of steps in the health communication process when
developing, implementing, or evaluating a health communication plan or project.
7. Discuss the points to consider when developing consumer-oriented health
communications.
8. Outline the basic considerations, advantages, and limitations of various formats
for communicating scientific information to health professionals such as poster
presentations, oral papers, roundtable discussions, and web-based presentations.
9. Identify and take advantage of opportunities for personal growth and
development in health promotion, health communication, and health information
technology.
Opening Statements: Challenges to
Promoting Oral Health
• Despite years of research on prevention of oral diseases, very little is known about
how best to promote oral health.
• Assuring oral health for all people will be difficult until the World Health
Organization's (WHO) eight prerequisites for health are achieved: peace, shelter,
education, food, income, stable ecosystem, sustainable resources, social justice,
and equity.1
• More community-based participatory research, in which community members are
involved at all stages, and more interdisciplinary research, with nondental
behavioral scientists, might shed more light on effective strategies.
• More evidence is needed to document that change in attitudes and beliefs about oral
health lead to improved oral health outcomes.
• Improved knowledge levels alone rarely translate into healthy behaviors, so
approaches need to be designed around proven behavioral and communication
theories.
• Most behavioral change that occurs after oral health education or promotion is
short term and not sustained without periodic reinforcement; it is important to
continue to seek an answer to what it takes to create sustainable changes.
• Today dental hygienists have unique and unlimited opportunities to become
involved in community health promotion activities and health communication
strategies; unfortunately these experiences don't always lead to community-focused
career opportunities using these skills.
• Exponential use of social media can increase knowledge but also can inundate
users with information, as well as misinformation that is not evidence-based.
• The main goal of this chapter is to help dental hygienists incorporate a thought
process for assessing needs, forming evaluation questions, and planning
communication strategies before jumping to implement what seems like a good
idea.
Health Promotion
Health, as defined in Chapter 1, is a personal resource that permits people to lead
productive lives.1 Health promotion is a broad concept defined by the World Health
Organization (WHO) as the process of empowering (enabling) people and
communities to increase their control over various determinants of health and
therefore to improve their own health.1 Health promotion introduces the role of
behaviors, not just attitudes and knowledge, into the health equation and goes
beyond a focus on individual behavior toward a wide range of social and
environmental interventions. Health promotion is more than health education and
links oral health to other health issues. Thus this chapter focuses on the concepts of
oral health promotion, strategies to affect behavioral and community changes, and
the dental hygienist's role in selecting communication pathways and communicating
health messages to other health professionals and to the public.
The Ottawa Charter, a global health promotion imperative created in 1986,
identified the WHO prerequisites for health and identified three basic health
promotion strategies to address these prerequisites: (1) advocating for health, (2)
enabling people to achieve their full health potential, and (3) mediating different
societal interests in pursuit of health.1 The following five action steps can help
achieve these strategies:1
• Build healthy public policy (e.g., tobacco-free restaurants and workplaces)
• Create supportive environments for health (e.g., exercise rooms and breastfeeding
rooms in workplaces)
• Strengthen community action for health (e.g., support for local farmers' markets)
• Develop personal health management skills (e.g., healthy meal planning and
cooking, monitoring blood pressure)
• Reorient health services (e.g., provider incentives for keeping people well)
Five additional global health promotion conferences held since 1986 reinforce
and provide further details about these strategies.1 All of these strategies have direct
relevance to oral health, the health promotion theories enumerated in this chapter,
and healthcare reform efforts in the United States and other countries.
Oral health promotion efforts can increase use of oral health and wellness
services and preventive self-care measures. The anticipated outcome of these efforts
is a reduced incidence and severity of oral diseases and reduced oral health
disparities among population subgroups, with improved oral health and overall
health. Yet as we see in the challenges in the Opening Statements, applied research
relating to oral health promotion is still struggling and is not yet well integrated or
coordinated with research and theories developed by other health disciplines. An
important goal is to achieve oral health equity “when every person has the
opportunity to attain full oral health potential and nobody is disadvantaged because
of social position or other socially determined circumstances.”2 Common risk
factors must be identified and addressed for multiple diseases, including oral
diseases, and preventive strategies and health promotion messages implemented that
can have an enhanced impact.3
TABLE 8-1
Levels of Influence of Health Promotion Models
Le ve l of
De finition
Influe nc e
Intrapersonal Individual characteristics that influence behavior, such as knowledge, attitudes, beliefs, and personality traits
Interpersonal Interpersonal processes and primary groups, including family, friends, and peers, that provide social identity, support, and role definition
Community
Institutional Rules, regulations, policies, and informal structures that may constrain or promote recommended behaviors
Factors
Community Social networks and norms or standards that exist formally or informally among individuals, groups, and organiz ations
Factors
Public Policy Local, state, and federal policies and laws that regulate or support healthy actions and practices for disease prevention, early detection,
control, and management
Data from Glanz K, Rimer BK. Theory at a Glance: A Guide for Health Promotion Practice. 2nd ed.
Bethesda, MD: National Institutes of Health, National Cancer Institute; 2005. Available at
http://www.sneb.org/2014/Theory%20at%20a%20Glance.pdf.
The following sections describe selected health promotion theories that relate to
these levels and that have the most relevance to oral health issues. A narrative of
each theory, including an oral health example and tips for remembering the theory,
is accompanied by a table that contains key concepts, definitions, and general
applications. For further elaboration or additional theories, see the resources and
references at the end of the chapter.
Examples of the use of public policy to influence oral health behavior are not
provided in this chapter; this concept is threaded throughout the textbook. Some
specific examples are the national initiatives and policy development in Chapter 1,
advocacy in Chapter 2, water fluoridation and other policies related to specific
community programs in Chapter 6, legislative advocacy in Chapter 9, and public
policy related to cultural competence and health literacy in Chapter 10.
Intrapersonal Level
TABLE 8-2
Stages of Change (Transtheoretical Model)
Adapted from Prochaska JO, Redding CA, Evers KE. The Transtheoretical Model and Stages of Change,
Chapter 5. In Glanz K, Rimer BK, Viswanath K. Health Behavior and Health Education: Theory, Research,
and Practice. 4th ed. San Francisco, CA: Jossey-Bass; 2008. Available at
http://www.med.upenn.edu/hbhe4/part2-ch5.shtml. Accessed February 2015.
Adapted from Champion VL, Skinner CS. The Health Belief Model, Chapter 3. In Glanz K, Rimer BK,
Viswanath K. Health Behavior and Health Education: Theory, Research, and Practice. 4th ed. San
Francisco, CA: Jossey-Bass; 2008. Available at http://www.med.upenn.edu/hbhe4/part2-ch3.shtml.
Accessed February 2015.
Interpersonal Level
The basic premise of this theory, also known as the Social Cognitive Theory, is
that people learn by observing the actions of others and the results of these actions,
as well as their own cognitive processing of that information and environmental
influences on behavior. Behavioral change is accomplished through the interaction
of behaviors, environmental influences, and personal cognitive processes. Thus
according to this theory, the world and one's behavior cause each other—a concept
known as reciprocal determinism. Another important concept that is part of this
theory is self-efficacy, which means that the individual has confidence that he or she
can exert control over his or her motivation, behavior, and social environment.
Table 8-4 lists the relevant definitions and applications of the major concepts.
TABLE 8-4
Social Learning Theory (Social Cognitive Theory)
Adapted from McAlister AL, Perry CL, Parcel GS. How Individuals, Environments, and Health Behaviors
Interact: Social Cognitive Theory, Chapter 8. In Glanz K, Rimer BK, Viswanath K. Health Behavior and
Health Education: Theory, Research, and Practice. 4th ed. San Francisco, CA: Jossey-Bass; 2008.
Available at http://www.med.upenn.edu/hbhe4/part3-ch8.shtml. Accessed February 2015.
Community Level
Adapted from Minkler M, Wallerstein N, Wilson N. Improving Health Through Community Organization and
Community Building, Chapter 13. In Glanz K, Rimer BK, Viswanath K. Health Behavior and Health
Education: Theory, Research, and Practice. 4th ed. San Francisco, CA: Jossey-Bass; 2008. Available at
http://www.med.upenn.edu/hbhe4/part4-ch13.shtml. Accessed February 2015.
TABLE 8-6
Diffusion of Innovations Theory
Adapted from Oldenburg B, Glanz K. Diffusion of Innovations, Chapter 14. In Glanz K, Rimer BK,
Viswanath K. Health Behavior and Health Education: Theory, Research, and Practice. 4th ed. San
Francisco, CA: Jossey-Bass; 2008. Available http://www.med.upenn.edu/hbhe4/part4-ch14.shtml.
Accessed February 2015.
TABLE 8-7
Characteristics of Adopter Categories and Suggested Strategies to
Encourage Adoption
Adopte r
Charac te ristic s Sug g e ste d Strate g ie s
Cate g ory
Innovators Want to be the first to try the innovation; are venturesome and interested in new Very little, if anything, needs to be done to appeal to this
ideas; very willing to take risks; often the first to develop new ideas group
Early Represent opinion leaders; enjoy leadership roles; embrace change opportunities; How-to manuals; information sheets on implementation;
Adopters already aware of the need to change and so very comfortable adopting new ideas do not need information to convince them to change
Early Rarely leaders but do adopt new ideas before the average person; typically need to see Success stories; evidence of the innovation's effectiveness
Majority evidence that the innovation works before they are willing to adopt it
Late Skeptical of change; will only adopt an innovation after it has been tried by the Information on how many others have tried the new idea
Majority majority and adopted it successfully
Laggards Bound by tradition; very conservative; very skeptical of change; the hardest group to Statistics; fear appeals; pressure from people in the other
bring on board adopter groups
Data from Diffusion of Innovations Theory. Boston University School of Public Health; 2013. Available at
http://sphweb.bumc.bu.edu/otlt/MPH-Modules/SB/SB721-Models/SB721-Models2.html. Accessed February
2015.
TABLE 8-8
Organizational Change: Stage Theory
Adapted from Butterfoss FD, Kegler MC, Francisco VT. Mobilizing Organizations for Health Promotion:
Theories of Organizational Change, Chapter 15. In Glanz K, Rimer BK, Viswanath K. Health Behavior and
Health Education: Theory, Research, and Practice. 4th ed. San Francisco, CA: Jossey-Bass; 2008.
Available at http://www.med.upenn.edu/hbhe4/part4-ch15.shtml. Accessed February 2015.
G ui di ng Pri nci pl es
Knowledge and Skills Needed to Assess, Change, and Evaluate
Health Behaviors and Systems of Care
• Factors that are considered a risk for development of oral diseases and those
factors that can be modified through preventive efforts at the primary, secondary,
and tertiary levels
• How to assess a person's risk for development of oral diseases and other health
problems and counsel about risk reduction
• The level of scientific evidence for and the extent of certainty of the effectiveness
of various preventive measures
• Ways in which innovations are diffused and ways of bringing about organizational
change
• Ways to motivate people to access services and return for continuing care
• How to evaluate efforts (e.g., effectiveness, costs, access, quality, outcomes) using
both qualitative and quantitative methods
Adapted from Lawrence RS, Runyan JW, Tilson HH, Wallace RB, Wiese WH. Inventory of Knowledge and
Skills Relating to Disease Prevention and Health Promotion. Association for Prevention Teaching and Research;
1994. Available from http://www.kagoon.com/inventory-of-knowledge-and-skills-relating-to-disease/main.
Accessed February 2015.
Some of the information and skills may be learned during the dental hygiene
educational process, with additional strategies acquired through professional
development, experience, and personal research. Resources for professional
development are discussed later in this chapter.
Health Communication and Health
Information Technology
Beliefs and behaviors about health are shaped by communication formats and
technology that people interact with on a daily basis. These formats and uses of
technology influence the way people search for, understand, and use health
information to make decisions and act on these decisions. Health communication
emerged as a separate focus area in the national Healthy People 2010 objectives and
had increased attention in the Healthy People 2020 (HP 2020) objectives.14
The Centers for Disease Control and Prevention (CDC) defines health
communication as “the study and use of communication strategies to inform and
influence individual decisions that enhance health.”15 Regardless of the many forms
of health communication and whether it is written or verbal, strategic planning is
essential to develop effective health communication.15 Box 8-1 demonstrates the
CDC's framework of the important steps in the health communication process that
center around the community oral health process consisting of assessment,
planning, implementation, and evaluation (see Chapter 6).
ox 8-1
B
Essenti al Strateg i c Pl anni ng Steps for Effecti ve
H eal th Communi cati on
1. Review background information to define the problem (What's out there?)
6. Select, create, and pretest messages and products (How do we want to say it?)
Data from: What is Health Communications? Atlanta, GA: Centers for Disease Control and Prevention; 2011.
Available at http://www.cdc.gov/healthcommunication/healthbasics/whatishc.html. Accessed February 2015.
Social Marketing
Social marketing is defined by the CDC as “the use of marketing principles to
influence human behavior to improve health or benefit society.”15 Social marketing
focuses on the consumer in relation to marketing health services. This can be
accomplished by emphasizing the four P's of marketing in relation to health
communication.15 Table 8-9 defines these four P's and provides examples in relation
to an oral health education objective.
TABLE 8-9
The Four P's of Marketing in Relation to Health Messages
Adapted from: What is Health Communications? Atlanta, GA: Centers for Disease Control and Prevention;
2011. Available at http://www.cdc.gov/healthcommunication/healthbasics/whatishc.html. Accessed
February 2015.
Using Technology
Mobile technologies and social media, such as Facebook or Twitter, create unique
opportunities for delivering personalized messages.20 For example, individuals can
receive messages that allow them to find where vaccinations or flu shots are being
given by entering their zip code. New mothers can sign up to receive messages that
include oral health tips for their babies. The Internet promotes individualization by
allowing people to search for and discuss information that applies to their particular
situations, answers their specific questions, or assists them in communicating with
their oral and other health providers.
Personalizing Communication
The most effective way to personalize information is to highlight only the
information and key messages that apply to the person who receives it.20 Tailored
messages reach a specific person on the basis of features unique to that person,
which are discovered through an assessment process. This is the basis of many risk
assessment/risk reduction and self-care programs in health care (e.g., heart disease
and diabetes) and in dentistry (e.g., caries management by risk assessment). Tailored
messages provide a more meaningful and motivating strategy built on a person's
specific input. The use of personal trainers for health improvement through
exercise is an example of this strategy. A professional who tailors a message
without going through the essential assessment process, however, may find that the
message is ineffective as a result of not adjusting the message based on the
individual's characteristics, gains, or lapses.
ox 8-2
B
Lang uag e Transl ati on Barri ers and Sug g esti ons
for Overcomi ng T hem
Problems with Translating Materials
• Medical and dental terms may not be understood, may have different meanings, or
may not be directly translatable to another language. Even within languages such
as Spanish, people from different nations or regions may use different words for
dental terms such as x-ray or baby teeth.
• Translating word for word (literally) often is confusing because there may be no
direct translation or a variety of phrases may be used, depending on the person's
age, gender, social standing, or other characteristics. Literal translations without
considering local language patterns and word usage may be annoying to the
intended audience, causing them to ignore the information or reducing its
credibility.
• Some people may speak a language that does not have a written equivalent, or they
may speak a language but not be able to read it.
• Field test translated materials with a variety of members from the intended
audience. Some researchers recommend two-way translation—one person
translates the text from English to the other language, and a second person
translates it back to English to identify any inconsistencies or mistranslations.
• Use only trained translators who are familiar with both low literacy and more
sophisticated readers.
Some educational materials are produced in a dual language format so that both
English and the other language are included. This can be useful for both print and
video productions.
Studies have shown that some health education programs are more likely to
change health outcomes. Intensive disease-management programs appear to reduce
disease prevalence and severity, and self-management interventions increase self-
management behavior. Effective interventions were those that were of high intensity,
had a theory basis, were pilot tested before full implementation, emphasized skill
building, and were delivered by a health professional. Interventions that change
outcomes such as the use of healthcare services and health outcomes appear to work
by increasing knowledge and/or self-efficacy, or by changing behavior.26
The focus group participants' responses are summarized and analyzed to help
make decisions on final content and format of the campaign materials before
release to the public.
Evaluation considerations.
Evaluation of the communication formats, channels, and materials is critical to
document that they are working.20 This is not only a best practice but it is also
necessary to assure program sustainability. Evaluation can occur both during and
after educational interventions (formative and summative evaluation). The
evaluation methods should be linked directly to the objectives, and both short-term
and long-term outcomes should be considered. See Guiding Principles for some
sample questions to be answered with the evaluation. Measures can be quantitative
(e.g., how many people increased their knowledge of the causes of early childhood
caries and how much increase in knowledge occurred?) or qualitative (e.g., why did
people participate in the activity and how do they intend to change their parenting
behaviors?). See Chapter 6 for a detailed discussion of program evaluation.
G ui di ng Pri nci pl es
Sample Questions to Determine the Effectiveness of Health
Communication/Health Promotion Interventions
• Has the intervention achieved the desired results in relation to program outcomes?
If not, why not?
• Are the resources (e.g., people, money, materials) that were used reasonable and
cost-effective?
ox 8-3
B
Ex ampl es of Si mpl e Eval uati on Mechani sms to
Determi ne Effecti veness of Communi cati on
Channel s, Formats, and Materi al s
• Ask five questions to assess parents' knowledge and attitudes about sealants before
and after a school-based sealant educational program.
• Provide healthy snack recipes to a day care center; follow up after 2 months to
determine which snacks have been prepared and served to the children and which
snacks the children seem to prefer.
• Survey school soccer coaches before and after initiating an oral injury or mouth
guard prevention campaign to determine use of mouth guards during practices
and games, changes in policies on athletic equipment, and barriers that have been,
or have not been, overcome in the attempt to implement the campaign.
• Record how many tweets are posted about a perinatal oral health campaign, what
the key messages were, and whether anyone reported following any of the
recommendations.
G ui di ng Pri nci pl es
Questions to Answer When Selecting a Topic and Format for a
Professional Presentation
• Who will be the audience? How large will the group be?
• What questions might the audience ask? Will I be able to learn new information
related to my topic from some members of the audience?
Web-based presentation.
A web-based presentation, also called a webinar (Figure 8-7), has become a
preferred means of presenting material to selected groups of professionals because
no travel costs or additional time are involved, and the presentation can be recorded
for future viewing.
Time: Most last 30 to 60 minutes, depending on how many people are presenting
the webinar or podcast
Format: Can do live video streaming or use prepared slides with live audio;
many options for audience interaction via live chats, polling and evaluation
questions, and unmuting audio lines; can also record and save to a website for later
viewing
Size of audience: Depends on online package being used; some limited to 100
phone lines although others are unlimited
Appropriate audiovisuals: Videos, slides, and personal demonstrations if using
video
Benefits and limitations: Can reach large audience with various levels of two-
way interaction; if using live video, can see presenter and sometimes audience if
they are gathered in a room with a video camera; can download slides before or
after presentation; can provide links to online resources; unintended noise or line
interference has been a major problem especially if audience lines aren't muted
Tips: Schedule a practice run before the presentation to assure you are familiar
with navigating the web interface; reduce any sources of noise during your
presentation
3. Choose a topic, audience, and three key messages for designing a patient handout.
Describe how you would vary the design and tailor the messages for three
additional audiences based on different ethnicity, age, or other factors. Using the
same audiences describe how you would adapt the messages for four different
communication channels, for example, tweets, YouTube videos, or blogs.
4. Choose an oral health topic for designing a health promotion activity for
consumers (nonhealth professionals). Each student should select a different
audience (e.g., different age or ethnic group) for the materials. Then (a) describe
how you would conduct a needs assessment, (b) select an appropriate educational
format, and (c) evaluate the outcomes of your approach.
5. Choose a topic for a 10-minute presentation. Describe how you would present this
topic as (a) a scientific poster, (b) an oral paper, (c) a roundtable discussion, and (d)
a web-based presentation.
7. Select three online or print journals that focus on health promotion or health
communications research or programs. Compare the journals in terms of target
audience, array of topics, whether they are peer reviewed, and frequency of
publication. Discuss which publications you think might be most useful to you in
your career.
8. Assume you have been asked by a local community clinic for your opinion on
how to reach their adult African American and Hispanic clients with preventive
messages about oral cancer. Provide at least two suggestions for key
communication strategies and messages for each group, noting the rationales for
your recommendations.
Dental Hygiene Competencies
Reading the material within this chapter and participating in the activities of
Applying Your Knowledge will contribute to the student's ability to demonstrate the
following competencies:
Core Competencies
C.10
Communicate effectively with diverse individuals and groups, serving all persons
without discrimination by acknowledging and appreciating diversity.
HP.5
Evaluate factors that can be used to promote patient adherence to disease prevention
or health maintenance strategies.
Community Involvement
CM.2
Provide screening, referral, and educational services that allow patients to access
the resources of the healthcare system.
CM.3
Provide community oral health services in a variety of settings.
CM.4
Facilitate patient access to oral health services by influencing individuals or
organizations for the provision of oral health care.
Community Case
You are a dental hygienist who has been working in clinical private practice for 3
years and now wants to work part-time in a public health setting. The local health
department has hired you to work on a project to help mothers of children ages 0 to
5 years learn about: (1) the relationship between consumption of sugar, including
sweetened beverages, and dental caries, (2) how to determine the amount and type of
sugar from food labels, (3) how to select foods low in refined sugars, and (4) how
to use these foods to create healthy snacks for their young children.
Your target population is approximately 2000 low-income women whose
children are eligible for Medicaid benefits and services from the Women, Infant,
and Children (WIC) program, and whose children attend Early Head Start or Head
Start programs. According to the most recent health department data, 50% of the
women are Hispanic, 10% are Caucasian, 25% are African American, 10% are
Asian, and 5% are of other ethnic backgrounds.
1. Your first task is to review the various health promotion theories and determine
which would be useful for this project. You decide that you need to assess whether
the women in the target population perceive that their children are consuming
foods high in sugars and, if so, whether the mothers perceive that it puts them at
risk for dental caries. Which one of the following theories is best to use for this
purpose?
a. Social Learning Theory
b. Stages of Change Theory
c. Health Belief Model
d. Organizational Change Theory
2. Your next task is to select and tailor health messages you want to include in your
health communication approaches. Which one of the following approaches is an
example of tailoring a message?
a. Use separate brochures for each ethnic group.
b. Develop learning modules that focus on the women's roles as mothers.
c. Design short learning modules geared to each level of caries risk identified
during the assessment process.
d. Use a short booklet that leaves a blank place in which to write the child's name.
3. All of the following EXCEPT one are useful strategies to help the target
population learn the information. Which one is the EXCEPTION?
a. Ask them to demonstrate a skill to help reinforce the written instructions.
b. Have them read rather than hear and see the information; they will learn more
from reading it.
c. Ask them to repeat instructions in their own words to help them remember the
information.
d. Use a hands-on, interactive, multimedia approach; this is most effective for
retaining knowledge.
4. You decide that the project materials need to be available in at least English and
Spanish. Which of the following approaches is LEAST likely to result in effective
and culturally relevant materials?
a. Use translators who are bilingual and bicultural.
b. Test the materials in three focus groups: (1) English-only readers, (2) Spanish-
only readers, and (3) partially bilingual readers.
c. Do a literal translation from the English version to Spanish.
d. Create the materials in dual-language format.
5. During the project you have an opportunity to present information on the project
at a statewide public health association meeting. You are most interested in
discussing and getting feedback on ways to improve the materials and messages.
Which presentation format would allow you the best opportunity to accomplish
this?
a. Roundtable discussion
b. Poster presentation
c. Oral presentation
d. Informal networking with individuals
References
1. World Health Organization. Milestones in Health Promotion: Statements
from Global Conferences. WHO Press: Geneva; 2009 [Available at]
http://www.who.int/healthpromotion/Milestones_Health_Promotion_05022010.pdf?
ua=1 [Accessed February 2015].
2. Health Equity. Centers for Disease Control and Prevention, Chronic Disease
and Health Promotion: Atlanta, GA; 2013 [Available at]
http://www.cdc.gov/chronicdisease/healthequity/index.htm [Accessed
February 2015].
3. Watt RG. Strategies and approaches in oral disease prevention and health
promotion. Bull World Health Organ. 2005;83:711 [Abstract available at]
http://www.ncbi.nlm.nih.gov/pubmed/16211164 [Accessed February 2015].
4. Glanz K, Rimer BK, Viswanath K. Theory, Research, and Practice in Health
Behavior and Health Education (Ch. 2). Glanz K, Rimer BK, Viswanath K.
Health Behavior and Health Education: Theory, Research, and Practice. 4th
ed. Jossey-Bass: San Francisco, CA; 2008 [Available at]
http://www.med.upenn.edu/hbhe4/part1-ch2.shtml [Accessed February
2015].
5. Ecological Model. Healthy Campus 2020. American College Health
Association: Hanover, MD; 2015 [Available at]
https://www.acha.org/HealthyCampus/Implement/Ecological_Model/HealthyCampus/
hkey=f5defc87-662e-4373-8402-baf78d569c78 [Accessed September 2015].
6. Social and Behavioral Theories (Chapter in eSource). [Washington, DC:
Department of Health and Human Services, Office of Behavioral & Social
Sciences Research; n.d.; Available at]
http://www.esourceresearch.org/eSourceBook/SocialandBehavioralTheories/4Impor
[Accessed September 2015].
7. Glanz K, Rimer BK, Viswanath K. The Scope of Health Behavior and
Health Education (Ch 1). Glanz K, Rimer BK, Viswanath K. Health
Behavior and Health Education: Theory, Research, and Practice. 4th ed.
Jossey-Bass: San Francisco, CA; 2008 [Available at]
http://www.med.upenn.edu/hbhe4/part1-ch2.shtml [Accessed February
2015].
8. Prochaska JO, Redding CA, Evers KE. The Transtheoretical Model and
Stages of Change (Ch. 5). Glanz K, Rimer BK, Viswanath K. Health
Behavior and Health Education: Theory, Research, and Practice. 4th ed.
Jossey-Bass: San Fransisco, CA; 2008 [Available at]
http://www.med.upenn.edu/hbhe4/part2-ch5.shtml [Accessed February
2015].
9. The Health Belief Model. Boston University School of Public Health; 2013
[Available at] http://sphweb.bumc.bu.edu/otlt/MPH-Modules/SB/SB721-
Models/SB721-Models2.html [Accessed February 2015].
10. McAlister AL, Perry CL, Parcel GS. How Individuals, Environments, and
Health Behaviors Interact: Social Cognitive Theory (Ch. 8). Glanz K, Rimer
BK, Viswanath K. Health Behavior and Health Education: Theory,
Research, and Practice. 4th ed. Jossey-Bass: San Fransisco, CA; 2008
[Available at] http://www.med.upenn.edu/hbhe4/part3-ch8.shtml [Accessed
February 2015].
11. Fawcett SB. Some Lessons Learned on Community Organization and Change.
Section 8 in Our Model for Community Change and Improvement.
Community Tool Box; 2014 [Available at] http://ctb.ku.edu/en/table-of-
contents/overview/model-for-community-change-and-
improvement/lessons-learned/main [Accessed February 2015].
12. Diffusion of Innovations Theory. Boston University School of Public
Health; 2013 [Available at] http://sphweb.bumc.bu.edu/otlt/MPH-
Modules/SB/SB721-Models/SB721-Models2.html [Accessed February
2015].
13. Butterfoss FD, Kegler MC, Francisco VT. Mobilizing Organizations for
Health Promotion: Theories of Organizational Change (Ch. 15). Glanz K,
Rimer BK, Viswanath K. Health Behavior and Health Education: Theory,
Research, and Practice. 4th ed. Jossey-Bass: San Fransisco, CA; 2008
[Available at] http://www.med.upenn.edu/hbhe4/part4-ch15.shtml [Accessed
February 2015].
14. Healthy People 2020. Health Communication and Health Information
Technology. [Available at] http://www.healthypeople.gov/2020/topics-
objectives/topic/health-communication-and-health-information-technology
[Accessed January 2015].
15. What is Health Communications? Centers for Disease and Control: Atlanta,
GA; 2011 [Available at]
http://www.cdc.gov/healthcommunication/healthbasics/whatishc.html
[Accessed January 2015].
16. Social Marketing. Centers for Disease Control and Prevention: Atlanta, GA;
2013 [Available at] http://www.cdc.gov/breastfeeding/pdf/strategy8-social-
marketing.pdf [Accessed February 2015].
17. Gallagher KM, Updegraff JA. Health message framing effects on attitudes,
intentions, and behavior: a meta-analytic review. Ann Behav Med.
2012;43(1):101; 10.1007/s12160-011-9308-7.
18. Mudd-Martin G, Martinez MC, Rayens MK, et al. Sociocultural tailoring of
a healthy lifestyle intervention to reduce cardiovascular disease and Type 2
diabetes risk among Latinos. Prev Chronic Dis. 2013;10:130137 [Available
at]
http://dx.doi.org/10.5888/pcd10.130137 http://www.cdc.gov/pcd/issues/2013/13_0137.
[Accessed February 2015; doi].
19. Savage MW, Scott AM, Aalboe JA, et al. Perceptions of oral health in
Appalachian Kentucky: Implications for message design. Health Commun.
2015;30(2):186; 10.1080/10410236.2014.974127.
20. Gateway to Health Communication & Social Marketing Practice. Centers for
Disease Control and Prevention: Atlanta, GA; 2011 [Available at]
http://www.cdc.gov/healthcommunication/index.html [Accessed January
2015].
21. Health Literacy. Centers for Disease Control and Prevention: Atlanta, GA;
2014 [Available at] http://www.cdc.gov/healthliteracy/learn/ [Accessed
February 2015].
22. Institute of Medicine of the National Academies. Oral Health Literacy
Workshop Summary. The National Academies Press: Washington, DC; 2013
[Available at] http://www.nap.edu/openbook.php?record_id=13484
[Accessed January 2015].
23. The Health Literacy of America's Adults: Results from the 2003 National
Assessment of Adult Literacy. NCES 2006483. U.S. Department of
Education, Institute of Education Sciences, National Center for Education
Statistics: Washington, DC; 2006 [Available at]
http://nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2006483 [Accessed
January 2015].
24. Federal Plain Language Guidelines. PlainLanguage.gov. Improving
Communication from the Federal Government to the Public; 2011
[Available at]
http://www.plainlanguage.gov/howto/guidelines/FederalPLGuidelines/FederalPLGuid
[Accessed February 2015].
25. Nápoles AM, Santoyo-Olsson J, Stewart AL. Methods for translating
evidence-based behavioral interventions for health-disparity communities.
Prev Chronic Dis. 2013;10:130133–
doi http://dx.doi.org/10.5888/pcd10.130133.
26. Berkman ND, Sheridan SL, Donahue KE, et al. Health Literacy Interventions
and Outcomes: An Updated Systematic Review. Evidence Report/Technology
Assessment No. 199. Prepared by RTI International–University of North
Carolina Evidence-Based Practice Center under contract No. 290-2007-
10056-I. AHRQ Publication Number 11-E006. Agency for Healthcare
Research and Quality: Rockville, MD; 2011 [Available at]
http://archive.ahrq.gov/research/findings/evidence-based-
reports/literacyup-evidence-report.pdf [Accessed February 2015].
27. Health Literacy for Public Health Professionals. Centers for Disease Control
and Prevention: Atlanta GA; 2014 [Available at]
http://www.cdc.gov/healthliteracy/training/ [Accessed February 2015].
Additional Resources
American Evaluation Association. Guidelines for Roundtable Presentations.
Available at www.eval.org/p/cm/ld/fid=171.
Glanz K, Rimer BK. Theory at a Glance: A Guide for Health Promotion Practice.
2nd ed. Bethesda, MD: National Institutes of Health, National Cancer Institute;
2005. Available at www.sneb.org/2014/Theory%20at%20a%20Glance.pdf.
Public Health Ontario. Partners for Health. At a Glance: The Six Steps to Planning a
Health Promotion Program. Available at
http://www.publichealthontario.ca/en/eRepository/Six_steps_planning_health_promotion_pr
Public Health Ontario. Partners for Health. At a Glance: The Twelve Steps to
Developing a Health Communication Strategy. Available at
http://www.publichealthontario.ca/en/eRepository/Twelve_steps_developing_health_commu
Public Health Ontario. Partners for Health. At a Glance: The Eight Steps to
Developing a Health Promotion Policy. Available at
http://www.publichealthontario.ca/en/eRepository/Eight_steps_to_policy_development_2012
Public Health Ontario. Partners for Health. At a Glance: The Ten Steps for
Conducting an Evaluation. Available at
http://www.publichealthontario.ca/en/eRepository/At_A_Glance_Evaluation_2015.pdf
Centers for Disease Control and Prevention.
OBJECTIVES
1. Discuss why healthcare systems are in crisis domestically and globally.
2. Discuss the concepts of social responsibility and professional ethics and how
they relate.
3. Discuss the various opinions surrounding healthcare access as a right or a
privilege.
4. Discuss the government's role in healthcare delivery in the United States (U.S.).
5. Discuss your professional responsibility in relation to policy development,
access to care issues, workforce, and patient responsibility for health actions.
6. Facilitate patient confidentiality and patient responsibility in accordance with
applicable legislation, methods of communication, and ethical codes.
7. Identify the roles of governmental organizations, nongovernmental
organizations, and healthcare professionals as they operate within a community in
relation to policy development and advocacy to strengthen the oral healthcare
delivery system.
8. Discuss the functionality of an interprofessional oral health workforce model.
9. Collaborate in a leadership role with community partners and
interprofessionally to achieve health promotion goals for individuals and
communities.
10. Describe the responsible use of social media to effectively communicate risk
to patients, families, communities, society, and peers.
11. Describe oral health professionals' responsibility relative to domestic
violence.
Opening Statements: Status and Future of
Health Care
• The healthcare system in the U.S. is in crisis.
• The public health system in the U.S. is fragmented and insufficient.
• Oral health is a component of overall health, and access to all healthcare services
should be considered to promote the general welfare of society.
• Human rights should be the foundation of public health practice, research, and
policy.
• Leadership involves social and civic responsibility, professionalism, and ethical
communication.
• Comprehensive oral health benefits for adults have been excluded in the Patient
Protection and Accountable Care Act (ACA)
A System in Crisis
The Preamble of The Constitution of the United States of America explains that part
of the reason for creating the Constitution was to “promote the general Welfare.”1
Society faces a crisis of enormous inequality in the distribution of health and oral
healthcare services despite societal goals, poverty initiatives, and viable common-
ground solutions. It is apparent also that the healthcare crisis has been recognized,
reported, discussed, and debated for more than 50 years. The 2000 Surgeon
General's Report on Oral Health specifically quantified the disparities in oral health
status among underserved populations and the barriers many people face in
obtaining care.2 The limited capacity of the health professions, including private-
and public-delivery systems, and national and state governments, coupled with
public apathy and a general lack of social responsibility on the part of society as a
whole, have contributed to the failure of making health care accessible to everyone.
In one form or another, health reforms have been recommended for several decades
with little success, and, in most cases, oral healthcare services have been curiously
excluded until 2010 with the passage of the Patient Protection and Affordable
Care Act (ACA).
Poverty at various levels impacts access to each citizen's fundamental right to
health care. Although there is no universal definition of poverty, the World Health
Organization (WHO) recognizes the crisis of poverty and health: “Poverty is
associated with the undermining of a range of key human attributes, including
health. More than one thousand million of the world's people have been excluded
from the benefits of economic development and the advances in human health
technology.”3 The poor are exposed to more health risks, and illness can reduce
productivity, thus perpetuating or increasing poverty. In general, the worse an
individual's socioeconomic status is, the worse their health is. Poverty is an
increasing problem in the U.S. In 2013, the number of Americans living below the
national poverty level was 45.3 million people (14.5%), a slight but insignificant
decrease from the year before and the first decrease since 2006. Of greater
significance is the poverty rate of children under age 18. In 2013, 19.9% of children
were living in poverty, also a slight decrease from the year before.4
The passage of the ACA in 2010 (Figure 9-1) decreased the number of uninsured
Americans from 18% in 2013 to 13.4% in 20145; yet for many segments of our
population barriers to health and oral health care still exist. If society accepts the
responsibility to care for the welfare of others, then that society should expect its
government to establish social justice. Furthermore, a government that expects
equality and fairness among citizens has a responsibility for the health of its citizens
through adequate health and social initiatives. What should be our social
responsibility as concerned citizens and ethical oral healthcare professionals? It is
imperative to have licensed dental hygienists included in social justice initiatives
that address the general and oral health crisis in America.
FIG 9-1 President Obama signing the Affordable Care Act on March 23,
2010. (Source: Pete Souza / Wikimedia Commons / Public Domain.)
Social Responsibility and Professional
Ethics
Social Responsibility
Frequently, dental hygiene students ask questions about the social responsibilities of
dental hygienists (see Guiding Principles). Certainly, the responsibilities of the
dental hygienist include all of these and more, as will be discussed in this chapter.
G ui di ng Pri nci pl es
Questions in Relation to the Social Responsibilities of Licensed
Dental Hygienists
• What are the hygienist's social responsibilities to the profession of dental hygiene,
to all patients, and to society as a whole?
Social responsibility is a broad term meaning that people and organizations are
expected to behave ethically and with sensitivity toward social, cultural, economic,
and environmental issues. Striving for social responsibility helps individuals,
organizations, and governments have a positive impact on development, business,
and society. Social responsibilities include the concepts of a person's right to health
care, the profession's obligation to raise the oral health literacy of the community,
and government's responsibility to promote the health and well-being of the public.
Professional Ethics
A term often equated with social responsibility is ethics, commonly defined as the
general study of right and wrong conduct. The professional, by the very nature of
being a professional, has made and continues to make an ethical commitment to
address the oral health needs of society. If individuals' oral health needs are not
being met because the system stands in the way, then correcting that system is part of
the ethical responsibility of society and the dental and dental hygiene professions.
Professional ethics is the code by which the profession regulates actions and sets
standards for its members, with the recognition that professionals are accountable
for their actions. This code serves as a guide to the profession to ensure a high
standard of competency, to strengthen the relationships among its members, and to
promote the welfare of the entire community. By virtue of extensive education,
written and clinical board examinations, and subsequent state licensure, the
profession of dental hygiene and its individual members are required to make
choices in practice that necessitate ethical decision making.
The Code of Ethics for Dental Hygienists adopted by the American Dental
Hygienists' Association (ADHA) provides this guidance for the dental hygiene
profession. The Code of Ethics and Standards of Professional Conduct also adopted
by the ADHA provide guidance for oral health professionals through seven basic
values6 (Box 9-1).
ox 9-1
B
Seven Basi c Val ues of the Dental H y g i ene
Professi on
Individual Autonomy and Respect for Human Beings
• We acknowledge that people have the right to be treated with respect, the right to
informed consent before treatment, and the right to full disclosure of all relevant
information so they can make informed choices about their own care.
Confidentiality
• We respect the confidentiality of client information and relationships as a
demonstration of the value we place on individual autonomy; we acknowledge
our obligation to justify any violation of a confidence.
Societal Trust
• We value client trust and understand that public trust in our profession is based on
our actions and behavior.
Nonmaleficence
• We accept our fundamental obligation to provide services in a manner that protects
all clients and minimizes harm to them and others involved in their treatment.
Beneficence
• We have a primary role in promoting the well-being of individuals and the public
by engaging in health promotion and disease prevention activities.
Veracity
• We accept our obligation to tell the truth and expect that others will do the same;
we value self-knowledge and seek truth and honesty in all relationships.
Data from Code of Ethics for Dental Hygienists. Chicago, IL: American Dental Hygienists' Association; 2014.
Available at http://www.adha.org/resources-docs/7611_Bylaws_and_Code_of_Ethics.pdf. Accessed February
2015.
G ui di ng Pri nci pl es
Questions about Dental Hygiene's Responsibility to Address Access
to Oral Health Care
• What is the responsibility of the dental hygienist to the broader group of public or
society, which includes the following: people without access to oral healthcare
services, culturally diverse populations, and individuals with special healthcare
needs?
• Do individuals have a right to receive quality oral health care at a cost they can
afford?
The American Dental Association has estimated that approximately 33% of the
U.S. population has difficulty accessing dental services through the current private
dental care delivery system.10 The Centers for Disease Control and Prevention
(CDC) reports that in 2012 the percentage of individuals with a dental visit varied by
age: 82.3% of children ages 2 to 17, 61.6% of adults ages 18 to 64, and 61.8% of
adults ages 65 and older.11 The difference in utilization for the various age groups is
significant in light of the fact that historically, children have had access to dental
insurance through Medicaid, although the other age groups have not.
Our current healthcare delivery system is fragmented between an individually
funded private system and a government-mandated and funded model of healthcare
delivery even since the passage of the ACA in 2010. This combination of private and
public forces is referred to as pluralistic. For the majority of the U.S. population
(70%), health care is still provided through a complex system of various health
insurance funding systems.8 Although the ACA has significantly increased the
availability of oral health care for low-income children through the expansion of
Medicaid, adults and older adults continue to have more limited access to dental
insurance.12
FIG 9-3 The iron triangle of health care. (Adapted from Breaking the Iron Triangle of
Healthcare. mHealthology. Available at http://mhealthology.org/category/articles/. Accessed April
2015.)
The U.S. government plays an important role in healthcare delivery; however, the
U.S. healthcare system is not a true system because of its fragmentation and lack of a
centralized decision-making body. Three governmental levels participate in the U.S.
healthcare system: federal, state, and local. The federal government provides a
range of regulatory and funding mechanisms including Medicare and Medicaid,
established in 1965 as funded programs to provide health access to the elderly, the
poor, and the disabled. The federal government determines a national healthcare
budget, sets reimbursement rates, and formulates standards for providers of eligible
Medicare and Medicaid patients. The individual states are responsible for regulatory
and funding mechanisms and provide healthcare programs as dictated and funded by
the federal government. The local level is responsible for implementing programs
dictated by both federal and state levels and providing health care for their
municipal employees.
Under the ACA, as of 2014 Medicaid coverage was expanded to nearly all adults
with incomes at or below 138% of the national poverty level in states that decided to
expand coverage, with tax credits for individuals who purchased coverage through
a Health Insurance Marketplace. Baseline estimates show that over 41 million
individuals were uninsured in 2013 before the start of the major ACA coverage
provisions, and early evidence suggests that the ACA has reduced this number. Early
data suggest that the ACA has helped to expand coverage of Medicaid to millions of
previously uninsured individuals and has decreased the uninsured rate by a full
percentage point. As of mid-April 2014 more than eight million people selected
plans through the federal or state marketplaces, and Medicaid enrollment grew by
eight million in the states that expanded Medicaid.8 On the other hand, some poor
adults, particularly in states that have not expanded Medicaid, are still left without
affordable insurance.
Policy Development
One of the professional roles of a dental hygienist is to be an advocate (see Chapter
2) for health policy initiatives that would improve the inequalities of the current oral
health delivery of care model, which will require procedural standards. As one of
the core functions of public health, policy development is often intertwined with the
social responsibility of promoting oral health initiatives. To be successful all policy
initiatives should involve collaborative efforts between partners and stakeholders,
including professionals, community leaders, coalitions, and the public: “Effective
policies can be leading drivers of change within a healthcare delivery system.
Policies can cut across culture, generation, and economic barriers. The future of
oral health will depend on effective policies that enhance access to care, help the
oral health workforce to become more efficient, and heighten the value system of
the communities served.”20
Understanding the policymaking process is crucial to serving the needs of the
public. Policy is used to connect the results of community assessment to assuring
that the oral health needs of the public are addressed. Thus the three core functions
of public health (assessment, assurance, and policy development; see Chapter 1)
function synergistically to generate the whole of public health practice.
The dental hygienist's social or civic responsibility includes knowing his or her
individual state and congressional legislators. This establishment of political
advocacy relationships is beneficial for educating and influencing legislators who
will be voting on bills that may impact oral health initiatives and the scope of
practice, supervision, and direct reimbursement for members of the dental hygiene
profession. In the role of political advocate the dental hygienist thereby influences
the oral health status of the public and society by improving access to oral health
care. Involvement in advocacy at the state level in this manner frequently involves
lobbying, which may be done through a professional organization or coalition.
Understanding the legislative process (Figure 9-4) by which an idea becomes a bill
and ultimately a law is important when involved in lobbying for passage of a state
statute.
FIG 9-4 How a bill becomes a law at the state level.
This responsibility is not just at the state level; a similar process occurs at the
federal and local levels. The same legislative process occurs at the federal level,
culminating in signing by the President. Also, dental hygienists are called on
frequently to fulfill their social responsibility by being involved in oral health
issues, program development, and policy development to impact the people in their
local communities. Regardless of the level of policy desired the order of
procedures to develop policy is nearly identical (Box 9-2).
ox 9-2
B
Order of Procedures for Pol i cy Devel opment
• Develop personal and professional relationships with policymakers and decision
makers
• Share data with partner and identify possible strategies and solutions
• In a succinct and clear manner, share data and desired solutions with policymakers
• Thank the policymaker, regardless of the outcome, and continue to maintain the
relationship for future efforts
G ui di ng Pri nci pl es
What It Will Take to Strengthen the Oral Healthcare Delivery
System
• Focus oral health care on prevention and wellness for individuals, families, and
communities
Chapter 1 highlights many other recent strides made by the oral health
professions to strengthen the current oral health delivery systems. The dental
hygiene profession has been a major player in these efforts (see Chapters 1 and 2).
Progress has been made over the past decade in regards to increasing the utilization
of dental services, especially among poor and near-poor children. In addition, there
has been headway in reducing the rich-poor gap in dental utilization and access to
care for children, and the annual percent of children who have visited the dentist has
increased.31
G ui di ng Pri nci pl es
The Use of Social Media for Healthcare Communication
• More than 40% of health consumers have used social media to access health-
related consumer reviews; for example, reviews of treatments or providers.40
• More than half of patients are very comfortable with their providers seeking
advice from online communities to better treat their conditions.41
• As many as 60% of physicians feel that social media improves the quality of care
they provide to their patients.41
Healthy People 2020 has identified goals concerning the use of information
technology, the Internet, and mobile access to improve health communication.42 In
addition, the value of greater use of social media by oral health professionals has
been suggested.43 By using technologies efficiently and securely, oral health
professionals can reinforce the oral healthcare provider/patient partnership in both
face-to-face and virtual associations. As online technologies expand and change,
oral health professionals can take the lead in remaining at the forefront of
technologic innovation for patient-centered oral health care.44
Inherent in the increase of interprofessional and social media information
sharing is an increased professional responsibility for oral health risk
communication. Successful health risk communication raises the level of people's
understanding of relevant issues and ensures that those involved are adequately
informed within the limits of available knowledge.45 Not only are risks dependent
on the context in which they are presented, but they also are intertwined with
personal values. Attitudes about certain risks are often influenced by factors other
than just what the data tell us. For example, people's attitudes are influenced by what
they believe about society, their relationship with nature, the benefits and
disadvantages of technology, cultural influences, occasionally religious beliefs, and
others' stories.46 Thus, understanding a message regarding health risk is not the
same as knowledge and does not necessarily translate into action; people may
understand a message perfectly but still maintain their own opinions, which will
influence their actions.
Sometimes health risk communication is in relation to topics about which patients
or communities have misinformation and incorrect perceptions. For example, a
segment of the general public perceives inherent risks in radiographs, amalgam
restorations, biofilms in dental unit water lines, instrument sterilization techniques,
transmission of disease (e.g., human immunodeficiency virus [HIV] infection and
hepatitis) in dental offices, and fluoridation of community water supplies. It is the
oral health professional's responsibility to be knowledgeable about current
evidence-based research regarding such issues, as well as the publicized
misinformation. Additionally, the oral health professional has a responsibility to
communicate risk in relation to issues such as these.45 Health communication is used
for this purpose and to communicate the risks associated with individuals' oral
health behaviors and treatment decisions (Figure 9-6).
FIG 9-6 An oral health professional talks to a patient about the risks associated
with dental radiographs. (© iStock.com.)
ox 9-3
B
Si g ns and Sy mptoms of Domesti c Vi ol ence
• Bruises, scrapes, cuts, or fractures, particularly around the head and neck, but may
be on extremities as well
• Cigarette burns, bite marks, rope burns, or welts with the outline of a recognizable
weapon, such as a belt buckle
Reporting of child abuse is a legal requirement in all states and oral health
professionals have an ethical responsibility to intervene with adult and older adult
victims as well.53 It is the ethical and professional responsibility of dental hygienists
to know the legal requirements in the community, the agency to call to report
documented information, and the steps to take to ensure safety for themselves and
the patient. It is imperative that oral health professionals be clinically educated,
prepared, and responsible to understand the magnitude of the various forms of
domestic violence. They need to have the knowledge and skills required to (1)
identify patients who have experienced domestic violence by doing a complete
patient assessment, (2) carefully document findings, and (3) intervene with valuable
resources.53
Accessing specific screening tools will assist the oral health professional in
responding to the needs of patients who have experienced domestic violence.
RADAR summarizes action steps that health professionals can take to identify cases
of domestic violence and assist patients in getting the professional help and
community support they need.50 The RADAR system presented in Box 9-4 has been
adapted to the role of the dental hygienist in patient care. Prevent Abuse and Neglect
through Dental Awareness (PANDA) programs provide training to oral health
professionals on the recognition and reporting of suspected cases of domestic
violence, including child abuse and dental neglect.53
ox 9-4
B
RA DA R
Action Steps For Recognizing and Assisting Patients Who Have
Experienced Domestic Violence
Document findings
3. Research the legislative agenda of your state dental hygiene association. Develop
a plan to advocate for an issue that is part of the agenda, and present it in class.
Core Competencies
C.1
Apply a professional code of ethics in all endeavors.
C.8
Promote the values of the dental hygiene profession through service-based
activities, positive community affiliations, and active involvement in local
organizations.
C.10
Communicate effectively with diverse individuals and groups, serving all persons
without discrimination by acknowledging and appreciating diversity.
Community Involvement
CM.4
Facilitate patient access to oral health services by influencing individuals or
organizations for the provision of oral health care.
CM.7
Advocate for effective oral health care for underserved populations.
Community Case
Umbrella Health (UH) is a for-profit organization whose mission it is to reduce
dental caries in school-aged children, especially children whose families are at a
low socioeconomic (SES) level. With the goal of increasing oral healthcare access
and utilization via a school-based program, UH is interested in piloting a project to
provide comprehensive preventive and primary oral health care to low SES
children within the elementary school environment. They anticipate that the
program will prove to be sustainable and continue long term. A team of dental
hygienists will provide oral healthcare services utilizing mobile equipment. The
efficiency of the program will be increased by using teledentistry communication
between the dental hygienists and the collaborating dentist hired specifically for the
program, for remote consultation, diagnosis, and referral for follow-up dental
treatment. The company has approached the school district administrators for
approval of a pilot project in your area. Additionally, UH has asked the local and
state dental hygiene associations for their support of this innovative initiative. As
president of your local dental hygiene society, you have been asked by UH to
advocate for the program.
1. What is the first action you should take relative to your social and professional
responsibility as a licensed dental hygienist to ensure that this organization is
credible?
a. Research the UH organization's mission, vision, credentials, and financials.
b. Meet with the UH stakeholders to discuss the program.
c. Contact UH patients about their satisfaction with oral health services provided
by the organization.
d. Speak with dental hygienists who you know through the dental hygiene society
and who have previously worked for UH.
2. If the decision of the local dental hygiene society is to support the UH pilot
project, what would be your first action as president in promoting the proposed
oral health initiative?
a. Seek federal grant assistance for the pilot project.
b. Meet with school administrators and teachers to explain the program and offer
assistance in educating parents about this oral health initiative.
c. Investigate the state statute concerning a licensed dental hygienist providing
oral healthcare services in a school-based program.
d. Meet with your executive board members of the local dental hygiene society
for feedback and support.
3. What professional role is represented by your involvement and participation as a
representative of your local dental hygiene society in this initiative?
a. Clinician
b. Public health advocate
c. Researcher
d. Administrator/manager
4. You sense public reluctance to support this project because it takes valuable
student-teacher contact time away from the students. How do you respond to the
parents' query, “So why provide dental treatment during school time?”
a. Share evidence-based research results that 50 million hours of school time are
lost annually because of dental disease and that school performance is
positively correlated to oral health.
b. Inform parents that they can choose not to allow their children to participate if
they are concerned about the issue of student-teacher contact time.
c. Take a vote of parents to determine the level of parental support for the
program.
d. Ignore the parents' concern for now because the decision to move forward with
the program should be made by the school administration, not the parents.
5. Which of the following strategies to promote the program would be LEAST
effective?
a. Develop a flyer describing the problem, the program, and the rationale for the
program.
b. Plan multiple information sessions in the schools, allowing time for questions
and answers.
c. Set up a booth at a school district-wide health fair with information on the
program.
d. Create a blog for parents to ask questions and discuss the value of the program.
References
1. U.S. Constitution Preamble. Cornell University Law School, Legal
Information Institute. [Available at]
https://www.law.cornell.edu/constitution/preamble [Accessed February
2015].
2. U.S. Department of Health and Human Services. Oral Health in America: A
Report of the Surgeon General. U.S. Department of Health and Human
Services, National Institute of Dental and Craniofacial Research, National
Institutes of Health: Rockville, MD; 2000 [Available at]
http://silk.nih.gov/public/hck1ocv.@www.surgeon.fullrpt.pdf [Accessed
February 2015].
3. Poverty. [Geneva: World Health Organization; Available at]
http://www.who.int/topics/poverty/en/ [Accessed February 2015].
4. DeNavas-Walt C, Proctor BD. Income and Poverty in the United States:
2013. U.S. Census Bureau: Suitland, MD; 2014 [Available at]
https://www.census.gov/content/dam/Census/library/publications/2014/demo/p60-
249.pdf [Accessed February 2015].
5. Blumenthal D, Collins SR. Healthcare coverage under the Affordable Care
Act—A progress report. N Engl J Med. 2014;371:275
[10.1056/NEJMhpr1405667; Available at]
http://www.nejm.org/doi/full/10.1056/NEJMhpr1405667 [Accessed
February 2015].
6. Code of Ethics for Dental Hygienists. American Dental Hygienists'
Association: Chicago, IL; 2014 [Available at]
http://www.adha.org/resources-
docs/7611_Bylaws_and_Code_of_Ethics.pdf [Accessed February 2015].
7. Concepts and Philosophies. [Center for Ethical Leadership; Available at]
http://www.ethicalleadership.org/concepts-and-philosophies.html
[Accessed February 2015].
8. Key Facts about the Uninsured Population. The Kaiser Commission on
Medicaid and the Uninsured; 2014 [Available at]
http://files.kff.org/attachment/key-facts-about-the-uninsured-population-
fact-sheet [Accessed February 2015].
9. Cummings EE. Today's call to action. Summary of the Sixth Leadership
Colloquium: Strengthening the Dental Care Delivery System:7–8. U.S.
National Oral Health Alliance: Washington, DC; 2013 [Available at]
http://www.usalliancefororalhealth.org/sites/default/files/static/Summary%20of%20th
[Accessed February 2015].
10. Access to Care. [American Dental Association; Available at]
http://www.ada.org/en/public-programs/action-for-dental-health/access-to-
care [Accessed February 2015].
11. Oral and Dental Health: Health Care Use. FastStats. Centers for Disease
Control and Prevention: Atlanta, GA; 2012 [Available at]
http://www.cdc.gov/nchs/fastats/dental.htm [Accessed February 2015].
12. Nasseh K, Vujicic M, O'Dell A. Affordable Care Act Expands Dental Benefits
for Children but Does Not Address Critical Access to Dental Care Issues.
American Dental Association Health Policy Institute: Chicago, IL; 2013
[Available at]
http://www.ada.org/sections/professionalResources/pdfs/HPRCBrief_0413_3.pdf
[Accessed January 2015].
13. Graham PA. Community and Class in American Education, 1865-1918. John
Wiley & Sons Canada Ltd.: Etobicoke, Ontario; 1974.
14. ADEA Position Paper: Statement on the Roles and Responsibilities of
Academic Dental Institutions in Improving the Oral Health Status of All
Americans. J Dent Educ. 2004;75:988.
15. Preamble to the Constitution of the World Health Organization. [Adopted by
the International Health Conference, New York; entered into force April
1948. Geneva: World Health Organization; Available at]
http://www.who.int/about/definition/en/print.html; June 1946 [Accessed
February 2015].
16. The Universal Declaration of Human Rights, Article 25. [United Nations;
Available at] http://www.un.org/en/documents/udhr/; 1948 [Accessed
February 2015].
17. Health. In Health Systems Strengthening Glossary. [Geneva: World Health
Organization; Available at]
http://www.who.int/healthsystems/hss_glossary/en/index5.html [Accessed
February 2015].
18. Comprehensive Health Planning and Public Health Services Amendments of
1966, Public Law 89-749. [Washington, DC: U.S. Congress; Available at]
http://www.gpo.gov/fdsys/pkg/STATUTE-80/pdf/STATUTE-80-Pg1180.pdf
[Accessed February 2015].
19. Carroll A. JAMA Forum—The “Iron Triangle” of Health Care: Access, Cost,
and Quality. [News@JAMA; Available at]
http://newsatjama.jama.com/2012/10/03/jama-forum-the-iron-triangle-of-
health-care-access-cost-and-quality/; 2012, Oct 3 [Accessed April 2015].
20. Summary of the Sixth Leadership Colloquium: Strengthening the Dental
Care Delivery System. U.S. National Oral Health Alliance: Washington, DC;
2013 [Available at]
http://www.usalliancefororalhealth.org/sites/default/files/static/Summary%20of%20th
[Accessed February 2015].
21. Schroeder SA. We can do better—Improving the health of the American
people (Shattuck Lecture). N Engl J Med. 2007;357:1221.
22. Mokdad AH, Marks JS, Stroup JS, et al. Actual causes of death in the United
States, 2000. JAMA. 2004;291:1238 [Erratum, JAMA 2005;293.].
23. Johnson NB, Hayes LD, Brown K, et al. CDC national health report: Leading
causes of morbidity and mortality and associated behavioral risk and
protective factors—United States, 2005–2013. MMWR. 2014;63(04):3
[Available at]
http://www.cdc.gov/mmwr/preview/mmwrhtml/su6304a2.htm [Accessed
February 2015].
24. Health Equity. Centers for Disease Control and Prevention, National Center
for Chronic Disease Prevention and Health Promotion: Atlanta, GA; 2013
[Available from] http://www.cdc.gov/chronicdisease/healthequity/
[Accessed February 2015].
25. Understanding Health Information Privacy. [Department of Health and
Human Services; Available at]
http://www.hhs.gov/ocr/privacy/hipaa/understanding/ [Accessed February
2015].
26. Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic
health records. N Engl J Med. 2010;363:501; 10.1056/NEJMp1006114
[Available at] http://www.nejm.org/doi/full/10.1056/nejmp1006114
[Accessed February 2015].
27. Healthy People 2020. Department of Health and Human Services, Office of
Disease Prevention and Health Promotion: Rockville, MD; 2015 [Available
at] http://www.healthypeople.gov/ [Accessed February 2015].
28. Access. In Health Systems Strengthening Glossary. [Geneva: World Health
Organization; Available at]
http://www.who.int/healthsystems/hss_glossary/en/ [Accessed February
2015].
29. Institute of Medicine, National Research Council. Improving Access to Oral
Health Care for Vulnerable and Underserved Populations. National
Academies Press: Washington, DC; 2011 [Available at]
http://iom.edu/Reports/2011/Improving-Access-to-Oral-Health-Care-for-
Vulnerable-and-Underserved-Populations.aspx [Accessed January 2015].
30. Booth M, Reusch C, Touschner J. Pediatric Dental Benefits under the ACA:
Issues for State Advocates to Consider. Georgetown University Health
Policy Institute, Center for Children and Families: Washington, DC; 2012
[Available at] http://ccf.georgetown.edu/wp-
content/uploads/2012/09/Pediatric-Dental-Benefits.pdf [Accessed February
2015].
31. Vujicic M. Moving Towards Fundamental Structural Change in the Dental
Care Sector. Summary of the Sixth Leadership Colloquium: Strengthening
the Dental Care Delivery System:43–44. U.S. National Oral Health Alliance:
Washington, DC; 2013 [Available at]
http://www.usalliancefororalhealth.org/sites/default/files/static/Summary%20of%20th
[Accessed February 2015].
32. Valachovic RW. 2013 ADEA President's Report: Looking around the Corner.
[Available at]
http://www.adea.org/about_adea/2013_ADEA_President_s_Report__Looking_Around
[Accessed February 2015].
33. Emerging Medicaid Accountable Care Organizations: The Role of Managed
Care. The Henry J. Kaiser Family Foundation; 2012 [Retrieved at]
http://kff.org/health-costs/issue-brief/emerging-medicaid-accountable-
care-organizations-the-role/ [Accessed February 2015].
34. Brownlee B. Oral Health Integration in the Patient-Centered Medical Home
(PCMH) Environment: Case Studies from Community Health Centers.
Qualis Health: Seattle, WA; 2012 [Available at]
http://dentaquestfoundation.org/sites/default/files/resources/Oral%20Health%20Integ
Centered%20Medical%20Home,%202012.pdf [Accessed February 2015].
35. Glassman P, Harrington M, Namakian M. The Virtual Dental Home:
Improving the Oral Health of Vulnerable and Underserved Populations
Using Geographically Distributed Telehealth-Enabled Teams. University of
the Pacific, Arthur A. Dugoni School of Dentistry, Pacific Center for
Special Care; 2013 [Available at]
http://dental.pacific.edu/Documents/community/special_care/acrobat/VirtualDentalHo
[Accessed February 2015].
36. Rethman J. Your year of self-mentorship. Dimen Dent Hyg. 2015;13(1):10
[Available at]
http://www.dimensionsofdentalhygiene.com/2015/01_january/Departments/Editors_N
[Accessed February 2015].
37. U.S. Department of Health and Human Services, Health Resources and
Services Administration. Transforming Dental Hygiene Education, Proud
Past, Unlimited Future: Proceedings of a Symposium. U.S. Department of
Health and Human Services: Washington, DC; 2014 [Available at]
http://www.hrsa.gov/publichealth/clinical/oralhealth/transformingdentalhygiene.pdf
[Accessed January 28, 2015].
38. Community Learning Exchange. [Center for Ethical Leadership; Available at]
http://www.ethicalleadership.org/community-learning-exchange.html
[Accessed February 2015].
39. Expert Panel on Cultural Competence Education for Students in Medicine
and Public Health. Cultural Competence Education for Students in Medicine
and Public Health: Report of an Expert Panel. Association of American
Medical Colleges and Association of Schools of Public Health:
Washington, DC; 2012 [Available at]
https://members.aamc.org/eweb/upload/Cultural%20Competence%20Education_revis
[Accessed February 2015].
40. PwC Report on the Impact of Social Media in Healthcare. Hitech Answers,
Social Media “Likes” Healthcare (blog post). [Available at]
http://www.hitechanswers.net/social-media-likes-healthcare/; 2012
[Accessed February 2015].
41. Honigman B. 24 Outstanding Statistics & Figures on How Social Media Has
Impacted the Health Care Industry. Referral MD (blog). [Available at]
https://getreferralmd.com/2013/09/healthcare-social-media-statistics/
[Accessed April 2015].
42. Health Communication and Health Information Technology (Overview of
Topic Area). Healthy People 2020. [Rockville, MD: Department of Health
and Human Services, Office of Disease Prevention and Health Promotion;
Available at] https://www.healthypeople.gov/2020/topics-
objectives/topic/health-communication-and-health-information-technology
[Accessed April 2015].
43. Dunlop D. Demystifying Social Media & Making It Relevant to Dentistry.
Jennings Healthcare Marketing (presentation at University of North
Carolina School of Dentistry). [Available at]
http://www.slideshare.net/dandunlop/social-media-and-the-dental-practice;
2012 [Accessed April 2015].
44. Lemaster M, Bobadilla H. Oral health goes high tech: Social media can aid
clinical efforts by helping patients comply with treatment regimens. Dimens
Dent Hyg. 2015;11(1):66 [Available at]
http://www.dimensionsofdentalhygiene.com/print.aspx?id=20245 [Accessed
February 2015].
45. Risk Communication. Centers for Disease Control and Prevention, Gateway
to Health Communication & Social Marketing Practice: Atlanta, GA; 2011
[Available at] http://www.cdc.gov/healthcommunication/risks/index.html
[Accessed April 2015].
46. Resnick L. Making health decisions: Mindsets, numbers, and stories.
Harvard Health Publications, Harvard Medical School, Harvard Health
Blog; 2011 [Available at] http://www.health.harvard.edu/blog/making-
health-decisions-mindsets-numbers-and-stories-201112123946 [Accessed
April 2015].
47. Bennett P, Calman K, Curtis S, et al. Embedding better practice in risk
communication and public health. Bennett P, Calman K, Curtis S, et al. Risk
Communication and Public Health, Ch 20. Oxford University Press, Oxford
Scholarship Online: New York; 2010;
10.1093/acprof:oso/9780199562848.003.20 [Available at]
http://www.oxfordscholarship.com/view/10.1093/acprof:oso/9780199562848.001.000
9780199562848-chapter-20 [Accessed April 2015].
48. What is Shared Decision Making?. [Informed Medical Decisions Foundation,
Healthwise Research and Advocacy; Available at]
http://www.informedmedicaldecisions.org/what-is-shared-decision-
making/ [Accessed April 2015].
49. Violence Prevention. Centers for Disease Control and Prevention: Atlanta,
GA; 2014 [Available at] http://www.cdc.gov/violenceprevention [Accessed
January 2015].
50. Albert EJ. Intimate Partner Violence: A Clinician's Guide to Identification,
Assessment, Intervention, and Prevention. 5th ed. Massachusetts Medical
Society: Waltham, MA; 2010 [Available at]
http://www.massmed.org/partnerviolence/ [Accessed February 2015].
51. Breiding MJ, Chen J, Black MC. Intimate Partner Violence in the United
States—2010. [Atlanta, GA: National Center for Injury Prevention and
Control, Centers for Disease Control and Prevention;2–14; Available at]
http://www.cdc.gov/violenceprevention/pdf/cdc_nisvs_ipv_report_2013_v17_single_a
[Accessed January 2015].
52. Child Abuse and Neglect Statistics. Child-Friendly Faith Project. [Available
at] http://childfriendlyfaith.org/child-abuse-and-neglect-statistics/?
gclid=CjwKEAiAgranBRDitfSQk_P7vnMSJAAhx5G5f0VZbZqlBFtSoP4ZJqVt0XGX
[Accessed February 2015].
53. Prevent Abuse and Neglect through Dental Awareness: The P.A.N.D.A.
Coalition. Arkansas Department of Health; 2011 [Available at]
http://www.healthy.arkansas.gov/programsServices/oralhealth/Pages/PANDA.aspx
[Accessed February 2015].
Additional Resources
Oral Health Atlas.
http://issuu.com/myriadeditions/docs/flipbook_oral_health/1.
Symposium on Oral Health and Primary Care, National Interprofessional
Initiative on Oral Health, 2012.
http://www.niioh.org/symposium-oral-health-and-primary-care.
All Eyes Engaged: National Interprofessional Initiative on Oral Health
(NIIOH), 2012 Symposium, Denta Quest, 2014—YouTube video.
https://www.youtube.com/watch?v=snNythtU-oQ.
The Dental Safety Net and Access to Oral Health, ADEA, 2014.
http://www.adea.org/dentalsafetynet/.
The Dental Safety Net and Access to Oral Health, ADEA, 2014—YouTube
video.
https://www.youtube.com/watch?v=pWLxRsJEqEI.
Schoolhouse Rock—How a Bill Becomes a Law—YouTube video.
https://www.youtube.com/watch?v=Otbml6WIQPo.
C H AP T E R 1 0
Cultural Competence
Christine French Beatty RDH, MS, PhD, Magda A. de la Torre RDH, MPH
OBJECTIVES
1. Describe key demographic, social, and cultural shifts and trends influencing
oral health among culturally diverse groups in the United States (U.S.).
2. Describe oral health disparities in the nation and relate them to the diversity of
the population.
3. Describe the components of culture and how culture is formed, and explain how
culture affects health.
4. Explain the importance of culture and cultural competence in relation to oral
health care.
5. Describe the role of federal and state guidelines and requirements in relation to
cultural competence in health care.
6. Describe, compare, and contrast models that are used in the development of
cultural competence.
7. Describe, compare, and contrast models that can be used to apply strategies and
approaches that enhance cross-cultural encounters and cross-cultural
communication in oral healthcare settings.
8. Describe patient-centered care and compare and contrast patient-centered care
and cultural competence; discuss the role and responsibility of the dental hygienist
with respect to cultural competence and the provision of culturally competent oral
health care.
9. Describe health literacy and its relationship to culture, cultural competence, and
oral health; explain the role of the dental hygienist in improving health literacy
and describe culturally competent ways to increase health literacy of the
population.
Opening Statements: The Role of Culture in
the Status and Future of Oral Health
• Closing the gap on oral health disparities among diverse cultural groups will lead
to better oral health for our nation and is a responsibility of all healthcare
providers.1
• Race, ethnicity, socioeconomic (SES) levels, and other cultural factors are
powerful determinants of oral health status, access to oral healthcare services, and
quality of oral health care.2
• We must commit ourselves to contributing to the establishment of a society in
which respect for human dignity and equality are valued.1
• A common quote repeated by many including Gandhi is, “The true measure of any
society is found in how it treats its most vulnerable members.”
• There are important variations among and within people from the same country or
culture,3 and there are cultural variations among generations.4
• Profound oral health disparities exist in the U.S., with poor children and other
vulnerable populations facing up to two times the rate of dental caries experience
and untreated tooth decay compared with their more affluent peers.1
• Two of the four overarching goals of Healthy People 2020 relate to culture; they
are (1) to achieve health equity, eliminate health disparities, and improve health for
all groups and (2) to create social and physical environments that promote good
health for all.5
• A common goal for all oral health professionals is to provide the best oral care to
all patients, which involves identifying ways to prevent and control oral diseases
and conditions for members of all cultural groups.6
Today's Evolving Diverse Population
The U.S. is highly diverse as evidenced in neighborhoods, schools, and
communities. Diversity extends to integral parts of our existence such as race,
culture, SES, language, and national origin. Diversity also extends to lifestyles,
traditions, personal and family histories, ages, abilities, and other dimensions that
constitute who we are. In most communities many languages are spoken in schools,
workplaces, and homes. All these components are fundamental in interpersonal
interactions and community relationships.
In the past societies primarily functioned with a monocultural and monolingual
perspective. People were expected to give up the values, norms, and beliefs of their
societies of origin in favor of new opportunities.7 However, our nation has lost the
image of a “melting pot” of racial and ethnic groups. Cultural diversity in
American society is more realistically an intricate mosaic, consisting of numerous
racial and ethnic groups.8,9
The concept of diversity encompasses acceptance and respect. It means
understanding that each individual is unique and recognizing our individual
differences. These dissimilarities can be along the various cultural dimensions of
race, ethnicity, gender, sexual orientation, SES, age, physical abilities, religious
beliefs, political beliefs, or other ideologies. Respect for diversity involves the
exploration of these differences in a safe, positive, and nurturing environment. It is
about moving beyond simple tolerance to embracing and celebrating the rich
dimensions of diversity contained within each individual.9
Today's society is continuing to become more multiracial, multicultural, and
multilingual. According to the 2010 U.S. Census data, every non-white group in the
population except American Indian/Alaskan Native increased in numbers from 2000
to 2010 (Table 10-1).10 More important is the increase in members of the population
who speak a language other than English at home. Data from the American
Community Survey conducted in 2013 by the Census Bureau revealed that one in
five U.S. residents speak a foreign language at home, representing an increase from
previous survey results (Table 10-2).11 Furthermore, of those who speak a foreign
language at home, 41% self-reported that they speak English “less than very well.”11
These data vary by state with a range of 2.3% to 43.8%.11 However, more than 20%
of the population in more than one fourth of the states speaks a foreign language at
home, and these data represent an increase in all except six states.11
TABLE 10-1
Percentage of Ethnic Groups in the United States Population, 2000 and
2010 Census
ETHNICITY PERCENTAGE
Rac e 2000 2010 Inc re ase in population 2000–2010
White/Caucasian 75.1 72.4 5.7
Hispanic/Latino 12.5 16.3 43.0
Black/African American 12.3 12.6 12.3
Asian American 3.6 4.8 43.3
Pacific Islander 0.1 0.2 35.4
American Indian/Alaskan Native 0.9 0.9 18.4
Other 5.5 6.2 24.4
Two or more races 2.4 2.9 32.0
From Humes KR, Jones NA, Ramirez RR. Overview of Race and Hispanic Origin: 2010. 2010 Census
Briefs. Washington, DC: U.S. Census Bureau; March 2011. Available at
http://www.census.gov/prod/cen2010/briefs/c2010br-02.pdf. Accessed May 2015.
TABLE 10-2
Linguistic Diversity in the United States: Percentage of People Speaking
a Language Other Than English at Home
The matters of race, ethnicity, and cultural differences have great significance for
all who live in the U.S. Society has embraced the concepts of cultural competence,
cultural diversity, cultural sensitivity, cultural pluralism, and multiculturalism.
These ideas are being incorporated not only into health care but also into business,
education, and governmental policies. In health care these concepts have
implications for how health care is delivered to multilingual and multicultural
clients and communities whose cultures vary from those of their healthcare
providers.9,12 The clients may have different beliefs, values, attitudes, behaviors, and
other cultural characteristics.
Three reasons for a healthcare provider to be in the constant pursuit of cultural
competence are (1) the societal realities of a changing world, (2) the influence of
culture and ethnicity on human growth and development, and (3) the challenge of
providing effective and quality health care to all people.13 These reasons indicate the
need and importance of cultural competence, including the significance of
developing the necessary skills to communicate and collaborate with persons of
other cultures.
FIG 10-1 A non-profit collaborates with the state oral health program to bring
healthcare services, including oral health care, to South Texas border towns along
the United States–Mexico border. Various healthcare organizations and individuals in
the state volunteer to provide free oral healthcare services to this underserved
population using an interprofessional collaborative model. (Photograph courtesy
Christina Horton.)
Considering Culture
Healthcare access problems include several components. Two important factors are
(1) an individual's perception of a given illness and (2) the decision to seek health
care, both of which are influenced by culture.2 A primary requirement in providing
culturally sensitive health care is a basic knowledge of the health status and needs of
the population groups being served.2 Historically, many of the healthcare providers
serving ethnic populations have been members of the same ethnic/racial groups.22
However, there is a need for all healthcare providers to have multicultural skills to
be able to deliver care to an increasingly diverse population.14
Healthcare providers traditionally have their own expectations about how health
care should be delivered and how patients should respond to care. However, to be
able to work effectively with a multicultural population, the healthcare workforce
must alter their traditional ways of interacting with patients and communities.14 To
be able to impact determinants of health and thus reduce health disparities, they must
be knowledgeable of and attentive to cultural differences and have the
communication skills to be able to interact with members of different cultural
groups.12
What Is Culture?
Culture is an integrated pattern of human behavior that includes thoughts,
communications, languages, practices, beliefs, values, customs, courtesies, rituals,
manners of interacting, roles, relationships, and expected behaviors of a racial,
ethnic, religious, or social group, as well as the ability to transmit these to
succeeding generations.23 As such, culture involves a specific set of social,
educational, religious, and professional behaviors, practices, and values that
individuals learn and adopt while participating in groups with whom they usually
interact daily.12
In common terms, culture is what we live every day, our daily cross-cultural
interactions at work, school, or in our community. It is the lens through which we
view the world and form our opinions, thoughts, aspirations, and goals. Culture is
both inherent and learned; it is a shared way of interpreting the world.9 Culture is
simple yet complex, common yet unique, and constantly evolving based on life
experiences.9,12 Several factors that influence culture are listed in Box 10-2.
ox 10-2
B
Some Factors T hat Infl uence Cul ture
• Age
• SES
• Gender
• Educational attainment
• Geography
• Family
• Place of birth
• Religious beliefs
• Individual experiences
• Sexual preference
• Power relationships
The Office of the Surgeon General has identified ways that state and local health
departments; businesses and employers; healthcare systems, organizations, insurers,
and clinicians; academic institutions; community organizations; and individuals and
families can respond to assist in carrying out these recommendations.31 To meet
these goals organizations must have the capacity to value diversity, conduct self-
assessment, manage the dynamics of differences, acquire and institutionalize
cultural knowledge, and adapt to diversity in the cultural contexts of the
communities they serve.5,18 In addition, organizations must incorporate cultural-
competency principles in all aspects of policymaking, administration, practice, and
service delivery and systematically involve clients, stakeholders, and the
communities being served.9,14,26
As a result of the public health community calling for increased efforts to
develop cultural competence in the national and local infrastructure over the last
decade,14 oral healthcare professional societies and organizations have developed
standards, initiatives, or statements encouraging, and in some cases requiring, the
workforce they serve to be culturally sensitive and culturally competent in relation
to oral health care.32-38 In addition, because of efforts over the last few decades,
many materials for this type of training are now available from the National Center
for Cultural Competence (NCCC), the DHHS Office of Minority Health (OMH), and
other recognized national organizations and universities. The NCCC has a training
site, the Curricula Enhancement Module Series, as well as multiple other resources
and links to other sites and resources on their website. The OMH has resources on
health disparities, health conditions and issues affecting racial and ethnic minorities,
and organizational capacity-building to improve healthcare services for minority
groups. See Additional Resources for URLs for these and other resources at the end
of the chapter.
Current and future leaders require specific training to increase their cultural
competence to improve the health of our nation. National initiatives have called for
greater emphasis on cultural competence in overall and oral health professional
education programs. The Association of American Medical Colleges and the
Association of Schools of Public Health responded by jointly developing a
competency document in 2012 entitled Cultural Competence Education for Students
in Medicine and Public Health.39 Included are suggested strategies and resources for
training in cultural competence. This significant initiative can be used by other
health professions as well, including dentistry and dental hygiene, not only for entry
level curricula but also for training of practicing health professionals.
ox 10-3
B
N ati onal Standards for Cul tural l y and
Li ng ui sti cal l y A ppropri ate Servi ces i n H eal th
and H eal th Care (N ati onal CLA S Standards),
2013
Principal Standard
1. Provide effective, equitable, understandable and respectful quality care and
services that are responsive to diverse cultural health beliefs and practices,
preferred languages, health literacy, and other communication needs.
FIG 10-5 The Purnell Model for Cultural Competence. (Modified from Purnell, L.
Transcultural health care: A culturally competent approach (2013). Philadelphia, F.A. Davis.)
ox 10-4
B
Tw el ve Cul tural Domai ns i n the Purnel l Model
for Cul tural Competence
Overview/Heritage
Concepts related to country of origin, current residence, the effects of the
topography of the country of origin and current residence, economics, politics,
reasons for emigration, educational status, and occupations.
Communication
Concepts related to the dominant language and dialects; contextual use of the
language; paralanguage variations such as voice volume, tone, and intonations; and
the willingness to share thoughts and feelings. Nonverbal communications such as
the use of eye contact, facial expressions, touch, body language, spatial distancing
practices, and acceptable greetings; temporality in terms of past, present, or future
worldview orientation; clock versus social time; and the use of names are
important concepts.
Family Roles and Organization
Concepts related to the head of the household and gender roles; family roles,
priorities, and developmental tasks of children and adolescents; child-rearing
practices; and roles of the ages and extended family members. Social status and
views toward alternative lifestyles such as single parenting, sexual orientation,
childless marriages, and divorce are also included in this domain.
Workforce Issues
Concepts related to autonomy, acculturation, assimilation, gender roles, ethnic
communication styles, individualism, and healthcare practices from the country of
origin.
Bicultural Ecology
Includes variations in ethnic and racial origins such as skin coloration and physical
differences in body stature; genetic, heredity, endemic, and topographical diseases;
and differences in how the body metabolizes drugs.
High-Risk Behaviors
Includes the use of tobacco, alcohol, and recreational drugs; lack of physical
activity; nonuse of safety measures such as seatbelts and helmets; and high-risk
sexual practices.
Nutrition
Includes having adequate food; the meaning of food; food choices, rituals, and
taboos; and how food and food substances are used during illness and for health
promotion and wellness.
Pregnancy and Childbearing
Includes fertility practices; methods for birth control; views toward pregnancy; and
prescriptive, restrictive, and taboo practices related to pregnancy, birthing, and
postpartum treatment.
Death Rituals
Includes how the individual and the culture view death, rituals and behaviors to
prepare for death, burial practices, and bereavement behaviors.
Spirituality
Includes religious practices and the use of prayer, behaviors that give meaning to
life, and individual sources of strength.
Healthcare Practices
Includes the focus of health care such as acute or preventive; traditional, magico-
religious, and biomedical beliefs; individual responsibility for health; self-
medication practices; and views toward mental illness, chronicity, organ donation,
and transplantation. Barriers to health care and one's response to pain and the sick
role are included in this domain.
Health Care Practitioner
Concepts include the status, use, and perceptions of traditional, magico-religious,
and allopathic biomedical healthcare providers. In addition, the gender of the health
care provider may have significance.
From Purnell Model for Cultural Competence. Silver Spring, MD: National Association of School Nurses; 2013.
Available at https://www.nasn.org/ToolsResources/CulturalCompetency/PurnellModelforCulturalCompetence.
Accessed May 2015. (Used with permission from Larry Purnell.)
ox 10-5
B
Descri pti on of the Si x Stag es of the Cul tural
Competence Conti nuum
Cultural Destructiveness
Characterized by attitudes, policies, structures, and practices within a system or
organization that are destructive to a cultural group.
Cultural Incapacity
The lack of capacity of systems and organizations to respond effectively to the
needs, interests, and preferences of culturally and linguistically diverse groups.
Characteristics include but are not limited to institutional or systemic bias; practices
that may result in discrimination in hiring and promotion; disproportionate
allocation of resources that may benefit one cultural group over another; subtle
messages that some cultural groups are neither valued nor welcomed; and lower
expectations for some cultural, ethnic, or racial groups.
Cultural Blindness
An expressed philosophy of viewing and treating all people as the same.
Characteristics of such systems and organizations may include policies that and
personnel who encourage assimilation; approaches in the delivery of services and
supports that ignore cultural strengths; institutional attitudes that blame consumers
—individuals or families—for their circumstances; little value placed on training
and resource development that facilitate cultural and linguistic competence;
workforce and contract personnel that lack diversity (race, ethnicity, language,
gender, age); and few structures and resources dedicated to acquiring cultural
knowledge.
Cultural Pre-Competence
A level of awareness within systems or organizations of their strengths and areas
for growth to respond effectively to culturally and linguistically diverse
populations. Characteristics include but are not limited to the system or
organization expressly valuing the delivery of high quality services and supports to
culturally and linguistically diverse populations; commitment to human and civil
rights; hiring practices that support a diverse workforce; the capacity to conduct
asset and needs assessments within diverse communities; concerted efforts to
improve service delivery usually for a specific racial, ethnic, or cultural group;
tendency for token representation on governing boards; and no clear plan for
achieving organizational cultural competence.
Cultural Competence
Systems and organizations that exemplify cultural competence demonstrate an
acceptance and respect for cultural differences and they practice the following:
• Implement specific policies and procedures that integrate cultural and linguistic
competence into each core function of the organization.
• Identify, use, and/or adapt evidence-based and promising practices that are
culturally and linguistically competent.
• Implement policies and procedures to recruit, hire, and maintain a diverse and
culturally and linguistically competent workforce.
• Develop the capacity to collect and analyze data using variables that have a
meaningful impact on culturally and linguistically diverse groups.
Cultural Proficiency
Systems and organizations hold culture in high esteem, use this as a foundation to
guide all of their endeavors, and practice the following:
• Continue to add to the knowledge base within the field of cultural and linguistic
competence by conducting research and developing new treatments,
interventions, and approaches for health and mental care in policy, education, and
the delivery of care.
• Develop organizational philosophy and practices that integrate health and mental
health care.
• Employ faculty and/or staff, consultants, and consumers with expertise in cultural
and linguistic competence in health and mental healthcare practice, education, and
research.
• Publish and disseminate promising and evidence-based health and mental health
care practices, interventions, training, and education models.
• Support and mentor other organizations as they progress along the cultural
competence continuum.
• Develop and disseminate health and mental health promotion materials that are
adapted to the cultural and linguistic contexts of populations served.
• Advocate with, and on behalf of, populations who are traditionally unserved and
underserved.
• Establish and maintain partnerships with diverse constituency groups, which span
the boundaries of the traditional health and mental healthcare arenas, to eliminate
racial and ethnic disparities in health and mental health.
From Tawara D. Goode, National Center for Cultural Competence Georgetown University Center for Child and
Human Development, University Center for Excellence in Developmental Disabilities, 2004 as adapted from
Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989). Towards a Culturally Competent System of Care, Volume
1. Washington, DC: CASSP Technical Assistance Center, Center for Child Health and Mental Health Policy,
Georgetown University Child Development Center. Included with permission of the Georgetown University
National Center for Cultural Competence, Georgetown University Center for Child & Human Development,
Georgetown University Medical Center.
G ui di ng Pri nci pl es
Actions That Foster Effective Cross-Cultural Communication
• Learn another language if clients are non-English speaking or if they are unable to
speak and are proficient in sign language; even learning some basic terminology
will assist with communication and denotes respect, interest, and caring.
ox 10-6
B
L.E.A .R.N . Model of Cross-Cul tural
Communi cati on
Listen … with sympathy and understanding to the patient's perception of the
problem.
Explain … your perceptions of the problem and your strategy for treatment.
Acknowledge … and discuss the differences and similarities between these
perceptions.
From Berlin E, Fowkes WA. A teaching framework for cross-cultural health care. West J Med 1983;39:934–8.
ox 10-7
B
R.E.S.P.E.C.T Model of Cross-Cul tural
Communi cati on
Rapport
• Connect on a social level.
Empathy
• Be empathic.
• Seek out and understand the patient's rationale for his or her behaviors or illness.
Support
• Ask about and try to understand barriers to care and compliance.
Partnership
• Be flexible with regard to issues of control.
Explanations
• Use simple language, pictures, maps, and other means of explanation.
Cultural Competence
• Respect the patient and his or her culture and beliefs.
• Understand that the patient's view of you may be identified by ethnic or cultural
stereotypes.
• Understand your personal style and recognize when it may not be working with a
given patient.
Trust
• Remember that self-disclosure may be an issue for some patients who are not
accustomed to Western medical approaches.
• Fulfill promises.
From Welch M. Enhancing Awareness and Improving Cultural Competence in Health Care. A Partnership Guide
for Teaching Diversity and Cross-Cultural Concepts in Health Professional Training. San Francisco, CA:
University of California at San Francisco; 1998.
ox 10-8
B
Questi ons Sug g ested for Kl ei nman's
Ex pl anatory Model of Il l ness
• What do you think caused your problem?
• How severe is your sickness? Do you think it will last a long time, or will it be
better soon in your opinion?
• What are the chief problems your sickness has caused for you?
• What do you fear most about your sickness?
• What are the most important results you hope to get from the treatment?
From Kandula N. The Patient Explanatory Model. Evanston, IL: Northwestern University, News; 2013 June 13.
Available at http://www.northwestern.edu/newscenter/stories/2013/06/opinion-health-blog-kandula-.html.
Accessed May 2015.
Another model similar to Kleinman's model is called the ETHNIC Model (see
Box 10-9).54 Also still in use today, this model is especially helpful to use with a
population that believes in alternative medicine.55 Use of these or similar models has
been suggested for dental hygienists to increase communication and elicit
responses, including culture-specific answers, that can be helpful in relation to
diagnosis, treatment planning, patient management, and motivation toward behavior
change.56
ox 10-9
B
ET H N IC Model of Cross-Cul tural
Communi cati on
Explanation
• Patient's perception of the illness/problem
Treatment
• Treatments previously tried by the patient
Healers
• Previous advice sought from folk healers
Negotiate
• Finding mutually acceptable options
Intervention
• Agreeing on an intervention
Collaboration
• Collaborating with patient, family, other healthcare professionals, healers, and
community resources
From Potter PA, Perry AG, Stockert P, Hall A. Essentials for Nursing Practice. 8th ed. St Louis, MO: Elsevier;
2015.
All these models are designed for use in clinical encounters in private,
community, and organizational systems to communicate with patients (Figure 10-8).
They foster creativity when interacting with patients and families in diverse
communities. Of particular importance to this chapter is their value when adapted
for application to oral health care for multicultural populations to increase cultural
competence of oral healthcare practitioners and organizations.54 Adaptation can be
accomplished by rephrasing questions to make them specific to oral health
conditions and oral healthcare situations.
ox 10-10
B
T hree Methods of Transl ati ng Wri tten
Materi al s
1. Create it separately in each language
Patient-Centered Care
Effective communication is at the heart of patient-centered care, a concept that has
become the standard in the healthcare industry. In this approach, “patients are known
as persons in context of their own social worlds, listened to, informed, respected,
and involved in their care—and their wishes are honored (but not mindlessly
enacted) during their healthcare journey.”59 Patient-centered care is described in
relation to individual patients, healthcare providers, and healthcare organizations or
systems.59 Patients are more active in consultations and treatment decisions.
Healthcare providers are more mindful, informative, empathetic, and collaborative.
Respect, compassion, concern, shared decision making, and communication are
seen as basic elements for patient-centered care.60
In addition, healthcare systems that focus on patient-centered care do not burden
providers with issues of productivity and overloaded schedules at the expense of
quality care. Rather, organizational policies strengthen the patient-clinician
relationship, promote communication about things that matter, help patients know
more about their health, and facilitate patients' involvement in their own care.59
Patient-centered care is evidence-based in its consideration of the patient's
preferences, goals, and situational needs (Figure 10-9).61
FIG 10-9 Patient-centered care is as important in community settings as it is in
private settings. In this program, dental students from a nearby dental school travel
to provide free dental care to low income individuals at a dental hygiene school
clinic; patients are referred by providers at a local university medical center and
faculty of the dental hygiene program. (Photograph courtesy Christina Horton.)
Patient-centered care and cultural competence have been compared; both aim to
improve the quality of health care, although each emphasizes different aspects of
quality.62 The main goal of patient-centered care has been to provide individualized
care with an emphasis on personal relationships. On the other hand, the primary aim
of striving for cultural competence has been to increase health equity and reduce
disparities. Nevertheless, at the core of both patient-centeredness and cultural
competence is the emphasis on seeing the patient as a unique person. Both depend on
the patient-centered approach and address individual patients' preferences and goals,
thus complementing each other in striving for quality of care. Box 10-11 presents
the overlap between patient-centered care and cultural competence at both the
interpersonal and healthcare system levels.62
ox 10-11
B
Overl ap betw een Pati ent-Centered Care and
Cul tural Competence
Interpersonal Level
• Understands and is interested in the patient as a unique person
Quality of Care
• Providing high quality, evidence-based health care to patients and their families
From Patient Centered Care. Chicago, IL: American Academy of Pediatric Dentistry, Pediatric Oral Health
Research & Policy Center; 2013. Available at
http://www.aapd.org/assets/1/7/PatientCenteredCarePolicyBrief.pdf. Accessed May 2015.
The AAPD also expressed concern that the individualized, patient-centered
approach required for cultural competence and patient-centered care may be
compromised by the changes in oral health care that are coming about as a result of
the Affordable Care Act.61 As the system becomes overburdened with additional
numbers of patients on Medicaid, it will be important to have policies in place to
protect patient-centered practices. The role of oral health professional advocates
working in private, corporate, and community-based settings includes
encouragement of culturally competent and patient-centered care at all levels.36,37,63
Health Literacy
Culturally competent oral health care involves taking into consideration the oral
health literacy of the population being served.64 Oral health literacy is important to
the discussion of culturally competent oral health care because low oral health
literacy is associated with the following:
• Lower oral health status65
• Greater oral health disparities14
• Reduced oral health knowledge14
• Higher risk of oral diseases and conditions14
• Lower rates of adopting healthy behaviors66
• Less frequent utilization of preventive oral health services67
• Poorer outcomes and higher hospitalization rates66
• Lower rates of dental insurance66
• Higher overall oral healthcare costs66
• Lower rates of participation in dental public health programs14
Health literacy is “the degree to which individuals have the capacity to obtain,
process, understand, and communicate basic health information and services needed
to make appropriate health decisions.”17 It is dependent on culture, context,
knowledge, certain skills, SES, and many other factors.14,17 Health literacy is not just
about knowledge. It involves having complex skills that are necessary to (1) find
health information and health services, (2) process the meaning and usefulness of
the information found, (3) navigate the healthcare system, including filling out
complex forms, locating providers and services, and making appointments, (4)
share personal information with providers, such as health history and current
medications, (5) engage in self-care and management of chronic disease, (6)
understand mathematical concepts such as probability and risk, and (7) apply
numeracy skills such as calculating blood sugar levels, reading nutritional labels,
and computing deductibles and copays.66
Low health literacy is most commonly seen in individuals who are older adults;
racial and ethnic minorities; the less educated, specifically those with less than a
high school diploma or general education development (GED) certificate; those
with lower general literacy and numeracy skills; those of low SES; nonnative
English speakers; and the medically compromised.66 However, health literacy does
not necessarily equate with literacy skills; a person may have outstanding literacy
skills and not possess health literacy.67 According to the Office of Disease
Prevention and Health Promotion of the DHHS, nine out of ten adults may be
considered to have low health literacy in the U.S.66 This means that the vast majority
of adult Americans struggle to understand fundamental health information such as
health history forms, consent forms, home care and medication instructions,
postoperative instructions, and drug labels.
In 2012 a collaborative effort took place between the dental and medical
communities representing the public, private, and educational sectors to explore the
issue of oral health literacy.17 Topics discussed included the definition of the
problem, commonalities between health literacy and oral health literacy, research
needs, and potential solutions and interventions at individual and community levels.
There was agreement that collaboration between these two communities at the
practice, organizational, educational, and policy levels could lead to successes in
solving the problem of inadequate oral health literacy in the population. In addition,
the need to focus on determinants of health and individual behaviors was discussed.
Since the workshop, the medical and dental communities have collaborated to
develop competencies and curriculum related to oral health for nondental primary
care providers to improve their oral health literacy and involve them in improving
the health literacy of the populations they serve.17
Improvement of oral health literacy is a necessary component of interventions
designed to improve oral health and reduce oral health disparities.14 Knowing that
many populations in the U.S. have low oral health literacy, the oral health literacy of
the target population must be considered to increase the potential for successful
outcomes.14 A target population's understanding of and willingness to participate in
oral health programs must be addressed.14 Also, developing oral health messages at
the appropriate literacy level and targeted to the language and cultural norms of
specific populations will help to promote oral health literacy.14,68
A number of initiatives at the federal level demonstrate the current emphasis on
health literacy. One is the inclusion of a topic area in Healthy People 2020—Health
Communication and Health Information Technology—with objectives that are
focused on the improvement of health literacy in the nation.47 Another is a report
published in 2012 by the Institute of Medicine in which a workgroup identified
attributes of a health literate organization.69 A health literate organization was
defined as one that “makes it easier for people to navigate, understand, and use
information and services to take care of their health.”69 The attributes were
developed as guidelines for healthcare organizations to be able to make sure that the
population gets the greatest benefit possible from the healthcare information and
services provided (Box 10-13).
ox 10-13
B
A ttri butes of a H eal th Li terate Org ani zati on
1. Leadership makes health literacy integral to the mission, structure, and operation
of the organization.
2. Health literacy is integrated into planning, evaluation, patient safety, and quality
improvement.
4. Populations that are served are included in the design, implementation, and
evaluation of health information and services.
5. Needs of populations are met with a range of health literacy skills while avoiding
stigmatization.
7. Easy access and navigation assistance are provided to health information and
services.
The Plain Writing Act passed by the federal government in 2010 mandated that
federal government agencies use plain language in written materials, with the goal
of making health information clear for low literacy readers.70 Important to the
improvement of health literacy, plain language is clear, concise, to-the-point, and
well-organized writing that is grammatically correct and includes complete
sentence structure and accurate word usage.71 Plain language is not unprofessional
writing or a method of “dumbing down” or “talking down” to the reader.71 The use
of plain language results in clear writing that tells the reader exactly what he or she
needs to know without using unnecessary words or expressions,71 making it easier
to understand and use health information.72 Federal guidelines for plain language
can be used by all healthcare organizations and workforce to assist in writing
materials that consumers can understand.70
Another federal government initiative was the passage in 2000 of an executive
order that required federal agencies to examine the services they provided, identify
the need for services to those with limited English proficiency, and develop and
implement a system to provide those services so persons with limited English
proficiency could have meaningful access to them.72 This has resulted in the
development of various programs and resources, many of which are highlighted in
this chapter.
In 2012, Sorensen, Van den Broucke, and Fullam et al. reported on the
development of a comprehensive conceptual and logical model of health literacy.73
The model identified 12 dimensions of health literacy, based on the four
competencies of health literacy (accessing, understanding, appraising, and applying
health information) in three domains (health care, disease prevention, and health
promotion). According to the creators of the model, it can support the practice of
health care, disease prevention, and health promotion by serving as a basis for
developing interventions that will enhance health literacy.73 The model can
contribute also to the development of health literacy measurement tools for use in
health literacy program evaluation and research.73 The expectation is that oral health
literacy will continue to be a major strategy focused on the improvement of oral
health and reduction of oral health disparities.17 The model can be applied to oral
health literacy (Table 10-3) to provide a framework for oral health practitioners to
use in the process of assessing the oral health literacy needs of patients and clients
and in designing programs and messages to improve their oral health literacy.
TABLE 10-3
Model of 12 Dimensions of Health Literacy Applied to Oral Health
Adapted from Sorensen K, Van den Broucke S, Fullam J, et al. Health Literacy and Public Health: A
Systematic Review and Integration of Definitions and Models. BMC Public Health (online) 2012;12:80e.
doi:10.1186/1471-2458-12-80. Available at http://www.biomedcentral.com/1471-2458/12/80. Accessed April
2015.
The primary responsibility to improve oral health literacy of the population lies
with oral health professionals.66 Necessary skills must be developed to clearly
communicate oral health information and teach patients and clients the health
literacy skills they need to be wise oral health consumers and make sound oral
health decisions. Some ways to accomplish this are listed in Box 10-14. Resources
to help with this important task are included in the references and Additional
Resources at the end of this chapter.
ox 10-14
B
Way s to Improve Oral H eal th Li teracy of the
Popul ati on
• Understand how to provide useful information and services.
• Consider which information and services work best for different situations and
people so they can act.
• Develop health information materials at the appropriate literacy level and targeted
to the language and cultural norms of specific populations.
• Verify understanding of what people are explicitly and implicitly asking for.
• Aid people in finding providers and services and in filling out complex forms.
2. Search online or find print journals that focus on cultural competence. Compare
the journal articles and identify which you think will be the most useful in your
interaction with patients of diverse cultures. Write a list of 10 points that you can
share with your classmates.
4. Think about folklore or ethnic traditions. Write down a family tradition or ethnic
tradition practiced in your family. It is encouraged that you select health or
healthcare-related traditions. Share with your class and learn from your peers the
differences and similarities in traditions among diverse cultures.
6. Go to the instruction page for the training course Effective Communication Tools
for Healthcare Professionals Course Overview from the Health Resources and
Services Administration at
http://www.hrsa.gov/publichealth/healthliteracy/uhcregistrationinstructions.pdf.
Follow the instructions on this page to register for the course that covers topics
relevant to this chapter, such as cultural competence, health literacy, and limited
English proficiency. Report what you have learned to the class.
7. Review the Toolkit for Community Action developed by the National Partnership
for Action to End Health Disparities at
http://minorityhealth.hhs.gov/npa/files/Plans/Toolkit/NPA_Toolkit.pdf. Study the
ideas proposed to carry out the suggested actions to address health disparities in
your community. Pick one and describe how you could implement it in your own
community in relation to oral health.
Dental Hygiene Competencies
Reading the material in this chapter and participating in the activities of Applying
Your Knowledge will contribute to the student's ability to demonstrate the following
competencies:
C.9
Communicate effectively with individuals and groups from diverse populations
both verbally and in writing.
C.11
Provide care to all clients using an individualized approach that is humane,
empathetic, and caring.
C.12
Initiate a collaborative approach with all patients when developing individualized
care plans that are specialized, comprehensive, culturally sensitive, and acceptable
to all parties involved in care planning.
OBJECTIVES
1. Define and discuss service-learning as experiential learning.
2. Clarify the stages of service-learning.
3. Discuss the benefit of using service-learning for interprofessional
collaborations.
4. Consider interprofessional strategies in service-learning.
5. Discuss the purpose and strategies for risk management in service-learning.
6. Apply service-learning to dental public health practice, and integrate public
health resources in service-learning.
Opening Statements: Highlights of Service-
Learning Research in Higher Education:
Dental Hygiene Student Comments
Service-Learning has a positive effect on student personal development such as a
sense of personal efficacy, personal identity, spiritual growth, and moral
development.
• “I knew I wanted to ‘help others,’ but after the first term in the dental hygiene
program, all I could focus on was keeping my GPA decent. The service-learning
project helped me to think again about what it means to help others.”
• “I was challenged by this type of instruction. I'm a traditional learner, but this
project repeatedly placed me in real-world situations, and this allowed me to
practice critical thinking often.”
• “It was comforting to know that we can evaluate our knowledge of a topic without
taking tests and quizzes!”
Service-Learning has a positive effect on interpersonal development, leadership
skills, communication skills, and the ability to work well with others.
• “Now I know why we completed a module on good communication and dialogue.”
• “My faculty said that we would ‘cultivate a yearning to understand others’; now I
know what she meant. I was really surprised that my peers were interesting, and
even more surprised that I had to ‘practice’ hearing what they had to say.”
• “I learned that there was a wrong way to brainstorm; I had to force myself to
practice good communication and dialogue skills.”
Service-Learning has a positive effect on social responsibility and citizenship
skills.
• “We had a chance to work in our very own communities!”
• “I think we made an impact on our community, and now I know that I can help
strengthen my community. I plan to find a place where I can similarly invest in my
community as a volunteer.”
• “Now I know what it means to be ‘socially accountable.’ It sounds intellectual in the
textbook and on the syllabus; this project made me really see the devastation right
in front of me.”
Service-Learning has a positive effect on commitment to service.
• “Without this type of learning experience, I would have earned a degree in dental
hygiene, but because of this program, I am going to use my dental hygiene
education in my community.”
• “We got the idea that parents were not involved with the child's oral health. This
made us really want to talk to the parents as well.”
• “Going through the research and then teaching it made me feel confident that I
know the material and I am not just regurgitating facts.”
Service-Learning contributes to career development.
• “The guest speakers made us understand that just because you graduate, it doesn't
mean that the learning stops.”
• “We have to be able to relate and speak in terms that community partners will
understand.”
• “I had to do some heavy-duty Internet research to find fantastic images and cases.
Even my textbook fell short of what I learned on my own.”
Students and faculty report that service-learning improves students' ability to
apply what they have learned in the “real world.”
• “I personally think that going out into the real world and teaching eager-to-learn
students was the most effective tool we've had thus far.”
• “Taking a learning objective from the course syllabus and teaching it to different
audiences is something that can never compare to just learning the objective from
a lecture. It is really important to put terminology into words your audience can
understand.”
• “Books suggest, but experience is the best teacher.”
Source of research highlights: Eyler JS, Giles DE Jr., Stenson CM, Gray CJ. At a
Glance: What We Know about the Effects of Service-Learning on College Students,
Faculty, Institutions, and Communities, 1993-2000. 3rd ed. Boston, MA: Learn and
Serve America National Service Learning Clearinghouse; 2001. Available at
http://www.compact.org/wp-content/uploads/resources/downloads/aag.pdf.
Accessed April 2015.
Introduction
The future of dental hygiene is public health! Preparing students for the public
health workforce is arguably one of the most important outcomes for today's dental
hygiene programs because this will contribute to advancing graduates' career
options. In 2011 the American Dental Hygienists' Association (ADHA)
commissioned a comprehensive survey of the organization to identify opportunities
and constraints that could impact the future of the profession.1 This type of
comprehensive assessment is known as an environmental scan and is completed for
the purpose of helping an organization envision, articulate, and plan for inevitable
changes that can influence its future outlook.
The ADHA environmental scan revealed external events that are occurring in the
broad healthcare system that will impact the way the dental hygiene profession
contributes to the public's health in the future. Several changes, referred to as
change drivers, were noted as having an impact on the profession (Table 11-1).
ADHA will apply this information in its plan for the future of dental hygiene. In
essence, the environmental scan revealed direction for the profession and the work
required by the profession to plan for and embrace new opportunities, many of
which are in public health employment.1,2
TABLE 11-1
Change Drivers That Are Impacting the Dental Hygiene Profession
Chang e
Summary ADHA Re sponse
Drive r
Future New opportunities for dental hygienists will emerge in community ADHA will need to take a leadership role in guiding practitioners to
Opportunities centers, healthcare organiz ations, and retail locations, but hygienists new, developing fields of practice and in ensuring that they have the
for Dental must work hard to secure these opportunities. skills to succeed.
Hygienists
Expanding Expanding access to oral health care will be a defining issue for ADHA can be the leader in promoting the expansion of quality oral
Access & dental hygienists looking to improve the health of the nation and health care and, in doing so, can ensure future opportunities for dental
Ensuring create new opportunities for practice. hygienists.
Equity in Oral
Health Care
Harmoniz ation Public and private payers will look to harmoniz e standards and ADHA will need to fight to standardiz e and expand the dental hygiene
of Practice scope of practice to improve quality of, and access to, oral health scope of practice.
care.
Growth of For- For-profit and corporate dental hygiene education programs will ADHA will need to work with for-profit schools to improve standards,
Profit Schools continue to grow, creating fierce competition for jobs in some gain control over accreditation, and grow ADHA membership.
and Corporate markets.
Education
Technology New advances in science and technology will radically alter oral ADHA must be ready to support members as they work to develop and
Advances in health care. learn how to use new technology to improve oral health care.
Oral Health
Aging Increase in the older-adult population will mean a greater demand ADHA will need to provide leadership for new opportunities in
Population for more complex oral health care and dental procedures and larger geriatric care, including the need for more skills and experience to
numbers who are at risk for oral cancer; higher rate of tooth serve older adults' more complex health and oral health needs and the
retention is also creating a greater demand for dental hygiene need for new strategies to bring dental hygiene care into the home and
services. long-term care facilities.
Aging The largest and most influential generation will be retiring over the ADHA will be challenged to develop the next generation of leaders,
Workforce next decade, including from dental hygiene and dental hygiene prepare adequate numbers of qualified dental hygiene faculty, and
education, leaving the workforce with a wealth of experience and create new forms of volunteerism and community engagement for the
seeking ways to remain active in the workforce and their retirees.
communities after retirement.
Public health research and educational initiatives have made it clear that the future
of dental hygiene is in the public health workforce and that dental hygiene curricula
must prepare future graduates to work in the changing public health environment.1,3
Because roadmaps directing the profession to opportunities are becoming clearer,
this chapter focuses on helping dental hygiene students prepare for their emerging
roles in the public health workforce. The chapter will define and clarify experiential
learning models to help students create and implement effective service-learning
projects that integrate public health resources and interprofessional considerations.
The chapter can be used as a bridge to prepare dental hygiene graduates for
advancing models of healthcare delivery, which have been discussed in previous
chapters.
For example, Chapters 1 and 2 discussed the importance and current direction of
preparing students for interprofessional collaborative practice (ICP). It was
pointed out that ICP will necessitate a shift from profession-specific education and
training to educating health professions students in an interprofessional
collaborative model, referred to as interprofessional education (IPE).3 IPE will
prepare graduates to practice in such a way that various disciplines can work
together in communities to strengthen identified community health issues that cut
across the disciplines. The shift from profession-specific education and training to
comprehensive team-based health professional education will require skill sets
conducive to this interdisciplinary collaboration.4 Collaboration at the student level
with health professional students from other disciplines will be critical.4,5 In relation
to community oral health programs, service-learning provides an opportunity for
academic exercises that will help students prepare for their future roles in ICP.6
The focus of this chapter is the planning and implementation of community-based
experiences and team-based collaborative projects that will help prepare students
for these changing roles in future dental hygiene practice.3-6 The first section of the
chapter focuses on the use of service-learning for community-based instruction.
The second section provides instruction to augment the dental hygiene student's
public health awareness and ability to use public health resources. The final section
connects service-learning instruction with public health practice and resources
through simulation exercises.
This chapter is designed to have value for faculty and students alike, to learn
about service-learning and identify ways to incorporate service-learning into a
community oral health course. Students will find the chapter useful in designing,
planning, and implementing assigned community-based service-learning projects.
The chapter provides information on the processes, procedures, and strategies of
service-learning, as well as ideas and resources to apply to service-learning
assignments.
Service-Learning as Experiential Learning
Experiential Learning
Also commonly referred to as practical learning or real-world learning,
experiential learning originated from the grassroots research of educational
theorists such as John Dewey, Kurt Lewin, Jean Piaget, and Carl Rogers.7,8
According to these educational researchers, hands-on learning was at the center of
the best learning experiences. Historically, dental hygiene students have provided a
form of experiential learning known as community service to instruct populations
about oral health. Educational methods used to prepare dental hygiene students to
instruct in these instances were limited in magnitude; they were taught to deliver
basic oral health educational facts. The benefits of this method proved to be useful
in preparing dental hygiene students to deliver oral health messages, but they were
oversimplified and deficient in preparing students to anticipate or meet the needs of
the public's oral health challenges.
An example of oral health education delivered as community service might
include dental hygiene students displaying and staffing a table at a local health fair.
In this situation, students interact with people who stop by their table. Visualizing
this example can underscore the limited effect of this delivery mode in expanding
the students' perspectives regarding the community in which they interact. In this
setting, how could the dental hygiene students anticipate the needs of their audience?
A higher level of experiential learning is needed to prepare dental hygiene students
to fulfill the oral health challenges of a rapidly diversifying population while
contributing to the current national oral health agenda.9-11
G ui di ng Pri nci pl es
Experiential Learning Outcomes
There are several well-known experiential learning methods used in the dental
hygiene curriculum (Box 11-1), and they vary in their purpose. The examples given
earlier in relation to assisting WIC participants and applying radiology concepts to
teach elementary school students are examples of service-learning, which has the
advantage of providing multiple purposes and enhancing student learning at various
levels.12-14 Some experiential learning methods described in Box 11-1 do not have a
curriculum connection and do not have the same learning value as service-learning.
Community service projects organized and conducted by student ADHA members
are an example (Figure 11-3).
ox 11-1
B
Ex peri enti al Learni ng Methods
Community Service
Students provide a service to the community, and the primary focus is on the
community's needs. Community service may or may not have a curriculum
connection. The student may provide the service for reasons other than a classroom
assignment (e.g., club requirement, religious obligation).
Clinical Rotation
Clinical rotation is a curriculum-based activity not necessarily associated with a
service outcome and is designed primarily to benefit the student learning. Students
are assigned rotations through clinical experiences to enhance their skills,
knowledge, and expertise.
Practicum/Internship
A practicum/internship is typically longer than a clinical rotation and is designed
to benefit the student. In this instance the student may be assigned to work in a
particular specialty area for an entire academic quarter or semester. An example of
practicum/internship is the assignment of senior-level students in a dental hygiene
bachelor's degree completion program to various public health agencies, higher
education institutions, and governmental agencies for the practical experience of
on-the-job exposure and training.
Volunteerism
Students provide a service to the community, and the major benefit is for the
community. Volunteerism is not necessarily associated with an academic course.
Examples include assisting at the concession stand at an athletic event and
participating in a secondary education tutoring program.
Service-Learning
Students participate in a teaching/learning method that stresses collaborative
planning and implementation of projects. It is structured in that it combines
community service with preparation and reflection, and it focuses on applying
course content to enhance learning. Students engaged in service-learning provide
community service in response to community-identified concerns and learn about
the context in which service is provided, the connection between the service and
their academic coursework, and their roles as citizens.
FIG 11-3 Student ADHA members participate in a Halloween carnival on campus
for community service. (Photograph courtesy Charlene Dickinson.)
Service-Learning
This chapter is focused on the experiential learning model of service-learning. By
its nature, service-learning is a teaching and learning method that stresses
collaborative planning between the student, the dental hygiene program faculty, the
community partner, and more recently students from other health disciplines as
well. Widely used in educating health professions students, service-learning
involves production of an implementation project that is mutually beneficial for
everyone involved in the collaborative arrangement. Dr. Sarena Seifer, MD,
provided an early definition of service-learning as former executive director of the
Community Campus Partnership for Health (CCPH), a nationally recognized
organization whose mission includes the improvement of the health of the public.15
The key elements of this definition have remained relevant over time (Box 11-2).
ox 11-2
B
W hat Is Servi ce-Learni ng ?
• A structured learning experience
G ui di ng Pri nci pl es
Creative and Unique Ideas That Can Be Integrated into Service-
Learning Projects
• Develop a brochure listing dental public health resources, including safety net
facilities.
• Plan and conduct a Basic Screening Survey (BSS), and issue oral health report
cards.
• Identify public and private dental facilities that are currently accepting public
health insurance (Medicaid and Children's Health Insurance Program [CHIP]) and
assist families in finding dental homes.
• Collaborate with local law enforcement officers and students to promote child
safety by performing bite impressions for use in identification of children.
• Develop and implement oral health lesson plans for allied health students or other
health professionals (e.g., medical doctors, physician assistants, nurse
practitioners, nurses).
FIG 11-4 Dental hygiene students, faculty, and a local Boy Scout troop collaborate
in this service-learning project in which the scouts learn about oral health and the
oral health professions. (Photograph courtesy Christina Horton.)
FIG 11-5 Dental hygiene students teach about oral health, oral hygiene, and the
importance of sealants and fluoride in a service-learning project in conjunction with
a school-based sealant program operated by the dental clinic of a local faith-based
community health center. (Photograph courtesy Terri Patrick.)
Stages of Service-Learning
Sometimes service-learning is described as a combination of a community service
project and academic coursework. But this definition is incomplete because it does
not describe fully that the service-learning process contains specific and ordered
components. It is important to note that the actual term service-learning consists of
two words separated by a hyphen. The very structure of the term implies equality
between the service component of the term (what is received by the community
partner) and the learning component (what is received by the dental hygiene student,
in this case).16-18
The configuration of the term should not be taken lightly; it is an important
consideration in ensuring that the needs of both the community partner and the
student are addressed. Likewise, when the term service-learning is used, both words
should be presented in matching fashion. In other words, the S in service and the L
in learning are always written in identical fashion, either capitalized or in lower-
case letters. The hyphen emphasizes the connection between the service and learning
components.16-18 In essence, service-learning experiences are jointly structured
learning experiences between the community partner and the academic course of
instruction.
What the community partner wants from the dental hygiene students is referred to
as the service objective (SO), which is a uniquely expressed need that flows directly
from the mission and purposes of the collaborating partner (Figure 11-7).16 A
course objective is selected as the learning objective (LO) for the service-learning
experience (Figure 11-8). Dental hygiene students' course objectives are
academically grounded and come directly from the course syllabus.17 Through
collaboration among the community partner, the dental hygiene students, and the
dental hygiene faculty member, the SO and the LO are purposefully combined to
form the service-learning objective (S-LO). Working together to combine the SO
and LO in creating the S-LO is critical to the service-learning process because it
supports the integrity of the service-learning experience and illustrates its mutually
beneficial nature (Figure 11-9).15-18 The systematic development of the S-LO and
further explanations of the SO, LO, and S-LO are presented in Figure 11-10.
FIG 11-7 The service objective (SO) is to provide oral health services for the
underserved population at this school. (Photograph courtesy Sheranita Hemphill.)
FIG 11-8 The learning objective (LO) is to apply screening techniques and indexes
to survey a priority population in the community. (Photograph courtesy Sheranita
Hemphill.)
FIG 11-9 The service objective (SO) and the learning objective (LO) are combined
as a service-learning objective (S-LO) in the implementation of this service-learning
project. (Photograph courtesy Sheranita Hemphill.)
FIG 11-10 Development of the service-learning objective (S-LO).
Collaboration
Collaboration means working together to accomplish a goal. Other words that may
come to mind when thinking about collaboration include joint effort, teamwork, or
partnership. In service-learning projects, the program is jointly planned by the
dental hygiene course instructor, the community partner, and the dental hygiene
students.14 This collaboration among all these parties is necessary to ensure that the
needs of all are met. The faculty member is interested in assuring that student LOs
are considered, the community partner is interested in ensuring that the
organization's needs are met, and the dental hygiene students are interested in
applying their health education knowledge and skills to benefit the community.
With traditional community-service projects, dental hygiene faculty members
have typically initiated the communications leading to a community service
experience for the students. The faculty member contacted an agency representative
and asked about placing dental hygiene students in their organization to gain
community experience. However, with service-learning, the faculty member,
community partner, or student can initiate the contact and request. The community
agency can contact the faculty member to request the services of the dental hygiene
students, and, likewise, the student can initiate the discussion by contacting an
agency to discuss the possibility of developing a mutually beneficial project. In this
instance the students must identify the appropriate LOs from the course syllabus,
work with the agency representative to identify their needs or SOs, and also seek
approval from the faculty member.
ox 11-3
B
Mutual Objecti ve Formati on
• An elementary school district's school nurse contacts a dental hygiene faculty
member for assistance in securing dental homes for children needing immediate
dental care. The faculty member meets with the school nurse to discuss a possible
collaboration.
• The faculty member and school nurse collaborate to present the project of finding
dental homes for low socioeconomic status (SES) public elementary school
children to the school administration and teachers.
• The school personnel are satisfied because this meets the needs of the school; the
summarized service objective (SO) is to keep children healthy for classroom
learning.
• The dental hygiene faculty member's goals are met in that the project will actively
engage dental hygiene students in advocating for populations with no or
inadequate dental insurance and access to dental care.
• The dental hygiene students are equally satisfied because they have the opportunity
to apply their program planning skills. After considering the service-learning
activity, the students decide which of the course's learning objectives (LOs) will
apply to the school's SO. The students can select one or multiple LOs.
• After informing the school nurse of their LOs, the students and the school nurse
meet to collaborate on combining their respective objectives to develop the
service-learning objectives (S-LOs), which are then presented to the faculty
member for approval.
Orientation
A formal orientation minimizes disruptions to the service-learning program.12,14
The overall agenda for the orientation should be for all parties to become familiar
with each other's programs, clarify expectations, formulate a time line, review risk
management policies and procedures, and deal with any other questions or issues
pertinent to the service-learning project. It is important for the dental hygiene
students, the agency (collaborative partner), and the dental hygiene faculty member
to become acquainted with each other's program mission, objectives, population
demographics, constraints, guidelines, operations, and facilities. Clear
communication and face-to-face meetings are good approaches to gaining insight to
the different perspectives.
Preparation
Program planning skills, which have been presented in previous chapters, will be
applied to the preparation of the service-learning project. This involves
brainstorming activities, identifying roles, developing action plans and contingency
plans, and setting time lines. Diligent skill sets, including leadership, listening skills,
and the assessment of community needs, are essential to preparation.
Reflection
The aim of service-learning reflection is to deliberately draw meaning from the
experience.19,20 Symbolized by the hyphen in service-learning, reflection provides
the opportunity to process the service-learning project and consider its implications
in the context of learning and growing. As an act of learning in the college
environment, student reflection should purposefully focus on connecting the
academic course objectives to all the learning experiences—including the agreeable
and the disagreeable experiences, thoughts, and reflections. However, this exercise
in reflection should not turn into a political venting session or a campaign to
convince others of one's position or opinion.
As a student who is reflecting on the learning experience, you should not assume
a position of authority or influence over others. You should state what the
experience meant to you in relation to the specific LO without the need to sway
others' thoughts, and you should be curious about others' perspectives. Reflection is
not about being right. Personal and civic perspectives are expected and encouraged
in this process.20 You cannot separate your overall experiences from your personal
feelings, nor from who you are as a person and your own prior experiences. Yet
you can't expect others to share your views. Herein lies the need for exceptional
preparation to engage in effective communication and dialogue; successful
reflection of service-learning cannot occur without them (Box 11-4).
ox 11-4
B
Sug g esti ons for Effecti ve Communi cati on and
Di al og ue
• Engage in introspective thinking; really listen to your inner thoughts, feelings, and
prejudices; think deeply.
• Speak to the entire group; avoid singling out any one person.
• Nurture openness and curiosity about others' perspectives; speak and listen with
conscious intention for real communication.
• Let go of the need to be right; share your perspective without trying to convince
others.
ox 11-5
B
Incorporati ng Refl ecti on i nto Servi ce-Learni ng
• Have community partners facilitate prepared and impromptu discussion sessions.
• Present a poster session and invite the entire college and community.
Evaluation
As with any other learning experience, evaluation of the service-learning project is
a continuous process that can be divided into two phases—formative evaluation and
summative evaluation—both of which were defined and discussed in Chapters 3 and
6. In relation to service-learning, formative evaluation involves examining the
service-learning project while it is ongoing or in-process (think of forming).
Summative evaluation involves a formal end-product review of the service-learning
project (think of summary). Making concrete plans to use both methods helps to
ensure permanence or institutionalization of the service-learning project in the
dental hygiene program. In this way, both faculty and students can assure that
valuable service-learning experiences can continue with future cohorts of dental
hygiene students. For example, dental hygiene student comments speak volumes
about the importance of using each of the stages of service-learning experience
listed in Box 11-3: Collaboration, Orientation, Preparation, Reflection, and
Evaluation (see Guiding Principles).
G ui di ng Pri nci pl es
Dental Hygiene Student Comments Regarding the Stages of Service-
Learning
Collaboration Comments
• “We watched our faculty interact with our community partners and speakers, and
we learned that a key ingredient to successful navigation of service-learning
projects is making everyone feel equally important and responsible for its
success.”
Orientation Comments
• “Several community partners were invited to our campus to present their
programs to our class. Later, we actually visited their booths and selected which
community partner we wanted to work with. It was amazing that so many agencies
showed up and it was so organized and professional. Our orientation started from
the moment that we signed-up with an agency.”
• “The initial discussions that we had with the teacher were very important. I learned
the status of the children's oral health and frequency of their dental visits. The
teacher gave us a realistic idea of what was going on with the children's oral
hygiene at home. She informed us that some of her students already had dental
crowns, and she believed that they weren't learning at home what they needed to
know to properly take care of their teeth.”
• “I wish that we had gotten to meet our actual teacher rather than a substitute at the
orientation, but I'm glad that we thought of initiating a follow-up communication
with the actual teacher. We were able to reschedule the orientation when she
returned to work.”
Preparation Comments
• “I wish that we'd had more formal questions to ask the community partners so that
we could have walked away with more information. Instead, we had to make a
second contact with them to get the information. It worked out in the end, but we
had to think creatively and act swiftly to prevent a stall in the existing plans.”
• “Dental hygiene students should contact teachers by email or phone to confirm the
planned time. In hindsight, it would have been valuable to have each teacher's
class schedule prior to going in to observe for the first time. In our case, the
children were asleep because we scheduled our observation during their
naptime.”
• “The observation meeting that we had before our service-learning project was
instrumental in preparing our lesson plans. From that meeting, we learned that we
need to change our initial ideas of what we might teach because the teacher had
explicit expectations of what she wanted her class to learn from us.”
Reflection Comments
• “One thing that I would do differently is to make sure that the group had a physical
activity to take home with them to show their guardians. I now realize the
importance of making oral health a family matter.”
• “We learned just how important it is to locate and use resources when working
with populations with secondary languages.”
• “We had no idea that putting images of ourselves in the PowerPoint presentation
would get so much attention from the 5th graders. Once they saw that it was us
posing in the different shots used in the PowerPoint for the service-learning
presentation to illustrate the dental radiology lab, they seemed to admire us even
more.”
Evaluation Comments
Formative Evaluation Comments from Students
• “I learned, really learned, what formative evaluation is. I had to use it. Many of the
kids asked more questions than we thought they would. We had to think on our
feet and make adjustments during our presentations.”
• “From some of the children, we got the impression that their parents are not
involved with their oral health, so it was quite an eye opener. This made us really
want to talk to the parents, so we initiated a contest to see which classroom could
get the most parental involvement.”
• “I feel satisfied with the experience. I believe the children retained the information
because they were able to still answer the questions correctly 2 weeks after the
lecture.”
• “As a direct result of this experience, we feel humbled and would love to continue
this type of volunteer work throughout our careers as dental hygienists.”
Benefits of Service-Learning for
Interprofessional Collaboration
Evolution from Traditional to Collaborative
Experiential Learning in Dental Hygiene
Curricula
Traditionally, dental hygiene students have been involved in many forms of
experiential learning, including community service, clinical rotations, and
observations.12-14 However, some of these models were typically designed to benefit
the dental hygiene students exclusively. Generally, the projects were conceived
entirely by the dental hygiene curriculum committee, and they focused on oral
health issues, almost at the exclusion of overall health concerns. The projects were
implemented at the convenience of the dental hygiene academic calendar, overseen
exclusively by the dental hygiene department with little or no input from those
receiving the care. The dental hygiene students received academic credit for
completing specific tasks, and the outcome was not widely shared.
This is not to say that these experiential learning models lacked value in the dental
hygiene curriculum. However, they did little to prepare graduates to fulfill the
forecasted needs and employment opportunities of the evolving profession as
expressed in ADHA's environmental scan and other national call-to-action
initiatives. On the other hand, service-learning makes way for early interactions of
the dental hygiene students with community partners, other health professions
students, and vulnerable populations in need of access to oral health care.1,3,4,14 In
this way, service-learning prepares tomorrow's workforce through timely
collaborative opportunities.1,3,4
There is increasing momentum at the national level to position oral health as an
integral part of overall health.1,4,11 International and national health initiatives and
professional organizations are continuously emphasizing the need for
interdisciplinary community-based strategies to address oral health disparities.9-11,22
These undertakings have advanced oral health concerns to authentic public health
issues and presented an opportunity for the profession of dental hygiene to
contribute to the improvement of the oral health of the nation starting right in our
own neighborhoods.
ox 11-6
B
Internati onal and N ati onal Ini ti ati ves and
Org ani zati ons Promoti ng the Integ rati on of
Oral H eal th i nto Communi ty -Based Strateg i es
• Healthy People 2020
ox 11-7
B
Core Val ues and Pri nci pl es N ecessary for
Effecti ve Interprofessi onal Col l aborati ve
Teamw ork
Values
• Honesty
• Discipline
• Creativity
• Humility
• Curiosity
Principles
• Shared goals
• Clear roles
• Mutual trust
• Effective communication
Interprofessional models.
Various models of delivering interprofessional health care have received substantial
recognition for their outcomes-driven results.1,3-6 Box 11-8 lists resources for
additional explicit examples and more information on new models of team-based
healthcare delivery. These resources can be used to learn about additional
characteristics and desirable features of interprofessional practice, including how to
create a better environment for veterans, use technology to support virtual
healthcare teams to assist individuals suffering from depression, work directly with
patients and their family members in hospital settings, and collaborate with primary
healthcare providers to coordinate health services.
ox 11-8
B
Resources for Team-Based Interprofessi onal
H eal thcare Del i very Model s
• Veterans Health Administration, Patient Aligned Care Team (PACT)
http://www.va.gov/health/services/primarycare/pact/index.asp
• BRIGHTEN Program (Bridging Resources of an Inter-disciplinary Geriatric
Health Team via Electronic Networking)
http://brighten.rush.edu/en/Pages/Home.aspx
• Cincinnati Children's Family- and Patient-Centered Rounds
http://www.cincinnatichildrens.org/professional/referrals/patient-
family-rounds/about/
• Vermont Blueprint for Health, Department of Vermont Health Access
http://blueprintforhealth.vermont.gov/
Risk Management in Service-Learning
When a person plans to travel, he or she typically considers obstacles that might be
encountered, thus impeding progress. These potential difficulties frequently are not
immense, but even small complications can be a hindrance to meeting one's goals.
Hence, it is wise to have an alternate plan in case of problems. For instance, if you
volunteered to pick up your niece during rush hour to transport her to a sporting
event 35 miles outside of the city, you might consider alternate routes in case of
traffic congestion. You would ensure that your vehicle had enough gas, that children
wore their seatbelts, and that you had the necessary personal identification and cash
or a credit card. This thoughtful process of preplanning is an important step in
managing possibilities.
Managing possibilities is another way to think of risk management. Alternate
plans in case of possible problems are referred to by several terms, such as a
contingency plan, emergency plan, or incident plan. These can be thought of as
what-if plans. In the same way, situations can occur in the process of a service-
learning experience. Risk management in higher education has been defined as “the
formal process by which an organization establishes its risk management goals and
objectives, identifies and analyzes its risks, and selects and implements measures to
address its risks in an organized fashion.”31 This risk management process is a
means of avoiding the problems that can lead to failure while maintaining the value
of programs that may include risk.32 The likelihood and severity of the risks must be
considered in this process.32
Planning for service-learning is not devoid of situational challenges. Risk
management suggests that such challenges or exposures can be managed through
thoughtful preplanning and organization.32 Academic institutions and community
partners are likely to have their own risk management departments that serve as
institutional clearing-houses with primary responsibility for guiding the risk
management procedures when service-learning is implemented. Managing
challenges and resources to maintain safety and quality is critical to be able to
sustain service-learning experiences and ongoing relationships with community
partners.
In educational institutions, a formal approval process exists for service-learning,
typically requiring action from the initiating faculty member, the institution, the
community partner, and the students. Institutions have policies and procedures in
place. Academic institutions may require community partners to sign affiliation
agreements; likewise, community partners may have similar agreements and policy
documents that require faculty and student signatures. A faculty member typically
initiates the process by learning what is needed to ensure a safe educational
experience for students. The overall goal of this formal process is to ensure that
everyone involved is aware of each other's expectations and responsibilities. A
number of issues should be considered for inclusion in risk management
discussions when preparing for service-learning experiences (Box 11-9). Checklists
can be used to organize risk management strategies.
ox 11-9
B
Ri sk Manag ement Consi derati ons
• University-community agency affiliation agreement
• Policies/procedures
• Contact information
• Emergency procedures
• Background checks
• Student misconduct
• Orientation checklist
• Scope of practice
• Supervision procedures and requirements
• Attendance policies
Leaders in the field of experiential learning suggest that all stakeholders involved
in service-learning should also be involved in planning for risk management.31 The
issue of risks for students, faculty, academic institutions, community agencies, and
community members should be discussed openly, and strategies should be
developed and distributed to all parties. Contingency planning, documentation, and
continual review are prudent components of risk management in experiential
learning opportunities.
Students and professionals alike are legally accountable for their actions. Legal
liability is a crucial consideration that is acknowledged and thoughtfully considered
by responsible institutions before sanctioning experiential learning experiences
such as service-learning.32 Initially, a student's awareness of an institution's risk
management processes and procedures may be vague, but students' levels of
awareness should increase through the process. This is an important learning
experience in relation to working in the community after graduation, where risk
management is the standard in educational and healthcare organizations.33 To
minimize legal liability, whether in a service-learning experience in college or later
in a community-based project involving practicing dental hygienists, risk
management is a key strategy to assure success and sustainability of community oral
health initiatives.
Service-Learning to Reinforce Dental Public
Health Learning
Learning the processes involved in assessment, program planning, and
improvement of oral health care can be enhanced with service-learning
experiences.12,14 Well-constructed service-learning projects can be the learning
platform for students to study the leading health indicators, oral health indicators,
and determinants of health—especially social determinants—as they impact
vulnerable populations. Opportunities are provided to locate and apply local, state,
and national oral health surveillance findings and national oral health objectives
(Figure 11-12).
ox 11-10
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Resources for Servi ce-Learni ng Projects
Healthy People 2020
• Science-based national health objectives, including oral health objectives, to
improve overall and oral health for all ages (see Chapters 4 and 5).
• Easily searchable website containing baseline data, targets for improvement, and
available progress data related to all health objectives, including oral health (see
Chapters 4 and 5).
• Provides information about the oral health program in the state, including the
mission, goals, priorities, and initiatives of the state oral health program as well
as the state's preventive programs and potential funding opportunities.
• Source of information about the Basic Screening Survey (BSS) for Children and
Adults (see Chapter 4), containing everything that a team of dental hygienists
would need to conduct a screening survey or to instruct school and agency
personnel how to conduct these basic screening surveys.
• A searchable database to find data relative to oral health status and trends and to
compare state oral health information.
• Useful for lesson planning purposes to view descriptive statistics that can be used
for needs assessment and for inclusion in presentations to vividly and graphically
illustrate oral health points (e.g, a state's ranking relative to the various oral
indicators, such as dental visits, teeth cleaning, tooth loss, dental sealants, caries
experience, untreated tooth decay, water fluoridation, and oral and pharyngeal
cancer).
• Gathers, develops, and shares high-quality and valuable information and materials
related to current and emerging public oral health issues to provide a
comprehensive source of information and other resources for community oral
health program planning.
• Linked to numerous other health- and oral health-related agencies to strengthen its
value as a resource.
• Through its Division of Oral Health (DOH), works with state oral health programs
and other organizations to improve access to oral health care, guides infection
control, and promotes proven oral health strategies.
• Searchable DOH website with an A-Z index of hundreds of health topics, including
health promotion, occupational health, health literacy, oral cancer, and multiple
other oral health topics.
Learning Opportunities
The rest of this chapter provides opportunities to apply the service-learning
concepts discussed throughout the chapter. In the Applying Your Knowledge section,
you are provided with hands-on opportunities to increase your understanding of
how to operationalize service-learning to get the most from the service-learning
projects you will be assigned. The purpose of these exercises is to provide practice
in integrating local, state, and national resources into service-learning lesson plans
and to offer practice developing S-LOs in the process of creating lesson plans. As
practice exercises these applications may not be as straightforward as desired and
may challenge you as you search out various available resources. Your faculty may
also modify the assignments to fit the course needs for your maximum value and
success.
Summary
Traditional methods of community-based outreach such as community service,
volunteerism, clinical rotations, and field experiences, though limited in scope, are
useful in the dental hygiene educational experience. However, these dental hygiene
community outreach efforts can be enhanced with service-learning, an underused
instructional method.
The experiential method of service-learning has the potential to enhance
educational experiences. It emphasizes partnership stability via collaboration among
students, faculty, and community partners throughout the process, including the
initial planning. This results in continuity of services, which contributes to the
success of future service-learning programs. Thus, service-learning can become
institutionalized as a vehicle to accomplish the articulated desires of community
partners and to meet the dental hygiene students' academic course requirements and
LOs. Students are the drivers of the service-learning vehicle, and as such they
should have a thoroughly mapped-out itinerary before starting. Through service-
learning, students are challenged and also compelled to become more active in their
own learning. In addition to listening to lectures, participating in classroom
discussions, and completing other assignments, service-learning allows the student
to tailor his or her own learning opportunities to improve in self-identified areas of
importance.
Truly, the service-learning experience can transform learning for dental hygiene
students and greatly impact the oral health of the community. It is also a powerful
method for use in IPE to prepare dental hygienists for ICP, an important
consideration as healthcare delivery systems evolve into this practice model.
Learning activities are provided in the chapter for practice in applying service-
learning to community oral health, which has the potential to enhance the learning
of both.
Applying Your Knowledge
Set A. Data Resources Exercises
The purpose of this set of exercises is to provide practice in integrating local, state,
and national resources into service-learning projects. These exercises may not be
completely straightforward; you may have to search the sites using additional key
terms. Your instructor may modify the assignments to better fit the needs of your
course
1. Use an Internet search engine to search for the Healthy People 2020 website.
Locate the Leading Health Indicators (LHIs), and read the description that explains
what they represent. Record your understanding of what an LHI is.
3. Click on the LHI Progress Update link to view the progress toward the oral health
LHI. In your own words, summarize what this table represents.
4. Log onto the state oral health program for your or another state (perhaps one
that you may consider moving to), then locate the state's oral health program
information. If you like, you can access all states through the ASTDD (see
Additional Resources at the end of the chapter). Explore the site for one instance of
county-specific oral health information, and record one way that you can use this
information in your service-learning project. Share your idea with a classmate.
5. Relate the Healthy People 2020 oral health LHI to your selected state. Search for
your state's ranking on the oral health LHI and record it.
6. Log onto the ASTDD website; review the step-by-step guide on how to conduct a
BSS oral health survey. After answering the following questions, discuss the results
with your classmates.
8. Search for the OHRC website. Use the A to Z link to access various resources,
including Bright Futures. Review these resources to determine how you might be
able to use them in your service-learning project.
9. Log on and review the HRSA Maternal and Child Health Bureau website.
Brainstorm with your service-learning project team how you could use this
resource in preparing your project.
10. Access and review the CDC website. Access the Division of Oral Health. What
resources can you use to assist you with your service-learning project? Discuss this
with your service-learning team.
1. SO
2. LO
3. S-LO
Exercise 2 is a service-learning grid exercise presenting an opportunity to
improve your skills of creating mutual objectives; you will practice combining SOs
with LOs to build S-LOs in Table 11-2. The first two examples are completed for
you.
TABLE 11-2
Example Se rvic e Obje c tive (SO) Le arning Obje c tive (LO) Se rvic e -Le arning Obje c tive (S-LO)
1 Dental hygiene students will support the Dental hygiene students will demonstrate Dental hygiene students will learn about the health
school nurse with follow-up and referral knowledge of health and nonhealth barriers to and nonhealth barriers to dental hygiene services by
dental services, including the identification dental hygiene services. assisting the school nurse with follow-up and
of resources. dental referrals.
2 Children and parents will receive age- Dental hygiene students will prepare oral health Dental hygiene students will prepare and present
appropriate and culturally sensitive oral education lessons for children in inner-city age-appropriate and culturally sensitive oral health
health education. public schools. education to families.
3 Adolescents will be able to list the oral Dental hygiene students will demonstrate skills
health consequences of a diet high in in communicating effectively with adolescents.
sugar.
4 Adolescent minority youth at the First- and second-year dental hygiene students
Jefferson House will be encouraged to will demonstrate an understanding of basic
consider careers in dental hygiene. principles of adolescent learning, including
behavior management.
5 Schoolteachers will learn basic pediatric Dental hygiene students will be able to
oral health information that will assist demonstrate effective skills and knowledge when
them in recogniz ing the need for urgent communicating with schoolteachers.
dental treatment.
6 The older adults will receive a Dental hygiene students will demonstrate
confirmation of oral findings. knowledge and skills in collecting and
analyz ing the results of an older adult Basic
Screening Survey.
7 The participants will receive an oral Dental hygiene students will develop a reporting
health report card that illustrates the instrument for a longitudinal study that will
results of a screening. convey the results of an oral screening.
1. Service-Learning
2. Learning objective
3. Service objective
4. Service-learning objective
1. Think like an elementary school teacher and type a concept that the teacher would
want a dental hygiene student to teach his or her class. What you are typing is called
the SO (this is the service to be provided). The following is an example of an SO,
stating what the teacher wants for his or her students: The teacher wants the third-
grade class to learn how the dentist finds tooth decay.
Record your example of an SO (what the teacher wants).
2. Now you will review the list of approved academic dental radiology course
objectives (Box 11-11) with the purpose of selecting one that you want to teach to a
group of elementary schoolchildren. You will notice right away that some of the
course objectives are too complex to be used in this assignment, although others can
be applied. Remember, the objective you select must come from the list of
radiology objectives. Next, record your chosen objective. This is called the LO (this
is what you will be learning in the dental radiology course). The following example
of an academic course LO is provided for guidance: The dental hygiene students
should be able to identify radiographic dental caries.
Box 11-11
Dental Radi ol og y Course Objecti ves
Imaging Techniques
1. Compare and contrast the principles of interproximal, paralleling, and bisecting
techniques.
2. Compare and contrast intraoral and extraoral imaging criteria and techniques.
Anatomy
1. Describe the normal radiographic appearance of teeth and the supporting
structures.
Interpretation
1. Identify radiographic appearance of restorative materials and foreign objects.
2. Identify and classify dental caries and describe common errors in interpretation.
3. Identify and describe radiographic bone loss.
3. Now combine the teacher's concept (the SO) and the dental hygiene course
objective (the LO) to make one complete statement (the S-LO) and record it. This
combined statement is known as the S-LO (a combination of the community
partner's wishes and the dental hygiene academic course objective). This may take a
few attempts before you get it just right. (Hint: If you are working with a dental
hygiene partner, each team member should work independently to create an S-LO
and then merge the two statements into one with which both of you are satisfied.
This is an example of collaboration.) The following example statement of a
combination objective is provided for guidance: The elementary school students
should be able to identify tooth decay on a radiograph.
Record your S-LO (combination objective).
Service Objective (SO) Le arning Obje c tive (LO) Se rvic e -Le arning Obje c tive (S-LO)
What community partner wants Academic course objective Combination of SO and LO
1. The teacher wants the third-grade class to learn The dental hygiene students At the end of this presentation, the third-grade students should be
how the dentist finds tooth decay. should be able to identify able to correctly identify three out of four areas of severe tooth
radiographic dental caries. decay on bitewing radiographs.
Performance verb: Identify
Condition: At the end of this presentation
Criterion: 75% accuracy
2. The teacher wants the fifth-grade class to learn The dental hygiene students At the end of this presentation, the…
how dental braces work. should be able to… Performance verb:
Condition:
Criterion:
3. The teacher wants the sixth-grade students to The dental hygiene students At the end of this presentation, the…
learn how to protect their teeth and mouths should be able to … Performance verb:
during sports activities. Condition:
Criterion:
In the lesson plan template, there is a place for basic information about the
presenter, the community partner, and a description of the audience. Beneath the
heading there is a place to document SOs, LOs, and S-LOs. After this section, there
is an area to indicate the concepts, teaching strategies, and the time frame needed to
accomplish each of the concepts.
This exercise may be assigned as an individual project or a small group activity,
depending on your instructor. In either case, the self-explanatory template should be
followed to outline the lesson plan. Likewise, your instructor may assign or allow
you to self-select a population or community partner for your lesson plan. After
you have completed the service-learning lesson plan template, it is useful to share
all of the templates in class so you can learn from each other's learning experiences.
Exercise 2: Develop a class-initiated project to develop and implement a service-
learning opportunity
1. Select an appropriate course objective from your course syllabus, or have your
faculty assign one.
3. Have each small group take 3 minutes or less to “report out” about their top idea.
Keep track of the list by writing it on the board.
4. Narrow the list of top ideas to two choices (a voting method works).
5. Use the ideas listed in the Suggestions for Effective Communication and Dialogue
in Box 11-5 to engage in meaningful dialogue about the merits of both ideas as a
service-learning project.
7. Independently, develop one SO, one LO, and one S-LO; then share with a small
group.
8. Report out to the larger group the best of the independent SOs, LOs, and S-LOs.
9. Now, again independently, create one measurable SO, one measurable LO, and
one measurable S-LO. To help you with this, refer to Set B, Exercise 4. Share these
in your small group like before.
Core Competencies
C.3
Use critical thinking skills and comprehensive problem-solving to identify oral
healthcare strategies that promote patient health and wellness.
C.8
Promote the values of the dental hygiene profession through service-based
activities, positive community affiliations, and active involvement in local
organizations.
C.10
Communicate effectively with diverse individuals and groups, serving all persons
without discrimination by acknowledging and appreciating diversity.
C.12
Initiate a collaborative approach with all patients when developing individualized
care plans that are specialized, comprehensive, culturally sensitive, and acceptable
to all parties involved in care planning.
C.13
Initiate consultations and collaborations with all relevant healthcare providers to
facilitate optimal treatments.
Community Involvement
CM.1
Assess the oral health needs and services of the community to determine action
plans and availability of resources to meet the healthcare needs.
CM.2
Provide screening, referral, and educational services that allow patients to access
the resources of the healthcare system.
CM.3
Provide community oral health services in a variety of settings.
CM.6
Evaluate the outcomes of community-based programs and plan for future activities.
CM.7
Advocate for effective oral health care for underserved populations.
PGD.3
Access professional and social networks to pursue professional goals.
Community Case
The local dental society and the local dental hygiene program collaborated on the
Give Kids a Smile Day (GKSD) national event. The dental hygiene department at
Your Community College (YCC) and volunteers from the dental society conducted a
massive oral screening on underserved children in the area. The results revealed
that 60% of the 250 children aged 7 to 13 years had an urgent need for dental
treatment, and 75% had never visited the dentist. The dental hygiene faculty,
community dentists, and dental hygiene students want to provide dental services for
this group of children. You are a student in the dental hygiene program, and you
have agreed to serve as a member of the planning committee. The committee
members consist of community members, agency members, dental hygiene faculty,
dental hygiene advisory board members, and dentists from the local dental society.
1. Which resource is the best one to assist the group in developing oral health
program objectives?
a. Healthy People 2020
b. National Oral Health Surveillance
c. Association of State & Territorial Dental Directors
d. Basic Screening Survey
2. Which of the following experiential learning methods for student involvement
will provide equal benefit to the students and to the children?
a. Community service by helping in a future service project
b. Volunteering to chair the planning committee
c. A service-learning project with the children and parents
d. A clinical rotation to a follow up GKS treatment day
3. In the development of this community dental program, which category of
evaluation will your committee use to make modifications during the planning
and implementation of the program?
a. Summative evaluation
b. Formative evaluation
c. Normative evaluation
d. Standard evaluation
4. What type of objective is the following: “Dental hygiene students will be able to
identify five major sources of public health financing for oral health services”?
a. A service objective
b. A learning objective
c. A service-learning objective
d. Both a learning and a service-learning objective
5. At what point should you approach the chair of the committee about using this
experience as your required service-learning experience?
a. Before the next meeting of the planning committee
b. After you have met with the committee and discussed your interest with your
course instructor
c. After the committee has met to make plans for the treatment phase of the GKS
program
d. After the committee has been oriented to the purpose and mission of GKS
References
1. Rhea M, Bettles C. Dental Hygiene at a Crossroads of Change:
Environmental Scan 2011–2021. American Dental Hygienists' Association:
Chicago, IL; 2011 [Available at] http://www.adha.org/resources-
docs/7117_ADHA_Environmental_Scan.pdf [Accessed April 2015].
2. ADEA Competencies for Entry into the Allied Dental Professions.
American Dental Education Association: Washington, DC; 2011 [Available
at]
http://www.adea.org/uploadedFiles/ADEA/Content_Conversion_Final/about_adea/go
[Accessed April 2015].
3. Mitchell P, Wynia M, Golden R, et al. Core Principles & Values of Effective
Team-Based Health Care (Discussion Paper). The National Academies,
Institute of Medicine: Washington, DC; 2012 [Available at]
http://www.iom.edu/Global/Perspectives/2012/TeamBasedCare.aspx
[Accessed April 2015].
4. Interprofessional Education Collaborative Expert Panel. Core Competencies
for Interprofessional Collaborative Practice: Report of an Expert Panel.
Interprofessional Education Collaborative: Washington, DC; 2011
[Available at] https://www.nationaahec.org/pdfs/VSRT-Team-Based-Care-
Principles-values.pdf [Accessed April 2015].
5. Nursing Midwifery Services Strategic Directions 2011–2015. World Health
Organization, Department of Human Resources for Health, Health
Professions Networks, Nursing, and Midwifery Office: Geneva; 2010
[Document No. WHO/HRH/HPN/10.3; Available at]
http://whqlibdoc.who.int/hq/2010/WHO_HRH_HPN_10.1_eng.pdf
[Accessed April 2015].
6. Trickett EJ, Beehler S, Deutsch C, et al. Advancing the Science of
Community-Level Interventions. Am J Public Health. 2011;101(8):1410–
1419; 10.2105/AJPH.2010.300113.
7. Kolb DA, Boyatzis RE, Mainemelis C. Experiential learning theory:
Previous research and new directions. Sternberg RJ, Zhang LF.
Perspectives on Cognitive, Learning, and Thinking Styles. Lawrence
Erlbaum: Mahwah, NJ; 2000.
8. Furco A. Service-learning: A balanced approach to experiential learning.
Taylor B. Expanding Boundaries: Serving and Learning. Corporation for
National Service: Washington, DC; 1996 [Available at]
http://www.shsu.edu/academics/cce/documents/Service_Learning_Balanced_Approac
[Accessed April 2015].
9. National Call to Action to Promote Oral Health (NIH Publication No. 03-
5303). National Institute of Dental and Craniofacial Research: Rockville,
MD; 2003 [Available at]
http://www.nidcr.nih.gov/DataStatistics/SurgeonGeneral/NationalCalltoAction/nationa
[Accessed April 2015].
10. Advancing Oral Health in America: Report Brief. The National Academy of
Sciences, Institute of Medicine: Washington, DC; 2011 [Available at]
https://www.iom.edu/~/media/Files/Report%20Files/2011/Advancing-Oral-
Health-in-
America/Advancing%20Oral%20Health%202011%20Report%20Brief.pdf
[Accessed April 2015].
11. Vanderbilt AA, Isringhausen KT, Bonwell PB. Interprofessional education:
The inclusion of dental hygiene in health care within the United States—A
call to action. Adv Med Educ Pract. 2013;4:227–229;
10.2147/AMEP.S51962.
12. Burch S. Strategies for service-learning assessment in dental hygiene
education. J Dent Hyg. 2013;87(5):265–270.
13. Simmer-Beck M, Gadbury-Amyot C, Williams KB, et al. Measuring the
short-term effects of incorporating academic service learning throughout a
dental hygiene curriculum. Int J Dent Hyg. 2013;11(4):260–266;
10.1111/idh.12015.
14. Aston-Brown RE, Branson B, Gadbury-Amyot CC, et al. Utilizing public
health for service-learning rotations in dental hygiene: A four-year
retrospective study. J Dent Educ. 2009;73(3):358–374 [Available at]
http://www.jdentaled.org/content/73/3/358.full.pdf+html [Accessed April
2015].
15. Seifer SD. Service-learning: Community-campus partnerships for health
professions education. Acad Med. 1998;73:273–277 [Available at]
https://depts.washington.edu/ccph/pdf_files/SL-CCPH%20Prof%20Ed.pdf
[Accessed April 2015].
16. Cauley K, Canfield A, Clasen C, et al. Service-learning: Integrating student
learning and community service. Educ Health. 2001;14:173–181;
10.1080/13576280110057563.
17. Eyler J, Giles DE. Where's the Learning in Service-Learning?. Jossey-Bass:
San Francisco, CA; 1999.
18. Canfield A, Clasen C, Dobbins J, et al. Service-learning in health
professions education: A multiprofessional example. AEQ (online).
2000;4(4Winter):102.
19. Tsang AKL. Oral health students as reflective practitioners: Changing
patterns of student clinical reflections over a period of 12 months. J Dent
Hygiene. 2012;86(2):120–129.
20. Coulson D, Harvey M. Scaffolding student reflection for experience-based
learning: A framework. Teach High Educ. 2013;18(4):401–413;
10.1080/13562517.2012.752726.
21. Bikker AP, Mercer SW, Cotton P. Connecting, assessing, responding and
empowering (CARE): A universal approach to person-centered, empathic
healthcare encounters. Educ Prim Care. 2012;23(6):454–457 [EBSCO
Accession No. 85190320].
22. Monajem S. Integration of oral health into primary health care: The role of
dental hygienists and the WHO stewardship. Int J Dent Hygiene. 2006;4:47–
51 [Available at] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3302011/
[Accessed April 2015].
23. Johannsen A, Bolander-Laksov K, Bjurshammar N, et al. Enhancing
meaningful learning and self-efficacy through collaboration between dental
hygienist and physiotherapist students—A scholarship project. Int J Dent
Hygiene. 2012;10(4):270–276; 10.1111/j.1601-5037.2011.00539.x [ePub].
24. Mpofu R, Daniels PS, Adonis T-A, et al. Impact of an interprofessional
education program on developing skilled graduates well-equipped to
practice in rural and underserved areas. Rural Remote Health. 2014;14:2671
[(online); Available at] http://www.rrh.org.au/articles/subviewnew.asp?
ArticleID=2671 [Accessed April 2015].
25. Santos M, McFarlin CD, Martin L. Interprofessional education and service
learning: A model for the future of health professions education. J Interprof
Care. 2014;28(4):374–375; 10.3109/13561820.2014.889102.
26. Bridges DR, Davidson RA, Odegard PS, et al. Interprofessional
collaboration: Three best practice models of interprofessional education.
Med Educ Online. 2011;16; 10.3402/meo.v16i0.6035.
27. Fried J. Interprofessional collaboration: If not now, when? J Dent Hyg.
2013;87(Suppl. 1):41–43.
28. Cuff PA. Interprofessional Education for Collaboration: Learning How to
Improve Health from Interprofessional Models Across the Continuum of
Education to Practice—Workshop Summary. The National Academies Press,
National Research Council: Washington, DC; 2013.
29. Fribergera MG, Falkmanba G. Collaboration processes, outcomes,
challenges and enablers of distributed clinical communities of practice.
Behav Inform Technol. 2013;32(6):519–531;
10.1080/0144929X.2011.602426.
30. Gray B, Macrae N. Building a sustainable academic-community partnership:
Focus on fall prevention. Work. 2012;41(3):261–267; 10.3233/WOR-2012-
1294.
31. Liliana-Viorica P. Risk management in higher education. Annals Constanta
Maritime Univ (online). 2012;18:49–52 [EBSCO Accession No. 85494835].
32. Bubka MA, Coderre P. Best Practices in Risk Management for Higher
Education: Addressing the “What If” Scenarios. PMA Companies: Blue
Bell, PA; 2010 [Available at]
http://www.pmacompanies.com/pdf/MarketingMaterial/PMA_Education_BestPractice
[Accessed May 2015].
33. Healthcare Risk Management: The Path Forward. American Society for
Healthcare Risk Management: Chicago, IL; 2014 [Available at]
http://www.ashrm.org/ [Accessed May 2015].
34. Sabo S, de Zapien J, Teufel-Shone N, et al. Service learning: A vehicle for
building health equity and eliminating health disparities: Commentary. Am J
Public Health. 2015;105(S1):S38–43; 10.2105/AJPH.2014.302364.
35. Meili R, Fuller D, Lydiate J. Teaching social accountability by making the
links: Qualitative evaluation of student experiences in a service-learning
project. Med Teach. 2011;33:659–666; 10.3109/0142159X.2010.530308.
36. Vanderbilt AA, Isringhausen KT, VanderWielen LM, et al. Health disparities
among highly vulnerable populations in the United States: A call to action
for medical and oral health care. Med Educ Online. 2013;18:1–3;
10.3402/meo.v18i0.20644.
Additional Resources
Association of State & Territorial Dental Directors.
http://www.astdd.org/.
Centers for Disease Control & Prevention.
http://www.cdc.gov/.
Community-Campus Partnership for Health.
http://depts.washington.edu/ccph/.
Healthy People 2020.
http://www.healthypeople.gov/.
Learn and Serve America: Corporation for National Service.
www.learnandserve.org/.
Learn and Serve America's National Service-Learning Clearinghouse.
www.servicelearning.org/.
Maternal and Child Health Bureau of the Health Resources and Services
Administration.
http://mchb.hrsa.gov/.
National Maternal and Child Oral Health Resource Center.
http://www.mchoralhealth.org/.
National Oral Health Surveillance System.
www.cdc.gov/nohss/.
Risk Management and Liability in Higher Education Service-Learning.
www.servicelearning.org/instant_info/fact_sheets/he_facts/risk_mgmt/index.php
State Oral Health Programs.
http://www.astdd.org/state-programs/.
C H AP T E R 1 2
Test-Taking Strategies and Community
Cases
Christine French Beatty RDH, MS, PhD
OBJECTIVES
1. Identify tips for examination preparation.
2. Develop guidelines for answering multiple-choice test items and community
testlets.
3. Develop an overview of the National Board Dental Hygiene Examination
(NBDHE).
4. Answer community oral health questions that employ the formats used on the
NBDHE.
5. Utilize critical thinking skills to take a mock NBDHE examination consisting of
community cases for practice and increase level of personal confidence in
preparing for the NBDHE.
Test taking is a skill. It involves abilities beyond just understanding the material
being tested. It is important to be thoroughly familiar with the format of an
examination before taking it. For example, in your courses you probably have asked
questions about the number and types of questions that will be on a test and the
professor's regulations related to the test-taking process in the course.
It is also important to develop proficiency in test taking. This chapter is focused
on information about the NBDHE to orient you to this important examination. Also
included are various test-taking tips designed to help you develop expertise in
taking tests, regardless of the type of test or setting (Box 12-1). In addition, Box 12-
2 presents the application of some of the logical clues explained in Box 12-1 to help
you analyze the correct answers to multiple-choice questions.
ox 12-1
B
Test-Tak i ng T i ps
1. Be prepared. Study all the information available on the NBDHE and related
websites. Research where you have to go to take the examination and how long it
will take to get there.
2. On the morning of the examination eat a good breakfast with protein for the brain
benefits.
3. Arrange back-up transportation. Allow extra time to get to the examination site.
Arrive early to reduce stress.
4. Use your time wisely. During the examination take the time to determine how
many questions are presented and how much time you will need to answer each
question or section of questions on the examination. Monitor the time you spend
on each question to be certain you will complete the examination.
6. Take your time; be careful not to skip questions, misread questions, or mismark
answers.
7. Actively reason through each question and read all answers before making your
choice.
8. Attempt to answer every question; if you are unsure of an answer, mark or flag
that question to enable you to return to it later. On the NBDHE, it is to your
advantage to make an educated guess if you do not know the best answer.
9. With a multiple-choice question, attempt to answer the question posed by the stem
before reading the possible answers; then read the answers to find the one that
most closely matches your answer.
12. If you are unsure of the right answer, use logical clues that
help you figure it out:
13. Take the time to review the test when you have completed it
to be certain you have answered all questions, made no
errors, and not mismarked any answers.
14. Change answers only if you find you misread the question
or come across information in the test that corrects a
previous answer.
15. Stay calm; if you find yourself becoming anxious, stop and
take a few deep breaths.
Data from Top 25 Test-Taking Tips, Suggestions & Strategies. Available at http://www.aps.edu/aps/7-
bar/TestTakingTop25.pdf. Accessed September 16, 2015; Ten Tips for Terrific Test Taking. Study Guides and
Strategies. Available at http://www.studygs.net/tsttak1.htm. Accessed September 16, 2015; Top Ten Test-Taking
Tips for Students. Teacher Vision. Available at https://www.teachervision.com/study-skills/teaching-
methods/6390.html. Accessed September 16, 2015.
ox 12-2
B
A ppl i cati on of Log i cal Cl ues to A nsw eri ng
Mul ti pl e-Choi ce Test Questi ons
The following multiple-choice test questions demonstrate how to answer multiple-
choice questions by applying the clues presented in Box 12-1. The answer to each
question is provided following the question, along with a rationale based on these
clues rather than knowledge of content. Questions relate to health promotion and
behavioral change; a knowledge review can be found in Chapter 8.
The correct answer is b. Answer b repeats the word change, which provides a
clue. Although answer choice a also includes the word changes, the topic is not
relevant since the question is supposed to be focused on health promotion and
behavioral change. Answer choices c and d have no wording similar to that of the
question stem.
3. You have developed a new program to promote oral health to teenage mothers,
and you would like to discuss your ideas with other health professionals at an
upcoming public health conference to determine ways to expand the program.
Which of the following formats would be best for this presentation?
a. Roundtable discussion
b. Oral presentation
d. Table clinic
The correct answer is a. This answer uses repetition of the term discuss (in
discussion), which provides a clue to the best answer. Answer choices b, c, and d
are ways to present the information, but a roundtable discussion best represents
the purpose of the presentation, which is to discuss ideas with other public health
professionals to determine ways to expand the program.
The correct answer is c. This answer is considerably longer than answer choices
a, b, and d. Also, it is logical that learners will retain information better when they
are actively involved and use more senses in the learning process.
Overview of the NBDHE
The NBDHE is written and administered by the Joint Commission on National
Dental Examinations (JCNDE) of the American Dental Association (ADA). The
purpose of this comprehensive, computer-based, pass/fail examination is to help
state boards assess the qualifications of individuals who seek licensure to practice
dental hygiene.1 “The examination assesses the ability to understand important
information from basic biomedical, dental, and dental hygiene sciences, and the
ability to apply this material in a problem-solving context.”2
According to the JCNDE, the current NBDHE consists of 350 multiple-choice
questions and is administered in two sessions with a one-hour optional break
between sessions.3 The first session (3½ hours) contains approximately 200
discipline-based questions; the second session (4 hours) contains 150 questions
based on 12 to 15 dental hygiene patient cases.2 The three major areas of the first
session and the 13 subjects associated with these three areas are presented in Table
12-1.
TABLE 12-1
Major Areas of the First Session of the NBDHE and Associated Subjects
Data from National Board Dental Hygiene Examination 2015 Guide. Chicago, IL: Joint Commission on
National Dental Examinations; 2015. Available at http://www.ada.org/en/jcnde/examinations/national-board-
dental-hygiene-examination. Accessed January 13, 2015.
The community cases are simulated situations that might occur in the community.
They usually involve the dental hygienist's participation in a particular community
oral health program or activity in relation to a specific target population. The
questions following each community case require application of information, such
as that within this textbook, to select the correct answer. The community cases are
referred to by the NBDHE as scenarios; a scenario in combination with the related
questions is called a testlet.
NBDHE Question Formats
Several different formats are used consistently for questions on the NBDHE,
including the community testlets.2 It is important to become familiar with these
question formats to be able to efficiently answer the community questions on the
examination. Practicing with sample testlets will be helpful to become comfortable
with the various types of questions and to review content. Explanations and
examples of the NBDHE question formats are presented in Box 12-3.
ox 12-3
B
N BDH E Questi on Formats
Question:
Used to test knowledge and understanding, as well as application, analysis,
synthesis, and evaluation of content; consists of a stem that poses the problem,
followed by a list of four or five alternatives or possible answers; one of the
alternatives is the correct or best answer, and the others are called distractors
Example:
What is the type of graph called that shows a plot of variables to depict their
relationship?
a. Pie chart
b. Histogram
c. Scattergram
d. Polygon
a. Administrator/manager
b. Advocate
c. Clinician
d. Researcher
b. Both the statement and reason are correct but NOT related.
b. Using the same message for all members of the population to ensure consistency
d. Focusing oral health education materials on the specific needs of the audience
Testlet No. 1
You practice dental hygiene in a low socioeconomic (SES), multicultural city with a
population of 1.5 million. However, the office where you are employed serves a
relatively higher SES population of the city. The city water supply is not fluoridated;
consequently, dental caries is prevalent in the community. Most families in the city
are of Hispanic descent. You recently assisted the public health dental hygienist in
conducting a screening on the children in a local Title I elementary school to
document their oral health status. Fluoridation was defeated 10 years ago because of
a strong antifluoridation campaign. Fluoridation will be on the ballot again in 8
months. The natural level of fluoride (F) in the community water is 0.2 mg/L. The
following questions relate to this scenario.
1. As a private practice hygienist, what would be the best thing for you to do to help
get the fluoride referendum passed?
a. Continue educating your patients on the benefits of fluoride
b. Start calling community leaders
c. Make a financial contribution to the cause
d. Check with your local dental hygiene component to determine whether a
unified plan of action has been developed and how you might help
2. All of the following political tactics EXCEPT one will be beneficial in ensuring
that the fluoridation referendum will pass. Which one is the EXCEPTION?
a. Public debate with the antifluoridationists
b. Analysis of the referendum of 10 years ago
c. Endorsements by community leaders
d. Distribution of literature in Spanish and English throughout the community
3. Which of the following methods would be best to communicate to the parents the
overall oral needs of their children after the screening?
a. Sending DMFT index results home with the children
b. Mailing literature on the importance of children's oral health to the parents
c. Phoning the parents to report findings of the screening on their children and
refer them for treatment
d. Sending Basic Screening Survey results home with a referral and list of local
community clinics
4. How much F should be added to the water to bring the F level to the optimal F
level recommended by the CDC?
a. 0.5 mg F
b. 0.7 mg F
c. 0.8 mg F
d. 1 mg F
5. If the fluoridation referendum fails to pass once again, which alternative program
would be the best to implement?
a. Send letters to parents to recommend that they take their children to the dentist
for treatment and fluoride
b. Give oral hygiene lessons in the classrooms
c. Initiate a school fluoride varnish program
d. Implement a sealant program
Testlet No. 2
Upon completion of a community oral health certification program, you are
employed as a public health dental hygienist in a local health department to develop
the first oral health unit in the department. You are asked to plan, implement, and
evaluate a school-based educational and preventive program for selected
elementary schools in the school district. The program is to be based on the Healthy
People 2020 oral health objectives. Your plan includes classroom education and the
use of a mobile dental van to provide screenings, cleanings, sealants, fluorides, and
referrals to dental homes. Data will be collected using the DMFT index. The
following questions relate to this scenario.
1. The program addresses all of the following Healthy People 2020 objectives
EXCEPT one. Which one is the EXCEPTION?
a. Increase the proportion of health departments that have an oral health
component
b. Increase the proportion of children who receive preventive dental services
c. Increase the number of dental public health programs that are directed by an
oral health professional with specialty public health training
d. Reduce the incidence of periodontitis and gingivitis in children
2. The index used to collect data will be helpful in assessing which of the following?
a. The demand for services from your oral health program
b. The amount of gingivitis and periodontitis in children's teeth
c. The need for dental services to be provided by the dental homes
d. The children's risk of contracting medical conditions
3. In the evaluation phase of the program, you plan to measure the children's
performance skills in the area of oral hygiene. Which method would be best to
accomplish this?
a. A written pretest and posttest
b. A demonstration of the procedures by the children
c. An oral survey of the children's attitudes about oral health
d. A surprise measurement of the index at the school after lunch
4. The DMFT scores are correlated with oral hygiene, resulting in a correlation
coefficient of 0.30. What is the correct interpretation of these results?
a. Moderate positive relationship
b. Weak positive relationship
c. Moderate negative relationship
d. Weak negative relationship
5. All of the following programs EXCEPT one would be potential resources for
payment for dental services that might be needed by this target population. Which
one is the EXCEPTION?
a. Medicare
b. Medicaid
c. State Children's Health Insurance Program (CHIP)
d. Private insurance
Testlet No. 3
One of your private practice patients is a nursing home administrator. She requests
your assistance in providing an oral healthcare program for the patients with
Alzheimer's disease who reside at the Manor Care. The program is to include
education, routine screening, and referral. Screening data are collected with the
BSS, PHP, and oral cancer examinations. The residents are from a lower SES group
and have complex health histories. The social worker has consents for dental
treatment, if needed, and the center has a vehicle to use for transportation. The
following questions relate to this case.
1. What would be the first step in planning the program?
a. Arrange a time for an in-service for the nursing home staff
b. Survey attitudes of the staff about oral health to determine what is needed
c. Arrange a meeting of key nursing home staff to assess needs and determine
goals and objectives
d. Plan an education session for the residents
2. The screening indicates that there is a need for better oral hygiene and dental
restorative treatment. All of the following EXCEPT one are possibilities for
dental care for the patients who are mobile. Which one is the EXCEPTION?
a. Ask the dentist and hygienist in your community who use portable equipment to
include Manor Care on their list of nursing homes to visit
b. Check with the nearby dental school to arrange to transport residents to their
clinic for dental treatment on a reduced-fee or no-cost basis
c. Take the residents to a community clinic that bases its fees on a sliding scale
d. Take the residents to a private practice dentist who accepts Medicare patients
3. The PHP is the only appropriate index to use to evaluate the program because
assessment and evaluation data can only be compared when they are collected
using the same criteria.
a. Both the statement and reason are correct and related.
b. Both the statement and reason are correct but NOT related.
c. The statement is correct but the reason is NOT.
d. The statement is NOT correct but the reason is correct.
e. NEITHER the statement NOR the reason is correct.
4. Six months after initiation of the program, family members are surveyed to
determine their satisfaction to be able to adjust program activities if necessary.
What type of evaluation is this?
a. Formative and quantitative
b. Summative and quantitative
c. Formative and qualitative
d. Summative and qualitative
5. Which ethical principle is reflected by the use of consents in this program?
a. Nonmaleficence
b. Beneficence
c. Autonomy
d. Fidelity
Testlet No. 4
You reside in a small town and work in a community clinic. The regional public
health dental hygienist asks for your assistance in assessing, planning, and
implementing oral health programs in your town. She is especially concerned about
the older adult population and about developing a tobacco awareness program in the
middle school. You examine secondary data to be able to provide a clear description
or “snapshot” of the community before proceeding with further steps in program
planning. The following questions relate to this scenario.
1. The assessment described in the scenario is called a community profile. The
assessment described provides all the data required to proceed with program
planning.
a. Both statements are true.
b. Both statements are false.
c. The first statement is true; the second is false.
d. The first statement is false; the second is true.
2. You decide to collect baseline data on the older adults who visit your clinic to
document their needs and possibly to use in securing funds for program
development for the older adult population in the community. You want to
measure the health of gingiva, presence or absence of bleeding, calculus,
periodontal pockets, and loss of attachment. The index of choice for this purpose
is which of the following?
a. OHI-S
b. DMFT
c. PDI
d. CPI
3. You intend to survey the middle school students to assess their perception of how
susceptible they are to addiction and cancer caused by tobacco products. In your
prevention program you will present the benefits of not smoking or chewing
tobacco and will discuss the results of their decisions. Which model of health
promotion are you using?
a. Stages of Change Theory
b. Social Learning Theory
c. Community Organization Theory
d. Health Belief Model
4. Upon completion of your tobacco awareness program, you intend to present the
results to other healthcare professionals at a health promotion meeting. Which
strategy would you choose if you wish to reach a large number of people, have
time for interaction, and do not intend to use audiovisual equipment?
a. Poster presentation
b. Roundtable discussion
c. Oral paper
d. Table clinic
5. You bring your tobacco awareness program to the state public health dental
hygienist. In attempting to follow the essential services of the public health core
functions, the state dental hygienist wants to support and implement programs at
all levels of prevention. At which level of prevention is your tobacco program?
a. Primary
b. Secondary
c. Tertiary
d. Assurance
Testlet No. 5
You are contacted by the administrator of a group home for mentally challenged
adults to develop an oral health program for the staff. The administrator has
received multiple complaints from the attending caregivers regarding the residents'
oral health. Limited manual dexterity abilities of the residents require that they
receive assistance with oral hygiene routines; yet complaints of severe resident
halitosis and bleeding during normal oral hygiene routines have made the
caregivers reluctant to provide assistance. After gathering basic demographic
information, you visit the facility to determine the actual oral health status of the
residents. The following questions relate to this case.
1. You conduct an oral health survey using the GI on the residents who have natural
teeth. The following scores are recorded: 2.50, 2.70, 2.80, 3.0, 2.50, 2.40, and 2.90.
What is the mean GI score of these residents?
a. 2.50
b. 2.69
c. 2.70
d. 7.0
2. What is the BEST way to assess that daily oral hygiene protocols are being
adhered to for the residents?
a. Assess the values of caregivers by conducting focus groups
b. Measure the plaque biofilm and gingivitis scores of residents over time
c. Observe the residents' ability to brush correctly
d. Observe the caregivers' ability to brush correctly
3. Which of the following is the BEST use of the dental hygienist in this situation?
a. Conduct an educational program for the residents regarding daily oral hygiene
care
b. Use portable equipment to provide dental hygiene services to the residents
c. Present an in-service training program to the group home staff
d. Provide daily oral hygiene care for the residents
4. Which of the following is an effective teaching strategy to raise the caregivers'
compliance in this situation?
a. Demonstrate the proper oral hygiene procedures to them
b. Provide a lecture for them on the importance of oral hygiene
c. Show them pictures of good oral health versus oral disease
d. Provide training on how to maintain personal oral hygiene skills for
themselves
5. What is the best action to take before conducting the screening to make sure the
results will be reliable?
a. Acquire informed consent
b. Calibrate the examiners
c. Inform the residents about the screening procedures
d. Plan how many residents will be screened
Answers and Rationales
The answers and rationales for each answer are presented. Also, chapter cross-
references are provided to help you review related information in the text.
Testlet No. 1
1. d. A unified plan of action is the best defense against a strong antifluoridation group. Answers a, b, and c are also possibilities of things you can do, but
d is best and foremost because it can have the greatest impact (see Chapter 6).
2. a. A public debate with antifluoridationists only provides them with an opportunity to reach more people with their scare tactics. In addition, most of
their arguments appeal to emotions, making it difficult to have an effective debate. Analysis of any prior fluoridation campaign efforts and getting
support of community leaders are key steps in preparing for a campaign. Use of educational materials in the primary languages of the community is
critical (see Chapter 6).
3. d. The Basic Screening Survey (BSS) is an easy tool to let parents know whether the child needs emergency care, treatment is necessary, or routine care
is recommended. Local community clinics provide the best fee for service for low-income patients. It is difficult to reach people by phone, and a
follow-up list for referral is important to the screening process for ethical reasons (see Chapters 2 and 4).
4. a. The addition of 0.5 mg F to the naturally occurring 0.2 mg F per L of water will result in 0.7 mg F, which is the new CDC recommendation for the
optimal level (see Chapter 6).
5. c . A school fluoride varnish program would be the next choice because it is inexpensive and would benefit all the children in reducing dental decay.
Sealants are more expensive and do not replace fluoride. Education does not guarantee a reduction in decay. Both sealants and education should be
used in conjunction with a community fluoride program (see Chapter 6).
Testlet No. 2
1. d. Increasing the proportion of health departments that have an oral health component, increasing the number of dental public health programs that are
directed by an oral health professional with specialty public health training, and increasing the proportion of children who receive preventive dental
services are all Healthy People 2020 objectives and have the potential to be impacted by the programs described (newly established oral health unit
that is directed by a dental hygienist with certification in community oral health and that provides preventive services [screening, cleanings, sealants,
fluorides, and referrals]). Reducing the incidence of periodontitis and gingivitis in children is not a Healthy People 2020 objective (see Chapters 3 and
5).
2. c . An assessment such as that conducted using the Decayed, Missing, or Filled Teeth (DMFT) index determines the need for oral health services, not the
demand. Answers b and d would not be appropriate because the DMFT is an assessment tool for determining dental caries experience, not gingivitis,
periodontitis, or risk of medical conditions (see Chapter 4 and Appendix F).
3. b. Evaluation of performance is best conducted with an activity or demonstration by the person being evaluated. Knowledge and attitudes do not indicate
that the children have developed the necessary oral hygiene skills. The DMFT does not measure oral hygiene (see Chapters 6 and 8 and Appendix F).
4. b. Correlation coefficient results demonstrate the strength and direction of the relationship between two variables. The sign of the coefficient (negative or
positive; below or above 0) indicates the direction of the relationship. The value of the coefficient indicates the strength of the relationship: 0.9 to 1.0
is very strong, 0.70 to 0.89 is strong, 0.50 to 0.69 is moderate, 0.26 to 0.49 is weak, and 0.25 and below shows little if any relationship (see
Chapter 7).
5. a. Medicaid, CHIP, and private insurance include dental treatment benefits for children. The Affordable Care Act requires dental insurance coverage for
children. Medicare is a program for older adults (ages 65 and older) and it does not cover routine dental services (see Chapters 5 and 6).
Testlet No. 3
1. c . Assessment of needs is always the first step in program planning. A meeting with agency staff must take place before implementing any needs
assessment activities with the target population. An educational program with the residents is not feasible for this population of Alz heimer's patients
(see Chapters 3 and 8).
2. d. All of these approaches would be feasible except choice d because Medicare does not offer benefits for routine dental treatment (see Chapters 5 and 6).
3. a. The same index should be used at evaluation that was used for screening to be able to compare the results of these measures to evaluate the program.
The Patient Hygiene Performance (PHP) index is the only index used for assessment in this scenario. The Basic Screening Survey (BSS) is a survey
method, not an index (see Chapter 4).
4. c . Measurement of ideas and opinions (satisfaction) is qualitative. Measurement during a program for the purpose of making adjustments is formative
(see Chapters 3 and 6).
5. c . Use of autonomy is agreeing to respect the rights of the residents to self-determine participation in the program. Nonmaleficence, beneficence, and
fidelity do not relate to informed consent (see Chapter 9).
Testlet No. 4
1. b. The community profile is a comprehensive description of the community developed through a formal organiz ed community assessment process. The
brief description or “ snapshot” described in the scenario is done as one of the first steps before collecting data as part of a comprehensive assessment
that can result in a community profile. Program planning is based on the needs and population characteristics identified in a community profile (see
Chapter 3).
2. d. The Community Periodontal Index (CPI) entails gathering data in all the areas described to assess periodontal status. It is a modification of the
Community Periodontal Index of Treatment Needs (CPITN) and is more readily used. The other indexes are too specific and not as inclusive. The Oral
Hygiene Index-Simplified (OHI-S) measures only oral hygiene, not parameters of periodontal disease. The DMFT measures only dental caries
experience. The Peridontal Disease Index (PDI) is not widely used anymore (see Chapter 4 and Appendix F).
3. d. The Health Belief Model (HBM) is the only one listed that includes information on the people's perceptions or beliefs about oral health. Also, one of the
key concepts of the HBM is a focus on the benefits of healthy behavior (see Chapter 8).
4. a. The poster presentation allows for the most interaction with the largest number of people. This is a popular presentation method at health promotion
meetings. Audiovisual equipment is not used and personal interaction is foremost (see Chapter 8).
5. a. A tobacco awareness program is an example of primary prevention, which is directed at preventing a disease before it occurs. Secondary prevention
involves treatment to reduce or eliminate disease in the early stages. Tertiary prevention limits disability from disease in more advanced stages.
Assurance is a core public health function that consists of services provided, including preventive programs that address any level of prevention (see
Chapters 1, 2, and 6).
Testlet No. 5
1. b. To find the mean, add the scores and divide by the total number of scores (n); the result is 2.69. The score 2.50 is the mode, 2.70 is the median, and
7.0 is n (see Chapter 7).
2. b. The only real measure of actual oral hygiene routines and their subsequent effectiveness is the residents' oral hygiene over time. Answers a and d
assess short-term objectives designed to lead to the final desired outcome, which in this case is improved oral hygiene of the residents. Answer c is
inappropriate since the residents' dexterity is compromised and the staff members are expected to assist them with daily oral hygiene (see Chapters 4
and 6).
3. c . A principle of the role of the dental hygienist in public health is to maximiz e the effect by educating and training others who can provide education or
services directly to the target population (see Chapter 2).
4. d. Training caregivers in personal oral hygiene will provide them an opportunity to experience the benefits of good oral hygiene. After this is valued, the
caregivers will be more likely to assist residents with their daily oral hygiene. In addition, this training will increase the caregivers' confidence in their
abilities to improve the residents' oral health (self-efficacy), which is also an important factor in compliance. Other answers are worthwhile strategies
but are less likely to increase compliance (see Chapter 8).
5. b. Training and calibration of examiners is the best way to make sure that the data being collected are reproducible or reliable (see Chapter 7).
References
1. Tsai TH, Dixon BL. Setting and validating the pass/fail score for the
NBDHE. J Dent Hyg. 2013;87:90.
2. National Board Dental Hygiene Examination 2015 Guide. Joint
Commission on National Dental Examinations; 2015 [Available at]
http://www.ada.org/en/jcnde/examinations/national-board-dental-hygiene-
examination [Accessed September 16, 2015].
3. National Board Dental Hygiene Examination Frequently Asked Questions;
November 21, 2014. Joint Commission on National Dental Examinations;
2015 [Available at] http://www.ada.org/en/jcnde/examinations/national-
board-dental-hygiene-examination [Accessed January 13, 2015].
AP P E N D I X A
Additional Websites for Community
Resources
In addition to the references at the end of each chapter, resources have been
provided in the Additional Resources at the end of most chapters. The government
websites in Appendix D listed as resources for assessment can be useful for
community programming as well. Other resources are the professional and
community organizations listed here.
www.agd.org
American Academy of Pediatric Dentistry (AAPD)
www.aapd.org
American Academy of Periodontology (AAP)
www.perio.org
American Association of Dental Research (AADR)
www.aadronline.org
American Association of Endodontists (AAE)
www.aae.org
American Association of Orthodontists (AAO)
www.aaoinfo.org
American Association of Public Health Dentistry (AAPHD)
www.aaphd.org
American Cancer Society
www.cancer.org
American College of Prosthodontists (ACP)
www.prosthodontics.org
American Dental Assistants Association (ADAA)
www.dentalassistant.org
American Dental Association (ADA)
www.ada.org
American Dental Education Association (ADEA)
www.adea.org
American Dental Hygienists' Association (ADHA)
www.adha.org
American Diabetes Association
www.diabetes.org
American Heart Association
www.heart.org
American Medical Association (AMA)
www.ama-assn.org
American Public Health Association (APHA)
www.apha.org
Association of State & Territorial Dental Directors (ASTDD)
www.astdd.org
Fédération Dentaire Internationale (FDI; World Dental Federation)
www.fdiworldental.org
International Association for Dental Research (IADR)
www.iadr.com
National Center for Dental Hygiene Research & Practice
dent-web10.usc.edu/dhnet
National Dental Practice-Based Research Network
www.nationaldentalpbrn.org
Oral Health America
www.oralhealthamerica.org
Society for Public Health Education (SOPHE)
www.sophe.org
AP P E N D I X B
Dental Hygiene Competencies
According to the Competencies for Entry into the Profession of Dental Hygiene
approved and adopted by the American Dental Education Association (ADEA)
House of Delegates in 2011, the dental hygienist must exhibit competencies in five
domains. The five general domains are themes or broad categories of professional
focus that transcend the curriculum and are intended to encourage professional
emphasis and focus throughout the curriculum. Within each domain, major
competencies expected of the program graduate are identified. Each major
competency reflects the ability to perform or provide a particular professional
activity that is intellectual, affective, psychomotor, or all of these in nature. These
competency statements are meant to serve as guidelines. The Competencies is not
intended to be a stand-alone document and should be used in conjunction with other
professional documents developed by dental hygiene and dental education
professional organizations.
Competency Domains
1. Core Competencies (C) reflect the ethics, values, skills, and knowledge integral to
all aspects of the dental hygiene profession. These core competencies are
foundational to the specific roles of the dental hygienist.
2. Health Promotion and Disease Prevention (HP) are key components of health
care. Changes within the healthcare environment require that dental hygienists have
a general knowledge of wellness, health determinants, and characteristics of various
patient communities.
3. Community Involvement (CM) involves a complex and expanding role for the
dental hygienist at the local, state, and national levels. This role requires that the
dental hygienist be able to assess, plan, implement, and evaluate programs and
activities designed to benefit the oral health of the general population as well as
specific priority populations. In addition, the dental hygienist must be prepared to
influence others to facilitate access to oral health care and services.
4. Patient Care (PC) competencies for the dental hygienist are described here in
ADPIE format. Dental hygienists assess, diagnose, plan, implement, and evaluate in
relation to dental hygiene treatment. The role of the dental hygienist in patient care
is ever changing, yet central to the maintenance of health. Dental hygienists must
follow the defined ADPIE process for the provision of patient care services and
treatment modalities. To that end they must be appropriately educated in an
accredited program and credentialed to provide patient care services according to
the varied requirements of individual jurisdictions.
Planning
PC.6 Utilize reflective judgment in developing a comprehensive patient dental
hygiene care plan.
PC.7 Collaborate with the patient and other health professionals as indicated to
formulate a comprehensive dental hygiene care plan that is patient-centered and
based on the best scientific evidence and professional judgment.
PC.8 Make referrals to professional colleagues and other health care professionals
as indicated in the patient care plan.
PC.9 Obtain the patient's informed consent based on a thorough case presentation.
Implementation
PC.10 Provide specialized treatment that includes educational, preventive, and
therapeutic services designed to achieve and maintain oral health. Partner with the
patient in achieving oral health goals.
Evaluation
PC.11 Evaluate the effectiveness of the provided services and modify care plans as
needed.
PC.12 Determine the outcomes of dental hygiene interventions using indices,
instruments, examination techniques, and patient self-reports as specified in patient
goals.
PC.13 Compare actual outcomes to expected outcomes, reevaluating goals,
diagnoses, and services when expected outcomes are not achieved.
Adapted from Oral Health Coalition Framework (PDF). Atlanta, GA: CDC Division of Oral Health;
2013. Available at www.cdc.gov/OralHealth/state_programs/pdf/coalition_framework.pdf. Accessed
July 2015.
AP P E N D I X D
Resources for Community Health
Assessment
Appendix D-1 Examples of Government
Resources for Health Data
Resources for health and oral health information are available from many
organizations and governmental agencies. These sources include: clearinghouses
and resource centers; federal, state, and local government agencies; foundations;
policy and research centers; professional, nonprofit, community, health, and
voluntary organizations; programs and initiatives; and health care organizations.
This section will concentrate on resources available through government entities.
Listed here are websites for some of the government resources for health and oral
health data. The National Maternal and Child Oral Health Resource Center listed
here also has a listing of Internet links to many organizations and agencies that
provide oral health information (www.mchoralhealth.org/Links/index.html).
Appendix A and many of the Additional Resources at the end of each chapter can
also be useful to access health data.
www.aoa.acl.gov
Administration for Children and Families (ACF)
www.acf.hhs.gov
Administration on Disabilities
www.acl.gov/Programs/AoD/Index.aspx
Agency for Healthcare Research and Quality (AHRQ)
www.ahrq.gov
Centers for Disease Control and Prevention (CDC)/Division of Oral Health (DOH)
www.cdc.gov/oralhealth/index.htm
Centers for Medicare & Medicaid Services (CMS)
www.cms.gov
Department of Health & Human Services (DHHS)
www.hhs.gov
Government Grants
www.grants.gov
Health Resources and Services Administration (HRSA)
www.hrsa.gov
Healthy People 2020
www.healthypeople.gov
Indian Health Service, Division of Oral Health
www.ihs.gov/DOH
National Center for Health Statistics (NCHS), CDC
www.cdc.gov/nchs/index.htm
National Institute of Dental and Craniofacial Research (NIDCR)
www.nidcr.nih.gov
National Institutes of Health (NIH)
www.nih.gov
National Maternal and Child Oral Health Policy Center
http://nmcohpc.net
National Maternal and Child Oral Health Resource Center (OHRC), Georgetown
University
www.mchoralhealth.org
National Oral Health Information Clearinghouse (NOHIC; a service of NIDCR)
http://www.ninds.nih.gov/find_people/government_agencies/volorg6
National Oral Health Surveillance System (NOHSS), CDC
www.cdc.gov/nohss/index.htm
Occupational Safety and Health Administration (OSHA)
www.osha.gov
Synopses of State Oral Health Programs, CDC
www.cdc.gov/oralhealthdata/overview/synopses/index.html
Water Fluoridation Reporting System (WFRS)
http://www.cdc.gov/fluoridation/factsheets/engineering/wfrs_factshee
World Health Organization, Oral Health Databases
www.who.int/oral_health/databases/en/index.html
Appendix D-2 Summary of Data Collection
Methods
Cost
Me thod Instrume nt and Advantag e
Time
Doc ume nt Study
Review and evaluate existing documents or records Information abstracted from archival sources (raw data, datasets of summary $-$$ Data often
describing past events or occurrences data, printed reports); qualitative or quantitative data from public legislative - readily
bodies, governmental officials and agencies, private businesses, professional available
and community organiz ations, and nonprofit foundations
Obse rvational Fie ld Study
Assessment of actual events, objects, or people in Assessors use checklists, evaluation forms, cameras, tape recorders, rating $$ Provides first-
“ natural” setting scales, and observation field notes; qualitative approach with content or hand
situational analysis information
Windshie ld or Walking Tour
Within community-designated boundaries, Observers and recorders document community characteristics and record $-$$ Provides first-
observers and recorders drive or walk in information using observational guides, checklists, survey tools, notes, - hand
community areas at varying times of day and days photos, audiotapes, and videotapes; qualitative approach with content or information
of the week to assess community activities, situational analysis; results summariz ed and displayed through written
interactions, and events through observation, narratives, tables, diagrams, slide and video shows, maps, and collages
informal conversations, and interactions with
community members
Maile d Surve y
Assessment (e.g., surveys, polls, evaluations) Self-administered standardiz ed, structured questionnaire with closed- and $$ Data can be
conducted by direct mail; adaptations include open-ended questions completed by respondent; quantitative approach with collected from a
questionnaire sent home with children from school, statistical analysis of responses large sample
telefax surveys, magaz ine or newsletter surveys,
or electronic surveys (using networked computers,
email, Internet, websites, blogs, social media, social
networking pages, Facebook, Twitter, Flickr)
Te le phone Inte rvie w
Survey interview conducted by telephone Interviewer reads structured interview schedule (standardiz ed, questionnaire) $$ Data can be
with closed- and open-ended questions to respondent; quantitative approach collected from a
with statistical analysis of responses large sample
Pe rson-to-Pe rson Inte rvie w
Survey interview conducted face-to-face between a Structured interview schedule (standardiz ed, questionnaire) with closed- and $$-$$$ Face-to-face
respondent and an interviewer open-ended questions read to respondent by an interviewer; quantitative - communication
approach with statistical analysis of responses allows for
more in-depth
information
and overcomes
lack of literacy
In-De pth Pe rsonal Inte rvie w
Survey conducted face-to-face to learn about life Interviewer uses open-ended, flexible, unstructured nondirective questions; $$-$$$ Can be used
history, events, and experiences transcriptions of tape recordings used for thematic analysis of content - with a smaller
sample with
expanded
perspectives
Sc re e ning Surve y
Rapid assessment using screening procedures Standardiz ed written criteria and measurements, measuring instruments, and $$ Can provide
protocols; cursory inspection provides crude estimates; quantitative approach practical and
with statistical analysis of results uniform
information in
a short time
period
Epide miolog ic Surve y
Extensive assessment using examination Standardiz ed written criteria and measurements, measuring instruments, and $$-$$$ Provides more
procedures, clinical samples, and clinical tests protocols; detailed planning of examination conditions, indices, criteria, - detailed
sampling approaches, personnel training, data collection, data management, information
and analysis; quantitative approach with statistical analysis of results
Asse t Maps
Geographic study and mapping that can identify Input and display of data from existing sources or new data onto geographic $-$$ Provides good
patterns of community characteristics, physical map using simple materials (map and adhesives or pushpins) or detailed - overview and
assets, or settings of human activity and community planning and evaluation computer software (e.g., Geographic visualiz ation
interactions Information System [GIS] computer software) and other powerful tools for of information
organiz ing location, distribution, and mapping of spatial data
Inve ntorie s or Dire c torie s
Documenting and cataloging of assets and Identify, evaluate, and organiz e assets and capacities in a community and $-$$ Data often
capacities of individual community members or develop adequate mechanisms for linkages that can produce opportunities for - have been
community resources such as institutions, action; such capacities may include assets owned or skills processed by collected
organiz ations, and associations individual community members; may also include sources of mutual aid, previously
connections, and resources among institutions, organiz ations, and
associations in a community
Foc us Group
Guided group discussion provides information on a Moderator leads guided group discussions among 6 to 12 individuals over 45 $$-$$$ Provides varied
specific topic from a certain population group to 90 minutes by using a series of open-ended questions on a preestablished - and ample
discussion guide; transcriptions from tape recordings and written field notes of information
discussions used for thematic analysis of content
Public Forum or Community Dialog ue Eve nt
Individuals or groups provide verbal input or Moderator solicits, collects, and summariz es written comments or oral $$ Provides first-
feedback on specific issues testimony; oral testimony recorded by tape recorder or court reporter to hand and
generate official record for analysis ample
information
Community Visioning Proc e ss
Groups of community stakeholders collectively Through an interactive approach (retreat or workshop format), a skilled $$-$$$ Provides varied
develop shared vision of their community in the facilitator brings individuals together over one or more days and guides - input for
future participants through the vision process by posing questions and assisting broad-based,
participants to visualiz e the future community and possibilities for forward ample
advancement; small groups discuss visions and images; creation of document information
to reflect visions; follow-up meeting held to refine visions and to develop plan
for incorporation of visions into community planning process
Cre ative Asse ssme nt
Community members document perceptions of Creative techniques and forums for expression (e.g., photography, film, $$-$$$ Provides
community through creative means theater, music, dance, murals, puppet shows, storytelling, drawings) used to - interesting and
convey wide range of perceptions of a community innovative
information
$, Inexpensive; $$, moderate cost; $$$, expensive; , less time-consuming; , moderately time-
consuming; , very time-consuming.
Appendix D-3 Examples of Information for a
Community Health Assessment
Community He alth Me asure s Example s
He alth Status (measurements of Birth statistics: Age, parity of mother, duration of pregnancy, types of births (single, twin), complications of pregnancy,
natality [births], morbidity complications of birth, birth defects, birth weight (e.g., low), premature births, and births to adolescent, older, or
[illness], and mortality [deaths]) unmarried females
Morbidity statistics: Incidence and prevalence of diseases, conditions, disabilities, injuries (distribution, intensity, and
duration) such as unintentional and intentional injuries, homicide, suicide, cancer, heart disease, diabetes, stroke,
infectious diseases (communicable), HIV/AIDS, tuberculosis, STD, mental illness, alcohol and drug abuse problems,
occupational diseases, disability and decreased independence, developmental disabilities (e.g., cleft lip and/or palate,
craniofacial anomalies), oral diseases or conditions (e.g., dental caries, periodontal diseases, or oral injuries)
Mortality statistics: Distribution of death rates by age, race/ethnicity, sex, cause, geographic location, leading causes of
deaths such as cancer (breast, colon, lung, or oral), heart disease, stroke, homicide, motor vehicle injuries, suicide,
unintentional injury, and infant, neonatal, and postneonatal mortality
He alth risks and prote c tive Self-rated (self-reported) general and oral health status: Recent poor health, days of work lost, days of school lost
fac tors (identification of patterns (e.g., caused by dental problems or care), average number of unhealthy days in past month, and satisfaction with quality
of behavioral and nonbehavioral of life and public health, health care, and social service system
factors) Occupational risks and work disability: Exposure to chemicals and physical, musculoskeletal, psychological, and other
forms of stress; loss of mobility; physical and emotional challenges
Stress indicators and resources (drunk driving, robberies, or assaults), access to drugs, recent drug use, alcoholic
beverage outlets, gang problems, family violence (child abuse and neglect, spouse and elder abuse), major depression, self-
esteem, alienation, discrimination, feelings of hope and despair, feelings of anger, social and family support, social and
family resources (adaptation and cohesion), life events, or stress (personal, family, or job stress)
Levels of health knowledge, beliefs, attitudes, behaviors, practices, and skills about self-care (toothbrushing with
fluoride toothpaste and flossing) and health interventions; lifestyle, including diet (low in sugar), physical activity,
health-related substance use (tobacco and alcohol), and safety practices (seat belts, mouthguards); and knowledge about
location, availability, and appropriate use of local health resources, services, programs, family healthcare expenditures
Use of child and adult preventive health services, including dental sealants, fluoride treatments, prenatal care in first
trimester, immuniz ations for children and adults, Pap smear, mammogram, and sigmoidoscopy for colon cancer
screening
Ac c e ss to public he alth, Access to community preventive services (community water fluoridation) and public health services: Scope and
he alth c are , and soc ial adequacy of local health department covering essential public health services (including infrastructure and capacity
se rvic e syste m (scope, adequacy, measures, local voluntary health programs, operational health promotion and education programs in work sites, schools,
accessibility, and availability of and community) by health providers, numbers, types, locations, and adequacy
services in a coordinated, Access to facilities for personal health care: Assessment of numbers, types, location, and adequacy of hospitals;
integrated system) emergency facilities; outpatient primary care; oral health care; hearing care; vision care; speech, physical, and
occupational therapy; urgent care; mental health care; alcohol and drug treatment programs; nursing homes; community
health centers
Access to health professionals: Adequacy and numbers of educated public health professionals and personal health
service professionals with expertise and competence, levels of knowledge, attitudes, behaviors, practices, and skills of
public health professionals and personal health service professionals
Access to health insurance and usual sources of health care: Comprehensive benefits with dental insurance and per
capita spending (e.g., Medicare, Medicaid, Children's Health Insurance Program [CHIP], private insurance, Supplementary
Security Income [SSI])
Scope and adequacy of local social service programs in addressing basic human, family, and community needs
DMF. Decayed, Missing, or Filled index in its various forms (DMFT for teeth and DMFS for surfaces; upper
case DMF for permanent dentition and lower case dmf, def, and df for primary dentition) and combinations
(D, M, F, DF, MF) to analyze rates of dental caries, caries experience, and untreated caries.
AP P E N D I X F
Common Dental Indexes
De ntal Inde x Crite ria/Inte rpre tation
De ntal Carie s Inde xe s
Dental caries indexes are cumulative and irreversible.
Decayed, Missing, or Filled (DMF) Index: • Components of DMF:
• An index used to measure clinically observable coronal caries in • D denotes dental caries, including recurrent decay.
permanent dentition only; can be scored on teeth (DMFT) or • M denotes missing as a result of dental caries.
surfaces (DMFS). • F denotes filled due to caries with no current decay.
• DMFT is recommended for population surveys, and DMFS is • Is typically based on 28 teeth (third molars are not scored).
recommended for clinical trials because it provides more • Tooth or surface is scored only as one component (e.g., if recurrent decay is present,
sensitivity even though it has greater variability. it is scored only as D).
• Missing and filled teeth for reasons other than caries are not scored (e.g., missing due
to periodontitis, orthodontic treatment, trauma, surgical removal of impaction, or
unerupted; filled due to cosmetic purposes, trauma, or bridge abutment).
• Interpretation requires analysis of components as well as total DMF (e.g., a high D
and low F reflects high caries experience and low utiliz ation of dental care whereas a
high F and low D reflects high caries experience but high utiliz ation of dental care;
also a high M reflects a different type of dental care, possibly emergent care only).
• Results can be reported in several ways:
• Total DMF = caries experience
• D/DMF = rate of decayed teeth or treatment needs (active caries or morbidity)
• M/DMF = rate of missing teeth (mortality)
• F/DMF = rate of filled teeth
dmf, def, df Indexes: • Components of dmf
• Lower case letters represent a variation of the DMF used to • d = decayed with no recurrent caries
measure observable caries in the primary dentition; teeth are • m = missing due to caries (not exfoliated)
scored as dmft, deft, or dft or surfaces are scored as dmfs, defs, or • f = filled due to caries
dfs. • Components of def
• dmf is applied only to primary molars. • d = decayed with no recurrent caries
• def and df are scored on all primary teeth; they are modifications • e = severe caries indicated for extraction (not extracted)
of the dmf by not counting missing teeth, thus avoiding potential • f = filled due to caries
errors due to exfoliation and increasing the reliability compared to • Missing teeth are not scored, regardless of reason
the dmf but also possibly resulting in underestimation of caries • def provides more information than df since it allows for two grades of severity of
experience. carious lesions (greater sensitivity).
NOTE FOR MIXED DENTITION: • Components of df
The DMF and dmf, def, or df indexes are scored separately and • d = decayed with no recurrent caries (no differentiation of severity of caries)
never combined or added together. • f = filled due to caries
• Missing teeth are not scored, regardless of reason
• df has greater reliability than def because it controls for the subjectivity of scoring
severity of carious lesion (as indicated for extraction).
• Other scoring criteria and interpretation of the dmf, def, and df indexes are the same
as for the DMF.
Root Caries Index (RCI): • Expressed as a percentage of decayed and filled root surfaces out of the population of
• Used to measure total root caries experience. at risk root surfaces.
• Scored on both supra- and subgingival root surfaces that are • All exposed root surfaces are scored (four surfaces per tooth: mesial, distal,
exposed to the oral environment. lingual/palatal, and facial).
• Only cavitated lesions are scored as decayed.
• Supra- and subgingival lesions can be reported separately.
Classification of Early Childhood Caries (ECC) and Severe ECC Criterion:
Early Childhood Caries (S-ECC): • One or more dmfs (cavitated or noncavitated) in children younger than 6 years
Evaluation of a preschool age child's primary dentition (from birth S-ECC Criteria (vary with age):
to age 72 months or up to age 6 years) to determine whether one or • Younger than 3 years: Any sign of smooth-surface caries
more surfaces are decayed (noncavitated or cavitated lesions), • Age 3 years: One or more cavitated dmfs in maxillary anterior teeth OR four or
missing (due to caries), or filled (because of dental caries). more dmfs
• Age 4 years: One or more cavitated dmfs in maxillary anterior teeth OR five or
more dmfs
• Age 5 years: One or more cavitated dmfs in maxillary anterior teeth OR six or more
dmfs
Ging ival Inde xe s
Gingival indexes are reversible.
Gingival Index (GI): • Scoring Criteria:
• The core index for measuring the severity of marginal gingivitis. 0—Normal, healthy gingival tissues
• Can be used to determine prevalence and severity of gingivitis in 1—Mild inflammation: slight change in color and/or slight edema; no bleeding on
epidemiologic surveys and individual dentition. probing
• Often used in controlled clinical trials of preventive or therapeutic 2—Moderate inflammation: bleeding on probing and other signs of inflammation
agents. 3—Severe inflammation: tendency to spontaneous bleeding and other marked signs of
• Measured by clinical observation, by pressing the probe on the inflammation such as striking redness, edema, and ulceration
gingiva to determine degree of firmness, and by “ walking” the • Interpretation of GI:
probe inside the gingival sulcus to determine the number of sites 0.1–1.0: Mild inflammation
of gingival bleeding. 1.1–2.0: Moderate inflammation
• Reported as a mean score for the individual, population, or 2.1–3.0: Severe inflammation
research group. • Results can be unreliable and difficult to replicate due to subjectivity of criteria
(calibration is critical).
Modified Gingival Index (MGI): • Scoring Criteria:
• Modification of the GI by eliminating the probing and redefining 0—Normal, healthy gingival tissues
the scoring, using the same clinical observation criteria used by 1—Mild inflammation involving any portion of but not the entire marginal or
the GI. papillary gingival unit
• Developed to reduce the probability of disturbing plaque during 2—Mild inflammation involving the entire marginal or papillary gingival unit
probing, decrease gingival trauma caused by probing, and 3—Moderate inflammation
minimiz e the calibration required to control examiner error. 4—Severe inflammation
• The MGI provides a less sensitive measure of gingivitis than the GI because of the
elimination of the bleeding component.
Sulcus Bleeding Index (SBI): • Scoring Criteria:
• A complex index designed to detect early (initial) symptoms of 0—Healthy appearance of P and M; no bleeding on probing
gingivitis. 1—Apparently healthy P and M with no change in color and no swelling, but bleeding
• Useful for short-term clinical trials. from sulcus on probing
• Measured by “ walking” the probe at the base of the sulcus. 2—Bleeding on probing and change of color caused by inflammation; no swelling or
• Four gingival units scored for each tooth: labial and lingual macroscopic edema
marginal gingival (M units) and mesial and distal papillary 3—Bleeding on probing and change in color; slight edematous swelling
gingiva (P units). 4—Bleeding on probing and obvious swelling; may have change in color
5—Bleeding on probing, spontaneous bleeding, change in color, and marked swelling
with or without ulceration
• Results can be unreliable due to subjectivity of criteria (calibration is critical).
Gingival Bleeding Index (GBI): • Scoring Criteria: Results are reported by frequency of score based on presence (1) or
• A simple, easy-to-implement, dichotomous measure of the absence (0) of bleeding.
presence or absence of interproximal bleeding. • Each area of gingiva is observed for bleeding for 30 seconds after flossing if
• Measured by passing unwaxed floss on each side of the papilla, bleeding is not immediate or not on the floss.
using a C shape and one up and down stroke. • Since the severity of bleeding is not measured, the GBI is less sensitive than the SBI
but more reliable and easier to calibrate.
Eastman Interdental Bleeding Index (EIBI): • Scoring Criteria: Results are reported by frequency of score based on presence (1) or
• A simple, easy-to-implement, dichotomous measure of the absence (0) of bleeding.
presence or absence of interproximal bleeding. • Each area is observed for bleeding for 15 seconds after insertion of interdental
• Measured by horiz ontally inserting an interdental cleaner.
cleaner/stimulator four times, depressing the papilla 1 to 2 mm. • Since the severity of bleeding is not measured, the EIBI is less sensitive than the
SBI but is more reliable and easier to calibrate.
Pe riodontal Dise ase Inde xe s
These periodontal indexes are cumulative and composite (measure both reversible and irreversible changes within the same index).
Community Periodontal Index (CPI): • To reflect current theory of periodontal conditions, the index consists of two
• An index used to measure periodontal status of a community. components scored and reported separately:
• Developed by the World Health Organiz ation (WHO); adaptation • CPI (periodontal status) codes
of the WHO Community Periodontal Index of Treatment Needs • LOA (loss of attachment; same as clinical attachment loss [CAL]) codes
(CPITN) by eliminating the treatment need codes from the CPITN; • The CPI divides the teeth into sextants for measurement, with the severest
in contrast to the CPITN, the CPI measures only periodontal measurement of the sextant being scored for each component.
status, and the CPITN reported periodontal treatment needs as • Scoring Criteria for CPI Codes:
well. Code 0—Entire colored band visible; healthy periodontal tissues: no bleeding
• Sulci/pockets are measured with the WHO specially designed, Code 1—Entire colored band visible; bleeding upon gentle probing
lightweight probe that has 0.5-, 3.5-, 5.5-, 8.5-, and 11.5-mm Code 2—Entire colored band visible; calculus present; bleeding may or may not be
markings, a colored area to denote 3.5- to 5.5-mm depth, and a present
ball tip. Code 3—Colored band on probe partially hidden by gingival margin denoting 4-5 mm
• The Periodontal Screening and Recording® (PSR) system pocket depth
developed by the American Dental Association (ADA) is based on Code 4—Colored band entirely hidden denoting ≥ 6 mm pockets
the CPITN and similar to the CPI. • If the cementoenamel junction (CEJ) is visible or the CPI is 4, LOA codes 1 to 4 are
used.
• Scoring Criteria for LOA (CAL) Codes:
Code 0—0-3 mm LOA: CEJ is covered by gingival margin and CPI score is 0 to 3
Code 1—3.5-5.5 mm LOA: CEJ is within the colored band on the probe
Code 2—6-8 mm LOA: CEJ is between the top of the colored band and the 8.5-mm
mark on the probe
Code 3—9-11 mm LOA: CEJ is between the 8.5- and 11.5-mm marks on the probe
Code 4—LOA ≥ 12 mm: CEJ is beyond the highest mark (11.5 mm) on the probe
Periodontal Disease Index (PDI): • Scoring Criteria: Used a 7-point scale to measure changes in gingiva (scores of 1
• A cumulative, composite index rarely used today to measure the through 3) and CAL (scores of 4 through 6) within the same scale.
presence and severity of periodontal disease, combining measures • The PDI is no longer recommended because of the current understanding that
of reversible and irreversible disease within the same index. gingivitis and periodontitis are two different disease entities.
• Was used for research purposes. • The PDI first introduced the current method of combining recession and pocket depth
• Currently a disaggregated approach is taken to measure the to determine CAL.
various components of the PDI that represent the clinical signs and • The six teeth scored by the PDI (teeth numbers 3, 9, 12, 19, 25, and 28), referred to
accumulated destructive results of past disease (bleeding, recession, as the Ramfjord teeth (after Dr. Ramfjord, who developed the index), are considered
pocket formation, and CAL). sensitive for partial mouth scoring of periodontal conditions and are frequently used
today with other periodontal-related indexes.
Fluorosis Inde xe s
Dean Fluorosis Index/Community Fluorosis Index (CFI): • Scoring Criteria:
• Most popular index of fluorosis, simple and easy to use, and used Normal (0)—Enamel presents the usual translucent semivitriform type of structure;
to establish prevalence in the population. the surface is smooth, glossy, and usually pale creamy white
• Developed by Dean as a classification with six categories, referred Questionable (0.5)—Enamel has slight aberrations from the normal translucency,
to as Dean's Fluorosis Index; later numbers ranging from 0-4 ranging from a few white flecks to occasional white spots; this classification is used
were added to denote the categories for surveillance purposes, and in when neither the Very Mild nor Normal classifications are definitively justified
the index was referred to as the Community Fluorosis Index Very mild (1)—Small, opaque, paper-white areas are scattered irregularly over the
(CFI); today these two names are used interchangeably to refer to tooth but not involving as much as approximately 25% of the tooth surface;
the same index. frequently included in this classification are teeth showing no more than about 1-
2 mm of white opacity at the cusp tips of premolars or second molars
Mild (2)—More extensive white opaque areas in the enamel but do not involve as
much as 50% of the tooth
Moderate (3)—All enamel surfaces of the teeth are affected, and surfaces subject to
attrition show wear; brown stain is frequently a disfiguring feature
Severe (4)—All enamel surfaces are affected; hypoplasia is so marked that the general
form of the tooth may be affected; discrete or confluent pitting is a the major
diagnostic sign of this classification; brown stains are widespread, and teeth often
appear as if corroded
Comparison to Other Fluorosis Indexes • An individual is categoriz ed by classification based on the lesser of the two worst-
The Thylstrup-Fejerskov Index (TFI) and the Tooth Surface Index affected teeth, with anterior and posterior teeth equally weighted.
of Fluorosis (TSIF) are two commonly used modifications of Dean's • Prevalence of each category is reported in a population; can be reported as the mean
Fluorosis Index. Developed for research purposes, both indexes have of all scores in the population, or as a percentage of the population scored in each
a wider range of scores with expansion of categories to create greater category.
sensitivity. • Interpretation: A classification of mild or less is not considered a cosmetic problem,
and a score of less than 0.6 is not considered a problem for the community.
Oral and Pharyng e al Canc e r
Staging of Cancer of the Lip and Oral Cavity Stage I—The cancer is less than 2 centimeters in siz e (about 1 inch) and has not
Provides a universally understood definition of the progress of spread to lymph nodes in the area.
cancers to allow surveillance, measure end results of treatment and Stage II—The cancer is more than 2 centimeters and less than 4 centimeters in siz e
prevention programs, determine prognosis, and aid in treatment (less than 2 inches) and has not spread to lymph nodes in the area.
planning. Stage III—The cancer is either (a) more than 4 centimeters in siz e, or (b) any siz e, but
has spread to only one lymph node on the same side of the neck as the cancer, and
the lymph node that contains cancer measures no more than 3 centimeters (just over
one inch).
Stage IV—The cancer has either (a) spread to tissues around the lip and oral cavity
but the lymph nodes in the area may or may not contain cancer, (b) grown to any
siz e and spread to more than one lymph node on the same side of the neck as the
cancer, to a lymph node on the other side of the neck, or to any lymph node that
measures more than 6 centimeters (over 2 inches), or (c) has spread to other parts of
the body.
Bibliography
Chattopadhyay A. Oral Health Epidemiology: Principles and Practice. Jones
and Bartlett: Sudbury, MA; 2011.
Funmilayo ASM, Mojirade AD. Dental fluorosis and its indexes, what's new?
IOSR-JDMS. 2014;13(7):55–60 [Ver.III; Accessed April 2015; Available at]
www.iosrjournals.org/iosr-jdms/papers/Vol13-issue7/Version-
3/M013735560.pdf [e-ISSN: 2279-0853, p-ISSN: 2279-0861].
National Health and Nutrition Examination Survey (NHANES). Oral Health
Dental Examiners Manual. Centers for Disease Control and Prevention:
Atlanta, GA; 2013 [Accessed February 2015; Available at]
www.cdc.gov/nchs/data/nhanes/nhanes_13_14/Oral_Health_Examiners.pdf.
Policy on Early Childhood Caries (ECC). Classifications, Consequences, and
Preventive Strategies. American Academy of Pediatric Dentistry: Chicago,
IL; 2014 [Accessed July 2015; Available at]
www.aapd.org/media/Policies_Guidelines/P_ECCClassifications.pdf.
Stages of Cancer. [Newport Beach, CA: The Oral Cancer Foundation;
Available at] www.oralcancer.org/discovery-diagnosis/stages-of-
cancer.php; 2015 [Accessed July 2015].
Wyche CJ. Indexes and scoring methods. Wilkins EM. Clinical Practice of the
Dental Hygienist. 11th ed. Lippincott Williams & Wilkins: Philadelphia, PA;
2013.
Glossary
Abstract A summary or brief description of a report, manuscript, or presentation,
placed at the beginning, approximately 200 words in length, and designed to
provide an overview; used to concisely define a research study's purpose,
methods, materials, results, and conclusions; also used for community reports
such as a community assessment or program outcomes.
Access to oral health care/access to care Assurance that conditions are in place
for people to obtain the (oral) health care they need and want, including
epidemiologic, social, demographic, personal, and psychological conditions, as
well as characteristics of the (oral) healthcare system such as availability,
accessibility, accommodation, affordability, and acceptability; reported by
Healthy People 2020 as the timely use of personal health services and dental
treatment to achieve the best (oral) health outcomes. Also referred to as access to
dental care.
Accountable Care Organization (ACO) A provider-run organization in which
participating providers are collectively responsible for the care of an enrolled
population and may share in any savings associated with improvements in the
quality and efficiency of care.
Administration for Children and Families (ACF) An agency of the DHHS that
promotes the economic and social well-being of families, children, individuals,
and communities; administers the Head Start program.
Administrator/Manager A supervisory role of the dental hygienist in which he or
she directs and oversees oral health programs.
Advanced dental hygiene practitioner (ADHP) A dental hygiene-based midlevel
provider of oral health care first introduced by the American Dental Hygienists'
Association (ADHA) to provide access to primary oral care to individuals and
communities with previously limited oral health services. Proposed to practice
under remote general supervision without a dentist present and to have a
master's degree.
Advocate/advocacy A role in which the dental hygienist works to promote change
and advance people's health through legislation, public policy, research, and
science, in response to seeing problems related to achieving optimal oral health
and attempting to develop a solution; may involve helping to create and
implement new or revised oral healthcare laws.
Agent factors Biologic or mechanical means of causing disease, illness, injury, or
disability, including microbial, parasitic, viral, and bacterial pathogens or
vectors; physical or mechanical irritants; chemicals; drugs; trauma; and
radiation; they interact with host and environmental factors in the multifactorial
perspective of epidemiology.
Alternative practice A setting outside the private office in which the dental
hygienist provides oral health services to members of the public who are
underserved by the traditional private practice setting.
Analysis of variance (ANOVA) A parametric statistical test used to compare three
or more sample means.
Analytic study An epidemiologic study that provides information about the
association of risk attributes in relation to a disease or condition to establish risk
and estimate causality.
Antifluoridationists Opponents of community water fluoridation.
Assessment/Assess A core public health function that includes the regular and
systematic collection, assemblage, and analysis of data and communication
regarding the oral health of the community; the first step of the program
planning or community health improvement process.
Association of State & Territorial Dental Directors (ASTDD) A national dental
public health organization whose membership includes each of the state
directors for oral health; provides a strong governmental presence regarding
issues, core functions, and best practices for community oral health practice and
is a central location to access resources for community oral health initiatives.
Assurance A core public health function in which agencies ensure that services
necessary to achieve agreed-upon health goals are provided, either by
encouraging actions by other entities (private or public sector), by requiring
such action through regulation, or by providing services directly.
ASTDD Seven-Step Model A community oral health assessment guide developed
by the ASTDD that describes the specific steps required in the community
assessment process; commonly referred to as the Seven-Step Model.
Bar graph A simple bar graph, in which bars do not touch, used to display
frequencies of nominal or ordinal data or the value of different but comparable
items (categorical data).
Baseline Initial observation or value that serves as the basis for comparison with
subsequently acquired data in a research study or program evaluation.
Basic Screening Survey (BSS) A simple screening survey model for collecting
oral health data to assess need and referral for dental care; developed by the
ASTDD.
Behavioral Risk Factor Surveillance Survey (BRFSS) A state-specific telephone
survey that is developed nationally to assess behaviors that influence health
status; includes questions to assess the use of oral health services.
Best practice approach A public health strategy that is supported by evidence,
including research, expert opinion, field lessons, and theoretical rationale, for
its effectiveness in reliably leading to a desired result.
Blind study (masking) A research study design in which the examiners and study
participants are unaware of group assignment (double blind) or only the
examiners are unaware of group assignment (single blind).
Block grant A consolidated grant of federal funds, formerly allocated for specific
programs, that a state or local government may use at its discretion for various
programs, including health.
Calibration A process used to determine, check, rectify, or adjust a measurement
device to increase the accuracy and precision of the measurements. Calibration
is applied also to examiners or raters who are involved in data collection to
achieve agreement with set criteria and a standard of performance.
Capacity/oral health capacity The ability of the healthcare system to deliver
services to the public; enables the development of oral health expertise and
competence and the implementation of oral health strategies.
Case-control study An observational research study in which two groups, one with
the disease (referred to as cases) and one without (referred to as controls), are
compared to identify factors in their history that can be associated with the
disease or condition (called exposures).
Categorical data Nonnumeric data that represent categories.
Centers for Disease Control and Prevention (CDC) A major federal agency of
the DDHS Public Health Service that monitors health, informs decision makers
about health topics, provides people with information so they can take
responsibility for their own health, provides healthcare workers with
information on health promotion, and prevents disease and promotes health.
Oral health is included in all these activities.
CHIP (Children's Health Insurance Program) A joint state-federal funded
program administered by states to provide comprehensive health insurance
coverage, including dental, to eligible children, through both Medicaid and
separate CHIP programs.
Chi-square test One of the most commonly used nonparametric statistical tests;
used to analyze differences in counts and proportions of categorical variables
and to test the significance of relationships between variables that have been
established by correlation.
Clinical rotation A curriculum-based experiential learning activity that is not
necessarily associated with a service outcome and is designed primarily to
benefit the student's learning. Students are assigned rotations to gain clinical
experiences that enhance knowledge, skills, and expertise; can be used to
provide exposure to community settings.
Clinical significance The practical importance of a treatment effect in research.
Clinical trial An experimental study that tests the safety, efficacy, and/or
effectiveness of procedures, therapies, drugs, or other interventions to prevent,
screen for, diagnose, or treat disease in humans.
Clinician A role in which the dental hygienist assesses oral health needs and
provides treatment for individuals.
Coalition A cooperative, collaborative effort on the part of many diverse
individuals and organizations that reflects a public-private partnership to build
systems and develop programs that improve community health.
Cohort study An observational research study design in which a group is observed
over time; can include a comparison group.
Collaboration The process of working together to accomplish a goal.
Communication plan Outlines objectives, key messages, activities, evaluation
methods, and responsibilities for communication projects or programs.
Community The public or group of people with common interests who live in a
specific locality; in relation to community oral health, can be used to refer to a
large or small group within the population.
Community cases/scenarios Short descriptions of community oral health real-
world situations used as examples for application of concepts and for
evaluation; referred to as scenarios and combined with test questions to form
testlets by the National Board Dental Hygiene Examination to test the community
health/research principles content area.
Community dental health coordinator A community health worker developed by
the American Dental Association that focuses on oral health education and
disease prevention in underserved rural, urban, and Native American
communities to expand access to dental care.
Community Fluorosis Index (CFI) Dean's Fluorosis Index with numbers assigned
to the categories for use in research studies; one of the most universally
accepted fluorosis indexes.
Community health Traditionally refers to the health of a defined group within the
population; frequently used synonymously with public health.
Community oral health assessment A multifaceted process of identifying factors
that affect the oral health of a selected population to be able to determine
resources and interventions needed for oral health improvement.
Community Organization Theory The process of involving and activating
members of a community or subgroup to identify a common problem or goal,
to mobilize resources, to implement strategies, and to evaluate their efforts.
Community partnership/community partner An arrangement between or among
agencies, organizations, businesses, and/or people that collaborate and combine
resources to work toward a unified, common goal; considered a key public
health activity in the community program planning process.
Community Periodontal Index (CPI) An index to assess periodontal status of a
population; includes measurements of gingival inflammation, bleeding,
calculus, clinical attachment loss, and periodontal pockets.
Community profile A comprehensive description of the community developed
through a formal organized community assessment process.
Community service When used in relation to education of students in community
oral health, students providing a service to the community with the primary
focus on the community's needs. This activity may or may not have a curriculum
connection.
Community trial A quasi-experimental study in which a community, rather than a
group of individuals, receives the intervention.
Community water fluoridation The addition of a controlled amount of fluoride to
the public water supply to bring it to an optimal level for the purpose of
preventing dental caries in the population.
Confidence interval An inferential statistic that estimates the accuracy of a sample
statistic representing the population parameter.
Continuous data Numeric data that can be expressed by a large or infinite number
of measures along a continuum, such as test scores, thus having real value when
expressed as a fraction.
Control group The group of study participants that does not receive the
experimental treatment or intervention for the purpose of comparison to the
experimental group.
Convenience sampling Using a group of individuals who are most readily available
to be participants in a research study.
Core functions of public health The commonly recognized central tasks of public
health identified by the Institute of Medicine that provide the basis for all public
health activities. The core functions are assessment, policy development, and
assurance.
Correlation A statistical method of determining whether a variation in one variable
may be related to a variation in another variable; used to determine the
association or relationship of variables.
Critical thinking The intellectually disciplined process of actively, objectively, and
skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating
information for the purpose of forming a judgment and making a decision.
Critical thinking is a core competency of dental hygiene educational programs
and required for community oral health practice.
Cross-cultural communication The communication or exchange of information
among persons from different cultures, which is necessary in a diverse
population.
Cross-cultural encounter Contact and interactions among diverse persons or
communities, which occurs with regularity in a diverse population.
Crossover study An observational or controlled experimental study in which study
participants receive a sequence of different treatments with a washout period
between; has the advantage of exactly matching the control and experimental
groups.
Cross-sectional study/survey An observational study that examines the
relationship between disease (or other health-related state) and other variables of
interest as they exist in a defined representative cross section of the population,
observed at a single point in time. A cross-sectional survey can identify the
frequency of variables without examining relationships.
Cultural competence The ability of healthcare providers to deliver services that
are respectful of and responsive to the health beliefs, practices, and cultural and
linguistic needs of diverse patients and communities, thus helping to fulfill the
profession's responsibility to reduce the burden of disease for people of various
cultures and backgrounds.
Cultural Competence Continuum A model commonly used for training in the
development of cultural competence, consisting of six stages: cultural
destructiveness, cultural incapacity, cultural blindness, cultural pre-competence,
cultural competence, and cultural proficiency. Through self-assessment,
individuals and organizations can evaluate their placement on the continuum and
plan for and track progress toward developing personal and professional
cultural competence and proficiency.
Cultural diversity The degree to which a population consists of diverse individuals
from different cultures, taking into account differences such as nationality,
ethnicity, race, gender, age, language, and religion.
Culture An integrated pattern of human behavior that includes thoughts,
communications, languages, practices, beliefs, values, customs, courtesies,
rituals, manners of interacting, roles, relationships, and expected behaviors of a
racial, ethnic, religious, or social group.
Data Facts or pieces of information used to calculate, analyze, or plan in the course
of community program planning or research.
Data collection The process of gathering information during the assessment or
evaluation process of program planning or the measurement of variables in the
conduct of research.
Dean's Fluorosis Index The conventional system used to assess for dental
fluorosis, developed by Dr. Dean and consisting of categories of fluorosis; is
the basis for other fluorosis indexes.
Decayed, missing, or filled teeth/surfaces (DMFT/DMFS) index A dental index
used in epidemiology and research to count dental caries on the teeth (T) or
surfaces (S) in the permanent dentition; adapted as the dmf, def, and df to count
dental caries on the teeth (t) or surfaces (s) of the primary dentition.
Defluoridation Water treatment that reduces the level of fluoride in the community
water when it is too high, to make it safe for human consumption.
Demand Health care services desired by the individual or community.
General supervision Supervision of the dental hygienist in which the dentist does
not have to be on the premises, but the patient must be one of record or seen by
the dentist previously.
Gingival Bleeding Index (GBI) A simple, easy-to-implement dental index used to
determine the extent of interdental inflammation based on bleeding that occurs in
response to passing unwaxed dental floss on each side of the papilla.
Gingival Index (GI)/Modified Gingival Index (MGI) The GI is a core dental index
to measure the severity of gingival inflammation based on clinical observation,
pressing the probe on the gingiva to determine degree of firmness, and
“walking” the probe inside the gingival sulcus; modified as the MGI by
eliminating the probing.
Goal A broad-based statement of desired change to result from a community oral
health program, from which specific objectives are developed.
Head Start A school-readiness program administered by the ACF that is designed
to break the cycle of poverty by providing a comprehensive early learning
program for preschool aged children of low-income families; oral health is
addressed by Head Start.
Health A state of complete physical, mental, and social well-being and not merely
the absence of disease.
Health Belief Model A health education/health promotion model that attempts to
explain and predict health behaviors by focusing on the attitudes and beliefs of
individuals; centered on perceptions of susceptibility to the disease, severity of
the disease and its effects, benefits or efficacy of the advised action, and tangible
or psychological costs of the advised action, referred to as barriers.
Health communication The use of communication strategies to inform and
influence individual decisions that enhance health.
Health disparities/disparities Uneven distribution of the burden of disease such as
oral disease throughout the population, especially in the poor, older adults,
disabled, and other vulnerable and underserved population groups; considered
unfair because it is caused by social or economic disadvantage.
Health education/oral health education A component of health promotion and the
process by which individuals are encouraged to become responsible for their
personal health; includes efforts to increase awareness of one's health and to
impart sound, evidence-based knowledge and skills to develop and maintain
behaviors and attitudes that lead to better health and wellness through prevention.
Oral health education is health education in relation to oral diseases and
conditions.
Health equity Achieved when every person has the opportunity to attain his or her
full health potential and no one is disadvantaged from achieving it because of
social position or other socially determined circumstances.
Health information technology The application of computers and
telecommunications equipment to health care for the comprehensive
management and communication of health information for decision making
related to health issues.
Health Insurance Portability and Accountability Act (HIPAA) Federal
regulations governing and protecting the rights and privacy of patients in health
care.
Health literacy The degree to which individuals have the capacity to obtain,
process, and understand basic health information and services needed to make
appropriate health decisions.
Health literate organization A healthcare organization that makes it easier for
people to navigate, understand, and use information and services to take care of
their health.
Health promotion A broad concept referring to the process of enabling people and
communities to increase their control over the determinants of health and thus to
improve their own health; moves beyond a focus on individual behavior toward
a wide range of social and environmental interventions.
Health Resources and Services Administrat ion (HRSA) The primary federal
agency for improving access to healthcare services for people who are
uninsured, isolated, or medically vulnerable.
Healthy People 2020 A dynamic national compilation of measurable 10-year health
goals and objectives for prevention of disease and promotion of health that
identify current nationwide health improvement priorities and are applicable at
the national, state, and local levels.
Histogram A type of graph with the bars touching; depicts frequencies of
continuous data.
Host factors Factors that affect a person's susceptibility and resistance to disease
and interact with agent and environmental factors in the multifactorial
perspective of epidemiology.
Hypothesis A statement that provides a supposition, prediction, or explanation of
the expected outcome of the proposed research (refer to null hypothesis and
research hypothesis).
Implementation/implement The third step in the program planning or community
health improvement process during which the plan is put into action and the
plan's activities, personnel, equipment, resources, supplies, and preliminary
progress toward program goals are monitored (formative evaluation).
Incidence The rate of new cases of a disease or health condition in a population at
risk during a designated period.
Independent variable The experimental treatment or intervention that is imposed
on the experimental group as it is manipulated by the researcher in an
experimental or quasi-experimental study to observe its relationship with some
other quality.
Inferential statistics Category of statistics used to make inferences or draw
generalizations about the population based on the sample data.
Infrastructure/oral health infrastructure The systems, people, relationships, and
resources that enable federal, state, and local agencies to perform public health
functions and address oral health problems.
Interprofessional collaborative practice/interdisciplinary collaboration Multiple
health workers from different professional backgrounds collaborating to work
together with patients, families, carers, and communities to deliver the highest
quality of care; can result in empowering communities in relation to health
improvement.
Interprofessional education Educating health professions students in an
interprofessional collaborative model to prepare health professions graduates to
practice using this approach in community settings to address identified
community health issues that cut across the disciplines.
Interrater reliability Agreement of measurement findings by two or more
examiners.
Interval scale A scale of measurement in which differences between values can be
quantified in absolute but not relative terms; characterized by having order and
equal distance between points on the scale but no absolute 0 value.
Interventions Activities of a community health program designed to bring about
the desired results of the community health improvement process.
Intrarater reliability Consistency of measurement findings by one examiner with
those previously recorded by the same examiner.
Iron triangle of health care A concept of health care that consists of three essential
and competing components of the healthcare system: quality, cost, and access.
Judgmental (purposive) sampling Sampling method in which the researcher uses
personal judgment to select study participants who are believed to best represent
the population.
Leading Health Indicators (LHI) A smaller set of Healthy People 2020 objectives
selected to communicate the highest priority health issues and actions that can be
taken to address them.
Learning styles The means by which individuals collect and retain knowledge
based on personal factors, behaviors, and attitudes that facilitate learning in
given situations.
Lesson plan A detailed description of an individual lesson that serves to guide
instruction.
Longitudinal study An observational research method in which data are gathered
for the same individuals repeatedly over a period of time.
Managed care A type of health insurance that uses techniques to control the cost of
providing benefits, including contracts with providers to deliver care at reduced
costs, financial incentives for beneficiaries to use these providers, and control of
services provided; the approved providers make up what is referred to as the
plan’s network.
Mann-Whitney U test A nonparametric test used to compare differences between
two independent groups when the dependent variable is either ordinal or is
continuous but not normally distributed.
Matching A research method applied during randomization to assure equivalency
of research groups when the sample is heterogeneous.
Mean Arithmetic average of a group of scores; the sum of the numbers divided by
the quantity of scores.
Median The exact middle score or value in a distribution of scores.
Medicaid A joint state-federal financed program that is administered by the states to
provide comprehensive medical coverage for individuals within certain income
limits; includes oral healthcare coverage for children of low-income families
and limited dental coverage for adults in some states.
Medical Expenditure Panel Survey (MEPS) A set of large-scale national surveys
of families and individuals, their medical providers, and employers on the cost
and use of health care and health insurance coverage; includes data on the
number of annual dental visits for various population groups.
Medicare A federal health insurance program that provides comprehensive health
care for adults ages 65 and older; is not a source of financing of oral health care
unless it is medically necessary.
Meta-analysis A statistical technique for combining the findings from independent
studies; used in systematic literature reviews to provide a higher level of
evidence for evidence-based decision making.
Midlevel oral health practitioner A dental hygiene-based midlevel provider of
oral health care similar to the ADHP but without the requirement of a master ’s
degree; proposed by the ADHA in 2015.
Midlevel provider In dentistry, a term that generally refers to an oral healthcare
provider who delivers routine direct care under the general supervision of a
dentist or via a collaborative practice agreement. Various models exist, some of
which are dental hygiene-based, and various levels of supervision are required
depending on the service provided.
Mode The score or value that occurs most frequently in a set of data; only measure
of central tendency that can be used with nominal data.
Monitoring Systematic examination of public health program coverage and
delivery for the purpose of assuring the program is proceeding as planned and
to provide opportunity to respond by adjusting the program as needed; includes
systematic assessment of the extent to which a program is consistent with its
design and implementation plan, is reaching its intended target population, and
can be justified in terms of a cost-benefit analysis.
Narrative review A nonsystematic, traditional descriptive summary that reviews
existing literature; typically includes a biased subset of studies based on
availability or author selection.
National CLAS Standards A comprehensive series of federal guidelines that
inform, guide, and facilitate practices related to culturally and linguistically
appropriate health services.
National Health and Nutrition Examination Survey (NHANES) A program of
survey research studies that uniquely combines interviews and physical
examinations to assess the health and nutritional status of adults and children,
including oral diseases and conditions.
National Health Interview Survey (NHIS) A survey that is used to collect data
through personal household interviews regarding health status, health care costs,
and progress toward achieving national health objectives, including oral health.
National Oral Health Surveillance System (NOHSS) A system of oral health data
sources designed to monitor the burden of oral disease, the use of the oral
healthcare delivery system, and the status of community water fluoridation on
both a national and state level; also involves timely communication of oral
health findings to responsible parties and the public. A collaborative effort
between the CDC, Division of Oral Health, and the ASTDD.
Need Those services deemed by the health professional to be necessary based on
analysis of assessment data.
Networking Meeting people and interacting with them as a means of cultivating
productive relationships for professional development and potential
employment.
Nominal scale A scale of measurement that merely allocates data to distinct
categories.
Nonparametric statistics The branch of statistics consisting of tests used when
assumptions about a normal distribution in the population cannot be met or when
the level of measurement is nominal or ordinal; contrasts with parametric
statistics.
Normal distribution A theoretical symmetric distribution that is characteristic of
data representing most occurrences in the world; results in a bell-shaped curve
in which approximately 68% of the population falls within 1 standard deviation
(SD) of the mean, approximately 95% falls within 2 SDs of the mean, and
approximately 99% lies within 3 SDs of the mean.
Null hypothesis A negatively stated hypothesis in which there is an assumption that
there is no statistically significant difference between the groups being studied,
and that sample observations occur by chance.
Objective A desired end result of community oral health program activities,
described in a specific, measurable way; more specific than a goal.
Observational research A classification of research studies that involves
systematic observation of study participants' behaviors, actions, or other
exposures to disease-related factors without influencing or interfering with the
variables; no variable is manipulated.
Optimal fluoride level The recommended level of fluoride in the community water
supply to prevent dental caries; currently set by the DHHS at 0.7 milligrams of
fluoride per liter of water (0.7 mg/L).
Oral health educator A role in which the dental hygienist works to prevent disease
and to promote oral health through the process of teaching them about oral
health.
Oral health indicators Quantifiable characteristics of a population used by
researchers to describe the oral health of a population; they generally line up
with Healthy People 2020 objectives and are tracked by the National Oral Health
Surveillance System.
Oral health–related quality of life (OHRQOL) Aspects of overall quality of life
that affect oral health status; for example, physical limitations, health risks, low
socioeconomic status, and lack of community resources that contribute to poor
oral health; builds on concepts of quality of life and health-related quality of life.
Oral Health Surveys: Basic Methods The World Health Organization's basic
manual that serves as a guide to conducting oral health surveys for the purpose
of encouraging countries to conduct standardized oral health surveys that result
in comparable data internationally.
Oral paper A method of professional presentation of a topic.
Ordinal scale A scale of measurement that orders data into categories in rank
order; the space between these categories is undefined.
Organizational Change: Stage Theory A model that describes how organizations
pass through a series of stages as they initiate change, and how organizational
structures and processes influence workers' behavior and motivation for change.
p value The value that determines the statistical significance of a study by providing
the smallest level of significance at which the null hypothesis can be rejected.
Parameter A term relating to a numeric characteristic of the population.
Parametric statistics Branch of statistics consisting of tests that are used when data
include interval or ratio scales of measurement, the sample is large and
randomized, and the population from which the sample is taken is normally
distributed; contrasts with nonparametric statistics.
Patient Protection and Affordable Care Act (ACA) Healthcare-reform
legislation passed in 2010; has resulted in increased oral healthcare coverage
through Medicaid, especially for children but also for a limited number of
adults. The ACA has provisions related to the expansion of traditional and
innovative oral healthcare workforce models.
Patient-centered care Concept regarded as a standard of care in which patients are
known as persons in context of their own social worlds; they are listened to,
informed, respected, and involved in their care; and their wishes are honored in
relation to their health care.
Peer review Process used by scientific journals to validate research and evaluate
submitted manuscripts; consists of review by a group of experts in the same
field.
Percentile A statistical measure that represents the value below which a specific
percentage of observations fall in a distribution of values.
Periodontal Disease Index (PDI) A classic, composite periodontal index that is no
longer recommended for use because of the current understanding that
gingivitis and periodontitis are two different disease entities.
Pie chart A circular graphic that illustrates numerical proportion by dividing the
whole circle or pie into sections; presents parts of a whole.
Pilot study/pilot testing Performance of a preliminary research study or trial run
of a community program in preparation for a major study or large-scale
community program.
Plain language Clear, concise, to-the-point, and well-organized writing that is
grammatically correct and includes complete sentence structure and accurate
word usage, making it easy to read, understand, and use; important to the
development of health literacy.
Planning/plan An organized response to a community's established needs to reduce
or eliminate one or more problems; the second step of the program planning or
community health improvement process.
Pluralistic In reference to a healthcare system, a combination of public and private
forces that coexist simultaneously, which tends to result in a fragmented,
uncoordinated, and complex system with many elements and entry points.
Policy development A core public health function in which laws and other policies
are planned and developed to support community oral health issues.
Population In community health, all the inhabitants of a particular area that are
served by public health; can be as small as a local neighborhood, school, or
residential facility, or as large as an entire country or region. In research, the
entire group or whole unit of individuals, having similar characteristics, to
which the results of an investigation can be generalized.
Population health The health outcomes of a group of individuals, including the
distribution of such outcomes within the group; focus is not just on the overall
health of a population but also embraces the distribution of health.
Poster A method of professional presentation of a topic during which the presenter
discusses a visual display individually with people who stop to look.
Poverty A general state of lacking a certain amount of material possessions or
money, but also a multifaceted concept that includes social, economic, and
political elements and is usually closely related to inequality. Poverty is
associated with the undermining of a range of key human attributes, including
health.
Power analysis A statistical determination of how many study participants are
needed to provide statistical significance; calculated using a specific statistical
formula.
Practicum/internship One form of experiential learning that is typically a longer
assignment than a clinical rotation. The student may be assigned to work in a
particular specialty area for an entire academic quarter or semester.
Pretest-posttest study An experimental study in which the dependent variable is
measured before and after the treatment intervention is introduced.
Prevalence The proportion of existing cases of a disease or health condition in a
particular population measured at some designated time.
Primary literature Original materials of new information, representing original
thinking, reporting a discovery from the time period involved, and not filtered
through secondary interpretation or evaluation.
Primary prevention Services that are designed to prevent a disease before it
occurs; includes health education, avoidance of disease, and health protection.
Priority populations Populations identified by federal mandate as having priority
to target public health efforts: inner-city, rural, low income, minority, women,
children, elderly, and those with special healthcare needs, including those who
have disabilities, need chronic care, or need end-of-life health care.
Program planning process Model commonly used in dental public health practice
that serves as the framework and provides a basic flowchart of steps to assess,
plan, implement, and evaluate in the process of community health improvement;
provides a systematic approach to the process of community oral health
improvement and takes into account the interrelated determinants of oral health.
Prospective A research design in which outcomes or phenomena are observed
forward in time, usually over a long period.
Public health The science and art of preventing disease, prolonging life, and
promoting physical health and efficiency within a population through organized
community efforts; concerned with protecting the health of entire populations,
not just individuals.
Public health problem Health problems addressed by public health, identified
according to the public health importance of the problem; the ability to prevent,
control, or treat the problem; and the capacity of the health system to implement
control measures for the problem.
Public health solution An effective measure designed to solve a public health
problem, focused on health promotion and disease prevention with the
community at large.
Qualitative data Information that reflects the quality or nature of things that cannot
be measured or analyzed numerically and must be expressed in words, such as
interview responses.
Qualitative research Broad category of research that answers questions of why and
how; focuses on exploring issues, understanding phenomena, and answering
questions by analyzing qualitative data.
Quantitative data Information that is objective and measurable; can be measured
and expressed as a quantity or amount (numbers).
Quantitative research Broad category of research that involves the systematic
empirical investigation of observable phenomena through mathematical,
computational, or statistical techniques.
Quasi-experimental research Similar to experimental research, but specifically
lacks the use of randomization.
Random sampling A sampling technique in which each member of the population
has an equal chance of being included in the sample, thus preventing the
possibility of selection bias.
Randomization In a controlled experimental study, random (by chance) assignment
of the participants to the treatment and control groups.
Range A crude measure of dispersion that provides an expression of the difference
between the highest and lowest values in a distribution of scores.
Ratio scale A scale of measurement that not only has all the properties of nominal,
ordinal, and interval data, but also has an absolute or fixed zero value, thus
permitting relative comparison of different values.
Refereed journal A journal in which the published articles have been reviewed by
an editorial board of peers; also referred to as a peer-reviewed journal.
Referral An essential component of assessment and screening and an ethical
obligation when a need for dental care is observed; without further observation
and referral for care, screening is ineffective.
Reflection In relation to learning, giving thought to an experience or encounter to
draw meaning from it; a necessary step in the process of service-learning and
critical thinking.
Relevant variable A variable that should be controlled because it can influence how
the independent variable affects the dependent variable; also called a
confounding variable.
Reliability The extent to which a measurement gives consistent results; an essential
component of validity.
Repeated measures A study design in which the dependent variable is measured
several times, usually at posttest; also referred to as a time series study design.
Replication The repetition of a study with different participants and in different
situations to determine if the basic findings of the original study can be
generalized further.
Research hypothesis A positive statement of the hypothesis that will be accepted if
the null hypothesis is rejected, based on the assumption that sample observations
are influenced by some nonrandom cause; also referred to as the alternate
hypothesis.
Researcher A role in which the dental hygienist uses scientific methods to acquire
knowledge on topics relevant to serving the needs of the public's oral health.
Retrospective A research study method whereby prior events are examined by
looking back or into the past in relation to an outcome that is established at the
beginning of the study.
Risk factor An aspect of personal behavior or lifestyle, an environmental
exposure, or an inborn or inherited characteristic that is associated with an
increased occurrence of disease or other health-related event or condition.
Risk management In relation to working in the community, a formal process by
which an organization identifies and analyzes its risks, establishes goals and
objectives to manage risk, and selects and implements measures to address its
risks in an organized fashion.
Root Caries Index (RCI) Dental index to measure cavitated root caries lesions
using an epidemiologic examination.
Roundtable discussion Method of professional presentation of a topic in which the
participants sit in a circular pattern and discuss issues relevant to the topic.
Safety net The array of providers in various settings that are developed through the
state and other institutions and that deliver care to people with no or limited
insurance.
Sample A portion or subset of the entire population.
Scattergram A graph that visually depicts the relationship between two variables.
School-based oral health program An oral health program that offers services at
the school, via school clinics with stationary equipment, in a room in the school
building using portable equipment, or in a mobile van parked at the school; may
provide one or a combination of the following: screening, sealants, fluoride
treatment, oral health education, other primary preventive services, clinical and
radiographic examination, restorative services, and extractions.
Scientific method A series of logical steps followed in the conduct of research
through which a problem is identified, relevant data are gathered, a hypothesis is
formulated, the hypothesis is empirically tested, and conclusions are drawn.
Scope of practice The procedures that an oral health professional is permitted to
practice according to the state statute.
Secondary literature Sources of information that provide interpretations and
evaluations of primary sources and offer a commentary on, and discussion of,
the evidence previously reported; do not contribute new evidence.
Secondary prevention Services that are designed to slow the progression of a
disease or its sequelae at any point after its inception; includes detection and
treatment of disease or injury as soon as possible to halt or slow its progress.
Service-Learning An experiential learning method that is a jointly structured
learning experience in which the course learning objectives (LO) and the
community partner's service objectives (SO) are deliberately combined to form
a service-learning objective (S-LO) for the mutual benefit of the student, the
health professional education institution, and the community; involves
collaboration and reflection.
SMART + C objectives A mnemonic acronym for criteria that are used as a guide
for setting program objectives: Specific, Measurable, Achievable, Relevant,
Timed, and Challenging.
Social justice The view that everyone deserves equal economic, political, and social
rights and opportunities.
Social Learning Theory A health education/health promotion model based on the
idea that people learn through their own cognitive processing of others’ actions
that they observe, their inferences about the results of these actions, their
imitation of others’ behaviors, the judgment of behaviors voiced by others, and
environmental influences on behavior. Behavioral change is accomplished
through the interaction of behaviors, environmental influences, and personal
cognitive processes.
Social marketing The use of marketing principles to influence human behavior to
improve health or benefit society.
Social media Computer mediated tools that allow people to create and share
information, ideas, and pictures or videos in virtual communities and networks.
Social responsibility A broad term meaning that people and organizations are
expected to behave ethically and with sensitivity toward social, cultural,
economic, and environmental issues; encompasses professionalism, personal
and professional ethics, and the role of a profession in the context of the greater
society.
Socioeconomic status The social standing or status of a person or group in a
community or society on a social-economic scale, measured by factors such as
education, type of occupation, income, wealth, and place of residence.
Split-mouth study Research study design in which all participants receive two or
more treatments to a separate unit of the mouth; has the advantage of exactly
matching the control and experimental groups.
Stages of Change Theory Health education/health promotion model based on
three major concepts or assumptions: (1) change is a process or cycle through
various stages that occur over time rather than as a single event, (2) people cycle
through the various stages of readiness to change and can even relapse, based on
the behavior to be changed and the supportive nature of the environment, and (3)
to motivate change in health behavior, one must design health education efforts
based on the individual’s current stage of readiness to change.
Standard deviation A numerical value that demonstrates how widely individual
scores in a group vary around the mean; used with interval and ratio data;
computed as the positive square root of the variance.
State oral health program (SOHP) A state-level dental public health program
under the organizational structure of the state health department; also referred to
as state dental public health program.
Statistic A numeric characteristic of a sample.
A
Abstract, 205
Access to care, 117–119
barriers to, 118, 118b
dental care financing in the U.S, 119–124
future considerations for, 123–124
dental public health programs and, 128–133
current status: structure and funding and, 131–132
infrastructure and capacity of, 129–131, 131b
performance of, 132–133, 132b
status and trends in, 129
success of, 131b
future directions for, 133, 133b
future trends of, 19–20, 20b
OHS and, 95–96, 96b
oral health services and, 235
oral health workforce and, 124–128
and population health, 117–133
barriers to, 118, 118b
dental care financing in the U.S, 119–124
dental public health programs and, 128–133
oral health workforce and, 124–128
publicly funded health insurance programs and, 122–123
regular visits and use of services and, 118–119, 118b
unmet dental needs and, 119
publicly funded health insurance programs and, 122–123
regular visits and use of services and, 118–119, 118b
supervision of, 20–22
and teledentistry, 128
unmet dental needs and, 119
water fluoridation, 94–95, 94b
Accountable Care Organizations (ACOs), 234–235
ACF. See Administration for Children and Families (ACF)
Action model, Healthy People 2020, 75, 76f
Active learning, 266–267
ADHP. See Advanced Dental Hygiene Practitioner (ADHP)
Administration for Children and Families (ACF), 5, 163–164, 169
Administrator
career as, 35–36
mini-profile of, 39b–41b, 43b
Adolescents
dental caries in, 109–110
demographic factors, 109
oral health disparities and, 110f
insurance coverage and, 120–122, 120f, 122f
ADT. See Advanced dental therapist (ADT)
Adults, dental coverage in, 122
Advanced Dental Hygiene Practitioner (ADHP), 11, 23t–25t, 27
Advanced dental therapist (ADT), Minnesota and, 23t–25t, 26
Advocate
career as, 34–35, 34f
mini-profile of, 38b–40b
Affordable Care Act (ACA), 9
Agency for Healthcare Research and Quality, 5
Agent factors, 54f, 56
Alaska, dental therapist in, 26
Alternative practice settings, 20, 20f–21f
Alternative workforce models, 22–28, 23t–25t
American Dental Association (ADA), 286
initiatives of, for dental health program, 11b
American Dental Education Association (ADEA), 11, 52
American Dental Hygienists' Association (ADHA), 11, 151
Analysis of variance (ANOVA), 200, 200t
ANOVA. See Analysis of variance (ANOVA)
Antifluoridationists, 155
Assess, 59–60, 60f
Assessing Oral Health Needs: ASTDD Seven-Step Model, 61–62
Assessment
community. See also Measuring oral health
dental caries, future directions in, 86
examples of information for, 305
guiding principles, 147b
OHRQOL and, 97
oral health, 74
patient care, 297
periodontal disease and, 88, 89b, 89f
resources for, 302–306
community description for, 63, 63b
for community oral health program planning, 50–72
community partnership for, 62
as core public health function, 7–8, 8b, 8t, 9f, 53–54
data collection for, 64–65, 65t
developing and implementing improvement plan following, 68
epidemiology and, 54–57
goals determination for, 63
guiding principles in, 53b
implementation of, 65
model examples of, 61–62, 62b, 62f
needs
evaluating, 68
planning of, 64–65
of oral health, in communities, 61–68, 61f–62f, 62b
prioritizing issues in, 66–67, 67b
purpose of, 63, 64f
reporting findings in, 67
roles of professionals in, 53–54, 53f, 54b
self-, 63
Asset maps, for data collection, 303t–304t
Association of State & Territorial Dental Directors (ASTDD), 11, 61–62, 80, 81b,
143
Assurance, as core public health function, 7–8, 8b, 8t, 9f
ASTDD. See Association of State & Territorial Dental Directors (ASTDD)
Audiovisual materials, 220t, 222
Authors, 202
B
Bar graph, 196, 197f
Barriers
to dental care, 118, 118b
translation, 219b
Basic Methods for Oral Health Surveys, WHO, 87
Basic Screening Survey (BSS), 80–81, 81t–82t
access to oral healthcare system and, 95, 96b
measurement of sealants with, 87b
oral and pharyngeal cancer and, 91, 91b
retention/loss of teeth and, 90
and root surface caries, 86
use of, to measure dental caries in a population, 85b
Behavioral objectives, 148
Behavioral Risk Factor Surveillance System (BRFSS), 82
access to oral healthcare system and, 95, 96b
retention/loss of teeth and, 90, 91b
Blinding, 189
Blindness, cultural, 251f, 252
Block grants, maternal and child health services, 168–169
BRFSS. See Behavioral Risk Factor Surveillance System (BRFSS)
BSS. See Basic Screening Survey (BSS)
Burden of oral disease
global, 104–105
in U.S., 104, 108–109
C
Calibration, 189
California Dental Association (CDA) Foundation, 155
Cancer, oral and pharyngeal, 113–115
deaths from, 114
disparities related to, 114
factors assessed in oral health surveys, 308
fluorosis indexes in, 313
measurement of, 90–92, 91b
NHANES and, 91, 91b
use of tobacco and, 91–92, 92b
rates of, 114
risk factors, 115
survival rates, 115, 115t
Careers, in public health, 18–49, 30t, 32t
ADHP and, 27
administrator, 35–36
ADT and, 26
advocate, 34–35, 34f
alternative practice settings in, 20, 20f–21f
CDHC and, 28
clinician, 31–33
community oral health practice, 18–19, 19f
dental therapist, 26–27
educator, 33–34
future trends in, 19–28, 20b
manager, 35–36
midlevel oral health practitioner, 23t–25t, 27–28
midlevel provider, 22–26
opening statements on, 18
reimbursement regulatory changes in, 20–22
researcher, 35
supervision and, 20–22
Caries. See Dental caries
CDC. See Centers for Disease Control and Prevention (CDC)
CDHC. See Community dental health coordinator (CDHC)
Centers for Disease Control and Prevention (CDC), 5, 143
recommendations to prevent fluorosis, 158b
Centers for Medicare and Medicaid Services, 5
Central tendency, measurement of, 192–193, 192t, 193f
Certification, of researcher, 35
Certified Health Education Specialist (CHES), 51
CFI. See Community Fluorosis Index (CFI)
Change drivers, 265, 266t
Children
dental caries in, 109–110
oral health disparities and, 110f
dental home for, 166
dental sealants and, 110–112, 112f
Medicaid and, 123
and WIC, 267
Children's Health Insurance Program (CHIP), 123, 169
percentages of children covered under, 123
Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA),
provisions in, 123
Children's Oral Health Coalition (COHC), 146
CHIP. See Children's Health Insurance Program (CHIP)
CHIPRA. See Children's Health Insurance Program Reauthorization Act of 2009
(CHIPRA)
Chi-square test, 200
Christian Community Action (CCA), 145, 145f
CLAS. See Culturally and Linguistically Appropriate Services (CLAS)
Cleft lip and palate, 115–116
lack of data on, 115–116
Clinical rotation, 268b
Clinical significance versus statistical significance, 206
Clinical trial, 185
Clinician, public health career, 31–33
educational requirements for, 32–33
environment in, 31
mini-profile of, 36b–38b, 40b–41b, 44b
population served in, 33
Coalition
local, 146
oral health, 52, 53f
Coalition Building Toolkit, 145
Code of Ethics and Standards of Professional Conduct, 229
Collaboration, 270–271
comments, 273b
Commission on Dental Accreditation (CODA), 52
Communication, health, 217–223
assessment and, 67
consumer-oriented, 217, 219b
cross-cultural, 251–255, 253b
focus group and, 219–220
formats, 220t
audiovisual materials, 220t
interactive, 220t
selecting and evaluating, 217
visual displays, 220t
written media, 220t
guiding principles regarding, 221b
planning process of, 218, 220f
presentations
guiding principles for, 221b
to health professionals, 219–223
for oral paper, 219
for poster display, 219, 222f
for roundtable discussion, 219–221
process of, 217
resources for, 221–223
risk, 235–237
strategic planning steps for, 217b
translation impacting, 219b
Community
fluoridated, 153–154, 154t
oral health programs in, 142–176
improving, 142–143
water fluoridation, 152–155
program, 154–155
Community, Homeless, and Migrant Health Programs/Centers, dental hygienist in,
32t
Community dental health coordinator (CDHC), 23t–25t, 28
Community Fluorosis Index (CFI), 93, 313
Community health, 2. See also Dental public health; Public health specific subject
oral health assessment, 61–68, 61f–62f, 62b, 74
oral practice in, 18–19, 19f
program planning
assessment for, 50–72
process of, 59–68, 60f
Community Organization Theory, 213–214, 214t
oral health example related to, 214
Community Periodontal Index (CPI), 88, 312
Community profile, 67, 68b
Community service, 266, 268b
Community-based health centers, 132
Competence, cultural. See Cultural competence
Competencies, dental hygiene, 296–297
community involvement in, 297
core, 296–297
domains of, 296
health promotion/disease prevention in, 297
patient care, 297
assessment, 297
dental hygiene diagnosis, 297
evaluation, 297
implementation, 297
planning, 297
professional growth/development, 297
Confidence intervals, 200
Consumer advocacy, 34
Consumer-oriented communication, 217
translation barriers and suggestions and, 219b
Continuous data, 191, 191t
Control group, 187–188
Convenience sampling, 187, 188t
Core competencies
dental hygiene, 296–297
for public health professionals, domains of, 52f
Corporate educator
mini-profile of, 42b
as public health career, 33–34
Correlation, 194–196, 195f–196f, 195t
CPI. See Community Periodontal Index (CPI)
Craniofacial anomalies
factors assessed in oral health surveys, 307
measurement of, 92
Craniofacial injuries
as common, 116
prevalence of, 116t
prevention of, 116
trends in, 116
Cross-cultural communication, 251–255, 253b
Cross-cultural encounters, 251
Cultural competence, 246–251
CLAS and, 248–249, 248b
community and organizational, 247–249
continuum, 249–251, 251f, 252b
blindness, 251f, 252
competence, 251f, 252
destructiveness, 251f, 252
incapacity, 251f, 252
pre-competence, 251f, 252
proficiency, 251f, 252
cross-cultural communication and, 251–255, 253b
cross-cultural encounters and, 251
Cultural Competence Education Model and, 249, 249f
knowledge and, 249, 249f
self exploration, 249, 249f
skill and, 249, 249f
development of, 249–251
diverse population and, 243–245, 244t
Kleinman Explanatory Model of Illness and, 253, 254b
LEARN model and, 253, 253b
opening statement and, 243
patient-centered care and, 255–256, 255f, 256b
people treated with, 247, 247f
Purnell Model for Cultural Competence and, 249, 250b, 250f
status and future of oral health and, 243
Culturally and Linguistically Appropriate Services (CLAS), cultural competency
and, 248–249, 248b
Culture, 246
considering, 245–246
effect on health and health-related factors, 246
factors influencing, 246b
D
Data, 191–192
cleft lip and palate, lack of, 115–116
continuous, 191, 191t
discrete, 191, 191t
displaying, 196–198
examples of government resources for, 302
qualitative, 64–65, 182
defined and analysis, 66
quantitative, 64, 182–183
scientific method and
collection, 189–190, 190f
presentation of, 191–201, 191t
types of, 191–192, 191t
types of, 64–65
Data collection, 65
analyzing data in, 66, 66f
implementing assessment and, 65
information in, types of, 64
measuring oral health and, 84, 84t
methods for, summary of, 303
organizing data in, 66, 66f
primary
determining necessity of, 65
planning, 65
tasks, examples of, 306
prioritizing issues in, 66–67, 67b
scientific method and, 189–190, 190f
from secondary sources, 64–65
sources of information for, 65t
utilizing data in, 66–68
Date of publication, 202–203
DDS. See Donated Dental Services (DDS)
Dean Fluorosis Index, 313
Dean's Fluorosis Classification, 93
Decayed, missing, and filled surface (DMFS), 85
application of, 85b
Decayed, missing, and filled teeth (DMFT) index
application of, 85b
permanent dentition and, 85
Decayed Missing Filled (DMF) Index, 310
Demand, resource and, 233
Dental caries
in children and adolescents, 109–110
oral health disparities and, 110f
factors assessed in oral health surveys, 307
measurements of, 84–86
coronal, 85–86, 85f
early childhood caries, 86
future directions in assessing, 86
root surface caries, 86
as multifactorial oral disease, 54f
as public health problem, 3
in young and older adults, 110, 111t–112t
Dental fluorosis
measurement of, 93–94, 94t
status/trends in, 116–117, 117f
Dental health aide therapist (DHAT), 23t–25t, 26
Dental Health Arlington (DHA), 145–146
Dental health professional shortage area (dental HPSA), 126, 127b
Dental hygiene faculty, 33
Dental hygiene therapist (DHT), 26
Dental hygienist
careers, 12, 18–49, 30t, 32t
ADHP, 27
administrator, 35–36
ADT, 26
advocate, 34–35, 34f
alternative practice settings in, 20, 20f–21f
CDHC, 28
clinician, 31–33
community oral health practice, 18–19, 19f
dental therapist, 26–27
educator, 33–34
future trends in, 19–28, 20b
manager, 35–36
midlevel oral health practitioner, 23t–25t, 27–28
midlevel provider, 22–26
opening statements on, 18
reimbursement regulatory changes in, 20–22
researcher, 35
supervision and, 20–22
roles of, 31f
working with Head Start, 165
Dental indexes, 310–313
Dental nurse, 26
Dental public health, 52. See also Oral health specific subject
careers in, 18–49, 30t, 32t
ADHP, 27
administrator, 35–36
ADT, 26
advocate, 34–35, 34f
alternative practice settings in, 20, 20f–21f
CDHC, 28
clinician, 31–33
community oral health practice, 18–19, 19f
dental therapist, 26–27
educator, 33–34
future trends in, 19–28, 20b
manager, 35–36
midlevel oral health practitioner, 23t–25t, 27–28
midlevel provider, 22–26
opening statements on, 18
reimbursement regulatory changes in, 20–22
researcher, 35
supervision and, 20–22
dental hygienist roles in, 31f
future of, 9–12
access to care, 19–20, 20b
career, 19–28
right direction of, 10–12, 11b
what needs to be done, 9–10, 10f
goals of, 12
programs for, 128–133
current status: structure and funding and, 131–132
infrastructure and capacity and, 129–131, 131b
performance of, 132–133, 132b
status and trends of, 129
success of, 131b
supervision and, 20–22
shortage area and, 22
Dental radiology course objectives, 279b
Dental screening, free, 36f
Dental sealants
CDC recommendations on, 159t
disparities among children for, 110–112, 112f
factors assessed in oral health surveys, 307
measurement of, 87, 87b, 87f
oral health status/trends in, 110–112, 112f
prevention and, 110–112, 112f
Dental therapist (DT), 26–27
Minnesota and, 26
Dental treatment, 165–166, 166f
Dental visits, MEPS regarding, 118, 118b
Dentition. See Permanent dentition; Primary dentition
Denton Christian Preschool (DCP), 156–157
Department of Agriculture, 5
Department of Defense (DOD), 5
dental hygienist in, 32t
Department of Health and Human Services (DHHS), 4, 5f, 143
Healthy People initiative and, 74
Department of Justice (DOJ), dental hygienist in, 32t
Department of Veterans Affairs (VA), dental hygienist in, 32t
Dependent variable, 189
Destructiveness, cultural, 251f, 252
Determinants of health, 57–59, 58b
guiding principles in, 59b
in relation to oral health, 58–59, 58b–60b, 59f
social, 58
DHAT. See Dental health aide therapist (DHAT)
DHHS. See Department of Health and Human Services (DHHS)
Diagnosis
cancer, oral and pharyngeal, 115
EPSDT and, 123
patient care and, 297
Dialogue, effective, suggestions for, 272b
Dialogue event, for data collection, 303t–304t
Dietary fluoride supplements, 157–158, 158t
effectiveness of, 156b
Dietary intake, factors assessed in oral health surveys, 307
Diffusion of Innovations Theory, 214–215, 215t
oral health example related to, 215
Direct access, definition of, 21–22
Directories, for data collection, 303t–304t
Discrete data, 191, 191t
Discussion, 205–206
Disease. See also Centers for Disease Control and Prevention (CDC)
assessment, periodontal disease and, 88, 89b, 89f
burden of oral
global, 104–105
in U.S., 104, 108–109
periodontal
assessing, future directions for, 89–90, 90b
CPI and, 88
factors assessed in oral health surveys, 308
measurement of, 88–90
NHANES and, 88–90, 90b
prevention core competency, 297
as public health problem, 4
Dispersion, measurement of, 193–194, 194b, 194t
Distribution of resources, shortage of dental health professionals and, 126
DMF index. See Decayed Missing Filled (DMF) Index
DMFS. See Decayed, missing, and filled surface (DMFS)
DMFT index. See Decayed, missing, and filled teeth (DMFT) index
Document study, for data collection, 303t–304t
Domestic violence, 237–238
RADAR and, 238b
signs and symptoms of, 237b
Donated Dental Services (DDS), 170
DT. See Dental therapist (DT)
E
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT), 123
Early childhood caries (ECC), classification of, 86, 311
Eastman Interdental Bleeding Index (EIBI), 88, 312
Edentulism, factors assessed in oral health surveys, 309
Education
for administrative role, 36
for advocacy role, 35
Cultural Competence Education Model and, 249, 249f
knowledge and, 249, 249f
self exploration, 249, 249f
skill and, 249, 249f
for dental hygiene faculty, 33
of dental professionals, 125, 125f, 125t
expanding dental hygiene, 216
lesson planning for, 160
oral health, 36f, 152–160
partnerships, community and, 300
for public health clinical position, 32–33
for researcher, 35
Educator, as public health career, 33–34
educational requirements for, 33–34
examples of programs in, 33
mini-profile of, 41b–42b, 45b
in oral health, role of, 33
Effective health interventions, selecting and planning, 150
EIBI. See Eastman interdental bleeding index (EIBI)
Empowerment, 62–63
Entrepreneur, mini-profile of, 37b–38b, 40b
Environmental factors, 54f, 56
Environmental objectives, 148
Epidemiologic survey, for data collection, 303t–304t
Epidemiologic triangle, 54–56, 54f
Epidemiology, 54–57
agent factors and, 54f, 56
basic concepts of, 54, 55t–56t
in changing health perspectives, 56–57, 57b
common terms used in, 55t–56t
environmental factors and, 54f, 56
host factors and, 54–56, 54f
uses of, 56, 56b
EPSDT. See Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)
Essential public health services for oral health, 144
Ethnic groups, in United States, 244t
ETHNIC Model, 253–254, 254b
Ethnocentrism, 246
Evaluation, 59–60, 60f
defined, 151
formative, 68, 150, 272
health communication formats and, 217
of needs assessment, 68
patient care, 297
qualitative and quantitative, 218, 221b
of research literature, 204, 204b
service-learning, 272
comments, 273b
summative, 68, 151, 272
Evidence-based decision making, 178–180, 179f
ranking of evidence for, 179–180, 179f
primary, secondary, and tertiary literature, 180
Evidence-based practices, 133
Experiential learning, 265–266
authenticity of, 267–268, 267f–268f
example of, 266–267, 267f
methods, 268b
outcomes, 267b
WIC facility example of, 267
Experimental group, 187
Experimental research, 185–186
F
Federal governmental agencies, for community oral health, 5b
Federal Interagency Workgroup (FIW), 74–75
Federally Qualified Health Center (FQHC), 169
Field study, observational, for data collection, 303t–304t
Financing program, oral health, 168–170, 168t
federal initiatives and, 168–169
federally qualified health center and, 169
volunteer dental services programs and, 170
FIW. See Federal Interagency Workgroup (FIW)
Fluoridated communities, 153–154, 154t
Fluoridation
additional sources of, 158
other programs, 156–158
dietary fluoride supplements, 157–158, 158t
fluoride varnish, 156–157, 156b, 157f
mouthrinse, 157
Fluoridation, water
community, 152–155, 156b
cost of, 154, 154t
effectiveness of, 152–153, 153f
Healthy People 2020 and, 112
measurement of access to, 94–95
population served, 154b
prevention and, 112–113
as public health solution, 3
Fluoride concentration, optimal, 94
Fluoride modalities, effectiveness of, 156b
Fluoride mouthrinses, effectiveness of, 156b
Fluoride varnish, 156–157, 156b, 157f
Fluorides, 152–160
factors assessed in oral health surveys, 307
mechanisms of action of, 153
optimal level of, 154
school-based, 156, 162f–163f
systemic, 153
Fluorosis, prevention of, 158, 158b
Fluorosis indexes, 313
Focus groups, 218
for data collection, 303t–304t
Follow up, with referral, 31
Fones, Alfred, 18
Food and Drug Administration, 5
Formative evaluation, 68, 150
Formats, communication, health, 220t
audiovisual materials, 220t
interactive, 220t
selecting and evaluating, 217
visual displays, 220t
written media, 220t
FQHC. See Federally Qualified Health Center (FQHC)
Framing health messages, 217–218, 218t
Frequency distribution tables, 196
Frequency polygon, 196–197, 197f
Future
dental caries and, 86
dental professional education, 125, 125f, 125t
of dental public health, 9–12
access to care, 19–20, 20b
career, 19–28
guiding principles in, 20b
right direction of, 10–12, 11b
what needs to be done, 9–10, 10f
directions for assessing OHRQOL, 98
for financing dental care, 123–124
of health care, 228
of oral health, 243
periodontal disease assessment, 89–90, 90b
G
GBI. See Gingival bleeding index (GBI)
GI. See Gingival index (GI)
Gingival Bleeding Index (GBI), 88, 312
Gingival Index (GI), 88, 311
Gingivitis, 88
Global Tobacco Surveillance System (GTSS), 92, 92b
Goals, 148
assessment and, 63
of dental public health, 12
Healthy People 2020 framework, 75–77
Government
agencies, 4–7, 5b, 5f
in core functions and essential services of public health, 7–9, 8b, 8t, 9f
in healthcare delivery, role of, 231–233, 231f
Medicaid and, 123
national initiatives of, 4–7, 6b–7b
partnerships, community and, 298
in public health, role of, 4–9
Graphs, 196–198
Guiding principles
assessment, 53b, 147b
communication, cross-cultural, 253b
communication, health, 221b
dental hygienists and
licensed, social responsibilities of, 229b
oral health care and, 230b
in determinants of health, 59b
experiential learning, 267b
future trends and, 20b
knowledge, 216b
oral healthcare delivery system and, 234b
for presentations, 221b
service-learning, 269b
comments, 273b
social media and, for healthcare communication, 236b
H
Head Start, 162–165, 163f
dental hygienists working with, 165
program description, 163–164, 163f
program statistics, 164t
Health. See also Oral health; Promotion, health specific subject
changing perspectives of, 56–57, 57b
defined, 1, 57
determinants of, 57–59, 58b
disparities, 76, 108, 244–245, 245b, 245f
effect of culture on, 246
equity, 76, 233
HRQOL and, 96–98, 96f
literacy, 218, 256–258, 257b–258b, 258t
prerequisites for, 57f
Health Belief Model (HBM), 212–213, 213t
oral health example related to, 213
Health care
comprehensive approach in, 234–235, 234b
government role in, 231–233, 231f
as privilege, 230–231, 230b, 230f
as right, 231
status and future of, 228
system in crisis and, 228
Health care system, access to, in community health measures, 305t
Health issue, measurable process and outcome objectives, 148–150
Health promotion, 57
Health promotion theories, 59
combining, 216
Health Resources and Services Administration (HRSA), 5, 156
dental hygienist in, 32t
Health risks and protective factors, in community health measures, 305t
Health services
Head Start and, 164
oral, 164–165, 165f
Health status, in community health measures, 305t
Health-related quality of life (HRQOL), 96–98, 96f, 98b
Healthy People, 74–79
establishment of, 74
FIW and, 74–75
Healthy People Consortium and, 75
history and development of, 74–75
national health objectives, 76–78
national oral health objectives, 78–79
Healthy People 2010, progress of, 106t–108t, 108b
Healthy People 2020, 7, 142–143
eliminating health disparities and promoting health equity, focus on, 76, 77f
FIW and, 74–75
framework, 75–76, 75b
action model, 75, 76f
goals, 75
topic areas, 77–78, 78b
history and development of, 74–75
and infrastructure, capacity, and resources, 98–99, 99f
national oral health objectives, 78–79, 79t–80t
objective for water fluoridation, 153–154
quality of life and, 96–97
water fluoridation and, 112
Healthy People Consortium, 75
Histogram, 196, 197f
Host factors, 54–56, 54f
HPSA, dental. See Dental health professional shortage area (dental HPSA)
HRQOL. See Health-related quality of life (HRQOL)
HRSA. See Health Resources and Services Administration (HRSA)
Human Resources and Services Administration, 127
MCHB and, 129–130, 130f
Hypothesis, development of, 181–182
I
Impact objective, 148
Implement, 59–60, 60f
Implementation
of interventions for oral health program, 150–151, 151b
patient care, 297
Incapacity, cultural, 251f, 252
Independent variable, 189
In-depth personal interview, for data collection, 303t–304t
Index, dental, 84, 84t
CPI, 88
DMF, 85, 85b
Indian Health Service (IHS), 5
dental hygienist in, 32t
Indiana State Department of Health (ISDH), 154–155
Information technology, health, 217–223
Insurance. See also Children's Health Insurance Program (CHIP); Children's Health
Insurance Program Reauthorization Act of 2009 (CHIPRA); Medicaid; Medicare
dental, 119t
adults and, 122
benefits plans, 121t
children and adolescents and, 120–122, 120f, 122f
expenditures, 120, 120b
mechanisms of payment for oral health care and, 121t–122t
public, vs. private health insurance, 120
younger and older adults, 122
publicly funded health, 122–123
CHIP, 123
Medicaid, 123
Medicare, 123
Interactive format, 220t
Interdisciplinary collaboration, 62–63
International Caries Detection and Assessment System (ICDAS), 86
Internship, 268b
Interprofessional collaborative practice (ICP), 28–30, 28b, 274, 274b
future of, in oral health, 29–30, 29f
and service-learning, 274–275
models, 275, 275b
strategies in, 274–275, 275b
Interrater/intrarater reliability, 190
Interval scale, 191
Interview, for data collection, 303t–304t
Inventories, for data collection, 303t–304t
Iron triangle, of health care, 231, 231f
J
Joint Commission on National Dental Examinations (JCNDE), 286
Journal, selecting, 202
Judgmental sampling, 187, 188t
K
Kleinman Explanatory Model of Illness, 253, 254b
L
Leadership, 235–237
Leading Health Indicators, National 2010 objectives for, 78, 78f
LEARN model
acknowledge component, 253b
cultural competency and, 253, 253b
explain component, 253b
listen component, 253b
negotiate component, 253b
recommend component, 253b
Learning objective (LO), 148, 269–270, 270f
academic course objective, 280t
examples of, 279t
Lesson plans
components of, 160
oral health education, 160b
service-learning, 281f–282f
Linguistic diversity, in United States, 244t
LO. See Learning objective (LO)
Local coalitions, 146
Logical clues, application of, to answering multiple-choice test questions, 287b
Long-Term Care Dental Campaign, of ADA, 11
M
Mailed survey, for data collection, 303t–304t
Maine, dental therapist in, 23t–25t, 26–27
Malocclusion
factors assessed in oral health surveys, 308
measurement of, 93
trends in, 116
Manager, career as, 35–36
Mann-Whitney U test, 200
Maps, for data collection, 303t–304t
Marketing, health, 217
Master Certified Health Education Specialist (MCHES), 51
Maternal and Child Health Bureau (MCHB), 129–130, 130f
MCHB. See Maternal and Child Health Bureau (MCHB)
McKay, Frederick, 152
Mean, 192, 192t
Measurable outcomes, 151
Measurement
of central tendency, 192–193, 192t, 193f
of dispersion, 193–194, 194b, 194t
Measuring oral health, 83–84
data collection methods and, 84, 84t
dental index and, 84, 84t
periodontal disease, 88–90
in populations, 83–84
types of measurements in, 84–99
access to OHS, 95–96, 95f
access to water fluoridation, 94–95, 94b
cancer, oral and pharyngeal, 90–92, 91b
craniofacial anomalies, 92
dental caries, 84–86
dental fluorosis, 93–94, 94t
dental sealants, 87, 87b, 87f
denture use, 93
dry mouth, 93
infrastructure, capacity, resources, 98–99, 99f
malocclusion, 93
oral health treatment needs, 86–87, 87b
oral health-related quality of life, 96–98, 97f, 98b
orofacial injuries and tooth trauma, 93
orofacial pain and temporomandibular disorders, 93
tooth loss, 90, 91b
tooth wear, 93
Median, 192t, 193
Medicaid, 123, 169
EPSDT and, 123
federal government and states and, 123
low income adults and, 123
percentages of children covered under, 123
Medical Expenditure Panel Survey (MEPS), 95
dental visits and, 118, 118b
Medicare, 123
MEPS. See Medical Expenditure Panel Survey (MEPS)
Methods/materials, 205
MGI. See Modified gingival index (MGI)
Midlevel oral health practitioner, 23t–25t, 27–28
Midlevel provider, 22–26
Miles of Smiles-Laredo (MOS-L), 162
Mini-profile
of administrator, 39b–41b, 43b
of advocate, 38b–40b
of clinician, 36b–38b, 40b–41b, 44b
of educator, 41b–42b, 45b
of entrepreneur, 37b–38b
of researcher, 38b–39b, 45b
Minnesota, dental therapist in, 23t–25t, 26, 27b
Mixed-methods research, 183
Mode, 192t, 193
Models
Assessing Oral Health Needs: ASTDD Seven-Step Model, 61–62
assessment model examples, 61–62, 62b, 62f
Cultural Competence Education Model, 249, 249f
knowledge and, 249, 249f
self exploration, 249, 249f
skill and, 249, 249f
Health Belief Model, 212–213, 213t
oral health example related to, 213
Healthy People 2020 action model, 75, 76f
Kleinman Explanatory Model of Illness, 253, 254b
LEARN model
acknowledge component, 253b
cultural competency and, 253, 253b
explain component, 253b
listen component, 253b
negotiate component, 253b
recommend component, 253b
patient-centered care and, 255–256, 255f, 256b
Purnell Model for Cultural Competence, 249, 250b, 250f
Transtheoretical Model, 212, 212t
oral health example related to, 212
Modified Gingival Index (MGI), 88, 311
Mouthrinse programs, 157
Mutual objective formation, 271, 271b
N
National Board Dental Hygiene Examination (NBDHE), 286, 288t
community case questions
answering, 289–294
critical thinking and, 289
community cases and, 286, 287b
community oral health program or activity of, 286
multiple-choice questions, 286
practice testlets, 289–292
No.1, 289–290, 292
No.2, 290, 293
No.3, 290–291, 293
No.4, 291, 293–294
No.5, 291–292, 294
question formats, 286, 288b–289b
National Board of Public Health Examiners (NBPHE), 51
National Commission for Health Education Credentialing, Inc. (NCHEC), 51
National Health and Nutrition Examination Survey (NHANES), 82, 83f
dental fluorosis measurement and, 93, 94t
oral and pharyngeal cancer and, 91, 91b
oral health status/trends and, 118
periodontal disease and, 88–90, 90b
National Health Interview Survey (NHIS), 82
retention/loss of teeth and, 90, 91b
National Health Service Corps (NHSC), dental hygienist in, 32t
National initiatives, for oral health, 4–7, 6b–7b
National Institutes of Health, 5
National Oral Health Objectives, 78–79
Healthy People 2020, 78–79, 79t
National Oral Health Surveillance System (NOHSS), 81–83
oral health indicators in, 82, 82t–83t
oral health status/trends and, 109
NBDHE. See National Board Dental Hygiene Examination (NBDHE)
NHANES. See National Health and Nutrition Examination Survey (NHANES)
NHIS. See National Health Interview Survey (NHIS)
NOHSS. See National Oral Health Surveillance System (NOHSS)
Noma, 105b
Nominal scale, 191
Nonparametric inferential statistics, 200
Normal distribution, 199, 199f
Null hypothesis, 181–182, 201t
O
Obamacare, 9
Observational field study, for data collection, 303t–304t
Observational research, 183–185
OHRQOL. See Oral health-related quality of life (OHRQOL)
Older adults, oral health services for, 167–168, 167f–168f
Oral health. See also Dental public health; Measuring oral health; Population
health; Prevention; Programs, oral health; Promotion, oral health; School-based
oral health programs; Surveillance systems, oral health; Surveys, oral
health; Workforce, oral health specific subject
assessment of community, 74
coalition, 144–145, 144b
framework, 301, 301f
in communities, assessment of, 61–68, 61f–62f, 62b
community practice of, 18–19
determinants of, 58–59, 59b–60b, 59f
developing and implementing improvement plan for, 68
education, 36f, 152–160
lesson plan template, 160b
educator role in, 33
ICP in, future of, 29–30, 29f
overall health and, 29
presentation
developing, 160
teaching methods for, 161b
prevention program, secondary and tertiary, 165–168
services for older adults, 167–168, 167f–168f
surveillance systems, 79–83, 81b
ASTDD, 80, 81b
BSS, 80–81, 81t–82t
future considerations for, 99–100
NOHSS, 81–83, 82t–83t
workforce, 124–128
public health preparation of, 52
Oral Health Resources for Health Professionals, 28–29
Oral health services, 164–165, 164b, 165f
access to, 235
Oral healthcare system, access to, 95–96, 95f, 96b, 117–119
Oral health-related quality of life (OHRQOL), future directions for assessing, 98
Oral paper presentations, 219, 222f
appropriate audiovisuals and, 222
benefits and limitations of, 222
time and, 222
tips and, 222
Ordinal scale, 191
Organizational Change: Stage Theory, 215–216, 216t
oral health example related to, 216
Orientation, 271
comments, 273b
Orofacial injuries
factors assessed in oral health surveys, 308
measurement of, 93
Orofacial pain, measurement of, 93
Outcome objective, 148
Overall health, oral health and, 29
P
p values, 201
Parameter, 187
Parametric inferential statistics, 199–200, 200t
Partnerships, community
assessment and, 62
potential, 298–300
business organizations/retail outlets, 300
community organizations, 299
education-related organizations/groups, 299
government agencies/programs, 298
health and human service providers/groups/organizations/associations, 300
higher/professional education, 300
patients/clients/consumers of services, 298
policymakers/organizations, 298
third-party payers, 300
Patient
confidentiality, 233–234
responsibility, 233–234
Patient care, 297
assessment, 297
dental hygiene diagnosis, 297
evaluation, 297
implementation, 297
planning, 297
Patient Protection and Affordable Care Act, 110, 166
Patient-centered care, 255–256, 255f, 256b
PDI. See Periodontal disease index (PDI)
Peer review, 202
Percentiles, 196
Periodontal disease
and CPI, 88
factors assessed in oral health surveys, 308
future directions for assessing, 89–90, 90b
measurement of, 88–90
NHANES and, 88–90, 90b
Periodontal Disease Index (PDI), 89, 89b, 312
Periodontitis, 88–90, 90f
Permanent dentition
DMF index and, 85
factors assessed in oral health surveys, 308
Personal interview, in-depth, for data collection, 303t–304t
Person-to-person interview, for data collection, 303t–304t
PHS. See Public Health Service (PHS)
Pie chart, 197–198, 198f, 199b
Pilot study, 187
Plan, 59–60, 60f
Planning. See also Lesson plans
data collection and, 65
following assessment, 68
oral health program, 146–152, 147t
goals, 148
objectives, 148–150, 148b
patient care, 297
program process, 146–152, 147t
Policy development
as core public health function, 7–8, 8b, 8t, 9f
social responsibility and, 232–233
how a bill becomes a law, 232f
order of procedures for, 233b
Population, 187
dentist-to-population ratio, 126
measuring oral health in, 83–84
scientific method and, 187
served by clinician, 33
served by fluoridation, 154b
Population health, 104–141
access to oral health care system, 117–133
barriers to, 118, 118b
dental insurance coverage and, 119
dental public health programs and, 128–133
oral health workforce and, 124–128
regular visits and use of services and, 118–119, 118b
and teledentistry, 128
unmet dental needs and, 118–119
defined, 2
future directions of, 133, 133b
opening statement, 104
status and trends, 104–109
burden of disease, global, 104–105
burden of disease in U.S, 104, 108–109
in cleft lip and palate, 115–116
in community preventive services, 110–113
in craniofacial injuries, 116
in dental caries, 109–110
in dental fluorosis, 116–117, 117f
dental sealant and, 110–112, 112f
Healthy People 2010 progress and, 106t–108t
in malocclusion, 116
in oral and pharyngeal cancer, 113–115
oral health in U.S., 105–109
in other oral conditions, 115–117
periodontal diseases and, 113, 114t
sealants and, 110–112
social impact of oral disease, 109, 109b
in tooth loss, 113, 115f
Poster display presentation, 219
appropriate audiovisuals and, 222
benefits and limitations of, 222
example of, 222f
size of audience and, 222
time and, 222
tips and, 222
Poverty, definition of, 228–229
Power analysis, 201
Practicum, 268b
Pre-competence, cultural, 251f, 252
Preparation, in service-learning, 271–272
comments, 273b
Presentation
guiding principles for, 221b
to health professionals, 219–223
for oral paper, 219
for poster display, 219
for roundtable discussion, 219–221
scientific method and, 191–201
Prevention
core competencies, 297
of craniofacial injuries, 116
fluorosis and, 158, 158b
oral health programs for, 152–160
secondary and tertiary, 165–168
water fluoridation, 112–113, 152–153, 153f
oral health status/trends in, 110–113
sealants and, 158–159, 159t
stages of, 20, 21t
Preventive care, factors assessed in oral health surveys, 308
Primary dentition, factors assessed in oral health surveys, 308
Primary health issues, identifying, 146–148
Primary prevention, 20, 21t
Private practice, public health comparison with, 2, 2t
Process objective, 148
Professional ethics, 229–230, 230b
Professional preparation, of public health workforce, 51–52, 51b
Professionals, dental
dental HPSA, 126, 127b
dental safety net and, 117–118
distribution of, 126–127, 126f
dental HPSA, 126, 127b
dentist-to-population ratio and, 126
education of, 125, 125f, 125t
HRSA and, 127
supply of, 124–125, 124f
education of, 300
growth/development, 297
population trends and future, 127–128, 128f
shortage of, 126
Professionals, health
oral, Code of Ethics and Standards of Professional Conduct and, 229
presentations to, 219–223
public, assessment and, 53–54, 53b–54b, 53f
Proficiency, cultural, 251f, 252
Program planning process, community health, 59–68, 60f
Program-planning goals, flowchart of, 150f
Programs, oral health, 128–133
assessment, guiding principles, 147b
current status: structure and funding in, 131–132
essential public health services for oral health and, 144
evaluating selected interventions, 151–152
financing, 168–170, 168t
fluoride, 156–158
Head Start, 162–165, 163f
health department role, 143–146
local level, 145–146
national level, 143
state level, 143–145
implementation
defined, 150
of selected interventions, 150–151, 151b
improving, 142–143
infrastructure and capacity and, 129–133, 131b
percent of, 143t
performance of, 132–133, 132b
planning, 146–152, 147t
goals, 148
objectives, 148–150, 148b
process, 146–152, 147t
prevention, 152–160
dental sealants, 158–159, 159t
education, 159–160
fluorosis, 158, 158b
water fluoridation, 152–153, 153f
school-based, 160–162, 162f
status and trends of, 129
steps, 167b
success of, 131b
writing objectives, sample performance verbs appropriate for, 149b
Promotion, health, 210–217
resources for, 221–223
strategies of, 210–211
theories of, 211–216, 211f, 212t
community level, 211f, 213–216
Community Organization Theory, 213–214, 214t
Diffusion of Innovations Theory, 214–215, 215t
Health Belief Model, 212–213, 213t
interpersonal level of, 211f, 213
intrapersonal level of, 211f, 212–213
levels of influence of, 211f, 212t
Organizational Change: Stage Theory, 215–216, 216t
Social Learning Theory, 213, 214t
Stages of Change Theory, 212, 212t
Promotion, oral health
challenges to, 210
opening statements, 210
Public forum, for data collection, 303t–304t
Public health. See also Dental public health; Health; Oral health; Population
health specific subject
accomplishments, 10
assessment and, 53–54
collaboration in, 52
core functions of, 7–9, 8b, 8t, 9f, 53–54
defined, 1–2
dental, 2
future of, 9–12
essential public health services for oral health and, 144
essential services of, 8t, 9f
government in, role of, 4–9
agencies, 4–7, 5b, 5f
national initiatives and, 4–7, 6b–7b
opening statements on, 1
practice, 51–52, 51f
private practice comparison with, 2, 2t
problem, 2–3
criteria for, 3b
dental disease as, 4
examples of, 2–3
professionals, assessment roles for, 53–54, 53b–54b, 53f
solution, 3–4
characteristics of, 3, 3b
examples of, 3
fluoridation as, 3
workforce, professional preparation of, 51–52, 52f
Public health fluoride varnish programs, 156
Public health resources, 276–277
Public Health Service (PHS), 5, 5f
Public health system, access to, in community health measures, 305t
Purnell Model for Cultural Competence, 249, 250b, 250f
Purposive sampling, 187, 188t
Q
Qualitative data, 64–65
Qualitative evaluation, 221
Qualitative research, 182–183
Quality of life, 96–98, 96f. See also Health-related quality of life (HRQOL)
Quantitative data, 64
Quantitative evaluation, 221
Quasi-experimental Research, 186
Question formats, of National Board Dental Hygiene Examination, 286, 288b–289b
R
Ramfjord teeth, 89, 89b
Random sampling, 187, 188t
Range, 193–194, 194b
Ratio scale, 192
RCI. See Root caries index (RCI)
Refereed, 202
Reflection, in service-learning, 272, 272b
comments, 273b
Reimbursement regulatory changes, 20–22
Reliability, 190
Research, 177–209
analysis of literature, 201–206, 202f
abstract, 205
components of a primary research report, 204–206
current topic of interest example in, 182b
discussion and, 205–206
evaluation of selected literature and, 204
methods/materials and, 205
results and, 205
selection of literature and, 202–203, 203b
blinding (masking), 189
cases and controls in observational studies, 188
communication of results, 190–191
convenience sampling, 187, 188t
correlation, 194–196, 195f–196f, 195t
data, 191–192, 191t
designs, 183–186
various, 184t–185t
ethical conduct of, 190–191
evidence-based decision making and, 178–180, 179f
experimental, 185–186
crossover design, 185
factorial design, 186, 186t
pretest-posttest design, 185
quasi-, 186
repeated measures design, 185
split-plot (split-mouth) design, 185–186
experimental/control groups, 187–188
formulating question, 180
frequency distribution tables, 196
general methods of, 182–183
graphs, 196–198
guiding principles and, 178b, 181b, 190b, 192b
inferential statistics, 192t, 198–200
length of study, 189
measures of central tendency, 192–193, 192t, 193f
measures of dispersion, 193–194, 194b, 194t
methodology, 186–191, 186b
mixed-methods, 183
nonparametric inferential statistics, 200
observational, 183–185
opening statements, 177–178
parametric inferential statistics, 199–200, 200t
percentiles, 196
population, 187
purposive sampling, 187, 188t
qualitative versus quantitative, 183t
questions in, 178–180
random sampling, 187
sampling, 187
scientific method and, 180–182, 181f
ANOVA, 200, 200t
collecting data, 189–190, 190f
statistical significance determination, 200–201
statistics, 192–201
stratified random sampling, 187, 188t
systematic sampling, 187, 188t
variables, 189
Research report, primary, components of, 204–206
Researcher
career as, 35
mini-profile of, 38b–39b, 45b
Resources, community, websites for, 295
RESPECT Model, 253, 254b
Restorations and Tooth Conditions Assessment (RTCA), 85–86
Results, 205
Risk. See also Behavioral Risk Factor Surveillance System (BRFSS)
communication, 235–237
factors, cancer, 115
SL management of, 275–276, 276b
Root Caries Index (RCI), 86, 311
Roundtable discussion presentation, 219–221, 223f
appropriate audiovisuals and, 223
benefits and limitations of, 223
size of audience, 223
time and, 222–223
tips, 223
S
Sample, 187
Sampling, 187
convenience, 187, 188t
purposive, 187, 188t
random, 187
stratified random, 187, 188t
systematic, 187, 188t
SBI. See Sulcus bleeding index (SBI)
SBSP. See School-based sealant programs (SBSP)
Scattergram, 197
Scenarios, 286
School-based fluoride, 156, 162f–163f
School-based oral health programs, 160–162, 162f–163f
School-based sealant programs (SBSP), 158, 159t
Scientific method, 180–182, 181f
ANOVA, 200, 200t
blinding (masking), 189
collecting data, 189–190, 190f
convenience sampling, 187, 188t
correlation, 194–196, 195f–196f, 195t
data, 191–192, 191t
formulating question, 180
frequency distribution tables, 196
graphs, 196–198
inferential statistics, 192t, 198–200
length of study, 189
measures of central tendency, 192–193, 192t, 193f
measures of dispersion, 193–194, 194b, 194t
nonparametric inferential statistics, 200
parametric inferential statistics, 199–200, 200t
percentiles, 196
population, 187
purposive sampling, 187, 188t
random sampling, 187
sampling, 187
statistical significance determination, 200–201
statistics, 192–201
stratified random sampling, 187, 188t
systematic sampling, 187, 188t
variables, 189
Screening survey, for data collection, 303t–304t
SD. See Standard deviation (SD)
Sealants. See Dental sealants
Self
assessment, community, 63
exploration, 249, 249f
Service objective (SO), 269–270, 269f–270f
community partner, 280t
examples of, 279t
Service-learning, 264–285
benefits of, 272–275
interprofessional collaborative practice, 274, 274b
traditional to collaborative experiential learning, 272–274
characteristics of, 269–270
collaboration, 270–271
evaluation, 272
mutual objective formation, 271, 271b
orientation, 271
preparation, 271–272
reflection, 272, 272b
clinical rotation, 268b
community service, 268b
defined, 268–269, 268b, 268f–269f
as experiential learning, 265–269
guiding principles, 269b
ideas that can be integrated into, 269b
interprofessional collaborative practice and, 274–275
lesson plan, 281f–282f
opening statements, 264–265
practicum/internship, 268b
process of, 270
to reinforce dental public health learning, 276–277, 276f
learning opportunities, 277
public health resources, 276–277
risk management in, 275–276, 276b
stages of, 269–272
volunteerism, 268b
Service-learning objective (S-LO), 269–270, 270f–271f
combination of SO and LO, 280t
examples of, 279t
Severe early childhood caries (S-ECC), classification of, 311
Shortage
area, 22
of dental health professionals, 126
of oral healthcare providers, 234
Significance, of data analysis, 66
Skill, 249, 249f
S-LO. See Service-learning objective (S-LO)
SMART + C objectives, 148
characteristics of, 148b
examples of, 149b
Smiles for Life, 28–29
SmilesMaker, 162
SO. See Service objective (SO)
Social impact, of oral disease, 109, 109b
Social Learning Theory, 213, 214t
oral health example related to, 213
Social marketing, 217
Social responsibility, 228–242
definition of, 229
demand versus resource and, 233
domestic violence and, 237–238, 237b–238b
government role and, 231–233, 231f
health care and
approach in, 234–235, 234b
as privilege, 230–231, 230b, 230f
as right, 231
leadership and, 235–237, 236f
opening statements in, 228
patient confidentiality and, 233–234
patient responsibility and, 233–234
policy development and, 232–233, 232f, 233b
professional ethics and, 229–230, 229b–230b
risk communication and, 235–237, 236b, 237f
system in crisis and, 228–229, 229f
Social service system, access to, in community health measures, 305t
Socioeconomic status (SES), public health and, 4
Soft tissue lesions, assessed in oral health surveys, 309
Stage Theory, Organizational Change, 215–216, 216t
oral health example related to, 216
Stages of Change Theory, 212, 212t
oral health example related to, 212
Standard deviation (SD), 193–194, 194b, 194t
State Oral Health Coalitions and Collaborative Partnerships, 144
State oral health programs (SOHP), 143
Statistics, 192–201
conclusion, 201
descriptive, 192, 192t
inferential, 192t, 198–200
nonparametric, 200
parametric, 199–200, 200t
statistical significance determination, 200–201
Status, 109
Stratified random sampling, 187, 188t
Study, length of, 189
Sulcus Bleeding Index (SBI), 88, 311
Summative evaluation, 68
Supervision, 20–22
levels of, 22t
Surveillance systems, oral health, 79–83, 81b
ASTDD, 80, 81b
BSS, 80–81, 81t–82t
future considerations for, 99–100
NOHSS, 81–83, 82t–83t
Surveys
for data collection, 303t–304t
oral health, 307–309. See also Basic Methods for Oral Health Surveys,
WHO; Basic Screening Survey (BSS); Medical Expenditure Panel Survey
(MEPS); National Health and Nutrition Examination Survey
(NHANES); National Health Interview Survey (NHIS)
conditions or factors that can be assessed in, 307t–309t
Systematic sampling, 187, 188t
T
Tailoring health messages, 217
Technical assistance, 34
Teledentistry, 128
history of, 128
successful examples of, 128, 129b
Telephone interview, for data collection, 303t–304t
Temporomandibular disorder (TMD), assessed in oral health surveys, 309
Temporomandibular joint (TMJ), 93
Testlet, 286
Test-taking strategies
community case questions
answering, 289–294
critical thinking and, 289
community cases and, 286–294, 287b
community oral health program or activity of, 286
multiple-choice questions, 286
National Board Dental Hygiene Examination, 286, 288t
practice testlets, 289–292
No.1, 289–290, 292
No.2, 290, 293
No.3, 290–291, 293
No.4, 291, 293–294
No.5, 291–292, 294
Texas, health steps program, 167b
Theories, health promotion, 211–216, 211f, 212t. See also Transtheoretical Model
community level, 211f, 213–216
Community Organization Theory, 213–214, 214t
Diffusion of Innovations Theory, 214–215, 215t
Health Belief Model, 212–213, 213t
interpersonal level of, 211f, 213
intrapersonal level of, 211f, 212–213
Organizational Change: Stage Theory, 215–216, 216t
Social Learning Theory, 213, 214t
Stages of Change Theory, 212, 212t
Theory, 211
Time series graph, 197, 198f
TMJ. See Temporomandibular joint (TMJ)
Tobacco
assessed in oral health surveys, 309
oral and pharyngeal cancer and, 91–92, 92b
Tooth decay, untreated, percentage of third-grade students with, in Southwestern
States, 135t
Tooth loss, 90, 91b, 113, 115f
assessed in oral health surveys, 309
Tooth trauma, measurement of, 93
Toothpaste, fluoride, effectiveness of, 156b
Traditional narrative review, 179
Translation
barriers and suggestions, 219b
overcoming problems in, 219
problems, 219
Transtheoretical Model, 212, 212t
oral health example related to, 212
Trend, 109
t-test, 199–200
Type I alpha (α) error, 201
Type II beta (β) error, 201
U
Urgency, of need for dental care, BSS criteria for, 82t
U.S. Public Health Service (USPHS), dental hygienist in, 32t
V
Validity, 189
Variables, 189
Variance, 193–194, 194b, 194t
ANOVA, 200, 200t
Various research designs, 184t–185t
Visioning process, for data collection, 303t–304t
Visual displays, 220t
Volunteer dental services programs, 170
Volunteerism, 268b
W
Walking tour, for data collection, 303t–304t
Water Fluoridation Reporting System (WFRS), measurement of access to water
fluoridation, 94–95
Web-based presentation, 221, 223f
Websites for community resources, additional, 295
WFRS. See Water Fluoridation Reporting System (WFRS)
WHO. See World Health Organization (WHO)
WIC. See Women, Infants, and Children's Program (WIC)
Wilcoxon signed-rank test, 200
Windshield, for data collection, 303t–304t
Wisconsin Oral Health Coalition (WOHC), 144
Women, Infants, and Children's Program (WIC), 169
facility, experiential learning and, 267
Workforce, oral health
access to care and, 124–128
distribution of, 126–127, 126f
educating future of, 125, 125t
population trends and future of, 127–128, 128f
supply of, 124–125, 124f, 125t
World Health Organization (WHO)
CPI and, 89
dental treatment need and, 87, 87b
Written communications, 254–255, 255b
Written media, 220t