Dental public health

The American Board of Dental Public Health (ABDPH) have devised a list of competencies for dental public health specialists to follow.[11] Dental public health specialists are a select group of certified dentists. The 10 competencies allow for growth and learning of individuals and set expectations for the future. An advantage of the design is that they are implementable on a global level. The list is updated periodically.[11]

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Major areas of dental public health activity include:

• Oral health surveillance

National Oral Health Surveillance system (NOHSS) is designed to monitor the effects of oral disease on the population, as well as monitor how the oral care is delivered. Additionally the status of water fluoridation on both a state and a national level is continually supervised [12]

• Assessing the evidence on oral health and dental interventions, programmes, and services
• Policy and strategy development and implementation
• Oral health improvement
• Health and public protection
• Developing and monitoring quality dental services
• Dental public health intelligence
• Academic dental public health
• Role within health services

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To allow a health problem to be properly managed, it is important that there is a set of rules or criteria to follow which determines what is defined as a public health problem and what is the best way to manage health problems in communities. The following are questions should be considered when addressing public health problems:

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Once these questions have been answered, the way a public health problem is acted upon to protect a population can be determined.

Water fluoridation is the implementation of artificial fluoride in public water supplies with the intentions to halt the progression of dental diseases.[14] Fluoride has the ability to interfere with the demineralisation and remineralisation process that occurs on the tooth surface and improves the mineral intake when the pH level may reduce below the neutral pH level.[15]

This achievement was implemented through the public health development in the 19th, 20th century and led into the 21st century. Research into the effects of fluoride on teeth began due to the concern about the presence of dental fluorosis.[16]

Many clinical case trials occurred in the beginning of the 20th century. However, the very first clinical trial to have occurred dates back to the 19th century when Denninger conducted a trial prescribing children and pregnant women with calcium fluoride.[15] From this trial it was recognised fluoride’s significance on tooth tissue and from this point, many clinical trials were conducted [14] Following these studies, the recognition of the positive outcome on dental tissues became clear and projects in water fluoridation became of significant importance.

The development of artificial water fluoridation began in 1945 in the Grand rapid Michigan followed by Newburgh, New York and Evanston, Illinois.[17] In 1955 three towns Watford, Kilmarnock and Anglesey trialled the water fluoridation implementation scheme.[14] In 1960 the Republic of Ireland implemented all public water supplies with artificial fluoridated water and four years later extending this into the main cities of Dublin and Cork.[14]

Currently, 40 countries have fluoridated water schemes implemented. Fluoride is still yet to be completely implemented across the full population however, progress is slowly improving and access is becoming more common.[14]

The world extent of water fluoridation.

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Prevention methods such as oral health promotion began with the education of clinicians and the population in the health promotion strategies. Since the mid 19th century oral health practice has revolved more around prevention and education rather than treatment of disease.[19] This education can be focused towards dental practitioners and to the wider population who may interested.

There has been a change in focus in the education of developing clinicians all over the world. The first dental school was developed in 1828 [20] and was followed by an ever-growing field of practice. The dental practice began with its main focus on the treatment of oral disease and branched into a wide scope of practice with many dental occupations involved.

The most common form of dental clinicians are either general dentists, oral health therapists, dental therapists and dental hygienist. When desired, some of these clinicians may seek further experience in projects that may assist the dental public system in bringing further awareness to prevention of dental diseases.[21]

Oral health prevention is the current form of practice of many clinicians. As education in oral care to the population is now believed to be the superior solution rather than the treatment of disease. Dental university education now develops clinicians to focus on the education of patients, education of the community and a wider population using different approaches.[19]

Oral health promotion focuses on individual behaviour, the Socioeconomic status and environmental factors. Underlying determinants that can also impact oral health, including non-milk extrinsic sugars consumption, alcohol consumption and smoking behaviour.[23]

The ability to remove dental plaque, exposure to fluoride and access to quality dental care can affect the ways the aforementioned underlying factors are and can be modified to the needs of the individual to obtain optimum oral health.[23] Ways in which oral health promotion can minimise the effects of these determinants;

• Promoting healthy eating.
• Teaching effective oral hygiene practices.
• Promoting the use of topical fluoride for preventing and control of dental caries.
• Facilitating early access to preventative dental services.[24]

It is also important to note that these factors are also influenced by socio-political considerations that are outside the control of most individuals.[23]

Community participation is a key factor in oral health promotion. Inter-sectoral collaboration is where relevant agencies and sectors are involved in partnership to identify key oral health issues and to implement new methods to improve oral health.[23]

The World Health Organization has agreed on a health promotion approach as the foundation for oral health improvement strategies and policies for the population. Oral health promotion is based on the principles of the framework, Ottawa Charter. There are five areas of action outlined to achieve oral health promotion; building Health public policy, creating supportive environment, strengthening community action, developing personal skills, re-orienting healthcare services.[22]

A study investigating the efficacy of staff workers' oral care education on improving the oral health of care home residents found that despite the education and training of care workers, certain ongoing barriers prevented them from conducting the necessary daily oral hygiene care for the residents. The most frequently listed obstacles to care included the residents' bad breath, inadequate time to perform oral care and uncooperative residents who do not perceive the need for oral care.[25]

Another study on the effects of oral health educational interventions for nursing home staff or residents, or both, to maintain or improve the oral health for nursing home residents shows insufficient supporting evidence.[26]

Researchers have concluded that it is unclear whether or not school screening programs improve attendance at the dentist. School screening initiatives with incentives attached, such as free treatment, may be helpful in improving oral health of children.[27]

One-to-one oral hygiene advice (OHA) is often given on a regular basis to motivate individuals and to improve one's oral health. However, it is still unclear if one-to-one OHA in a dental settings is effective in improving one's oral health.[28] Nevertheless, despite the increased oral hygiene education programs in schools due to the higher quality of life, there is an increased intake of processed food, especially of sweetened beverages.[29] The favorable effect of the increased level of dental health education may be counteracted by nutritional behavior, especially sweets intake and low attendance of regular dental office check-ups and insufficient oral health practices (tooth brushing) generating a still increased caries prevalence and DMFT index in adolescents.[30] Irregular dental check-up and sugary dietary habits were associated with high prevalence the occurrence of dental conditions as assessed by the Decayed, Missing (due to caries), and Filled Teeth (DMFT) index.

This systematic review wanted to determine the effectiveness of different interventions in preventing dental caries in children and when was the most effective time to intervene during childhood. Overall the evidence found showed low certainty that combining oral health education alongside supervised toothbrushing or professional intervention would reduce dental caries in children (from birth to 18). The most effective time to intervene in  childhood was still unclear as well. Improving the diets of children and the access to fluoride showed only a limited impact to improving the oral health of children.[31]

• A Government funded program which provides assistance for basic dental services for children aged 2–17 years. Services provided include: examinations, dental x-rays, cleaning, fissure sealants, fillings, extractions and root canals
• The CDBS is means tested, those who qualify are eligible to $1,000 of the aforementioned treatments over a two-year period.[32]

To find out if a child is eligible, families can contact the Department of Human Services [32]

• As part of the National Partnership Agreement on Adult Public Dental Services, between 2015- 2016 $155 million was provided to service around 178,000 adult public patients
• On 15 December 2016, a further $320 million was provided by the Australian Government for dental services to public adult patients; the funding is to last for three years.[32]

In 1985 three dentists with the sponsorship of Colonel Joy Wheeler Dow, Jr., implemented an Oral Health Program in the Autonomous Region of Madeira with the aid of five assistants.

The four-year program reached 15,000 children around the main island and Porto Santo and it included Oral Hygiene Instruction classes, informative literature including films, fortnightly fluoride mouth-rinse and daily fluoride tables with the collaboration of the school teachers.

During this period a study was undertaken using the World Health Organization (WHO) Combined Oral Health Assessment (CPTIN) plan resulting in the final report where it was found that there had been a decrease of 44% in the need for fillings, 40% decrease in the need for extractions, whilst the caries free children population grew from the initial 1% to 5%.

National Health Service (NHS) is the name of the public health services of England, Scotland and Wales and is directly funded from taxation. The dentistry services are available to all, regardless of wealth. In order to find a NHS dentist search NHS Dentist Near You Some clinics may not have the capacity to take on new patients so waiting lists may occur.[33]

• Availability of treatment

All treatment deemed necessary to maintain optimal oral health will be provided by the dentist, however not all treatments will be funded by the Dentistry NHS and will incur private fees.[33]

• Fee's

Dentistry performed under the Dentistry NHS will involve fees, however are heavily subsidized by the government, below is some information which explains how the fee’s system works, only one charge is required per treatment course of care, regardless of the amount of appointments needed [33]

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Nepalese population is at a greater disadvantage than westernized societies in terms of oral health. The benefit of implementing health insurance is to assist a large number of people with similar risks by sharing funding.[34] In Nepal, implementing health insurance is difficult due to limited supply of finances. To assist families with accessing health care “elimination of direct payments is necessary but is not sufficient alone; costs of transportation and loss of income can have more impact than direct payment of services” must be considered.[34]

Oral Health Promotion in Nepal - teaching children

• The amount of dental professionals produced from tertiary education has increased in Nepal over the years, but remains low in comparison to the rest of the world. There were approximately only 100 dentists in the workforce in the year 2000, which has increased to 240 in the present.[35]
• Nepal is now using dental hygienists, therapists and oral health therapists to increase access to dental treatment.[36]
• Programs such as training rural women about oral health promotion are being utilized to increase awareness of basic dental problems in remote areas.[37]

• Attempts to reduce the gap in dental health of Nepalese people through volunteer work provides oral health care education and basic treatment to small villages.
• Services provided include oral hygiene instruction, distribution of free toothbrush and fluoride toothpaste, application of fluoride gel, application of sealant, screening and charting out treatment plan under a supervising dentist, scaling, filling, extraction, prescribing medicine, and free dispensing distributing medicines

For more information, you can access the Around Good People fact sheet