Christine French Beatty - Community Oral Health Practice For The Dental Hygienist (2017) - 2

Community
Oral Health Practice for

the Dental Hygienist
FOURTH EDITION
CHRISTINE FRENCH BEATTY, RDH,

MS, PhD
Professor Emeritus
Dental Hygiene Program
Texas Woman's University
Denton, Texas
Table of Contents
Cover image
Title Page
Copyright
Dedication
Contributors
Reviewers
Preface
Acknowledgments
Chapter 1 People's Health

Opening Statements: What Is Public Health?
Health, Public Health, and Dental Public Health
The Public Health Problem and the Public Health Solution
Role of Government in Public Health
Future of Dental Public Health
Summary
Applying Your Knowledge
Dental Hygiene Competencies
Community Case
References
Additional Resources
Chapter 2 Careers in Public Health for the Dental Hygienist

Opening Statements: Career Possibilities
Community Oral Health Practice as a Career
Future Trends for Dental Hygienists in Public Health
Interprofessional Collaborative Practice
Careers in Public Health
Summary
Community Case
References
Chapter 3 Assessment for Community Oral Health Program Planning

Opening Statement: Example of a Community Profile
Public Health Practice
Assessment: a Core Public Health Function
Overview of Epidemiology: Population-Based Study of Health
Determinants of Health
The Community Health Program Planning Process
Summary
Community Case
References
Chapter 4 Measuring Oral Health Status and Progress
Opening Statement: Healthy People 2020 Leading Health Indicators (LHI) and Targets 1
Health Assessment: Essential in Monitoring Community Health
Healthy People
Oral Health Surveillance Systems
Measuring Oral Health and Its Determinants in Populations
Types of Measurements
Future Considerations for Oral Health Surveillance
Summary
Community Case
References
Chapter 5 Population Health

Opening Statement: The Burden of Oral Diseases in the United States
Part One: Oral Health Status and Trends
Status and Trends of Specific Oral Conditions in the U.S.
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
Improving Oral Health in the Community
National, State, and Local Programs: Role of the Health Department
Program Planning Process
Primary Prevention Programs: Fluorides, Sealants, Oral Health Education
School-Based Oral Health Programs
Head Start
Secondary and Tertiary Oral Health Prevention Programs
Financing Programs
Summary
Community Case
References
Chapter 7 Applied Research

Opening Statement: Questions in Research
Using Research to Answer Questions
The Scientific Method and Development of a Research Question
General Methods of Research
Research Designs
Research Methodology
Presentation of the Data and Data Analysis
Analysis of the Literature
Summary

Community Case
References
Chapter 8 Health Promotion and Health Communication

Opening Statements: Challenges to Promoting Oral Health
Health Promotion
Health Communication and Health Information Technology
Resources for Professional Development
Summary
Community Case
References
Chapter 9 Social Responsibility

Opening Statements: Status and Future of Health Care
A System in Crisis
Social Responsibility and Professional Ethics
Health Care: a Privilege or a Right?
Government Role in Healthcare Delivery
Patient Responsibility and Patient Confidentiality
Health Care: a Comprehensive Approach
Leadership
Domestic Violence
Summary

Community Case
References
Chapter 10 Cultural Competence

Opening Statements: The Role of Culture in the Status and Future of Oral Health
Today's Evolving Diverse Population
Considering Culture
Cultural Competence
Culturally Competent Patient Care
Health Literacy
Summary
Community Case
References
Chapter 11 Service-Learning
Opening Statements: Highlights of Service-Learning Research in Higher Education: Dental Hygiene
Student Comments
Introduction
Service-Learning as Experiential Learning
Stages of Service-Learning
Benefits of Service-Learning for Interprofessional Collaboration
Risk Management in Service-Learning
Service-Learning to Reinforce Dental Public Health Learning
Summary
Community Case
References
Chapter 12 Test-Taking Strategies and Community Cases

Overview of the NBDHE
NBDHE Question Formats
Answering Community Case Questions (Testlets)
Answers and Rationales
References
Appendix A Additional Websites for Community Resources
Appendix B Dental Hygiene Competencies

Competency Domains
Competencies for the Dental Hygiene Profession
Appendix C Community Partnerships for Oral Health

Appendix C-1 Potential Community Partners
Appendix C-2 Oral Health Coalition Framework
Appendix D Resources for Community Health Assessment

Appendix D-1 Examples of Government Resources for Health Data
Appendix D-2 Summary of Data Collection Methods
Appendix D-3 Examples of Information for a Community Health Assessment
Appendix D-4 Examples of Primary Data Collection Tasks

Appendix E Selected Oral Conditions and Factors Influencing Oral Health That Can
Be Assessed in Oral Health Surveys
Appendix F Common Dental Indexes

Bibliography
Glossary
Index
Copyright
3251 Riverport Lane

St. Louis, Missouri 63043
COMMUNITY ORAL HEALTH PRACTICE FOR THE DENTAL HYGIENIST, 4TH

EDITION ISBN: 978-0-323-35525-4
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Previous editions copyrighted 2012, 2005, and 2002.
Library of Congress Cataloging-in-Publication Data

Names: Beatty, Christine French, author.
Title: Community oral health practice for the dental hygienist / Christine French
Beatty.
Description: Fourth edition. | St. Louis, Missouri : Elsevier, [2017] |
Preceded by Community oral health practice for the dental hygienist / edited by
Kathy Voigt Geurink. 3rd ed. 2012. | Includes bibliographical references and
index.
Identifiers: LCCN 2015049614 | ISBN 9780323355254 (pbk. : alk. paper)
Subjects: | MESH: Community Dentistry | Dental Hygienists | United States
Classification: LCC RK52 | NLM WU 113 | DDC 362.19/76–dc23 LC record
available at http://lccn.loc.gov/2015049614
Content Strategist: Kristin Wilhelm

Content Development Manager: Ellen Wurm-Cutter
Publishing Services Manager: Hemamalini Rajendrababu
Project Manager: Srividhya Shankar
Designer: Ashley Miner
Printed in United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1

Dedication
This textbook is dedicated to oral health professionals who have

participated in community efforts to improve the oral health of all citizens.
Oral health, as an integral component of the overall health and well-
being of individuals, must be available to and attainable by all
populations. Throughout my career working in the field of community
oral health, I have observed how oral health professionals have
demonstrated their dedication and commitment to this goal. They need to
be commended and thanked and told to keep up their efforts. Many
worthwhile programs and services have been provided, but there is still
much to be accomplished.
Contributors
Christine French Beatty RDH, MS, PhD
Professor Emeritus
Denton, Texas
People's Health: An Introduction; Careers in Public
Health for the Dental Hygienist; Assessment for
Community Oral Health Program Planning; Measuring
Oral Health Status and Progress; Population Health;
Oral Health Programs in the Community; Applied
Research; Social Responsibility; Cultural Competence;
Test-Taking Strategies and Community Cases
Magda A. de la Torre RDH, MPH
Assistant Professor, Clinical
University of Texas Health Science Center at San Antonio
School of Dentistry-Department of Comprehensive Dentistry
San Antonio, Texas
Oral Health Programs in the Community; Cultural

Competence
Charlene B. Dickinson RDH, BSDH, MS
Assistant Clinical Professor
Denton, Texas
Careers in Public Health for the Dental Hygienist;
Measuring Oral Health Status and Progress; Oral Health
Programs in the Community
Sheranita Hemphill RDH, MS, MPH
Professor
Dental Health Sciences
Sinclair Community College
Dayton, Ohio
Service-Learning: Preparing Dental Hygienists for

Collaborative Practice
Amanda M. Hinson-Enslin RDH, CHES, MPH, PhD(c)
Senior Lecturer
University of Texas at Dallas
Department of Interdisciplinary Studies
Richardson, Texas;
Graduate Teaching Assistant/Instructor of Record
Department of Health Studies
Denton, Texas
Assessment for Community Oral Health Program

Planning; Population Health; Oral Health Programs in
the Community; Applied Research
Beverly Ann Isman RDH, MPH, ELS
Dental Public Health Consultant
Davis, California
Health Promotion and Health Communication
Sharon C. Stull BSDH, MS
Lecturer and Program Director
BSDH Post-Licensure Online Program
Chief Department Advisor
Gene W. Hirschfeld School of Dental Hygiene
Old Dominion University
Norfolk, Virginia
Population Health; Social Responsibility
Chapter 2: Mini-Profiles
Tammy L. Allen RDH
Co-owner, LifeCycle Dental Resource, Inc.
Fort Worth, Texas
Lynn Ann Bethel RDH, MPH

Executive Director
Oral Health Nevada, Inc.
Reno, Nevada
Diann Bomkamp RDH, BSDH, CDHC

Clinical Dental Hygienist
St. Louis, Missouri
Terri Chandler RDH, EFDA, CDA

Future Smiles Founder/CEO/Executive Director
American Dental Hygienists' Association
Council on Regulation and Practice
Las Vegas, Nevada
Lieutenant Cynthia Chennault RDH, BSDH

Oral Health Promotion/Disease Prevention Coordinator
U.S. Public Health Service Commissioned Corps
Catawba Service Unit, Indian Health Services
Rock Hill, South Carolina
Joyce Bartle Flieger BSDH, MPH, RDH, EFDH

First Smiles Program
Oral Health Professional
University of Arizona
College of Agriculture and Life Sciences
Cooperative Extension
Tucson, Arizona
Christy Jo Fogarty RDH, ADT, BSDH, MSOHP

Advanced Dental Therapist, Registered Dental Hygienist
Children's Dental Services
Minneapolis, Minnesota
Becki Hale RDH, MA

Special Projects and Initiatives Coordinator
Community Health Outreach
Cook Children's Health Care System
Fort Worth, Texas
Stacy P. Redden RDH, MS

Practice Administrator
Dental and Orthodontics Clinics
Children's Health Specialty Center
Children's Medical Center Dallas
Dallas, Texas
Annette Wolfe RDH, BS

Academic Manager, Southwest
Colgate Oral Pharmaceuticals
New York, New York
Reviewers
Lorinda Coan RDH, MS
Assistant Professor
Dental Hygiene and Dental Assisting Programs
University of Southern Indiana
Evansville, Indiana
Amy Marie VanEss-Krueger CRDH, BSDH, MS

Assistant Professor
St. Petersburg College
Pinellas Park, Florida
Jennifer S. Sherry RDH, MSEd

Associate Professor
Dental Hygiene
Southern Illinois University
Carbondale, Illinois
Pam Cushenan RDH, MS

Assistant Professor
Department of Dental Hygiene
Georgia State University
Dunwoody, Georgia
Preface
“Why do I need to know anything about community oral health?”
Many dental hygiene students ask this question of their faculty at the beginning of
the Community Oral Health course. The purpose of this textbook is to provide
students with information about community oral health that is relevant to dental
hygiene. It is my intention that, through reading the chapters and participating in the
suggested activities, dental hygiene students can find the answer to this question and
develop an understanding of the importance of this integral component of their
education to their future profession regardless of their practice setting. Although
this textbook is written specifically for dental hygiene students, it also is a valuable
resource for all oral health professionals practicing their professional
responsibility of improving the oral health of their community.
Community Oral Health is a required course for dental hygiene accreditation. In
the Accreditation Standards for Dental Hygiene Education Programs effective as of
February 2013, the Commission on Dental Accreditation (CODA) states that the
curriculum in dental hygiene schools must include content in the following four
general areas: general education, biomedical sciences, dental sciences, and dental
hygiene science. CODA requires that these areas must be incorporated with
“sufficient depth, scope, sequence of instruction, quality, and emphasis to ensure
achievement of the curriculum's defined competencies.” Furthermore, these CODA
Standards state:
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
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.
Public Health/Private Practice

The practice of dentistry and dental hygiene in the private dental office setting is
integral to dental public health in the U.S. because it is the setting in which the
majority of the population is served. However, community oral health practice is
unique in many respects and requires the acquisition of specific knowledge and
skills.
Understanding the association between community oral health practice and
private practice (Table 1-1) will help in grasping the concept of community oral
health. On the community level, the oral health professional focuses on the
community as the patient rather than the individual. Although individual patients are
treated in community settings, the emphasis is on the individual as part of the
community. Community oral health practice extends the role of the dental hygienist
in private practice to include the people of the community as a whole. The public
health facility or community setting (e.g., hospital, community clinic, school, or
agency), rather than the private dental office, becomes the environment in which the
service of oral health care is provided.
TABLE 1-1
Relationship of the Components in Private Practice and Public Health
Private Prac tic e Public He alth

Patient Community
Examination Survey/Assessment
Diagnosis Analysis
Treatment planning Program planning
Treatment Program implementation or operation
Fee/payment Budget/financing/program funding
Patient evaluation Program evaluation/appraisal
The components of community oral health practice17 parallel those in private

practice. The patient's oral examination compares to the community survey as a
means of assessment.Diagnosis and analysis are comparable in the process of
identifying and prioritizing problems. Treatment planning and program planning
for the community are similar; both include the many facets of preparation, such as
determining various methods, strategies, and costs of choosing the best plan. The
treatment and the program implementation or program operation occur as the plan
is carried out. The fee or payment for dental services is equated with program
funding. Various methods of payment or financing are often explored in both cases.
Evaluation of treatment is similar to program evaluation or appraisal and should
occur during implementation and at the end of treatment or program operation.18
This comparison should help the private practice hygienist become comfortable
with the concepts of assessment, analysis, program planning, implementation,
evaluation, and financing in relation to community programs (see Chapters 3 and 6).
The Public Health Problem and the Public
Health Solution
Public Health Problem
Upon reading these definitions carefully, you are ready to review two concepts of
importance to your comprehension of public or people's health: (1) the public health
problem and (2) the public health solution. The public health problem, as perceived
by the public, usually brings to mind an infectious disease such as acquired
immunodeficiency syndrome (AIDS) or the swine flu (H1N1). The spectrum of
problems, however, is vast and more extensive than one might first realize.
Examples of public health problems that were the focus of the Centers for Disease
Control and Prevention (CDC) in 2013 included the following:8,9
• More than 1 million Americans get a health care–associated infection during the
course of their medical care, which accounts for billions of dollars in excess
healthcare costs.
• An estimated 1.1 million Americans are living with HIV; stigma and complacency
are among our most insidious opponents in the fight against HIV.
• Less than 40% of girls aged 13–17 years in the U.S. were fully immunized against
HPV; the rate of immunization was much lower among boys.
• Nearly 800,000 people die in the U.S. each year from cardiovascular disease,
accounting for 1 in 3 deaths and more than $300 billion in direct medical costs and
lost productivity.
• About 1 in 5 American adults (17.8%) were current smokers; the rate was higher in
men (20.5%) than women (15.3%)
• Nearly 6000 babies born in the U.S. with severe disorders, most of which are
treatable, are identified each year using newborn screening programs.
• It is estimated that foodborne illness sickens about 48 million people in the U.S.
each year, resulting in 128,000 hospitalizations and 3000 deaths.
• One billion people are disabled, killed, or disfigured by parasitic diseases
worldwide and millions in the U.S. are infected.
• More than 1 billion children—half of all children in the world—are victims of
violence each year. These children are at greater risk for common and destructive,
yet entirely preventable, consequences, including HIV, chronic diseases, crime,
drug abuse, and serious mental health problems.
• More than 25% of all Americans and two-thirds of older Americans have multiple
chronic conditions, which account for more deaths than acute illnesses and
infectious diseases; treatment for older adults accounts for 66% of the country's
healthcare budget.
Such examples of public health problems help to illustrate what constitutes public
health. Public health problems, as described by the CDC, must meet certain criteria
(see Guiding Principles). The history of public health demonstrates that when the
problem is identified and knowledge and expertise have been developed to solve the
problem, the community must unify to find social and political support to proceed
with the public health solutions.
G ui di ng Pri nci pl es
Criteria for Identifying Public Health Problems
1. Public health importance of the problem:
• Incidence and prevalence
• Severity, sequela, and disabilities
• Mortality caused by the problem
• Socioeconomic impact
• Communicability
• Potential for an outbreak
• Public perception and concern
• International requirements
2. Ability to prevent, control, or treat the health problem:
• Preventability
• Control measures and treatment

3. Capacity of health system to implement control measures for the health problem:
• Speed of response
• Economics
• Availability of resources
• Requirement for surveillance of the problem

Data from An introduction to applied epidemiology and biostatistics, lesson 5. Principles of epidemiology in
public health practice. 3rd ed. Centers for Disease Control and Prevention; 2011. Available at
http://www.cdc.gov/ophss/csels/dsepd/ss1978/lesson5/section3.html. Accessed January 19, 2015.
Public Health Solution

A public health solution is an answer to a public health problem designed to solve
the problem. Examples of solutions to public health problems that most persons are
familiar with include immunizations, tobacco cessation programs, fluoridation of
drinking water, early detection of disease, control of exposure to prevent spread of
disease, and use of seat belts and air bags to prevent injuries and mortality. These
public health solutions are concerned with health promotion and disease prevention.
They address the problems of the community at large and are effective measures
that follow seven characteristics (see Guiding Principles). The effectiveness of a
public health solution is dependent on how well it possesses these characteristics.
Seven Characteristics of Public Health Solutions
• Not hazardous to life or function

• Effective in reducing or preventing the targeted disease or condition
• Easily and efficiently implemented; minimum compliance required
• Potency maintained for a substantial period
• Attainable regardless of socioeconomic status (SES)
• Effective immediately upon application
• Inexpensive and within the means of the community
Community water fluoridation can be used to illustrate these characteristics of a

public health solution. Fluoridation has proved to be a safe, cost-effective solution
for reducing dental decay in children. It is easily implemented by adding fluoride to
the water supply, and the only compliance required is to drink the fluoridated water.
Its potency is maintained as long as the fluoridated water is consumed, and it
reaches all people regardless of SES. It is effective immediately upon initiation and
costs far less than the financial burden of restorative treatment. It meets all seven
characteristics of a public health solution and is considered by public health
officials to be an effective solution to the problem of dental caries.10
SES is an important concept in public health. SES is the social standing or
position of a person or group in a community or society on a social-economic
scale. It is measured by factors such as education, type of occupation, income,
wealth, and place of residence. Often, the population served by public health dental
programs and clinics has low SES. Populations of lower SES generally are at
increased risk for dental disease, experience more oral health disparities, and have
limited access to oral health care for a variety of associated reasons.11
Oral Disease as a Public Health Problem

Many oral diseases are universal, chronic problems that do not undergo remission
if left untreated. Dental caries is a significant oral disease that is common and
widespread for many Americans, especially children from minority, racial, and
ethnic groups, and low-SES individuals of all ages.11 For children ages 2 to 11
years, 43% have had dental caries in primary teeth, and 21% have had caries in
permanent teeth.12 In addition, 23% of children ages 2 to 11 have untreated caries in
primary teeth, and 8% have untreated caries in permanent teeth.12 Almost 25% of
adults experience some form of facial pain, and toothaches are the most common
pain of the mouth reported.13 About 25% of adults age 60 and older no longer have
any natural teeth, and they may experience tooth decay in their remaining teeth at
rates higher than children.14 Older adults also have racial/ethnic and income
disparities in relation to untreated dental disease and oral health–related quality of
life.15
Dental disease has been described as a dental public health problem of universal
prevalence that can be alleviated, and even prevented, with future public health
measures.16 The extent and severity of dental caries warrant the need for treatment
and prevention programs throughout the U.S. If left untreated, dental caries
continues to escalate and results in expensive surgical procedures. Therefore it is
important to focus on prevention of the disease.
Community water fluoridation is a perfect example of a dental public health
solution to the problem of dental caries.10 Organized community efforts since 1945
have brought fluoridated drinking water to more than 204 million people and the
results have shown a significant reduction in the amount of dental caries in the U.S.10
Nevertheless, approximately 100 million Americans do not have access to
fluoridated water and national data showed a slight although significant increase in
dental caries in primary teeth, especially in the youngest age group, during the
decade 2000 to 2010.11 Thus, the nation's oral health agenda aims to increase the
percentage of the population served by community water systems that receive
optimally fluoridated water, from 75% in 2012 to almost 80% by 2020.10 Because
dental caries still exists as a public health problem of the twenty-first century,
additional oral health education, promotion, and prevention programs are needed.
Chapter 5 presents additional data on dental caries and other significant oral
diseases and conditions in the population. Chapters 6 and 8 describe various
programs and health promotion efforts that can be implemented and expanded upon
within communities nationwide as public health solutions to these problems.16
Role of Government in Public Health
Government Agencies
As a dental hygienist you may choose a variety of ways to fulfill your ethical
responsibility to contribute to the health of people in the community.19 One possible
way is through participation in community oral health promotion activities (see
Chapter 8). You may elect to present an educational program at a school or conduct
a cancer screening at a facility for older adults. The more formal public health
programs, however, generally fall under the aegis of the government. Both
prevention and the delivery of services are concerns within the programs developed
by government agencies.
The federal government's role in participating in dental health–related activities
primarily falls under the jurisdiction of the Department of Health and Human
Services (DHHS). The goals of the DHHS for the period 2014–2018 are the
following:20
1. Strengthen health care
2. Advance scientific knowledge and innovation
3. Advance the health, safety, and well-being of the American people
4. Ensure efficiency, transparency, accountability, and effectiveness of DHHS

programs
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
National Oral Health Initiatives

Whether an oral health program is at the national, state, or local level, the objectives
should be tied in with the current national oral health initiatives. It is important to
review these initiatives and their development to have a complete understanding of
how to reflect the current national agenda in our community programs. In fact, even
strategies and services that are implemented through the private sector should
reflect the current national initiatives. In this way all oral health programs and
activities, whether public or private, are coordinated for maximum benefit to the
population's health.
The first major national oral health initiative that continues to impact dental
public health today is the publication of the 2000 Surgeon General's Report, Oral
Health in America.16 This 300-page document focused exclusively on oral health
issues. It was the first federal government publication to acknowledge the
importance of oral health to the overall health of the public and emphasized the need
for public health programs to address dental disease in the population. The foremost
messages of the report are presented in Box 1-2.
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
• Oral health can be achieved by all Americans
• Profound and consequential disparities exist in the oral health of Americans
Principal Actions and Implementation Strategies Charged by A

National Call to Action to Promote Oral Health (2003)
• Change perceptions about oral health
• Build the science and accelerate the transfer of the science
• Increase collaborations (partnerships, coalitions)
• Increase workforce diversity, capacity, and flexibility
• Overcome barriers by replicating effective programs
Key Points, Goals, and Strategies of Promoting and Enhancing the

Oral Health of the Public: HHS Oral Health Initiative 2010
Key Message
Oral health is integral to overall health
Goals:
• Emphasize oral health promotion/disease prevention
• Increase access to care
• Enhance oral health workforce
• Eliminate oral health disparities
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 National Institute of Dental and Craniofacial Research, CDC's Division of

Oral Health, and CDC's National Center for Health Statistics have launched an
effort to enhance the oral health surveillance data capability in the U.S. and
develop a long-range plan that will lead to a comprehensive National Oral Health
Surveillance Plan.
• 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 National Institutes of Health is supporting and promoting an effort to build a

web-accessible national dental consortium research infrastructure network to
facilitate the standardization of dental research. The purpose is to have rigorous
clinical studies whose outcomes have the potential to fundamentally change dental
practice and improve oral health. A second phase of this project will help to
ensure that new discoveries lead to improved public health by reducing the time it
takes for laboratory discoveries to become treatments for patients, to assure that
communities are engaged in clinical research, and to facilitate the training of
future clinical and translational researchers.
• 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.
Recommendations of Advancing Oral Health in America (2011)

• Establish high-level accountability
• Emphasize disease prevention and oral health promotion
• Improve oral health literacy and cultural competence
• Reduce oral health disparities
• Explore new models for payment and delivery of care
• Enhance the role of nondental healthcare professionals
• Expand oral health research and improve data collection
• Promote collaboration among private and public stakeholders
• Measure progress toward short-term and long-term goals and objectives
• Advance the goals and objectives of Healthy People 2020
Recommendations of Improving Access to Oral Health Care for

Vulnerable and Underserved Populations (2011)
• Oral health care should be integrated into overall health care
• Changes need to be made in laws and regulations such as scope of practice laws
• Dental education needs to be improved in relation to treating diverse populations

in various settings
• Financial and administrative barriers need to be reduced to enhance access to care
• Capacity of oral health care needs to be expanded

Several federal, state, and local initiatives were developed in response to the
Surgeon General's Report on oral health. In 2003 the Surgeon General released a
follow-up report, A National Call to Action to Promote Oral Health.23 This initiative
was a combined effort of a broad coalition of public and private organizations and
individuals. The report charged oral health professionals, employed in both the
field of public health and private practice, to work together to educate the
community and provide the necessary programs to treat and prevent further disease.
In addition, oral health professionals were challenged to partner with other
healthcare professionals and community agencies to reduce disparities and take
specific actions that could ultimately lead to optimal oral health for all Americans.
As oral healthcare providers, we are called to participate in this report's
recommended principal actions and implementation strategies that are presented in
Box 1-2.
Healthy People 2020, a publication of the DHHS, consists of a list of health
objectives for the nation, including oral health objectives, that are meant to be
achieved by the year 2020.25 These objectives direct the agenda of government
health programs and form the foundation for all other community health
programming. At the end of each decade the DHHS leverages scientific insights and
lessons learned from the past decade, along with new knowledge of current data,
trends, and innovations, to create Healthy People reports with new objectives for the
next decade. The Healthy People initiative is in its fourth version.
Healthy People 2020 reflects assessments of major risks to health and wellness,
changing public health priorities, and emerging issues related to our nation's health
preparedness and prevention.25 The objectives provide a framework to address risk
factors and determinants of health and the diseases and disorders that affect our
communities. Oral health is included with objectives and guidance for reaching the
new targets for the next 10 years. Healthy People 2020 objectives are discussed in
detail in Chapters 4 and 5 and referred to in relation to other topics throughout this
book.
At the time that Healthy People 2020 objectives were being developed, it became
evident that many oral health challenges that were identified 20 years before had not
been addressed successfully. As a response the DHHS agencies developed a
coordinated and integrated initiative with activities across multiple agencies titled
Promoting and Enhancing the Oral Health of the Public: HHS Oral Health Initiative
2010.26 The purpose of this DHHS-wide effort was to improve the nation's oral
health by realigning existing resources and creating new activities in an attempt to
maximize outputs. The vision, goals, and strategies of this initiative are described in
Box 1-2.
In 2011 the Institute of Medicine (IOM) released Advancing Oral Health in
America.11 This report described the continuation of the problems of oral disease
status and disparities in the population. It also reinforced the association of oral
diseases and complications with medical diseases and conditions. Recommendations
in this report are summarized in Box 1-2.
Another important initiative in 2011 was the publication of the IOM report
Improving Access to Oral Health Care for Vulnerable and Underserved
Populations.24 This treatise highlighted the problem of disparities and suggested
strategies to improve access to oral health care for those who need it the most. The
focus of this initiative is summarized in Box 1-2.
These national oral health initiatives have the common goals of improving oral
health, expanding quality of life, and eliminating oral health disparities. The public,
healthcare providers, policymakers, communities, and anyone interested in the
improvement of oral health must work together to achieve the vision, goals, and
objectives of the national oral health initiatives.
Core Functions and Essential Services of Public

Health
Federal, state, and local programs have been charged with improving the health of
the people through the core functions of public health, which are assessment,
policy development, and assurance. These core functions were identified by the
IOM in 1988 and reinforced in an IOM report in 2003.27 The purposes of the core
public health functions are to protect and promote health, wellness, and the quality
of life and to prevent disease, injury, disability, and death. These core functions,
described in detail in Box 1-3, continue to be reflected in public health initiatives
today.28
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.)
• Increased grant opportunities for general, pediatric, or public health dentists

• Funding for National Health Service Corps loan repayment programs
• CDC initiation, in consultation with professional oral health organizations, of a 5-
year national public education campaign focused on oral health prevention and
education.
To maximize these opportunities afforded by the ACA, oral health professionals,
dental public health officials, and lawmakers must work in partnership to develop
the most beneficial strategies,11,23 a process that will likely challenge the multiple
stakeholders.47
Going in the Right Direction

Although the oral health professions must continue to seek changes to move toward
improved oral health of the public, it appears that progress is being made to meet
the goals of dental public health. The fourth iteration of Healthy People, Healthy
People 2020, identified oral health as one of the 12 leading health indicators. This is
significant in that it indicates a more profound understanding by others of the
importance of oral health than ever before.48 Many of the current national oral
health initiatives (Box 1-2) reflect this greater emphasis on oral health.
Water fluoridation was identified by the CDC as one of the 10 most important
public health accomplishments of the twentieth century.49 More recently the CDC
listed the 10 great public health accomplishments of the first decade of the twenty-
first century.50 Dentistry and dental hygiene have had a role in several of these
successes. Their promotion of participation in tobacco cessation programs has
contributed to the significant decrease in tobacco use.51,52 The professions' attention
to and training of office personnel for safe practices have helped to reduce work-
related injuries.53,54 Finally, oral health professionals have contributed to the
reduction of cardiovascular disease by screening for high blood pressure and
promoting the importance of oral health in relation to cardiovascular health.55,56
There has been a major effort by oral health organizations, policymakers, and
advocacy groups to address access to care for American citizens. In 2009 the ADA
held the first Access to Dental Care Summit.57 This conference drew together
representatives from a variety of communities of interest, including spokespersons
from ADA leadership, ADHA leadership, dental special interest groups, federal
agencies, healthcare policymakers, dental product companies, consumer advocacy
groups, education and research institutions, financing groups (including third-party
payers and philanthropic organizations), safety net providers, nondental healthcare
providers, dental volunteer leaders, and state dental societies. These diverse oral
health stakeholders examined relevant issues of the past, present, and future,
clarifying common ground and empowering members to take responsibility for
collective action through focused initiatives. It laid the foundation for a common
vision to begin to improve access to oral health care for underserved people. At the
conclusion of the summit, the participants identified the following eight areas on
which to focus future efforts:
• Workforce development strategies
• Reorganization of the dental delivery system
• Financing models
• Population-based prevention strategies and strengthening the public health
infrastructure
• Improving oral health literacy through social marketing (see Chapter 8)
• Collaboration between the medical and dental communities
• Developing metrics for measuring and defining access
• Building a sustainable infrastructure for communication and collaboration
To meet these goals the ADA launched a program in 2013, Action for Dental
Health (ADH), designed to provide dental care to underserved populations,
strengthen and expand the public/private safety net, and bring disease prevention and
education into communities.58 These aims of the ADH program will be
accomplished through the initiatives described in Box 1-4. In 2014 the ADA
proposed a bill to Congress to authorize grants to state and local dental societies
and other organizations at local and state levels to implement ADH initiatives to
reduce barriers to care.59
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
Get People the Right Care, in the Right Setting—Emergency

Department to Dental Chair
• Reduce the utilization of emergency departments for dental conditions
• Increase access to care in dental offices and clinics for patients requiring
emergency treatment to solve the underlying patient problems
Promote Community-Based Contracting Between Local Dentists

and Federally Qualified Health Centers
• Increase access to care for publicly insured patients by contracting private dental
practices with Federally Qualified Health Centers to accept publicly insured
patients in the private practice setting
Promote Dentists Providing Care to Nursing Home Residents—

Establish the Long-Term Care Dental Campaign
• Promote the participation of dentists in nursing home care and prevention
programs through local community outreach, continuing education, and training
to work in long-term care
Expand Give Kids a Smile—Local Community Screening and

Treatment Efforts
• Screen and provide preventive treatment for more children through this
public/private partnership community-based program
• Offer dental treatment to children in need and establish dental homes for continuity
of care
Expand Community Water Fluoridation—Tap into Your Health

• Support the Healthy People objective to increase the percentage of Americans with
access to fluoridated public water systems to 80% by 2020
Improve Utilization of the Existing Safety Net Through the Use of

Community Dental Health Coordinators: Working with Patients in
15 States by 2015
• Expand the number of community dental health coordinators (CDHC) working as
patient navigators, preventive specialists, and the oral health screening workforce
within the community health center dental programs and private dental practices
• Reduce barriers to access and increase capacity of the community health center
dental programs and private dental practices
Educate All Americans to Be Mouth Healthy for Life

• Improve oral health literacy among the general public
• Establish the ADA sponsored site MouthHealthy.org as the most respected and
trusted online resource for oral health information
• As a founding and executive member of the Partnership for Healthy Mouths,

Healthy Lives, support and expand the efforts of this educational resource and the
Ad Council campaign through ADA member dentists in the local community
Reduce the Barriers to Provider-Participation in Medicaid/CHIP

Through Reductions in Administrative Burdens and State-
Developed Solutions for Sustainable Reimbursement
• Increase the number of states that have a dental Medicaid advisory committee and
streamline their Medicaid provider credentialing process
Data from Action for Dental Health. Chicago, IL: American Dental Association. Available at
http://www.ada.org/en/public-programs/action-for-dental-health. Accessed January 24, 2015.
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.
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).
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:
Health Promotion and Disease Prevention

HP.1
Promote positive values of overall health and wellness to the public and
organizations within and outside the profession.
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
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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.
Summary of Actions Resulting from Recent Government and
Professional Oral Health Initiatives
• Allocating additional funds for dental programs and services
• Expanding treatment for special populations
• Creating volunteers and donated dental services
• Providing service programs
• Providing additional dental benefits through existing public insurance programs
• Extending educational loans and loan forgiveness for oral health professionals
• Creating tax credits for providers
• Forming career ladders for dental providers
• Increasing flexible licensure requirements
• Increasing the scope of practice for dental hygienists
• Decreasing supervision of dental hygienists in community settings
• Allowing Medicaid and insurance reimbursement of dental hygienists
• Expanding coverage for provider services
• Developing new oral health workforce models, including dental hygiene–based

midlevel providers
• Increasing opportunities for interprofessional collaborative practice
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
• Community water fluoridation
• School-based or school-linked dental sealant and fluoride varnish programs for

children at high risk for dental caries and untreated decay
• Incorporation of oral health in all aspects of coordinated school health programs
• Adequate funding for prevention and treatment programs designed to improve

oral health among underserved sectors of the population
• Use of dental hygienists in community health programming
• A national health program that guarantees financial support for primary

preventive and therapeutic oral health services
According to the ADHA report Dental Hygiene at the Crossroads of Change:

Environmental Scan 2011–2021, dental hygienists will be in demand and have ample
opportunities to improve the oral health of the population by expanding into a
variety of community-based oral health programs, retail clinics, pediatric centers,
senior and assisted living communities, and other settings outside of the traditional
private practice. Also, advances in teledentistry will make it easier to supervise
dental hygienists who provide care in an off-site clinic or community center.
However, it is predicted that in most states to be able to reach this potential, dental
hygienists' scope of practice (the procedures that a dental hygienist is permitted to
practice according to the laws of the state) will need to be expanded, and supervision
requirements will need to be relaxed.9
Alternative Practice Settings

Public health settings are categorized as alternative practice settings (i.e.,
providing oral hygiene services outside the private office in a “nontraditional”
setting).8 Examples of alterative practice settings include a community-based clinic,
a mobile van, a school-based oral health program, a hospital, a long-term care
facility, and the home of a homebound individual (Figures 2-3, 2-4, and 2-5). The
delivery of oral health services in a private practice does not address the need for
services for those without means or without the capability of accessing care. In an
alternative setting oral health care can be brought to these underserved vulnerable
populations. Dental hygienists can provide preventive services in these settings,
reaching large numbers of people who might not otherwise receive care.
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
Supervision and Reimbursement Regulatory

Changes
Because of the need for services in places that don't already have oral health
programs such as schools, nursing homes, and migrant health centers, dental
hygienists are initiating programs in these alternative settings. They are also filling
community positions beyond those connected with existing public health facilities
where there is a dentist available to provide supervision.
ADHA has advocated for dental hygiene supervision and reimbursement
regulatory changes nationwide.12 The purpose is to allow dental hygienists to
practice in such positions to be able to bring oral health care to underserved
populations that do not have access. ADHA's advocacy efforts are based on their
2001 Access to Care Position Paper in which the ADHA confirmed its stance that
dental hygienists who are graduates from an accredited dental hygiene program can
be fully used in all public and private practice settings to deliver preventive and
therapeutic oral health care safely and effectively. According to ADHA, “Licensed
dental hygienists, by virtue of their comprehensive education and clinical
preparation, are well prepared to deliver preventive oral healthcare services to the
public, safely and effectively, independent of dental supervision.”13
Levels of supervision are described in Table 2-2. Research has indicated a
decrease in required dental supervision levels nationwide over time, with evidence
that more states have adopted fewer supervision regulations in recent years.14
TABLE 2-2
Levels of Supervision
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.
Alternative Workforce Models

Midlevel Provider
In the medical field the term midlevel provider is used to refer to a clinical medical
professional who provides patient care under the supervision of a physician. The
midlevel provider is capable of examining, diagnosing, and providing some
treatments, all of which must be signed off by a supervising licensed physician.21
Examples are the nurse practitioner and the physician assistant. These professionals
have advanced medical training but not to the level of the physician. They are
increasingly providing services independently, especially in rural and remote areas,
to make up for physician shortages. It has been reported that physician assistants and
nurse practitioners provide a majority of physician services for a much lower cost
than the physician, thereby addressing the unmet need for medical services by
providing quality care to more people at a lower cost.22
The midlevel provider concept has been applied to dentistry to address the
problems of access to oral health care for underserved populations. Initial reports
describe the same cost-reduction benefits as seen in medicine while maintaining the
high quality of dental care that is provided by dentists in this country.23 Various
models of workforce delivery have been developed to serve the populations who
cannot easily access dental services as the result of problems of geographic
location, poor financial resources, no dental insurance, a lack of understanding
about disease prevention measures, a shortage of dentists to meet the needs of the
population, and low dentist participation in Medicaid programs6 (Table 2-3). Some
of these models are based on the concept of midlevel provider although others are
not.
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.
2. Dental therapists appear to be practicing safely, and clinics report improved

quality and high patient satisfaction with dental therapist services.
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.
5. Benefits attributable to dental therapists include direct costs savings, increased

dental team productivity, improved patient satisfaction, and lower appointment
fail rates.
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.
7. Start-up experiences have varied, and employers expect continuing evolution of

the dental therapist role.
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.
10. With identical state public program reimbursement rates for

dentist and dental therapist services, there is not necessarily
an immediate savings to the state on each claim paid;
however, the differential between these reimbursement rates
and clinics' lower personnel costs for dental therapists
appears to be contributing to more patients being seen.
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
Advanced Dental Hygiene Practitioner

In June 2004 the ADHA House of Delegates, addressing the problem of access to
oral health care, approved the concept of the ADHP workforce model (see Table 2-
3) as a midlevel oral health provider.38 As stated in Chapter 1, the goal of this
credential was to allow dental hygienists to provide diagnostic, preventive,
restorative, and therapeutic services directly to the public, primarily in public health
settings.39
The vision for the ADHP was that dental hygienists with the ADHP credential
would graduate from an accredited dental hygiene program and subsequently also
complete an ADHA-approved advanced educational curriculum with a master's
degree. This model was designed to improve and enhance the oral healthcare
delivery system by providing complete direct access, thus opening the door for
ADPHs to work in school systems, nursing homes, and other community programs,
as well as with underserved populations throughout the nation.39
An important feature of the ADHP proposal is graduate-level education. A case
has been made for the educational requirement being at the graduate level for the
following reasons: 1) the ADHP represents an expanded scope of dental hygiene
practice requiring 2 years of additional education and training; 2) dental hygienists
are already completing the number of college hours close to or equal to a
bachelor's degree; and 3) to participate fully and be respected within the
multidisciplinary healthcare system, the ADHP must present education similar to
other midlevel providers, such as a nurse practitioner, pharmacist, and speech and
language pathologist.40,41
Another significant element of the ADHP proposal is that it is dental hygiene–
based. ADHA has advocated for a hygiene-based rather than a nonhygiene–based
workforce model for the following reasons:42
• The workforce is educated, licensed, prepared, and available with over 185,000
licensed dental hygienists in the U.S.
• The educational infrastructure is in place with the vast number of entry-level dental
hygiene programs
• Dental hygienists currently work in a variety of settings to increase access
• The public will benefit from a practitioner who can provide both preventive and
restorative services
According to ADHA, six states besides Maine have introduced dental hygiene–
based workforce models in the legislature since 2012.42 One of those states is New
Mexico. A report from the New Mexico Dental Hygienists' Association indicates
strong member support (82%) for a dental hygiene–based dental therapist.43
Midlevel Oral Health Practitioner

In 2015 ADHA proposed a midlevel oral health practitioner, also a dental hygiene–
based model and defined as “a licensed dental hygienist who has graduated from an
accredited dental hygiene program and who provides primary oral health care
directly to patients to promote and restore oral health through assessment,
diagnosis, treatment, evaluation, and referral services. The mid-level oral health
practitioner has met the educational requirements to provide services within an
expanded scope of care and practices under regulations set forth by the appropriate
licensing agency.”42 This concept is similar to the ADHP but without the requirement
of a master's degree. This is the direction that many states are taking to address the
need for new workforce models that will expand the capacity to treat underserved
citizens of the state.44 The dental hygiene therapist recently authorized in Maine that
was described earlier in this chapter has the characteristics of this proposed model.
A 2014 report of the National Governors' Association summarizes the varied
ways in which different states have leveraged dental hygienists in an expanded
capacity to increase access to dental care. Some of the ways that states have
attempted to increase access to basic oral health care include deploying dental
hygienists outside of dentists' offices, altering supervision or reimbursement rules
for existing dental hygienists, creating new professional certifications for
advanced-practice dental hygienists, and allowing independent practice of dental
hygiene (see Table 2-3). Studies of pilot programs of expanded scope of practice
for dental hygienists have shown safe and effective outcomes.44 In addition,
evaluation of expanded dental hygiene workforce models have demonstrated that
they are increasing access to oral healthcare services for underserved populations,
primarily children, older adults, and special needs patients.8,23,31,45,46,47
ADHA is a resource of information on states in which dental hygienists have
direct access and the diverse versions of direct access used by different states.48 State
statutes are changing continually with the current emphasis on improving access to
dental care. Current information can be found at http://www.adha.org/direct-access.
Community Dental Health Coordinator

To support the existing dental workforce in reaching out to underserved
communities, in 2006 the American Dental Association (ADA) proposed the
development of the community dental health coordinator (CDHC) and piloted it
starting in 200949 (see Table 2-3). The CDHC works under the supervision of the
dentist to promote oral health for communities and to assist patients in navigating
through the healthcare system to establish a dental home.49 To reduce cultural,
language, and other barriers that might reduce their effectiveness, CDHCs have been
recruited from the same types of communities in which they would serve, often the
actual communities in which they grew up.49
In 2012 the ADA conducted an evaluation of both the individual CDHC's value
and the degree to which they are helping increase access to dental care in their
communities. Results met and exceeded expectations,50 and interest in the CDHC is
growing.49 As part of the Action for Dental Health: Dentists Making a Difference
campaign, the ADA has expanded this workforce model to eight states and is
working to bring CDHCs to dentally underserved communities nationwide.50
One of the unique characteristics of public health practice is the use of
interprofessional collaborative practice (ICP). According to the World Health
Organization, ICP “happens when multiple health workers from different
professional backgrounds work together with patients, families, carers and
communities to deliver the highest quality of care.”51 This method of practicing
health care can enable the integration of oral health into overall health at the level of
healthcare delivery. Collaboration and communication among dental, medical,
social services, and other health professionals can enable the sharing of data,
resources, health education materials, and general community information relevant
to all health needs, including oral health.
Community health centers in urban and rural areas, school-based health centers,
clinics in local public health departments, hospital-based clinics, and other
comprehensive community healthcare settings lend themselves to this
interprofessional team approach.52,53 In these settings, effective interaction of dental
hygienists with other health professionals can increase the awareness and
importance of the relationship between oral health and general health. This can
result in collaboration to identify risk, make preventive recommendations, and
implement treatments that integrate oral and overall health. In addition, oral health
and primary care practitioners can design and deliver integrated health messages
that address the health issues relevant to the target group in a way that reflects the
oral-systemic link. This interprofessional team approach is comprehensive, cost-
effective, and has the potential to improve healthcare outcomes of individuals
served in a community health center. Examples of this approach are presented in the
Guiding Principles.
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.
• In a community-based health clinic a dental hygienist and a member of the medical

staff collaborate to develop and implement referrals and health educational
materials that link oral health and diabetes for use with patients in a diabetes
prevention program.
• A dental hygienist partners with mental health professionals in a community clinic

to address the oral healthcare effects of various psychological problems treated
in the clinic, including substance abuse.
• 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.
• In a school-based clinic, a dental hygienist and school nurse team up to establish

oral health programs for the schoolchildren that will also improve their overall
health and educational outcomes.
• 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.
Disconnect of Oral Health Care and Overall Health

Care
Although oral health has been shown to directly affect a person's overall health, and
progress has been made toward integration of oral health and overall health, “oral
health care is still largely treated as separate and distinct from broader health care in
terms of financing, education, sites of care, and workforce.”57 An initiative of
HRSA, Integration of Oral Health and Primary Care Practice, addressed the need
for ICP with the medical profession.58 This proposal includes the preparation of a
draft set of oral health core clinical competencies appropriate for primary care
clinicians to be implemented in primary care practices to increase access to oral
health care for underserved and uninsured populations in the U.S. In addition,
recommendations include the development of infrastructure and payment policies to
enhance the adoption of these oral health core clinical competencies by primary
care clinicians.
Having recognized that failing to integrate oral health into overall health adds a
significant barrier to improving children's health outcomes, the American Academy
of Pediatrics (AAP) sponsored the Summit on Children's Oral Health in 2008.59 As a
result of this conference, the AAP coordinated the production of a special issue of
Academic Pediatrics, the official journal of the Academic Pediatric Association,
devoted to children's oral health. The purpose of this issue was to equip their
readers with necessary information to treat patients and to inform policymakers
about children's oral health issues. Of further significance is the fact that in the 5-
year subsequent period, 2010–2014, 38 articles related to oral health appeared in the
Journal of Pediatrics, a publication that serves as a practical guide for clinically
practicing pediatricians.60
Even though there is an increasing recognition of the relationship between oral
health and overall health, the American Association of Public Health Dentistry
(AAPHD) has described a disconnect between oral health care and health care.
Though the dental home and medical home concepts have resulted in earlier and
more effective health care, they do not adequately connect oral health care and
overall health care. The AAPHD has called for the support of initiatives that
recognize the value and integration of oral health, which now is relegated to dental
homes, into healthcare homes that currently provide patient-centered medical health
care.61
Future of Interprofessional Collaborative Practice

in Oral Health Care
A comprehensive application of ICP to the delivery of oral health care is being
promoted to address the detachment of oral health care and health care.62,63 There is
a growing interest in embracing ICP by oral health professions. The American
Association of Dental Education and the Association of Schools of Public Health
partnered in 2011 with four other stakeholders representing health occupations
education to develop the report Core Competencies for Interprofessional
Collaborative Practice.64 The purpose of this collective effort was to encourage
varied health occupations educational programs to incorporate interprofessional
education (IPE) to inspire future practitioners to embrace ICP to improve the
public's oral health (Figure 2-6).
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
Ag e nc y De ntal Hyg ie ne Profe ssional Role De sc ription

U.S. Public Health Service • Various roles depending on the • A Commissioned Corps of officers—one of the seven uniformed services for the
(USPHS) position federal government (not an armed service)
www.usphs.gov/ • Begin as clinician and oral health • Excellent benefits, including retirement similar to military retirement
educator; can advance to other roles • Federal school loan repayment programs available if working in an underserved
area
• Work as clinician and educator in clinics located on Indian reservations, in
federal prisons, and in immigrant detention facilities
• Work as administrator/manager and advocate with various federal agencies,
including HRSA
• Work as researcher with various federal agencies, including CDC and HRSA
• Can be deployed to areas in need of emergency response (e.g., 9/11 and Katrina)
• Internships available for dental hygiene students (COSTEP)
Health Resources and Services • Administrator • Work in various positions related to improving access to oral health services for
Administration (HRSA) • Researcher the country
www.hrsa.gov • Can serve as a civil service hire or USPHS officer (see earlier)
National Health Service Corps • Clinician • Serve primarily low-income and underserved populations
(NHSC) • Oral health educator • Work in community clinics, clinics at federal prisons, Indian reservations, and
nhsc.hrsa.gov/ immigrant detention facilities that have been classified as dental HPSAs
• Established by HRSA as a federal school loan repayment program
• Healthcare equivalent of the Peace Corps
Indian Health Service (IHS) • Clinician • Work in clinical facilities with the Native American population, in urban or
www.ihs.gov/ • Oral health educator rural settings
• Manager of a community-based • Can serve as a tribal hire, military transfer, civil service hire, or USPHS officer
program (see earlier)
• Benefits vary according to the type of hire
• Federal school loan repayment programs available
Department of Justice (DOJ) • Clinician • Work in clinical facilities at federal prisons
www.justice.gov/ • Oral health educator • Can serve as civil service hire or USPHS officer (see earlier)
• Manager • Benefits vary according to type of hire
• Federal school loan repayment programs available
Department of Veterans Affairs • Clinician • Full-time, part-time, and on-call work
(VA) • Oral health educator • Work in VA hospitals and with various veteran's programs, including homeless
www.va.gov/ • Manager programs for veterans
• Researcher • May be assigned to supervise other dental hygienists
• Federal school loan repayment programs may be available
Department of Defense (DOD) • Clinician • Work as employee of DOD, not a member of the military
www.defense.gov/ • Oral health educator • Provide primarily clinical and oral health education on military bases and other
• Manager DOD facilities
• Researcher • May be assigned to supervise other dental hygienists
• Can function at both domestic and overseas locations
Community, Homeless, and • Clinician • Work in federally qualified community health centers funded by HRSA and/or
Migrant Health • Oral health educator the USPHS
Programs/Centers • Advocate for population served • May be assigned to supervise other dental hygienists
• Administrator or manager • Can advance to administrative role
• Can be part of the NHSC (see earlier)
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.
Oral Health Educator

A second educator role in community oral health is the delivery of oral health
education to the public (see Chapter 8). This is important to accomplish with
individual patients as a clinician and with groups in the community. Oral health
education is used to inform patients and clients about scientifically based methods
for preventing oral diseases, promoting total wellness by reinforcing the
relationship of oral health to overall health, encouraging clients to become
responsible for personal oral health, and empowering clients' adoption of behaviors
and practices to improve health.
The oral health educator in public health collaborates with other health
professionals on the public health team. He or she shares information about a
common population, explores the relationship of oral health and other health
problems of the population, plans ways to include oral health education in programs
planned to intervene in other chronic medical conditions, and collaborates in the
public health processes of assessment, planning, implementation, and evaluation
(see Chapter 3) to deliver health education programs.
Oral health education programs can address a wide variety of oral health topics
and can be directed to diverse target groups. Examples of oral health education
programs include a smokeless tobacco intervention program related to prevention
of oral cancer, promotion of dental sealants for schoolchildren, education about
prevention of early childhood caries for daycare providers, denture care classes for
nursing home staff, and promotion of the use of mouth guards for athletes and
coaches in a school district.
Oral health education programs can be associated effectively with health
campaigns sponsored by health organizations and professional associations. For
example, the American Cancer Society promotes the Great American Smokeout on
the third Thursday of November each year, the American Heart Association has
identified February as American Heart Month, and the March of Dimes sponsors
March for Babies every March. In addition, the months of February (National
Children's Dental Health Month sponsored by ADA), April (Oral Cancer Awareness
Month promoted by the Oral Cancer Foundation), and October (Dental Hygiene
Month sponsored by ADHA) provide opportunities for oral health educational
activities. The ADA promotes their Give Kids a Smile program during February,
when on a specific day local dental professionals provide free dental care to
underserved children in the community. Oral health educators can collaborate with
local dental hygiene societies and dental hygiene educational programs on plans for
these special events.
Educational requirements for oral health educator positions vary from an
associate's degree to a graduate degree, depending on specific job responsibilities
and requirements. Certification in health education or as a Certified Health
Education Specialist (CHES) can be valuable also. The oral health educator in the
community needs organizational skills, current scientific knowledge, excellent
written and oral communication skills, creativity, and flexibility to meet the
challenges of community health improvement (see Chapter 8). Also helpful is
experience with patients who have special healthcare needs and experience with a
diverse patient population and their parents, guardians, and caregivers.
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.)
Another form of advocacy is to provide technical assistance to nondental

community groups interested in oral health issues. Some states and regions have
active oral health coalitions that have consumers ready to work on access to care
issues. These coalitions welcome the participation of a dental hygienist. Also,
nonprofit organizations can benefit from the expertise of a dental hygienist on their
boards, especially if the organization is small and has limited staff to implement
oral health programs. Some examples of ways for a dental hygienist to contribute to
a coalition or to other community organizations are to establish and plan oral health
programs for the population served by the organization; seek funding for oral
health programs, including grant writing; recruit volunteers for oral health
initiatives; and provide guidance on the appropriateness of oral health educational
materials. Although these activities involve other professional roles described in
this section, they are accomplished in the role of advocating for the population
being served by the coalition or organization.
Consumer advocacy can also encompass protection of the public. A dental
hygienist who serves on a state dental board is certifying individuals for licensure
to practice dental hygiene, reviewing any problems or complaints regarding
individual dental hygienists or their practices, and enforcing the laws regulating the
practice of dental hygiene. Serving on a regional examining board also involves
evaluation of new practitioners' skills to endorse them for licensure to practice
dental hygiene. Serving on committees to develop the National Board Dental
Hygiene Examination relates to the certification of new practitioners as well. Dental
hygiene faculty who serve as consultants to the Commission on Dental
Accreditation evaluate dental hygiene programs to assure the potential
qualifications of their graduates. All these are examples of activities that protect the
public by assuring the competence of practicing dental hygienists who are serving
the public.
Membership in the ADHA, its state constituents, and local component societies
guarantees a platform to be an advocate for dental hygiene. A request for expert
testimony on oral health issues might come from state legislative bodies, state and
local boards of health, city councils, and other government entities. In this advocacy
role the dental hygienist is advocating for the health of the public through
legislation and public policy changes.
On the other hand, an advocate dental hygienist could be proactive as a change
agent by lobbying at the state level for the relaxation of dental hygiene supervision
laws, changes in regulations regarding direct reimbursement of dental hygienists,
expansion of the dental hygienists' scope of practice, or implementation of a new
dental workforce model in the state (Figure 2-9). Successful attempts in other states
can serve as a model for such changes,73,74,75 and the ADHA can provide resources
to assist with the process. Most of the state-level changes related to these issues
described earlier in this chapter have resulted from dental hygiene's advocacy.
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.)
The required educational level to function effectively as an advocate depends on

the nature of the advocacy role. To advocate for the public we serve, a specific
educational degree beyond dental hygiene may not be required, but a bachelor's or
master's degree in health, community health, public health, healthcare management,
social services or the equivalent would be very helpful. A master's or law degree
would be preferred for a lobbyist or legislative representative and helpful for a
dental hygienist wishing to run for office as a legislator.
Change can be a slow process so advocacy can require patience and tenacity. An
effective advocate is current in scientific knowledge and public health issues,
familiar with legislative and other government processes, confident, a good
communicator, able to influence change, and eager for all citizens to have optimal
oral health. Advocacy requires experience working with special needs populations;
facilitating connections between individuals and oral health services; and strong
computer competency, including knowledge of electronic medical records,
computerized appointment/billing programs, and Microsoft Office programs.
Ability to speak a foreign language is helpful as well. Dental hygienists who
become advocates may have several years of experience in their profession and
have the ability to visualize the “big picture” of dental hygiene in relation to the
complexities of dental public health.
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.)
An administrator/manager will often have additional professional roles. This

individual may be required to provide some consulting, become an advocate for
changing public policy, or be involved with social marketing for a new oral health
initiative. Administrators and managers frequently are called on to collaborate with
leaders of other programs.
Educational requirements of this administrative role are a bachelor's or master's
degree in dental hygiene or a related field. Especially helpful would be a master's
degree in public health, community health, public administration, or healthcare
administration.
Required skills to function effectively as an administrator/manager vary
according to whether it is a state or local position and the magnitude of the
program. Necessary skills can include personnel management, program
development and implementation, project management, program evaluation, oral
and written communication, collaboration, grant writing, and organizational skills.
It can be important also to have current knowledge of dental and dental hygiene
sciences; dental public health issues, practices, and operations; and business
management such as budget development, supply ordering and inventories, and
record keeping. Also of value are experience in local, city, and county public
assistance dental programs; state Medicaid programs; dental policy development;
and provider relations. Several years of experience are generally needed to perform
successfully as an administrator/manager.
D ental H y g i eni st Mi ni -Profi l e

Public Health/Clinician
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!

Entrepreneur/Public Health/Clinician
Name:
Terri Chandler, RDH, EFDA, CDA
Founder/CEO/Executive Director of Future Smiles, Las Vegas, Nevada
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.
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.
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.
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.

Advocate/Researcher
Name:
Diann Bomkamp, RDH, BSDH, CDHC
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.
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.
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.
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.

Administrator/Public Health/Advocate
Name:
Lynn Ann Bethel, RDH, MPH
Executive Director
Oral Health Nevada Inc.
Reno, Nevada
I am self-employed and contract with various organizations such as Oral Health
Nevada (OHN) and the Association for State and Territorial Dental Directors. OHN
is a newly formed not-for-profit organization in Nevada whose vision it is to
“empower all Nevadans to have the best oral health possible . . . especially those
who are the most vulnerable, by expanding access to affordable preventive and
restorative services, promoting oral health education, and expanding
communication and support through diverse partnerships”
(www.oralhealthnevada.com). OHN serves as the statewide oral health coalition and
a resource for oral health educational information, access to care information, and
other material related to improving the oral health of the state. It also plays a role in
educating policymakers about the impact that poor oral health has on the economy
and is a voice during the development of proposals, budgets, regulations, and other
matters related to oral health issues that have statewide influence.
I research evidence-based science in relation to developing proposed oral health
policies for legislative consideration; develop and work with coalitions to promote
access to oral health care for all residents of the state; develop communication
venues including website content, white papers, fact sheets, and social media; write
grants; and interact with professionals from diverse organizations, agencies, and
institutions to address oral health issues affecting vulnerable population groups
such as individuals with low income or who are developmentally challenged, and
older adults.
Qualifications and Experience Required for This Position:
Necessary qualifications include dental and public health training. Also needed are
content knowledge and experience in implementing essential dental public health
services and initiatives, with coalitions, and in relation to consensus building.
Extensive knowledge of survey methodology; oral health prevention strategies; and
applicable laws, regulations, and policies are required as well for this position.
Additionally, it is essential to have experience in developing, delivering, and
evaluating creative and successful dental public health assessment/delivery systems
and prevention programs, including school sealant programs and community water
fluoridation. Experience in advocacy, policy development, and grant writing are
also significant.
Personal Comment:
I knew in high school after working one summer in a Head Start classroom that I
wanted to be a public health dental hygienist. After dental hygiene school at Cape
Cod Community College, I earned my bachelor's degree from Old Dominion
University with a minor in Sociology. After that, while raising a family and after
attending graduate school part-time, I earned my Master of Public Health degree
from Boston University School of Public Health.
While attending graduate school, I practiced in a community health center dental
program in the city of Boston. Then from 2000 to 2011, I taught full-time at Mount
Ida College Dental Hygiene Program, during which time I developed the
community dental health curriculum, established community externships, and
developed my first school-based sealant program, which was implemented by the
second-year dental hygiene students using portable dental equipment. I also
practiced clinical dental hygiene part-time in a pediatric dental office for nine of
those years.
The many diverse experiences in my dental hygiene career served as a
foundation for taking a leadership position as the state dental director for the
Commonwealth of Massachusetts. In that capacity, it was my responsibility to
improve, promote, protect, and advocate for the oral health of all Massachusetts
residents. I managed a yearly budget of several million dollars and had a staff of
dental hygienists and student interns who planned, implemented, and evaluated
statewide oral health programs that targeted vulnerable populations—children,
low-income individuals, older adults, and individuals with special and chronic
healthcare needs.
Among other responsibilities, I developed curricula to train medical
professionals about oral health and fluoride varnish, and I worked with the
licensing board to create regulations to support dental hygienists working without
supervision in public health settings. My staff and I trained water operators and
spoke to community groups about the evidence supporting community water
fluoridation. We developed and implemented school-based prevention programs
and community-based programs serving older adults, and we worked with other
departments and agencies to integrate oral health into their programs and policies.
I resigned as Massachusetts Dental Director in 2012 to move to California to
serve as the executive director of a community action agency, and I now work as a
consultant for nonprofits and organizations with a focus on dental public health. I
also serve as an elected member of the Executive Board of the American Public
Health Association. In my more than 30 years as a dental hygienist, I have served in
several professional roles. The public health role has offered, and continues to
offer, the chance to help people and improve the lives of many at one time. I'm able
to work alongside different professional disciplines at the local, state, and national
levels to influence their knowledge about oral health and its importance.
The dental hygiene profession is not about just clinical services for individual
patients. Higher levels of education bring increased opportunities to have a greater
impact on the health of the public. You are able to improve the oral health of entire
communities and populations through many different approaches at the community
level, bringing immense personal satisfaction.

Entrepreneur/Clinician
Name:
Tammy L. Allen
Co-owner, LifeCycle Dental Resource, Inc., Fort Worth, Texas
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.
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.
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.
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.

Public Health/Administrator/Educator/Clinician
Name:
Joyce Bartle Flieger, BSDH, MPH, RDH, EFDH
Oral Health Professional, First Smiles Program, University of Arizona College of
Agriculture and Life Sciences Cooperative Extension, Tucson, Arizona
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.
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.
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.
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.

Corporate Educator
Name:
Annette Wolfe, RDH, BS
Academic Manager, Southwest Colgate
Oral Pharmaceuticals
New York, New York
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.
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.
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.
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.

Administrator
Name:
Stacy P. Redden, RDH, MS
Practice Administrator
Dental and Orthodontic Clinics
Children's Health Specialty Center
Children’s Medical Center Dallas
Children's HealthSM, formerly known as Children's Medical Center Dallas, has the
mission “to make life better for children” (www.childrens.com). The organization
encompasses a full range of pediatric health, wellness, and acute care services for
children from birth to age 18, built around academic medical centers, specialty
care, primary care, home health, a pediatric research institute, and community
outreach services, among other forms of healthcare delivery. Children's HealthSM is
the seventh-largest pediatric healthcare provider in the country and the only
academically affiliated pediatric hospital in the area.
The hospital is home to numerous out-patient affiliated clinics that represent
interdisciplinary collaboration in treating patients; the dental clinic and
orthodontics clinic are two of them. The dental and orthodontics clinics address the
entire range of needs, from routine and preventive oral health care to treatment for
complex dental problems, and from conventional orthodontics for the purpose of
straightening teeth to specialized strategies for a variety of particular needs and
situations such as cleft palate.
As the Practice Administrator, I manage the day-to-day operations of the dental and
orthodontics clinics of the hospital, including supervision of 23 staff members and
management of almost 300 patients each week. I am the “go to” person for my
Division Director and other dental school faculty who supervise the pediatric
dentistry residents who actually provide the dental treatment for our patients. I serve
as the intermediary and communicator of information from our leadership team to
my staff. Finally, I function in an interdisciplinary collaborative capacity with
administrators of other clinics to work on initiatives aimed at assuring that
excellent service is provided by our staff to our patients.
Qualification and Experience Required for This Position:
Master's degree and management experience are needed. Children's HealthSM
preferred a Master of Business Administration or Master of Health Administration
degree for the Practice Administrator position. However, because my predecessors
held the same degrees as mine (Bachelor of Science and Master of Science in
Dental Hygiene), my credentials were accepted.
Personal Comment:
I practiced dental hygiene in private dental offices for several years before I
returned to school to get my MSDH. I decided to return because, even though I
loved my patients and where I worked, I felt stagnant. At the time I had several
patients diagnosed with cancer, discovered that I had a passion for working with
that patient population, and equally enjoyed researching ways to make them more
comfortable. This draw plus an interest in clinical teaching after I visited with the
Dental Hygiene Department at Baylor College of Dentistry prompted me to pursue
graduate education.
While in my graduate program I did an internship at Children's HealthSM under
the supervision of the Dental Clinic Practice Administrator at that time. This
experience resulted in my falling in love with the hospital and the Practice Manager
position. Because of my interest, I did my master's thesis on the provision of daily
oral care by nurses in hospitals. After my internship I continued to volunteer
through graduate school and beyond until I was employed in 2012.
The program was developed already when I came to Children's HealthSM so my
focus has been to continue to expand our services, market our clinics to parents of
children who require our specialized care, and identify new community partners
who can assist us with this. Our biggest challenge is in relation to working with
dental insurance. Many of our patients are covered by Medicaid, with its
cumbersome reimbursement mechanisms and continual changes in benefits and
other provisions. Another challenge is being diligent about careful interviewing
and medical consults before treatment to assure that we have complete medical
information for our children, some of whom are exceptionally medically
compromised. Our chief concern is to keep our patients happy and healthy while
they are in our care.
Regardless of the professional role that appeals to you, I recommend working in
clinical practice for a while to hone your skills and gain experience working with
patients outside of the school environment. Take as many continuing education
courses as possible relative to subjects or patient populations of interest so you can
solidify the areas that appeal to you for your professional career long term. Then
find someone working in the area or role that you are drawn to, visit with them
about their career, and ask if you can do an internship or volunteer to shadow them
to experience what they do on a day-to-day basis. I also recommend pursuing
graduate education. Even though I did a MSDH, I believe a Master of Health
Administration or Master of Business Administration would be more beneficial for
the dental hygienist interested in pursuing a management role in a hospital setting.

Public Health/Clinician
Name:
Lieutenant Cynthia Chennault, RDH, BSDH
Advanced Clinical Dental Hygienist, USPHS, and IHS, Catawba Service Unit, Rock
Hill, South Carolina
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.
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.
A dental hygienist can follow one of the following three routes to work for the IHS:
1. Federal Civil Service requires a preemployment background investigation with

fingerprint check; Selective Service registration for males born after December
31, 1959; U.S. citizenship; a current, valid state driver's license; and a current
license to practice dental hygiene in a state or territory of the U.S. or Washington,
DC.
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.
In addition, prior clinical experience and a background in community oral health

program planning prepared me for this position in relation to ensuring that oral
healthcare standards are being met and community resources are maximized.
Personal Comment:
I wanted my dental hygiene career to be professionally fulfilling and rewarding,
and I was drawn to public health as my desired path to accomplish this goal. I enjoy
contributing to the improvement, protection, and advancement of the oral health of
our nation, particularly in American Indian and Alaskan Native communities. I have
had the extraordinary privilege of living in two of the most beautiful parts of the
country in Native American communities that are deeply rooted in spirit and
tradition.
I began my career with the USPHS as a registered dental hygienist serving the
Fort Belknap Indian Reservation in Montana. One of the joys of working with IHS
is learning about the culture of the populations I serve. The Fort Belknap
reservation is home to two tribes, Gros Ventre (People of the White Clay) and
Assiniboine (Nakoda). Together, the tribes have formed a deep respect for the land,
culture, and heritage. Their main industry is cattle ranching and agriculture
consisting of raising alfalfa hay for feed and larger dry farm lands. Working with
this rural community that has a rich history was an incredible and unique
opportunity. The Fort Belknap Service Unit is a critical access hospital, providing
routine medical, emergency, and dental services to registered Native Americans
and Alaskan Natives. I provided necessary clinical dental hygiene services to an
appreciative, yet medically underserved, patient population at the Fort Belknap
Service Unit and the Hays satellite health clinic. I was especially pleased to be able
to establish a mobile school-based sealant and fluoride varnish program, which
resulted in 500 Native American children receiving preventive services. During the
school year, I provided care in the clinic on the reservation 1 to 2 days a week and
provided preventive care into the schools with a mobile program the remainder of
the week.
After two and a half years of service in Montana, my USPHS career led me to my
current assignment with the Catawba Tribe in Rock Hill, South Carolina. The
Catawba Service Unit provides routine medical and dental services for
approximately 1600 tribal members. The Catawba Tribe also has a long history and
a rich culture. The Catawba Nation's greatest legacy is its pottery. They have strict
standards for making their traditional pottery. All pieces must be made from their
local clay, which comes from the Catawba River. The clay is hand rubbed with
smooth river rock; some of these river rocks are passed down to future potters
through the generations. The pottery is hand formed, all natural from start to finish,
never glazed or painted, and pit fired using oak wood. The Catawba Native
American pottery is on display in the White House, in museums throughout the
state of South Carolina, and in the Smithsonian Museum.
I chose the USPHS for my career with the IHS because of the many different
options they provide that utilize our education and talents. I will start a Master of
Public Health degree in the fall of this year, after which I can advance into
numerous other positions within 18 federal agencies. For example, I can stay with
the IHS and work at the area or headquarters level in an administrative role, or I
can move to another federal agency such as the CDC to manage an oral health
program at the national level.
Advice for Future Public Health Dental Hygienists:
A career with IHS offers dental hygienists an extraordinary opportunity to provide
preventive oral health services to a diverse and culturally rich population. Although
job openings are available in urban areas, the majority of locations are rural and
remote, offering exciting opportunities for those who seek the “great outdoors”
lifestyle. As you search for the right opportunity, choose a community that matches
your personal and professional needs. Also, be patient as you pursue a career
within IHS or the USPHS. The application process can be lengthy. But if providing
care to a culturally rich, underserved community is your passion, then waiting for a
position with the IHS is well worth the wait. Additionally, a career with the USPHS
is extremely rewarding and provides amazing benefits.

Researcher/Educator
Name:
Becki Hale, RDH, MA
Special Projects and Initiatives Coordinator, Community Health Outreach, Cook
Children's Health Care System, Fort Worth, Texas
Cook Children's is one of the country's leading integrated pediatric healthcare
systems. This not-for-profit, national award-winning organization is “a connected
system of specialists, pediatricians, clinics, a medical center, and community
programs that benefit patients' families through access to a myriad of
resources . . . designed to fulfill their promise to improve the health of every child
in the region through the prevention and treatment of illness, disease and injury”
(www.cookchildrens.org). The Community Health Outreach Department supports
Cook Children's by bringing information and services to the community in relation
to multiple health focus areas, including oral health. They support initiatives in
surrounding counties that comprise its service area. One of these initiatives is to
operate the Children's Oral Health Coalition of Tarrant County.
My responsibilities are to research best practices, develop curriculum for
community outreach programs, create training materials for community partners,
provide formative and summative evaluation of projects and programs, and assist
with staff development of the Community Health Outreach Department personnel
relative to critical issues or topics such as health literacy and adult learning. These
tasks revolve around not only oral health, but also mental health, child obesity
prevention, child abuse prevention, injury prevention, and asthma. In addition, I
serve as a content expert for our department's oral health education and messaging.
I research best practices related to children's oral health for our oral health
programs. The focus is the importance of maternal oral health during pregnancy
and oral health practices for children up to age four. This research is used to
develop awareness messaging for underserved populations in targeted zip codes,
and also as the background for our training curriculum and materials. This training
is an interdisciplinary education session for various community professionals on
how to teach parents the proper techniques for taking care of their children's teeth. I
also present this educational training once a year for our community partners.
My position requires a background in community health principles and practice and
an understanding of the nature of community health practice. A bachelor's degree is
required, but a master's degree is preferred.
Personal Comment:
In dental hygiene school my favorite course was Community Dental Health. I knew
that one day I would work in the area of community health. After graduating from
the University of Texas, Health Science Center at Houston, Dental Hygiene
Program, I began clinical dental hygiene practice, simultaneously working toward
a B.S. in Community Health at Texas A&M University.
Shortly after completing that degree program I had the opportunity to teach as an
adjunct clinical instructor. I enjoyed teaching and eventually became the instructor
of Community Dental Health. At that time I thought about eventually becoming a
full-time faculty member, so I enrolled in a master's program in community health
because I enjoyed that field and wanted to enhance my knowledge and skills in it. A
dentist with whom I previously worked in clinical practice also worked part time
managing a dental program in the Community Health Outreach Department at Cook
Children's. She introduced me to this department, and I fell in love with the work
they do. When a position in the department became available, I promptly applied.
My first position with the Community Health Outreach Department was as
coordinator for the Children's Oral Health Coalition. This position involved
coordinating the coalition meetings and events throughout the year, such as
providing administration for the coalition, planning and coordinating an annual
toothbrush drive, and coordinating educational trainings. This role furthered my
skills in time management and communication.
One challenge I faced at the beginning of my alternative dental hygiene career
was my youth. I had been practicing dental hygiene for only 3 years before
becoming a clinical instructor. Both my students and my colleagues put my abilities
and knowledge to the test. It was not always easy but I welcomed the challenge and
feel that I rose to the occasion.
When I began in my current position as Special Projects and Initiatives
Coordinator, I had a similar challenge. It is very different from dental hygiene, and
it was quite new to me. What helped me meet these challenges successfully was to
have humility and be “teachable.” I still strive to practice this today, remaining open
to constructive criticism, continually learning by observing, and keeping a positive
attitude.
Continue your education! Go for the master's degree! You never know where the
journey will take you, and having that next degree will help open doors. Also, be
kind, helpful, and professional in all situations. Don't be above getting in there and
doing what needs to be done, whether it's taking out the trash or cleaning someone
else's mess.
Summary
Various career options exist for dental hygienists in the public health arena. Public
health career options offer many challenges and opportunities for the dental
hygienist to become actively involved in providing optimal oral health for the
community. The trend of less-restrictive dental hygiene regulations to facilitate the
dental hygienist's desire to provide preventive treatment to underserved populations
is explored, in relation to scope of practice, direct access, supervision, and
reimbursement.
Workforce models are defined, which may provide an advanced career path that
students can pursue to address the problems of access to oral health for underserved
populations. Public health career options and public health positions for dental
hygienists are available in a variety of settings. Within the primary setting of your
dental hygiene career, you may choose to develop and apply public health skills in
the role of clinician, educator, advocate, researcher, or administrator/manager. You
also may select to apply these roles in entrepreneurial or corporate positions. The
skills and education necessary to fulfill these roles are delineated in the chapter, and
dental hygienists in these various roles and positions are highlighted.
1. Check with your state health department to determine whether public health or
community dental hygiene positions are available in your community. Obtain a job
description, and evaluate the skills needed for this position using the dental hygiene
roles and positions described in the chapter.
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.
4. Participate in a community rotation/service project that is considered an

alternative practice setting.
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.
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.

HP.1
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
CM.7
Professional Growth and Development

PGD.1
Pursue career opportunities within health care, industry, education, research, and
other roles as they evolve for the dental hygienist.
PGD.3
Access professional and social networks to pursue professional goals.
Community Case
In your position as the oral health program coordinator for the Division of Dental
Health, State Health Department, you are assigned the task of developing an
educational campaign to promote oral health as critical to overall health. You also
are in charge of setting up a dental sealant program in a part of the state that is
classified as a dental HPSA. You will be responsible for selecting schools to
participate in the dental sealant program and for organizing the project, including
planning all meetings, ordering supplies, supervising personnel, and arranging the
schedule.
1. According to the laws of this state, a dentist must screen the children to approve
the teeth for dental sealants before a dental hygienist places the sealants; the
dentist does not have to be present at the time that the dental sealants are placed.
Which of the following is a correct statement?
a. This is an example of direct supervision.
b. This is a direct access state.
c. This describes general supervision.
d. Assessment is within the scope of practice for dental hygienists in this state.
2. You decide to set up a committee to help develop the “healthy mouth, healthy
body” campaign and invite a public health nurse, a nutritionist, a mental health
specialist, and a chronic disease health educator to join. This step is an example
of which of the following?
a. Advocating for policy changes
b. Interprofessional collaborative practice
c. Working under remote supervision
d. Secondary prevention strategies
3. What professional role is represented by your responsibility for the school-based
sealant program?
a. Clinician
b. Researcher
c. Administrator/manager
d. Educator
4. You will be reviewing all of the following factors EXCEPT one to determine the
location for the sealant program. Which one is the EXCEPTION?
a. The ratio of dental providers to people
b. The number of people who don't have access to dental care
c. The number of elementary, middle, and high schools
d. The number of dentists and dental hygienists
5. The educational campaign would be categorized as a primary prevention
measure. The sealant program would be a secondary method of prevention.
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.
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Administration; 2014 [Available at]
http://www.hrsa.gov/publichealth/clinical/oralhealth/primarycare/integrationoforalhe
59. National Summit on Children's Oral Health: A New Era of Collaboration.
American Academy of Pediatrics; 2008 [Available at]
http://www2.aap.org/oralhealth/SummitOralHealth.html [Accessed
February 7, 2015].
60. Pediatrics. Official Journal of the American Academy of Pediatrics.
[Available at]
http://pediatrics.aappublications.org/cgi/collection/dentistry:oral_health_sub?
page=4 [Accessed February 7, 2015].
61. Toward a Comprehensive Health Home: Integrating the Mouth to the Body
(policy statement). American Association of Public Health Dentistry; 2012
[Available at] https://www.google.com/ [Accessed January 29, 2015].
62. Fried J. Interprofessional collaboration: If not now, when? J Dent Hyg.
2013;87(Suppl. 1):41.
63. Mallonee LF. The need for inter-professional collaboration. J Dent Hyg.
2012;86:56.
[Available at] http://www.aacn.nche.edu/education-resources/ipecreport.pdf
65. Transforming Dental Hygiene Education: Proud Past, Unlimited Future.
Santa Fe Group; 2013 [Available at]
66. 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].
67. Doherty M. When Two Becomes One: An Effective Model for Medical-Dental
Integration. DentaQuest Institute, Safety Net Solutions; 2011 [Available at]
http://www.nnoha.org/nnoha-content/uploads/2013/09/When-Two-
Becomes-One-An-Effective-Model-for-Medical-Dental-Integration.pdf
68. Working (column). Access. 2014;28(7):27.
69. Nathe C. Public health remains a part of dental hygiene career paths. RDH.
2013;33:5e [Available at] http://www.rdhmag.com/articles/print/volume-
33/issue-5/columns/public-health-remains-a-part-of-dental-hygiene-career-
paths.html [Accessed January 31, 2015].
Association. [Available at] https://www.adha.org/resources-
docs/714112_DHiCW_Roles_Dental_Hygienist.pdf [Accessed February 5,
2015].
71. Safety Net Dental Clinic Manual. National Maternal & Child Oral Health
Resource Center: Georgetown University, Washington DC; 2011 [Available
at] http://www.dentalclinicmanual.com/ [Accessed February 9, 2015].
Association. [Available at] https://www.adha.org/resources-
docs/73213_Professional_Roles_of_DH.pdf [Accessed February 5, 2015].
73. 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.
74. 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.
75. The History of Introducing a New Provider in Minnesota: A Chronicle of
Legislative Efforts 2008-2009. American Dental Hygienists' Association;
2014 [Available at] http://www.adha.org/resources-
docs/75113_Minnesota_Story.pdf [Accessed February 8, 2015].
76. Bright Smiles, Bright Futures®. Colgate-Palmolive; 2015 [Available at]
http://www.colgate.com/app/BrightSmilesBrightFutures/US/EN/Our-
Commitment.cvsp [Accessed April 21, 2015].
Information on the alternative workforce models.
www.adha.org.
Supervision levels for dental hygiene services by state.
www.adha.org/resources.
States where dental hygienists may deliver local anesthesia.
States where dental hygienists may deliver nitrous oxide.
Career Opportunities in Public Health, Power Point presentation, 2014.
How a dental hygienist can improve access and productivity in a community
health center.
C H AP T E R 3
Assessment for Community Oral
Health Program Planning
Amanda M. Hinson-Enslin RDH, CHES, MPH, PhD(c), Christine French Beatty RDH, MS, PhD
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:
• Community water system is not fluoridated
• Access to oral health care: limited because of lack of dental

workforce; area identified by the U.S. Department of
Health and Human Services (DHHS) Health Resources and
Services Administration (HRSA) as a dental health
professional shortage area (see Chapter 5)
• No dental sealant programs in the schools
• Fluoride varnish program present in all public schools in

the community
• One community-based health clinic with a dental
component
• Oral health behaviors:
• 45% of elementary schoolchildren have not visited a dentist

within the last year
• 33% of elementary schoolchildren have not visited a dentist

within the last 5 years
• Oral diseases/conditions:
• 42% of 3- to 9-year-old children have untreated dental

caries
• 22% of 6- to 9-year-old children and 42% of 13- to 15-year-

old adolescents have at least one dental sealant in a
permanent molar tooth
• Resource availability:
• Grant funding available for school-based sealant program
• Mobile dental equipment available at community-based

clinic
• Oral health workforce available one Thursday and one

Friday a month to place sealants
• Oral health workforce available one Friday a month to treat
dental caries
• Three local business leaders willing to assist with funding

and facilities
Public Health Practice
Professional work in community health is dynamic because the environment
changes continually. Community health is affected by social, demographic, political,
economic, and technologic changes. In this milieu, public health practitioners
perform a broad array of duties focused on entire populations, with the overarching
goal that people are healthy and live in healthy communities.1,2 The mission of
public health focuses on preventing disease and providing an environment in which
people can live and function healthily. The American Public Health Association's
definition of public health3 and how it is carried out1,2 are presented in Figure 3-1.
FIG 3-1 Public health.
Public health services incorporate the roles of a myriad of public health

professionals in various sectors and from diverse disciplines that form the public
health workforce in the United States.1,2,4 Public health professionals can belong to
many professional disciplines, including oral health, nursing, nutrition, social
work, health promotion, laboratory science, environmental health, administration,
and epidemiology.2 Public health professionals have expertise in diverse public
health practices.1,2 Several organizations and agencies have called for an increase in
the visibility of public health and the core workforce that forms its foundation.5
Professional Preparation of the Public Health

Workforce
As a result, collaborative efforts have been undertaken to enhance the recognition of
the public health professions by measuring and improving the competency and
consistency of public health workers nationwide. In 2005 the National Board of
Public Health Examiners (NBPHE) was established to ensure that graduates from
schools and programs of public health accredited by the Council on Education for
Public Health (CEPH) have mastered the knowledge and skills relevant to
contemporary public health.6 The NBPHE has developed and now administers an
examination for the credential Certified in Public Health (CPH).7 The national
examination covers the five core areas of knowledge offered in CEPH-accredited
schools and programs, as well as interdisciplinary cross-cutting areas relevant to
contemporary public health8 (see Guiding Principles).
Subject Areas Represented on the CPH National Certification
Examination
Core Areas:
1. Biostatistics
2. Environmental health sciences
3. Epidemiology
4. Health policy and management
5. Social and behavioral sciences
Interdisciplinary Cross-Cutting Areas:

1. Communication and informatics
2. Diversity and culture
3. Leadership
4. Public health biology

5. Professionalism
6. Program planning
7. Systems thinking
Another organization with the purpose of improving and boosting the

recognition of the public health professions is the National Commission for Health
Education Credentialing, Inc. (NCHEC). Having emerged in 1978 with the mission
to enhance the professional practice of health education, NCHEC provides a
Certified Health Education Specialist (CHES) certification.9 Health educators strive
to promote healthy behaviors and empower individuals, groups, and communities to
adopt healthy behaviors and maintain those healthy behaviors throughout life.9 In
2009 NCHEC passed advanced credentialing known as the Master Certified Health
Education Specialist (MCHES).9 Eligibility requirements must be met to sit for the
CHES and MCHES certification examinations. The tasks listed in the Seven Areas of
Responsibility are included on the CHES and MCHES national examinations: 1)
assess needs, assets, and capacity for health education; 2) plan health education; 3)
implement health education; 4) conduct evaluation and research related to health
education; 5) administer and manage health education; 6) serve as a health education
resource person; and 7) communicate and advocate for health and health
education.10
In addition, the Council on Linkages Between Academia and Public Health
Practice developed a set of core competencies for public health professionals to
help strengthen public health workforce development.11 Revised in 2012, these
competencies guide academic institutions and training providers to develop
curricula and course content and to evaluate public health education and training
programs. The competencies are used in practice settings as a framework for hiring
and evaluating staff and assessing organization-wide gaps in skills and knowledge.11
The competencies are divided into eight domains (Figure 3-2). Skills and
knowledge are outlined within each domain and linked with important attitudes
relevant to the practice of public health. This effort of the council focuses on core
competencies as they apply to three different categories of professional positions:
front line staff, senior level staff, and supervisory and management staff.11
FIG 3-2 Domains of core competencies for public health professionals, Council on
Linkages Between Academia and Public Health Practice. (Data from Core
Competencies for Public Health Professionals. Washington, DC: The Council on Linkages
Between Academia and Public Health Practice, Public Health Foundation; 2014. Available at
http://www.phf.org/resourcestools/Documents/Core_Competencies_for_Public_Health_Professionals_2014June.pdf
Accessed February 2015.)
The core competencies were crafted to transcend the boundaries of specific

disciplines and to help unify the public health profession. The list has been cross-
referenced with the Essential Public Health Services (see Chapter 1) to ensure that
the competencies help build the skills necessary for assuring the provision of these
services. Academic institutions and health departments nationwide, the Centers for
Disease Control and Prevention (CDC), the Centers for Public Health Preparedness
(CPHP), and the HRSA-funded Public Health Training Centers have used the core
competencies to extend capacity and to ensure that public health professionals have
expertise in key public health services.
Public Health Preparation of the Oral Health

Workforce
Dental public health is “the science and art of preventing and controlling dental
diseases and promoting dental health through organized community efforts. It is that
form of dental practice that serves the community as a patient rather than the
individual. It is concerned with the dental health education of the public, with applied
dental research, and with the administration of group dental care programs as well
as the prevention and control of dental diseases on a community basis.”12 The
driving force of dental public health is achieving the oral health and related goals
set by Healthy People 2020, following the principles and practices described
throughout this textbook.
The Commission on Dental Accreditation (CODA) and the American Dental
Education Association (ADEA) both have developed and revised accreditation
standards and competencies, respectively, that emphasize dental public health in the
education of the future oral health workforce. According to ADEA general dentists
provide prevention, intervention, and educational strategies and “serve beyond those
served in a traditional practice setting.”13 CODA adopted accreditation standards for
the dental curriculum in 2010 that reflect a stronger emphasis on community in
terms of advocacy compared with the previous standards.14 CODA also has
established accreditation standards for the specialty program in dental public
health.12 According to the 2013 standards, to be accredited by CODA a dental public
health specialty program must include instruction in epidemiology, biostatistics,
behavioral sciences, environmental health, and healthcare policy and management.
ADEA competencies (see Appendix B) and CODA accreditation standards for
dental hygiene have greater emphasis on community oral health than predoctoral
dental education programs. According to the CODA standards, dental hygiene
graduates must be able to assess the needs of a community, plan and implement an
oral health program, and evaluate its effectiveness.15 The ADEA dental hygiene
competency document is presented in full in Appendix B. In addition, specific
related community oral health competencies are highlighted at the beginning of
each chapter of this textbook. A review of these competencies for entry into the
dental hygiene profession will reveal a high level of community oral health practice
reflected in the expectations for the profession. In addition, the ADEA competencies
for graduate-level dental hygiene education have an even stronger emphasis on
community oral health in terms of advocacy, public health policy, program
development and administration, health promotion, facilitation of collaborative
partnerships, and other related content areas.16
Collaboration in Public Health Practice

Successful provision of public health services requires collaboration among public,
nonprofit, and private partners within a given community, across various levels of
government, and across disciplines.1,2,3 To accomplish this partnerships must have
broad-based representation of constituency and stakeholder groups, including
private, voluntary, nonprofit, and public agencies or organizations involved in
overall health, mental health, substance abuse, environmental health protection, oral
health, and public health.2
A coalition is a type of collaboration; it is an alliance of multiple groups,
organizations, and individuals whose combined actions aim at accomplishing a
specific, common goal.2 Coalitions exist to bring broader attention and action to a
goal that affects many stakeholders and may disband when the goal is achieved
(Figure 3-3).17,18 There is power in the combined efforts of the members of a
coalition to provide the capacity to mobilize resources to approach community oral
health problems and to identify and implement solutions. Appendix C provides a
framework for a coalition that can guide the process of creating a community oral
health coalition. Examples of organizations, agencies, and other groups that can be
engaged in coalitions and collaborative partnerships to improve oral health of
communities are presented in Appendix A and Appendix C. Partnerships will be
discussed in more detail later in the chapter.
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.
Roles of Public Health Professionals in Assessment

The effective use of information in the twenty-first century is crucial to ensure that
healthy children and adults are living in healthy communities. Technologies
available to public health professionals influence the capacity and ability to generate
and collect a vast amount of information. In addition, evidence-based decision
making is shaping the development of public health policies, programs, and
practices. Therefore, it is essential for public health practitioners to have skills in
collecting, analyzing, disseminating, and effectively using data and information.20,21
In addition, public health professionals must have specific knowledge, skills, and
values to perform certain functions (see Figure 3-4).
FIG 3-4 Public health workers need the knowledge, skills, and attitudes to perform
these functions. (Data from Best Practice Approaches. Reno, NV: Association of State &
Territorial Dental Directors; 2011–2015. Available at http://www.astdd.org/best-practices/. Accessed
May 2015.)
Public health dental hygienists are expected to play a leadership role in

community oral health assessments.22 As agencies and organizations take on greater
responsibility in conducting periodic assessments, public health dental hygienists
will be involved in evaluating assets, needs, problems, and resources of the
populations they serve in the community. Dental public health professionals
working at the national, state, and local levels will be responsible for community
oral health assessment.22 The essential public health services for oral health can be
applied to assessment and evaluation22 (see Guiding Principles). These vital
activities are discussed in more detail in Chapters 4 and 6.
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.
• Analyze determinants of identified oral health needs, including resources.
• Assess the fluoridation status of water systems and other sources of fluoride.
• Implement an oral health surveillance system to identify, investigate, and monitor

oral health problems and health hazards.
• Evaluate the effectiveness, accessibility, and quality of population-based and

personal oral health services.
• 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.
• An oral health educator assesses the knowledge, attitudes, and opinions of a

community about community water fluoridation to develop an oral health
promotion campaign.
• 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.
• An oral health services provider monitors oral health indicators in the

neighborhood surrounding a community health center.
• 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.
Epidemiology is the study of the distribution and determinants of health-related

states and events in specified populations and the application of this study to the
prevention and control of health problems.20,23 Epidemiologists consider the
interactions and relationships among the multiple factors that influence health status
and health problems.23 Methods used in epidemiology and research are combined to
focus on comparisons between groups or defined populations. Epidemiologists
make comparisons by examining the occurrences of the health events, locations,
times, and variations to assess the distribution and determinants of health events.20
The principal factors analyzed in epidemiology are as follows:
• Distribution
• Population dynamics
• Occurrences
• Affected population
• Place characteristics
• Time
• Determinants
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.
FIG 3-5 Epidemiologic triangle: Dental caries is a multifactorial oral disease.
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.
• Describe normal biologic processes.
• Elucidate mechanisms of disease transmission.

• Describe the natural histories of acute and chronic diseases.
• Test hypotheses for prevention and control of diseases, injuries, disabilities, and
deaths through special studies in populations.
• Evaluate services (e.g., community preventive services, population-based health

promotion services, and clinical health services).
• Study nondisease health and social problems such as occurrences of intentional

and unintentional injuries.
• 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.
• Evaluate interventions and strategies to prevent and control diseases, disabilities,

injuries, and deaths.
• Predict trends of diseases, disabilities, injuries, and deaths.
• Identify health assets, gaps, needs, problems, resources, solutions, and

partnerships within the context of a community assessment.
Changing Perspectives of Health

During the twentieth century and continuing into the twenty-first century, major
transformations took place in the concepts of health and the understanding of the
determinants of diseases, disabilities, and injuries. Many historic developments have
contributed to these expanded visions, which continue to have a profound effect on
the health of individuals and populations. These developments continue to contribute
to changes in clinical health care and public health practice. Box 3-3 outlines broad
trends influencing the conceptions of health and health practice in the 20th and 21st
centuries.
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
• Shifts in views of civil and human rights
• Shifts in governmental involvement in social services, including healthcare

services
• Population growth, demographic change, and migration
• Recognition of environmental health and ecology
• Technologic changes influencing work, home, life in communities, and treatment

of diseases (e.g., transportation, telecommunications, computing, telemedicine,
teledentistry)
• Advancements in the biologic, physical, quantitative, social, and behavioral

sciences
• Acknowledgment of the impact of globalization and urbanization on population

health
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
1. Inherited determinants are factors that are inborn or genetically determined.
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:
• A city ordinance that prohibits smoking in public and government buildings

prevents second-hand smoke inhalation.
• State law requires that seatbelts be worn in cars to protect people in the event of a
car accident.
• A city council votes to adopt fluoridation of the municipal water supply.
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:
• Social determinants: Socioeconomic conditions, such as concentrated poverty,

transportation options to reach healthcare and oral healthcare clinics, quality of
schools.
• Physical determinants: Housing, parks, sidewalks, biking lanes, ramps and

sidewalk cuts to accommodate individuals with physical disabilities trying to
access oral healthcare services.
Health Services:
Definition: Access to health services and the quality of health services.
Examples:
• Availability of the oral health workforce in rural areas.
• Access to healthcare providers who speak the same language as the patient.
• Insurance and dental insurance coverage.
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.
• Practicing adequate oral hygiene, which depends on access to suitable and

sufficient oral hygiene tools and supplies.
Biology and Genetics:

Definition: Basic biologic and organic make-up of the human body; also the
inherited predispositions to specific diseases and conditions.
Examples:
• Age
• Sex
• Inherited conditions (e.g., congenitally missing teeth, tooth morphology)
• Family history of a condition (e.g., cancer, heart disease, or diabetes; familial

transmission of bacteria associated with dental caries)
• 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.
The boundaries between the specific categories of determinants are indistinct

because they interact and influence each other continuously.20,21 During different
stages of human development, the multiple determinants act synergistically, rather
than separately, to affect health.
To illustrate, consider this scenario: A 32-year-old middle class male has a family
history of type 2 diabetes, which means he has a genetic predisposition to developing
type 2 diabetes. His lack of physical activity and heavy carbohydrate diet increases
his risk of developing type 2 diabetes as he ages. He also lives and works in an
environment that promotes a sedentary lifestyle, which also increases the risk of
developing type 2 diabetes. His employer provides health insurance and health
programs and has office policies that encourage healthy habits. However, he has to
make the decision to adopt personal behaviors that will prevent his developing type
2 diabetes.
This example also illustrates that no single determinant of health is the most
important because multiple factors work in combination.27 Also, factors vary in
importance in different situations. Thus causation is usually described as
multifactorial; that is, multiple factors determine health conditions, including
diseases, disabilities, and injuries among individuals who live, work, and play in
communities.
Social Determinants of Health

A greater emphasis has developed on the social determinants of health,
demonstrated by Healthy People 2020 having a new topic area of Social
Determinants of Health.31 These social determinants of health have become the
targets for refocused strategies for population health.32 Social determinants are
shaped by the distribution of money, power, and resources at global, national, state,
and local levels, which are themselves influenced by policy choices.29,31 Social
determinants of health are primarily responsible for health inequities32—the unfair
and avoidable differences in health status seen within and between various
populations (see Chapters 4 and 9). See the Guiding Principles for a comprehensive
description of the social determinants of health according to Healthy People
2020.29,31
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
• High school graduation
• Enrollment in higher education
• Language and literacy
• Early childhood education and development

3. Social and community context
• Social cohesion
• Civic participation
• Perceptions of discrimination and equity
• Incarceration/institutionalization
4. Health and health care
• Access to health care
• Access to primary care
• Health literacy
5. Neighborhood and built environment
• Access to healthy foods
• Quality of housing
• Crime and violence
• Environmental conditions
Determinants of Health in Relation to Oral Health

Multiple determinants of oral health have been described in the literature.33-41 The
same principles of health determinants that relate to various significant health
conditions, such as cancer, obesity, cardiovascular disease, diabetes, respiratory
diseases, mental illness, and trauma, also apply to oral health. The determinants of
health described in Box 3-4 are illustrated in Figure 3-7, specifically in relation to
oral health and with additional examples of oral health determinants for greater
understanding. To further explain these concepts, sample scenarios in Box 3-5
describe how health determinants impact oral health for individuals and families.
The community case in Box 3-6 depicts the effects of health determinants on
inequities in oral health in a population. All of these aids focus on social
determinants and overall health determinants as they relate to oral health.
FIG 3-7 Determinants of health in relation to oral health. (Adapted 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.)
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.
Health promotion theory has moved toward a complex, holistic, interactive

approach, with a systems orientation focused on healthy people living in healthy
communities.20,21,32,42,43 Health promotion approaches are embracing the principles
of population health, social ecology and epidemiology, and community
participation.20,21,32,42,43 These transformations about the meanings of health,
wellness, and quality of life, as well as health problems within communities, are
continuing to evolve in the twenty-first century. By adopting a holistic approach to
improving oral health and through collaborative work with partner agencies and
organizations, dental public health professionals can achieve the aim of improving
both the oral health and overall health of populations.
The Community Health Program Planning
Process
The program planning process is a model commonly used in public health
practice, providing a basic flowchart of steps to 1) assess a community to identify
primary health issues, 2) plan a measurable process and outcome objectives to
measure progress in addressing the health issues, 3) select effective interventions
to help achieve the objectives and plan the interventions, 4) implement the selected
interventions, and 5) evaluate the selected interventions based on objectives and use
the evaluation results to improve the oral health program.44 Also referred to as the
community oral health improvement process, the community health program
planning process can serve as the framework to develop an oral health plan, design
a dental public health intervention, and measure oral health outcomes to quantify the
performance of a program at a population level.
The program planning process is continuous, and each stage can be further
subdivided into detailed steps for a long-term health improvement process in the
community.44 Figure 3-8 illustrates the community health program planning process
with detailed steps outlined. This process can be applied to any size program,
whether on a large scale at the state or community level, or on a smaller scale with a
priority group, such as a school, residential facility for older adults, Head Start
program, or community-based health center.
FIG 3-8 Community health program planning process. (Data from The Community
Guide: Program Planning Resource. Washington, DC: U.S. Department of Health and Human
Services; 2014. Available at http://www.thecommunityguide.org/uses/program_planning.html.
Accessed April 2015.)
Although it is important to follow a process for community health program

planning, it is also essential to understand the need to be flexible in public health
practice. Because of the dynamics in community health, new circumstances can
arise, making it necessary to adjust the plan. Sometimes activities initially outlined
in a plan may not be followed as sequentially ordered, necessitating modifications
in the work plan. Even so, all the steps of the program planning process should be
included in a plan to guide the process and assure effective community oral health
programs.44
Following such a program planning process for community oral health
programs allows a methodical approach of assessing different factors; considering
various options for actions, policies, programs, and initiatives in the planning
phase; implementing well-thought-out ideas; and evaluating outcomes to track
progress and determine long-range actions. Thus, this process can support a
coordinated community effort of assessment, planning, implementation, and
evaluation. When these efforts are institutionalized over time into the community
fabric, long-term oral health benefits are likely to be achieved by the community.
The Division of Oral Health of the CDC has also developed Infrastructure
Development Tools. These materials provide “how-to” guides for planning and
implementing assessment activities using logic models for guidance. The
publications focus on standards and priorities of the CDC for surveillance,
monitoring, and evaluation. Their purpose is to assist public health programs in the
planning, designing, implementation, and evaluation of programs, using practical
and increasingly comprehensive evaluation of oral health promotion and disease
prevention efforts. The Internet-based materials are a resource for dental public
health professionals responsible for program planning and evaluation activities to
demonstrate accountability to diverse stakeholders.45 This and other resources are
available in the References and Additional Resources at the end of the chapter.
Assessment of Oral Health in Communities

The first step of the community health program planning process is to conduct a
community assessment.45 A community oral health assessment should be
developed on the basis of the specific aims of the assessment and the available
resources, special circumstances, and expertise in the community.46 The essential
components that are reviewed in this section should be included in all community
oral health assessments, regardless of the size of the community or the purpose of
the assessment.46 The upcoming content provides an overview of assessment as a
key component within a comprehensive process that communities can adopt to
improve oral health. A community oral health assessment is a multifaceted process
that is community-oriented and community-directed.46 An oral health assessment
considers assets, gaps, needs, problems, resources, solutions, and partnerships
within the context of the community. Its purposes are to identify factors that affect
the oral health of a population and to determine the availability of resources and
interventions that can be used to impact these factors to improve oral health.46
Communities are better served and improved outcomes are more sustainable
when assets-oriented assessment methods are used, in contrast to deficiency-based
approaches that focus on needs and problems. For example, assets-oriented
assessment focuses on what assets the community has available, such as funding,
workforce, materials, and facilities. On the other hand, a deficiency-based approach
concentrates solely on the problems without taking into account the big picture of
what strengths and assets the community has available to solve the problem. By
engaging and fostering the community in a community-building process, one can
gain insight about the specific factors in the community that influence health.
Through a participatory framework for action and capacity development, a better
understanding of opportunities for health enhancements can emerge over
time.17,20,21,46
To know and understand the community's needs and resources, certain questions
need to be answered during a community assessment (Figure 3-9). Answers to these
questions will provide a better understanding of the oral health needs of the
community and how to approach the program planning process.46 These answers
can assist in the final determination of critical oral health issues and priorities.
FIG 3-9 Questions to answer during a broad-based community oral health
assessment.
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
• Association for Community Health Improvement (ACHI) Community Health

Assessment Toolkit37
• New York State Community Health Assessment (CHA) Clearinghouse How-To

Guide: 10-Step Assessment Process38
• Minnesota Community Health Assessment and Action Planning (CHAAP)39
• North Carolina Community Health Assessment Guide40
• Community Health Assessment and Group Evaluation (CHANGE)41
• Community Health Improvement Process (CHIP) reviewed in an Institute of

Medicine (IOM) report42
Step 1: Identify Partners and Form an Advisory Committee

The first step of the ASTDD Seven-Step Model is identifying partners and forming
an advisory committee (see Figure 3-10).46 Looking to the public, private, and
nonprofit sectors will offer opportunities for potential champions of the assessment
mission and process. A community partnership is an arrangement between or
among agencies, organizations, businesses, and people that collaborate and
combine resources to work toward a unified, common goal. Mobilization of
community partnerships to identify and solve oral health problems has been
identified as a key public health activity to improve the oral health of
communities.17,20,21,47
Collaborative partnerships and community coalitions are prominent strategies for
community health improvement.17,20,21 Community involvement is crucial in
identifying oral health issues and concerns.46 Community partners can broaden the
scope, approaches, and perspectives during the process of an assessment, providing
community input, data sources, resources, expertise, and sponsorship that can assist
with the common goal. The community partners can provide resources and political
support as well.
Engaging community partners in the assessment process is critical also to
building support for community oral health improvement plans and initiatives that
will arise from the assessment outcomes.20,21 Examples of this kind of support could
be financial support for communication of the findings and promotion of the
strategies identified by the assessment. Thus involvement and support of partnering
agencies and organizations throughout the assessment process can have a positive
influence on the attainment of mutual missions and goals upon completion of the
assessment.47
Community action and community-building efforts that engage and empower
communities can have positive outcomes when they are sustained over time.17,20,21,47
Empowerment, as it pertains to community health, is enabling the community to
take control and make decisions as a whole about the achievement of health in their
own community. The empowerment process aids and provides the appropriate tools
and knowledge to the community members to enable them to make decisions for the
community where they had previously been unable to. One of the principles of
public health practice is that interdisciplinary collaboration (across disciplines)
and broad community involvement are crucial to the empowerment of communities
in relation to health improvement.17,20,21,47 It is important to consider ways to identify
and recruit partners that will result in an inclusive and empowering process.
In the process of finding support in the community it is strongly recommended
that an advisory committee be developed to plan and conduct the needs assessment.46
Through forming partnerships and gaining support from the community members,
organizations, and agencies, individuals can be identified who can serve on and lead
an advisory committee to guide the needs assessment process. Successful and
effective needs assessment and program planning are determined by the
organizations and partnerships that are represented on the advisory committee.
People and organizations should be selected that share the desire to accomplish
the same goals.46 Broad-based community partnerships should be engaged and
participants enlisted to reflect the cultural, racial, ethnic, gender, economic, and
linguistic diversities of the community.47 It is essential to involve diverse partnering
agencies, organizations, associations, and individuals in community
partnerships.20,21,47 Potential partners should include a cross-section of the
community, such as technical staff, program managers, and leaders from business,
media, religious, civic, philanthropic, community, and political realms.20,21,47 They
should represent a variety of diverse perspectives and be active in various
disciplines to increase the opportunities to develop innovative approaches for the
needs assessment.47 In addition, they should represent the demographics of the
community and consist of participants, community leaders, agency and organization
leaders, service providers, and policymakers.20,21,46
The community partners involved in an assessment may vary according to the
overall focus of the assessment process. Appendix C provides a list of potential
constituents and stakeholders that should be considered as potential partners to
support the various phases of community-based efforts, including assessment. The
coalition framework in Appendix C can also serve as a guide to selection of
members for a community oral health assessment advisory committee. Appendix A
consists of a list of various community and professional organizations that can be
potential partners for specific initiatives of common interest.
Mechanisms for community participation, input, and dialog must be incorporated
throughout the assessment process.47 It is imperative to a successful community oral
health assessment that the community be mobilized and actively involved
throughout the process. Procedures should be in place to ensure opportunities to
communicate with and get feedback from the community, sustain support
throughout the process, and evaluate the assessment process and results.20,21
Resource materials can be helpful by offering innovative ideas about building
effective collaborative partnerships and community coalitions.20,21,43 Many of these
resources discuss in-depth ways to initiate and sustain vitality of collaborative
relationships. Specific factors and conditions that are conducive to effective
collaborative partnerships should be supported and nurtured for measurable and
lasting results.47 A variety of resources are available in the References and
Additional Resources at the end of this chapter.
Describing the community.

Before proceeding to the next step, the advisory committee must develop a clear
description of the community. This is an important task of the assessment that must
be accomplished at the onset of the process.20,21 Communities are a collection of
people, places, and systems that define how the people and places interact on an
ongoing basis.20,21 Before planning a community assessment it is necessary to
identify the traits of the community in an overview or “snapshot” of the community.
This snapshot profiles the health of the community by reporting on a spectrum of
health indicators. In addition, it identifies the targeted community for the needs
assessment. Data collected for a snapshot would briefly describe the features of the
community but not detailed statistics at this point20,21 (see Guiding Principles).
Factors to Use in Understanding and Describing a Community
• People (socioeconomics and demographics, health status, risk profiles, cultural

and ethnic characteristics)
• Location (geographic boundaries)
• Connectors (shared values, interests, motivating factors)
• Power relationships (communication patterns, social and political networks,

formal and informal lines of authority and influence, stakeholder relationships,
resource flows)
More comprehensive, detailed community data should be compiled during the

data collection phase of the community assessment. This will be discussed in a later
step in the process.
Step 2: Conduct a Self-Assessment to Determine Goals and

Resources
Step two of the ASTDD Seven-Step Model is conducting a self-assessment46 (see
Figure 3-10). Self-assessment is accomplished to identify the goals or purpose of
the needs assessment through consensus of the advisory committee.46 There are
many possible reasons to conduct a community oral health assessment, and a
community may have more than one purpose. Before beginning the assessment
process, the community partners must understand why the community is conducting
an assessment, what the community hopes to achieve from it, and what will be
gained through the assessment process.46
A few of the many potential purposes for conducting a community oral health
assessment are listed in Figure 3-11. This self-reflective step will thus guide the
necessary scope and size of the assessment and influence other decisions relative to
planning the needs assessment.46 In addition, when necessary, self-assessment can
include internal evaluation of the organization and its role; external evaluation of
the missions and roles of other organizations in the community that can affect the
oral health assessment process or the future oral health improvement plan; and
consideration of the organizational capacity, power structures, strategic plans,
commitment, and resources available.47
FIG 3-11 Potential purposes for conducting a community oral health
assessment. (Kuthy RA, Siegal MD, Phipps K. Assessing Oral Health Needs: ASTDD Seven-Step
Model: Step 2; 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.)
Step 3: Plan the Needs Assessment

The third step of the ASTDD Seven-Step Model is planning the needs assessment46
(see Figure 3-10). Different types, sources, and levels of information are needed for
a comprehensive health assessment.20,21 It is vital to collect information and evaluate
data related to the current status of assets, gaps, needs, problems, resources,
solutions, and partnerships in the community. Examples of information needed for a
community assessment are included in Appendix D. In addition, Appendix E
provides a comprehensive list of oral conditions and factors influencing oral health
that could be included in a community assessment. Based on the goals and resources
identified in the self-assessment the advisory committee can resolve what
information needs to be collected for the assessment and how it should be gathered.
During the planning step a priority-based structure is developed to identify realistic
means of obtaining the needed data. This requires development of data collection
methods.46
A standard element of an assessment is the compilation and synthesis of existing
data from secondary sources.20,21 These secondary sources will likely provide much
of the needed information, but generally gaps exist in the available data. Thus, after
existing information is assessed, a decision can be made about the collection of new
information from primary sources. These activities that are undertaken to achieve
the goals of the assessment must be refined continually as information is collected
and in light of available resources.20,21
Collecting existing data from secondary sources.

Multiple resources of information are widely available to the general public. The
sources of data used in an oral health assessment should be diverse to ensure a
broad portrayal of the factors influencing oral health in the community.20,21 A
variety of data resources should be tapped, for example:
• Government agencies and private and nonprofit organizations compile data and
produce excellent reports on the various determinants of overall health and oral
health, oral health status, and trends.
• Sources of local information include local reports, literature reviews, magazines,
newspapers, newsletters, maps, and marketing data.
• Previous assessments that have been conducted in the community can provide
valuable information, insights, and a historical perspective.
Table 3-2 outlines examples of various sources of information for community
oral health assessments. In addition, Appendix A provides a list of specific
community and professional resources, and government resources for health data
are listed in Appendix D. Other resources are included in the References and
Additional Resources at the end of this chapter, Chapter 4, and Chapter 5.
TABLE 3-2
Sources of Information for a Community Oral Health Assessment
Pote ntial Sourc e Example s

Federal, state, and local • Health department, human services department, and social services department; department of aging; department of
government agencies (see disabilities and special needs; highway safety department; police departments (documents, reports, surveys, statistics)
Appendix D) • Population surveys
• National, state, and local health surveys
• Surveillance system; reports and records
• Population-based registries
• Health agency records and reports of participants enrolled in programs
• Agency records and reports of health professionals; health professional shortage areas; community health centers
• State or local child protection agency records
• Environmental agency records and reports
Private and public (community) Hospitals; health plans (health insurance claims data); healthcare systems (health charts and dental records, pathology
health, healthcare (clinical or reports); professional associations; trade groups; community advisory committees; community collaborative groups and
personal health care), social, and coalitions (community surveys); health and social service groups; professional and community organiz ations, societies,
human service programs and associations (documents; reports, surveys, statistics)
Philanthropic, nonprofit, and Religious organiz ations and groups; voluntary agencies; civic organiz ations; service and voluntary groups; community
charitable organiz ations organiz ations; advocacy groups (documents, reports, surveys, and statistics; local information and referral service
inventories)
Schools and colleges School districts; school boards; school campuses; colleges; universities (student statistics, school health reports, school
entry records)
Businesses, employers, and Major employers or chambers of commerce; marketing data and survey data (e.g., Nielsen Claritas); economic statistics
business organiz ations and financial records; corporate annual reports (e.g., sales of drugs, foods, tobacco)
Media Media sources (newspapers, magaz ines, newsletters, radio, television, Internet, social media)
During secondary data collection, it is important to methodically conduct a broad

search of available information and to organize an inventory of this information.
Information from secondary sources should be carefully compiled to establish a
system to record, process, and organize the data.
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.
2. Qualitative data refer to information that cannot be numerically measured or

analyzed; rather, the quality or nature of factors influencing a health problem is
reflected. Qualitative data add meaning to the numbers and help answer the question
of why a problem exists in a community. Some possible sources of these data are
personal interviews, descriptions of traditions and the history of a community, and
information gathered from participant observations or focus groups.
Step 4: Collect Data

The fourth step of the ASTDD Seven-Step Model is the collection of data46 (see
Figure 3-10). Data collection is the gathering of information that the community
can use to make decisions and set priorities. This is the actual implementation of the
community oral health assessment, which consists of collecting the various types of
data that were identified as important in the assessment planning phase.46
Determining the necessity of primary data collection.

After the existing data from secondary sources is assessed (see Step 3), a decision
can be made about the necessity to collect new data from primary sources.20,21
Sometimes it may be necessary to collect original data when important gaps in
information needs still exist. This key decision should be made based on the
following:
1. An analysis of the findings from the secondary data sources
2. A reevaluation and possible refinement of the assessment goals
3. Available resources to support primary data collection
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.
Planning and collecting primary data.

When it is necessary to collect primary data, the community partners must develop a
plan that outlines objectives, activities, roles, responsibilities, a budget, and a
timetable for this activity.20,21 Examples of tasks that should be considered for
conducting primary data collection are listed in Appendix D. One of the crucial
tasks that will affect the primary data collection plan is making decisions about
primary data that are required and data collection methods and instruments to be
used. These decisions will depend on the aims of the community oral health
assessment and the resources available.20,21
It is essential to study the many alternative ways by which primary data can be
collected, considering both the advantages and limitations of the data collection
options in light of the goals of the community assessment.20,21 Based on this analysis
the group can strategically determine the final primary data collection plan
according to identified priorities and resources. After this is accomplished the
group will need to develop data collection instruments, such as surveys and
questionnaires, along with detailed instructions for their implementation.46
Also in Appendix D is a description of assorted nonclinical data collection
methods that can be used to collect primary data. Sometimes a clinical oral health
survey will be required to collect primary data of oral health diseases and
conditions that exist in the community. Appendix F and Chapter 4 are resources for
various measurements and dental indexes that can be used for such an oral health
survey.
Step 5: Organize and Analyze the Data

The fifth step of the ASTDD Seven-Step Model is to organize and analyze the data46
(see Figure 3-10). Analysis and interpretation of data often require special
knowledge and experience, and this is where the background and experience of the
advisory committee members, community partners, and other professionals in the
community are invaluable. Enlisting their expertise and assistance in analyzing and
validating impressions and interpretations of the assessment data is vital.
To analyze and interpret both primary and secondary data, numerous actions are
necessary. After the data have been organized by topic for ease and clarity, as
recommended by ASTDD, the initial action is to synthesize the information and
summarize the findings.46 A critique of each data source is required to assess its
trustworthiness.20,21 Limitations of the data and data sources must be checked for
potential errors or bias. It is important to consider the sampling technique of
research studies that were reviewed, such as type of sample, sample size,
participation of population segments, and generalization of findings to population
groups (see Chapter 7).20,21
Because of the potential for human error it is essential to review the methods and
processes used to ensure that protocols were followed in collecting, recording,
compiling, and analyzing data.48 This will enable reduction of any possible bias and
errors in the results and/or interpretation of those results. Information should be
reviewed carefully to consider the possibility of errors in coding and groupings of
data, erroneous instructions, typographical errors, or misinterpretation.20,21,48
When the data have been determined to be reasonably free of errors, they should
be compared with other data. Data used for comparison should be as alike as
possible to allow for valid comparison.49 Analysis of trends can be included by
comparing new, current data with data from previous years. These comparisons
may show changes in the community over time, which can be very useful for later
program planning purposes. Figure 3-12 provides some suggestions of data sources
with which the community assessment data can be compared.20,21
FIG 3-12 Assessment data can be compared with other data from various
sources.
At this point it can be determined whether opportunities exist to analyze the

secondary data further. If existing data sets are available and additional analysis will
generate new information, this alternative may result in more insight. In addition,
there may be value in adding or integrating the collection of new types of data into
ongoing data collection efforts.20,21,48
The next action in the analysis process is to determine the meaning and
significance of the data analysis.20,21 The term significance means that the resulting
information truly reflects that a problem exists in a community. Studying the data
for significance involves identifying any possible misleading findings before
conclusions can be drawn from the findings. An abundance of data combining
different types of data allows for a more accurate and meaningful determination of
the significance of the findings.48
Significance can be determined through the analysis of quantitative and
qualitative data. Statistical significance of quantitative data using mathematical
methods is discussed in Chapter 7. However, significance of qualitative data is not
determined through statistical analysis.49 Textual data collected from transcripts of
interviews, focus groups, or field notes of observations are explored with the use of
contextual analysis. Actions in qualitative data analysis include familiarization with
the data by reviewing it repeatedly, identifying a thematic framework, indexing,
charting, mapping, and interpreting.49 With the use of specific methods, data in
contextual form are indexed to assess common or unique themes and to generate
analytic categories and theoretic explanations.49 The following questions are
answered by analyzing qualitative data:49
• Does the information reflect relationships?
• Does the information describe a pattern of key themes and explain a social
phenomenon?
Feedback on the meaning of the findings can be provided by evaluating the
implications of the data within the context and expectations of the community.20,21
The findings from quantitative and qualitative data can provide direction for future
actions that build on community assets. With potential strategies indicated, this
action may move the assessment phase toward the planning stage of a community
oral health improvement process. At the same time, additional questions may arise
that may direct the process toward the need for more information and
supplementary assessment activities.20,21
Step 6: Utilize Data for Program Planning, Advocacy, and

Education
Step number six of the ASTDD Seven-Step Model is to utilize the data for program
planning, advocacy, and education (see Figure 3-10).46 As reflected in Figure 3-10,
this step consists of two actions: 1) prioritize the issues and 2) report the findings.46
Prioritizing the issues.

The issues that impact the oral health of the community were identified through the
interpretation of the data in the previous step (Step 5). In Step 6 these issues are
prioritized to determine which must be addressed first.46 Prioritization is a decision
making process that involves an impartial and balanced approach to deciding the
order of importance of the issues.46 Prioritization of issues is influenced in part by
the availability of resources, including funding and workforce.20,21,46 Community
partners should be actively involved through a deliberative process in all aspects of
identifying and prioritizing the critical issues that will be addressed later in the
program planning process.20,21 Key steps to follow in determining and prioritizing
community oral health issues are outlined in Box 3-8.
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.
2. Ensure clear determination of oral health priorities in conjunction with the

community.
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.
6. Identify community programs currently addressing oral health priorities that

were identified through the assessment efforts. Consider expanding partnerships
and building upon effective strategies. This may allow for more effective and
efficient use of limited resources.
7. Identify best practices to determine effective approaches to guide future planning,

development, implementation, and evaluation of policies and programs.
Prioritizing oral health issues within a community can accomplish the
following:46
• Help oral health programs decide where to target resources based on sound
evidence
• Assist underfunded and overworked agencies deal with the “crisis of the day”
created by the public, media, or legislation
• Assure the rational distribution of resources
• Raise awareness of what the public wants or sees as important
• Increase the public's understanding of the critical oral health issues
Reporting the findings of the community oral health

assessment.
After the oral health issues have been prioritized, the results of the assessment
should be presented to an intended target audience.46 This intended target audience
could be personnel of health departments or community-based clinics, oral health
and other health professionals, legislators, community leaders, members of the
media or the public, or other groups that have an interest in the outcomes. The
results can be used in program planning to improve the oral health status of the
community, advocating for changes in policies and legislation to improve the oral
health status of the community, education of the community about oral health issues,
and proposals for funding and support of future initiatives.20,21,46
The information presented to the intended target audience should address the
issues that the audience considers important and pertinent.46 This communication of
the community oral health assessment to the community allows for further input by
the community into how the results will be utilized and the critical oral health issues
that will be addressed with program planning.
It is essential to establish a plan to communicate and disseminate the findings of
the community oral health assessment.20,21 These findings should be publicized and
distributed widely to various community members, using diverse communication
channels, such as public forums, news conferences, publications, electronic media,
and social media. See Chapter 8 for contemporary strategies to promote community
oral health and communicate oral health findings. The assessment outcomes should
be communicated in a straightforward manner. To this end, it is important to
prepare an executive summary that succinctly highlights key findings.20,21
The community partners should present the findings from the data collected and
analyzed and share information about the overall assessment quest.46 Components of
a report can include a statement of the purpose, materials and methods used to
conduct the assessment, results, a discussion of the significance of the findings,
conclusions, a summary, and an abstract.20,21 The report should include the outcomes
of the inventory of community assets and resources to emphasize the availability of
resources and to note the limitations of existing resources in the community.46 It is
helpful to illustrate the findings through charts, graphs, tables, and maps (see
Chapter 7 for ways to present data). In addition, partners can provide the audience
with a frame of reference to show how the community data compare with similar
data from other local, state, or national figures.46 Also it is vital to explain the
limitations of the data.20,21,49
A detailed description of the community should be included in the report. The
data gathered can expand on the initial community overview or “snapshot” and
compile a comprehensive, detailed community profile.20,21,48,49 Community profiles
can be used to help stakeholders and funders visualize the community that was
assessed. Examples of information in a community profile are presented in Box 3-9,
and an example of a basic community profile is provided in the Opening Statement
at the beginning of the chapter.
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.
Program planning, advocacy, and education.

The intended purpose of a community oral health assessment is to utilize the data to
make plans for initiatives that can result in improving the oral health of the
community. In the process of interpreting the findings of the assessment and
communicating these to the community, the community partners can begin to
engage the community in considering solutions to the problems and issues
identified through the assessment.46 In this way, Step 6 leads naturally to the
development of an oral health improvement plan.
At this point the identified assets, gaps, needs, problems, resources, solutions, and
partnerships in the community should be considered, and community partners
should communicate the community's assets and resources to create a shared vision
of change.20,21 Greater creativity is encouraged when community partners are
engaged in building capacity to address problems and obstacles. It also helps to
promote consensus among community partners about possible long-term and short-
term solutions to address the identified oral health problems.20,21
Step 7: Evaluate the Needs Assessment

After steps 1 to 6 have been completed, there is a need to review and evaluate the
needs assessment in Step 7 (see Figure 3-10).46 The evaluation process provides the
advisory committee an opportunity to determine whether the original goals of the
needs assessment were met, decide if problems arose in the assessment process that
should be addressed in future assessments, and make improvements to the needs
assessment process for the future.
A critique of the assessment at the end of the process, which is a form of
summative evaluation, provides a record of lessons learned for future health
assessments in the community.47 Upon completion of the evaluation, the community
assessment process loops back to Step 2 to create a continual assessment process
(see arrow in Figure 3-10).46 The feedback loop provides the opportunity to use
what is learned during the evaluation to improve the assessment.47 Also this ongoing
assessment, similar to a surveillance system (see Chapter 4), is important to keep
assessment and program planning dynamic, resulting in a more effective and
sustained oral health improvement process.46
As with any community oral health practice, incorporating formative evaluation
throughout the assessment process is also important. The collaborating community
partners should continually step back to evaluate the assessment process on a
systematic basis. Allowing time for this formative evaluation along the way can
provide opportunity to implement changes that will improve the assessment results.
Multiple ways exist to collect information that can be used to assess the health,
determinants of health, and other related issues in a population, community, or
priority group within the community. Numerous resources are available that
describe methods and offer guidance for community health assessments. Use of
these resources can assist in developing a methodical approach to a community oral
health assessment. Some of these resources are available in the References and
Additional Resources at the end of this chapter.
Next Steps: Developing and Implementing an

Improvement Plan
With the published report of the assessment disseminated and the priorities
identified, it is time to move to the next phase of the community oral health
improvement process. At this stage oral health improvement strategies can be
developed to address the prioritized oral health issues outlined in the oral health
assessment. Concrete goals, objectives, policies, and programs can be planned and
implemented (see Chapter 6) based on the findings, evidence, best practices, and
priorities from the oral health assessment.20,21,42,44 A community oral health
assessment is virtually useless unless the information is used to develop and
implement evidence-based oral health strategies. Healthy People 2020 (see Chapter
4) and other resources in the References and Additional Resources in this chapter
and Chapters 4 and 5 can provide guidance in the development of an oral health
improvement plan.27,31,41,44,47
Summary
Assessment is a core public health function, and dental hygienists involved in public
health practice must be proficient in the various aspects of oral health assessment.
Assessment is an integral component of a community oral health improvement
process. Information gained from a community assessment can be used to plan,
implement, and evaluate oral health improvement strategies.
Community health assessment efforts are applied to evaluate assets, gaps,
problems, resources, solutions, and partnerships in the community. This allows a
community to assess the determinants of health, evaluate needs, quantify disparities
and inequities among population groups, and measure preventable disease, injury,
disability, and death. A systematic approach is crucial to accomplish a
comprehensive community oral health assessment. This chapter has reviewed the
key elements necessary when a community undertakes an assessment. Data
collection methods and instruments are varied, and their application depends on the
overall aims of the assessment and resources available in the community.
This chapter reviewed how epidemiology involves a multifactorial perspective to
analyze the interacting relationships among host factors, agent factors, and
environmental factors that contribute to health in populations. As information about
the determinants of oral health grows, it will be essential for dental public health
professionals to have the knowledge, values, and skills to assess oral health at
global, national, state, and local levels.
1. Select three of the following groups and situations to illustrate the determinants
of oral health, and present your results in class.
a. Dental injuries among schoolchildren in a neighborhood
b. Dental caries among adolescents in a city without

fluoridated drinking water
c. Oral cancer among older adults in a county
d. Adults without access to annual dental visits in a rural

county
e. Periodontal disease among disabled young adults in a

region of a state
f. Early childhood caries among preschool children in a state
g. Edentulism among adults in a region of the country and

comparisons between multiple states
h. Dental caries among children across nations on a global

level
2. In a small group, discuss one of the following situations, and report to class:
a. The social worker from the County Agency on Aging calls

you to discuss the dental problems of the older adults
attending local nutrition sites near your community health
center. The state health department has recently distributed
the State Oral Health Improvement Plan, which notes a
high rate of oral cancer among older men and a low rate of
dental attendance for older edentulous adults. How would
you maximize these “windows of opportunity” to initiate a
community oral health assessment? Whom would you
contact? What steps would you take? Do you think these
efforts could advance the development and implementation
of a community oral health improvement plan?
b. At a local child care conference a prominent speaker

describes the high rate of early childhood caries among
preschool children attending Head Start programs in the
city. Also during the conference, the new Director for the
Supplemental Food Program for Women, Infants, and
Children (WIC) from the local health department
highlights the need to improve the nutrition, health, and
dental education for families enrolled in WIC. After the
conference, the Community Coalition for Healthy
Children (CCHC) asks you to join as a representative of
the local component of the American Dental Hygienists'
Association. How would you maximize this opportunity to
focus on oral health and young children? Whom would
you contact? What steps would you take to initiate a
community oral health assessment? How might the CCHC
evaluate the assets, gaps, needs, problems, resources,
solutions, and partnerships within the context of your
community? How might this assessment promote the
development and implementation of a community oral
health improvement plan?
3. Perform a windshield survey (see Appendix D) of a neighborhood other than
your own to assess oral health status and problems of the people and environment
and the dental care resources in the community. Observe the oral status as far as you
can tell from interacting with individuals in the community. Assess the number of
dental care facilities, both private and public, and determine whether they are easily
accessible. Is public transportation available and easily used to reach dental care
facilities? What is the socioeconomic status of the area? Record the details of your
observation. Based on what you observed prepare a summary to report your
findings and your conclusions about the needs and resources of the community.
Gather with other classmates and compare what you discovered.
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.
competencies:

HP.4
HP.5
Evaluate factors that can be used to promote patient adherence to disease prevention
or health maintenance strategies.
CM.1
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.
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health-assessment-7-step-model/ [Accessed May 2015].
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Assessing Oral Health Needs: ASTDD Seven-Step Model.
Proven and Promising Best Practices for State and Community Oral Health
Programs.
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(OCPHP).
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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
Healthy People 2020 History and Development

Healthy People 2020 is continuing the ambitious but achievable 10-year agenda for
improving the nation's health. Healthy People 2020 is the outcome of a multiyear,
extensive collaborative process that has relied on input from a diverse collection of
individuals and organizations, both within and outside the federal government, with
a common interest in improving the nation's health.7 The Federal Interagency
Workgroup (FIW) on Healthy People 2020 oversaw and managed the development
of Healthy People 2020 using input from the Secretary of Health and Human
Services' Advisory Committee on National Health Promotion and Disease
Prevention Objectives for 2020 and other Healthy People stakeholders.7
Representatives from agencies within the DHHS served on the FIW. Federal
agencies outside of DHHS also served on the FIW in support of the Healthy People
2020 framework, which embraces the social determinants of health approach to
advanced health improvements.7,9
In addition, the Healthy People initiatives have been developed through the
involvement of the Healthy People Consortium, a public-private alliance of national
organizations and state, territorial, and tribal public health, mental health, substance
abuse, and environmental agencies.7,8 These national efforts have brought together
national, state, and local agencies; nonprofit, voluntary, and professional
organizations; businesses; communities; and individuals to focus on improvements
in the health of all Americans. Organizations with an interest in improving oral
health have participated actively in the Healthy People Consortium and advocated
for oral health to be integrated into the Healthy People initiative.
Healthy People 2020 Framework

The Healthy People 2020 framework consists of a vision statement, mission
statement, and overarching goals that provide structure and guidance for achieving
the Healthy People 2020 objectives9 (Box 4-1). The framework embraces the
determinants of health as an approach to health improvement and promotes the
integration of policies that advance health.9 Also, the framework is influenced by a
perspective of risk factors as a guide to improving health and builds on past
versions of Healthy People.7,9 Although the framework is general in nature it offers
a specific focus on important areas of emphasis in which action must be taken if the
U.S. is to achieve better health by the year 2020.
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:
• Identify nationwide health improvement priorities.
• Increase public awareness and understanding of the determinants of health,

disease, and disability and the opportunities for progress.
• Provide measurable objectives and goals that are applicable at the national, state,
and local levels.
• Engage multiple sectors to take actions to strengthen policies and improve

practices that are driven by the best available evidence and knowledge.
• Identify critical research, evaluation, and data collection needs.
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.
The Healthy People 2020 framework emphasizes a broad perspective on health,

including an ecologic and determinants approach to health promotion and disease
prevention, the use of health information technology and health communication to
improve health, and a focus on being prepared for national disasters.9 The
overarching goals of Healthy People 2020 continue the tradition of earlier Healthy
People initiatives by advocating for improvements in the health of every person in
the country.7 They address the environmental factors that contribute to collective
health and illness by calling for healthy places and supportive public policies,
placing particular emphasis on the determinants of health.9 These health
determinants include a range of personal, social, economic, and environmental
factors that determine the health status of individuals or populations and are
embedded in the social and physical environments.9
Figure 4-1 graphically displays the factors and processes involved in achieving
the overarching goals of the Healthy People 2020 framework. This figure illustrates
the emphasis of multiple determinants of health, represented by an inner circle and
four outer circles. Within the innermost circle are innate individual traits: age, sex,
race, and biologic factors related to the biology of health and disease. The second
circle represents individual behavior; the next circle represents social, family, and
community networks; and the fourth circle represents living and working
conditions. The figure defines living and working conditions as including
psychosocial factors, employment status and occupational factors, socioeconomic
status (based on income, education, and occupation), the natural and built
environments, public health services, and healthcare services. The built environment
includes transportation systems, water and sanitation systems, housing, and other
dimensions of community planning.
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.
Focus on Eliminating Health Disparities and Promoting Health

Equity
Eliminating health disparities and promoting health equity are embedded in Healthy
People 2020. Achieving these lofty goals will require actions to address all
important determinants of health disparities that can be influenced by institutional
policies and practices.7 This includes targeting disparities in health care and other
health determinants, such as living, working, social, economic, cultural, community,
and environmental conditions that affect health. Social policies related to education,
income, transportation, and housing are powerful influences on health because they
affect factors, such as the types of foods that can be purchased, the quality of the
housing and neighborhoods in which individuals can live, and access to quality
education and health care.
Figure 4-2 displays the process of eliminating health disparities and promoting
health equity. The concepts of health equity and health disparity are inseparable in
their practical application. Policies and practices aimed at promoting the goal of
health equity do not immediately eliminate all health disparities, but they can
provide a foundation for moving closer to that goal. There are a variety of
definitions of health disparity and health equity. The Advisory Committee on
National Health Promotion and Disease Prevention Objectives for 2020 (Advisory
Committee) defined these terms for the purposes of Healthy People 2020.7
FIG 4-2 The process of eliminating health disparities and promoting health equity.
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
National Health Objectives

The overarching goals of Healthy People provide general direction for
development of health objectives that can be used to track progress of population
health within the decade.7 The national health objectives developed for Healthy
People over the years have called for action to promote healthy behaviors and
healthy and safe communities; improve systems for personal health and public
health; and prevent diseases, injuries, disabilities, and disorders.5,7,8,9 To improve
health in the coming decade, Healthy People 2020 objectives also target reductions
in adverse social and physical determinants.9
Healthy People 2020 contains 42 topic areas (Box 4-2) and approximately 1200
objectives related to these topic areas.10 The Healthy People 2020 objectives were
established by a diverse group of individuals and organizations and reviewed by the
FIW on Healthy People 2020.7 The final set of Healthy People 2020 objectives were
developed with input from public comments collected at public meetings and in
writing via a public comment website.7 Also, the final national health objectives for
2020 were refined through further deliberations of the Topic Area Workgroups, the
FIW on Healthy People 2020, and the Secretary's Advisory Committee on National
Health Promotion and Disease Prevention Objectives for 2020.7
ox 4-2
B
Healthy People 2020 Topi c A reas
• Access to Health Services
• Adolescent Health*
• Arthritis, Osteoporosis, and Chronic Back Conditions
• Blood Disorders and Blood Safety*
• Cancer
• Chronic Kidney Disease
• Dementias, Including Alzheimer's Disease*
• Diabetes
• Disability and Health
• Early and Middle Childhood*
• Educational and Community-Based Programs
• Environmental Health
• Family Planning
• Food Safety
• Genomics*
• Global Health*
• Health Communication and Health Information Technology (IT)
• Health-Related Quality of Life & Well-Being*
• Health Care–Associated Infections*
• Hearing and Other Sensory or Communication Disorders
• Heart Disease and Stroke
• Human Immunodeficiency Virus (HIV)
• Immunization and Infectious Diseases
• Injury and Violence Prevention
• Lesbian, Gay, Bisexual, and Transgender Health*
• Maternal, Infant, and Child Health
• Medical Product Safety
• Mental Health and Mental Disorders
• Nutrition and Weight Status
• Occupational Safety and Health
• Older Adults*
• Oral Health
• Physical Activity
• Preparedness*
• Public Health Infrastructure
• Respiratory Diseases
• Sexually Transmitted Diseases
• Sleep Health*
• Social Determinants of Health*
• Substance Abuse
• Tobacco Use
• Vision
*Reflects new topic areas for Healthy People 2020 objectives.
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.
A smaller set of Healthy People 2020 objectives were identified as high-priority

health issues and are referred to as the Leading Health Indicators (LHI).11 The LHI,
which are presented in the Opening Statement of this chapter, are composed of 26
indicators organized in relation to 12 topic areas. As key measures for national
report cards on population health, these LHI “will be used to assess the health of the
nation, facilitate collaboration across sectors, and motivate action at the national,
state, and community levels to improve the health of the U.S. population.”11
Although not all topic areas of Healthy People 2020 are represented in the LHI, one
of the LHI represents the oral health topic area11 (Figure 4-3). Since the launch of
Healthy People 2020, there has already been improvement in 14 of the 26 indicators,
but no improvement has been demonstrated in the oral health LHI.12
FIG 4-3 Leading health indicator (LHI) representing oral health topic area. (Data from
Healthy People: Leading Health Indicators. Atlanta, GA: Centers for Disease Control and
Prevention, National Center for Health Statistics; 2015. Available at
http://www.healthypeople.gov/2020/Leading-Health-Indicators. Accessed March 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).
National Oral Health Objectives

Oral health is one of the 42 specific topic areas of Healthy People 2020.10 The
national oral health objectives have defined the nation's oral health agenda and
served as a road map for national benchmarks since the beginning of the Healthy
People initiative in the early 1980s.7 Table 4-1 summarizes the Healthy People 2020
oral health objectives. Additionally, oral health is integrated into other topic areas in
the Healthy People 2020 objectives; Table 4-2 outlines selected health objectives
from other Healthy People 2020 topic areas that relate to oral health topics.
TABLE 4-1
Healthy People 2020: National Oral Health Objectives, Including Data
Sources
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
Topic Are a: Ac c e ss to He alth Se rvic e s

• (Developmental) Increase the proportion of persons with dental insurance
• Reduce the proportion of persons who are unable to obtain or delay in obtaining necessary medical care, dental care, or prescription medicines
Topic Are a: Canc e r
• Reduce the oropharyngeal cancer death rate
Topic Are a: Tobac c o Use : He alth Syste ms Chang e s
• Increase tobacco screening in dental care settings
• Increase tobacco cessation counseling in dental care settings
Topic Are a: Diabe te s
• Increase the proportion of adults with diabetes who have at least an annual dental examination
Topic Are a: Educ ational and Community-Base d Prog rams
• (Developmental) Increase the proportion of preschool Early Head Start and Head Start programs that provide health education to prevent health problems in
the following areas: unintentional injury, violence, tobacco use and addiction, alcohol or other drug use, unhealthy dietary patterns, inadequate physical
activity, dental and oral health, and safety
• (Developmental) Increase the proportion of preschool Early Head Start and Head Start programs that provide health education to prevent health problems in
dental and oral health
Topic Are a: Olde r Adult: Pre ve ntion
• Increase the proportion of dentists with geriatric certification
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:
• A state-based oral health surveillance system contains a

core set of measures that describes the status of important
oral health conditions and behaviors. These measures serve
as benchmarks for assessing progress in achieving good
oral health.
• An oral health surveillance system communicates data and

information to responsible parties and to the public in a
timely manner.
• Data and findings from the surveillance system are used for
public health actions.
2. Efficiency:
• Data collection is managed on a periodic but regular

schedule.
• Cost-effective strategies are used in collecting, analyzing,

and communicating surveillance data.
3. Demonstrated Sustainability:
• A mature surveillance system shows several years of data

and analyzes trends.
4. Collaboration/Integration:
• Partnerships are established to leverage resources in data

collection for the surveillance system.
• Data and findings from the surveillance system are used to

integrate oral health into other health programs (see
Appendix C).
5. Objectives/Rationale:
• A state-based oral health surveillance system has a clear

purpose (i.e., why the system exists) and objectives that
specify how the data will be used for public health action.
Data from Best Practice Approach State-Based Oral Health Surveillance System. Association of State and
Territorial Dental Directors; 2011. Available at http://www.astdd.org/docs/BPASurveillanceSystem.pdf. Accessed
April 2015.
Basic Screening Survey

The ASTDD also developed the Basic Screening Survey (BSS) for basic oral health
screenings among preschool children, schoolchildren, and older adults.17 Designed
to minimize the time required and resources necessary for scoring, the BSS uses a
basic screening approach in which a tongue blade, dental mirror, and appropriate
lighting are used for visual detection via direct observation. Instruments for
detection of caries are not used.18,19 Therefore, the BSS is recommended for use in
descriptive, cross-sectional surveys for the purposes of surveillance and
assessment.18,19 The survey tools are used in state-level surveillance surveys and are
recommended for screening in local oral health programs and needs assessment for
program planning. Because it uses a basic screening approach and dichotomous
measures of the screening indicators (yes/no), the BSS does not possess the
precision normally required for use in a research setting.17
Within the BSS survey, data can be collected via questionnaire, intraoral
screening, or both.18,19 Specific variables, called screening indicators in the BSS, are
recommended for intraoral screening, and others are optional (Table 4-3).
Definitions of the criteria and validated questions for questionnaires are available in
the BSS manuals in the References at the end of this chapter.18,19 The criterion
“Urgency of need for dental care” is further defined in Table 4-4.
TABLE 4-3
Basic Screening Survey Screening Indicators
Pre sc hool Childre n Sc hoolc hildre n Olde r Adults

Re c omme nde d Indic ators
• Untreated decay • Untreated decay • Dentures and denture use
• Treated decay • Treated decay • Number of natural teeth
• One or more upper front teeth with treated and/or untreated decay (Early • Dental sealants on permanent • Untreated decay
Childhood Caries) molars* • Root fragments
• Urgency of need for dental care • Urgency of need for dental care • Need for periodontal care
• Suspicious soft tissue lesions
• Urgency of need for dental care
Optional Indic ators
• Rampant decay (seven or more teeth with untreated and/or treated decay) • Rampant decay • Functional posterior occlusal
• Number of quadrants with untreated decay (0, 1, 2, 3, 4) • Number of quadrants with untreated contacts
decay • Substantial oral debris
• Severe gingival inflammation
• Obvious tooth mobility
• Severe dry mouth
*
Sealants are now being tracked on primary molars on the NHANES using BSS protocol to monitor
progress on Healthy People 2020 sealant objective. Source: National Health and Nutrition Examination
Survey, 2009-2010 Data Documentation, Codebook, and Frequencies: Oral Health—Dentition
(OHXDEN_F). Atlanta, GA: Centers for Disease Control. Available at
http://wwwn.cdc.gov/nchs/nhanes/2009-2010/OHXDEN_F.htm. Accessed April 2015.
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.
TABLE 4-4
BSS Criteria for Urgency of Need for Dental Care
Re c omme ndation for Ne xt

Cate g ory Crite ria
De ntal Visit
Urgent need for As soon as possible Signs or symptoms that include pain, infection, or swelling
dental care
Early dental care Within several weeks Caries without accompanying signs or symptoms or individuals with other oral health problems
needed requiring care before their next routine dental visit
No obvious Next regular checkup Any patient without previously mentioned problems
problems
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
Association of State and Territorial Dental Directors; 2010. Available at http://www.prevmed.org/wp-
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
National Oral Health Surveillance System

A surveillance system provides the functional capacity for data collection and
analysis, as well as the timely dissemination of information derived from these data
to persons who can undertake effective prevention and control activities.14 The
National Oral Health Surveillance System (NOHSS) is an important system of oral
health data sources used for the purpose of surveillance. It was established by and
operates through a collaborative effort between the CDC Division of Oral Health
(DOH) and the ASTDD.20 The NOHSS is designed to monitor the burden of oral
disease, use of the oral healthcare delivery system, and the status of community
water fluoridation on both a national and state level. The purpose of the NOHSS is
to track oral health surveillance indicators based on data sources and surveillance
capacity available to most states.20
The NOHSS is under continual revision to provide the best data available for
decision making. A functioning state oral health surveillance system is central to
enabling states to submit data for inclusion in the NOHSS.16 At the same time, the
submission of data by states for inclusion in the NOHSS is imperative to provide a
complete national picture and to enable comparisons among states.21
The NOHSS was developed to track basic oral health indicators, including a
minimal set of standard oral health indicators.20 These oral health indicators are
evaluated and revised as the need arises.16 The last oral health indicators lined up
with the Healthy People 2010 oral health objectives20 (Table 4-5). In 2012 a new set
of oral health indicators was approved by the Council of State and Territorial
Epidemiologists16,21 (Table 4-6). These new indicators were developed to line up
with the expanded Healthy People 2020 oral health objectives. The new indicators
take into consideration the availability of new state-level and national electronic data
sources and an improved understanding of the conceptual framework for
surveillance systems.16 According to the CSTE,21 these recent revisions and
additions to the oral health indicators will provide several improvements: (1) more
information for program planning, (2) increased ability to evaluate the impact of
interventions designed to improve access to oral health preventive and treatment
interventions, and (3) enhanced monitoring of the oral health status of the most
vulnerable populations in each state.21
TABLE 4-5
Oral Health Indicators in National Oral Health Surveillance System
(NOHSS), 2010
Oral He alth Indic ator Asse ssme nt Me asure

Dental Visit Adults aged 18+ who have visited a dentist or dental clinic in the past year
Teeth Cleaning Adults aged 18+ who have had their teeth cleaned in the past year (among adults with natural teeth who have ever visited
a dentist or dental clinic)
Complete Tooth Loss Adults aged 65+ who have lost all of their natural teeth because of tooth decay or gum disease
Lost Six or More Teeth Adults aged 65+ who have lost six or more teeth because of tooth decay or gum disease
Fluoridation Status Percentage of people served by public water systems who receive fluoridated water
Caries Experience Percentage of third grade students with caries experience, including treated and untreated tooth decay
Untreated Tooth Decay Percentage of third grade students with untreated tooth decay
Dental Sealants Percentage of third grade students with dental sealants on at least one permanent molar tooth
Cancer of the Oral Cavity and Incidence and mortality rates for oral and pharyngeal cancers
Pharynx
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
Indic ator Data Sourc e

Oral He alth Outc ome s
Prevalence of caries experience (Head Start, Basic Screening Survey (BSS)—ASTDD program
kindergarten, third grade)
Prevalence of untreated tooth decay (Head Start, BSS
kindergarten, third grade, vulnerable older adults)—
coronal and root caries
Percentage of population with dental treatment needs BSS
(Head Start, kindergarten, third grade, vulnerable older
adults)
Tooth loss (complete tooth loss ≥65 years, loss of six Behavioral Risk Factor Surveillance System (BRFSS)—U.S. Centers for Disease Control and
or more teeth ≥65 years) Prevention (CDC) data source
Oral and pharyngeal cancer (incidence and mortality) U.S. Cancer Statistics (USCS); Surveillance, Epidemiology, and End Results Program (SEER);
National Program of Cancer Registries (NPCR); National Vital Statistics System (NVSS)—all CDC
data sources
Ac c e ss to Oral He alth Care
Dental visit in past year (1–17 years old, ≥18 years BRFSS; National Survey of Children's Health (NSCH), Health Resources and Services
old, Federally Qualified Health Center (FQHC) patients, Administration (HRSA) Uniform Data Set—Data Resource Center data source; U.S. Department of
adults with diabetes) Health and Human Services (DHHS)
Percentage of population with a preventive dental visit Centers for Medicare & Medicaid (CMS) 416 report: Medicaid Early and Periodic, Screening,
in the past year (Medicaid and Children's Health Diagnosis and Treatment (EPSDT) Utiliz ation; CMS CHIP Annual Reporting Template System
Insurance Program [CHIP]–enrolled children) (CARTS)—Maternal and Child Health Bureau; Executive Office of the President
Percentage of population with dental sealants (third BSS; CMS 416 report: Medicaid EPSDT Utiliz ation
grade, Medicaid-enrolled children ages 6–9 years and
10–14 years)
Percentage of population with a dental treatment visit CMS 416 report: Medicaid EPSDT Utiliz ation; CMS CARTS
in the past year (Medicaid- and CHIP-enrolled children)
Teeth cleaning (≥18 years, pregnant women) BRFSS; Pregnancy Risk Assessment Monitoring System (PRAMS)—both CDC data sources
Inte rve ntion Strate g ie s
Water fluoridation Water Fluoridation Reporting System (WFRS)—CDC data source
Percentage of school-based health centers that provide National Assembly for School-Based Health Care
sealants, dental treatment services, and topical fluoride
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.
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:
1. Information of interest (e.g., types of conditions and factors to be assessed)
2. Social and demographic factors of the population and community
3. Purpose of the assessment (e.g., surveillance, needs assessment)
Common nonclinical measures include face-to-face personal interviews,

telephone interviews, a self-administered questionnaire, and a computer-assisted
personal interview, although other nonclinical methods can be used to assess
different factors influencing oral health16 (see Appendix D). Topics of oral health
questions that can be used in oral health surveys for assessment and surveillance are
outlined in Appendix E.
Clinical methods used for assessment and surveillance include basic screenings
and epidemiologic examinations.15,18,19,25 Basic screenings involve the use of direct
observation to visually detect and identify gross dental and oral lesions in the oral
cavity with a tongue blade, a dental mirror, and appropriate lighting.18,19 On the
other hand, an epidemiologic examination entails the use of detailed visual-tactile
assessment of the oral cavity with dental instruments and a light source.24,26 Basic
screenings and epidemiologic examinations do not constitute a thorough clinical
examination,18 and they do not involve making a clinical diagnosis that would result
in a treatment plan. The basic screening approach is generally not appropriate for
research; more precise measures are required for clinical trials.17 Various oral
conditions and related factors can be assessed via basic screenings and
epidemiologic examinations18,19 (see Appendix E).
Frequently, a dental index is used for measurement during an epidemiologic
examination. A dental index is an abbreviated measurement of the amount or
condition of oral disease or related condition in a population.24,27 An index is based
on a graduated numeric scale with defined upper and lower limits. It is an aid in data
collection, allowing for comparisons among population groups that are classified
by the same criteria and methods. Thus, dental indexes, also called dental indices,
can be used to assess oral diseases and conditions in oral health surveys and are
frequently used also to measure variables in clinical trials (see Chapter 7).
When planning data collection with a dental index, it is critical to select an
appropriate index24 (Table 4-7). Appendix F is a resource of common dental indexes
for use in epidemiologic examinations of clinical measures. These indexes can be
used for either assessment or research purposes.24,27 Dental indexes are used also
for surveillance, although currently the basic screening approach is used for
surveillance in many cases.
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.
Regardless of whether clinical or nonclinical data are required, community oral

health assessment involves the use of surveys. Surveys are descriptive and cross-
sectional in that they allow for oral health determinants to be ascertained and oral
health status to be estimated for a defined population at a point in time24,28 (see
Chapter 7 for more details about research methods).
Types of Measurements
This section describes specific dental indices and measurements used to assess the
various diseases and conditions of interest, as well as specific factors that relate to
oral health. Table 4-1 lists the data sources used to track progress on the Healthy
People 2020 objectives, and Table 4-6 summarizes the data sources, surveys, and
surveillance systems that are being used to monitor and report data for the oral
diseases and conditions represented by the NOHSS oral health indicators. The
measurements described in this section are used to generate the data within the data
sources. Review of Table 4-1, Table 4-6, and Appendix D in conjunction with
reading this section of the chapter will enhance the reader's understanding of the
measurements in relation to assessment, surveillance, the NOHSS, and Healthy
People 2020 oral health objectives. Also, resources in the References and Additional
Resources at the end of the chapter can be used to locate supplementary information
on the various measurements used to assess the oral diseases and conditions and
related factors that are highlighted here.
Measurements of Dental Caries

Dental caries (i.e., tooth decay) results in demineralization and ultimately cavitation
of the tooth surface unless the process is controlled and the tooth is remineralized.29
Dental caries can occur in primary or permanent teeth. General types of tooth decay
include coronal (i.e., occurring on the crowns of teeth) and root surface (i.e.,
occurring on the roots of teeth). All of these characteristics have significance in
relation to the various measurements of dental caries.
Coronal Dental Caries

In surveys of populations, coronal caries can be assessed by a systematic evaluation
through epidemiologic examination or screening procedures.24 The best known and
most widely used index to measure coronal caries is the Decayed, Missing, or
Filled Index.24,27,30 Recorded by an oral epidemiologic examination, this index is
used to measure past and present coronal caries experience of a population on
permanent teeth (DMFT) or surfaces (DMFS), as well as on primary teeth or
surfaces (dmf, df, or def). Each tooth space (T) or surface (S) is scored as sound,
diseased, restored, or missing because of caries. The DMF is considered
irreversible because it indicates the cumulative, lifetime caries experience. Scoring
criteria for the DMF are presented in Appendix F. Examples of applying DMF
results to decision making in relation to program planning are described in Box 4-
4.
ox 4-4
B
A ppl i cati on of Decay ed, Mi ssi ng , and Fi l l ed
(DMF) Resul ts i n Rel ati on to Communi ty
Prog ram Pl anni ng
Assessment
DMF survey results can be used to prioritize community programming needs by
considering the total DMF score for the population in combination with the scores
within each category. For example, a high DMF signifies a high level of caries
experience, indicating a need to develop programs to prevent and control caries in
the population. However, to determine which specific programs are priorities, the
D and M components must be analyzed. A high D demonstrates a need for dental
treatment, and a high F indicates that the population is receiving treatment. A high
M indicates the need for education and earlier intervention to avoid additional
extractions in the future.
Program Evaluation
DMF scoring can be repeated for a comparison of outcomes data with baseline
data, providing a measure of program success or failure. For example, a reduction
of the D component along with an increase in the F component indicates that the
population is benefiting from dental treatment. On the other hand, a marked
increase in the D component indicates failure of caries prevention.
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.
• Untreated decay is generally detected by visual inspection only; explorers are

usually not used.
• 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.
*Also see Tables 4-3 and 4-4.
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
Association of State & Territorial Dental Directors; 2010. Available at http://www.prevmed.org/wp-
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.)
Additional measurements of dental caries have been developed to reflect

treatment needs and to provide a broader profile of the impact of dental caries in
population groups.31 For example, the Restorations and Tooth Conditions
Assessment (RTCA) was created to supplement the DMF index in the NHANES III in
1988 to 1991.31 The RTCA characterizes the prevalence and severity of physical and
biologic conditions that result from dental caries. These complex indices have not
been used for surveillance purposes on a regular basis.22
Early childhood caries.

For preschool-age children, a more detailed reporting of dental caries can be
accomplished with the Early Childhood Caries (ECC) Classification system. This
system consists of case definitions based on the number of dmf surfaces and age of
the child,27 as described in Appendix F. The dental caries classified as ECC can be
assessed with an epidemiologic examination or the basic screening approach,
depending on the purpose of the assessment and the precision required in the
resulting data.
Missing anterior teeth in preschool children can be a result of caries or traumatic
injury. Therefore, the cause of missing anterior teeth should be identified by
questioning the parent or guardian, if present during the screening. An alternative is
to include a question on the consent form.18
Root Surface Caries

Basic screening and epidemiologic examinations can be used to assess the
occurrence of root surface caries in oral health surveys.22 The BSS is used to screen
older adults for root caries using dichotomous scoring on a per-person basis.19
Although not one of the screening indicators of the BSS, root caries is considered
along with coronal caries in scoring untreated decay in older adults (Table 4-3). In
addition, BSS scoring can be adapted to score root caries and coronal caries
separately. A similar dichotomous scale for assessing root caries with an intraoral
epidemiologic examination was applied in the 2013–2014 NHANES.22 Similar to the
BSS, with this approach the survey participant's whole mouth is scored by the
examiner for the following variables:
• Root caries detected/root caries not detected/cannot be assessed
• Root restoration detected/root restoration not detected/cannot be assessed
The Root Caries Index (RCI) is a common index that can be used to score root
caries in a survey with an epidemiologic examination when more precise data are
required.27 Cavitated root carious lesions are scored on each surface. Details of
scoring criteria can be found in Appendix F. The measurement of root surface
caries in populations with the RCI is generally based on the proportion of root
surfaces that are decayed or filled, in relation to the number of surfaces that are
present in the mouth and at risk for dental caries, including subgingival root
surfaces.24
Future Directions for Assessing Dental Caries

Even though major improvements are shown in the oral health of the nation, new
concerns have emerged over the past decade regarding an increase in caries in
children ages 3 to 9 years and about the lack of improvement of the dental caries
status of vulnerable population groups.8,32 Thus, oral epidemiologists have
suggested the use of evidence-based approaches to better detect, assess, diagnose,
prevent, and monitor dental caries.32 Discussions are emerging about case
definitions, diagnostic criteria, and stages of progression related to dental caries in
clinical practice, clinical research, and population-based assessments.32
Because of the dichotomous scale used by dental caries measurements (presence
or absence of caries), assessment of the severity of caries in oral health surveys has
been limited generally to the number of teeth or surfaces involved. For example,
with the DMF the severity of caries is indicated by the number of teeth or surfaces
scored; the higher the number, the more severe the caries experience.24 Thus,
although the DMF index has been used extensively in oral health surveys for over
70 years, it is limited in its ability to measure thoroughly the characteristics of
dental caries and the severity of lesions.24,30 As patterns of dental caries change,
technology develops, and the goals of oral health surveys shift toward more
situational analyses in communities, different approaches for the measurement of
dental caries may emerge.24,33
In light of these points, the International Caries Detection and Assessment System
(ICDAS) was developed in an attempt to provide better quality information to
inform decisions about appropriate diagnosis, prognosis, and clinical management
at both the individual and public health levels.24,34 The ICDAS assesses coronal and
root surfaces with extended diagnostic criteria and definitions to evaluate specific
stages of dental caries progression by including enamel carious lesions and dentinal
carious lesions.24,34 The system is designed to evaluate changes in the stages of the
caries processes, integrate assessments of risks, measure caries activity (e.g.,
progressing, arrested, or regressing), and link with oral healthcare options.34
Findings from assessments integrating ICDAS in population surveys could provide
greater details about caries and be useful in monitoring dental caries to target
prevention programs at the earliest stages of dental caries progression for
individuals, groups, and communities.24,34
Measurement of Oral Health Treatment Needs

Findings of treatment needs can be useful for planning and monitoring purposes.
They can be helpful in estimating personnel and service requirements, with demand
levels for these services taken into consideration. However, assessing treatment
needs can be problematic. In a population-based survey, it is challenging to
standardize clinical judgments for the most appropriate treatment required based on
the treatment needs of the average person in the community. For example, when a
tooth is scored for treatment need in an oral health survey, the examiner can record
the need for a sealant or other preventive and caries-arresting care.25 This
assessment can be difficult because criteria for dental sealant need and caries-
arresting care have not been standardized for oral epidemiologic surveys.
Even so, summary assessments that record overall need for oral health care (e.g.,
treatment urgency) are used in oral health surveys. As previously explained, with the
BSS the proportion of the population with untreated dental caries is reported as a
measure of population treatment needs.18,19 In addition, the BSS includes an
assessment of treatment urgency for each survey participant to determine the need
and the urgency of the need for referral for oral health care. This referral is a
necessary component of assessment and screening and is an ethical obligation when
the need for dental care is observed (see Tables 4-3 and 4-4).
Another system for determining treatment needs comes from the World Health
Organization (WHO). Population-based surveys that apply the WHO Oral Health
Surveys: Basic Methods are used to assess a population's current oral health status
and predict future needs.25,35 This survey method includes an appraisal of status on
several major oral diseases and conditions along with an evaluation of the need for
intervention. The results of the community assessment are used to determine the
extent to which oral health programs match the needs of the population, and the
nature and urgency of oral health interventions that may be needed for disease
prevention and health promotion.25,35 Assessment categories include the following:25
• Dentition status: basic screening
• Periodontal status: Community Periodontal Index (CPI) (see Appendix F)
• Loss of attachment: CPI
• Enamel fluorosis: Dean's Fluorosis Index (see Appendix F)
• Dental erosion
• Traumatic dental injuries
• Oral mucosal lesions
• Denture status
• Intervention urgency
For each person examined, the clinical examination includes an assessment of
evident dental caries, periodontal disease, and abnormalities of the tissues of the
head and neck.25 Determination of intervention urgency is based on this assessment.
The BSS18,19 and the WHO25 system both classify the urgency of treatment needs,
as does the NHANES.22 These classification systems differ in the number of
categories with slight variations in definitions. They are contrasted in Box 4-6 to
provide better understanding of how these various systems classify treatment needs.
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)
Measurement of Dental Sealants

Dental sealants are traditionally assessed in populations through a basic screening
or epidemiologic examination procedure (Figure 4-6).15,18,22,25 Tooth surfaces and
teeth can be evaluated for the presence or absence of dental sealants in the pits and
fissures of erupted primary or permanent teeth. See Box 4-7 for BSS scoring
criteria related to dental sealants.
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
• On a permanent molar in 6- to 9-year-olds
• On a permanent molar in 13- to 15-year-olds

• A sealant is scored whether it covers all or part of the pits or fissures or is
partially lost.
*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
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
Measurement of Periodontal Disease

The term periodontal disease represents a group of closely related different
diseases with similar presentation rather than a single disease entity.24 Measurement
of periodontal disease in the U.S. population involves assessment of gingivitis and
mild to moderate periodontitis, based on the signs and symptoms of each disease.22
Gingivitis
Gingivitis is characterized by localized inflammation, swelling, and bleeding of the
soft tissues surrounding a tooth; it does not involve loss of connective tissue or
bone support.37 The BSS includes an optional indicator of severe gingival
inflammation, measured on a dichotomous scale (yes/no) and based on the
following definition of severe gingival inflammation: “marked redness and edema,
ulceration, tendency to spontaneous bleeding.”19 Population measurement of
gingivitis on the NHANES was accomplished by measuring bleeding on the 2003–
2004 survey.36 This measurement was based on the Healthy People 2010 definition
of bleeding as the presence of at least one bleeding site.8 However, the NHANES
methodology for assessing gingival bleeding used at the baseline for Healthy
People 2010 was modified over the course of the decade, and a new definition had
not been defined by the time Healthy People 2020 launched. Therefore, an objective
for gingivitis was not included in Healthy People 2020,8 and thus assessment of
bleeding has not been included in recent NHANES surveys.22
The Community Periodontal Index (CPI) was developed by the WHO to assess
periodontal status and included in their Oral Health Surveys: Basic Methods
manual.25 The CPI is used for community surveillance (see Appendix F), and
bleeding is one component. The CPI criteria describe its scoring on a specific tooth
in each sextant.27 However, the WHO survey methods include scoring of bleeding
around all teeth in the process of probing to determine clinical attachment loss
(CAL).25
When more precision is required, bleeding indices with extended diagnostic
criteria are available to measure severity of bleeding on an ordinal scale.27 Three
common bleeding indices are the Sulcus Bleeding Index (SBI), the Gingival
Bleeding Index (GBI), and the Eastman Interdental Bleeding Index (EIBI). Each
has different criteria and different uses, from simple assessment to collection of
data for clinical research (see Appendix F). In addition, the Gingival Index (GI) is a
core dental index that can be used to assess swelling, color, and consistency in
addition to bleeding. The original GI has been modified as the Modified Gingival
Index (MGI), eliminating the probing requirement to avoid potential trauma and to
increase reliability.24 The criteria for these indexes are described in Appendix F.
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.
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
• Tooth #9: Left maxillary central incisor

• Tooth #12: Left maxillary first premolar (bicuspid)
• Tooth #19: Left mandibular first molar
• Tooth #25: Right mandibular central incisor
• Tooth #28: Right mandibular first premolar (bicuspid)
Data from Chattopadhyay A. Oral Health Epidemiology: Principles and Practice. Sudbury, MA: Jones and
Bartlett; 2011.
Because of the association of periodontal disease with systemic diseases, there is

a greater focus on an interprofessional collaborative approach to the provision of
oral healthcare services (see Chapter 2). In response to the need to consider this
oral-systemic link in oral healthcare practice, a Healthy People 2020 oral health
objective was added in relation to dentists or dental hygienists testing or referring
patients for glycemic control. The following question has been added to the 2013–
2014 NHANES to track progress on this objective:36
• In the past 12 months, did a dentist, hygienist, or other dental professional have a
direct conversation with you about the dental health benefits of checking your
blood sugar?
This objective will be measured through the Annual Synopses of State and
Territorial Dental Public Health Programs routinely prepared by the ASTDD.32
Future directions for assessing periodontal disease.

Current methods of periodontal disease surveillance in the population have
traditionally required clinically based periodontal examinations, which are resource
intensive and costly.24,39 As a result of funding reductions, the NHANES eliminated
the clinical periodontal assessment from some of the surveys in the past decade.24
Also, although public health activities are designed to target state and local
populations, existing state and local oral health surveillance systems do not have the
resources required to support collection of clinical data for periodontal disease
surveillance.16,39 Thus, the capacity to monitor the disease at the population level has
been restricted.
In light of these considerations, in 2003 the CDC/DOH collaborated with the AAP
to form the CDC Periodontal Disease Surveillance Project. The purpose of this
ongoing workgroup is to explore alternative methods for monitoring periodontitis
that can have broader application at the population level.40 A major focus of this
workgroup has been to examine the feasibility of using self-reported measures for
population-based surveillance of periodontal disease.40
This collaborative effort has made significant advancements toward the goal of
improved surveillance of periodontal disease in the U.S., including developing valid
self-report measures that can be obtained from interview-based surveys to predict
prevalence of periodontitis in populations. After an extensive literature review that
suggested the potential for this method of surveillance of periodontal disease, self-
report oral health questions were developed and included in the 2009–2010
NHANES to test them for validity.24,36,39 The self-reported measures performed well
in predicting periodontitis, and the workgroup concluded that where preferred
clinically based surveillance is unattainable, locally adapted variations of these self-
reported measures may be a promising alternative for surveillance of
periodontitis.39 The use of self-reported measures to assess periodontal disease is
expected to impact the future of periodontal disease surveillance because it will
allow surveillance of periodontitis at the state and local levels and in countries
where clinical resources for surveillance are scarce.40 These self-report questions
were included again on the NHANES in 2011–2012 and 2013–2014; they are listed
in Box 4-9.22,36
ox 4-9
B
Sel f-Report Questi ons Rel ated to Peri odontal
H eal th and Di sease, N H A N ES, 2013–2014
Q1. Do you think you might have gum disease?
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.)
Measurement of Tooth Loss

Complete tooth loss reflects no remaining teeth regardless of the cause of the loss.25
Loss of all natural teeth is referred to as edentulism or being edentulous.19 An
individual with at least one natural tooth is considered dentate. Tooth retention is the
presence of a tooth in the mouth; the term is used to refer to the retention of some
or all teeth.25 For example, if 10 teeth are lost, 22 teeth are retained.
Tooth retention and tooth loss can be measured in oral health surveys. The
number and types of teeth retained by the individual can be assessed by scoring each
tooth space as present or absent.22,25 These data can be used to indicate tooth loss at
the tooth level, arch level, or individual level for population studies. Assessment of
tooth loss can be made in the primary or permanent dentition. However, the missing
primary tooth should be scored only in an age group in which tooth absence would
not be a result of normal exfoliation. Missing teeth can be assessed also according
to cause of loss (e.g., caries, periodontal disease, trauma, congenital absence, or
orthodontia).22,25 However, determining the exact cause of tooth loss is difficult and
can be problematic for a dental examiner.
It is recommended that tooth loss be measured in older adults using a basic
screening approach.19,25 The BSS for older adults includes assessment of edentulism
on a per-person basis. In addition, the BSS criteria describe a simple count of the
number of teeth present in each arch to determine partial tooth loss.19 In the U.S.
complete tooth loss status has been assessed also by self-report with face-to-face
and telephone interviews.41,42 Tooth loss was assessed in 2014 via the BRFSS
telephone interview with a single question.41 In addition, the NHIS included a
question related to edentulism in 2014.42 Both questions are presented in Box 4-10. A
combination of the BSS screening and interview questions is adequate to track
progress of partial and complete tooth loss in relation to the Healthy People 2020
objective and NOHSS oral health indicator.
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.
Measurement of Oral and Pharyngeal Cancer

Several epidemiologic characteristics of oral and pharyngeal cancer (OPC) are
important to a discussion of its surveillance and measurement:24
• OPC is considered to be a sizable problem that primarily affects older people.
• A significant racial/ethnic disparity exists in relation to the burden and outcomes
of OPC.
• A significant delay occurs between the clinical presentation of OPC and final
diagnosis.
• The worldwide 5-year survival rate of OPC is less than 50%.
• The complications of OPC and its therapy have a major psychosocial and
economic impact on patients with cancer, their families, and society.
Together the CDC National Program of Cancer Registries and the NIH National
Cancer Institute's Surveillance, Epidemiology and End Results (SEER) Program
collect data for the entire U.S. population on OPC occurrence, including the type,
extent, and location of the cancer.43,44 This national coverage enables researchers,
clinicians, policymakers, public health professionals, and members of the public to
monitor the burden of OPC, evaluate the success of programs, and identify
additional needs for OPC prevention and control efforts at national, state, and local
levels.43
Data to measure the number of deaths resulting from OPC are obtained from
death certificates collected through the National Vital Statistics System within the
CDC National Center for Health Statistics (NCHS)45; such data are available at the
state and local levels.24 This measure is based on the number of deaths resulting
from OPC per 100,000 people attributed to cancers that are classified in the 10th
edition of the International Classification of Diseases (ICD-10), sponsored by the
WHO.46 The ICD-10 is used to define the measurement of OPC for the Healthy
People 2020 cancer topic area objective to reduce the OPC death rate.10 OPC
includes cancers of the lip, tongue, buccal mucosa, floor of the mouth, pharynx,
parotid gland, tonsil, nasal cavity, and sinus.46
Also tracked is the proportion of OPC lesions diagnosed at the earliest stage (e.g.,
stage 1, localized; see Appendix F for details of stages),8 which is associated with an
increased survival rate.47 The stage of diagnosis is collected through state cancer
registries and SEER.44 Specific factors related to population groups (e.g., age,
gender, race, or ethnicity) are often identified in assessments of OPC in
populations.44
A strategy to increase the diagnosis of OPC at the earliest stage is to increase the
occurrence of oral cancer screening by oral health professionals.24 Because the
proportion of OPC diagnosed in the earliest stage dropped during 2000 to 2010,8 a
Healthy People 2020 objective was selected to increase oral cancer screening.32 The
receipt of an examination to detect OPC has been assessed using a self-report
method. Five questions on the 2013–2014 NHANES interview of adults 18 years and
older were used to track examination for oral cancer.36 Also, the questionnaire
portion of the BSS for older adults includes a self-report question on oral cancer
screening.19 The NHANES and BSS questions are presented in Box 4-11.
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.
Use of Tobacco in Relation to Oral and Pharyngeal Cancer

Tobacco in all forms is the biggest risk factor for OPC, placing extreme importance
on efforts to reduce the use of tobacco products.24 An important approach to help
accomplish this is the provision of tobacco counseling by health professionals.
Studies have shown that such counseling by oral health professionals can be
enhanced by increasing their skills and confidence related to asking sensitively
about smoking, providing them opportunity to build rapport with patients,
incorporating smoking status into general history taking, and adopting
organizational policies related to assisting patients to quit smoking.48,49
One of the Healthy People 2020 oral health objectives is to increase the
proportion of adults who receive information from a dentist or dental hygienist
focused on reducing tobacco use or on smoking cessation.32 To track this objective
the following question was included on the 2013–2014 NHANES questionnaire:36
• In the past 12 months, did a dentist, hygienist, or other dental professional have a
direct conversation with you about the benefits of giving up cigarettes or other
types of tobacco to improve your dental health?
Having a strong tobacco surveillance system enables a country to build an
effective program that can address tobacco issues and reduce the use of tobacco
significantly.50 To assist other countries with these efforts, the CDC collaborated
with the WHO and the Canadian Public Health Association to develop the Global
Tobacco Surveillance System (GTSS) for the WHO Tobacco Free Initiative.50
Through this surveillance system, the WHO is collecting data on the prevalence of
tobacco use and related factors, which are made available globally. The GTSS also
supports the tobacco surveillance efforts of other countries by making available
questionnaires that can be used by countries and communities for tobacco
surveillance, to which they can add their own country- or community-specific
questions. Also available are resources for tobacco prevention and control
programs. The intended result of these surveillance efforts is to enhance the
capacity of countries to design, implement, and evaluate their national
comprehensive tobacco action plans and to monitor their efforts related to tobacco
control.50 Box 4-12 presents a description of tobacco surveillance questionnaires
that are part of the GTSS.
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
• 56 core questions designed to gather data on the following

seven domains:
• Knowledge and attitudes of young people toward cigarette
smoking
• Prevalence of cigarette smoking and other tobacco use

among young people
• Role of the media and advertising in young people's use of

cigarettes
• Access to cigarettes
• Tobacco-related school curriculum
• Environmental tobacco smoke
• Cessation of cigarette smoking

• Global School Professionals Survey (GSPS)—survey for teachers and
administrators from the same schools that participate in the GYTS
• Collects information on tobacco use
• Determines school personnel knowledge of and attitudes

toward tobacco
• Evaluates existence and effectiveness of tobacco control

policies in schools
• Provides training and materials to implement tobacco

prevention and control interventions
• Global Health Professions Students Survey (GHPSS)—survey for use with third-
year students pursuing degrees in dentistry, medicine, nursing, and pharmacology
• Core questions over the following:
• Demographics
• Prevalence of cigarette smoking and other tobacco use
• Knowledge and attitudes about tobacco use
• Exposure to second-hand tobacco smoke
• Willingness to stop smoking
• Training received regarding patient counseling on smoking

cessation techniques
• Global Adult Tobacco Survey (GATS)—a household survey to monitor tobacco
use among adults (15 years and older)
• Has been implemented in more than 19 low- and middle-

income countries with the highest burden of tobacco use
• Topics included in GATS questions:
• Tobacco use prevalence (smoking and smokeless tobacco

products)
• Second-hand tobacco smoke exposure and policies

• Tobacco cessation
• Knowledge, attitudes, and perceptions
• Exposure to media
• Economics
• Example subset of key questions from the GATS:
• Current Smokeless Tobacco Use: Do you currently use

smokeless tobacco on a daily basis, less than daily, or not
at all?
• Past Daily Smokeless Tobacco Use: Have you used

smokeless tobacco daily in the past? (yes, no, or don't
know)
• Past Smokeless Tobacco Use: In the past, have you used

smokeless tobacco on a daily basis, less than daily, or not
at all?
Data from Tobacco Free Initiative (TFI). Surveillance and Monitoring: Survey. Geneva: World Health
Organization; 2015. Available at http://www.who.int/tobacco/surveillance/survey/en/. Accessed May 2015.
Measurement of Other Oral and Craniofacial

Diseases, Conditions, and Injuries
Some less common oral diseases and conditions are not routinely represented in
oral health surveillance, the Healthy People 2020 objectives, or the NOHSS oral
health indicators. Even so, conditions, such as orofacial clefts (cleft lip and cleft
palate), malocclusion, orofacial pain and temporomandibular disorders, orofacial
injuries and tooth trauma, xerostomia, and tooth wear can adversely affect overall
and oral health and impact quality of life. In addition, failure or inability to use
dentures when indicated can be detrimental to health and quality of life. This section
will provide an overview of some of these conditions in relation to oral health
surveillance.
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
Orofacial Injuries and Tooth Trauma

Measurement of orofacial injuries and tooth trauma can be incorporated into oral
health surveillance. Tooth trauma has been assessed in specific-aged children and
adults on past NHANES by questioning individuals in the sample about a history of
tooth trauma and by examining the eight permanent incisors.36
Orofacial Pain and Temporomandibular Disorders

A temporomandibular joint (TMJ) assessment is included in the WHO basic oral
health survey guide.25 The guide suggests an epidemiologic examination to evaluate
signs, such as the occurrence of clicking, tenderness on palpation, and reduced jaw
mobility on opening greater than 30 mm. The additional use of survey questions is
suggested also to assess this condition.
General oral pain unrelated to TMJ has been assessed as well. Past NHANES have
included an orofacial pain examination and a questionnaire to assess the frequency
of experiences in the past 30 days with specific types of orofacial pain in addition to
TMJ, including toothache; sores or irritations; dull, aching pain across the face; and
burning sensations in the mouth.36 Positive responses to questions about orofacial
pain led to quality-of-life questions to assess worry or concerns about the pain
sensations and days lost to usual activities of daily life (e.g., work, school, self-care,
and recreation) because of orofacial pain (see later section for discussion of oral
health–related quality of life). The questionnaire used in the 2013–2014 NHANES
included a basic assessment of pain with the following single question:36
• How often during the last year have you had painful aching anywhere in your
mouth?
Tooth Wear and Erosion

The NHANES included a measurement of dental tooth wear and erosion on the
2003–2004 surveys to assess the prevalence of the condition across the lifespan
among varied population groups aged 13 years and older.36 The purpose of this
assessment was to discern if health disparities existed nationally in relation to tooth
wear and erosion. An epidemiologic examination of tooth wear and erosion was
accomplished with a standard index. In addition, variables, such as dietary factors,
medications, health conditions, and demographics were included in the assessment
for analysis of related factors.36
Measurement of Dental Fluorosis

Dean's Fluorosis Index, described in its final and current form in 1942, is the
conventional system used to assess for dental fluorosis.27 Later, numbers were added
to assign scores to the classifications for the purposes of research, resulting in the
Community Fluorosis Index (CFI).51 This index is one of the most universally
accepted classifications for dental fluorosis, and other fluorosis indices are based
on it.24 Although less sensitive than some other fluorosis indexes, it is still
recommended for use in community studies.27 Criteria for scoring the CFI can be
found in Appendix F. The individual's fluorosis score is based on the most severe
form of fluorosis found on two or more teeth.27 Community levels of fluorosis are
indicated by the proportion of survey participants that receive scores in each
category.27
The CFI scores, as originally established, ranged from 0 to 4, with a smaller
score differential from the normal to mild categories51 (see Appendix F). However,
it is frequently applied today as a range of 0 to 5, with equal differences of scores
among the classifications.27 Dean's CFI is included in the WHO basic oral health
survey methods.25
Dean's Fluorosis Index and scoring criteria have been slightly modified for the
NHANES to include scoring of nonfluoride opacities.22 Differentiation of mild
fluorosis from nonfluoride opacities is difficult to distinguish. It has been suggested
that this situation could have led to fluorosis misclassification, which may have
resulted in inflation of fluorosis prevalence.24 The greater awareness of fluorosis
issues and the sensitive political nature of water fluoridation could increase such a
measurement error.24 Table 4-8 describes how to differentiate mild fluorosis from
nonfluoride opacities.24
TABLE 4-8
Enamel Opacities: Differential Diagnosis
Charac te ristic Mild Fluorosis Nonfluoride Opac itie s

Area affected Usually seen on or near cusp tips or incisal edges Usually centered in smooth surface; may involve entire
crown
Shape of lesion Irregular shape; form irregular caps on cusps Often round or oval
Demarcation Shades off imperceptibly into surrounding enamel Clearly differentiated from adjacent normal enamel
Color Slightly more opaque than normal enamel; paper-white areas; cusp tips may Usually pigmented at time of eruption; often creamy-
appear frosted; no staining yellow to dark reddish orange
Teeth affected Most frequently affects teeth that calcify slowly (cuspids, bicuspids, second and Any tooth affected; frequent on labial surfaces of lower
third molars); rare on lower incisors; usually seen on six or eight homologous incisors; usually one to three teeth affected; may occur
teeth; extremely rare in deciduous teeth singly; common in deciduous teeth
Gross None; no pitting in milder forms; glaz ed appearance of enamel surface; smooth Absent to severe; enamel surface etched and rough to
hypoplasia to point of explorer explorer
Detection Often invisible under strong light; most easily detected by line of light Seen most easily under strong light on line of sight
tangential to tooth surface perpendicular to tooth surface
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
Measurement of Access to Water Fluoridation

Community water fluoridation has been recognized as the major contributor to the
decline of dental caries in the U.S. during the last half of the twentieth century.1
Water fluoridation is achieved by adjusting the fluoride in the municipal water
supply to obtain an optimal fluoride level of 0.7 mg/L as recommended by the U.S.
Public Health Service.52 (See Chapter 6 for a detailed discussion of fluoridation.)
This is a change from the recommendation that has been in place since 1962 to
adjust the fluoride concentration to a range of 0.7 to 1.2 mg/L (previously referred
to as parts per million or ppm), based on geographic location in relation to varied
water consumption according to mean air temperature.
The Federal Panel on Community Water Fluoridation of the DHHS published the
new recommendation in 2015 in the report U.S. Public Health Service
Recommendation for Fluoride Concentration in Drinking Water for the Prevention of
Dental Caries.52 Also included in this report were four conclusions to its review of
public comments related to the new recommendation52 (see Box 4-13). According to
the panel, 0.7 mg/L is the concentration that provides the best balance of protection
from dental caries and also limits the risk of dental fluorosis.
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.
2. In addition to drinking water, other sources of fluoride exposure have contributed

to the prevention of dental caries and an increase in dental fluorosis prevalence.
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.
Community water fluoridation is measured by the percentage of people served by

public water systems that are optimally fluoridated.32 In 2012 approximately 282.5
million people in the U.S. were on community water systems, and 210.6 million of
them (74.6%) received fluoridated water.53 Unfortunately, more than 90 million
people did not have access to fluoridated water in the same year.53 A Healthy People
2020 oral health objective addresses this problem; the target for 2020 is that 79.6%
of the population that is served by a community water system will be served by an
optimally fluoridated community water system.32
Information about the fluoridation status of public water systems can be obtained
from the Water Fluoridation Reporting System (WFRS), a voluntary, interactive,
Internet-based monitoring and surveillance program developed by the CDC in
partnership with the ASTDD.54 In this system state and tribal fluoridation managers
enter a variety of data into the WFRS to monitor fluoridation quality, including
average fluoride concentrations, results of daily testing, laboratory split sample
results, and dates of facility inspections and operator training.54 The data in the
WFRS are available for various purposes, including the following:54
• State and tribal fluoridation managers can generate reports from the WFRS that
can be used to assure program quality, including the number of months the system
is operating with optimal fluoride concentration.
• Water fluoridation data from WFRS are used to update the water fluoridation maps
maintained by the CDC in Oral Health Maps, a web-based Geographic Information
System interactive-mapping application that shows the percentage of people
receiving fluoridated water at the state and local levels.
• The WFRS information is the basis for national surveillance reports that describe
the percentage of the U.S. population on community water systems who receive
optimally fluoridated drinking water.
The CDC site My Water's Fluoride (see Resources at the end of this chapter) is a
source of information available to the public.54 Approximately 40 states share
fluoridation data from WFRS and the fluoridation status of their state via this CDC
data application. For states that participate, professionals and consumers can learn
basic information about their community water system, including the number of
people served by the system and the fluoride level.
Measurement of Access to the Oral Healthcare

System
Many facets comprise access to the oral healthcare system, referred to more simply
as access to oral health care, including availability, accessibility, accommodation,
affordability, and acceptability.1,2,3,4 Multiple factors have been assessed to explain
the use of clinical oral healthcare services. These factors have been summarized as
epidemiologic, social, demographic, personal, and psychological, as well as
characteristics of the oral healthcare system.1,2,3,4,22
A common measure of access to and use of the oral healthcare system is having
an annual dental visit in the past year, sometimes referred to as dental attendance
(Figure 4-9).18,19,22,25,32,41,42,55 As previously discussed, this measure is one of the 26
LHI and the only LHI that represents oral health (Figure 4-3). It is also a Healthy
People 2020 oral health objective.32 Other important measures associated with
access to oral health care that have been used in several national, state, and local
surveys include questions to assess the following:1,2,3,18,19,22,25,41,42,55
• Dental attendance for routine checkups or cleanings
• Dental insurance coverage
• Self-reported oral health
• Time since last dental visit/Frequency of dental visits
• Access to oral health care
• Receipt of oral cancer screening
FIG 4-9 A young child patient has a routine dental examination in a dental office. (©
iStock.com.)
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
Basic Screening Survey (BSS) for Older Adults

Access to Oral Health Care
• Is there a particular dentist or dental clinic that you usually go to if you need dental
care or dental advice? (yes, no, don't know)
• 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)
Behavioral Risk Factor Surveillance Survey (BRFSS)

• How long has it been since you last visited a dentist or a dental clinic for any
reason? Include visits to dental specialists such as orthodontists. (within the past
year, 1 to 2 years, 2 to 5 years, 5 or more years)
• 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. (1 to 5, 6 or more but not all, all, none,
don't know/not sure, refused to answer)
Data from Basic Screening Survey: An Approach to Monitoring Community Oral Health: Older Adults.
Association of State & Territorial Dental Directors; 2010. Available http://www.prevmed.org/wp-
content/uploads/2013/11/BSS-SeniorsManual.pdf. Accessed March 2015; 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 March 2015.
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.
Measurement of Oral Health–Related Quality of Life

The four overarching goals of Healthy People 2020 (see Box 4-1) incorporate
quality of life (QOL), which has been defined as individuals' perceptions of their
position in life in the context of culture and value systems in which they live, and in
relation to their goals, expectations, standards, and concerns.57 The concept of QOL
is integral to the WHO definition of health discussed in Chapter 1: “a state of
complete physical, mental, and social well-being and not merely the absence of
disease.”58 Six broad domains describe multidimensional core aspects of QOL
cross-culturally57,59 (Figure 4-10).
FIG 4-10 Core aspects of quality of life.
Health-Related Quality of Life

The concept of health-related quality of life (HRQOL) builds upon QOL,
considering the construct in relation to health and disease.60 Going beyond direct
measures of health, life expectancy, and causes of death, HRQOL focuses on the
effects of health status on quality of life for both individuals and a society.57 A
related concept of HRQOL is well-being, which assesses the positive aspects of a
person's life, such as positive emotions and satisfaction with life.60 Well-being
occurs when supportive environments are used to make the most of one's physical,
mental, and social functioning to produce a full, satisfying, and productive life.60
The measurement of HRQOL is subjective, more difficult than measuring health
outcomes, and based on the individual's self-report of perceptions of health.57,60,61
Even so, Healthy People 2020 has added the topic area Health-Related Quality of
Life & Well-Being.10 Formation of the two HRQOL objectives in Healthy People
2020 was based on the following tools that have been used to measure HRQOL:60
• Global assessments: Personal rating of health as poor, fair, good, very good, or
excellent
• Healthy days: Estimate of the number of days of poor or impaired physical and
mental health in the past 30 days
• Years of healthy life: A combined measure developed for the Healthy People
initiative by evaluating the difference between life expectancy and years of healthy
life to reflect the average amount of time spent in less than optimal health because
of chronic or acute limitations
Oral Health–Related Quality of Life

QOL is now recognized as a valid parameter in patient assessment in nearly every
area of physical and mental health care, including oral health.57 Oral health–related
quality of life (OHRQOL) shares the same elements as QOL and HRQOL and is the
effect of oral health on a person's QOL, describing people's perspectives of the
ways in which oral diseases, conditions, and treatments affect their lives.24,57,59
Because OHRQOL is one aspect of HRQOL, an understanding of OHRQOL builds
on the comprehension of QOL and HRQOL and cannot be considered separately.
A link between oral health and QOL has been reported for a number of oral
health conditions, including dental caries, poor oral hygiene, severe periodontitis,
TMD, craniomandibular pain, xerostomia, partial tooth loss and edentulism,
diseased teeth, untreated disease, malocclusion, orodental trauma, craniofacial
anomalies, oral cancer, unmet dental needs, and occasional and episodic dental
treatment.24,25,62,63 OHRQOL considers how these conditions affect a person's QOL
based on the following dimensions, which are also illustrated in Figure 4-
11:1,3,24,25,57,59,61,62,63
• Oral health dimensions (pain and discomfort [acute or chronic, dental or facial])
• Functional dimensions (ability and comfort related to biting, chewing, swallowing,
speaking, relaxing, sleeping, and cleaning one's teeth)
• Psychological factors (self-esteem, self-concept/sense of self, smiling without
embarrassment, eating or speaking in front of others, facial appearance, intimacy,
personal contact/social integration/social interaction, and emotional stability)
• Social factors (ability to work/study [school-loss days, restricted-activity days,
work-loss days, and bed days] and the subsequent direct and indirect economic
impact)
• Treatment expectations (satisfaction with respect to oral health and treatment
outcomes)
FIG 4-11 Dimensions of oral health–related quality of life (OHRQOL). (Adapted from
Sischo L, Broder HL. Oral health-related quality of life: What, why, how, and future implications. J
Dent Res 2011;90(11):1264–1270. doi: 10.1177/0022034511399918. Available at
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3318061/. Accessed April 2015.)
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)
• Difficulty in biting foods
• Difficulty chewing foods
• Difficulty with speech/trouble pronouncing words
• Dry mouth
• Felt embarrassed due to appearance of teeth
• Felt tense because of problems with teeth or mouth
• Have avoided smiling because of teeth
• Had sleep that is often interrupted
• Have taken days off work
• Difficulty doing usual activities
• Felt less tolerant of spouse or people who are close to you
• Have reduced participation in social activities

Data from 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.
Future Directions for Assessing Oral Health–Related Quality

of Life
Instruments have been developed for the measurement of OHRQL in various
populations, such as children, nursing home residents, and older adults in
community centers, and these efforts will be continued to identify the best
measurements for various groups.24,61 Future developments should focus also on the
development of measures that can be used to evaluate longitudinal change in
OHRQL.61 In addition, application of instruments to measure OHRQOL outcomes
has not been attempted in regular clinical practice. It has been suggested that such
application has the potential to improve quality of care, patient satisfaction, quality
of research, and public health practice.24
As more attention and resources are invested in the measurement of OHRQOL to
evaluate outcomes of treatments and initiatives, it has been stressed that maintaining
the measurement of traditional clinical outcomes is also essential.63 Relevant
information about QOL is of practical significance for various entities in the health
sector, such as health policymakers, health services researchers, epidemiologists,
and health program evaluators to enhance decision making. However, evaluation of
OHRQOL should not substitute for evaluation of clinical outcomes; rather they
should complement each other as applied to decisions concerning the improvement
of oral health and the OHRQOL of the nation.63
Measurement of Infrastructure, Capacity, and

Resources
Infrastructure, capacity, and resources are key elements by which states and
localities can effectively address oral health problems.16,32,64 Infrastructure consists
of systems, people, relationships, and resources that enable states and localities to
perform public health functions and address oral health problems.64 Within a public
health agency, infrastructure includes assessment, surveillance, information
systems, planning, policy development, applied research, training, standards
development, quality management, coordination, and systems of care.64
Capacity enables the development of expertise and competence and the
implementation of strategies. Resources include personnel, financial capital, and
available time.64 The public health and personal health workforce must have the
necessary capacity and expertise to effectively address oral health problems and
issues.64 Strong infrastructure and adequate capacity at the federal, state, and local
levels are necessary to be able to sustain effective state oral health programs
(SOHP) that can impact the oral health of the public over time.64 This will require
collaborative efforts within the overall public health system to strengthen SOHP and
their relationships with partner groups and local communities.64 (See Chapter 5 for
further discussion of infrastructure and capacity and Appendix C for a list of
potential community partners.)
To ensure achievement of the Healthy People 2020 oral health objectives it is
necessary that instruments and methods be developed to assess the current status,
best practices, and future development of infrastructure, capacity, and resources
necessary to improve oral health at state and local levels.64 States and localities that
can develop and evaluate these key elements will be better prepared to maintain fully
effective essential public health services for oral health and to achieve the oral
health objectives.64 As a matter of fact, Healthy People 2020 oral health objectives
address the need to improve infrastructure and capacity of SOHP by increasing the
number of states and territories that have a SOHP director with dental and public
health training.32 In addition, a Healthy People 2020 objective in the Older Adults
topic area relates to the need to increase the proportion of dentists with geriatric
certification to be able to strengthen the capacity of the dental workforce in relation
to treating this vulnerable population.10
The mission of the ASTDD is to “provide leadership to advocate a governmental
oral health presence in each state and territory, to formulate and promote sound oral
health policy, to increase awareness of oral health issues, and to assist in the
development of initiatives for prevention and control of oral diseases.”65 To this
end, in 2012 the ASTDD, funded by the CDC, published an assessment of SOHP
infrastructure from 2000 to 2010 by the title State Oral Health Infrastructure and
Capacity: Reflecting on Progress and Charting the Future.64 The aim of this
evaluation was to assist state agency staff, policymakers, coalitions, funders, and
other organizations in gaining a better understanding of ways to achieve positive
oral health outcomes by building, expanding, and sustaining current SOHP.16
In general, the outcomes of this evaluation demonstrate the need to strengthen the
infrastructure and capacity of SOHP.64 Many states do not have a strong SOHP;
numbers, training, and longevity of dental public health workforce are inadequate,
and funding is limited.64 Figure 4-12 shows the still limited number of states that
have a dental professional as the SOHP director, which is key to the sustainability of
a strong SOHP. Chapter 5 presents additional results of this ASTDD evaluation.
FIG 4-12 States with a dental professional as the state oral health program
(SOHP) director, 2010 (Data from 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/docs/infrastructure-enhancement-project-feb-2012.pdf. Access ed
March 2015.)
Future Considerations for Oral Health
Surveillance
A core foundation of successful planning in dental public health is information
collected through oral health surveillance systems about the epidemiology of oral
diseases and factors that could be targets for prevention.24 Assessment of key oral
health indicators is central to effective public health planning that tailors oral health
policies, programs, and practices based on oral health status and the progression of
oral diseases among population groups. Oral health surveillance efforts are crucial
to collect data on oral diseases, conditions, and behaviors.1,6,24,64 Changes are
occurring rapidly in oral health surveillance because provisions for oral health
promotion, disease prevention, and surveillance were included in the Patient
Protection and Affordable Care Act signed into law in 2010.
An impending need exists to develop ways to use new techniques for oral health
surveillance, for example, implementing standardized assessments and using
electronic health records and diagnostic codes in dentistry. These methods have the
potential to enhance the monitoring of oral diseases and conditions, access to oral
health care, and cost effectiveness of services.24 Other opportunities include testing
the validity of self-reporting instruments, further developing visual assessment,
developing screening protocols for oral diseases, and improving the monitoring of
protective and risk factors. Surveillance activities for oral diseases will require
developing a permanent process to share information and having the support of the
research community for validation of new surveillance tools. These activities are
the focus of attention by federal agencies and national organizations collaborating
to standardize methods and develop best practices for oral health surveillance.64
Major challenges for oral health surveillance are a limited infrastructure,
insufficient funding, and public health workforce shortages.64 A consistent
workforce with public health knowledge and skills is required to ensure high quality
surveillance.64 Thus, future considerations should focus on the challenges faced by
federal, state, and local agencies to ensure that sufficient resources (e.g., staffing
and funding) are available. These issues must be addressed to assure that oral health
surveillance systems can be maintained, continue to mature, and be linked at the
national, state, and local levels.
States need to expand their oral health surveillance to include indicators that meet
the needs and resources of each individual state.64 State dental directors should
coordinate various oral health surveillance programs to help develop and maintain
a state oral health surveillance system at a high priority level. States and localities
have reported cost-effective approaches, such as linking to existing surveillance
systems for oral health data (e.g., the CDC/BRFSS) and adding new oral health
questions to existing surveys or surveillance systems.
Identification of cost-efficient methods of oral health surveillance is a priority.64
Substantial resources are needed to collect primary oral health data through open-
mouth screenings. Although the unit cost of a survey screening using the BSS tool is
more cost-efficient compared with an epidemiologic survey that uses the DMFT
index, states and local agencies require ongoing resources to regularly and
periodically collect oral health status data through screening surveys.64 In addition,
repetition of these costly screening surveys is necessary to monitor trends over time
and to collect data for different population groups (e.g., preschool children, school-
age children, adults, older adults, and special needs individuals).
These oral screenings for the purposes of surveillance of dental diseases and
conditions have typically been completed by dentists. The use of dental hygienists to
measure clinical indicators, such as dental caries, sealants, and probing depths has
been attempted in recent NHANES survey periods.66 If successful, this procedure can
prove to be a more cost-effective solution to conducting open-mouth screenings.
Data reliability analyses conducted for outcomes of these NHANES periods
indicated an acceptable level of data quality and similar dental examiner (dental
hygienist) performance compared with prior survey periods that utilized dentists as
examiners.66 Oral health assessment methods should evolve as oral disease patterns
and population demographics change. These changes demand new techniques and
the development of skills by dental professionals working in public health. Future
considerations need to seek cost-effective alternatives to assess the level of oral
diseases, such as techniques to estimate the level of disease among populations,
counties, or communities without having to expand the survey sample for primary
data collection.64
Summary
This chapter presents the goals and oral health objectives of Healthy People 2020;
these benchmarks provide an important framework for the assessment of oral health
in the U.S. during the remainder of this decade. Furthermore, the chapter focuses on
oral health surveillance as the ongoing and systematic collection, analysis, and
interpretation of oral health indicators for use in planning, implementing, and
evaluating dental public health practice. The chapter describes how assessments are
important to monitor changes in the following:
• Oral health and disease patterns
• The use of oral health services
• Social, demographic, and economic factors that influence oral health
• Workforce and service system capacity with the public, private, and nonprofit
sectors
Specific measures used in assessing oral health and related factors in populations
are examined. Examples of oral health surveys are presented, and the importance of
using standardized measurements to assess oral health trends is highlighted. Also
discussed is the need to strengthen surveillance measures for future planning,
implementation, and evaluation of dental public health practice.
1. Select three Healthy People 2020 oral health objectives. For each one describe
what data sources you would use to retrieve existing data for your local area
population. Retrieve data on each one, and share the results with your class.
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?
4. As a local practicing dental hygienist, you serve on the board of a community-

based dental clinic that provides oral healthcare services and school-based primary
preventive initiatives in the Title I schools of the local school district. You and
another board member collaborate to write a grant to help support the school-based
prevention programs. What Healthy People 2020 objectives would you be targeting
with the grant? What data would be required to demonstrate a need for funding for
sealant and fluoride varnish programs for schoolchildren in your community?
Where could you find data to help with the grant proposal?
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?
competencies:

HP.4
HP.5
CM.1
CM.6
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
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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].
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/
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.
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.
In the nineteenth century noma occurred in the U.S. in areas of poverty,

malnutrition, and unsanitary conditions as the pioneers migrated west.9 As public
health measures improved environmental conditions and oral cleanliness became
more the norm, noma virtually disappeared from developed countries during the
twentieth century.9 Exceptions are isolated cases reported in concentration camps
and more recently in patients with HIV/AIDS, as well as in Native American
children with underlying severe combined immunodeficiency syndrome (SCID).10
Communities throughout the world face dental public health problems as

individuals experience preventable oral diseases, particularly vulnerable and
disadvantaged groups in developing countries.6,7,11-13 Different oral disease patterns
and development trends between countries reflect the impact of applying effective
evidence-based preventive oral health programs.6,7 The important role of
behavioral, social, cultural, and environmental factors in oral health and disease has
been shown in epidemiologic surveys and data systems supported by the World
Health Organization (WHO) Global Oral Health Program.14
Initiatives to address global oral health problems are under way. In 1995 the
WHO Oral Health Country/Area Profile Programme (CAPP) was developed to
organize and present data for various countries and regions so that oral health status
and services could be described on the web.14 The WHO Global Oral Health
Database was developed as part of the WHO Global InfoBase with the aim of
mapping oral health indicators for target population groups worldwide to depict the
oral disease burden globally.14 Also, the Global Oral Health Atlas has mapped oral
health across the world, describing oral health status and key factors influencing
trends in oral diseases.15
These efforts provided the impetus for a global summit on oral health in 2011 at
which the United Nations recognized that oral diseases are a major health burden
for several countries.13 The United Nations recommended that national public health
initiatives for the control and prevention of oral diseases in all countries be based
on similar risk factors and include oral health promotion combined with disease-
prevention schemes.13
National oral health indicators from the U.S. are included in the global and
regional oral health surveillance systems. Selected oral health indicators are tracked
by the 39 nations in the Americas, including those reported by the U.S. The Pan
American Health Organization (PAHO) serves as the WHO Regional Office for the
Americas (AMRO) and leads this regional oral health surveillance effort on an
international level.14
Oral Health in the United States

In the U.S. progress has been made in reducing the extent and severity of common
oral diseases. During the last half of the twentieth century and since the beginning of
the twenty-first century, major strides in oral health have been seen nationally for
many Americans, yet oral diseases remain common and widespread. Oral diseases
and conditions still afflict most people at some time throughout their lifespan. For
example, dental caries is considered one of the most common and preventable
chronic diseases in the U.S.1
As explained in Chapter 4, Healthy People is the system used by the nation to set
objectives each decade to improve the public’s health, based on the current health
status established by surveillance data. Each decade the oral health section of
Healthy People addresses objectives to improve the oral health of our nation. Thus,
the outcomes of Healthy People 2010 oral health objectives became the basis for
setting Healthy People 2020 oral health objectives. In this way the nation continually
re-evaluates progress toward targets and sets new objectives accordingly. As a
result, it is important to review outcomes data at the end of each decade to be able to
set goals for continued improvement.
Table 5-1 presents the final review data for outcomes of Healthy People 2010
oral health objectives that served as the foundation for Healthy People 2020 oral
health objectives.16 The column labeled “HP 2010 Percentage Change, Baseline to
Final” presents the amount of progress made during the decade 2000 to 2010. The
adjacent column “Percentage of Target Achieved, 2000 to 2010” shows the progress
made on each objective during the decade. Positive progress was made on a number
of Healthy People 2010 objectives, represented by a ☺ or * symbol, in which case
the percentage of positive change is indicated. On the other hand, ground was lost
on several important objectives represented by a ☹ symbol, meaning that the data at
the end of the decade showed regression instead of the progress anticipated (see
Guiding Principles).
Healthy People 2010 Objectives That Experienced Regression
• Increase in caries and untreated decay in children
• Increase in untreated caries in adults
• Decrease in proportion of oral and pharyngeal cancers detected at the earliest

stage
• 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
Burden of Oral Diseases in the United States

Despite improvements in oral health status, profound oral health disparities remain
in specific population groups in the U.S.17 Oral health disparities are defined as
differences in oral health status among segments of the populace. For some oral
diseases and conditions, the magnitude of these differences is striking.17 Many
different demographic and social characteristics are associated with oral health
disparities, including income, education, race/ethnicity, culture, geography
(urban/rural), age, sex, disability status, and behavioral lifestyles. These factors
reflect the diversity of the U.S. population.
Factors that contribute to this burden of oral disease include poverty, literacy
levels, limited oral health education and promotion efforts, and unhealthy lifestyles
(e.g., poor diet and nutrition, poor oral hygiene, use of tobacco and alcohol).6,17
Limited availability and accessibility of timely and affordable clinical oral health
services are other major risk factors for oral disease.6,17 Many communities lack
dental public health programs, face limited capacity for oral health services, and
have inadequate facilities and an inequitable distribution of dental professionals.6,17
Thus, the burden of oral diseases is spread unevenly throughout the population.17
People who experience the worst oral health are found among the poor of all ages;
poor children and poor older Americans are particularly vulnerable. Members of
racial and ethnic minorities experience a disproportionate level of oral health
problems. People who are medically compromised or who have disabilities are at
greater risk for oral disease; in turn, oral diseases further jeopardize their overall
health and well-being.18
Social Impact of Oral Diseases

Oral diseases are progressive, cumulative, and become more complex over time.1
These diseases can have various effects that jeopardize physical growth,
development, self-concept, and the capacity to learn1,18-22 (Box 5-2). Poor oral
health–related quality of life, partially resulting from the burden of oral diseases,
can affect economic productivity and compromise a person's ability to work at
home and on the job, as well as school performance.19 Both adults and children who
experience oral diseases are more likely to be at a low socioeconomic level.19 Poor
oral health also can result in premature death when oral diseases are left untreated.19
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
• Have poor self-concept
• Avoid talking
• Have poor school performance
• Miss school
• Avoid smiling
• Experience difficulty eating and drinking
Adults
• Experience impaired oral functions
• Suffer disfigurement
• Have poor work performance
• Lose work hours
• Have difficulty speaking
• Affected by poor nutrition
• Endure stress within the work-family relationship

Status and Trends of Specific Oral
Conditions in the U.S.
National benchmarks have been established to assess health in the U.S. through the
Healthy People initiative.17 Tracking systems have been developed, and regular
progress reports are used to monitor the attainment of the national oral health
objectives.17 As previously described Table 5-1 summarizes the progress made
toward achieving the Healthy People 2020 oral health objectives since their
implementation in 2010.
National trends are revealed by several surveys and data systems in the U.S. that
are used to track national oral health indicators (see Chapter 4). A recent summary
suggests that 14 out of the 26 health indicators have improved, whereas others have
remained at baseline or have had little to no change.23 In recent years lack of
funding has limited pursuits in oral health research to measure progress in relation
to status of oral diseases and conditions (see Chapter 1). More recently there has
been an increase in funding, and research is now under way to evaluate progress of
Healthy People 2020 objectives. Additional reports are expected in the near future to
update the oral health status of Americans and assess progress made in attaining the
Healthy People 2020 objectives.
This chapter provides a broad overview of the status and trends associated with
oral health. Status is the current state or condition, whereas a trend is the direction
of a condition on a particular course over a period of time. The chapter is focused
on the National Oral Health Surveillance System (NOHSS) oral health indicators
introduced in Chapter 4 and the benchmarks in the Healthy People 2020 oral health
objectives presented in Chapter 4 and earlier in this chapter. The oral health status
and trends discussed in this chapter have been established with the various
assessment and data collection methods and dental indexes discussed in Chapters 3
and 4 and presented in Appendixes D and F and retrieved from the data sources
described in Appendix D.
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.
Children and Adolescents

Despite a tremendous decline in dental caries in children in the U.S. since the 1950s,
tooth decay remains the single most common chronic disease of childhood.1 It has
been reported to be five times more common than asthma and seven times more
common than hay fever. As demonstrated in Table 5-1, the prevention of dental
caries continues to be a primary national focus.
The prevalence of dental caries among school-age children declined within the
U.S. in the 1980s and 1990s. The decline is the result of various preventive measures
such as community water fluoridation, increased use of other fluorides, and
application of dental sealants.17,19 But these improvements for children appear to
have stalled and, for some indicators, actually regressed slightly in the 2000s24 (see
Table 5-1). More than half (53%) of children aged 6 to 8 years old experienced
dental caries in their primary or permanent teeth in 1999 to 2004, compared with
52% in the years 1988 to 1994.24
Not only is the prevalence of caries experience a concern; the increase in the rate
of untreated caries in children is also alarming (see Table 5-1). Healthy People 2010
final data indicate that although untreated decay in adolescents decreased by 10% in
the last decade, it increased by 18.8% in 3- to 5-year-olds and by 3.6% in 6- to 9-
year-olds16 (Table 5-1). Specific data and associated demographic factors related to
untreated dental caries in children and adolescents published by the CDC can be
viewed in Figures 5-1 and 5-2.
FIG 5-1 Percentage of Untreated Dental Caries Among Children and Adolescents
by Race, 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 5-2 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
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).
Young and Older Adults

Dental caries is a problem in adults as well. Tables 5-2 and 5-3 present the most
currently published national data on adult dental caries. In addition, Table 5-1
indicates a 3.7% increase in untreated dental caries in adults in the last decade.17

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.
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).
Community Preventive Services

Dental Sealants
Dental sealants can be very effective in preventing dental caries on the pit and
fissure surfaces of teeth, but few children receive them.23,27 The most recent report
(2011–2012) showed that 37.6% of 6- to 9-year-olds had at least one dental sealant
placed, and 22.2% of 13- to 15-year-olds had at least one dental sealant placed.2
Although these rates are still lower than ideal, the proportion of children with sealed
permanent molars increased significantly during the previous decade by 39.1% in 6-
to 9-year-olds and by 40% in 13- to 15-year-olds16 (Table 5-1). It is also
encouraging that by 2012 the rates for both age groups improved further and the
2020 target had already been reached for 6- to 9-year-olds16 (Table 5-1). Disparities
for dental sealants among children and adolescents are illustrated in Figure 5-3.
Healthy People 2020 objectives are directed toward increasing the use of sealants in
children ages 3 to 5, 6 to 9, and 13 to 1517 (Table 5-1). The inclusion of a new
objective for sealants in 3- to 5-year-olds seems to indicate a more aggressive
approach to prevent dental caries in this age group.
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.)
An important aspect of the status of sealants in the population is the diffusion of

its acceptance and use by the public and oral health practitioners. Because research
has demonstrated that most people acquire knowledge of the need for sealants from
their oral health practitioners, it is important that oral healthcare providers be
knowledgeable and have positive attitudes about the use of sealants. A recent report
found that dentists used sealants and had high levels of positive attitudes about using
them.28 However, overall knowledge regarding the appropriate use of sealants was
low.28 Another survey of practicing dental hygienists revealed that 95% of them
were moderately knowledgeable about the need to place sealants.29 A survey of
parents found that more than one third of parents still were unaware of what sealants
are.30
Community Water Fluoridation

Community water fluoridation is a cornerstone public health preventive service in
the U.S.4,19,31 During the second half of the twentieth century, a major decline in the
prevalence and severity of dental caries resulted from the use of fluorides as an
effective method of preventing caries.19 Fluoridation of the public water supply is
the most equitable, cost-effective, and cost-saving method of providing fluoride to
the community. It is an effective, safe, and inexpensive method for preventing dental
caries.4,19 In contrast to other fluoride delivery modes, systemic community water
fluoridation benefits Americans of all ages and SES.4
Water fluoridation has been a national health objective since the beginning of the
Healthy People initiative. During the last decade the proportion of the U.S.
population served by community water systems who receive optimally fluoridated
water increased by 16.1%16 (Table 5-1). A Healthy People 2020 oral health objective
is to increase this proportion to 79.6%17 (Table 5-1). In 2012 approximately 210
million people were on fluoridated drinking water systems, and 5.3% of these were
on naturally fluoridated public water systems.4 This translates to 74.6% of the
population served by community water systems who received optimally fluoridated
water.4 This CDC analysis of fluoridation data from the 50 states and the District of
Columbia (D.C.) revealed a steady increase in the overall U.S. population served by
community water systems that are optimally fluoridated, from 62% in 1992 to 65%
in 2000 to 69% in 2006 to 72.4% in 2008 to 74.6% in 2012.32 Although
approximately 90% of Americans received their household water through a
community system in 2012 (the rest used well water or some other form of
individual access to water), more than a quarter of them still did not have access to
optimally fluoridated water.4,17,32
These percentages varied substantially by state from 10.8% of the population in
Hawaii benefiting from water fluoridation to 100% in D.C. in 2012.4 Also, in 2012
only 22 of the 50 (44%) states in the U.S. had reached the national benchmark based
on Healthy People 2020 of providing fluoridated water to 79.6% of their population
on community water systems.4 In 10 states—Alaska, Hawaii, Idaho, Louisiana,
Montana, New Hampshire, New Jersey, Oregon, Utah, and Wyoming—the share of
the population with fluoridated community water had not reached even 53%, which
would represent two-thirds of the benchmark.4 In three states—Hawaii, New Jersey,
and Oregon—less than 25% of the population had fluoridated community water.4
The fact that a significant number of states are so far below the benchmark is of
special significance because of the diffusion or halo benefit of fluoride from
fluoridated communities to surrounding nonfluoridated communities via the
exportation of bottled beverages and processed foods. A study conducted to analyze
this diffusion effect showed that 12-year-old children living in states where more
than half of the communities had fluoridated water had 26% fewer decayed tooth
surfaces per year than 12-year-old children living in states where less than one
quarter of the communities were fluoridated.33 In other words, children living in
nonfluoridated communities in states that are highly fluoridated receive partial
benefits of fluoridation from eating foods and drinking beverages processed in
fluoridated communities.4
Of the 50 largest cities in the U.S., 42 have community water fluoridation, and two
have natural fluoride levels that are optimal.34 The six cities that are not benefiting
from fluoridation are San Jose, CA; Portland, OR; Albuquerque, NM; Tucson, AZ;
Fresno, CA; and Wichita, KS.34 Public health officials, policymakers, and
stakeholders in states and major cities with lower percentages of residents receiving
water fluoridation should expand their efforts to promote fluoridation of
community water systems.17,18 In addition, since the optimal recommended
concentration of fluoride in the water was reduced to 0.7 ppm, major cities have
begun evaluating their fluoridation status. Local public health officials and
stakeholders must be alert to the potential for antifluoridationists to use this
opportunity to gain ground for their cause.
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
Total Pe rc e ntag e of Pe rc e ntag e of Se ve re Pe rc e ntag e of Mode rate Pe rc e ntag e of Mild

PD PD PD PD
Total 47.2 8.5 30.0 8.7
Ag e Groups
30–34 24.4 1.9 13.0 9.4
35–49 36.6 6.7 19.4 10.4
50–64 57.2 11.7 37.7 7.9
65+ 70.1 11.2 53.0 5.9
Ge nde r
Male 56.4 12.6 33.8 10.0
Female 38.4 4.5 26.4 7.5
Rac e /Ethnic ity
Mexican American 66.7 17.3 35.1 14.3
Non-Hispanic White 42.6 6.3 28.5 7.8
Non-Hispanic Black 58.6 13.2 33.6 11.8
Educ ation
<High School 66.9 17.3 40.6 9.0
High School 53.5 9.8 43.2 9.5
>High School 39.3 5.5 25.4 8.4
Pove rty Le ve l
<100% 65.4 16.3 37.8 11.3
100–199% federal poverty level 57.4 14.1 32.9 10.3
(FPL)
200–499% FPL 50.2 7.9 34.4 7.9
>400% FPL 35.4 4.1 23.5 7.9
Marital Status
Married 44.3 7.2 28.6 8.4
Widowed 62.2 10.4 45.1 6.7
Divorced 49.4 12.1 28.2 9.1
Separated 60.9 15.7 34.1 11.2
Never Married 45.7 6.3 28.6 10.8
Living with Partner 57.6 14.1 34.5 9.0
Smoking Status
Current Smoker 62.4 17.7 36.5 10.0
Former Smoker 52.5 9.0 35.6 8.0
Nonsmoker 39.8 5.4 25.6 8.7
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
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.)
Oral and Pharyngeal Cancer

Oral and pharyngeal cancers include different malignant tumors that affect the oral
cavity and pharynx and are largely a preventable type of cancer.38 Oral and
pharyngeal cancers, most of which are squamous cell carcinomas,38 represent 2.5%
of all new cancer cases in the U.S.39 and include cancers of the lip, tongue, floor of
the mouth, palate, gingival and alveolar mucosa, buccal mucosa, and oropharynx.
The most common sites intraorally are the floor of the mouth, lateral border of the
tongue, soft palate, and tonsillar pillar.40 In advanced stages these cancers
metastasize to the lymph nodes of the neck and then to more distant sites.40 Cancers
on the vermillion border of the lip are also very common in individuals with fair
skin in association with sun exposure; these cancers have a better prognosis than
cancers of the oral mucosa.40
Estimates from the Surveillance, Epidemiology, and End Results (SEER)
Program of the National Cancer Institute indicated that 281,591 people in the U.S.
were living with cancers of the oral cavity and pharynx in 2011.39 The incidence of
oral and pharyngeal cancer in 2007 to 2011 was 11 per 100,000 population per year,
and the death rate in this same time period was 2.5 per 100,000 population per year.39
The 5-year survival rate was 62.7% from 2004 to 2010.39 The 5-year relative
survival rate for oral and pharyngeal cancers increased from 52.6% in 1975 to
64.7% in 2006.39 The American Cancer Society has projected that in 2015 in the U.S.,
39,500 people will be diagnosed with oral and pharyngeal cancers, and 7,500
persons will die of these cancers.39
Significant disparities exist in some population groups, especially in minority
men, who experience a higher incidence of oral and pharyngeal cancers and higher
death rates. Also, oral and pharyngeal cancers are about twice as common in men
compared with women. These cancers occur more frequently also in certain racial
and ethnic groups and in lower SES groups. The highest rates are in black males.41
In recent years there has been an increase in oropharyngeal cancers linked to human
papillomavirus (HPV) infection, especially among non-Hispanic white men and
women.38 Individuals who have oral cancers caused by HPV infections tend to be
younger and are less likely to be smokers and drinkers.38 It has been suggested that
the decreased death rate in the last decade is because of this increase in HPV-related
cancers that are more vulnerable to existing treatment modalities, providing a
significant survival advantage.40
Diagnosing oral and pharyngeal cancers at the earliest stage significantly
increases 5-year survival rates (Table 5-5). However, only 31.4% are detected at the
earliest stage,39 and 30.8% are diagnosed as localized or Stage I.39 Thus, Healthy
People 2020 has an objective to increase the proportion of oral and pharyngeal
cancers diagnosed at the earliest stage compared with those diagnosed at later stages
and another to increase the proportion of adults who receive an oral and pharyngeal
cancer screening by a dentist or dental hygienist in a dental office.17 Unfortunately
the proportion of these cancers diagnosed at the earliest stage decreased by 8.3%
during the last decade; new data sources since the launch of Healthy People 2020
indicate a continuation of this trend16,17 (Table 5-1). On the other hand, the
proportion of adults who received an oral and pharyngeal cancer screening in the
past year increased by 38.5% during the last decade16 (Table 5-1).
TABLE 5-5
5-Year Survival Rates of Oral and Pharyngeal Cancers Detected at
Various Stages, SEER 2013
Stag e by Loc ation 5-Ye ar Survival Rate

Localiz ed 82.7%
Spread to Regional Lymph Nodes 60.5%
Metastasiz ed 37.3%
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
Other Oral Conditions

Cleft Lip and Cleft Palate
Of all the possible birth defects, cleft lip with or without cleft palate is one of the
most common.42 The occurrence of cleft lip or cleft palate can be either isolated or
part of an inherited disease or syndrome.43 Recent research by the Office of the
Surgeon General found an inferred causal relationship between maternal smoking
and cleft lip and cleft palate.43 Other risk factors are maternal diabetes and use of
certain medications to treat epilepsy.43
Orofacial clefts can be repaired to varying degrees with surgery. Treatment is
long-term, multistage, specialized complex, and may consist of several surgeries.
Children with orofacial clefts frequently suffer from self-esteem issues in addition
to being burdened with accompanying medical and dental problems and the
discomfort of long-term treatment.42 Reports estimate that the lifetime cost of
treating children born each year with orofacial clefts is $697 million.44 For these
reasons, researchers are working to understand the developmental processes that
lead to clefting and how to prevent the condition or more effectively treat it.
Because there is no national surveillance of orofacial clefts, data to track trends
are not available. In their absence, national estimates are generated using data from
the National Birth Defects Prevention Network (NBDPN) that collects cleft lip and
cleft palate data annually from 11 states (Alabama, Arkansas, California, Georgia,
Hawaii, Iowa, Massachusetts, North Carolina, Oklahoma, Texas, and Utah).44 Based
on the results of data collected in these states, the prevalence of clefts was estimated
to be as follows:45,46
• 10.20 per 10,000 population were born with cleft lips and cleft palates annually
from 2000 to 2005.
• Cleft palate occurred in 6.35 per 10,000 live births annually from 2004 to 2006.
• Cleft lip without cleft palate occurred in 10.63 per 10,000 live births annually
between 2004 and 2006.
• Cleft palate occurred in a total of 2651 live births annually between 2004 and 2006.
• Cleft lip without cleft palate occurred in a total of 4437 live births between 2004
and 2006.
Another study obtained records from 2002 to 2006 from the NBDPN and the
National Vital Statistics Reports from the CDC to determine that the prevalence of
cleft lip and cleft palate varied among 32 states.46 Results of this study indicated an
average prevalence of birth defects of 18.82 per 10,000 population among the 32
states.46 The prevalence of cleft lip with or without cleft palate in the different states
ranged from 21.46 to 2.59 per 10,000 live births.44
Based on the results of these studies, it has been recommended that states should
plan and implement an effective method for identifying, recording, referring, and
following up with infants diagnosed with oral clefts and craniofacial anomalies for
treatment. Of the 50 states plus D.C., 32 reported having referral and reporting
systems for children and youth with cleft lip and/or palate in the Healthy People
2020 baseline data.17 Care by a multidisciplinary team has been shown to be an
effective approach for providing services for people across the lifespan with
craniofacial anomalies. Thus, continued access to an integrated healthcare system is
essential for children and adults to receive necessary dental and healthcare services.
Tracking of the national oral health objectives related to clefts last decade revealed
a 106.3% increase in the number of states with reporting systems16 (Table 5-1). The
Healthy People 2020 objectives were expanded to include increasing the number of
states that have referral and surveillance systems17 (Table 5-1).
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
Traits Ove rall Pe rc e ntag e of All Inc isal Trauma

6–8 years old 2.92
Males 6–11 years old 8.62
Females 6–11 years old 5.54
12–15 years old 17.79
Males 12–19 years old 24.64
Females 12–19 years old 15.53
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.
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.
Barriers to Dental Care

Many children and adults in the U.S. do not receive preventive and therapeutic dental
care that is essential for their healthy growth, development, and well-being.
Americans of all ages can gain improved oral health with increased access to
appropriate, timely, and quality dental care. A host of barriers to this care have been
identified in several reports and include obstacles related to patients, health
professionals, the healthcare system, and society1,19,59-67 (Box 5-3).
ox 5-3
B
Key Barri ers to A ccessi ng Oral H eal th Care
• Lack of availability of providers
• Narrow scope of dental hygiene practice
• Not having a dental home
• Financial cost
• Lack of health or dental insurance
• Lack of awareness of the importance of oral health
• Lack of perceptions about need for regular dental care by both individuals and
health professionals
• Cultural values and beliefs
• Fear of dental care
• Age
• Language
• Habits
• Lack of education
• Low perceived need
• Lack of access
• Attitudes
• Belief in invulnerability
• Lack of faith in treatment
• Belief that treatment is unsafe
• Denial of diagnosis
• Denial of seriousness of disease

• Inconvenience of treatment
• Illiteracy
• Low health literacy
• Lack of transportation
• Provider conflicts
• Culturally insensitive providers
• Dental hygiene supervision requirements
Regular Dental Visits and Use of Oral Health Services

The NHANES and Medical Expenditure Examination Survey (MEPS, see Chapter 4)
assess the frequency of dental visits among American citizens, which is the leading
oral health indicator for Healthy People 2020 and a measure of access to oral health
care.17 Box 5-4 presents results of the previous NHANES and MEPS surveys
regarding frequency and disparities of dental visits.70-72 Healthy People 2010 final
data reported a 2.3% decrease during the past decade in the proportion of children,
adolescents, and adults who used the oral healthcare system in the past year 16 (Table
5-1). According to the most recent Healthy People 2020 progress report, the
proportion of Americans who visited the dentist during the previous year has
decreased further from 44.5% in 2007 to 41.8% in 2011.17 In 2012 82.3% of children
ages 2 to 17 visited a dentist in the past year along with 61.6% of adults aged 18 to
64 and 61.8% of adults 65 years and older.73 Other research reports have described a
decline in dental care utilization among working adults from 2000 to 2011.17
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.
• 3% of 12- to 19-year-olds had never visited a dentist.

• 60% of 20- to 64-year-old adults had not visited a dentist within a year.
• 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.
• Non-Hispanic black and Hispanic children, as well as children without insurance,

were less likely to have visited the dentist.
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
Unmet Dental Needs

People's perception of their unmet healthcare needs is an important indicator
regarding access to health care. The rates of unmet dental care needs increased from
1997 to 2009.72 In 2009 working-age adults 18 to 64 years of age were more likely
to report having unmet dental healthcare needs in the past 12 months because of
cost, compared with other age groups.72 The percentage of adults 18 to 64 years of
age who reported not receiving needed dental care because of cost grew from 11%
in 1997 to 17% in 2009.72 However, the percentage of the population indicating cost
as a barrier to receiving needed dental care fell from 2010 to 2012, a reversal of the
increase that occurred from 2000 through 2010.76 Various factors can explain the
decrease in financial barriers to dental care from 2010 to 2012, including the
economic recovery, a flattening of dental fees, and recent increases in public dental
insurance coverage.
In 2009, during the previous 12 months, 28% of adults aged 18 to 64 and with
disabilities had not received needed dental services because of the financial burden
of cost of dental care, whereas 13% of adults in the same age group without
disabilities had unmet dental needs for the same reason.72 Women of working age
were more likely to report unmet dental healthcare needs than men. On the other
hand, children and older adults had similar rates of reported unmet dental healthcare
needs.72
Dental Care Financing in the U.S.

Dental insurance coverage (also called third-party payment) is an important factor
that influences access to oral health services. A complex combination of private and
public insurance is utilized by our pluralistic system of oral healthcare delivery
(Table 5-7). In general, fewer people have dental insurance than overall healthcare
coverage.77 Figure 5-7 compares the percentage of dental insurance coverage
among the American people in 2010 and 2012. Coverage is expected to increase in
the future as a result of opportunities provided by ACA. People without dental
insurance pay out of pocket on a fee-for-service basis.
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
Type of Plan Provide r De sc ription

Fe e -for-Se rvic e
Indemnity For profit, Traditional fee-for-service plan (services are paid for as itemiz ed) in which the beneficiary (client or patient) has
Dental commercial freedom of choice (can visit any provider) and the provider is free to set fees; includes coinsurance, deductible, and
Insurance Plan insurance maximums; company reimburses client or provider based on fee profiles (similar to UCR) and patient is responsible for
companies any difference between the benefit paid and the fee charged; most expensive form of insurance
Direct Employers Self-funded plan that reimburses patients according to dollars spent on dental care, not type of treatment received;
reimbursement employers pay employees a percentage of actual treatments received, saving the cost of the middle man (the insurance
plan administrator); allows freedom of choice and autonomy of decision making about treatment; includes an annual
limit on the amount the employer sets aside to reimburse each employee; not a true insurance plan
Manag e d Care
Preferred Health service and Dentist contracts with insurer to provide care at lower-than-average fees; insurer selectively directs patients to specific
Provider dental service providers (referred to as preferred providers); patient can visit a dentist outside the PPO (referred to as out-of-network)
Organiz ation corporations (not and pay the difference in cost; includes coinsurance, deductible, and maximum coverage; insurance company
(PPO) for profit) and reimburses patient or dentist accepts payment directly from insurance company; less costly than traditional indemnity
commercial plan; variation is an Exclusive Provider Organiz ation (EPO), also known as Exclusive Provider Arrangement (EPA),
insurance that does not cover out-of-network care
companies (for
profit)
Dental Health Health service and Beneficiaries must use one dentist or facility (plan does not pay if they go outside HMO); includes copayment and
Maintenance dental service possibly maximums but no deductibles; uses capitation; usually lowest cost program; uncommon for dental insurance;
Organiz ation corporations; dentists frequently limit number of HMO patients to offset loss of income; a variation is the point-of-service (POS)
(HMO; Pre- commercial plans that are similar except that the beneficiary may seek care outside the HMO (out-of-network)
Paid Plan) insurance
companies; prepaid,
large group
practices
Dental Employers; Providers join the plan by paying a fee and agreeing to offer discounted fees, then are listed as a member provider (a
Discount Plan provider way of recruiting patients); patients join the plan by paying a fee, receive a list of providers who are on the plan and a
organiz ations; card to present to the member provider, and pay deeply discounted fees to member providers; no deductibles, no annual
corporate clinic limits, no copayments, no paperwork for the client or dentist for reimbursement, and no prequalifications; not a true
organiz ations insurance plan
Individual Association of More of a business arrangement than a dental insurance plan; organiz ation contracts with independent dentists to
Practice independent dental provide services to HMO patients for discounted fees or through capitation arrangement
Association providers
(IPA)
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.
• Dental care accounted for 6.6% of all healthcare expenditures in 2010.
• The average annual expense for dental care per person was $666 in 2010.
• About 40% of the noninstitutionalized population reported a dental care expense 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
Dental Insurance Coverage: Children and Adolescents

Children receive dental coverage from private insurance, Medicaid, and CHIP.
Children 19 years of age and younger experienced an increase in dental coverage
from 2000 to 201086 (Figure 5-7). Dental insurance coverage among children varies
by age, family income, race and ethnicity, and family education.86 Also, children
who are living close to, at, or below the FPL have been less likely to have dental
coverage.86 Figure 5-8 presents this data by racial group. It is anticipated that the
ACA will impact these data in the future.
FIG 5-8 Percentage of Children Who Lack Dental Coverage in the Poor and Near-
Poor Categories, MEPS, 2009. (Data from Henry J. Kaiser Family Foundation. Kaiser
Commission on Medicaid and the Uninsured Policy Brief, 2012. Available at
https://kaiserfamilyfoundation.files.wordpress.com/2013/01/7681-04.pdf. Accessed January 2015.)
Hispanics, non-Hispanic African Americans, and non-Hispanic whites have the

same rate of being uninsured when they are at 200% or more below the FPL.86 Lack
of dental insurance is a barrier to receiving timely and needed dental care because
of the financial burden. This has been especially true for children in families who
are below the FPL. Because of the ACA, dental coverage is now available to more
children living at or below the federal poverty level. As of June 2013 more than 28
million children were enrolled in Medicaid, and 5.7 million were enrolled in CHIP,
but more than 7 million children still remained uninsured.87
Dental Coverage: Younger and Older Adults

Like with children, dental insurance coverage among adults varies by age, family
income, race and ethnicity, and education. The overall coverage with adults has
increased since the implementation of the ACA, but the ACA does not take into
account the older adult population. When older adults retire, they have the potential
of losing their employer-based dental benefits, but the ACA does not address this
issue.74 This limits access to dental coverage and access to dental services for older
adults.
As for younger adults, in 2010 it was estimated that 113.8 million persons over
the age of 21 had dental coverage.74 Of that, 17.5 million had dental coverage
through Medicaid, 4.1 million through individual plans, and 92.2 million through
employer-based insurance.74 Since the implementation of the ACA, there has been a
slight increase in dental coverage among adults (Figure 5-7).
From 2006 to 2011 50% of young adults 19 to 25 years old reported having
private dental coverage, and 53.1% of young adults 27 to 30 years of age reported
having dental coverage.88 The group that was most affected by the ACA was young
adults between the ages of 19 and 25. Because of the dependent coverage mandate in
the ACA, there was an increase of 6.7% in private dental coverage among young
adults in this age group.88
Publicly Funded Health Insurance Programs
The cost of dental care can be a significant burden for low-income Americans.
Thus, dental care in the private sector is often not accessible for many Americans.
Medicaid and CHIP are sources of dental benefits for individuals who qualify for
these programs.
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
Children's Health Insurance Program (CHIP).

CHIP has provided important opportunities to improve access to dental care for
children from low-income and modest-income families since its inception in 1997
(then named the State Children's Health Insurance Program, or SCHIP).89 In CHIP
programs that are Medicaid expansions, the EPSDT mandate applies for oral health
services.89,93 However, in separate (non-Medicaid) CHIP programs, dental benefits
are optional, and there is no requirement that states cover all medically necessary
health care. Consequently, dental benefits in states with separate CHIP programs
have varied by state and could change over time. Because dental benefits in CHIP
were optional before 2009, state governments had the prerogative to include
benefits in CHIP programs, and a few states have not included dental benefits over
the years.96
Provisions in the Children's Health Insurance Program Reauthorization Act of
2009 (CHIPRA) guaranteed dental benefits under CHIP.96 Beginning October 1,
2009, all CHIP programs are required to cover dental services for children that are
necessary to prevent disease and promote oral health, restore oral structures to
health and function, and treat emergency conditions based on a benchmark
standard.89 In addition, states were required to report annually on utilization of
dental services.96 CHIPRA also gave states a new option to offer a dental-only
supplement or cost-sharing protection for dental services to children who would
qualify for CHIP except that they have other health coverage.96
Medicaid and CHIP, the nation's safety-net health insurance programs, are a major
source of dental coverage for children in the U.S.97 In 2013 the two programs
covered more than 37% of all children.87 Children from families with low incomes
in the U.S. received dental coverage through Medicaid and CHIP during at least part
of the previous year.87 The ACA expansion of Medicaid and CHIP enables more
children to be eligible for dental benefits because dental benefits are considered
essential health benefits by ACA.87,91 In December 2014 it was estimated that over 28
million children were enrolled in Medicaid, and 5.7 million were enrolled in CHIP.87
The 2018 projection is an expected increase of 3.2 million children with Medicaid
and CHIP dental benefits.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
Future Considerations for Financing Dental Care

Oral healthcare coverage for the majority of adults and older adults was not
included in the provisions for health reform enacted in 2010.74 A great opportunity
to assure universal access to dental coverage for all, including adults and older
adults, was lost. This dark shadow will continue to be a major challenge to
expanding access to necessary oral health care for the increasing number of adults
and older adults. Dental public health professionals will be called on to foster
linkages for adults to access dental care in communities across the country. Also,
programs will be required to provide direct oral health services to individuals
lacking dental care and not covered by the provisions in the ACA.100 Addressing the
oral healthcare needs of adults, especially among vulnerable population groups,
will be an ongoing struggle for communities in the coming decade unless
significant policy changes are made.
Oral Health Workforce

Supply of Oral Health Professionals
The current dental workforce is unable to meet present day demand and need for
dental care. Additionally, considering the estimated number of workforce in the
future and the projected need and demand for dental care by the public, this
inadequacy is expected to increase. This is partially because of changing population
trends and increased public dental insurance coverage. The nation needs to advocate
for a vital and sufficient healthcare workforce so that each individual has the ability
to access needed oral healthcare services.
In 2011 there were 5042 dental school graduates and 3100 dentists who graduated
with advanced dental education (Figure 5-9).101,102 Also, it is estimated that the
number of dental graduates will increase by approximately 5300 per year by
2020.103 Thus, progress is being made in increasing the number of dental graduates
to meet the demand. However, according to the DHHS, the dental graduation rate
will not keep up with the increasing demand. The number of practicing dentists in
the U.S. was 190,900 in 2012, and it is projected to increase by 6% by 2025.104 On the
other hand, the estimated demand for dentists is expected to increase by 10%.104
Based on these data, the DHHS projects a significant shortage of dentists in 2025104
(Table 5-10).
FIG 5-9 Oral Health Workforce Graduates in the U.S., ADEA, 2011. (Data from
American Dental Education Association. Graduates of Advanced Dental Education Programs, 2010-
11. Available at http://www.adea.org/publications/tde/Pages/Students/advanced-dental-
students.aspx. Accessed January 2015; 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;
American Dental Education Association. Advanced Dental Students. Number of Accredited
Advanced Dental Education Programs, 2004–05 to 2010–12. Available at
http://www.adea.org/publications/tde/Pages/Students/advanced-dental-students.aspx. Accessed
January 2015.)
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.
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.)
Besides the total supply of the workforce, another important workforce

consideration in relation to access to care is the number of oral healthcare
professionals available to provide oral healthcare services to individuals with
Medicaid benefits. From 2012 to 2013 eight states had 10% to 19.9% of counties
with no Medicaid dentist, and seven states had 20% to 51.5% of counties with no
Medicaid dentist.75 In addition, only 16 states allowed direct Medicaid
reimbursement to dental hygienists in 2014, limiting their ability to provide care
through collaborative agreements with dentists, even in some states where the state
statute allows direct access of the dental hygienist to the public with no or limited
dental supervision.110
Educating Future Oral Health Professionals

Each year academic dental institutions, including dental schools, allied dental
programs, and postdoctoral and advanced dental education programs, graduate new
practitioners to join the dental workforce (Table 5-11). It is at these private and
public educational institutions across the U.S. that future oral health practitioners
and researchers gain their knowledge, the majority of dental research is conducted,
and significant oral health care is provided in clinical dental and dental hygiene
settings. From 1990 to 2014 the number of dental programs has remained relatively
flat, with 56 programs in 1990 and 65 in 2014; however, the number of dental
hygiene programs has increased dramatically from 202 in 1990 to 335 in 2014.109
TABLE 5-11
Number of Oral Health Workforce Programs
Disc ipline Numbe r Ye ar

Dental Hygiene1 335 2013
Dental Assisting1 278 2013
Dental2 66 2014
Advanced Dental3 741 2012
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.)
Distribution of Dental Professionals

Recent national reports have discussed the maldistribution of dentists and how it
influences the ability to meet the oral health needs of the nation.1,113-116 Even when
the number of dentists is adequate, the distribution of dentists remains a major
challenge, indicating a need to develop workforce solutions that will address the
greater need in underserved areas. The distribution of the dental workforce is
placing stress on the public, nonprofit, and private sectors that provide services in
the oral healthcare system, causing reductions in access to oral health services.1
Geographic maldistribution of dental professionals contributes to poor access to
dental care in many areas, especially in rural and urban areas, as local programs
struggle to meet the oral healthcare needs within their communities.1,113,115 The
number of dentists in relation to the population (dentists per 100,000 people)
provides a means of describing the distribution and comparing one area to another
area in terms of the adequacy of the workforce. The national average of dentist-to-
population ratio was 60.46 dentists per 100,000 persons in 2013.116 On the other
hand, in 2001, rural counties had 29 dentists per 100,000 people,1 and urban counties
had 61 to 62 dentists per 100,000.1 An example of the striking disparity in the
distribution from one area to another is that in 2013, Arkansas had 40.90 dentists per
100,000 persons, in contrast to D.C., which had 89.20 dentists per 100,000 people.116
The overwhelming majority of dental professionals are located in urban areas; thus,
people in rural areas have less access to dental care.1 From 2012 to 2013 72.7% of
states had one to more than 10 counties with no dentist.75
A dental health professional shortage area (dental HPSA) is one type of health
professional shortage area identified by the federal government.117 It is defined as
any of the following that has been determined to have a shortage of dental
professional(s): (1) a geographic area (urban or rural), (2) a population group, or
(3) a facility (public and/or nonprofit private medical/dental facility).117 The federal
government designates areas as having dental practitioner shortages if a minimum
number of specified criteria are met for the geographic area, population group, or
facility117 (Box 5-6). The dental HPSA designation is made by the Health Resources
and Services Administration (HRSA) in collaboration with local communities and
state health departments.117
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
• Meet one of the following conditions
• Have a population to full-time-equivalent (FTE) dentist

ratio of at least 5000 : 1
• Have a population to FTE dentist ratio of less than 5000 : 1

but greater than 4000 : 1 and unusually high needs for
dental services
• Dental professionals in contiguous areas are overutilized, excessively distant, or
inaccessible to the population
Population Groups Must:
• Reside in a rational service area for the delivery of dental care 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
• Members of federally recognized Native American tribes are automatically

designated; other groups may be designated if they meet the basic criteria
described earlier.
Facilities Must:
• Be either federal or state correctional institutions or public or nonprofit medical
facilities
Federal or State Correctional Facilities Must:

• Have at least 250 inmates and
• Have a ratio of the number of internees per year to the number of FTE dentists
serving the institution of at least 1500 : 1
Public or Nonprofit Private Dental Facilities Must:

• Provide general dental care services to an area or population group designated as
having a dental HPSA and
• 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
Population Trends and Future Dental Workforce

The oral healthcare system depends on the size, composition, characteristics, and
distribution of the oral health workforce.1,124 Incorporation of the interprofessional
practice model has been suggested as a characteristic that needs to change in the
delivery of oral health care.125 Factors such as scope of practice, productivity,
practice settings, and participation of providers have an impact on the capacity of
the workforce to serve the population, especially vulnerable population
groups.1,126,127 Several publications have noted inadequacies of the workforce that
have contributed to problems with dental public health capacity.1 This includes lack
of board-certified public health dentists and lack of diversity among the dental
workforce and students.1 Also, regulatory issues related to state licensure boards
and state practice acts regarding dental hygiene practice were evaluated in the
reports.1
Various current dental public health issues are likely to influence the dynamics of
the oral healthcare system as changes in the organization and financing of health
services occur in the coming decades. The following factors are expected to impact
future changes in the composition and size of the dental workforce:1,124,126-128
• Decline in the number of dentists
• Growth in the number of dental hygienists
• Demographic shifts among graduates of academic dental institutions
• Number and location of retiring dentists
• Shifts in population and demographic trends
• Changing oral disease patterns
• Barriers to dental care faced by underserved population groups
Changing demographics within the U.S. will have a long-term impact on the oral
healthcare system in the future. By 2060 minorities are expected to increase to more
than one half of the U.S. population (241.3 million, which will represent 57%).129
The number of older adults is expected to more than double between 2012 and 2060
from 43.1 million to 92 million.129 These population trends will have far-reaching
effects not only for the oral healthcare system but also for patients and oral
healthcare providers in the coming decades. There will be a need for more long-
term care for older adults and more oral health services because of the increased
rate of tooth retention. Also, with the growth of minorities, a more culturally
competent oral health workforce will be needed. Moreover, oral health
professionals can provide leadership locally and at the state and national levels to
assure universal access to effective oral health services. These professionals will
have opportunities to contribute to improvements in oral health outcomes of
individuals and communities by shaping policies, programs, and practices that will
influence the future development of an integrated system of quality health services
including oral health care (Figure 5-13).
FIG 5-13 Oral health professionals can provide leadership to assure universal
access to effective oral health services. (© iStock.com.)
Teledentistry: Improving Population Health Through

Technology
As previously discussed, numerous entities are available through the safety net
provider system to provide treatment for individuals who experience barriers to
oral health care. In this way, the safety net is able to expand access to oral healthcare
services and improve population oral health for vulnerable, underserved
populations.1,18 However, even with the variety of options available, the safety net
still does not meet the needs of all who are left out of the private system, often
because of a lack of capacity of providers or a perceived lack of affordable options
by individuals.130-133
Therefore, new models of care are emerging that are designed to meet the needs
of vulnerable, underserved, and rural communities. Teledentistry is one of those
models that can expand the inadequate capacity of the workforce previously
discussed. Teledentistry is the use of information technology and
telecommunication for dental care, consultation, education, and public awareness in
the same manner as telehealth and telemedicine.134 In the recent Institute of Medicine
report Improving Access to Oral Health Care for Vulnerable and Underserved
Populations published in 2011, the use of telehealth technologies was highlighted as
a promising strategy.18 This approach makes it possible to take oral healthcare
services to underserved communities where significant barriers exist to interfere
with the delivery of dental and dental hygiene care in a traditional dental office
setting.18,135-137 In this way, teledentistry can be used to bring oral health care to hard-
to-reach areas where there are no dentists by facilitating the greater use of
nondentist providers, such as dental hygienists and midlevel providers, to increase
the available workforce in underserved communities.
Teledentistry has the capacity to impact oral health care in other ways besides
increasing workforce capacity and improving access to care. It has been suggested
that its use will increase interprofessional collaboration that will improve the
integration of oral health care into the overall healthcare delivery system.138
Additionally, teledentistry can enhance early diagnosis and treatment of oral
diseases.138
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
Successful Examples of Teledentistry.

Several states are at the forefront of telehealth technology, including Alaska,
Minnesota, and California.139 Three examples of the use of teledentistry are
highlighted in Box 5-7. These programs are organized differently, provide care for
diverse segments of the population, and utilize various workforce models.
However, they share a common focus, which is to expand access to care for
underserved populations.
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
Dental Public Health Programs

State dental public health programs, referred to as state oral health programs
(SOHP) by the Association of State & Territorial Dental Directors (ASTDD),
are also known as departments or divisions because they are organized within state
health departments. SOHPs are a major part of the infrastructure for the delivery of
oral health services and activities. Similar are the territorial dental public health
programs operated by American Indian nations. Many local programs, activities,
and services are supported through these state and territorial oral public health
programs.
This section describes the infrastructure and capacity of SOHPs and other similar
programs at the local level, such as county dental public health programs in larger
urban areas. In this discussion, the term dental public health program, or oral public
health program, refers to a large-scale program operated by a governmental entity,
not to be confused by the common use of the same term to denote a local initiative
such as a fluoride varnish program operated by a local dental hygiene society in a
Head Start program or a school-based dental sealant program operated by a faith-
based community health center.
Status and Trends

The burden of oral diseases and the needs of populations are in transition, and oral
health systems and scientific knowledge are changing rapidly. The challenges of
improving oral health are great in many communities. Oral health needs of many
adults, children, and vulnerable population groups are unmet.1,18,19 Economic
fluctuations stress families and challenge their abilities to access oral health care.18
The infrastructure and capacity of many dental public health programs at the
national, state, and local levels are limited and stretched.1,18,146 Challenges are faced
in the U.S. in ensuring that a viable dental public health infrastructure exists, as well
as making sure that state- and community-based programs are in place that can
ensure access to dental care for underserved populations in the U.S.1,146
Public Health Infrastructure and Capacity

SOHPs and similar agencies at the national, state, and local levels are running at full
capacity because their programs are part of the critical safety net that is used by
population groups that have no other access to oral health care.1 At the same time
the structures of public health agencies are undergoing significant changes.1 These
agencies and the related oral public health programs at all levels vary in size,
structure, staffing, and funding.1,18,146 Nevertheless, public health infrastructure and
capacity are critical to ensure that agencies are effective and efficient in meeting the
oral health needs of the populations they serve. Oral health infrastructure consists
of systems, people, relationships, and the resources that enable federal, state, and
local dental public health programs to perform public health functions.129 Oral
health capacity enables the development of oral health expertise and competence
and the implementation of oral health strategies.129 SOHPs and related programs in
some localities have shown significant progress in collaborating with partnering
organizations and agencies to address necessary changes to strengthen
infrastructure and build capacity; yet many have not been able to do so.
The three core public health functions and 10 essential public health services,
both described in Chapter 1, provide the foundation of public health programs to
assure adequate infrastructure and capacity. The core functions and essential
services have been adapted by various agencies to support the infrastructure for
developing and evaluating national, state, and local programs. One example is the
pyramid of public health services developed by the HRSA Maternal and Child
Health Bureau (MCHB).147 This pyramid (Figure 5-14) describes four levels of
public health activities that are reflected within the programs provided by the
MCHB.147 The pyramid provides a useful framework for understanding
programmatic directions of the MCHB to link oral health and other public health
programs that can contribute to collaborative partnerships in meeting the mission
and accomplishing the goals of the MCHB, including the improvement of oral
health of young children.147
FIG 5-14 Pyramid of Health Services Provided by the Maternal and Child Health
Bureau. (Source: MCH Programs Overview. Health Resources and Services Administration,
Maternal and Child Health. Available at http://mchb.hrsa.gov/programs/. Accessed April 2015.)
The ASTDD has been instrumental in identifying ways to strengthen the

infrastructure and build the capacity for SOHPs in the U.S. In 2000 the ASTDD
established guidelines for state and territorial oral public health programs to assure
that they reflect the necessary infrastructure and capacity to be able to meet
adequately the needs of the populations served148 (Box 5-8). During an analysis of
these guidelines in 2004, the ASTDD established that in order for dental public
health programs to be successful, the public health infrastructure that supports these
dental public health programs needs the following:149
• An adequate workforce
• Sufficient administrative presence in health departments
• Adequate financial resources to implement programs
• Legal authority to use personnel in an effective and cost-effective manner
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.
• Integrate, coordinate, and implement population-based interventions for effective

primary and secondary prevention of oral diseases and conditions.
• Build community capacity to implement community-level interventions.
• Develop health systems interventions to facilitate quality dental care services for
the general public and vulnerable populations.
• Leverage resources to adequately fund public health functions.
In 2009 ASTDD developed competencies as a companion tool to the guidelines.150

The competencies represent needed skill sets for a SOHP to be successful. An
important follow-up finding in 2011 was that infrastructure activities such as those
in the ASTDD guidelines increase program sustainability.146
In 2012 ASTDD published a report in which they evaluated the infrastructure and
capacity of SOHPs across the nation over the last two decades to determine the need
to revise the guidelines.146 The results of this evaluation confirmed that the
infrastructure and capacity in general are still inadequate in relation to SOHPs
nationwide, reinforced the importance of the ASTDD guidelines for SOHPs that
were adopted in 2000, and identified key factors associated with the success of
SOHPs and improvements in oral health146 (Box 5-9).
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.
• Continuous, strong, credible, forward-thinking leadership with the ability to create

partnerships and leverage available assets to ensure that (1) the state program is
addressing the 10 essential public health services and the Guiding Principles of
the SOHP Competencies, and (2) clinical services are being provided at the local
level. Increasing dental public health training of dentists, dental hygienists, and
other oral health providers is critical to this factor.
• Ongoing, high-quality oral health surveillance with broad dissemination
• 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.
• Program resiliency to be able to meet and bounce back from environmental,

financial, political, public relations, or other challenges, misfortunes, or
disasters.
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).
Current Status: Structure and Funding

Most SOHPs are located within a health department, FQHC, or a broader department
of human services.128 Whatever the designation, most states place dental public
health programs or functions under a broader organizational umbrella such as
maternal and child health, family health, rural health, primary care, chronic disease
or disease prevention, or health promotion.1,128 This practice reduces the
effectiveness of the program. According to an ASTDD report, “State dental
directors who have more direct communication with the health officer often have
more successful programs and more resources than those who have to navigate
multiple levels of bureaucracy to communicate their needs to high level
administrators and get a ‘seat at the table.’”146
From 2012 to 2013 all states and D.C. reported having a dental director (four
were part time, and 47 were full time).75 Many served also in an advisory capacity to
other programs or state agencies. Thirteen states did not require the dental director
to have public health experience.75 In service areas with populations over 250,000,
about 50% of the dental directors were dental professionals with a master's degree
or higher in public health.146 These patterns are significant in light of ASTDD's
recommendation that the state dental director should be full time and have public
health experience and skills to function effectively in today's public health
environment.75 In addition, in 33 states the dental director had less than 5 years of
service.75 According to ASTDD vacancies and repeated turnovers in directors and
staff of SOHPs interfere with program development and continuity.146
Staffing patterns for SOHPs vary substantially in terms of numbers of personnel,
job categories, responsibilities, level and type of education, lines of supervision,
employee or contractor status, and job location.75 Many state programs are small.
From 2012 to 2013, 39.3% of responding state programs had three or fewer full-
time-equivalent (FTE) employees, and 74.5% had three or fewer FTE contractors
funded by the state program.75 Some programs also may hire, contract with, or
share with other state programs an epidemiologist, statistician, evaluator,
fluoridation engineer, or other specialized staff. Higher numbers of employees are
likely to reflect states that administer programs that provide services directly. These
programs often employ clinicians, clerical staff, and administrative personnel in
programs such as school-based dental sealant programs, community clinics, and
mobile clinics.148 In some states grants are offered for oral health initiatives and
programs to increase access to oral health care locally, through which competent
and skilled oral health professionals are hired who may not be state employees.75,148
Consistently funded state programs have shown evidence of positive outcomes in
building and maintaining infrastructure and capacity.146 They are able to provide
programs and resources to decrease oral diseases and promote oral health by
establishing systems that foster oral disease surveillance, coalition-building, and
partnerships. States are then able to leverage support for increased promotion and
coordination of effective public health preventive interventions such as school-
based dental sealant programs and community water fluoridation.75
SOHPs are funded by a variety of means, including state general revenues,
foundations, and federal grants.75,148 According to the ASTDD, there is a need to
diversify funding resources to maintain fully effective dental public health
programs at the state and territorial levels.146 Having multiple sources of funding
increases sustainability of programs.146
Many state and local initiatives that are offered and coordinated by SOHPs have
been funded by various departments of the DHHS. Some examples include the
following:
• CDC Preventive Health Services Block Grant has funded community preventive
services such as community water fluoridation in some states.75
• Community-based dental clinics are funded through a variety of sources, including
the HRSA Bureau of Primary Health Care.151
• The HRSA MCHB has funded efforts to promote oral health activities for children
with special healthcare needs.151
• The Office of Head Start, National Center on Health, has funded programs to
promote the oral health of Head Start children and their families, including
children with disabilities.151
• The HRSA Office of Rural Health funds state offices of rural health that partner to
provide oral health programming.151
Since 2003 numerous agencies, including HRSA, CDC, NIDCR, and ASTDD,
have focused on building the infrastructure and capacity of SOHPs to be able to
positively impact the oral health of the nation in the future.
Community-Based Health Centers

For more than 45 years HRSA-supported health centers have provided
comprehensive, culturally competent, and quality primary healthcare services to
underserved communities and vulnerable populations.152 Health centers are
community-based and patient-directed organizations that serve populations with
limited access to health care.152 These include low-income populations, the
uninsured, those with limited English proficiency, migrant and seasonal farm
workers, homeless individuals and families, and those living in public housing.152
More than 1300 community health centers operate 9000 service sites, providing
one of the largest safety net systems of primary and preventive care.121 The
proportion of community health centers with an oral health component increased
from 76% in 2007 to 78.6% in 2012; the Healthy People 2020 target is 83%.17
Nationwide, in 2008, health centers employed 2300 FTE employees as dentists and
900 as dental hygienists, serving in a multidisciplinary collaborative practice
model152 (see Chapter 2). The ACA established a fund to increase funding to
community health centers to be able to increase delivery of primary and preventive
oral health services.121
In 2008 3.1 million patients in community health centers received oral health care
during 7.3 million visits,152 which reflected an increase of 158% compared with the
10 years prior.152 Even so, it was estimated that more than 12 million health center
patients did not have access to oral health services because not all community health
centers had an oral health component.152
Dental Public Health Program Performance
State, territorial, tribal, and local governments are uniquely situated within
government structures to develop partnerships and resources that provide
leadership for oral health initiatives. There is consensus that well-established oral
public health programs are critical to the oral health of the American people. It is
essential to strengthen these programs through systematic oral health surveillance
linked with planning, implementation, and evaluation of effective measures to
prevent oral diseases and promote oral health.1,18
The Pew Charitable Trusts regularly grades the performance of states in relation
to their oral health policies and programs.153 In their report The State of Children's
Dental Health: Making Coverage Matter Pew described results of their most recent
assessment and grading of the 50 states and D.C. on their implementation of eight
cost-effective preventive strategies and promising policy approaches to improve
access to oral health services for children153 (Box 5-10). Results of this Pew
assessment indicated that several states had demonstrated progress by implementing
some of the recommended strategies and approaches (called benchmarks); however,
many states were still experiencing barriers to enacting some significant oral health
initiatives. The key findings of this Pew oral health report card were as follows:153
• No state met all eight benchmarks, meaning that all states needed at least some
improvement.
• Only seven states merited a grade of A, which reflected meeting at least six of the
eight benchmarks.
• 22 states received a B by meeting five benchmarks.
• 18 states and D.C. received a grade of C or D, meeting just three or four of the
policy goals.
• Five states received an F, meeting two or fewer benchmarks, and three of the five
states earned an F for the second consecutive year.
• 22 states improved their grades since 2010, and six of them did so by at least two
letter grades.
• States that raised their grades made progress primarily by adopting policies to
reimburse physicians for preventive dental services, expanding water fluoridation,
and increasing the percentage of Medicaid-enrolled children who receive care.
• Grades dropped in six states, mostly because of the failure of Medicaid
reimbursement rates to keep pace with the growth in dental fees.
• 24 of the states did not have key policies in place.
ox 5-10
B
Ei g ht Key Pol i cy Benchmark s Used by PEW for
Gradi ng States' Performance
1. Having sealant programs in at least 25% of high-risk schools
2. Allowing a hygienist to place sealants in a school-based program without

requiring a dentist's examination
3. Providing optimally fluoridated water to at least 75% of residents who are served
by community water systems
4. Meeting or exceeding the 2007 national average (38.1%) of Medicaid-enrolled

children ages 1 to 18 receiving dental services
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
7. Authorizing a new type of primary-care dental provider
8. Submitting basic screening data to the national database that tracks oral health
status
Policymakers continue to be challenged to address the oral healthcare crisis in the

U.S.154 To meet this challenge effectively, public health administrators, stakeholders,
and decision makers are asked to assure sufficient levels of funding for tools,
capacity, and application of evidence-based practices. These are needed to be able to
assess and monitor health needs, implement intervention strategies, and design
policy options appropriate for their unique circumstances to improve the
performance of the public health system and the oral healthcare system. Although
there have been some gains in the size and strength of SOHPs in the U.S., these
programs generally remain small, understaffed, and underfunded with great
variation in capacity to meet oral health needs.1,18,89
SOHPs and similar programs at the local level need to maximize opportunities to
secure funding from all available sources to implement evidence-based oral health
measures. Sustained resources and collaborative partnerships are crucial for
development of oral public health programs. A range of complementary strategies
can be developed and implemented using strong and sustainable partnerships with
local, state, federal, and international agencies. Yet dental public health strategies
and initiatives essentially will begin at the local level; empowering local
communities to become actively involved in oral public health efforts will be
crucial to the success of reaching all those in need.
Future Directions
Oral Health in America: A Report of the Surgeon General described the oral health
successes of the twentieth century and discussed the oral health challenges
confronting the nation at the turn of the century. A National Call to Action to
Promote Oral Health proposed opportunities to reduce oral health disparities in the
twenty-first century. National oral health objectives each decade have outlined oral
health benchmarks. The Healthy People 2020 oral health objectives now provide the
road map for the next decade. These foundational reports provide the framework
for oral health improvements in the future, and some oral health indicators show
promise of improvement. Two Institute of Medicine reports this decade—Advancing
Oral Health in America and Improving Access to Oral Health Care for Vulnerable
and Underserved Populations—reinforced the findings of earlier reports and
provided greater focus and direction for action and initiatives at the national level
that can impact the oral health of our nation.
The ACA, enacted in 2010, offers opportunities to expand oral health promotion,
strengthen disease prevention, increase access to dental care, enhance professional
education, and build public health programs to improve oral health outcomes in the
nation.87,95 Also, the assorted other initiatives of various entities highlighted in
Chapter 1 can contribute to the forward direction toward improved oral health of
the population.
Political will is critical at all levels of government for improved oral health
outcomes to come to fruition in the U.S. by 2020 and beyond. Future national, state,
and local dental public health programs need certain key elements to be better
prepared to achieve the Healthy People 2020 oral health objectives to realize
improved population oral health (see Guiding Principles).
Key Elements Necessary to Achieve Improved Oral Health in the
Future
• A workforce educated and competent in dental public health representing the

diversity of the U.S.
• Adequate workforce developed through innovative solutions to maximize the

provision of oral health services in a cost-effective manner.
• Sufficient administrative presence with skilled staff and leadership from full-time
oral health program directors at the international, national, state, and local levels.
• Collaborative oral health planning and implementation that integrates evidence-

based public health principles and practices.
• Support of informed policymakers to develop and promote oral health policies.
• Strong and vibrant public-private partnerships.
• Ability to obtain and leverage sufficient financial resources.
• Legal authority to use personnel in an effective and cost-efficient manner.
• Infrastructure and capacity that are necessary to plan, implement, and evaluate oral
health policies, practices, and programs that are sustainable in the future.
• Evidence-based, population-based interventions that prevent oral diseases in

communities.
• Health systems interventions that ensure access to oral health care for adults,
children, and vulnerable, underserved population groups.
• Interprofessional collaborative approach to practice and education.
Specific focus areas should be considered as the nation moves forward in an

attempt to improve oral health of the public. These include the following:
• Conducting surveillance of oral diseases and conditions
• Reporting the burden of disease
• Facilitating the development and implementation of oral health coalitions
• Careful and far-sighted planning of oral health initiatives
• Implementing dental sealant programs
• Coordinating and monitoring community water fluoridation
• Managing program capacity and infrastructure to sustain a dental public health
program
• Increasing capacity of the workforce to support programs
• Focusing on comprehensive, evidence-based oral health education aimed at
improvement of preventive oral health behaviors
Summary
This chapter presents the oral health indicators used for tracking and monitoring
national oral health objectives. These benchmarks provide an important framework
for the assessment of oral health in the U.S. in the past and in the coming decade.
The current status and trends of oral health and access to oral health services used as
key indicators in the U.S. are described and discussed also. In addition, important
oral health disparities among population groups based on race and ethnicity, family
income, education level, gender, geographic location, and disability are highlighted
in the chapter. Finally, critical issues are discussed that must be considered in the
future to improve population health in our nation.
1. Select an oral health indicator such as dental caries or periodontal disease. For the
oral health indicator you selected, find information on the current status, past trends,
and disparities among population groups. Use information presented in the chapter,
websites listed in the appendixes, library resources, and the Internet for updated
information now available to describe the oral health status of the selected indicator.
Present the information in class.
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:
a. State Dental Director
b. County Oral Health Director
c. Dental Director in a Community Health Center

3. Develop a dental public health plan of strategy for a specific population that will
increase access to oral healthcare services for the underrepresented public using
teledentistry as an emerging model of patient care. Present your plan in class.
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.
competencies:

HP.4
CM.1
CM.4
CM.5
Evaluate reimbursement mechanisms and their impact on the patient's access to oral
health care.
CM.6
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
State Sc hool Ye ar Pe rc e ntag e (%) with Untre ate d Tooth De c ay

Ariz ona 2012–2013 29.5
California 2014–2015 28.7
Colorado 2013–2014 25.4
Nevada 2012–2013 41.3
New Mexico 2013–2014 43.1
Oklahoma 2013–2014 34.5
Texas 2011–2012 33.2
Utah 2012–2013 29.4
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
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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*
Prog ram Has Prog ram No Prog ram Not Re porte d

Abuse/Neglect or PANDA Program 19.6% 78.4% 20%
Access to Care Program 51% 44.1% 3.9%
Dental Screening Program 60.8% 37.3% 20%
Dental Sealant Program 68.6% 29.4% 20%
ECC Prevention Program 54.9% 43.1% 20%
Emergency Preparedness Protocol 25.5% 70.6% 3.9%
Fluoride Mouthrinse Program 35.3% 60.8% 3.9%
Fluoride Supplement Program 11.8% 86.3% 20%
Fluoride Varnish Program 64.7% 33.3% 20%
Mouthguard/Injury Prevention Program 13.7% 84.3% 20%
Oral Health Education and Promotion 82.4% 13.7% 3.9%
Oral Health (Open Mouth) Surveys 64.7% 35.3% 0%
Programs for Pregnant Women 43.1% 52.9% 3.9%
Programs for Older Adults 21.6% 76.5% 20%
Programs for Children with Special Healthcare Needs 35.3% 62.7% 20%
Craniofacial Recording System 78.4% 19.6% 20%
Craniofacial Referral System 66.7% 31.4% 20%
*
Includes all states and District of Columbia.
PANDA, Prevent Abuse and Neglect through Dental Awareness; ECC, early childhood caries.
Data from Summary Report: 2015 Synopses of State Dental Public Health Programs: Data for FY 2013-
2014; 2015. Reno, NV: Association of State and Territorial Dental Directors; 2015. Retrieved at
http://www.astdd.org/docs/synopsis-of-state-programs-summary-report-2015.pdf. Accessed June 2015.
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.
Role of Oral Health Coalitions

Many SOHP operate in conjunction with a state oral health coalition. For example,
the Washington state oral health plan described earlier was developed through the
Washington State Oral Health Coalition.14 Support from an oral health coalition is
essential to a successful SOHP.15
A coalition is a diverse group of individuals, organizations, and agencies that
unite to reach a common goal. Coalitions combine efforts on the part of many
individuals and organizations to build systems and develop programs that improve
community oral health. Appendix C provides examples of community partners for
coalitions and other collaborative relationships. SOHP depend on oral health
coalitions and community advocates to implement and promote comprehensive oral
health services in the state and local communities to improve the oral health and
overall health for people of all ages.15
Another state oral health coalition is the Wisconsin Oral Health Coalition
(WOHC), which is facilitated by the Children's Health Alliance of Wisconsin (the
Alliance).16 The WOHC is a dedicated group that collaborates with 170 diverse
individuals, organizations, and agencies to improve oral health access and improve
oral health statewide.16 The WOHC provides funding and administrative support for
five local oral health coalitions in Wisconsin. In addition, it partners with the
Wisconsin Department of Health Services to administer the Wisconsin Seal-A-Smile
Program, which provides grants for school-based and school-linked dental sealant
programs. The Alliance also administers Earlier Is Better, an interdisciplinary
collaborative program that provides parent oral health education for pregnant
women and families with children in Wisconsin Early Head Start (EHS) programs.
Earlier Is Better provides training for home visitors/parent educators to provide
face-to-face oral health education to parents, caregivers, and pregnant women with
the goal of reducing the dental caries experience of Wisconsin's EHS children.16
The ASTDD Best Practices Project includes the report State Oral Health
Coalitions and Collaborative Partnerships. This report describes the importance of
coalitions as a public health approach (Box 6-1). In addition, the report assesses
their effectiveness and provides a list of examples of coalition practices to illustrate
successful, innovative implementation of coalition strategies.15 The report can be
used by oral health professionals to enhance the work of oral health coalitions.
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.
• Enable organizations to become involved in new and broader issues without

having the sole responsibility for managing or developing those issues.
• 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.
• Mobilize more talents, resources, and approaches to accomplish what single

members cannot.
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.
Christian Community Action

An example of a local program is Christian Community Action (CCA), which is a
faith-based nonprofit organization. Headquartered in Lewisville, Texas, CCA is one
of the largest private nonprofits in North Texas, providing more than 10,000
individual services each year. This organization was started in 1973 by a Bible study
group of seven people and has grown into an organization of over 150 staff
members and more than 2500 volunteers.18 The CCA Adult Health Center offers
comprehensive health and dental care services to uninsured adults. Oral health
services include preventive dental services and restorative services.18 The dental
clinic also collaborates with the local dental hygiene society and a local dental
hygiene program to apply dental sealants and fluoride varnish to children at local
Title 1 schools (Figure 6-1).
FIG 6-1 Dental hygienists and dental hygiene students apply sealants at a local
school-based sealant program sponsored by a faith-based health center. (Photograph
courtesy Terri Patrick).
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.
1. Identify the primary health issues.
2. Develop a measurable process and outcome objectives to assess progress in

addressing the health issues.
3. Select and plan effective health interventions to help achieve the objectives.
4. Implement selected interventions.
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
Identifying the Primary Health Issues

A community is comprised of numerous people, each with a unique personality,
personal issues, values, beliefs, and health status. Even so, communities have similar
health conditions that are caused by similar factors in the community such as social
norms, culture, beliefs, access to oral health care, and access to fluoridated water.21-
23
Systematically analyzing these factors and information leads to identifying the
primary health issues of the specific community and the causes of any existing
health inequalities. This is accomplished through assessment, which is an organized
and systematic approach to defining and describing a priority group, determining
the extent and severity of oral health needs present, identifying the factors present in
the community that are associated with the health status, and prioritizing the needs
that are identified.
For example, suppose there is a rural community without water fluoridation, with
limited access to dentists who accept Medicaid dental coverage, and composed
primarily of families with incomes below the federal poverty level (FPL). Survey
data indicate high caries rates and that over 60% of the 6- to 9-year-old school
children in the area have at least one tooth with untreated decay. Comparison of
these data to data for other oral health needs and other groups in the community
leads to the conclusion that that untreated tooth decay is the primary health issue for
this priority group of school children.
Assessing the relative importance of needs can be a complex process. It depends
on human values, some of which are universally agreed on and others are more
controversial. For example, a need that involves life or death generally receives
higher priority. However, a choice between a health need that might affect the lives
of a few people and one that affects the lives of large numbers of people is less
clear-cut. Although many would argue that the needs of larger numbers must take
priority, others want to consider factors such as age and the future impact on
society.21-23 For example, a community with limited resources may need to decide
about initiating a free influenza vaccine program for its older population,
enhancing the immunization program for children, or adding a clinic offering
reduced dental care for indigent families (see Guiding Principles).
Establishing Health Priorities
• What is the magnitude of the problem (does it cause death or disability)?
• How many people are affected (one person, small community, or entire country)?
• What types of resources are available (personnel, money, facilities, and

technology)?
• What has already been done in the community?
• What are the prevailing attitudes toward the problem?
• Which groups are expressing the most interest in the problem?

• What are the legal constraints?
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.
Developing a Measurable Process and Outcome

Objectives to Assess Progress in Addressing the
Health Issue
After the needs are assessed and prioritized, the planning of oral health programs
can begin. Planning is an organized response to the community's needs to reduce or
eliminate one or more problems identified during the assessment. The first step of
planning is to develop the appropriate goals and objectives.21-23 The formulation of
program goals and objectives is an active process, offering specific proposals for
changes to be made in the community. These changes address the specific problems
identified in the needs assessment. Just like with assessment, it is essential to have
community involvement and participation during this step.21-23
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)
• Measurable, meaning that information concerning the objective potentially can be

collected, detected, or obtained from records
• Achievable in the sense that the objectives themselves are possible and that the
organization, agency, community, or priority group is capable of attaining them
• Relevant to the overall vision and mission of the organization, program,

community, or priority group
• 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.
• Realistic: Although it reflects an increase in compliance, not all participants are

expected to comply; it reflects a realistic number of participants achieving the
objective.
• 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.
• Challenging: Given that the participants are adolescents, it might be a challenge to

increase their compliance of using mouthrinse two times a day from 10% to 30%.
The performance verb is critical to having a specific, measurable objective. The
verb must be an action verb that communicates the activity and outcome, such as
adopt, implement, write, demonstrate, or recite. Other verbs such as understand,
value, or learn broadly describe outcomes but do not represent actions that can be
measured, thus resulting in objectives that are not specific and measureable. Box 6-4
presents more examples of action verbs that are appropriate for use in developing
specific, measurable objectives. Another critical step in developing objectives is to
consider the baseline data to which the outcomes will be compared. This is
important in being able to create objectives that are both achievable and
challenging.25
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
There are different levels of objectives for an intervention: process objectives,

outcome objectives, and impact objectives.22,23,26 The terms for these different levels
of objectives are sometimes used interchangeably in different sources, which can
create confusion. The descriptions and their use presented here is based on
Mobilizing for Action through Planning and Partnerships, a community-wide
strategic planning tool for improving community health developed by the National
Association of County and City Health Officials in partnership with the CDC.27
An outcome objective describes the “level to which a health (or health-related)
problem should be reduced within a specified time period”27 as a result of the
program. Outcome objectives are long term, measurable, and involve mortality,
morbidity, or disability;26 thus, these outcomes are expected to be measured after the
program has been in place. An impact objective expresses the “level to which a
direct determinant or risk factor is expected to be reduced within a specified time
period.”27 Impact objectives are intermediate (1 to 3 years) rather than long term and
are also measurable.27 A process objective is an “action statement aimed at affecting
one or more of the contributing factors that influence the level of risk factors and
determinants.”27 Process objectives are short term (1 year or less) and measurable.
Impact objectives are “comprised of learning (i.e., awareness, knowledge,
attitudes, and skill development), behavioral, and environmental objectives.”22 It is
not necessary to have all these categories of impact objectives in a program. Rather,
the category of impact objectives needed will depend on the nature of the program.22
Learning objectives, also called instructional objectives, explain what the
participants will learn as a result of an educational program. They should tell the
learner or audience what he or she needs to be able to do to successfully
demonstrate achievement of the objective, indicating that learning has occurred.22,23
Learning objectives can address the different learning domains (e.g., cognitive,
psychomotor, and affective) while focusing on expected changes in the learner's
awareness, knowledge, attitudes, and skill development.26 Behavioral objectives
describe what actions participants will take to improve or resolve the health issue,
reflecting changes in “the behaviors of people (what they are doing and saying) and
the products (or results) of their behaviors.”21 Environmental objectives explain how
the emotional, physical, and social surroundings of the community will change after
the implementation of the program.22,23 Refer to Figure 6-2 for an illustration of
these different levels and categories of objectives and an example of each one.
FIG 6-2 Flowchart of program-planning goals and objectives.
Developing goals and objectives is critical to effective community program

planning. Without a clear understanding of the desired outcomes, it is difficult to
plan activities that can result in those outcomes. Also, proceeding without goals and
objectives makes measurement of program success impossible. It is important to be
able to measure success to justify continuation of a program.
Selecting and Planning Effective Health

Interventions to Help Achieve the Objectives
When the primary health issues have been identified and program goals and
objectives have been established with a description of the program outcomes, the
next step is to select and plan health interventions to bring about the desired
results.21-23 This area of program planning describes how the objectives will be
accomplished. An intervention or activity is selected based on best practices, which
are established by evidence of their effectiveness. (Review previous discussion of
the best practices approach earlier in this chapter.) Community involvement and
participation are essential during this step of program planning as well.21-23
In planning these program activities, one must carefully consider the types of
resources available, as well as program constraints. For example, in planning a
school-based fluoride varnish program, available resources might include (1) the
site at which the program will be conducted, (2) supportive personnel at the site, (3)
supplies on hand at the site, and (4) an industry sales representative willing to donate
fluoride varnish. Constraints might include (1) availability of dental personnel to
conduct screenings and apply fluoride varnish, (2) negative attitudes from some
parents, (3) the amount of time children are out of the classroom, or (4) lack of
funding for additional costs. Additional information on development of strategies
for oral health programs and for oral health promotion is presented in detail in
Chapters 8 and 11 and later in this chapter.
Planning is a crucial element to a successful program. A community oral health
program that is well planned, with specific evidence-based interventions, strategies,
and activities, and consideration given to resources and constraints, is more likely
to be successful in terms of implementation and program outcomes.
Implementing the Selected Interventions

The implementation phase of a program includes the ongoing process of putting
the plan into action and monitoring the plan's activities, personnel, equipment,
resources, and supplies.21-23 Feedback from personnel and participants, as well as
ongoing evaluation mechanisms, should be included during the implementation step
to ensure effectiveness of program processes. Called formative evaluation and
sometimes referred to as process evaluation, this type of evaluation provides an
internal assessment of a program and examines the processes, procedures, or
activities of a program as they are taking place either before or during program
implementation. The purpose of formative evaluation is to identify problems and
solutions to assist in revising the program as needed even as it is being conducted.
Implementation, like planning, involves individuals, agencies, and the community
working together. A strategy should be developed for implementation; the questions
in Box 6-5 should be answered in the process of developing the implementation
strategy.21-23
ox 6-5
B
Questi ons to Be A nsw ered duri ng
Impl ementati on Strateg y Devel opment
Question: Why?
• What is the potential effect of the initiative on the health problem?
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?
Question: How much?

• What is the cost estimate of materials and time?
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.
Community Water Fluoridation

Community water fluoridation is 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. Fluoridation is recognized as one of the
top ten public health measures of the twentieth century.30 At the beginning of the
twentieth century, most Americans could expect to lose their teeth by middle age.
That situation began to change with the discovery of the properties of fluoride, the
observation that people who lived in communities with naturally fluoridated
drinking water had far lower dental caries rates than people in comparable
communities without fluoride in their water supply, and the introduction of water
fluoridation and other uses of fluoride for dental caries prevention.30
In the early 1900s, Dr. Frederick McKay first noticed that many of his patients in
Colorado had intrinsic brown stains on their teeth but few if any decayed teeth. He
surveyed his practice area to establish the prevalence of this Colorado brown stain,
later called mottled enamel. Dr. McKay determined that it was only present in long-
term residents and most prevalent where deep artesian wells were the source of
drinking water. By the 1920s, Dr. McKay reached the conclusion that the etiologic
agent had to be a constituent of some community water supplies.31
By the 1930s new methods of spectrographic chemical analysis of water had
developed, and a chemist with Alcoa Chemical identified fluoride (F) as the
common constituent of the water samples. The amounts of fluoride in Colorado
water ranged up to 14 parts per million (ppm) or 14 mg F per liter of water.31
In the 1930s Dr. H. Trendley Dean was appointed to the newly established National
Institutes of Health Dental Hygiene Unit (now the National Institute of Dental and
Craniofacial Research) to conduct research on fluorosis and dental caries. Through
epidemiologic studies he determined the prevalence of fluorosis nationwide and
demonstrated the relationships among mottled enamel, water fluoride concentration,
and dental caries rates. Additionally, he renamed the condition fluorosis, developed
the Dean's Fluorosis Index to document it, built a database of many water samples
nationwide to determine that only fluoride could be related to fluorosis, established
the minimal threshold (amount incapable of causing fluorosis) as 1 ppm F in the
water, and defined 1 ppm F as “the permissible maximum” level of fluoride.
Through further research in the 1940s, Dr. Dean also determined the minimum level
of naturally occurring fluoride that resulted in dental caries reduction.31
Fluoride is the thirteenth most abundant natural element; it is found in rocks, soil,
fresh water, ocean water, and virtually all plants and animals. Therefore, trace
amounts of fluoride are found in all natural water sources. Many community water
supplies are reservoirs of collected surface water and do not have adequate levels of
fluoride. Nevertheless, as a result of the general availability of these public water
sources to most people, the adjustment of the natural fluoride content found in the
water to optimal levels has proved to be a successful public health measure. This
approach provides fluoride to the population, with minimal regard to
socioeconomic factors, in a passive vehicle for the consumer that has been proven
to be safe and cost effective.30,32
Effectiveness of Water Fluoridation

The first city in the U.S. to adjust the fluoride content in the community water supply
was Grand Rapids, Michigan, in the 1940s. Subsequent studies of adjusted
fluoridation demonstrated a 50% to 70% reduction of dental caries in the permanent
teeth of children. To illustrate this marked caries preventive effect, Figure 6-3
shows the relationship between the percentage of the population residing in areas
with fluoridated community water systems in the U.S. and the mean number of
decayed, missing, and filled teeth (DMFT) among children aged 12 years in the U.S.
from 1967 to 1992. The average number of DMFT steadily declined from 1967 to
1992 because of the increase in water fluoridation during that period.33,34
FIG 6-3 Association of the percentage of the U.S. population residing in areas with
fluoridated water systems and the mean decayed, missing, and filled tooth index
(DMFT) among children 12 years old, 1967 to 1992. (Data from Centers for Disease
Control and Prevention (CDC) Fluoridation Census, 1993; CDC: Third National Health and Nutrition
Examination Survey, 1988 to 1994; National Center for Health Statistics, 1974 and 1981; and
National Institute of Dental Research, 1989.)
Today decay reduction rates in fluoridated communities are approximately 25%

for children and adults.30 Although the benefits of water fluoridation are lower
today because of the multiple other sources of fluoride that are available to the
population, it is still recommended as the most effective population-based means of
preventing dental caries and is consistently effective across all socioeconomic
strata. These conclusions are based on an updated systematic review of water
fluoridation studies.35 Research also has shown that children living in
nonfluoridated communities in states that are highly fluoridated receive partial
benefits of fluoridation from eating foods and drinking beverages processed in
fluoridated communities. One study demonstrated that 12-year-old children living in
states where more than half of the communities were fluoridated had 26% fewer
decayed tooth surfaces per year than 12-year-old children living in states where less
than one quarter of the communities were fluoridated.30
Over the years water fluoridation has resulted in improved overall oral health. As
decay rates decreased, tooth loss and iatrogenic causes of periodontal problems
were reduced as well. In addition, water fluoridation has resulted in lower
expenditures for dental restorative procedures and fewer absences from school and
work resulting from oral pain, with a subsequent increase in learning and
productivity.34 An indirect benefit has been greater job satisfaction for dental
personnel based on the ability to focus on prevention and a variety of other oral
conditions.36
The safety and benefits of fluoride are well documented and have been
reevaluated frequently and reviewed comprehensively by several scientific
organizations. No credible evidence supports an association between fluoridation
and any potential adverse health effect or systemic disorder such as increased risk
for cancer, Down syndrome, heart disease, osteoporosis and bone fracture, immune
disorders, low intelligence, renal disorders, Alzheimer's disease, or allergic
reactions.33
Mechanisms of Action of Fluoride

The primary mechanism of action of fluoride in caries inhibition is posteruptive.31
Systemic fluoride is excreted partially via the saliva, thus making it available for
absorption by plaque and in frequent contact with tooth surfaces for continual
uptake and remineralization of the enamel. Because small quantities of fluoride are
consumed throughout the day through water and foods that absorb fluoridated water
during irrigation or while cooking, fluoridated water provides a continual source
of topical fluoride to the teeth.31
A secondary effect of fluoride for caries inhibition is the preeruptive replacement
of hydroxyapatite with fluorapatite during the enamel crystalline matrix formation
of the developing tooth. There is current evidence that systemic exposure to fluoride
during tooth development reduces dental caries rates in the population.31 At one
time, the caries-inhibitive properties of fluoride were attributed almost exclusively
to this preeruptive effect. Today, however, it is accepted that the posteruptive effect
on caries prevention is far greater compared with the preeruptive effect.31
Another topical effect of fluoride is the inhibition of glycolysis in
microorganisms, thereby hindering the ability of bacteria to metabolize
carbohydrates and produce acid.31 The continual presence of fluoride in plaque is
important to this process, as well as for remineralization. Drinking fluoridated
water and using fluoride toothpaste are the major contributors of the fluoride that is
available in plaque and saliva.37
Because the posteruptive effect is the primary benefit, the benefits of water
fluoridation continue through life as long as consumption of fluoridated water
continues. If fluoridation is discontinued or a city changes to a nonfluoridated water
source, the caries reduction benefits are lost and caries rates will increase.31 This
posteruptive effect also explains how fluoridation reduces coronal and root caries
in adults.
Fluoridated Communities
In the 1950s and 1960s, many states and cities in the U.S. were quick to implement
community water fluoridation programs. In the next years this trend began to level
off. Fluoridation decisions are currently left to states and frequently to local
governments and city councils. Therefore, the expansion of fluoridation is not
easily accomplished and requires decisions at various levels. Increases in
community water fluoridation in the last few decades can be attributed to the
emphasis on its importance in caries prevention as discussed in the various national
reports and recognized in the Healthy People oral health objectives.2,3,10
Nearly all developed countries practice fluoridation. However, water fluoridation
is not feasible in many other countries where community water supplies do not
exist. The World Health Organization recommends water fluoridation where
feasible, and the use of salt or milk to deliver fluoride as an alternative when
necessary.33
The Healthy People 2020 objective for water fluoridation is to increase the
proportion of the population served by community water systems with optimally
fluoridated water to the target goal of 79.6% of the population by 2020.10 The CDC
periodically releases data related to this goal. In 2012 approximately 282.5 million
people were served by community water systems, and 210.6 million (74.6%) were
on fluoridated drinking water systems30 (Box 6-6). Table 6-3 presents a distribution
of the number of states with various proportions of the population that have access
to water fluoridation, showing that 52.9% of the states met the Healthy People 2020
goal in 2012. Detailed data for the various reporting periods for the nation and by
state can be accessed by visiting the CDC website, Reference Statistics on Water
Fluoridation Status, at http://www.cdc.gov/fluoridation/statistics/reference_stats.htm.
See Chapter 5 for additional information about current community water
fluoridation.
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
Pe rc e nt of Population Numbe r of State s Pe rc e nt of State s

<25.0% 3 5.9%
25.0%-49.9% 5 9.8%
50.0%-74.9% 16 31.4%
≥75.0% 27 52.9%
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.
Several state health departments have fluoridation projects that assist

communities in their efforts to assess the need for fluoridation, as well as in the
design, implementation, evaluation, and funding of fluoridation of their public
water systems. The state fluoridation staff also provides consultation for local
fluoridation campaigns and assists with training and technical assistance for local
water facility operators.38
Cost of Water Fluoridation

An evaluation of the cost of water fluoridation published in 1992 reported a range
of cost depending on the size of the population.39 Cost differences result from the
various types of equipment and chemicals that are required to add fluoride to
different size water systems.39 Cost figures are adjusted for inflation to estimate
current cost (Table 6-4).
TABLE 6-4
Estimated Annual Per Capita Cost for Community Water Fluoridation,
1992 and 2015*
Community Population Siz e Cost/Pe rson

1992 2015
<10,000 (small systems) $3.00 $5.09
10,000-50,000 (medium-siz e systems) $0.98 $1.66
>50,000 (large systems) $0.68 $1.15
*
2015 cost computed by adjusting for inflation on CPI Inflation Calculator. Washington, DC: Bureau of Labor
Statistics Databases, Tables & Calculators by Subject; n.d.
Available at http://www.bls.gov/data/inflation_calculator.htm. Accessed November 2015.
The return on investment is a more important factor in determining the cost-

effectiveness of community water fluor idation. This also varies with the size of the
community, increasing as the community size increases. Community water
fluoridation is cost-saving, even for small communities. An economic evaluation
published in 2001 estimated an annual per person cost savings ranging from $16 in
very small communities of 5000 or less to nearly $19 for larger communities of
20,000 or more.30 With the escalating cost of health care, community water
fluoridation remains a preventive measure of minimal cost, saving more than it
costs. In determining the economic importance of fluoridation, it is important to
remember that the cost of treating dental disease is paid not only by the affected
individual but also by the public through health departments, health insurance
premiums, federally supported programs such as Medicaid and CHIP, and publicly
supported community-based clinics.
Optimal Level of Fluoride

In 1962 the DHHS recommended levels for water fluoridation ranging from 0.7 to
1.2 ppm F (equivalent to 0.7 to 1.2 mg F per liter of water [mg/L]), depending on the
average daily temperature for the area. The range was based on the hypothesis that
water consumption increased with increasing climatic temperature.40 This
recommendation remained in place until 2015, when the Public Health Service
issued the final recommendation that the optimal fluoride level be changed to
0.7 mg/L regardless of climatic conditions.32 The reasons for the recommended
change were (1) an increase in access to multiple sources of fluoride today, (2) a
trend of increasing prevalence of fluorosis in the population attributed to the
multiple sources of fluoride, and (3) the controlled climatic environment with air
conditioning, resulting in similar water intake across the nation regardless of
climatic conditions.32 (See Measurement of Access to Water Fluoridation section
and Box 4-13 in Chapter 4 for more details.)
As a safe drinking water standard the Environmental Protection Agency (EPA)
requires defluoridation when the natural fluoride level of the community water is
greater than 4.0 mg/L. To reduce the risk of fluorosis, the EPA recommends
defluoridation when the natural fluoride level of the community water is between
2.0 and 4.0 mg/L.41 (See Chapter 5 for further discussion of fluorosis.)
Example of a Community Water Fluoridation Program

An example of a state that has successfully adopted fluoride into its community
water systems is Indiana. The Indiana State Department of Health (ISDH) gave
community water fluoridation a high priority and reached the Healthy People water
fluoridation objective in the 1970s.42 The budget for the program is supported by a
Maternal and Child Health Services block grant.43 The state of Indiana currently
provides fluoridated water to over 4.3 million people via almost 300 public water
systems, 20 rural school water systems, and 90 naturally fluoridated public water
systems throughout the state.42 A total of 96% of Indiana residents served by public
water systems and who reside in areas with optimal levels of naturally occurring
fluoride have access to fluoridated water.42
The ISHD Fluoridation Program staff provides surveillance, training, and
technical assistance to schools and owners and operators who fluoridate their public
water supplies. Important evaluation measures of the program are ongoing
surveillance visits to monitor the amount of fluoride levels in the community
drinking water and regular DMFS surveys to evaluate the success of the program in
terms of reduced dental caries rates.43 Indiana's tooth decay rate declined by 75%
during the 25-year period before 2002.38
The successful implementation of this program can be attributed to effective
assessment, planning, implementation, and evaluation procedures. Assessment of the
community needs and feasibility studies provided the necessary data for effective
program planning. The cooperative efforts of professionals, city officials, and
citizens resulted in positive voluntary voting for the implementation of community
water fluoridation. The efforts of dedicated professionals, including dental
hygienists fulfilling the roles of health educators and consumer advocates, have
played and continue to play an important role in the continuing success of
fluoridation in Indiana.
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
Antifluoridationists attempt to appeal to people's emotions by providing

inaccurate, false information to the public and elected officials and attempting to
link fluoridation with adverse health effects. Using evidence-based methods of
health communication (see Chapter 8), dental hygienists in the roles of educators,
resource persons, and advocates can influence the public knowledge about the
benefits of fluoridation in their community, provide accurate scientific information
to community officials, and influence future fluoridation decisions.
For antifluoridationists to be defeated, community education must be executed in
a well-planned, unified manner. As active members of ADHA and the local
components, dental hygienists can be an effective force in the community. An
organized plan of action can make a difference. The California Dental Association
(CDA) Foundation, a nonprofit organization founded to improve the oral health of
all Californians by supporting the dental profession in its efforts to meet community
needs, has published a planning guide for water fluoridation campaigns.44
Community organization, developing a broad base of community partners, being
aware of the issues, and being well versed on fluoridation studies and cognizant of
the political process are necessary steps in winning a fluoridation campaign.
Dental hygienists have a professional responsibility to take an active role in
assuring the passage and continuation of community water fluoridation in their own
communities as part of meeting the ADHA ethical code to “promote access to dental
hygiene services for all, supporting justice and fairness in the distribution of
healthcare resources.” In addition to community education, this can be accomplished
by being a spokesperson for fluoridation with patients, family, and friends. Multiple
water fluoridation resources are available to help oral health professionals fulfill
this responsibility. Some of these resources are the following:
• State oral health programs provide assistance with fluoridation campaigns;38 this
support is available through one's state health department.
• The ADA is launching a social media campaign in response to the threat of
escalating organized negative social media regarding fluoride coming from
antifluoridationists in local communities nationwide.45
• The ADA offers a toolkit to help local organizations and coalitions involved in
initiating or trying to retain community water fluoridation programs. Tap in to
Your Health: Fluoridation Toolkit contains more than 30 ready-to-use resources
and tips on using social media.45
• The Campaign for Dental Health website sponsored by the American Academy of
Pediatrics provides information on the science and technical aspects of
fluoridation and suggested actions for physicians and others to advocate for
fluoridation (see Additional Resources at the end of this chapter).
• The CDC's Division on Oral Health provides technical assistance; help with
responses to questions regarding community water fluoridation; resources; and
links to resources from other federal government agencies, state programs, and
professional organizations and associations (see Additional Resources at the end
of this chapter).
Some states and cities have taken administrative action to implement fluoridation;
this means that state legislatures or city government entities have voted to
implement fluoridation. People usually prefer to have a voice in the decision
making process. However, avoidance of a fluoridation referendum (a public vote)
has been recommended because of their low success rate.36 Less than 41% of
fluoridation referendums from 1950 to 2010 successfully resulted in passage of
water fluoridation.46 If fluoride is on the ballot as a referendum, people need to be
educated on the issue to make a wise decision and encouraged to go to the polls to
vote.
More recently communities have had to defend existing fluoridation that has been
challenged by antifluoridationists. The ADA reported that between 2011 and 2014,
46 states in the U.S. faced fluoridation challenges at the state or local level.45 A
report of key lessons learned from these campaigns, Community Water Fluoridation
Brief: Highlights and Lessons Learned from 2014, can serve as a guide for
communities facing similar challenges.47 The report outlines questions to ask and
factors to consider in relation to the following five basic components of a
successful campaign: (1) understand the local context, (2) involve key players, (3)
establish a strategy, (4) obtain necessary funding, and (5) understand the opposition.
Whether by referendum or administrative action, education is crucial to the success
of a fluoridation campaign.
Other Fluoride Programs

Water fluoridation and fluoridated toothpaste have historically been the most
common sources of fluoride in the U.S.37 Additional fluoride measures such as
mouthrinses, dietary supplements, and fluoride varnishes are recommended for at-
risk populations or individuals.48,50 Because of the ready availability of fluoride
toothpaste to the public and its intense marketing by manufacturers, distribution of
fluoride toothpaste is not considered cost effective as a public health program.36 The
effectiveness of these various fluoride modalities in the reduction of dental caries is
shown in Box 6-7. The addition of multiple sources of topical fluoride to water
fluoridation has an additive effect on caries inhibition and can be beneficial to
reduce caries in high-risk individuals and populations.48 It is important to remember
that even though other sources of fluoride are available and despite the increased
risk of fluorosis with the availability of multiple sources of fluoride, community
water fluoridation remains the most cost-effective, most practical, safest means of
preventing tooth decay.30,32
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.*
• Fluoride toothpaste: Clinical trials conducted between 1945 and 1985

demonstrated a 23% to 32% reduction in caries.*
• Fluoride varnish: A 2013 Cochrane review showed moderate quality evidence of

a 43% average reduction of DMFS in children and adolescents with permanent
teeth and a 37% average reduction in decayed, missing, and filled surfaces
(DMFS) in primary teeth.†
*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:
• Low socioeconomic status
• Ethnic minority status
• Speaking English as a second language
• Homeless or in otherwise unstable living conditions
• Limited education
• Special healthcare needs
• Lack of access to fluoridated water or fluoride toothpaste

• Lack of access to dental care
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.
An example is a school-based fluoride varnish program conducted by Texas

Woman's University dental hygiene students at Denton Christian Preschool (DCP), a
local nonprofit preschool for 3- and 4-year-old children from low-income families
with multiple other population caries risk factors54 (Figure 6-4). The program is set
up in an extra classroom of the facility with a minimum of resources. Children are
screened and receive fluoride varnish application twice a year. The program
includes classroom education and orientation to the varnish application in all 3- and
4-year-old classes and a parent education program. In addition, children brush daily
at school, supervised by DCP staff, and oral hygiene supplies are sent home to
assure that children have the necessary tools to brush at home. DCP staff personally
contact the parents of children who are identified during the screening as needing
urgent dental care. The program was started as a student project with financial
assistance from a local dental hygiene society55 and continues today with support of
the collaborating partners and in-kind donations of supplies.
FIG 6-4 Dental hygiene students apply fluoride varnish in a preschool program for
at-risk children, set up in an extra classroom of the facility. (Photograph courtesy
Christine French Beatty.)
Because of the established effectiveness of fluoride varnish, program

administrators should concentrate evaluation efforts on the ability to apply varnish
multiple times, acceptability, and cost effectiveness of the program.52 Children
enroll at DCP as 3-year-olds and typically continue in the program for 2 years,
receiving oral health education, screening, and fluoride varnish application twice a
year. The DCP program has experienced 95% to 100% participation of children
during varnish application over the last 8 years as a result of the orientation and
education phase (Figure 6-5) and teacher involvement in the program (Figure 2-5 in
Chapter 2). Resources to assist with development of a fluoride varnish program are
included in the References and Additional Resources at the end of this chapter.
FIG 6-5 Providing education in conjunction with a preschool-based fluoride varnish
program increases student compliance during the varnish application
phase. (Photograph courtesy Christine French Beatty.)
Fluoride Mouthrinse Programs

In communities in which a public water source is not available or community water
fluoridation is undesired for various reasons, school-based fluoride mouthrinse
programs have been implemented, offering the benefits of fluoride in a structured
environment.56 Such programs are a cost-effective means of providing fluoride
benefits for children. These programs are less common in the U.S. today because of
the increased adoption of water fluoridation. A school-based program requires
involvement and cooperation of school personnel, oversight by a licensed oral
health professional according to the individual state laws, and parental permission
for participation of children.57
Mouthrinse programs are administered by school personnel or volunteers on a
weekly basis to participating children. The children rinse for 60 seconds with 10 ml
of 0.2% sodium fluoride. The fluoride rinse is then expectorated into a paper cup, a
napkin is placed inside the cup to absorb the solution, and the cup is discarded. The
procedure takes less than 5 minutes.58 Many state and local health departments have
manuals to guide the planning and implementation of school-based fluoride
mouthrinse programs (see References and Additional Resources at the end of the
chapter).
Dietary Fluoride Supplements
The use of dietary fluoride supplements is another popular way of providing
fluoride to children. These supplements are available only by prescription. Dietary
fluoride supplements are recommended only for children living in nonfluoridated
areas to increase their fluoride exposure to a level equivalent to children who live in
optimally fluoridated areas.59 Limiting their use to nonfluoridated areas will
decrease the risk of dental fluorosis in permanent teeth.60
Supplements are available in two forms: (1) drops for infants aged 6 months and
older and (2) chewable tablets for children and adolescents. The correct dosage is
based on the child's age and the existing fluoride level in all available drinking
water sources, including water in the home, bottled water, and water at the school or
day care center and after-school care program (Table 6-5).61 The ADA has stated,
“The new recommendation (the PHS guideline of 0.7 mg F per liter of water for
water fluoridation released in April 2015), which was supported by the ADA, does
not change the ADA Council on Scientific Affairs' systematic review and clinical
recommendation for the use of dietary fluoride supplements that was released in
2010.”61
TABLE 6-5
Dietary Fluoride Supplement Schedule, 2010
Fluoride Ion Level in Drinking Water (ppm *)

Ag e <0.3 ppm 0.3-0.6 ppm >0.6 ppm
Birth-6 mo None None None
6 mo-3 yr 0.25 mg/day † None None
3-6 yr 0.50 mg/day 0.25 mg/day None
6-16 yr 1.0 mg/day 0.50 mg/day None
*
1.0 part per million (ppm) = 1 milligram/liter (mg/L).
†
2.2 mg of sodium fluoride contains 1 mg of fluoride ions.
Data from Fluoride Supplements. Chicago, IL: American Dental Association. Available at www.ADA.org.
Accessed June 2015; Guideline on Fluoride Therapy. Chicago, IL: American Academy of Pediatric
Dentistry; 2012. Available at http://www.aapd.org/media/Policies_Guidelines/G_fluoridetherapy.pdf.
Accessed June 2015.
All sources of fluoride should be evaluated with a thorough fluoride history

before dietary fluoride supplementation.61 Patient exposure to multiple water
sources can make proper prescribing complex. The need for continuation of
fluoride supplements should be reevaluated in the event of a child's change of
residence or increasing access to other sources of systemic fluoride. Ingestion of
higher than recommended levels of fluoride by children has been associated with an
increase in mild dental fluorosis in developing, unerupted teeth (see Chapter 5).
The need for daily compliance over an extended period of time is a major
procedural and economic disadvantage of community-based fluoride supplement
programs.61 This liability makes them impractical as an alternative to water
fluoridation as a public health measure. Although total costs of the purchase of
supplements and administration of a program are small, compared with the
installation and startup costs associated with fluoridation equipment, the overall cost
of supplements per child is much greater than the per capita cost of community
water fluoridation. Additionally, community water fluoridation provides dental
caries prevention for the entire population regardless of age, socioeconomic status,
educational attainment, or other social variables.30 This is particularly important for
families and individuals who do not or cannot access regular oral health services.
School-based fluoride supplement programs were common several decades ago
before water fluoridation became more prevalent. Though less common today,
these programs are still utilized in some nonfluoridated areas.62
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)
• Encourage parents, caregivers, and school/Head Start personnel to supervise

children's toothbrushing to reduce the swallowing of excess toothpaste
• Target mouthrinses to children at high risk for developing tooth decay
• Prescribe fluoride supplements judiciously
• Advocate for the labeling of the fluoride concentration of bottled water
• Know the fluoride concentration of children's primary source of drinking water to

be able to make appropriate decisions about using other fluoride products,
especially dietary fluoride supplements
• Use an alternative source of water for children ≤8 years old whose primary
drinking water has a fluoride level >2 mg/L
• Collaborate with professional healthcare organizations, public health agencies,

and suppliers of oral care products in the education of healthcare professionals
and the public
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
Topic Re c omme ndations

Indications for sealant Seal sound and noncavitated pit and fissure surfaces of posterior teeth, with first and second permanent molars receiving
placement highest priority.
Tooth surface assessment Differentiate cavitated and noncavitated lesions:
• Unaided visual assessment is appropriate.
• Dry teeth before assessment with cotton rolls, gauz e, or compressed air when available.
• An explorer may be used to gently confirm cavitations.
• Radiographs are unnecessary solely for sealant placement.
• Other diagnostic technologies are not required.
Sealant placement and Clean the tooth surface:
evaluation • Toothbrush prophylaxis is acceptable.
• Additional surface preparation, such as air or enameloplasty, is not recommended.
• Use a four-handed technique when resources allow.
• Seal the teeth of children, even if follow up cannot be assured.
• Evaluate sealant retention within 1 year.
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.
Oral Health Education

Oral health education is the process of teaching people about oral health directed
at helping them prevent oral disease. The intent of oral health education is to assist
people in making decisions about their oral health and to choose behaviors
conducive to maintaining this health. Oral health education should focus on
intervention and stress skill acquisition and adoption of evidence-based risk-
reducing behaviors. Various factors, including social factors, attitudes, and the
environment, influence these decisions and affect the outcomes of oral health
education.4 Thus, for oral health education to be effective, it must be based on sound
health promotion and health education theory (see Chapter 8).
Many large-scale oral health education programs have been focused on children
with the thought that they are the future of society. The school setting is ideal to
reach children and, through them, their families, community members, and
organizations.67 Therefore school-based oral health education has been an important
component of the goal of optimal oral health for all citizens. Oral health education
should be an integral component of school health education curricula and school-
based oral health services such as dental sealants and treatment programs.68
Other community-based opportunities for oral health education are available
through various faith-based, community-based, social service, healthcare, and
policymaking organizations and groups such as the WIC Program, HS, service
clubs, scouting and similar organizations, other youth organizations, sports clubs,
hospitals, clinics, long-term care facilities, city councils, and other governmental
groups. Oral health education can be directed to the public, other health
professionals who provide care for the public, and policymakers. Information about
diverse oral health topics can be presented in these settings and targeted to various
priority populations, for example:
• Prenatal and postnatal oral care for parents, infants, and toddlers
• Oral health concerns of special care patients such as human immunodeficiency
virus (HIV) and stroke
• Oral and denture care for older adults
• Oral health effects of tobacco and oral cancer information
• Daily oral care needs of institutionalized physically and mentally challenged
individuals
• Diet and nutrition related to oral health for all stages of life
• Oral-systemic link for other healthcare professionals
• Information on access to oral health care presented to policymakers
• Water fluoridation information presented to a city council or similar municipal
group
• Oral hygiene procedures for a HS program
The dental hygienist in the role of health educator uses the knowledge of primary
preventive measures to inform people about how to improve their oral health.
Keeping updated on health promotion and educational theory and available
resources and health education programs for special populations in the community
is as important as staying up-to-date on the dental and dental hygiene science of oral
diseases and prevention.
Developing an Oral Health Presentation

Careful planning is required to develop effective oral health education presentations
for the community. Structured oral health curricula and other resources for oral
health education are available to oral health professionals, other healthcare
professionals, and school nurses through state oral health programs, oral health
professional organizations such as ADA and ADHA, oral health coalitions and
nonprofits such as Oral Health America, universities, CDC and other federal
agencies, and oral health industry companies such as Colgate and Crest/Oral B.
Many of these materials can be adapted for use in presentations. See Additional
Resources at the end of this chapter and in Appendices A and D-1 for examples of
resources that can be used in developing community oral health presentations.
These resources can be used to develop a lesson plan, which is a necessary step in
planning an oral health presentation.69 An outline of a lesson plan is provided in
Box 6-10 to serve as a guide. The components of the lesson plan should be based on
the assessment of the audience to assure that the presentation is relevant to their
needs.
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
• Allows interaction among participants • Strong personalities can influence a group

• Provides two-way communication between presenter and audience • Poor discussion leader may contribute to failure of the discussion
• Encourages individuals to participate/contribute • Nothing may be achieved; discussion may go in many directions without closure
• Engages participants in problem solving (higher order learning) • May not be profitable if group members do not have appropriate background
• Encourages teamwork, tolerance of divergent opinion, and • Difficult to manage among young children
development of interpersonal skills
• Can be focused on both cognitive and affective learning
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.)
An example of such a program is Miles of Smiles—Laredo (MOS-L), which is a

school-based oral health promotion program for children attending economically
disadvantaged elementary schools in the city of Laredo and Webb County in Texas.70
In existence since 2007 and funded by HRSA, MOS-L is a collaborative program
that is part of a larger Miles of Smiles program serving San Antonio, Texas, as
well. The multiple partners of MOS-L are the University of Texas Health Science
Center at San Antonio (UTHSCSA) School of Dentistry, the City of Laredo Health
Department, the United Independent School District of Webb County, the Laredo
Independent School District, and Gateway Community Health Center, Inc.
The objectives of Miles of Smiles are the following:70
• To plan, develop, implement, and evaluate a model community-based oral health
program that utilizes public-private partnerships
• To disseminate this model to other Texas communities
The MOS-L program has multiple components, including oral screening, oral
health education, dental sealants, fluoride varnish, and dental referral. Services are
provided with the use of portable dental equipment transported and assembled on-
site at elementary schools. During the 2011 to 2012 school year, MOS-L provided
services to over 2000 children who received over $100,000 worth of dental
services, and approximately 100 children with urgent oral health needs were
referred for dental treatment.70 Currently, approximately 8500 children receive
services annually in the MOS-L program as a result of program expansion funded
by an HRSA grant.70
Children in kindergarten through third grade receive a limited oral evaluation
and dental screening using the ASTDD Basic Screening Survey (BSS; see Chapter
4). The BSS for school children includes measures for untreated decay, treated
decay, dental sealants on first permanent molars, and urgency of need for dental
care. The BSS is used nationally as a dental public health surveillance tool to
measure and monitor oral disease and evaluate program achievement of Healthy
People 2020 objectives.
SmilesMaker, an innovative electronic data entry tool, was created for use by the
Miles of Smiles program to record longitudinal BSS data.70 The MOS-L dental team
uses iPads to access SmilesMaker and enter screening data through a secure and
encrypted connection to the UTHSCSA server. SmilesMaker is available free to
other community oral health programs by contacting Miles of Smiles on the web at
https://milesofsmiles.uthscsa.edu/SmilesMaker.php.70
Dental sealants are placed on the first permanent molar teeth of second-grade
children. Third-grade children who had dental sealants placed the previous year
through the MOS-L program are examined during the BSS screening for sealant
retention, and sealants that are lost are reapplied. Kindergarten through third-grade
children also receive classroom and individual oral health education and fluoride
varnish application. In addition, information on oral health is provided to parents.
This school-based oral health promotion program, including the placement of
dental sealants, is conducted entirely in the school setting. School-based dental
programs assure highly effective access to dental services through an evidence-
based delivery approach.67 The program is designed to maximize participation by
targeting high-risk children unlikely to receive routine dental care in clinical
settings that are not school-based. Bringing preventive dental services on-site
through the use of portable dental equipment is a more cost-effective approach and
eliminates barriers associated with the lack of transportation, limited service hours,
and access to dental providers.
Appropriate referrals are made for children who need restorative or emergency
care. Children with urgent and routine oral healthcare needs identified during the
BSS screening and who do not have a regular dentist are triaged into a case
management system. Dental case managers and staff contact the parents and identify
a source of dental care using public-private partnerships. School nurses are
incorporated into the case management process.
The success of a school-based oral health promotion program depends on the
integration of the program with other school health programs. The CDC Division
of Adolescent and School Health have endorsed eight interactive components as
essential elements of a coordinated school health program71 (CSHP; Figure 6-7).
The school can therefore be the facility where families, healthcare professionals,
youth organizations, teachers, and other staff can interact to maintain the well-being
of children and families. According to ASTDD policy, CSHP should “utilize a
strategic effort to improve students' oral health by ensuring that oral health
education, prevention, and/or treatment programs are integrated into each
component of the CSHP model.”67,68
FIG 6-7 Oral health is integrated into coordinated school health programs. (Source:
Components of Coordinated School Health. Atlanta GA: Centers for Disease Control and
Prevention, Adolescent and School Health; 2015. Available at
http://www.cdc.gov/healthyyouth/cshp/components.htm. Accessed June 2015.)
Head Start
The Head Start (HS) program provides a unique opportunity to reach preschool
age children with school-based oral health programs. Dental hygienists can be
involved at multiple levels (Figures 6-8 and 6-9).
FIG 6-8 Head Start children will benefit from fluoride varnish programs. (Photograph
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.)
Head Start Program Description

HS was founded in 1965 as part of President Johnson's War on Poverty. Congress
passed the most recent HS Reauthorization Act in 2007, set to run through 2012.
Congressional funding has continued since 2012 even though the program has not
yet been reauthorized by Congress.72
The HS program was designed to break the cycle of poverty by providing a
comprehensive early learning program for preschool aged children of low-income
families. Beginning as a summer program before kindergarten, it has progressed to
a full-time year-round program for 3- and 4-year-old children. HS programs
promote school readiness by enhancing the social and cognitive development of
children through the provision of educational, health, nutritional, social, and other
services to enrolled children and families. Recognizing the mounting evidence of
the importance of the earliest years to a child's growth and development, Early
Head Start (EHS) was established in 1995 to serve children from birth to age 3.
Parents are an integral part of these programs, engaging in their children's learning,
learning about effective parenting skills, and making progress toward their own
educational, literacy, and employment goals.73
Eligibility for HS and EHS services is based on a family income at or below
100% of the FPL, which was $23,850 for a family of four in 2014.72 The age and
racial/ethnic composition of children in HS programs is presented in Table 6-8.
Many HS families are non-English speaking; in 2014 30% of HS children were
from families that primarily spoke a language other than English at home, and 25%
were from families that spoke mainly Spanish.73
TABLE 6-8
Head Start Program Statistics, 2014
Total Enrollme nt 1,076,000

Ag e s*
Pregnant women 1%
5 years old and older 1%
4 years old 46%
3 years old 35%
2 years old 7%
1 year old 5%
Younger than 1 year old 4%
Rac ial/Ethnic Composition*
White 43%
Black/African American 29%
Unspecified/Other 13%
Bi-Racial/Multi-Racial 9%
American Indian/Alaska Native 4%
Asian 2%
Hawaiian/Pacific Islander 0.6%
Ethnic ity
Hispanic or Latino Origin 62%
Non-Hispanic/Non-Latino Origin 38%
*
Percentage does not total 100% because of rounding.
Data from Head Start: Program Facts Fiscal Year 2014. Washington DC: Head Start Early Childhood
Learning & Knowledge Center; 2015. Available at http://eclkc.ohs.acf.hhs.gov/hslc/data/factsheets/2014-
hs-program-factsheet.html. Accessed July 2015.
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.
Oral Health Services

In recognition of the critical importance of oral health for young children, certain
requirements related to oral health are incorporated into the Head Start Program
Performance Standards74 (Box 6-12). Children learn about toothbrushing through
required daily brushing at school after meals (Figure 6-10) and parents receive oral
health education and encouragement to support preventive oral health practices at
home.74 Also local HS programs are required to work with every enrolled family to
establish a dental home and assure that children receive dental examinations,
necessary treatment, monitoring, and preventive measures such as fluoride.74
National data indicate that the number of HS children with a dental home increased
significantly during the 2013-2014 program year.73
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.
• Provide assistance to parents related to obtaining prescribed medications and

supplies related to dental conditions.
• Include dental follow up and treatment as recommended by a dental professional.
• Provide follow up for fluoride supplements, topical fluoride treatments, or other

necessary preventive measures if a lack of adequate fluoride level is determined
or for every child with moderate to severe tooth decay.
• Respond to each child's individual needs based on dental evaluations and

treatments.
• Establish and implement policies and procedures for rapid response to dental
emergencies with which all staff are familiar and trained.
• Implement effective oral hygiene (toothbrushing) among children after meals.
• Provide oral health education programs for program staff, parents, and families.
• Assist parents in understanding how to enroll and participate in ongoing family

dental care.
• Encourage parents to become active partners in their children's oral healthcare
process and to accompany their child to dental examinations and appointments.
• 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.”
These challenges can be minimized by maintaining open and clear

communication between HS staff, oral health professionals, and parents.75 The OHS
has employed a variety of strategies to support HS programs in meeting the
performance standards, including establishing partnerships with federal agencies
with oral health expertise, such as the HRSA Maternal and Child Health Bureau or
DHHS, and providing training and technical assistance through a national network
of providers.
For example, in 2011 Pennsylvania's Healthy Smiles, Happy Children: A Dental
Home for Every Child Oral Health Initiative was awarded funding through the OHS
to establish a collaborative program designed to connect HS children and families
with dental providers to create dental homes.76 The goals of the program are to (1)
establish oral health coalitions across the state, (2) provide oral health education for
staff and families, (3) improve medical/dental collaboration locally statewide, and
(4) establish a dental home for HS children. Because of the program's success, in
2012 the Pennsylvania and Massachusetts Head Start Associations received a
DentaQuest Foundation Grant to replicate the Pennsylvania program in
Massachusetts.76
Dental Hygienists Working with Head Start

As licensed professionals, dental hygienists are a valuable resource to HS
programs. Their services can potentially include providing and coordinating
screenings, preventive services, education, and referral for treatment; assisting in
the coordination of follow-up care; providing leadership for the HSAC, and
advocating for the HS children and families. They can facilitate finding and
establishing dental homes that will allow the HS child an opportunity to receive
comprehensive oral health care.77 Dental hygienists working with HS are enabling
the HS grantee to meet the oral health–related performance standards and to bring
improved oral health to every HS child.74
Examples of programs where dental hygienists are involved with finding dental
homes for HS children are seen nationwide. Many states have adopted less
restrictive practice acts to allow dental hygienists to work in public health settings,
including HS. Promoting expanded practice settings and removing restrictive
supervision barriers are essential to the success of improving the oral health of
underserved populations.78
The National Maternal & Child Oral Health Resource Center's HS activities are
supported by the intraagency agreement between the OHS and the Maternal and
Child Health Bureau of HRSA with the goal of enhancing the quality of oral health
services for pregnant women, infants, and children enrolled in HS. The resource
center has developed a wealth of educational materials, such as brochures for
pregnant women and parents of infants and young children, tip sheets for HS staff
and parents, and fact sheets. These resources can assist dental hygienists who wish to
become involved in HS programs (see Additional Resources at the end of this
chapter).
Secondary and Tertiary Oral Health
Prevention Programs
Dental Treatment
Primary preventive procedures can successfully reduce the prevalence and
incidence of the major oral diseases; elimination of oral diseases, however, has not
been accomplished. In 2013 only approximately 83% of children (ages 2 to 17),
62% of adults (ages 18 to 64), and 61% of older adults (ages 65 and older) in the
U.S visited a dental office for treatment, not all of which was part of comprehensive
care.79 Various barriers are responsible for people failing to seek dental care or
seeking it only in emergencies, including cost, limited geographic access, low oral
health literacy, language, cultural barriers, fear, and the belief that dental care is
only important when in pain.80 Failure to receive primary preventive care results in
the need for more costly secondary and tertiary preventive treatment of oral
diseases.
The cost of secondary and tertiary treatment programs can be reduced by fully
utilizing alternative workforce models, such as dental hygiene-based midlevel
providers (see Chapter 2) and denturists who have direct access to the population to
provide dentures.81 In addition, the provision of local anesthesia and nitrous oxide
by dental hygienists, currently allowed in 45 states, facilitates and reduces the cost
of secondary and tertiary dental treatment in public health.82
Delivery of oral healthcare services in public health can be accomplished through
stationary community-based dental clinics, which may be run by federal, state,
county, city, or private nonprofit organizations. The delivery of clinical dental and
dental hygiene services in the public health setting is also accomplished with the use
of mobile equipment, using vans, portable dental equipment, or a mobile-portable
hybrid system.83 Several resources in the Additional Resources at the end of this
chapter can be helpful in designing and implementing a mobile oral health program
to provide clinical services.
Dental hygienists are allowed to initiate treatment in community settings without
the presence of a dentist in 37 states.84 This direct access allows easier delivery of
preventive services and provides an entry into the delivery system to receive further
dental care. In this way, direct access can result in increased secondary and tertiary
dental treatment, which is an essential element of a dental public health program to
promote optimal oral health of the population. Because of the low rates of dental
utilization by the most vulnerable population groups, whenever possible it is
important to include screening and referral in oral health education programs to
assist people in identifying resources for necessary dental care (Figure 6-11).
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.)
The Dental Home for Children

According to the American Academy of Pediatric Dentistry, a dental home should
be established no later than 12 months of age and include referral to dental
specialists when appropriate.77 An example of a public health program to implement
this recommendation is the First Dental Home Initiative initiated by the Texas
Medicaid Program. This program engages general and pediatric dentists to initiate
preventive dental checkups for children enrolled in Early and Periodic Screening,
Diagnosis, and Treatment (EPSDT) programs beginning at 6 months of age.85
The passage of the Patient Protection and Affordable Care Act (ACA) of 2010
has stimulated new approaches to improving access to dental care for children,
including the addition of the dental home concept to the medical home in a
collaborative practice approach. A new emphasis on interprofessional collaborative
practice (ICP) stresses the coordination of the medical and dental home to provide
an ongoing relationship between the patient and all the patient's healthcare
providers, including oral healthcare professionals. This encourages the delivery of
all aspects of overall and oral health care in a comprehensive, continually
accessible, coordinated, and family-centered way.86
Growing evidence supports the need for this team-based delivery approach to
achieve better outcomes in primary care of patients, requiring greater emphasis on
interprofessional education (IPE).87 In 2012, the National Center for
Interprofessional Collaborative Practice and Education (NCIPE) was formed at the
University of Minnesota, funded by HRSA and several major health foundations.
The purpose of the NCIPE is to provide leadership, scholarship, evidence,
coordination, and national visibility to advance ICP and IPE. “This substantial
funding speaks to the belief of those in government and philanthropy that
interprofessional collaboration is essential to a viable, effective and efficient
healthcare delivery model moving forward.”86 (See Interprofessional Collaborative
Practice in Chapter 2 for additional information on ICP.)
Many initiatives are already in place to address this need for ICP to assure that
vulnerable populations have a medical and dental home. One example is the
increased emphasis on oral health in the Bright Futures initiative that serves as a
guide to primary care physicians as the initial healthcare providers for infants and
young children.87 Another example is greater coordination and case management of
Medicaid and other government-funded healthcare coverage through state Medicaid
offices. For instance, THSteps works to recruit and retain qualified providers to
assure that comprehensive preventive health, dental, and case management services
are available to children from birth to age 20 who are enrolled in Medicaid.88
Participants enrolled in THSteps receive assistance with finding a provider, setting
up appointments to see a dentist through THSteps Outreach, arranging
transportation or reimbursement for gas money to see a dentist, and consultation
about eligible services. Enrolled THSteps dental providers are reimbursed for
providing Medicaid and THSteps dental services through Medicaid and additional
sources of funding for services that are not covered by Medicaid.88 Dental services
available through THSteps are listed in Box 6-13.
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
• Oral health education
Treatment Services
• Restorative treatment (e.g., fillings and crowns)
• Endodontic treatment (e.g., pulp therapy and root canals)
• Periodontal treatment
• Prosthodontics (full or partial dentures, implants, and maxillofacial prosthetics)
• Oral surgery (extractions)
Emergency Services
• Procedures necessary to control bleeding, relieve pain, and eliminate acute
infection
• Operative procedures that are required to prevent imminent loss of teeth
• Treatment of injuries to the teeth or supporting structures
Orthodontic Services (require prior authorization)

• Correction of cleft palate
• Provision of orthodontic appliances
• Crossbite therapy
• Treatment for facial accidents involving severe traumatic deviation
• Treatment for severe, handicapping malocclusion

Data from Texas Health Steps Dental Program. Texas Department of State Health Services; 2013. Available at
http://www.dshs.state.tx.us/dental/thsteps_dental.shtm. Accessed June 2015.
Oral Health Services for Older Adults

An expanding population in need of both primary prevention and secondary and
tertiary care is the older adult population. It is estimated that by the year 2050 the
number of Americans aged 65 and older will reach 89 million, twice as many as
recorded in 2010.89 The growth of this population is expected to every facet of
American society.
Older adults are at high risk for developing chronic health conditions that can
negatively affect their oral health. It is estimated that 60% of them will manage more
than one chronic illness by the year 2030. In response to the increasing need to
address the overall and oral health of older adults, Healthy People 2020 health
objectives incorporated a new Older Adults topic area90 and an older adult oral
health objective was added to the Oral Health topic area.10 The Healthy People goal
of these objectives is to “improve the health, function, and quality of life of older
adults.”90 Based on Healthy People 2020, many opportunities exist to serve the oral
health needs of older adults in the community (Figures 6-12 and 6-13).
FIG 6-12 A and B, Older adults living in a retirement community participate in an
oral health fair to gain information and resources to empower them to maintain their
oral health. (Photographs courtesy Charlene Dickinson.)
FIG 6-13 Oral cancer screening along with teaching self-examination for oral
cancer is a priority oral health program for older adults in community
settings. (Photograph courtesy Charlene Dickinson.)
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
Prog ram Explanation

Medicaid (funded jointly by Comprehensive dental services for children under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)
federal and state governments) program
Children's Health Insurance Provides direct legislative mandate for dental services in each state's program; 2015 reauthoriz ation provides eligibility for
Program (CHIP; funded jointly dental benefits for children who have medical insurance through a private source
by federal and state
governments)
Medicare (funded by federal Medical insurance program for older adults that does not cover dental care except when dental services are directly related to
government) the treatment of the medical condition
Head Start (funded by federal Includes mandated screening and referrals for necessary care for all Head Start participants; fluoride treatments provided and
government) dental care paid for in some programs for children who are not covered by Medicaid, using alternate funding; program
requirements include toothbrushing by children at school after meals and oral health education for children and families
Successful financing programs result when government leaders collaborate with

private entities to establish networks of community, county, city, and state systems to
strengthen the core foundation of oral healthcare financing. To this end, the private
sector and the business community work with state governors on initiatives that
strive to improve health status and strengthen families. Some public and private
financing programs for community oral health programs are described in this
section.94 (Additional information regarding financing of oral health care,
especially Medicaid and CHIP, is in Chapter 5.)
Federal Initiatives
Federal initiatives provide public funding to states for programs that primarily
address women and children's oral health issues. Several of these initiatives are
described subsequently.
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
Women, Infants, and Children's (WIC) Program

The WIC program provides grants for supplemental foods, nutritional education,
immunizations, and healthcare referrals for low-income pregnant women, mothers
of young children and infants, and children aged 5 years and younger who are
found to be at nutritional risk. To be eligible, the participant's family income must
be at or below 185% of the FPL. WIC is administered at the federal level through
multiple state agencies, providing supplemental food through thousands of
authorized retailers. WIC operates in clinics in all states through local health
agencies.96 In 2015, WIC grants totaled over $6.5 billion.96 Information on healthy
eating, including the relationship of diet and health, is provided to WIC
participants.97 Oral health is incorporated into this educational component. Also,
local WIC programs collaborate with other agencies and organizations for oral
health information and referrals for dental services.97 Clinical services such as
fluoride varnish application that are offered at WIC sites are financed through
Medicaid.
Children's Health Insurance Program (CHIP)

The CHIP Reauthorization Act of 2015 (CHIPRA 2015) approved continuation of
CHIP, which is a joint state-federal funded program to finance comprehensive
health insurance coverage, including dental, for children who are not eligible for
Medicaid, do not have other health insurance, and meet the family income eligibility
requirements (see Chapter 5).98 CHIP is mandated to provide oral health services in
addition to traditional medical services.98 The new CHIPRA law also provides a
wraparound benefit so that children who have medical insurance benefits are now
eligible for CHIP dental benefits. In several states CHIP also provides insurance-
premium assistance to help pay for employer-based health insurance for parents of
children who are eligible for Medicaid or CHIP. CHIPRA 2015 allotted a total of
$39.7 billion through fiscal year 2017 to support the CHIP program.98 The law also
authorized an allotment of $40 million for national and state-level outreach to
enroll more children in Medicaid and CHIP; $140 million was spent on these
outreach efforts from 2009 to 2015.98
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/.
Administration for Children and Families (ACF)

The ACF, an agency of the DHHS, promotes the economic and social well-being of
families, children, individuals, and communities, administering more than 60
programs that are operated by 16 different government offices with a budget of
more than $51 billion.103,104 Programs provide critical assistance to vulnerable
populations and help families achieve prosperity and independence. One of the
programs administered by ACF is HS (see description earlier in the chapter).
The provision of oral health services to uninsured individuals who fall outside
the eligibility guidelines for entitlement programs such as Medicaid can be
addressed through fee-for-service vouchers. Provided through ACF Temporary
Assistance for Needy Families block grants,105 these vouchers may be administered
by state health departments, by state dental associations, or through private
nonprofit entities.106 Many of the fee-for-service programs provide emergency oral
health services for school-age children and adults who are transitioning into
employment.105 Some of these programs use nominators, who are generally school
nurses or social workers familiar with the economic status of the families seeking
services. Although the initiation of the fee-for-service program is generally because
of an emergent cause, providers are encouraged to try to meet all of the oral health
needs of the patient within the guidelines of the program.
Federally Qualified Health Centers

A federally qualified health center (FQHC) is a community health center serving
an underserved area or population as defined by HRSA and receiving grants under
Section 330 of the Public Health Service Act (PHS). FQHC also qualify for
enhanced reimbursement from Medicare and Medicaid and other benefits.107 These
centers must adhere to government regulations pertaining to the scope and quality
of health services provided to anyone, regardless of ability to pay. A FQHC Look-
Alike is a community health center that meets the PHS eligibility requirements but
does not receive PHS funding. FQHC Look-Alikes may also receive special
Medicare and Medicaid reimbursement.107
Currently, there are over 1200 FQHC across the U.S., with over 9000 service
delivery sites, and serving over 22 million people.108 FQHC and Look-Alikes
provide comprehensive health care, including oral health in many cases, using an
interprofessional collaborative approach. The president's DHHS budget for 2016
includes $4.2 billion for health centers, including $2.7 billion to support
establishment of new health centers where they do not exist.109
Volunteer Dental Services Programs

Dental and dental hygiene professionals have responded to the need for greater
access to dental care for underserved vulnerable populations by donating their time
and sometimes their finances to provide oral health services free of charge. This is
done frequently through organized volunteer dental services programs. For
example, various state and local dental hygiene professional organizations operate
dental sealant programs in local schools such as Sealants Across Texas, a program
conducted and staffed by volunteer dental hygienists.110 Another example is the ADA
Give Kids a Smile (GKS) program that was launched in 2003 to provide free oral
health services for children and facilitate the establishment of dental homes. In 2015
over 10,000 volunteer dentists and almost 30,000 other volunteer dental team
members, including dental hygienists, served more than 350,000 children during
over 1500 local GKS community events nationwide.111
Dental Lifeline Network (DLN), a nonprofit organization that was formerly
known as the National Foundation of Dentistry for the Handicapped, operates
several programs through which volunteer dental personnel provide access to
dental care for people who cannot afford it and have a permanent disability, are
aged 65 or older, or are medically fragile.112 Donated Dental Services (DDS) is their
flagship program that provides free, comprehensive dental treatment to this
vulnerable population. With programs in every state, DDS is a joint effort of more
than 15,000 volunteer dentists and 3600 dental labs across the U.S. and has surpassed
$250 million in donated dental services to more than 120,000 people since its
inception in 1985. Another DLN program, Dental HouseCalls, operates in Colorado
and Illinois. This program utilizes mobile dental equipment to bring dental care to
people who cannot easily travel, including residents of nursing homes and people
who are homebound. Bridge/Campaign of Concern is a DLN dental outreach
program in Colorado to help developmentally disabled individuals. Dental
hygienists are brought into schools, vocational centers, and group homes to provide
preventive educational services, screenings, referrals, and staff training. Donated
Orthodontic Services is a program of the American Association of Orthodontists in
partnership with DLN that enables low-income children to receive orthodontic
treatment. This program currently operates in Illinois, Indiana, Kansas, New Jersey,
North Carolina, Rhode Island, Tennessee, and Virginia.
Summary
The various community oral health programs introduced in this chapter offer
practicing dental hygienists an extension of their private practice experience.
Becoming acquainted with the oral healthcare needs of the community at large—in
conjunction with an understanding of the best practices for available oral health
programs; funding resources from the local, state, and national levels; and effective
program planning processes—provides an opportunity for dental hygienists to have
a positive outlook on the overall health of their communities.
1. Research and prepare a report on fluoride concentration levels in existing water
supply sources in the communities served by your dental hygiene program clinic.
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.
5. Research the possibility of forming an oral health coalition in your community

using the web to find a toolkit or other source that provides information about how
to form a coalition. Whom would you invite to join the coalition? Decide on the
goals and objectives of the organization.
competencies:
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
organizations.

HP.1
CM.1
CM.2
Provide screening, referral, and educational services that allow patients to access
the resources of the healthcare system.
CM.3
CM.4
CM.5
Evaluate reimbursement mechanisms and their impact on the patient's access to oral
health care.
CM.6
CM.7
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
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
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88. Step into a Healthy Future with Texas Health Steps!. Texas Department of
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92. Medicare Dental Coverage. DHHS Center for Medicare & Medicaid
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96. Women, Infants, and Children (WIC). [Alexandria, VA: U.S. Department of
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June 2015].
97. WIC Nutrition Services Standards. U.S. Department of Agriculture, Food
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2015].
98. Medicare Access and CHIP Reauthorization Act of 2015: Summary of Key
Provisions Impacting Children. Georgetown University Health Policy
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99. Early and Periodic Screening, Diagnostic, and Treatment. [Baltimore, MD:
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100. Dental Care. [Baltimore, MD: DHHS Centers for Medicare and Medicaid;
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101. Medicaid & CHIP: January 2015 Monthly Applications, Eligibility
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eligibility-and-enrollment-data.pdf [Accessed June 2015].
102. VanLandeghem K, Bronstein J, Brach C. The Role of Medical Care Use and
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June 2015].
103. Head Start Program Facts FY 2014. Office of the Administration for
Children & Families, Head Start Early Childhood Learning & Knowledge
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factsheet.html [Accessed June 2015].
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105. Temporary Assistance for Needy Families (TANF). DDHS ACF Office of
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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:
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108. America's Health Centers (Fact Sheet). National Association of Community
Health Centers: Bethesda, MD; 2014 [Available at]
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109. HHS FY2016 Budget in Brief. Department of Health & Human Services:
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].
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2014 [Available at] http://www.adafoundation.org/en/give-kids-a-smile
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[Available at] http://dentallifeline.org/about-us/ [Accessed June 2015].
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Roles, Activities and Resources: Guidelines Matrix, ASTDD.
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examples-andresources-4-2013-revisions.pdf.
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Community Health Services & Patient-Centered Primary Care Oral Health
Section.
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2012%20Revisions.pdf.
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Fluoride Varnish Manual, Texas Department of State Health Services Oral
Health Program.
https://www.dshs.state.tx.us/dental/.
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National Spit Tobacco Education Program (NSTEP).
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http://mchoralhealth.org/about/index.html.
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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.
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Maternal & Child Oral Health Resource Center.
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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.
Broad Categories of the National Dental Hygiene Research Agenda
Health Promotion/Disease Prevention

Studies concerned with “health maintenance and disease prevention; public health
policy, advocacy and legislation; and development, validation and testing of
instruments, strategies and mechanisms that demonstrate effectiveness”
Health Services Research
Studies that are “designed to improve the quality of health care, reduce its cost,
address patient safety and medical errors, and broaden access to essential services.
It includes evidence-based information on healthcare outcomes, quality and cost,
use and access”
Professional Education and Development
Studies “concerned with educational methods, curricula, students and faculty;
recruitment and retention of students and faculty; and, promoting graduate
education and career path options”
Clinical Dental Hygiene Care
Studies that “address the dental hygiene process of care (assessment, diagnosis,
treatment planning, implementation and evaluation); decision making and clinical
reasoning; and data management systems”
Occupational Health and Safety
Studies that “focus on the practitioner, as well as the patient; exposure to risks;
compliance and prevention issues; behavioral issues; and workforce recruitment
and retention”
(Data from 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.
Research reports published in reputable scientific journals and on the web

disseminate the results of independent research. To determine whether the
information contained therein is indeed reliable, valid, and useful, certain
knowledge and skills must be a part of the repertoire of every competent dental
hygienist. This chapter provides a basic overview of what research entails and a
means of evaluating the results of that research.
Evidence-Based Decision Making

Evidence-based practice (EBP) in dental hygiene is the conscientious, explicit, and
judicious use of current best evidence in answering questions about the care of
individual patients.2 This means that dental hygienists practicing according to EBP
are meticulous in carefully and wisely using clear scientific evidence from research
results to make practice-based decisions. EBP applies to all areas of dental hygiene
practice, including the various roles of the dental hygienist. Most applications are
made to clinical practice, but decisions about delivery of oral health education,
community oral health program planning and evaluation, advocating for the oral
health of the public as well as for the profession, and even appropriate ways to
conduct research must be based on sound EBDM as well.
EBDM involves a combination of relevant components: (1) scientific evidence,
(2) professional expertise and judgment of the practicing dental hygienist, (3)
patient or community preferences or values, and (4) circumstances of the situation3
(Figure 7-1). These factors require critical evaluation to determine the best decision
for the individual patient, community group, or other practice circumstance. All of
these components are important.3 Decisions based on only one or a few of these
elements can result in ineffective treatment and programs. Thus EBDM aims to
connect research results with real-world circumstances and situations to provide
more complete information for the practitioner's professional decision making.
This will enhance treatments and programs for patients and clients, which
subsequently can result in increased eminence of the dental hygiene profession.4
FIG 7-1 Evidence-based decision making. (Adapted from Forrest J. Evidence-Based

Decision Making: Introduction and Formulating Good Clinical Questions. Dentalcare.com
Continuing Education Courses, Course Number 311; 2014. Available at
http://www.dentalcare.com/en-US/dental-education/continuing-education/ce311/ce311.aspx.
Accessed March 2015.)
An example will illustrate these components of EBDM. If an early childhood

caries (ECC) prevention program is being planned for a group of teenage mothers,
it is important to consider research results relative to specific preventive strategies
for ECC; the values and preferences of the young mothers, such as the importance
they place on oral health and their preferred learning environments and methods;
circumstances of these young teenage mothers such as their specific concerns, age,
living situation, family support, financial resources, and children's current health
status and oral health needs; and the oral health professional's expertise and
judgment relative to working with this population. All these elements are important
in planning the most effective ECC prevention program for this target population.
Ranking of Evidence for Evidence-Based Decision Making

(EBDM)
This chapter will focus on the scientific evidence component of EBDM. Research
evidence for EBDM is ranked according to its value, based on the relative authority
of various types of research (Figure 7-2). The highest level of evidence available
should be used for EBDM.2 Understanding how to distinguish between these
different types of scientific evidence is critical to being able to judge the validity
and relevance of reported findings to make sound evidence-based decisions.3
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, secondary, and tertiary literature.

The sources of scientific evidence can be classified as primary, secondary, or
tertiary.7 Primary sources should be used for EBDM whenever possible. However,
this can be confusing in that journal articles can be primary, secondary, or tertiary;
some textbooks are secondary, and some are tertiary; and some books are even
primary.
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.
Formulating a Research Question

The first step in beginning a research study is the formulation of a research
problem, which is the topic you would like to investigate, or the focus of the
research. As this idea is narrowed or clarified it leads to a research question to be
answered. Studies can have several research questions. They should be clear,
specific, relate to the research problem, and be relevant to the population of interest.
Also research questions should be simple and concise; a successful study often
depends on an uncomplicated research design resulting from a simple research
question. A well-written research question can point to appropriate research
methods. Variations of research questions for different types of studies will be
discussed later in the chapter. During the clinical phase of dental hygiene education,
students might debate about simple, relevant topics that can lead to research
questions to investigate (see Guiding Principles).
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?
The germane available literature is reviewed in the process of refining a research

problem and developing important research questions. Thorough examination of a
general topic in the literature will help to bring it into sharper focus and enable the
researcher to create pertinent research questions that will address unknown or
unexplained areas of the problem. Analysis of the literature is described later in this
chapter.
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
Crite ria Qualitative Quantitative

Purpose To understand social interactions To test hypotheses, determine cause and effect, and make predictions
Group Studied Smaller and not randomly selected Larger and randomly selected
Variables Study of the whole; not focused on variables Specific variables studied
Types of Data Words, images, or objects Based on precise measurements using validated data collection
Collected instruments
Type of Data Identify patterns and themes Identify statistical relationships
Analysis
Results Specializ ed findings that are less generaliz able Generaliz able findings that can be applied to other populations
Scientific Exploratory or bottom-up; the researcher generates a new hypothesis Confirmatory or top-down; the researcher tests the hypothesis and
Method and theory from the data theory with the data
Focus Wide-angle lens; examines the extensiveness of phenomena Narrow-angle lens; tests a specific hypothesis
Final Report Narrative report with contextual description and direct quotes Statistical report with correlations, comparisons of means, and
statistical significance findings
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 Approach

Obse rvational Example Re se arc h
Type of Study De sig n Use /Purpose Re lative Advantag e (s)
Charac te ristic s Que stion*
Cohort study: Longitudinal, Determine incidence; Highest level of evidence of all Will the knowledge of ECC of
One group is observed over time; can be prospective determine risk; estimate observational studies; strongest young mothers change over the
compared with a comparison group causality indication of risk time period that their children
are enrolled in Head Start?
Case-control study: Retrospective Determine risk; estimate Less costly, shorter in duration, and Will a relationship be evident
Two groups, one with disease (cases) and causality; examine easier to conduct compared with between ECC knowledge of
one without (controls), are compared to relationships among cohort studies mothers and their own oral
identify factors in their history that can variables that cannot be health when a group with high
be associated with the disease or studied prospectively oral health status is compared
condition (exposures) because of ethical with a group that has low oral
concerns about research health status?
participants
Cross-sectional study: Cross-sectional Determine prevalence; Easy to conduct; weaker design Is there a relationship between
Representative cross-section of the can indicate associations than others to show associations the ECC knowledge level of a
population is observed at one point in between risk attributes between exposure to risk factors group of teenage mothers and
time; disease attributes and potential risk and outcome of interest; and outcome of interest; bias of their own oral health?
attributes are measured to test association cannot be used to response and level of nonresponse
confirm risk factors or are concerns of design
estimate causality;
useful to generate
hypotheses
Ecological study: Can be Identify prevalence and Inexpensive, less time consuming, Is the prevalence of ECC in a
Existing group-level data (rather than longitudinal or incidence; should be used and easy to carry out; less reliable country associated with per-
data collected from individuals) are used cross-sectional; to generate hypotheses than other designs; prone to bias, capita consumption of sugar in
to relate risk attributes to health or other can be rather than to establish confounding of variables and the country?
outcomes retrospective definite relationships ecological fallacy (observed
Two types: association for groups may not
1. Ecological comparison: assessment of represent the association that exists
correlation between exposure rates and for individuals within the groups)
disease rates among different populations
over same time period
2. Ecological trend: correlation of
changes in exposure with changes in
disease over time within the same
community or other group to establish
trends
Expe rime ntal Re se arc h Approac h
Experimental study: N/A Test hypotheses; Greatest control of all study Will the ECC knowledge level
Experimental treatment is manipulated establish causality designs; highest level of evidence of of a group of teenage mothers
and dependent variable is measured in all studies increase as a result of an
two or more randomiz ed groups; educational program, compared
characteriz ed by controlled methods; also with an equivalent group that
called a randomiz ed controlled trial; does not receive the educational
variations include pretest/posttest, program, when the groups are
repeated measures, crossover, split- randomly formed?
mouth, factorial
Quasi-experimental study: N/A Test hypotheses; Used when randomiz ation is not Will the ECC knowledge level
Shares similarities with the traditional establish causality practical or is impossible of a group of teenage mothers
experimental design but lacks in one high school increase as a
randomiz ation; also referred to as result of an educational
nonrandomiz ed program, compared with
another high school that does
not receive the educational
program?
*
All research question examples relate to the same research problem of early childhood caries.
From Chattopadhyay A. Oral Health Epidemiology: Principles and Practice. Sudbury, MA: Jones & Barlett;
2011; Welkowitz J, Cohen BH, Lea RB. Introductory Statistics for the Behavioral Sciences. Chichester:
John Wiley & Sons; 2011. Available at eBook Collection (EBSCOhost). Web, December 2014; Creswell J.
Research Design: Qualitative, Quantitative and Mixed Methods Approaches. 4th ed. Thousand Oaks, CA:
SAGE Publications; 2014; Friis RH, Sellers TA. Epidemiology for Public Health Practice. 5th ed. Burlington,
MA: Jones & Bartlett Learning; 2014; Keele R. Nursing Research and Evidence-Based Practice: Ten Steps
to Success. Sudbury, MA: Jones & Bartlett Learning; 2011; Terry AJ. Clinical Research for the Doctor of
Nursing Practice. Sudbury, MA: Jones & Bartlett Learning; 2012.
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.
Split-Plot (Split-Mouth) Design

This design is convenient to apply to oral health research because of the ability to
assign equivalent pairs (teeth, pockets, arches, sides of mouth, quadrants) to
experimental and control groups. In the split-mouth study design, all study
participants receive two or more treatments to a separate unit of the mouth. This
design also has the advantage of exactly matching the control and experimental
groups.12
An example of this design is to have all study participants use the water flosser on
one side of the mouth and the floss on the other side of the mouth. Combining
different experimental designs can be illustrated via adding a crossover component
by switching sides after a period of time.
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:
○ No xylitol chewing gum ○ No xylitol chewing gum
○ Use of antimicrobial ○ Use of antimicrobial
Group 5: Group 6:
○ Use of xylitol chewing gum ○ Use of xylitol chewing gum
○ No antimicrobial ○ No antimicrobial
Design consists of two levels of three factors:

• Frequency of fluoride: Twice a year and four times a year
• Use of xylitol gum: Yes or no
• Use of antimicrobial: Yes or no
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
• Base the study on valid assumptions
• Operationally define variables clearly
• Use the appropriate population for the type of study
• Use a representative sample
• Have an adequate sample size to accommodate for loss of participants
• Control extraneous variables
• Use an appropriate type of control or comparison group
• Control group differences by using randomization and stratification
• Use participants as their own control when appropriate
• Use blind and double-blind procedures (masking)
• Use a pretest for comparison

• Control for pretest sensitization
• Use valid and reliable instruments
• Control examiner error with standardization and calibration
• Carefully control and supervise procedures
• Control errors in measuring the dependent variable
• Standardize study conditions in all groups
• Use repeated measures when appropriate
• Use several measures of the dependent variable when called for
• Have a long enough trial to detect new disease or change
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 and Sampling

It is important to clearly understand what is meant by the population and sample and
how they relate to each other. Equally important is comprehension of the various
ways that samples can be formed and the value of randomization.
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.
Experimental and Control Groups in the Experimental

Approach
The sample is divided into groups for an experimental and quasi-experimental study
in which a treatment or intervention is imposed or manipulated to determine its
effectiveness. The experimental group is the sample group in a study that is
exposed to or receives the experimental treatment or intervention. The control
group is the group in a study that does not receive the intervention, providing a
comparison group against which the effects of the intervention on the experimental
group can be contrasted.10
The control group can receive a placebo, a traditional or standard treatment, or
no treatment. A placebo is used to control the placebo effect, which can occur if
study participants behave differently by virtue of knowing whether they are
receiving the treatment or the control.12 For example, they may be more compliant
if they know they are using a new mouth rinse that is being tested to control
gingivitis rather than no mouth rinse or a mouth rinse that is currently on the
market. Use of the standard treatment is important in some cases when it would be
unethical to withhold a standard level of treatment or therapy. To illustrate, if a new
toothpaste formula is being tested, it would be unethical to withhold a current
therapeutic toothpaste product from the control group because the benefits of the
standard toothpaste have been established. Also use of the standard treatment as a
control can demonstrate if it is more effective than the current treatment. Applying
no treatment to the control would establish only the value of the new treatment
compared with no treatment, although the new treatment may be no more effective
than the current treatment.
In experimental research assuring that groups are equivalent for any relevant
variables is important (see Variables section later in chapter). This will control bias,
which will help ensure that any positive study results are not a function of group
differences. Equivalent groups are achieved through randomization, which is the
process of randomly assigning members of the sample to the study groups.13 In the
process of randomization, stratification or matching the groups for relevant
variables can ensure group equivalency when the sample is heterogeneous for a
factor that can affect the study results.10 When randomization is not possible the
study is quasi-experimental rather than experimental.
An example of randomized matching would be an experimental study performed
to test the effects of a new antimicrobial mouth rinse in controlling gingivitis in the
IHS clinic patients with moderate periodontitis (the population previously used for
various examples). The sample would be divided into two groups: the experimental
group would use the new mouth rinse, and the control group would use a standard
therapeutic mouth rinse. This could be done by randomly assigning the study
participants to the two groups and also matching the two groups in the process. It
would be important to match the groups for gender and age, both of which are risk
factors for periodontitis. This would provide the control necessary for an
experimental study.
If the groups were formed without random procedures, for example, patients
treated on different days, the study would be quasi-experimental. Even if the days
were selected randomly, the actual study participants would not be assigned
randomly. Another example of a quasi-experiment is the use of intact groups. An
example of this would be using patients from two different clinics, with one clinic
using one mouth rinse and the other clinic using the other mouth rinse. Although the
experimental treatment could be assigned randomly to the intact groups, this method
also would not provide randomization.10,12
Cases and Controls in Observational Studies

In observational research, the terms cases and controls are used.10 Groups are
formed according to their current disease or other outcome of interest. For
example, in a case control study the researcher identifies a group of individuals with
a disease (cases) and a group of individuals without the disease (controls) to
retrospectively investigate what factors are associated with the disease (called
exposures). Another example is an ecological study in which the different disease
rates of two populations are studied to identify an associated factor. The group with
the higher rate of disease is the cases group, and the group with the lower rate is the
control.
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.)
Ethical Conduct of Research

The dental hygiene profession addresses ethical expectations in relation to research
in the Code of Ethics of the ADHA.18 In addition, standards concerning the ethical
conduct of research with human participants have been established10 and are
required by the federal government and enforced by research review committees of
organizations involved in research18,19 (see Guiding Principles). For details of these
ethical standards refer to the National Institutes of Health (NIH) tutorial Protecting
Human Research Participants listed in the chapter references.
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.
• Voluntary Participation. Participation must be completely voluntary, and

participants may withdraw from a study for any reason at any time without
penalty or loss of benefits.
• Confidentiality/Anonymity. Confidentiality and anonymity must be protected

during and after the study, including in relation to reporting results of the study.
• Protection of Human Research Participants. Participants must be protected to

assure beneficence, nonmaleficence, and a risk-benefit ratio that favors the
benefits side.
• Social Justice. Individuals and groups participating in a study must be treated

fairly and equitably in terms of bearing the burdens and receiving the benefits of
research. Also, when placebos are used, participants must be treated fairly.
• Research Misconduct. Research misconduct must be avoided, including

plagiarism, copyright or patent infringement, falsifying or fabricating data,
misrepresenting data, and conducting frivolous research.
Communication of Research Results

In addition to these standards, a responsibility discussed in the ADHA Code of
Ethics is to share the results of research.18 Failure to communicate results means
they are not available to the community of practitioners; conversely, sharing results
of research adds to the profession's body of knowledge. Thus dental hygienists in a
research role, regardless of the primary professional role, have an ethical
responsibility to communicate research results in a meaningful way, either in
writing or through oral presentations. This will allow other practitioners access to
the information for the benefit of the public. For example, unusual clinical cases,
innovative procedures, and successful community programs can profit other
professionals and the patients and communities they serve.
Presentation of the Data and Data Analysis
After variables have been defined and measured, and the data have been collected
from the study participants, the next steps of the scientific method are to analyze the
data and present the results.
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
Type of Sc ale s of Appropriate Data

Charac te ristic s Example s
Data Me asure me nt Display
Categorical • Descriptive • Socioeconomic status • Nominal • Frequency
• Have no numerical value • Ethnicity • Ordinal distribution table
• Each individual data point is assigned to a group or • Political preference • Bar graph
category • Religion
• There is no rank order to the categories • Stages of cancer
• Considered to be qualitative in nature (descriptive) • Periodontal classification
Dichotomous • Categorical data with exactly two categories • Male/Female • Nominal • Frequency
• Considered to be qualitative in nature (descriptive) • Yes/No • Ordinal distribution table
• Dentulous/Edentulous • Bar graph
• Pass/Fail
Discrete • Numeric data with a set of fixed or finite values • How many times a person brushes • Interval • Frequency
• Can be counted only in whole numbers; fractions have his or her teeth • Ratio distribution table
no real meaning • Number of DMF* teeth or surfaces • Bar graph
• Considered quantitative in nature • Number of dental visits in a year
Continuous • Numeric data • Test scores • Interval • Frequency
• Can be expressed by a large or infinite number of • Millimeter probe depths • Ratio distribution table
measures along a continuum • Height • Histogram
• Have real value when expressed as fractions • Weight • Frequency polygon
• Considered to be quantitative in nature • Time
*
DMF—Decayed, Missing, Filled
The various types of data are represented by different scales of measurement

(Table 7-5). The scale of measurement that data possess also determines the
appropriate statistical procedures for summary and analysis of the data. The scales
of measurement, in order of complexity, are as follows:13
1. Nominal scale—Consists of named, mutually exclusive categories that have no

order. For example, females are in one category of gender, and males are in
another. Other examples of nominal scale data are ethnic group membership and
religious preference. The nominal scale is the simplest or least complex of the four
scales 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.
Each scale of measurement takes on the characteristics of the previous one,

building up to the ratio scale, which is the most complex. Because of their greater
complexity, ratio scale data are considered most powerful and are preferred
whenever possible to provide stronger research results.
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).
Different Research Results Derived by Using Descriptive Versus
Inferential Statistics
• Only 26% of the patients treated in a specific community-based health center

report using dental floss regularly.
This is an example of a research result derived with descriptive statistics. The

data from the sample exactly describes the status of the variable (regular use of
dental floss), relates only to that group, and provides no inference or
generalization to a larger population.
• The regular use of dental floss can help prevent periodontal disease.
This statement exemplifies a research result determined with inferential

statistics. It is a result of generalizing to a larger population based on the analysis
and interpretation of sample data. Also, a judgment is required, for example,
contrasting periodontal disease rates of those who floss regularly to rates of those
who do not.
TABLE 7-6
Selected Descriptive and Inferential Statistics
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
Measures of central tendency.

Measures of central tendency include the mean, median, and mode (Table 7-7). As
the first step in describing a distribution of data, they communicate the middle or
centrality of a distribution of scores.21
TABLE 7-7
Measures of Central Tendency
Me asure Charac te ristic s Type of Data

Mean • Arithmetic average • Ratio (continuous, discrete)
• Affected by extreme scores • Common practice to use with dental indexes and rating scales
• Used in further statistical procedures to test hypotheses
Median • Middle score • Ratio, interval, ordinal
• Not distorted by outliers
Mode • Most frequently occurring score • Nominal (categorical, dichotomous)
• Distribution may be unimodal, bimodal, multimodal, or have no mode
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
Me asure Charac te ristic s

Range • Simplest
• Computation includes only the highest and lowest scores in the distribution
Variance • Most sophisticated
• Computation includes all scores in the distribution
Standard deviation • Square root of the variance
• Has same characteristics as the variance
• Commonly reported in oral health research reports
The simplest measure of dispersion is the range, which communicates the

difference between the highest and lowest values in a distribution of scores (Box 7-
3). A more sophisticated measure of dispersion, called variance, is a method of
ascertaining the way individual scores are located on a distribution in relation to the
mean. The standard deviation (SD), which is the square root of the variance, is
frequently reported rather than the variance. The advantage of the variance and SD
compared with the range is that every data point in relation to the mean is used in
calculating the statistic, which provides a truer picture of how the individual scores
relate to the mean.
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
Computation of Range, Variance, and Standard Deviation

Range is the difference between highest and lowest score: 100 − 30 = 70.
Variance is the average deviation or spread of scores around the mean.
The variance is calculated as (individual score − mean)2/# of scores.
(60 − 67)2 = 49
(30 − 67)2 = 1369
(100 − 67)2 = 1089
(45 − 67)2 = 484
(95 − 67)2 = 784
(90 − 67)2 = 529
(50 − 67)2 = 289
49 × 6 (# of scores of 60) = 294
1369 × 3 (# of scores of 30) = 4107
1089 × 3 (# of scores of 100) = 3267
484 × 4 (# of scores of 45) = 1936
784 × 4 (# of scores of 95) = 3136
529 × 5 (# of scores of 90) = 2645
289 × 5 (# of scores of 50) = 1445
All above summed = 16,830
16,830 ÷ 30 (total number of scores) = 561
561 is the variance
Standard deviation is the positive square root of the variance:
The square root of 561 = 23.7
23.7 is the standard deviation
The steps to calculate the variance and SD are as follows (Box 7-3):
1. Subtract each data point from the mean.
2. Square these differences.
3. Add the squared differences.
4. Divide by the total number of data points.
5. Figure out the square root of the result.
The formula for the SD is as follows:
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
Note: All scores and calculations are rounded to whole numbers.
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
Sig n of Coe ffic ie nt Value (+ or −) Dire c tion of Re lationship/Inte rpre tation

+ Positive
As one variable increases, the other also increases; and vice versa
– Negative
As one variable increases, the other decreases; and vice versa
Value of Coe ffic ie nt Stre ng th of Assoc iation/Inte rpre tation
0.00–0.25 Little if any
0.26–0.49 Weak
0.50–0.69 Moderate
0.70–0.89 High
0.90–1.00 Very high
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
FIG 7-7 Posttest scores and hours of education (positive correlation).
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).
A perfect positive (+1) or negative (−1) correlation coefficient is possible in

theory. However, it would be rare to find a perfect relationship because other
variables can be associated also with the variables that are being evaluated with the
correlation analysis. For example, although dental caries and use of fluorides are
strongly associated, the relationship is not perfect because other variables such as
diet, oral hygiene, and genetics are associated with dental caries as well.
It is important to remember that correlation communicates only association of
variables, which indicates risk. It cannot be used to indicate cause and effect without
follow-up longitudinal studies.22 For example, correlation between Alzheimer's
disease and periodontal disease only indicates they are associated. The nature of the
relationship is not clear until longitudinal studies are conducted to test if one causes
the other or if a third factor is causally associated with both, such as in the case of
dental caries and fluorosis.
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
Displaying the Data

Data can be presented in tables and graphs, also called charts, for easier
understanding and interpretation. In some cases tables are preferred, and in some
cases graphs are preferred. Tables interact with the reader's verbal system and work
best when the data presentation is used to look up or compare individual values,
requires precise values, or has values that involve multiple units of measure. Graphs
are perceived by the reader's visual system and work best when communicating the
shape of a distribution of values or a relationship among values.24
Frequency distribution tables.

Frequency distribution tables can be produced for all types of data. They show the
frequency or number of times that values or categories occur in a data distribution.21
To create a frequency distribution table, the raw data are put in order and then the
frequency for each value or category is calculated. Frequencies can be expressed as
an actual frequency or counts, or as a relative frequency or percentages. By
examining a frequency distribution table, one can easily determine the mode and get
a sense of the shape of the distribution. As an example, the data in Box 7-3 are
presented in a frequency distribution table with the test scores in order and with
frequency counts and percentages.
Graphs.
Creating a frequency distribution table is the first step of generating a graph of
frequency data. Various types of graphs can be used to present data pictorially:21
several are described in this section. The appropriate graphs to use for various types
of data are presented in Table 7-5.
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.
FIG 7-9 Pretest scores of 12 participants as shown in a bar graph.
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).
FIG 7-10 Age of 12 participants in the research study as shown in a histogram.
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.
Time series graph.

Graphs can be used also to show change in the measure of a variable over time. For
example, monthly mean Simplified Debris Index (DI-S) scores (see Appendix F) of
children who brush daily at school in a Head Start program could be communicated
with a bar graph to show progress of brushing ability over the school year (Figure
7-12). Time series graphs are more frequently presented as line graphs (Figure 7-
13). An advantage of the line graph is the ability to compare two groups. For
example, let's suppose the children in this Head Start program routinely received
oral health education at school and supervision during brushing to improve their
brushing technique. A line graph could show a comparison of the mean DI-S over
the school year for this Head Start program (Head Start Program 1) to another Head
Start program (Head Start Program 2) that did not provide an educational program
and daily supervision of brushing (Figure 7-13). Although a bar graph could be
used to compare the two data sets, it is easier to understand in a line graph. Both
these graphs are referred to as time series graphs because they plot a variable over
time.
FIG 7-12 Time series bar graph of mean DI-S of Head Start children over the
school year.
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.
Parametric inferential statistics.

When data meet certain assumptions, parametric statistics can be used. First the
data must be continuous, which includes data that represents ratio and interval scales
of measurement. Ordinal or discrete data that have a large number of possible
scores can be analyzed with parametric statistics as well.22 Other assumptions are
that the sample size is adequate, the population distribution is normal, and the group
variances are equal. Examination of the mean, median, and mode, as well as the
variance or SD, will help indicate if the assumptions have been met. Data are more
likely to meet these assumptions when the sample is drawn randomly from the
population, hence the greater value placed on experimental studies versus quasi-
experimental studies.
An understanding of the normal distribution will help with understanding these
required assumptions for using parametric statistics. A normal distribution is a
theoretical symmetric bell-shaped curve that is characteristic of data representing
most occurrences in this world. The distribution of the data in this curve is such that
approximately 68% of the scores fall within one SD above or below the mean,
approximately 95% lie within two SDs of the mean, and 99% are within three SDs of
the mean13 (Figure 7-16). We saw earlier in the chapter that the symmetry of the
normal distribution results in the mean, median, and mode being equal, in contrast
to skewed curves (see Figure 7-6). Thus, to decide whether parametric statistics are
warranted, one can examine the similarity of the mean, median, and mode of the
population data to determine whether the distribution is normal. To decide whether
the group variances are equal, the variances or SDs of both study groups
(experimental and control) are examined to determine their similarity.
FIG 7-16 Normal distribution (bell curve).
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
Sensitivity Rating for Each Brand of Toothpaste

Patie nt Numbe r TP 1 TP 2 TP 3 TP 4 TP 5
1 6 5 4 5 2
2 5 5 3 4 3
3 7 5 4 5 3
4 5 4 4 3 4
5 6 5 5 4 4
Mean sensitivity rating 5.8 4.8 4 4.2 3.2
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.
Nonparametric inferential statistics.

When the data do not meet the assumptions for parametric statistics (see earlier), it
is necessary to apply nonparametric statistics.22 Nonparametric techniques are
most useful for data that is measured on the nominal or ordinal scale because of
their qualitative nature. Although these data are represented by numbers, such as a
rating scale, the numbers are derived subjectively. Nonparametric tests involve
fewer assumptions about the population so they can be utilized also with all types of
data when sample and group sizes are small. Variations of nonparametric tests exist
for different sample sizes (five or less and greater than five).
Several nonparametric statistical tests are utilized commonly in oral health
research.12 One of the most common is the chi-square test, various versions of
which can be used in different ways: (1) counts of categorical variables can be
compared between two or more independent groups, similar to using the t-test to
compare group means; (2) proportions of categorical data within distributions can
be examined to determine the differences between observed and expected
frequencies; and (3) the relationship between variables that has been established by
correlation can be tested for significance. The Wilcoxon signed-rank test and the
Mann-Whitney U test are nonparametric equivalents to the t-test for use with
ordinal data. Others can be reviewed in various statistics books listed in the
references of this chapter.
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.
Determining Statistical Significance

The final outcome of a statistical analysis with inferential statistics is to determine
whether the results are statistically significant.10 Statistical significance is a way of
indicating that the results found in an analysis of data are unlikely to have been
caused by chance; in other words, statistical significance communicates the chance
that the results have been caused by the independent variable.
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.
The statistical conclusion.

The researcher formulates a statistical conclusion to either accept or reject the null
hypothesis of the study founded on the statistical results of the data analysis.17 For
example, let's suppose that a study compares the effectiveness of two teaching
methods in a community setting in relation to increasing oral health knowledge and
improving routine oral health behaviors. At the end of the study the increase in
knowledge of the two groups is compared, resulting in a p value of 0.05. The
statistical conclusion is to reject the null hypothesis, meaning that one teaching
method resulted in a greater increase in knowledge. Based on the statistical
significance of p = 0.05, there is a 95% chance that the greater increase in
knowledge in that group was a result of the teaching method. Stated another way,
there is a 5% chance that the greater increase in knowledge is because of chance
occurrence rather than a result of the superiority of the teaching method.
Because the statistical analysis is based on probability rather than certainty, there
is the possibility of error in the statistical conclusion.12 Errors can be minimized by
using appropriate research designs, carefully following suitable research
procedures, controlling variables and other sources of error or bias, and having an
adequate sample size.8,9,11,12,13,17,22 Two types of errors exist, and they tend to cancel
each other out (Table 7-12). Efforts to reduce one type of error generally result in
increasing the other type.
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.)
Becoming skillful in obtaining scientific information is not as easy as might be

expected. However, it is a skill that must be cultivated by every professional dental
hygienist because it is necessary to be able to access current information for EBDM.
This section describes an overview of what is available in the form of written
resources, how to choose the best sources of this information, and how to critically
review this literature. Although a critical analysis of the scientific literature is ideal,
it is best to remain open-minded when inquiring about new products, services, and
techniques.26 Keeping focused on the research of specific information to be
reviewed should help to provide simple yet intelligent answers to the question at
hand.
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.
Other Sources of Literature

In today's age of electronics, journals are not the only source of valid literature.29
Reliable electronic resources are available through websites of various
organizations and government agencies (see Appendices A and D). When using
literature from websites, it is important to critically evaluate web sources based on
specific criteria (Box 7-6). Generally, reliable websites for scientific information
have an extension of .edu or .gov, and other valuable information can be found at
.org and .net sites (Box 7-7). Websites with a .com extension are less reliable
sources of scientific information because they reflect individual web pages and web
pages of commercial establishments. Sometimes use of these sites is appropriate,
depending on the information sought, but they should be used with care when
conducting a literature review. Articles found on a website should be evaluated
using the same criteria used to evaluate journal articles.
Box 7-6
Cri teri a to Eval uate Web Sources of Li terature
Authority
• Who is the author?
• What are the author's qualifications?
• Has the author published articles or books other than web pages?
• Is the source peer-reviewed or edited?
• Does the author belong to an organization?
• If the page is authored by an organization, what additional information about that

organization is available?
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?
• Can the information be verified elsewhere, perhaps in a print source?
• Are there obvious errors (e.g., spelling, grammar)?
Currency
• Are the copyright dates and time period of the page current?
• When was the page last updated?
• Is the information on the page current or outdated?
• Are the links current or are there any dead links on the page?
• Do links lead to current or foundational material or outdated, useless information?
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?
• Is the information free or is there a fee to access more detailed data?
Purpose or Type of Page

• What does the Statement of Purpose, Mission Statement, or About Us link tell you?
• What kind of web page is this: advocacy, business, informational, news,

advertising/sponsorship, or personal?
• Does the page have the required level of scholarship for scientific information?
• Does the page include enough information to be useful?
Intended Audience
• For whom was the page written, readers of scientific or professional information
or the general public?
• Is the purpose to inform or entertain?
Biased Opinion
• Does the page or author reflect a particular bias or viewpoint? Does research done
on the author indicate a bias?
• Is inflammatory or provocative language included that reflects a particular

agenda? If so, it is biased.
• 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
• Government agencies (e.g., NIH, CDC, military) = .gov, .mil
• Universities and colleges = .edu
• Foundations and other nonprofits = .org, .net
• Community agencies = .org, .net
• 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.
Evaluation of the Selected Literature

Regardless of the source of research articles for the literature review, print or web-
based, different types of research articles can be used as indicated in the ranking of
evidence for EBDM (Figure 7-2). It is important to seek literature that is at the
highest level of evidence available.2 One significant type is the systematic review
with meta-analysis, which reflects a comprehensive review of a topic accomplished
by using the scientific method explicitly and resulting in a critical appraisal and
synthesis of all available evidence on the topic and a more powerful statistical
analysis. Systematic reviews and meta-analysis are foundational to EBDM and so
should be searched out whenever possible.12 However, many times you will not find
a strong systematic review and will have to depend on other levels of evidence.
Thus it is important to be able to evaluate a primary research report.
Validation of a research report, whether it is a systematic review or a primary
research report, should include evaluation of the criteria already discussed,
including author's expertise; comprehensive, accurate, and current references; and
the reputation, scientific credibility, potential political stance, and peer review of a
journal. Also, regardless of the type of literature reviewed, full-text materials,
rather than abstracts, should be used. Because an abstract is a brief summary and
does not include the detail of information, it can be misinterpreted and is at the
lower end of the levels of evidence for EBDM.
When reviewing a systematic review, the following questions should be asked:30
(1) Did the review explicitly address a sensible question? (2) Was the search for
relevant studies detailed and exhaustive? (3) Were the primary studies of high
methodological quality? (4) Were selection and assessments of the included studies
reproducible? Additional information to guide evaluation of systematic reviews is
available from the references included in this chapter.
When reviewing a primary research report it is important also to evaluate all
components of the content of the research report to assure its value in contributing
sound evidence on the topic27 (Box 7-8). The following section discusses what to
look for in each section of the primary research report.
ox 7-8
B
Eval uati on of a Pri mary Research Report
Journal
• Use of peer review (refereed)
• Nature of the journal; political stance
• Reputation of the journal
• Respectable scientific or professional publisher or sponsor
• Not commercially published; limited advertising; not a magazine
Author(s)
• Credentials and qualifications
• Scholarly experience; previously published
• Professional affiliation
• No affiliation of author or research facility with funding agency
Date of Publication
• Within 3 to 5 years, except for classic studies or historical perspective
• More recent if rapidly changing topic of study
Abstract
• Approximately 200 words
• Clear statement of purpose of study in the first few sentences
• 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
• Description of research problem or purpose/reason for the study
• Statement of research question or hypothesis (research or null)
Materials and Methods

• Appropriate type and design of research to answer research question
• Appropriate method of conducting research (prospective, retrospective,

randomized)
• Adequate description of population and sample and appropriate sampling

technique
• Appropriate selection of instrument(s) and establishment of validity and reliability

• Use of valid and reliable data collection methods
• Variables and sources of error controlled
• Clear description of research procedures
• Descriptive enough to allow replication of the study
• Use of ethical methods and procedures
Results
• Appropriate treatment of data
• Clear and understandable presentation of data
• Appropriate statistical tests
• Correct statistical conclusion
Discussion/Conclusions
• Interpretation of results
• Discussion of results in relation to previous research results presented in

introduction
• Inferences and opinions stated as such
• Discussion of clinical significance
• Description of limitations of study
• Discussion of plans or recommendations for further research
• Valid conclusions, based on facts
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.
Methods and Materials

This section of the primary research report describes the population, sample, and
data collection methods, as well as the other methods and materials used to
manipulate the independent variable. Enough detail should be provided in this
section that other researchers can replicate the study. The purpose of replication is
to reproduce the results to add to the body of research on the topic, or to modify the
study design as needed to refine the conclusions or answer new related questions.
The reviewer will need to determine the appropriateness of the various methods
used to conduct the study.8,9,11,12,13,17,22 First, were the population and sample
appropriate for the research question studied? For example, if the study was of
nonsurgical periodontal therapy, were the level of disease, age, and other relevant
characteristics of study participants appropriate for the research question? The
sample should consist of individuals who represent the population. The number of
participants assigned to the groups is important also. Were there enough study
participants in the study to allow for valid data analysis and generalization of
findings to the population of interest?
Other methods to evaluate are the selection of an appropriate study design, the
control of all relevant variables in the study (e.g., diet, standard of living, gender,
age, dental history) to prevent extraneous variables, the control of all other sources
of error such as valid and reliable data collection methods, the use of the
appropriate type of control group in an experimental study, the application of
ethical research methods, and the correct application of appropriate statistical
methods. Finally, it is critical that study methods avoid bias, which is defined as any
influence that produces a distortion in the results of a study. Following are some
questions to consider in the evaluation of the methods:
• If instruments (e.g., questionnaire, survey, index, actual dental instrument, or dental
equipment) were used to collect data, were they previously established as valid and
reliable? If a dental index is used to measure an oral disease or condition (see
Appendix F), is it applied appropriately? If an instrument was developed for this
study, was it tested for validity and reliability as part of this study?
• Were the examiners calibrated and their reliability established?
• Were the research conditions consistent for all groups and completely described?
Were the treatment and control groups treated in the same manner except for the
independent variable?
• Was the length of the study appropriate for the dependent variable being studied?
• Were all groups monitored for an adequate period of time to assess long-term
results of the treatment?
• Were ethical procedures followed such as approval of research by a research
review committee, informed consent, voluntary participation, protection of
confidentiality and anonymity, and protection of human research participants?
• Were study participants also patients of the researcher who developed the new
technique being studied, possibly indicating a bias?
• Were blind (masking) procedures followed to assure that

examiners were unaware of which participants were
assigned to the treatment and control groups?
• Was the research conducted in an independent research

facility by independent researchers to avoid influence by
funding agencies?
Ways to control sources of error and bias in a research study are summarized in
Box 7-2.
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.
Clinical significance versus statistical significance.

When statistical results of a study indicate statistical significance, it is important also
to consider the practical or clinical significance of the results. Clinical significance
has to do with clinical judgment, not with statistics.30 Results can be statistically
significant without having clinical importance or practical implications.10,12
Several circumstances can lead to results that are statistically significant without
being clinically significant. When study groups are very large, even slight
differences can result in statistical significance, which may not be clinically
important.25 Even with appropriate sample size, sometimes the actual reduction in
disease in a study group or difference in disease levels between groups may be
statistically significant but not important.30 For example, an experimental group
using a new mouth rinse may experience a statistically significant greater reduction
of gingivitis than the control group using the standard mouth rinse. Yet close
scrutiny of the data might reveal that the experimental group still has a level of
gingivitis that is clinically significant, meaning that neither mouth rinse is the best
treatment to recommend to patients. Another possibility is that the new mouth rinse
is not as acceptable to patients so they may not be willing to use it. In both cases it is
important to consider the lack of clinical significance of the results of the study.
On the other hand, study results can be statistically nonsignificant, yet have
clinical application.30 For example, very small study groups can lead to a lack of
statistical significance, and yet the differences in disease can have clinical
importance. Another example is if a new treatment procedure is tested and found to
be no more effective than the current standard treatment, but the new treatment has
other benefits (e.g., easier to use, more comfortable for the patient, or less costly).
In this case the new treatment could be considered clinically significant without
being statistically significant. Thus it is essential that the professional dental
hygienist critically interpret results of investigations when making evidence-based
decisions to apply these research outcomes to his or her dental hygiene practice. It is
also critical that the whole body of literature on a topic be considered, not just the
results of one study, in determining clinical significance of research results and
application to EBDM.
Summary
This chapter provides an overview of the basics of research, including the steps in
the scientific method, the methods of research and data analysis, how to interpret
research results, keys in analyzing the literature, and the components of a primary
research report. In addition, the role of research and critical analysis of the
literature are discussed in relation to EBDM. Although all research should be
conducted according to the scientific method to provide results with a measure of
validity and reliability, scientific research remains an inexact science. However,
when studies are properly designed, results are accurately analyzed with the use of
the appropriate statistical procedures, and results are thoughtfully and critically
interpreted, valid and up-to-date information can be obtained that can improve
current dental hygiene practice and serve as a springboard for further studies. The
inventive and inquisitive practitioner will seek to discover information that
enhances the practice of dental hygiene in all its contemporary roles and keeps the
profession moving in a forward direction.
1. Design a mock experimental research study based on a question you have that is
related to the field of dental hygiene. Formulate a research problem, and develop a
hypothesis and a null hypothesis for the research problem. Then define or describe
the following for the mock study:
a. Population
b. Sample
c. Experimental group
d. Control group
e. Independent variable
f. Dependent variable
g. Data—classify it as categorical, continuous, or discrete,

and identify the scale(s) of measurement of the data as
nominal, ordinal, interval, or ratio
2. Complete a literature review for the research problem formulated in No. 1.
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.
8. Complete the NIH tutorial Protecting Human Research Participants at

https://phrp.nihtraining.com; report to the class what you learned from the course.
competencies:
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.
CM.1
CM.6
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
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February 2015].
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excellence through evidence based practice. J Dent Hyg. 2013;87(Suppl.
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4. Marshall T, Straub-Morarend CL, Qian F, et al. Perceptions and practices of
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Cochrane Handbook for Systematic Reviews of Interventions; 2011
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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.
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& Barlett: Sudbury, MA; 2011.
13. Rosenthal JA. Statistics and Data Interpretation for Social Work. Springer
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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:
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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].
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[Available at]
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March 2015].
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Public Health Practice: An Introduction to Applied Epidemiology and
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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
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25. Forrest JL, Miller SA. Evidence-based decision making. Darby M, Walsh M.
Dental Hygiene: Theory and Practice. 4th ed. Elsevier Saunders: St Louis;
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26. Houser J. Nursing Research: Reading, Using and Creating Evidence. Jones &
Bartlett Learning: Sudbury, MA; 2013.
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2015].
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Periodontol. 1965;36:177–187 [Available at]
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checklist.html [Accessed March 2015].
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Chapel Hill Health Sciences Library. Introduction to Evidence-Based
Practice (tutorial); 2015 [Available at]
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March 2015].
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Work Group. Recommendations for using fluoride to prevent and control
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December 2014].
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March 2015].
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Fluoride Varnish for Caries Prevention; 2008 [Adopted January; Available
at] https://www.google.com/?gws_rd=ssl#q=fluoride+varnish+aaphd
35. Marinho VCC, Worthington HV, Walsh T, et al. Fluoride varnishes for
preventing dental caries in children and adolescents. Cochrane Libraries
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2015].
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Recommendations and Supporting Systematic Review; 2013 [Available at]
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37. American Academy of Pediatric Dentistry. Guideline on Fluoride Therapy.
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http://www.cebd.org/.
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http://subjectguides.library.american.edu/litreview.
Guidelines for reading/reviewing scientific research papers.
http://www.unm.edu/~lkravitz/UNM%20Pages/readingreseach.html.
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National Dental Hygiene Research Agenda.
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%20A%20Data%20Collector%27s%20Field%20Guide.pdf.
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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
Health Promotion Theories

When promoting health and preventing disease, a theory helps us analyze and
interpret health problems and then develop and evaluate interventions based on the
analysis. A theory is a set of interrelated concepts, definitions, and propositions that
present a systematic view of events or situations by specifying relations among
variables to explain and predict the events or situations.4 This is an abstract notion
that comes to life only when it is applied to specific topics and problems. Sometimes
theories are called conceptual frameworks or models.
How can theories be applied to dental hygiene practice and public health practice?
Every day, dental hygienists face challenging situations that result in oral health
problems such as families who feed their babies sweetened liquids in baby bottles,
athletes who sustain oral injuries because they refuse to wear a mouth guard or
other facial protection, adults who say they are too busy to follow oral care
recommendations, or teens who use tobacco products. Theories can help us analyze
these situations and apply solutions that have been effective in similar
circumstances.
Dental hygienists too often view oral health problems primarily as the patient's
problem and proceed to educate the patient with facts and lectures about how to
improve oral health. This approach is doomed to failure because it skips directly to
a generic intervention and does not assess or validate the patient's point of view or
health beliefs and does not consider the environmental, literacy, or cultural
circumstances that have influenced the person's attitudes, beliefs, or health practices.
It is important to analyze oral health problems from more than one perspective and
to understand how each perspective affects the others.
Behavior that leads to improved oral health can be influenced at various levels
(see Figure 8-1 and Table 8-1). These levels provide an ecologic approach to health
promotion that focuses on both population-level and individual-level determinants
of health and interventions.5 The ecologic approach is based on the idea that
behaviors both shape and are shaped by the social environment.6 According to this
approach, multiple interventions are often needed that are community-based, not just
individually focused, to initiate and sustain behavior change effectively.7
FIG 8-1 Levels of influence of health promotion theories. (Adapted from 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/4ImportantTheoriesandTheirKeyConstructs/tabid/73
Accessed September 2015.)
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
Stages of Change Theory (Transtheoretical Model).

Years of research have shown that a one-time educational intervention without a
follow-up is totally ineffective for long-term retention of knowledge or behavior
change. The Stages of Change Theory views change as a process or cycle that
occurs over time rather than as a single event. This theory allows the dental
hygienist to assess a person's readiness to change a behavior toward a more
healthful lifestyle such as daily brushing to prevent gingivitis. The theory assumes
that at any point in time everyone is at a different stage of readiness to make
lifestyle changes and that people cycle through the various stages over time,
depending on the behavior to be changed and whether the environment is
supportive. Relapse can occur as temptation to revert to old behaviors overcomes
one's ability to maintain the desired behavior change. The theory is based also on
the assumption that in order for change in behavior to occur, the health educator
must address the individual in relation to his or her current stage of readiness to
change.8 This theory is focused on strategies rather than information. The major
stages of this model with definitions and applications are outlined in Table 8-2.
TABLE 8-2
Stages of Change (Transtheoretical Model)
Conc e pt De finition Applic ation

Precontemplation Being unaware of problem; not having thought about Increase awareness of need for change; personaliz e information on risks
change and benefits
Contemplation Thinking about change in the near future Motivate and encourage the making of specific plans
Decision/ Making a plan to change Assist in developing concrete action plans or setting gradual goals
determination
Action Implementing specific action or plans Assist with feedback, problem solving, social support, and reinforcement
Maintenance Continuing desirable actions or repeating periodic Assist in coping, using reminders, finding alternatives, and avoiding slips
recommended steps or relapses
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.
[Memory Tip: Readiness to change cycles through stages]

Oral health example.
The cycle starts by increasing one's awareness of a problem (e.g., a person has
gingivitis) to initiating behavior change (e.g., brushing and flossing effectively and
using antimicrobial rinses) and progresses to maintaining motivation to continue
preventive actions (e.g., returning in 3 months to check progress). To be effective in
changing behavior, health messages and programs should be matched to an
individual's current stage of readiness to change. The dental hygienist's goal is to
help the individual move to the next stage on the cycle of adopting effective
preventive behaviors.
Health Belief Model.

Originated as a way to explain people's use of preventive health services, the Health
Belief Model (HBM) suggests that specific perceptions are necessary to motivate an
individual to take preventive action.9 These beliefs are that (1) s/he is susceptible to
the disease or condition, (2) the disease or condition is serious, (3) the
recommended action will prevent the disease or condition, and (4) the costs or
negative aspects of the preventive action are outweighed by the benefits. The
primary hypothesis is that adopting these perceptions in the order listed will
influence the potential of taking action. In addition, perceived ability to take action,
referred to as self-efficacy, and cues to action are important factors in this model.
The HBM is applied by developing messages that address these perceptions in an
attempt to influence decisions to improve their oral health. In contrast to the Stages
of Change, the HBM is focused on information. The model has been criticized
because it is strictly information-based and does not take into account attitudes,
beliefs, habitual behaviors, individual determinants of health decisions, and
environmental or economic influences on health behaviors. The components of the
model and some applications are presented in Table 8-3.
TABLE 8-3
Health Belief Model

Perceived One's opinion of chances of getting a condition Define population at risk and risk levels; personaliz e risk based on a person's
susceptibility features or behavior; heighten perceived susceptibility if too low
Perceived One's opinion of how serious a condition and its sequelae are Specify consequences of the risk and the condition
severity
Perceived One's opinion of the efficacy of the advised action to reduce Define action to take: How, where, when; clarify the positive effects to be
benefits risk or the seriousness of effect expected
Perceived One's opinion of the tangible and psychological costs of the Identify and reduce barriers through reassurance, incentives, and assistance;
barriers advised action, and that any actual costs are outweighed by assist the individual in doing a cost/benefit analysis of the recommended
the benefits preventive action
Cues to Strategies to activate readiness Provide how-to information; promote awareness; send reminders
action
Self-efficacy Confidence in one's ability to take action Provide training and guidance in performing action
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.
[Memory Tip: Susceptibility, risk, seriousness, benefits, barriers, cues to action,

and self-efficacy are key terms]

Does your father think that he is at risk for developing oral cancer because he
smokes a pipe (i.e., susceptibility)? Does he believe that oral cancer is serious
enough to warrant the inconvenience or sacrifice of taking preventive action (i.e.,
severity)? Does he believe that limiting his use of the pipe will reduce his oral
cancer risk (i.e., benefits)? Does he believe that it is possible to stop smoking a pipe
(i.e., barriers)? Does he have confidence that he can succeed in changing his pipe
smoking habit by overcoming the temptation to smoke it, and what counseling and
support does he need to stop pipe smoking (i.e., self-efficacy)? What information,
reminders, or other cues does he need to appropriately limit his use of the pipe (i.e.,
cues to action)?
Interpersonal Level
Social Learning Theory.

The Social Learning Theory posits that people learn primarily in the following
four ways:10
1. Vicarious learning, also called observational learning, as a result of observing

others' behavior
2. Remembering and imitating the observed behaviors of others (modeling)
3. Inferences made from the evidence of observed outcomes of behavior
4. Motivation from judgments voiced by others such as testimonies or promotions

by experts
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)

Reciprocal Behavioral changes result from interaction between the person Involve the individual and relevant others; work to change the
determinism and the environment; change is bidirectional environment, if warranted
Behavioral Knowledge and skills to influence behavior Provide information and training about action
capability
Expectations Beliefs about likely results of action Incorporate information about likely results of action in advance
Self-efficacy Confidence in ability to take action and to persist in action Point out strengths; use persuasion and encouragement; approach
behavioral change in small steps
Observational Beliefs based on observing others like oneself and/or visible Point out others' experience and physical changes; identify role models to
learning physical results emulate
Reinforcement Responses to a person's behavior that increase or decrease the Provide incentives, rewards, praise; encourage self-reward; decrease
chances of recurrence possibility of negative responses that deter positive changes
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.
[Memory Tip: Learning by observing, copying, processing consequences, and

listening to others]

You are asked to help a single mother increase her confidence about brushing her
young child's teeth. First you assess what she is currently doing, how she has
determined to do things this way, and what questions or concerns she has. Then you
help her refine her current skills or learn a new skill by using techniques such as
having her observe others who do it well, asking her to research what experts whom
she respects recommend, giving her the opportunity for guided practice of what she
has learned, having her process what she is learning through reflection and
discussion, providing ongoing encouragement, and giving periodic feedback. When
the mother gains some confidence in her skills, you then ask her to help you assist
the child care workers and other parents at the day care center in learning these
skills so they can support each other and so oral hygiene care becomes a daily
activity for all the children.
Community Level
Community Organization Theory.

Community Organization Theory is the process of involving and activating
members of a community or subgroup to (1) identify a common problem or goal of
importance to them, (2) mobilize resources to address the problem, (3) implement
strategies, and (4) evaluate their efforts.11 The community can be large or small and
can represent a diverse definition of community such as a geographic location, an
organization, a workplace setting, or even a group with a common cause.
Community organization involves social planning, social action, group consensus
about common concerns, collaboration in problem solving, and formation of
community partnerships or coalitions. It is based on the community's emotional and
social commitment to action. People usually refer to this process as community
empowerment because it is a grassroots approach to health promotion, rather than
an effort that is initiated and conducted solely by health professionals. The role of
the health educator is to guide and facilitate the community organization process as
the community learns the skills to solve their own problems. Table 8-5 outlines the
key components.
TABLE 8-5
Community Organization Theory

Empowerment Process of gaining mastery and power over oneself or one's Give tools and responsibility to individuals and communities for making
community to produce change decisions that affect them
Community Community's ability to engage in effective problem solving Work with community to identify problems, create consensus, and reach
competence goals
Participation Learner (community) should be active participant; work Help community set goals within the context of preexisting goals, and
relevance should start “ where the people are” encourage active participation
Issue selection Identifying winnable, simple, and specific concerns as focus Assist community members in examining how they can communicate the
of action concerns and whether success is likely
Critical Developing understanding of root causes of problems Guide consideration of health concerns in broad perspective of social
consciousness problems
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.
[Memory Tip: Grassroots organization and empowerment]

Consider the role of a church pastor and a congregation in oral health promotion.
Church members notice that many of the older adult members have stopped coming
to church suppers because they have lost their teeth or dentures and are embarrassed
to eat in public. The pastor forms a committee of the congregation that includes
older adult members. They contact a local dental school to help them develop a
dental program to assist the older adults, and they involve the congregation to raise
funds to help defray the cost of examinations and new dentures for the older adults.
Dental and dental hygiene student teams work together to assess the program
participants' needs, attitudes, and interests; to fabricate and fit the dentures; and to
develop programs for the older adults based on their input. The topics include a
discussion of oral health in relation to overall health, denture care, and the
challenges of eating various foods with dentures. Gradually, the older adult
members become comfortable eating and speaking with the dentures, and they
resume their attendance at church suppers. In addition, the selection of food at these
suppers is changed to accommodate the varied dietary practices and chewing
abilities. The following year, the committee and church leaders continue to work
with the student teams to promote oral health to people of all ages within their
parish.
Diffusion of Innovations Theory.

The Diffusion of Innovations Theory helps us assess and plan for the spread of
new ideas, products, or services within a society or other groups.12 Attention is
directed to (1) the characteristics of the innovation, (2) the communication channels,
and (3) the social systems. A key aspect of this theory is relative advantage, which is
how much the innovation is perceived to be better than an approach or product that
it replaces. Understandably, this perception affects the adoption of innovations so it
is important to attempt to change perceptions when necessary. Another important
concept is the different categories of adopters that embrace a new idea quickly, in
moderation, or slowly. Diffusion of an innovation can be extremely slow or very
rapid, depending on the characteristics of the population. Understanding of these
characteristics is necessary to determine how to introduce a new idea. Different
strategies are useful to appeal to the various adopter categories. Table 8-6 displays
the components of this theory, and Table 8-7 presents the adopter categories, their
characteristics, and suggested strategies to appeal to them.
TABLE 8-6
Diffusion of Innovations Theory

Relative The degree to which an innovation is seen as better than the idea, Point out unique benefits such as monetary value, convenience, time
advantage practice, program, or product it replaces saving, prestige, and others
Compatibility How consistent the innovation is with values, habits, experience, Tailor innovation to the intended audience's values, norms, or situation
and needs of potential adopters
Complexity How difficult the innovation is to understand or use Create a program, idea, or product that is easy to use and understand
Trialability Extent to which one can experiment with the innovation before a Provide opportunities to try on a limited basis (e.g., free samples,
commitment to adopt is required introductory sessions, money-back guarantee)
Observability Extent to which the innovation provides tangible or visible results Ensure visibility of results through feedback or publicity
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.
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.
[Memory Tip: How innovations are adopted]

Researchers in the 1990s found that despite numerous clinical trials showing the
effectiveness and safety of dental sealants in caries prevention, their adoption by
practitioners proceeded slowly. Adoption occurred much sooner in public health
clinics, where higher caries rates resulted in a more critical need for low-cost,
effective, caries-preventive measures and strong advocacy for the procedure. By
contrast, in private dental offices many children had lower caries rates, some
insurance companies did not reimburse for sealants, and practitioners were wedded
to the use of amalgam restorations to manage rather than prevent dental caries. Over
time caries rates in occlusal surfaces declined dramatically in children who received
regular care and sealants at the clinics, whereas caries rates remained stable in the
children treated in private or public dental practices that did not apply sealants.
In addition, the clinical procedure for sealant placement was technique-sensitive
and required additional training for dentists and dental hygienists. In due course,
sealant materials were improved and more oral health professionals received the
required training. Major educational and advocacy efforts were used to eventually
change attitudes, patterns of practice, and reimbursement policies, thus resulting in
use of sealants and reduced rates of occlusal caries in children treated in both the
public and private sectors. Depending on their adopter category, some dentists
needed to see for themselves the value and effectiveness of dental sealants before
they were willing to accept their use.
Organizational Change: Stage Theory.
Organizations pass through a series of four stages as they initiate change.
Organizational structures and processes influence workers' behavior and motivation
for change. For the Organizational Change: Stage Theory to be successful, all
stages must be implemented, including integration of new policies within the
organization. Specific strategies are required at each stage of change, depending on
where the organization is in the process of adopting, implementing, and sustaining
new approaches13 (Table 8-8). In addition, organizational structures and processes
influence workers' behavior and motivation for change.
TABLE 8-8
Organizational Change: Stage Theory
Conc e pt De finition Applic ation Strate g ie s

Definition of Problems recogniz ed and analyz ed; solutions sought and Involve management and other personnel in awareness-raising activities
problem evaluated
Initiation of action Policy or directive formulated; resources for beginning Provide process consultation to inform decision-makers and implementers
change allocated of what adoption involves
Implementation of Innovation is implemented; reactions and role changes occur Provide training, technical assistance, and aid in problem solving
change
Institutionaliz ation Policy or program becomes entrenched in the organiz ation; Identify high-level champion, work to overcome obstacles to
of change new goals and values internaliz ed institutionaliz ation, and create structures for integration
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.
[Memory Tip: Organizations change in four stages]

For months health educators had asked the cafeteria staff in their hospital to offer
healthier foods. A number of stages were involved in instituting the change (e.g.,
pricing different food items, buying from local farmers, reviewing sample menus,
announcing the new food items on a trial basis, and interviewing employees about
the changes). Over time more employees began to select the new food options and
suggest new recipes, thus creating healthier lunches. The health educators and the
cafeteria staff then collaborated to host a weekly onsite farmers' market and to
distribute health-promoting recipes so that employees also were encouraged to
prepare healthy meals at home. This process not only resulted in institutional
change but also created healthier lifestyles in the employees' families.
Combining Health Promotion Theories

Frequently health promotion theories are combined within an intervention. The
various components of different theories can be brought together to address a
specific health issue. In this way the strengths and limitations of the diverse theories
can be balanced when they are used in combination. For example, the HBM can be
used to design educational materials, and the strategies used to implement the
educational materials can be formulated around the Stages of Change Theory to
assess readiness to change and motivate movement through the stages. Furthermore,
the Social Learning Theory can be used to add activities and encounters that will
provide experiential learning and motivation to move from one stage to the next.
In addition, multiple theories are combined to enhance the ecologic dimension.5
For example, a community-wide intervention can include policy development,
community organization, organizational change, and individual behavior change to
include all levels of influence.7 Thus, having an understanding of various health
promotion and health education models and theories is important to be able to
develop successful comprehensive community oral health programs.
Expanding Dental Hygiene Knowledge and

Strategies
To use these theories effectively dental hygienists need to acquire the knowledge
and approaches necessary to assess and change health behaviors and systems of
care, as well as to evaluate outcomes (see Guiding Principles). In addition, dental
hygienists need to keep abreast of innovative programs occurring in other
professions and ways that other healthcare systems and countries address health
problems.
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
• Which categories of interventions (e.g., personal behaviors, programs, societal

and environmental modifications, policies) yield the desired impact
• Effective oral, written, and electronic communication skills
• Appropriate and effective communication methods and channels
• 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
• The structure and function of various healthcare systems and community-based

organizations
• How to deliver effective services and education
• How to evaluate efforts (e.g., effectiveness, costs, access, quality, outcomes) using
both qualitative and quantitative methods
• Appropriate and effective communication methods and channels
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.
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?)
2. Set communication objectives (What do we want to accomplish?)
3. Analyze and segment target audiences (Who do we want to reach?)
4. Develop and pretest message concepts (What do we want to say?)
5. Select communication channels (Where do we want to say it?)
6. Select, create, and pretest messages and products (How do we want to say it?)
7. Develop promotion plan/production (How do we get it used?)
8. Implement communication strategies and conduct process evaluation (How do we

get it out there?)
9. Conduct outcome and impact evaluation (How well did we do?)
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.
Health information technology also is of increasing importance in HP 2020

where Health Communication and Health Information Technology are a combined
topic area. Objectives in this subject emphasize improving health literacy,
improving health provider communication skills, increasing use of the Internet and
electronic personal health management tools, improving the quality of health-
related websites, increasing the use of social marketing in health promotion and
disease prevention, and using best practices to communicate crisis and emergency
risk messages.14 Using technology in health communication is important to meet
current consumer expectations in today's age of technology.
One of the challenges in designing health communication programs is to identify
the most effective channels, context, and content that will capture people's attention
and motivate them to use health information. Research on strategies to address these
challenges is becoming more widespread, sophisticated, and cross-cutting, with
results that are applicable to oral health.
Creating and Delivering Health Communication

A variety of techniques can be used to increase the potential effectiveness of health
communication messages. Some are discussed here. In all cases use of needs and
risk assessment will enhance outcomes of health communication.
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
Oral He alth Me ssag e : The Importanc e of Giving Up the Use of Tobac c o

P Explanation of the P Oral Health Example
Product Represents the desired behavior you are asking your audience to do Behavior: Stop smoking
and the associated benefits, tangible objects, and/or services that Benefits: Improved general health and prevention of future health
support behavior change problems
Tangible objects: Immediate health benefits such as improved cough or
asthma, savings of cost of cigarettes, improved breathing
Services that support the change: Available counseling or family
support
Price The cost (financial, emotional, psychological, or time-related) of Financial: Cost of counseling or medical support
overcoming the barriers the audience faces in making the desired Emotional: Necessity of staying away from family and friends who
behavior change smoke and changing places to “ hang out”; giving up other triggers such as
coffee, alcohol
Psychological: Withdrawal symptoms, learning to deal with temporary
failures in the process of quitting
Time-related: Appointments for counseling or medical support; self-
analysis, journaling, and planning for change
Place Where the audience will perform the desired behavior, where they Performance of desired behavior: Changes needed in the home, work, or
will access the program, products, and services, or where they are leisure environments to support the change
thinking about your issue Access to program: Computer-based and social media support
Thinking about the issue: Effect of environment on desire to continue
smoking
Promotion Communication messages, materials, channels, and activities that Messages: Information that needs to be conveyed
will effectively reach your audience Materials: Actual health education materials, such as a brochure or a blog
Channels: Media used to communicate messages (e.g., visual, written, or
oral)
Activities: Something the client participates in to receive the health
message (e.g., reading a blog, viewing a video, developing an action plan,
or attending counseling sessions)
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.
Framing Health Messages

New forms of health information technology, especially social media, are changing
our options for framing, delivering, and evaluating health messages for the public.
The concept of framing health messages relates to how messages are crafted rather
than the content of the messages. Certain cues in a message—for example, sounds,
symbols, words, and pictures—can signal how and what to think about an issue. In
the process of framing messages an attempt is made to connect to people's values,
beliefs, knowledge levels, and emotions. Framing brings meaning to a message. “A
well-framed message incorporates values held by and information relevant to the
target audience and excludes information the audience finds irrelevant.”16
Gain-framing a message is focusing on what is to be gained by adopting the
recommended health behavior; loss-framing is the opposite, focusing on the effect
of continuing to practice an unhealthy behavior.17 An example of gain-framing is to
focus on the benefits of seeking treatment (e.g., comfort and appearance), and loss-
framing would focus on the pain and loss of teeth that can result from continuing
not to seek treatment. Research has shown that gain-framing is more effective than
loss-framing to promote preventive health behaviors aimed at avoiding disease.17
Tailoring Health Messages

Tailoring health messages relates to making messages meaningful to a specific
individual by taking into consideration particular known characteristics of the
targeted person.18 A fundamental error in many oral health education efforts is to
assume that increased knowledge will result in meaningful changes in behavior. As
a result, oral health messages often are packaged as generic messages such as, “See
your dentist/dental hygienist twice a year”—a message not based on individual risk
assessment.
Limiting Content of Messages

Another common error is to use health messages that cover a number of concepts to
try to appeal to the greatest number of people. For example, one brochure might
cover brushing and flossing and the use of fluorides, sealants, antimicrobials, and
other preventive measures. It might also describe various diagnostic procedures
such as radiographs, periodontal probing, and microbial tests. This type of
brochure is based on the assumption that dental hygienists should provide as much
information at one time as possible, and that people will sort through the
information to select the pieces that apply to them. Numerous research studies have
shown that this assumption is not valid.19 Use of an approach that overwhelms
people with information is not an effective strategy for changing behaviors. This is
particularly true when people are busy, when they are low-level readers, or when
only some of the information is immediately relevant to their needs.20
Targeting the Audience

With a more focused approach, health professionals can target materials to reach a
specific subgroup or population, usually based on demographic characteristics (e.g.,
older adults, pregnant women, African Americans). The assumption that underlies
this approach is that enough homogeneity exists in the group to justify the messages
and formats used. Subgroups, however, often are very heterogeneous, thus reducing
the effectiveness of this approach in some situations.20
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.
Selecting and Evaluating Communication Formats

for Different Audiences
Consumer-Oriented Communication
Before providing health information to an individual or group, an assessment and
planning process is crucial. Depending on the audience and topic, a needs
assessment can be accomplished through a literature review, informal observations
or conversations, health literacy assessments, in-depth interviews, or focus groups.
A needs assessment reveals important cultural beliefs, health practices, health
literacy, and knowledge levels that can result in misconceptions, barriers to care, or
stumbling blocks to behavioral change.
Health literacy has been defined as “the degree to which individuals have the
capacity to obtain, process, and understand basic health information and services
needed to make appropriate health decisions.”21 Health literacy is affected by several
factors:
• Communication skills of laypersons and professionals
• Lay and professional knowledge of health topics
• Culture
• Demands of the healthcare and public health systems
• Demands of the situation/context
A 2003 National Assessment of Adult Literacy noted that, in the U.S., health
literacy acts as a barrier to almost 90% of adults understanding and using health
information.22 In addition, health literacy affected people's ability to (1) navigate the
healthcare system, including filling out complex forms and locating providers and
services; (2) share personal information, such as health history, with providers; (3)
engage in self-care and chronic-disease management; and (4) understand
mathematical concepts such as probability and risk.21
Health literacy serves as the foundation for oral health literacy. Survey research
results show that the public lacks understanding about (1) how to prevent and
manage oral diseases, (2) the impact of poor oral health, (3) how to navigate the
oral health system, and (4) the best techniques in patient-provider communication.22
Higher degrees of oral health literacy have been associated with increased oral
health knowledge, greater use of dental services, and better oral health status.23 Low
oral health literacy is associated with both poorer overall health and poorer oral
health.
HP 2020 objectives specifically address ways to improve the health literacy of the
population.14 Numerous national and state agencies have developed resources that
emphasize the need to develop clear communication with plain language. This
means the communication can be understood by the audience members the first time
they hear or read it. Written materials are said to use plain language when readers
can “find what they need, understand what they find, and use what they find to meet
their needs.”24
In addition, communication should be culturally sensitive and linguistically
competent. In other words, language and graphics should be inclusive and not
promote stereotypes. Special considerations are needed when designing or
translating materials for non-English speakers.25 Box 8-2 lists some problems
associated with translating health education materials and suggestions for
preventing or overcoming these problems. These should be considered also during
any needs assessment and when field testing materials.
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.
Suggestions for Overcoming Translation Barriers

• Use materials originally developed in that language or have new materials
developed in the target languages rather than using a literal translation from
English.
• 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.
• It is best to use translators who are both bilingual and bicultural.
• 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 planning process.

Using findings from a needs assessment (see Chapters 3 and 6), a health
promotion/health communication plan should be developed before any
interventions are started. This plan should include project objectives; activities; key
messages; target audiences; time-lines; resources needed and available; responsible
parties; and evaluation methods, measures, and anticipated outcomes.20 Planning the
communication formats, channels, and materials to be used in a program or
campaign is part of the planning process. Evaluation measures should be planned
with consideration given to the kinds of information needed (see Evaluation
Considerations later in this section). Resources to assist in developing a
communication plan are included at the end of the chapter.
A variety of resources are available for dental hygienists to use when selecting
communication formats and channels and designing and evaluating health messages.
Examples of formats for presenting information to the public are included in Table
8-10, along with the uses and limitations of some of these formats. The increasing
use of infographics is a way to pair words with graphics (see Figure 8-2), which
makes health communication more understandable. The information about ways
people learn depicted in this figure also demonstrates the value of using
communication methods that utilize multiple senses and incorporate hands-on
activities.
TABLE 8-10
Uses and Limitations of Various Health Communication Formats for the
Public
Cate g ory and Example s Use s Limitations

Visual Displays: posters, bulletin boards, information Combines graphics and written information; Requires legwork to post; has to be eye-catching; may
kiosks, billboards best in public places to highlight key not reach target population; not as effective as other
messages; most useful to bring issues to the formats to change behavior
attention of the audience
Written Media: newsletters, newspaper articles, fact Can include multiple messages in multiple Increases knowledge but may not change behaviors;
sheets, booklets, fotonovelas, blogs, storybooks, languages; covers topic in more depth; tells a graphics needed for low literacy readers; may not reach
pamphlets story; can be tailored to different ages and target audience
target groups
Audiovisual Materials: CDs and DVDs, public service Taps into audio and visual learning paths; Some expensive to produce; need to market for purchase
announcements, websites, TV, streaming video can use champions or celebrities; can be or viewing; may not reach target audience; technology
tailored to specific audiences and ages; may may not be available or have glitches; discussion or
help with adoption of new behaviors some other interaction is needed to improve potential for
behavior change
Interactive Formats: songs, role playing, storytelling, Uses multiple learning pathways to increase Some can be expensive to produce and require human
gaming, theater or puppet shows, demonstrations, understanding, retention, and behavior resources for interaction; need to match format to target
interactive computer programs, science experiments change; allows interaction/participation; can audience and be culturally and linguistically appropriate
or science fairs, debates, simulations, text messages, share different perspectives; can adapt for
other social media different audiences
FIG 8-2 Example of an infographic about how people learn.
Using a variety of formats can accommodate for differences in learning styles of

the audience.27 Assessing learning styles of individuals is much easier than planning
messages to reach a diverse group of people. Each person has a preferred way to
learn. Hands-on and interactive multimedia formats account for different learning
styles in a group and are usually more effective for retaining knowledge than
simply reading or listening to a message. This is true whether one is presenting
information to the general public or to other health professionals. Finally, research
indicates that the use of multiple strategies has a greater effect on improved health
literacy and increased use of healthcare services.26
The use of focus groups is one effective method for determining, before
launching a program, whether messages are at the appropriate language and literacy
level and whether they are culturally acceptable to the people in the group.20
Information about the appearance and appeal of materials can be gathered this way
also. Group interviews, 30 to 60 minutes in length, are conducted with 5 to 10
members of the intended target audience in each group. A moderator uses structured
questions to guide the group discussion (Figure 8-3). When developing or testing
health messages or materials, the moderator can use one or more versions of the
materials to ask contrast questions. For example, in field testing a media campaign
about dental sealants, you might ask the following:
• What is one message you remember from the campaign?
• Were there any messages that were confusing?
• Which materials were most informative? Motivational? Attractive? Appealing?
• Did you relate to the people in the photographs? How were they like you?
Different from you?
• Were the campaign messages too short, just right, or too long?
• Should the campaign include more resources for those who want more
information on dental sealants?
• Would this campaign motivate you to ask about dental sealants for your child's
teeth?
FIG 8-3 A moderator uses structured questions to guide the discussion in a focus
group. (© iStock.com.)
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.
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?
• What messages or activities produced the best results?
• Should this intervention be continued in its current form?
• How can the intervention be improved?
• Can it be replicated successfully in other settings?
• Are the resources (e.g., people, money, materials) that were used reasonable and
cost-effective?
Evaluation plans do not always have to be complicated or use sophisticated

statistical analysis. The key is to plan how to evaluate your efforts before executing
an intervention and then document the outcomes of the evaluation. It is important to
document intended outcomes and impact, as well as barriers to success, lessons
learned, and unintended outcomes. See Box 8-3 for examples of simple evaluation
strategies.
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.
• Use a consumer feedback questionnaire or interview in a clinic to determine

whether the patients are receiving all of the health information they want and need
in formats that answer their questions or concerns in a clear and culturally
appropriate manner.
Presentations to Health Professionals

The purpose of most professional presentations is to deliver thought-provoking
information to a group of health professionals in a short period of time in a clear,
concise, and appealing format that will be educational and promote discussion.
Presentations often focus on new research or programs, emerging issues, clinical
techniques, products or materials, career opportunities, educational techniques,
policies or legislation, healthcare systems, or methods for disease prevention or
detection. Information should cover a specific topic with key messages highlighted
and sources documented. Presentations can be made to small groups, to large
groups at conferences, or via webinars, podcasts, or other online learning formats.
The same principles and processes that apply to communicating with the general
public also apply to communicating with other health professionals. Although direct
needs assessment of the audience may not be possible before a presentation,
acquiring some background information from the organizers or at the beginning of
the presentation can help with tailoring information to the audience.
This section provides general information about four common types of
professional presentations although specific guidelines for presentations may vary
by the sponsoring organization. When planning a presentation at a professional
conference it is always critical to check with the organization that is planning the
meeting. Also additional information on professional presentations is available in
the online resources at the end of this chapter. Specific questions should be
considered when selecting a topic and a format for a presentation (see Guiding
Principles).
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 is the audience's level of knowledge or interest in my topic?
• What level of interaction will I have or do I want with the audience?
• What questions might the audience ask? Will I be able to learn new information
related to my topic from some members of the audience?
• How much time will I need to cover my key points?
• What audiovisual materials will most enhance my key points?
Professional presentations typically are organized with a similar flow or order.

Regardless of the type of presentation, most presentations are based on the
following basic outline:
1. Introduction and background of the topic/project/presentation
2. Methods and materials, research or intervention strategies, and evaluation

questions
3. Findings/results and key points
4. Discussion and significance
5. Summary and conclusions
Presentation of a poster display.

The poster presentation display format (Figure 8-4) is popular because a large
number of presentations can be accommodated in a short time frame and no
audiovisual equipment is needed.
FIG 8-4 Format for a poster presentation. (Photograph courtesy Beverly Isman.)
Time: Session lasting 1 to 2 hours; each poster presentation lasting 5 to 10

minutes, depending on criteria of organization hosting the event
Format: Presenter discusses visual display with people who stop to look; posters
lined up next to each other; poster usually attached by pushpins to a board or other
backing material
Size of audience: Varies greatly; some people “cruise by” quickly, some just pick
up handouts, and others stop to read display and discuss topic
Appropriate audiovisuals: Text, data, artwork, or photographs usually printed as
one large banner; audio or video applications not allowed; handouts encouraged
Benefits and limitations: Opportunity to discuss topic with individuals, share
ideas, and acquire additional ideas; unpredictable attendance (sometimes crowded
and noisy but at other times attendance is sparse); not appropriate for topics that
require videos or other types of media
Tips: Use color and photographs to attract attention and highlight key points; use
large, readable print and catchy title; intersperse categories of information with
charts, graphics, and photographs; consider setup logistics and transport; include
copy of abstract, which is usually printed in the meeting program
Presentation of an oral paper or panel discussion.

The oral paper format (Figure 8-5) usually is part of a session with a theme or a
panel.
FIG 8-5 Presentation of an oral paper. (© iStock.com.)
Time: Usually 10 to 15 minutes, including time for questions

Format: Oral presentation of information, using notes and accompanied by
audiovisuals
Size of audience: Usually more than 30 people but suitable for hundreds of
people, especially if part of a satellite session broadcast to many sites
Appropriate audiovisuals: PowerPoint slides, short videos, other computerized
applications; Internet connectivity, including free wireless, may be available
Benefits and limitations: Large group can be reached; presenter can speak from
printed notes or directly from slide notes on computer; room lighting sometimes
fairly dark; usually standing behind a podium with a microphone; interaction with
audience often limited; varying degrees of knowledge about topic in audience
Tips: Try to maintain some eye contact and do not simply read from your papers;
use uncomplicated and effective audiovisual materials that highlight important
information rather than detract from or repeat information you give orally; practice
delivery, timing, and use of audiovisuals before the presentation; decide what
information to delete if you are running over the time allowance; include transitions
between sentences and sections; upload your presentation per the sponsor's
directions and check computer controls, placement for notes, and room
environment/lighting before your session
Presentation as a roundtable discussion.

The roundtable discussion format (Figure 8-6) is gaining in popularity for a more
informal presentation.
FIG 8-6 Roundtable discussion. (Photograph courtesy Beverly Isman.)
Time: 30 to 60 minutes; presentation sometimes repeated to a new group

Format: Oral presentation and discussion supplemented by limited audiovisuals
to people seated at a table or in a circle
Size of audience: Usually 8 to 10 people but could be more
Appropriate audiovisuals: Handouts, materials, or products; can use laptops
with video application but not usually audio; Internet connectivity may be too
expensive unless free wireless is available
Benefits and limitations: Format allows interactive discussion; participants can
introduce themselves and share information with the whole table; good for
controversial topics or new ideas and programs; limited number of people hear the
topic; too many tables close together creates difficulties hearing the information
Tips: Speak from notes, handouts, or laptop; facilitation skills and ability to
refocus discussion is important if discussion is off-track or is monopolized by an
individual
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.
FIG 8-7 Web-based presentation. (Photograph courtesy Charlene Dickinson.)
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
Audience evaluation of a professional presentation.

The effectiveness of professional presentations can be assessed through the use of
course and conference evaluation forms completed by the onsite or online attendees
or by asking the audience directly for some immediate feedback. Evaluation
measures usually address the presenter's organization of information, effective use
of audiovisuals, accuracy and relevancy of content, relation of theory to practice,
knowledge of subject area, introduction of new information and ideas, and
presentation style. In addition, questions can be asked about applicability to an
individual's work, intent to use or share the information, and interest in future
presentations or sharing resources on the topic.
Resources for Professional Development
Multiple avenues are available to dental hygiene students and practitioners to
develop skills in health promotion and health communication. Chapter 7 outlines the
importance of continual review of the scientific literature to keep abreast of new
research and trends in dental hygiene and public health research and practice.
Because public health covers such a broad array of topics hygienists would benefit
by reading literature from other subject areas such as health education, health
promotion, health communications, injury prevention, cancer prevention and early
detection, maternal and child health, geriatrics, and school health, to name a few.
The many Internet sites and social media postings devoted to health topics facilitate
quick perusal and acquisition of information on any topic. Self-study continuing
education courses on a variety of topics are now more available online. Useful
online resources on health promotion, health communication, and health literacy
are listed at the end of the chapter. In addition, the references can provide additional
information. The CDC and other Department of Health and Human Services
agencies are excellent ongoing sources of information on health promotion, health
communication, and health literacy.
Another avenue for updating knowledge, practicing presentation skills, and
networking with other professionals is attending professional association meetings.
Many of these organizations promote student involvement through reduced
membership rates, free or reduced registration fees, and special contests and
awards. Dental hygiene horizons are broadened also by attending general public
health or health communication meetings. In addition, the CDC and other groups
sponsor annual learning institutes and conferences on topics such as health literacy,
health communication, and evaluation. The annual National Oral Health Conference,
sponsored by the Association of State and Territorial Dental Directors and the
American Association of Public Health Dentistry, offers a variety of learning
opportunities related to a wide range of public health topics of current significance
to all oral health practitioners, especially in relation to prevention and health
communication.
Summary
We live in a multicultural, global society in which some people are bombarded with
health information and others are isolated from scientific advances, new
communication technologies, and current health information. In an attempt to create
a more equitable distribution of resources and information, dental hygienists must
broaden their perspectives on how to acquire and provide health information in a
credible, appropriate, efficient, and effective manner. Ways to accomplish this
include (1) applying well-researched health promotion and communication theories
to oral health programs, (2) assessing people's learning styles, preferences,
information needs, and other characteristics to be able to frame and tailor health
communications, (3) delivering health communication using plain language in a
culturally and linguistically appropriate manner based on needs assessment data, (4)
selecting appropriate communication channels and strategies for the target
audiences, and (5) evaluating the outcomes and impact of the interventions,
activities, and teaching materials used.
Endless opportunities exist for using new communication modalities in a variety
of settings outside a clinical private practice setting. Online courses, professional
associations, and a variety of conferences can be valuable resources for preparing
dental hygienists to meet today's health promotion and health communication
challenges.
1. Create a game based on various health promotion theories. You can use the
format of well-known games or a simple matching or fill-in-the-blank format.
2. Work in groups to design role-playing scenarios based on the types of behaviors

described in the health promotion theories. You might use actual family or personal
situations/behaviors and brainstorm how to change the behaviors using the theories.
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.
6. Acquire information, examples of journals or newsletters, calls for

abstracts/presentation proposals, and agendas of annual meetings from various
professional associations. Include at least one dental-related group, one public
health group, and one health promotion or communication group. Compare the
organizations for similarities and differences, including the potential for student
presentations.
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.
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.4
HP.5
CM.2
CM.3
CM.4
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
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[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
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February 2015].
11. Fawcett SB. Some Lessons Learned on Community Organization and Change.
Section 8 in Our Model for Community Change and Improvement.
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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
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objectives/topic/health-communication-and-health-information-technology
15. What is Health Communications? Centers for Disease and Control: Atlanta,
GA; 2011 [Available at]
http://www.cdc.gov/healthcommunication/healthbasics/whatishc.html
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
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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.
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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;
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February 2015].
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Workshop Summary. The National Academies Press: Washington, DC; 2013
[Available at] http://www.nap.edu/openbook.php?record_id=13484
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
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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
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
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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
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American Evaluation Association. Guidelines for Roundtable Presentations.
Available at www.eval.org/p/cm/ld/fid=171.
Community Tool Box. Chapter 3, Section 6. Conducting Focus Groups. Available at

http://ctb.ku.edu/en/table-of-contents/assessment/assessing-community-needs-and-
resources/conduct-focus-groups/main.
Community Tool Box. Chapter 6, Section 1. Developing a Plan for Communication.

Available at http://ctb.ku.edu/en/table-of-contents/participation/promoting-
interest/communication-plan/main.
Gateway to Health Communication and Social Marketing Practice. Available at

www.cdc.gov/healthcommunication/.
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;
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Harvard School of Public Health. Health Literacy Studies. Available at

www.hsph.harvard.edu/healthliteracy/overview/#chart.
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www.hrsa.gov/healthit/toolbox/oralhealthittoolbox/introduction/index.html.
Healthy People 2020. Health Communication and Health Information Technology.

Available at www.healthypeople.gov/2020/topics-objectives/topic/health-
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Bethesda, MD: National Cancer Institute; 2002. Available at
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Developing a Health Communication Strategy. Available at
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Developing a Health Promotion Policy. Available at
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Conducting an Evaluation. Available at
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Centers for Disease Control and Prevention.
Radel J. Oral Presentations. Available at

http://people.eku.edu/ritchisong/oralpers.html.
C H AP T E R 9
Social Responsibility
Sharon C. Stull BSDH, MS, Christine French Beatty RDH, MS, PhD
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.
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?
• Do these responsibilities entail taking a leadership role in a professional

organization or in public health, and/or in advocating for evolving governmental
policies?
• Do these responsibilities include maintaining competency in clinical skills and

being current on evidence-based research in dental and dental hygiene sciences so
as to provide the best possible care for the patient and for the needs of the
community?
• Do these responsibilities look beyond the patients of record in a practice to

individuals and communities that lack access to needed oral health care?
• Do these responsibilities embrace the art of health promotion communication to

assure that the public has the knowledge to improve its own oral health?
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.
Justice and Fairness

• We value justice and support the fair and equitable distribution of health care
resources; we believe all people should have access to high-quality, affordable
oral health care
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.
The professional dental hygienist's commitment to ethical conduct is the

foundation of society's trust and confidence in the dental hygiene profession. Ethical
conduct is not confined to a particular practice setting; it is knowing and applying
those core values in all aspects of life while serving the common good.7 Both as a
member of society and as a member of the profession, dental hygienists are
challenged to provide fair and just distribution of oral healthcare services to all
individuals in need. As of October 2014, the current healthcare model still left over
33 million individuals out of the system.8 Several thought-provoking questions will
guide the discussion in this chapter of how dental hygiene as a profession will apply
professional ethics to the access to care problem (see Guiding Principles).
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?
• What is a fair or just distribution of limited oral healthcare resources?

Health Care: a Privilege or a Right?
It is important to understand the U.S. healthcare delivery system, how it operates,
who participates in the system, what legal and ethical issues arise as a result of the
system, what problems continue to plague the healthcare system, and if health care,
including oral health care, is a right or a privilege for each citizen. These questions
will be discussed.
Health Care as a Privilege

“If we want a strong America, we must have a well America.”9 Historically, the U.S.
has not offered healthcare coverage as a right of citizenship. The U.S. healthcare
system is one of individualism and self-determination focusing on the individual
rather than the collective needs of the population. It has become a privileged system
of healthcare access based on those who can afford to be healthcare consumers;
however, this does not answer the needs of all the citizenry. In this system, those
who can afford to be healthcare consumers will receive the benefits and privileges
through employer-based insurance or a fee-for-service system of health care. On
the other hand, those who are without insurance tend to seek dental treatment only
when it becomes an emergency (Figure 9-2).
FIG 9-2 Mission of Mercy: A coordinated national dental access event for
underserved adults who do not have a dental home or access to oral healthcare
services. (Photograph courtesy Virginia Dental Association.)
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
Health Care as a Right

The country made an ethical decision that a sound basic education was the right of
each child, and by 1918 all states required elementary education for all children.13
Furthermore, during its development the U.S. decided it was a right of citizens to
have security provided through government-funded police, fire, and defense forces
and also to have access to other public services such as fresh water, waste removal,
libraries, roads, and bridges, also provided by the government. All of these assumed
rights of a modern citizen are possible through taxation, which raises revenues
needed to establish such support.
What about health care? In 1965 the passage of legislation establishing Medicare
and Medicaid placed this country on the path of having government pay for health
care to take care of the elderly, poor, and disabled. Additionally, the country decided
that anyone who presents at a hospital emergency room will be treated, regardless
of insurance coverage or ability to pay. The recently passed ACA addressed the
ever-increasing number of uninsured individuals in the U.S. Thus incrementally the
U.S. has made decisions that health care is a right of all American citizens.
The Constitution of the United States does not specifically guarantee a “right to
health” because “health” is a dynamic state, unique to each individual.13 One
interpretation is that health and access to health care are not so much a legal right;
rather, they are a moral right and as such the obligation of society as a whole is to
provide care in response to that right, with providers playing an important role. The
duty to ensure basic oral health for all Americans is a shared duty that includes
federal, state, community, public, and private responsibilities. The oral health
professions, entrusted by society, have the duty to lead the effort to ensure oral
health access for all Americans.14 However, society has not universally accepted
their share of the responsibility despite several key events that have attempted to
highlight the relationship among individual rights, human dignity, and the human
condition.
In 1946, the Constitution of the World Health Organization defined health as “a
state of complete physical, mental, and social well-being, and not merely the
absence of disease or infirmity”15 (see Chapter 1). This view of health was
reinforced in the Universal Declaration of Human Rights adopted by the United
Nations General Assembly in 1948: “Everyone has the right to a standard of living
adequate for the health and well-being of himself and of his family, including food,
clothing, housing and medical care.”16 Moreover, this definition of health is still in
force today.17
In an amendment to the U.S. Public Health Service Act in 1966 Congress declared
“that fulfillment of our national purpose depends on promoting and assuring the
highest level of health attainable for every person.”18 The fundamental basis of
human rights is the recognition of the equal worth and dignity of everyone and
implies that individuals, institutions, and society as a whole should protect and
promote health and should ensure that health is neither impaired nor at risk.
Government Role in Healthcare Delivery
Many healthcare systems are evaluated using the iron triangle of health care, a
concept that consists of three essential aspects: quality, cost, and access19 (Figure 9-
3). According to health economists, the three legs of the triangle are in competition
and thus balance each other through inherent trade-offs. The theory is that one or
possibly two of the legs can be improved, but it is always at the expense of the
other(s). In other words, an increase in access will result in a decrease of quality
and/or an increase in cost, an increase in quality will result in an increase in cost
and/or a decrease in access, and a decrease in cost will result in a decrease in access
and/or a decrease in quality. Additionally, because the relationship among these
three aspects of the healthcare system is reciprocal, it is difficult to have any
significant change in the healthcare system. The balance of these aspects will affect
the outcome of any significant changes in the healthcare system of the nation,
including the recent changes resulting from the ACA.19
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
• Collaborate with partners to identify data needed

• Assess and quantify oral health needs and existing resources
• Share data with partner and identify possible strategies and solutions
• In a succinct and clear manner, share data and desired solutions with policymakers
• Be available to policymakers for questions at all stages of the process and to

provide information and testimony
• Thank the policymaker, regardless of the outcome, and continue to maintain the
relationship for future efforts
• Consider supporting other health policy initiatives supported or sponsored by this

policymaker that may not have an oral health focus
Demand Versus Resources

When tremendous differences exist between need and demand, and between supply
and resources in a community, it is imperative that healthcare providers educate the
public and policymakers regarding how to bring public healthcare capacity to a
level that will provide the resources necessary to optimally meet the demand for
healthcare services. Herein lies a major social responsibility of all healthcare
providers. For dental hygienists this translates into their social responsibility to
advocate for or promote oral health and wellness by (1) communicating about,
educating on, and advocating for the prevention of oral health risks and (2)
advocating for changes in dental hygienists' scope of practice, supervision, and
direct reimbursement to increase oral healthcare capacity. Such advocacy efforts
must be based on what is best for the public rather than on individual needs of
healthcare providers or the profession.
Patient Responsibility and Patient
Confidentiality
Because “the United States spends more on health care than any other nation in the
world, yet ranks poorly on nearly every measure of health status,”21 it is important
to seek ways to improve the health of our nation. In a society such as ours where a
pluralistic health system exists, greater emphasis is placed on individual
responsibility for health. Thus, it has been suggested that “[t]he single greatest
opportunity to improve health and reduce premature death lies in personal behavior.
In fact, behavioral causes account for nearly 40% of all deaths in the United
States.”21 Furthermore it has been proposed that improvement of the public's health
will be a result of behavioral change rather than improved technology22 in spite of
the greater emphasis on development and use of expensive technology to diagnose,
treat, and manage chronic diseases.
Patient responsibility for health is more significant today because of the increase
in chronic diseases that result in greater morbidity and mortality rates. Seven of the
ten leading causes of death in the U.S. are chronic diseases, accounting for more
than 65% of deaths.23 Several of these chronic diseases relate to oral health.
Prevention is a key and would go a long way toward reducing the need for
emergency and episodic health care, as well as reducing the incidence of related
oral diseases. Such prevention requires patient responsibility to adopt protective
behaviors. Effective health communication and improvement of health literacy of
the public are critical to this process (see Chapters 8 and 10).
In relation to oral health, patient responsibility depends partially on access.
Various protective factors involve professional treatment, many of which can be
accomplished by a dental hygienist. Direct access of the dental hygienist to the
public is important to increase accessibility for this purpose. Lack of access to oral
health care produces a downward cycle of poor oral health. In addition, the
relationship of access to care and socioeconomic status can be viewed as
bidirectional. An individual's oral healthcare inequity can foster a decline in
personal confidence and reduced employment opportunities. This in turn can further
distance the individual from improved oral and overall health, thus perpetuating an
inability to improve socioeconomic status. This societal inequality is really an
example of disparities in health equity. According to the CDC, “health equity is
achieved when every person has the opportunity to attain his or her full health
potential and no one is disadvantaged from achieving this potential because of
social position or other socially determined circumstances.”24 Not all people have
opportunities for the same health outcomes because of barriers imposed by society,
such as underlying social status, wealth, ethnicity, geographic location, and other
factors.
Particularly difficult is assigning personal responsibility to children whose dental
caries experience, for example, reflects the socioeconomic and educational
constraints of their parents and caregivers. Assignment of personal responsibility is
questionable also with the elderly who experience increased periodontal disease,
decay, incidence of oral cancer, and tooth loss as income becomes fixed or
decreases. Individuals should be held accountable for adopting behaviors that have
the potential to improve their oral health, including participation in conscientious
regular dental visits, if no barriers exist.
When an individual is able to access oral healthcare services, confidentiality
becomes a primary ethical responsibility to patients and clients.6 Also assurance of
protection of privacy in the transfer of personal health information between
providers is mandated by the Health Information Portability and Accountability
Act (HIPAA).25 Patient confidentiality must be adhered to in all practice settings in
both private and public sectors such as public health sites, service learning events,
health fairs, with community stakeholders, and in the academic environment.6 The
more recent emphasis placed by Congress on health information exchange (HIE)
and electronic health records (EHR) is assisting providers in sharing crucial
information for the purpose of improving health outcomes.26
Health Care: a Comprehensive Approach
Strengthening the Current Dental Care Delivery
System
It is essential to understand the term access to care and its relationship to social
responsibility. According to Healthy People 2020, “access to health services means
the timely use of personal health services to achieve the best health outcomes.”27 The
WHO adds to the definition “ease in reaching health services or health facilities in
terms of location, time, and ease of approach.”28 A final consideration is that “access
to comprehensive, quality healthcare services is important for the achievement of
health equity and for increasing the quality of a healthy life for everyone.”27 Access
involves assuring that conditions are in place for people to obtain the care they need
and want. Access to health care varies across countries, groups, and individuals,
largely influenced by social and economic conditions. Access is affected also by the
health policies that are in place, such as those that relate to available coverage,
approved services, timeliness of care, and an available, well-qualified workforce.27
The oral health professions have a social responsibility to advocate for policies
that assure the necessary conditions to enhance access to oral health care. According
to Healthy People 2020 access to health care and oral health care in the U.S. are
unreliable. Furthermore the ACA will challenge the capacity of the delivery systems
to accommodate the influx of people with health and dental insurance for the first
time.27 Vulnerable and isolated populations in the U.S. especially will continue to
experience numerous barriers to overall health care and oral healthcare services.29
The existing gap between the current dental system capacity and the increasing
oral health demands of the community will provide a challenge. However, the ACA
has significantly increased oral health provisions for children from low-income
families in the following ways:30
• Mandated oral health benefits for children with no out-of-pocket costs for
preventive services
• Improved oral health surveillance in all states
• Availability of grants to school-based health centers, including oral health services
• Promotion of oral health, including a focus on early childhood caries, prevention,
oral health of pregnant women, and oral health of at-risk populations
• Increase in school-based sealant programs
• Maximizing the role of dental homes within health homes to establish relationships
among family, oral health providers, and other primary care providers
• Establishment of training, workforce development, and loan repayment provisions
Several unifying messages emerged from the Sixth Leadership Colloquium titled
Strengthening the Dental Care Delivery System sponsored by the U.S. National Oral
Health Alliance in 2013.20 These themes point to the social responsibility of the oral
health professions to strengthen the oral care delivery system so that access to oral
health care can be realized by all, not just a select few (see Guiding Principles).
What It Will Take to Strengthen the Oral Healthcare Delivery
System
• Focus oral health care on prevention and wellness for individuals, families, and
communities
• Move toward interprofessional, cost-effective workforce models and care delivery

systems
• Transform education for a future strengthened by team-based oral health and

medical care
• Empower communities to support highly effective oral healthcare systems
• Align payment and systems approaches to promote and support wellness
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
Transforming to an Oral Health Interprofessional

Workforce Model
The inability of the oral healthcare system to keep pace with a rapidly changing
society is a matter of maldistribution and, in some instances, a shortage of oral
healthcare providers (see Chapter 5). Such conditions have a direct impact on access
and utilization of services. This presents an opportunity to transform the oral health
workforce into one that practices using an interprofessional collaborative approach
(see Chapter 2) that can “align and incentivize oral, medical and behavior health
systems to support an interprofessional care delivery model for the individual,
family, and the whole community which includes patient-centered care, prevention,
education, and risk reduction to strengthen health outcomes.”20 This model of care
will result in improving the oral health of underserved populations by providing
services in communities where underserved individuals receive social, educational,
and general health services, thus transitioning from a surgical model to a
comprehensive primary care model. The inadequate capacity of the current oral
healthcare workforce also provides an opportunity to explore new models of oral
health workforce, such as expanded care dental hygienists and midlevel providers
(see Chapter 2).
In 2013 Accountable Care Organizations (ACOs) served an estimated 14% of
the population.32 An ACO is “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.”33 Although few ACOs currently integrate oral health care, this is expected
to increase.32 In this new practice model midlevel oral health providers and dental
hygienists are integrated with nondental providers, physicians, nurses, and others to
deliver coordinated, high-quality preventive and primary oral health care.34 The
convergence of health professionals can substantially increase capacity by
developing integrated health homes using telehealth systems to enable people to
communicate across distances, emphasizing prevention and early intervention, and
providing care for otherwise underserved populations.35 (See Chapter 5 for an
expanded discussion of teledentistry.)
The profession of dental hygiene is rapidly transforming within this
interprofessional health workforce model. This evolution of our profession is
beginning to result in expanded opportunities for dental hygienists. Recent changes
include the following trends:36
• Midlevel providers are increasing access to care, especially for underserved
population groups.
• Medical offices are utilizing dental hygienists for their expertise.
• Corporate entities are hiring dental hygienists for myriad positions, including
research, sales, and health promotion.
A notable initiative in relation to these trends is the ADHA's plan to evaluate
dental hygiene curricula in relation to preparation for interprofessional practice
(see the Future of Dental Public Health section of Chapter 1).37
Leadership
Considering the number of people who have no health or dental insurance,
continued leadership on the part of the dental and dental hygiene professions is
needed to eliminate oral health disparities and to ensure access to oral health
services for all. A leader in the dental hygiene profession works within the
community to develop consensus on what oral health care for all might look like.38
He or she enables others to see the problem firsthand and participate in
implementing solutions. A leader in dental hygiene challenges the way things have
always been done and seeks new ways to maximize resources and productivity while
remaining mindful of ethical decision making processes and commitment to quality
oral care.38 Dental hygiene leaders function at various levels and in different
capacities to improve the oral health of the public they serve. Regardless of the level
or capacity, leaders demonstrate the following actions:
• Advocate for changes in oral healthcare practice that can bring about improved
oral health and increased access to oral health care.
• Model public health practice by ensuring equal access to care and not tolerating
prejudice against any person seeking care.
• Encourage other professionals in the community to participate in health promotion
and disease prevention activities and celebrate successes.
• Stay abreast of current research and critically evaluate scientific literature in
relation to quality oral health care; effective preventive and therapeutic measures;
and changes in infrastructure, workforce, and policies to improve the delivery of
oral health care.
• Respect all healthcare providers in the community and forge collaborative
relationships to facilitate provision of overall health care for the public.
• Work within the profession to ensure continued competency, lifelong learning, and
maintenance of quality standards of practice.
All of these leadership actions are taken in relation to specific issues, several of
which are discussed in this chapter and others that are discussed throughout this
textbook. Leadership is the foundation for fulfilling the social and professional
responsibilities discussed in this chapter (Figure 9-5).
FIG 9-5 Leadership is the foundation for fulfilling our ethical, professional, and
social responsibilities.
The responsibility to provide leadership to cause change in relation to these and

other issues is independent of the dental hygienists' professional role. Dental
hygienists have a professional responsibility to lead and advocate for change to
improve oral health of the public as it relates to whatever professional role they are
involved in (see Chapter 2).
Furthermore meeting these leadership responsibilities as oral health
professionals requires involvement with one's professional organization. The
ADHA and its state constituents and local societies provide all dental hygienists
opportunities for leadership in promoting the oral health of the public at various
levels. In addition, dental hygienists in public health positions have opportunities to
lead change through various dental public health organizations highlighted
throughout this textbook.
The Role of Communication in Leadership
Dental hygiene leadership embraces the following concepts:
• Social responsibility
• Professionalism
• Ethics
• Communication
The earlier sections of this chapter have addressed the first three of these
leadership topics, all of which relate to beliefs and practices. However, exercising
leadership as a professional will require leading not just through beliefs and
practice but also through communication. The ability to communicate effectively
with patients, community members, other community leaders, public health
advocates, colleagues, other health professionals, and government officials, as well
as friends and neighbors, is an essential attribute of leadership.
Successful communication in a culturally competent and sensitive manner helps
to reduce disparities and promotes enhanced health and wellness. The ability to
communicate within the frame of reference of one's patient(s) and community
improves the delivery of appropriate care and increases the likelihood that
programs, services, and policies will be relevant to diverse populations. This can
result in improvement of oral health outcomes and reductions of oral health
disparities.39 Effective oral and written communication skills are important in a
leadership role, not only because they affect others' understanding of the issues but
also because they influence how others view the profession. Thus, they can
influence the success of advocacy efforts for initiatives designed to improve oral
health of the public.
Use of Social Media for Health Risk

Communication
Effective communication is not only important in relation to leading change in the
profession. It is also critical to be able to communicate health information to the
public (see Chapter 8). The way that health information is communicated has
evolved. The following statistics reveal that social media is becoming a standard
means of healthcare-related communication (see Guiding Principles).
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
• A reported 61% of patients are likely to trust information posted online by

healthcare providers.40
• More than half of patients are very comfortable with their providers seeking
advice from online communities to better treat their conditions.41
• A reported 31% of healthcare organizations have specific social media guidelines

in writing.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.)
Effectively communicating for shared decision making depends on respecting

beliefs, gathering information consistent with the public's point of view, and then
providing a professional account of the evidence underlying sound health decisions
and treatment modalities. In this way, oral health professionals can (1) ensure
compliance with recommended protocols, regardless of the practice or community
setting, (2) minimize risks, (3) communicate pertinent and accurate health
information to the public, (4) reduce misinformation, and (5) enable others to make
good decisions that will promote oral health for themselves and others. Thus,
effective health risk communication can impact health outcomes.45
The means by which health professionals must communicate oral health risks has
changed.47 Because of multiple sources of information through social media and
other forms of technology, people are now exposed to more diverse forms of
information, some of which are inaccurate. Thus, individuals now need to be able to
filter, interpret, and make sense of the information they are given, in increasingly
sophisticated ways. This places the burden on oral health professionals to be
familiar with evidence-based oral health information and the inaccurate information
that is available to the public. In addition, oral health professionals are ethically
bound to communicate with patients, community leaders, policymakers, and
stakeholders in a way that enables them to make sound, informed decisions via a
process of shared decision making.48 The use of social media provides a means for
oral health professionals to carry out this responsibility in a form that is acceptable
and easily accessible to the public, which is already using social media for other
purposes.
Domestic Violence
Domestic violence remains a highly prevalent and preventable societal public health
problem that affects millions of Americans.49 The terms domestic abuse, domestic
violence, child abuse, elder abuse, and, most recently, intimate partner violence are
collectively gathered under the umbrella of family abuse.50 According to a CDC
survey conducted in the U.S. in 2010, approximately one in six women (15.9% or
nearly 19 million) and one in 12 men (8% or approximately 9 million) have
experienced sexual violence other than rape by an intimate partner.51 In 2013 in the
U.S., an estimated 679,000 children were victims of abuse and neglect, and 1520
children died as a result of abuse or neglect.52
Given that approximately 65% to 75% of physical injuries from domestic
violence are inflicted to the head, face, mouth, and neck,53 oral health professionals
are in a unique position to identify the signs and symptoms of domestic violence
(Box 9-3). However, even with this large percentage of domestic violence injuries
to the head and neck area, dental professionals report less than 1% of domestic
violence cases.53
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
• Bruises of various colors, which indicate multiple stages of healing
• Broken or loose tooth or teeth
• Cigarette burns, bite marks, rope burns, or welts with the outline of a recognizable
weapon, such as a belt buckle
• Injuries inconsistent with stories of how they occurred
• Inappropriate clothing for the temperature, such as long-sleeved garments in hot,

humid climates
• Unusual shyness or withdrawal or a reaction to oral procedures
Data from Dryden-Edwards R. Domestic violence. E Medicine Health; 2014. Available at

http://www.emedicinehealth.com/domestic_violence/page4_em.htm. Accessed February 2015.
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
Routinely screen female patients
Ask direct questions
Document findings
Assess patient safety
Refer to local domestic violence hotline

Data from Albert EJ. Intimate Partner Violence: A Clinician's Guide to Identification, Assessment, Intervention,
and Prevention, 5th ed. Waltham, MA: Massachusetts Medical Society; 2010. Available at
http://www.massmed.org/partnerviolence/. Accessed February 2015.
Summary
The dental hygienist is a professional. Inherent in the role of the professional is the
responsibility to make ethical decisions to practice dental hygiene in ways that will
improve oral health for the public and increase access to oral health services for all
populations. Dental hygienists have a social and professional responsibility to (1)
apply interprofessional collaborative leadership to uphold the ethical standards of
the dental hygiene profession, (2) advocate for changes to the oral healthcare
system that will improve oral healthcare delivery, (3) recognize the determinants of
health, the risk factors for oral diseases and conditions, and the influences of
overall health on oral health, (4) continually use effective health promotion
communication skills to advance optimal oral health for all, (5) apply evidence-
based practices to improve oral health, (6) advocate for policies to address access to
care initiatives, and (7) provide leadership for these and other critical public health
and professional issues. These concepts and their relationships are summarized in
Figure 9-5.
1. Watch and discuss What If Our Healthcare System Kept Us Healthy? with Rebecca
Onie on Ted Talk at
http://www.ted.com/talks/rebecca_onie_what_if_our_healthcare_system_kept_us_healthy
Answer the following questions:
a. What are the strengths and weakness of the U.S. healthcare

system?
b. As a future oral health professional what did you

personally gain from this Ted Talk?
c. Did your perspective change on the social and civic

responsibility of the access to care issue?
d. Are there viable interprofessional solutions to the

challenges of reaching those who are excluded from our
system of health care?
2. Read the book Nickel and Dimed by Barbara Ehrenreich and published by
Metropolitan Books (ISBN 0-8050-6388-9). This is a timeless ethnographic
portrayal of the working poor and a societal consciousness-raising call to action
toward social and civic responsibility. Answer the discussion questions at
http://barbaraehrenreich.com/website/nickel_and_dimed_reading_group_guide.htm.
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.
4. Research domestic violence in your local community. Identify a community

organization that is involved in advocating for victims of domestic violence, and
pinpoint ways that your class or student ADHA organization could get involved.
5. Research leadership to identify ways to develop yourself as a leader in your

profession of dental hygiene. Develop five professional development goals that you
can carry out over the next 5 years in relation to leadership.
competencies:
Core Competencies
C.1
Apply a professional code of ethics in all endeavors.
C.8
organizations.
C.10

HP.1
CM.4
CM.7
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]
February 2015].
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36. Rethman J. Your year of self-mentorship. Dimen Dent Hyg. 2015;13(1):10
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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
Population 2000 2010 2013 Growth 2000–2013

Total population (5 years old and older) 17.9% 20.6% 20.8% 32%
School-age population (ages 5–17) n/a n/a 21.8% n/a
n/a = not available

From Zeigler K, Camarota SA. One in Five U.S. Residents Speaks Foreign Language at Home, Record
61.8 million: Spanish, Chinese, and Arabic Speakers Grew Most Since 2010. Washington, DC: Center for
Immigration Studies; 2014 Oct. Available at http://cis.org/record-one-in-five-us-residents-speaks-language-
other-than-english-at-home. Accessed May 2015.
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.
Oral Health Disparities of a Diverse Population

In 2000, Oral Health in America: A Report of the Surgeon General was published; it
is focused on oral health issues. The report served as a reminder that in spite of
significant improvements in oral health during the twentieth century, serious
challenges remained for the future, significant oral health issues still existed, and
profound disparities in oral health endured.13 Two more recent national reports,
Advancing Oral Health in America14 and Improving Access to Oral Health Care for
Vulnerable and Underserved Populations,1 both published in 2011, reinforced the
facts of continuing significant oral health issues and oral health disparities in our
nation. In fact, two of the organizing principles of Advancing Oral Health in
America were to improve oral health literacy and cultural competence and to reduce
oral health disparities.14
A health disparity has been defined by Healthy People 2020 as “a particular type
of health difference that is closely linked with social, economic, and/or
environmental disadvantage. Health disparities adversely affect groups of people
who have systematically experienced greater obstacles to health based on their
racial or ethnic group; religion; SES; gender; age; mental health; cognitive,
sensory, or physical disability; sexual orientation or gender identity; geographic
location; or other characteristics historically linked to discrimination or
exclusion.”15
Special population groups, such as infants and young children, the poor, those
living in rural areas, the homeless, persons with disabilities, racial and ethnic
minorities, the institutionalized, and frail older adults experience a greater burden
of oral and craniofacial diseases.1,16 Pronounced disparities also exist in access to
oral health care and use of preventive services, each vital to the establishment and
maintenance of optimal oral health.1,16 It is understood in the health, medical, and
dental communities that there is a critical need to eliminate disparities in oral health
care among the diverse populations in the U.S.1,14,17 In response to these issues,
greater emphasis has been placed on efforts to increase access to oral health care to
reduce disparities, with a significant focus on access in the Healthy People 2020
oral health objectives.18
Disparities in health status, including oral health, are compounded by reduced
access to healthcare services. Although increased use of health services can reduce
disease and contribute to improved health status,18 this is not the complete picture.
Powerful, complex relationships exist between health and biology, genetics, and
individual behavior, and between health and health services, SES, the physical
environment, discrimination, racism, literacy levels, and legislative policies.2 These
factors that influence an individual's or population's health are known as
determinants of health.2 In an attempt to reduce disparities, Healthy People 2020
has placed a strong focus on these determinants of health, many of which are culture
bound.2 Culture has been shown to impact perceptions and behaviors that relate to
oral health.19
Health services is one of the five categories of health determinants described by
Healthy People 2020. This category encompasses both access to health services and
the quality of health services as they impact health.2 Also described are the
following barriers to accessing health services:2
• Lack of availability
• High cost
• Lack of insurance coverage
• Limited language access
These barriers to accessing health services lead to unmet health needs, delays in
receiving appropriate care, inability to benefit from preventive services, and
hospitalizations that could have been prevented.2,14
Other categories of health determinants that contribute to health disparities are
social factors, individual behavior, biology and genetics, and policies.2 Some
specific examples include transportation, accessibility and availability of facilities,
and capacity of workforce, especially a multicultural and culturally sensitive
workforce. Numerous recommendations have come from public health officials,
professional organizations, educators, and researchers to increase the diversity and
improve the cultural competence of the workforce that provides oral health
care.2,14,20 Refer to Chapters 3 and 4 for a complete discussion of the determinants of
health and their incorporation into the Healthy People initiative.
The National Partnership for Action to End Health Disparities in collaboration
with the U.S. Department of Health and Human Services (DHHS) Office on Minority
Health has suggested five actions for individuals and groups to address disparities
in their communities (Box 10-1).21 These actions reflect an advocacy role for oral
health professionals, which is a critical need to be able to make a difference at the
community level (Figure 10-1). The collaborating partners also developed a Toolkit
for Community Action, which has practical ideas about how to carry out the
suggested actions (see Additional Resources at the end of this chapter).
ox 10-1
B
Fi ve A cti ons to A ddress H eal th Di spari ti es i n
Your Communi ty
• Increase awareness about health disparities.
• Support health and safe behaviors in your community.
• Improve access to health care.
• Create healthy neighborhoods.
• Become a leader for addressing health disparities.

From National Partnership for Action: Toolkit for Community Action. Department of Human Services and
National Partnership for Action to End Health Disparities; 2011. Available at
http://minorityhealth.hhs.gov/npa/files/Plans/Toolkit/NPA_Toolkit.pdf. Accessed May 2015.
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
• Length of residence in the U.S.
• Religious beliefs
• Individual experiences
• Sexual preference
• Power relationships
Why Consider Culture?

As the U.S. becomes a more racially and ethnically diverse nation, healthcare
systems and oral healthcare providers need to respond to the wide diversity present
in modern societies.12 Cultural competence is a necessary skill, allowing us to
provide appropriate services to all individuals and communities. Given our modern
technologies, it is also a skill we need for global survival. Historically, the
challenges of insufficient cultural competence for cross-cultural collaboration go
back to the earliest beginnings of humanity.
Every human culture teaches its members to value their beliefs, morals, and views
as the best or ideal; unfortunately, in some cases, cultures teach that only their
beliefs are acceptable. The resulting lack of cultural interchange and adaptation can
lead to ethnocentrism—judging other cultures by one's own standards, not
accepting other groups, and considering other cultures inferior.24 Ethnocentrism can
lead to making false assumptions about cultural differences, forming premature
judgments, and producing divisions among members of different ethnicities, races,
and religious groups in society.24 Ethnocentric individuals believe that they are
better than other individuals for reasons based solely on their heritage. Ultimately,
ethnocentrism is related to problems of racism and prejudice.24
It is possible to incorporate culture into daily activities, such as reading, movies,
television, social interactions, community events, and social outings. Exposure to
multiple cultures has value to accomplish the following:
• Understand and appreciate the values, attitudes, and behaviors of others
• Avoid stereotypes and biases that can undermine efforts
• Focus on commonalities rather than differences
• Be able to develop and deliver services that are responsive to the individual needs
of patients and clients
Effect of Culture on Health and Health-Related

Factors
Health is culture-bound. This means that culture influences the conceptions,
perceptions, expressions, and approaches to health, healthy living, sickness, and
disabilities at both the individual and community levels.2 Also influenced are
attitudes toward healthcare providers and facilities and how health information is
communicated.20 Culture can even influence healthcare-seeking behaviors,
preferences for traditional versus nontraditional approaches to health care, and
perceptions regarding the role of family in health care.2,14,25 Some health-related
factors that vary according to culture include the following:
• Self-treatment strategies
• Body image
• Social networks and social support
• Family rituals
• Crisis management
• Dietary patterns
• Child-rearing practices
• Gender roles
• Beliefs about origins of disease
• Folklore
• Traditional healing beliefs and folk medicine
Some of these issues relate to oral health, as well as overall health. Although
there are standards of care that are followed during patient treatment,
individualizing patient care necessitates understanding these cultural differences in
relation to health issues.20 This approach is considered a hallmark of quality of care.
A cross-cultural approach to health care and healing does not eliminate the
foundation of Western medical methods. Instead it expands and enhances the ways
that we assess and deliver healthcare services by acknowledging, appreciating, and
incorporating the beliefs, values, rituals, symbols, and standards of conduct that
belong to the community with whom we work and that may also affect their health
status. The cross-cultural approach combines medical science and social science for
the most effective outcomes.25
Cultural Competence
Cultural competence is critical to reducing oral health disparities and improving
access to high-quality oral health care.26,27 Cultural competence in health care is 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.”12 Cultural competence is a developmental process that occurs over
an extended period, and one can be at various levels of awareness, knowledge, and
skills along a continuum in relation to applying cultural competence in these
different settings.26
Included in cultural competence is the adaptation of oral health promotion,
disease prevention, and clinical oral health services to meet the patient's social,
cultural, and linguistic needs.14 All people must be treated in a culturally competent
manner, but this may provide a greater challenge for specific groups, such as
children, older adults, people with disabilities, unfamiliar ethnic and racial groups,
and low-SES groups (Figures 10-2 and 10-3).1 Because culture impacts oral health
and oral health care, cultural awareness and competence among oral health
professionals is paramount.19
FIG 10-2 Cultural competence is critical to dental hygiene students as they

conduct a basic screening of homeless clients at a soup kitchen to connect them
with oral health services in the community as a way of addressing their need for
access to oral health care. (Courtesy Our Daily Bread, Denton, TX.)
FIG 10-3 Individuals who must be treated in a culturally competent manner include
children, older adults, and individuals with disabilities. (© iStock.com.)
Community and Organizational Cultural

Competence
Cultural-competency skills are needed at the individual, organization, and
community levels.14,28 When developed and implemented as a framework, cultural
competence enables the healthcare system and associated agencies and
organizations to understand the needs of groups accessing health information and
health care.26 Although it is important to focus on the culture of a group or
community, it is also imperative to keep in mind that the skill of cultural
competence is to learn useful general information about a culture while at the same
time being aware and open to variations and individual differences.3,29 One should
not fall into the trap of stereotyping all members of a specific ethnic or cultural
group; people are individuals even when they share commonalities.3
The DDHS National Prevention Council has identified several broad strategies to
continue the important focus on cultural competence in our nation's healthcare
system to improve the health of our increasingly diverse population:30
1. Ensure a strategic focus on communities at greatest risk.
2. Reduce disparities in access to quality health care.
3. Increase the capacity of the prevention workforce to identify and address

disparities.
4. Support research to identify effective strategies to eliminate health disparities.
5. Standardize and collect data to better identify and address disparities.
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.
Culturally and Linguistically Appropriate Services (CLAS)

The OMH of the DHHS published the first version of the National Standards for
Culturally and Linguistically Appropriate Services in Health and Health Care
(National CLAS Standards) in 2000. The OMH released an updated version of the
National CLAS Standards in 2013 (Box 10-3).28,40 These enhanced National CLAS
Standards were developed in response to health and healthcare disparities, changing
demographics, and legal and accreditation requirements.28 They reflect the past
decade's advancements, exhibit an expanded scope, and have greater clarity to
ensure understanding and implementation.41
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.
Governance, Leadership, and Workforce

2. Advance and sustain organizational governance and leadership that promotes
CLAS and health equity through policy, practices, and allocated resources.
3. Recruit, promote, and support a culturally and linguistically diverse governance,
leadership, and workforce that are responsive to the population in the service
area.
4. Educate and train governance, leadership, and workforce in culturally and

linguistically appropriate policies and practices on an ongoing basis.
Communication and Language Assistance

5. Offer language assistance to individuals who have limited English proficiency
and/or other communication needs, at no cost to them, to facilitate timely access
to all health care and services.
6. Inform all individuals of the availability of language assistance services clearly

and in their preferred language, verbally and in writing.
7. Ensure the competence of individuals providing language assistance, recognizing

that the use of untrained individuals and minors as interpreters should be avoided.
8. Provide easy-to-understand print and multimedia materials and signage in the

languages commonly used by the populations in the service area.
Engagement, Continuous Improvement, and Accountability

9. Establish culturally and linguistically appropriate goals, policies, and
management accountability and infuse them throughout the organizations'
planning and operations.
10. Conduct ongoing assessments of the organization's CLAS-

related activities and integrate CLAS-related measures into
assessment measurement and continuous quality
improvement activities.
11. Collect and maintain accurate and reliable demographic data

to monitor and evaluate the effect of CLAS on health equity
and outcomes and to inform service delivery.
12. Conduct regular assessments of community health assets
and needs and use the results to plan and implement services
that respond to the cultural and linguistic diversity of
populations in the service area.
13. Partner with the community to design, implement, and

evaluate policies, practices, and services to ensure cultural
and linguistic appropriateness.
14. Create conflict and grievance resolution processes that are

culturally and linguistically appropriate to identify, prevent,
and resolve conflicts or complaints.
15. Communicate the organization's progress in implementing

and sustaining CLAS to all stakeholders, constituents, and
the general public.
From The National CLAS Standards. Rockville, MD: U.S. Department of Health and Human Services, Office of
Minority Health; 2013. Available at http://minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlid=53. Accessed
May 2015.
Changes in the new National CLAS Standards include a broader definition of

culture, including groups identified by geographic, religious and spiritual, biologic,
and sociologic characteristics; a broader audience, including health organizations
in addition to healthcare organizations; an explicit definition of health, including
physical, mental, social, and spiritual well-being; and a broader scope of recipients,
including all individuals and groups involved with health and healthcare
organizations, not just patients and consumers.28 The intention of the 2013 update is
“to advance health equity, improve quality, and help eliminate healthcare disparities
by establishing a blueprint for individuals as well as health and healthcare
organizations to implement culturally and linguistically appropriate services.”41
An implementation guide for the National CLAS Standards (The Blueprint) can
be accessed from the website to help federal and state health agencies, community
healthcare systems and organizations, policymakers, national organizations, and
others advance and sustain culturally and linguistically appropriate services within
health and healthcare organizations.28 The CLAS standards are not legislated but are
mandated in some cases for recipients of federal funds. State agencies have
embraced the importance of cultural and linguistic competence since the initial
standards were released. A number of states have proposed or passed legislation
pertaining to cultural-competency training for one or more segments of the state's
health professionals, and at least six states have mandated some form of cultural and
linguistic competence for either all or a component of their healthcare workforce.41
Developing Cultural Competence

Models and curricula abound that describe how cultural-competency skills are
acquired for implementation in patient encounters, in organizations and systems,
and in community outreach. Some of these models can be used also to evaluate the
effectiveness of cultural-competency skills in these settings. Following are a few
examples of models that can be implemented in various settings for cross-cultural
encounters to ensure that culturally competent attitudes, knowledge, and behaviors
are implemented when providing oral health care in a multicultural clinical or
community setting.
Cultural Competence Education Model

The Cultural Competence Education Model is a conceptual model that focuses on
the process of developing cultural-competency knowledge and skills in healthcare
practices to deliver quality care.8 This model is designed as a tool to foster
understanding, acceptance, and constructive relations between persons of various
cultures. The model is framed on the following three areas of intervention (see
Figure 10-4):8
• Self-exploration: To become aware of one's own cultural heritage and increase
acceptance of different values, attitudes, and beliefs.
• Knowledge: To understand that one culture is not intrinsically superior to another
and to recognize individual and group differences and similarities.
• Skill: To master appropriate and sensitive strategies and skills in communicating
and interacting with persons from different cultures and to seek information about
various cultures within a society.
FIG 10-4 Cultural Competence Education Model.
As depicted in Figure 10-4, these three areas in various combinations impact

attitude, perception, and behavior. Behaviors are adapted and implemented through
self-exploration/awareness and skill development. The development of skills and
knowledge affects perception about people of diverse cultures. Attitude is explored,
enhanced, and broadened by self-exploration/awareness of and increased
knowledge about diversity and the importance of culture to our daily lives. The
value of self-assessment and self-exploration have been demonstrated in the
development of cultural-competency skills,42 and they are part of many current
training programs and curricula.
Purnell Model for Cultural Competence

The Purnell Model for Cultural Competence is a classic, holistic, complex
organizing framework presented to understand culture as a means of guiding the
development of cultural competence among healthcare teams of all disciplines who
are providing care for multicultural populations in a variety of primary, secondary,
and tertiary settings.43 It can be used to learn about one's own culture and the cultures
of patients, families, communities, and society. The model can be utilized in
individual one-on-one settings, communities, or organizations.43
As depicted in Figure 10-5, the Purnell model has an outer rim that represents the
global society, a second rim that represents the community, a third rim that
represents the family, and an inner rim that represents the individual. The interior of
the figure contains 12 cultural domains that are not intended to stand alone because
they affect one another.43 These cultural domains that make up the heart of the
cultural experience and identity are described in Box 10-4. Oral healthcare
providers can use this model to explore their own cultural beliefs, attitudes, values,
practices, and behaviors, and to understand those of others. Within this model the
development of cultural competence is conceptualized as an upward curve of
learning and practice, moving through four levels of achievement of cultural
competence: (1) unconscious incompetence, (2) conscious incompetence, (3)
conscious competence, and (4) unconscious competence.44
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.)
Cultural Competence Continuum

Less complex than the Purnell model, the Cultural Competence Continuum is
extensively referenced in cultural-competency literature and widely used in training
programs.45 Originally presented by Cross et al. in 1989 in a monograph entitled
Towards a Culturally Competent System of Care, Volume 1,46 the model was revised
in 2004 by the NCCC.45 It still serves as a guide today for systems and organizations
to conduct self-assessment and use the results to set goals and plan for meaningful
growth.45 The model can be used also by individuals to self-assess and plan for their
own personal development in relation to cultural competence. Oral healthcare
practitioners can use the descriptors of the steps on the continuum to challenge their
growth toward becoming more culturally competent.
The Cultural Competence Continuum is based on the following definition of
cultural competence, also originally developed by Cross et al. and modified by the
NCCC; this NCCC definition is foundational to the model.45
Cultural competence requires that organizations:
• Have a defined set of values and principles, and demonstrate behaviors, attitudes,
policies, and structures that enable them to work effectively cross-culturally.
• Have the capacity to (1) value diversity, (2) conduct self-assessment, (3) manage
the dynamics of difference, (4) acquire and institutionalize cultural knowledge, and
(5) adapt to diversity and the cultural contexts of communities they serve.
• Incorporate the above in all aspects of policymaking, administration, and practice
and service delivery, systematically involving consumers, families, and
communities.45
The Cultural Competence Continuum is dynamic and not linear, although it has
been described and depicted by some as a ladder and involves a progression
through stages of cultural-competency development (Figure 10-6).45 Through self-
assessment, individuals and organizations can evaluate their placement on the
continuum and plan for progress toward development of personal and professional
cultural competence and proficiency.45 The model allows for positive progress even
if cultural proficiency and competence are not achieved. Also, it is possible to be at
different stages at different times with different populations and cultural groups.
The six stages are described in Box 10-5.
FIG 10-6 Cultural Competence Continuum. (Data 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.)
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:
• Create a mission statement for the organization that articulates principles,

rationale, and values for cultural and linguistic competence in all aspects of the
organization.
• 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.
• Develop structures and strategies to ensure consumer and community participation

in the planning, delivery, and evaluation of the organization's core function.
• Implement policies and procedures to recruit, hire, and maintain a diverse and
culturally and linguistically competent workforce.
• Provide fiscal support, professional development, and incentives for the

improvement of cultural and linguistic competence at the board, program, and
faculty and/or staff levels.
• Dedicate resources for both individual and organizational self-assessment of

cultural and linguistic competence.
• Develop the capacity to collect and analyze data using variables that have a
meaningful impact on culturally and linguistically diverse groups.
• Exercise principles of community engagement that result in the reciprocal transfer

of knowledge and skills between all collaborators, partners, and key stakeholders.
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.
• Actively pursue resource development to continually enhance and expand the

organization's capacities in cultural and linguistic competence.
• 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.
A caution is necessary in relation to studying cultures for the purpose of

becoming culturally competent. Although the goal is to strive to develop cultural
proficiency, it is important to realize that it is difficult to completely understand a
culture that is not one's own. No matter how much you study another culture, you
cannot personally identify with the culture nor share the experiences of growing up
in that culture with its shared traditions, history, and issues. However, cultural
competence can be achieved over time.
Various federal government and other agencies have focused resources on the
development of a culturally competent workforce. Multiple resources are available
for individual development of cultural-competency skills and for training in
healthcare organizations. The NCCC has developed a number of educational self-
assessment tools based on these and other models to help healthcare providers
develop cultural competence and linguistic skills. See the References and Additional
Resources at the end of this chapter.
Culturally Competent Patient Care
Cross-cultural encounters often are challenging because they reflect situations that
are unfamiliar to daily living and beliefs. They also can provide opportunities for
personal growth and development in cultural competence (Figure 10-7).
FIG 10-7 Experiences with cross-cultural encounters in alternative practice

settings can help dental hygienists develop cultural competence. (Photograph courtesy
Schelli Stedke.)
Effective Cross-Cultural Communication

Cross-cultural communication is a key to successful cross-cultural encounters.
Cross-cultural communication refers to the effective communication with
someone of a different culture. The importance of patient communication and
linguistic skills in relation to cultural competence and health outcomes has been
emphasized in the literature and is reflected by Healthy People 2020 objectives in
the topic area Health Communication and Health Information Technology.12,23,47
According to the report Advancing Oral Health in America, “As the U.S. population
grows more diverse, more will need to be understood about the importance of
cultural competence in communication. For example, the cultural and linguistic
misunderstandings in health care can be a contributing factor to adverse events such
as unnecessary emergency room visits and longer hospital stays.”14
Oral health professionals experience daily cross-cultural interactions with
patients that can help them practice and refine their cross-cultural communication
skills. In the process, one can learn about the way of life of individuals, families,
and communities to better understand the cultural influences on their oral health.2,14
Some actions to assist with effective cross-cultural communication are listed in the
Guiding Principles.
Actions That Foster Effective Cross-Cultural Communication
• Communicate in a language that is clear and at the client's level of understanding;

send clear messages and provide complete instructions.
• 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.
• Use translators when necessary.
• Use technology, such as assistive technology devices, as needed.
• Define any dental terminology; avoid jargon.
• Listen well to the client's questions and stories.
• Carefully observe the client's body language.
• Look beyond the superficial.
• Be patient, persistent, and, most important, flexible.
• Recognize your own cultural biases.
• Emphasize common ground; do not focus on differences but on similarities.

• Withhold judgment; accept others' differences.
• Empathize; treat each person as an individual.
• Use active listening.
• Do not assume understanding; ask for clarification.
• Always communicate in a respectful manner.
Linguistic competence can also be considered in relation to an organization. It is

defined as “the capacity of an organization and its personnel to communicate
effectively, and convey information in a manner that is easily understood by diverse
groups, including persons of limited English proficiency, those who have low
literacy skills or are not literate, individuals with disabilities, and those who are deaf
or hard of hearing.”48 Linguistic competence involves responding to the health
literacy needs of the populations served. To be considered linguistically competent,
organizations must have policies, structures, practices, procedures, and dedicated
resources to support linguistic competence.48
Models of Communication for Cross-Cultural Encounters

Several effective models are described in the literature that can be helpful in
improving cross-cultural communication to improve the management of cross-
cultural encounters in healthcare settings. Such models can be used for training by
organizations, for inclusion in health profession educational program curricula,
and for self-development of cultural-competency skills. Two of these are the
L.E.A.R.N. Model (see Box 10-6)49 and the R.E.S.P.E.C.T. Model (see Box 10-7).50
Both of these classic models apply specific behaviors and attitudes to the
communication process during cross-cultural encounters and are still in use today.51
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.
Recommend … treatment while remembering the patient's cultural parameters.
Negotiate … agreement; strive to understand the patient's explanatory model so the

treatment fits into his or her cultural framework.
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.
• Seek the patient's point of view.
• Consciously attempt to suspend judgment.
• Recognize and avoid making assumptions.
Empathy
• Be empathic.
• Remember that the patient has come to you for help.
• Seek out and understand the patient's rationale for his or her behaviors or illness.
• Verbally acknowledge and legitimize the patient's feelings.
Support
• Ask about and try to understand barriers to care and compliance.
• Help the patient overcome barriers.

• Involve family members if appropriate.
• Reassure the patient you are and will be available to help.
Partnership
• Be flexible with regard to issues of control.
• Negotiate roles when necessary.
• Stress that you will be working together to address medical problems.
• Reinforce the partnership.
Explanations
• Use simple language, pictures, maps, and other means of explanation.
• Check often for understanding.
• Use verbal clarification techniques.
• Use the patient's language.
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.
• Be aware of your own biases and preconceptions.
• Know your limitations in addressing medical issues across cultures.
• 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.
• Take the necessary time and consciously work to establish trust.
• Fulfill promises.
• Follow through with commitments.
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.
An explanatory model is a way of exploring the sociocultural context of health

conditions with patients.52 Kleinman introduced the Kleinman Explanatory Model of
Illness in the 1970s as a way to better understand how people view their illness in
terms of how it happens, what causes it, how it affects them, and what will make
them feel better.53 Still applied to healthcare encounters today, this explanatory
model consists of an individualized approach of asking the patient or client and
family a series of what, why, how, and who questions to seek information relevant
to the health condition (Box 10-8).52 Especially recommended for use in
multicultural healthcare encounters, it has an application to understanding the health
concerns of all patients.52 The wording and number of questions can be adapted
according to the patient, the health condition, and the setting.52 The model can be
applied to oral health care, especially when working with multicultural populations.
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?
• Why do you think it started when it did?
• What do you think your sickness does to you?
• 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 kind of treatment do you think you should receive?
• 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.
FIG 10-8 Culturally sensitive cross-cultural communication is important during

cross-cultural encounters such as this one, in which dental hygienists complete an
oral health intake and provide oral health counseling and referral for an indigent older
adult client at a community soup kitchen. (Courtesy Our Daily Bread, Denton, TX.)
Written Communications
Effective communication also involves the ability to use written communications
effectively. Several factors must be considered with written communications. First is
the literacy level. Written materials should be written at the literacy level of the
intended audience, using vocabulary and sentence structure that is understandable,
and including images as needed to help with understanding.48 If individuals cannot
read or have difficulty reading, they may require adaptation of written materials,
and communications should be delivered in the preferred mode of the population
served.48 This may involve the use of alternative communication methods such as
audio, Braille, or enlarged print.57 The second factor to consider is language.
Written materials should be in the preferred language of the population being
served to maximize their understanding.48
Sometimes it is necessary to translate health communications, health forms, and
other materials from English to another language. In this case, professional
translators should be used who have the necessary writing skills, fluency in English
and the other language, and cultural knowledge to produce a culturally and
linguistically appropriate translation that is easy for the intended readers to
understand and use.58 It is also best that the translator have some knowledge of the
subject matter of the materials being translated.58 Three methods of translation are
suggested in the Centers for Medicare & Medicaid Services translation guidelines
(Box 10-10).58 The method selected should be based on the best use of available
resources and may depend on the material being translated and its purpose.58 For
example, a full, formal back-translation may be required for legal documents, but
simple one-way translations may be adequate for patient forms and leaflets.
ox 10-10
B
T hree Methods of Transl ati ng Wri tten
Materi al s
1. Create it separately in each language
• Write an original version of the written material from

scratch in each language
• Not an actual translation

• Good method to use if the material has not been created in
English yet
• Faster and possibly less costly if an English version is not

available
2. One-way translation
• English version is translated by a professional translator
• Single version of the translation
• Simplest and least expensive method
• Should involve additional bilingual people who are familiar

with the cultural and language patterns of the intended
readers, to review, edit, and proofread the translated
material
• Multiple versions of the translation
• Translated by different translators and reconciled to

produce the final version
• More expensive and time consuming
• May be unnecessary if a single translation is done

professionally with adequate review
3. Two-way or “back” translation
• One person translates English version to another language,
a second person translates it back to English, and a third
person compares the two English versions and edits and
rewrites the translated version as needed
• More time consuming and more costly than one-way

translation
From Toolkit for Making Written Material Clear and Effective, Section 5: Detailed Guidelines for Translation,
Part 11: Understanding and Using the Toolkit Guidelines for Culturally Appropriate Translation. Washington, DC:
Centers for Medicare & Medicaid; 2012. Available at http://www.cms.gov/Outreach-and-
Education/Outreach/WrittenMaterialsToolkit/Downloads/ToolkitPart11.pdf. Accessed May 2015.
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
• Uses a biopsychosocial model
• Explores and respects a patient's beliefs, values, perceptions of the meaning of

illness, preferences, and needs
• Builds rapport and trust
• Finds common ground
• Is aware of own biases and assumptions
• Maintains and is able to convey unconditional positive regard
• Allows involvement of friends or family when desired
• Provides information and education tailored to patient's level of understanding
Healthcare Systems Level

• Services aligned to meet patient's needs and preferences
• Healthcare facilities convenient to community
• Documents tailored to patient's needs, literacy, and language
• Data on performance available to consumers

Saha S, Beach MC, Cooper LA. Patient centeredness, cultural competence and healthcare quality. J Natl Med
Assoc 2008;100(11):1275–85. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2824588/. Accessed
May 2015.
The American Academy of Pediatric Dentistry (AAPD) developed a research

brief and policy document in 2013 on patient-centered care.61 In this brief, the AAPD
discussed principles of patient- and family-centered oral care in the context of
cultural competence (see Box 10-12). These AAPD principles demonstrate that
cultural competence is integral to the concept of patient-centered oral care and that
in some cases the family is an essential component of this concept.
ox 10-12
B
Pri nci pl es of Pati ent- and Fami l y -Centered
Oral Care
Respect and Cultural Competence
• Cultural sensitivity toward the family
• Respectfully considering the family's needs and preferences
• Advocating services with the purpose of building on the family's strengths
Integration and Coordination of Care

• Multidisciplinary teams working together to deliver care
• Successfully facilitating care among these multidisciplinary teams to improve

collaborative efforts and access to care
Communication and Information Sharing

• Maintaining open communication among the healthcare team and between the team
and family
• Enhancing health literacy
Quality of Care
• Providing high quality, evidence-based health care to patients and their families
• Gaining feedback from families and the healthcare team
Whole-Person and Comprehensive Care

• Ensuring the patient's physical and mental healthcare needs are met
• Placing an emphasis on health promotion
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.
3. The workforce is prepared to be health literate and monitored for progress.
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.
6. Health literacy strategies are used in interpersonal communications, and

understanding is confirmed at all points of contact.
7. Easy access and navigation assistance are provided to health information and
services.
8. Print, audiovisual, and social media content that is distributed is easy to

understand and act on.
9. Health literacy is addressed in high-risk situations, such as communications about

medicine.
10. Health plan coverage and individual responsibility to pay

for services are clearly communicated.
From Brach C, Dreyer B, Schyve P, et al. Attributes of a Health Literate Organization: A Discussion Paper.
Washington, DC: Institute of Medicine of the National Academies; 2012. Available at
http://www.jointcommission.org/assets/1/6/10attributes.pdf. Accessed May 2015.
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
ACTION/COMPETENCY RELEVANT TO ORAL HEALTH INFORMATION

Ac c e ss/Obtain Unde rstand/De rive Me aning Proc e ss/Appraise Apply/Use
Oral Ability to access information Ability to understand oral health Ability to interpret and evaluate oral Ability to make informed
health on oral health issues information and derive meaning health information decisions on oral health issues
care
Oral Ability to access information Ability to understand information on Ability to interpret and evaluate Ability to make informed
disease on risk factors for oral health risk factors for oral health and derive information on risk factors for oral decisions on risk factors for oral
prevention meaning health health
Oral Ability to update oneself on Ability to understand information on Ability to interpret and evaluate Ability to make informed
health determinants of oral health in determinants of oral health in the social information on oral health decisions on oral health
promotion the social and physical and physical environment and derive determinants in the social and determinants in the social and
environment meaning physical environment physical environment
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.
• Use plain language to communicate health information.
• Use lay language rather than technical language to communicate health

information.
• Convey information in the patient's or the client's primary language, using a

translator when needed.
• Verify understanding of what people are explicitly and implicitly asking for.
• Take time to check a patient's or a client's recall and comprehension of new

concepts.
• Provide assistance in learning basic numeric skills such as calculating doses or

understanding concepts like risk.
• Aid people in finding providers and services and in filling out complex forms.
• Provide families with access to educational materials and support programs to

help them understand and achieve treatment objectives and outcomes.
• Develop a workforce whose members represent the culture of the population

being served or have been trained to be culturally competent.
Summary
To become a culturally competent oral healthcare provider, it is important to apply
cultural competence to all levels of oral health promotion and disease prevention,
for example, individual, family, community, educational, organizational,
administration, programs, and policies. It is up to the oral healthcare delivery
system and individual oral healthcare providers to value, implement, support, and
foster cultural competence in every encounter made with a client and in all
organizational decisions. This is true for dental hygienists in all roles, including
clinician, health educator, educator, consultant, advocate, researcher, and
administrator/manager, and practicing in all settings. As oral healthcare providers,
it is vital to appreciate the key role that culture plays in the general and oral health
of the public we serve. It is also important to develop cultural competence to
enhance our ability to positively influence the overall and oral health of our patients
and clients in both individual and group encounters in private, corporate, and
community settings. We must not allow cultural barriers to limit our ability to meet
the oral health needs of the public or reduce their opportunities to benefit from the
services we can provide. This chapter reviews the concepts of culture and cultural
competence and provides helpful guidelines and tools to understand culture and
assess and develop cultural competence. Health literacy is discussed in relation to
cultural competence as are ways to improve health literacy of the population.
1. Choose an ethnicity or race other than your own. Apply the Purnell Model for
Cultural Competency to understand the culture of the group you selected and to
compare and contrast it to your own culture. Prepare a 10-minute presentation in
class to describe what you learned.
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.
3. Conduct a discussion in your class on the importance of cultural competence and

discuss ways that you can apply culturally competent skills in your clinical setting
and your community activities.
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.
5. Review the website of the National Center for Cultural Competence at

http://nccc.georgetown.edu/resources/assessments.html. Complete one of the self-
assessments. Share with your class what you learned from completing the self-
assessment.
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.
competencies:
Core Competencies (C)

C.6
Continuously perform self-assessment for life-long learning and professional
growth.
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.
Health Promotion and Disease Prevention (HP)

HP.2
Respect the goals, values, beliefs, and preferences of the patient/client while
promoting optimal oral and general health.
Community Case
You are the dental hygienist in a community/migrant health center. You have been
asked by the health center director to participate in applying for a grant to fund an
interdisciplinary project for Vietnamese older adult clients of the health center that
includes a component of developing cultural competence of the workforce caring
for this population. The grant will focus on health promotion and disease
prevention. One of the key criteria of the grant is to take into consideration the use
of alternative or folk medicine by the population served.
1. All of the following EXCEPT one are important factors to learn about the
community to enhance the cultural competence of the proposed grant. Which one
is the EXCEPTION?
a. Social network and social support
b. Tooth loss
c. Dietary patterns
d. Ability and use of English language
2. The grant requires that a model be applied to the development of cultural
competence of the oral healthcare workforce that will be caring for the
population. In addition, progress of cultural competence development must be
tracked and reported to the agency that is offering the grant. Which of the
following models would be most suitable for these purposes?
a. Cultural Competence Continuum
b. Cultural Competence Education Model
c. L.E.A.R.N. Model
d. Purnell Model for Cultural Competence
3. You are planning interdisciplinary service training for the health professionals
who will be gathering and recording the data collected for the grant. All of the
following EXCEPT one are factors that need to be included in the training to
enhance cross-cultural communication during the data collection. Which one is
the EXCEPTION?
a. Be patient and flexible to make clients comfortable.
b. Observe clients' body language to improve communication.
c. Use technical discipline-specific terminology during communication to avoid
misunderstanding and confusion.
d. Listen well to clients' questions and stories to establish rapport.
4. Oral healthcare personnel will be trained in culturally competent communication
skills in an attempt to improve the use of preventive oral healthcare services by
the population. The grant requires that a model be used to design and implement
training strategies. Which of the following models would be most appropriate for
this purpose with this priority population?
a. L.E.A.R.N. Model
b. R.E.S.P.E.C.T. Model
c. Kleinman Explanatory Model of Illness
d. ETHNIC Model
5. Oral health educational materials will need to be created for the priority
population. Existing materials written in English are available for translation. The
grant criteria limit the resources used for this purpose. Which of the following
translation methods should be incorporated into the grant application?
a. Development of materials in both English and Vietnamese
b. One-way translation
c. Two-way translation
d. Translation by an English-speaking staff member who is taking Vietnamese
classes.
e. No translation should be planned; verbal communication is more effective for
this target population.
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C H AP T E R 11
Service-Learning
Preparing Dental Hygienists for

Collaborative Practice
Sheranita Hemphill RDH, MS, MPH
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.
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.
ADHA, American Dental Hygienists' Association.

Source: Rhea M, Bettles C. Dental Hygiene at a Crossroads of Change: Environmental Scan 2011-2021.
Chicago, IL: American Dental Hygienists' Association; 2011. Available at http://www.adha.org/resources-
docs/7117_ADHA_Environmental_Scan.pdf. Accessed May 2015.
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
A Dental Hygiene Example of Experiential Learning

The community service example just mentioned can be contrasted with the
following example of experiential learning in a dental hygiene course. In this
example, first-year dental hygiene students enrolled in a didactic dental radiology
course are learning how to interpret radiographic findings, but they are not
encouraged by their scores on the quizzes. After the midterm examination the
faculty member announces that she has initiated a collaborative project with an
elementary school teacher in which the dental hygiene students will teach some of
the concepts they are learning to the elementary school students. The faculty
member further explains to the dental hygiene students that they will be able to
connect their didactic learning with the real needs that the elementary school teacher
has identified for her students.
For the dental hygiene faculty member the purpose of the experiential assignment
is to enhance the dental hygiene students' comprehension of the radiology course
material. Because active learning is an important principle in educational theory and
because dental hygiene students will have to construct much of the elementary
school learning experience themselves (active learning), chances are that they will
benefit from this assignment by an increased comprehension of the radiology
course content compared with the first half of the semester. Not only do they have to
assess the real needs of the elementary school students as specified by the
elementary school teacher, but they have to decide how to teach the content and how
to evaluate the effectiveness of their teaching. This initiative is a collaborative
project in contrast to traditional teaching and learning methods such as lectures,
reading assignments, and even radiographic interpretation exercises. These
traditional methods are enhanced as a result of being engaged in the experiences of
active learning.
In this way, experiential learning can be used to change the focus of learning,
shifting it from the confines of the classroom to the community (see Figure 11-1)
while maintaining a key focus on adding to the student's knowledge base. Routine
learning methods can be supplemented with purposeful, active, and work-based
learning opportunities within the community. At the same time, to ensure that the
course objectives are met, the dental hygiene students apply their program planning
skills with guidance from their faculty and from the community partner (the
elementary school teacher in the example given).
FIG 11-1 First-year students reinforce their acquired radiographic interpretation
skills by teaching others. (Photograph courtesy Sheranita Hemphill.)
Authenticity of Experiential Learning

Experiential learning takes place in authentic situations.7 A Women, Infant, and
Children's (WIC) facility is a good example of a service-learning setting in which a
broader understanding of oral health is necessary to effect change for a lifetime.
Let's say, for example, that in the community oral health course, students are
learning about the social determinants of oral health. A typical strategy would be to
show an image of a woman standing in line at a local WIC facility, followed by
dental hygiene students documenting their thoughts about this woman, followed by
small group discussions to explore the social determinants of oral health. However,
without actually interacting with the woman, how can they really know what her
visits to the WIC facility signify? Perhaps she is seeking nutritional provisions for
her child, but is that all?
On the other hand, if the dental hygiene students are assigned to actually assist
women at a WIC facility, the students will have to use their learned skills to see
beyond the obvious. They will be required to apply cognitive skills, such as the
recall of facts regarding the mission of the public health facility. They will also
need to construe oral health needs that the mother and her family may have that may
not be obvious and clear-cut; the reality is bigger than the image. In this case the
dental hygiene students will likely learn much more because they will have to
construct strategies to assist these women and their families. They will brainstorm,
share ideas, and possibly remind each other to be thoughtful and use evidence-based
information in their discussions rather than anecdotal opinionated fragments of
thought. In essence, they will learn through experience—and the learning
environment becomes a part of the learning experience.7
Experiential learning represents an umbrella term that refers to various models
of learning in which experience governs the educational process for the student.
Another example is to learn about fluoride varnish programs by actually
participating in one in a community setting (Figure 11-2). Experiential learning
outcomes found in the literature are vastly optimistic about the results of linking
academic learning outcomes to community-based settings12-14 (see Guiding
Principles).
Experiential Learning Outcomes
• Connects classroom learning with authentic situations
• Continuously reinforces learned knowledge and skills through practical

experience
• Challenges the student to think critically in addressing real needs
• Increases aptitude for teaching various populations
• Enhances the skills of the dental hygiene workforce

FIG 11-2 A dental hygiene student applies fluoride varnish during a service-
learning varnish project planned and implemented by her classmates. (Photograph
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
• Community service combined with collaboration, preparation, and reflection

• A response to community-identified concerns
• An opportunity for student learning that incorporates
• The context in which service is provided
• The connection between students' service and their

academic coursework
• Students' roles as citizens

This definition of service-learning promotes collaboration between community
partners, students, and health professions educational institutions (Figure 11-4). It
emphasizes the importance of requests for community service being self-identified
by the community partner and the importance of the community partner's
involvement in the service project. Of equal importance is the fact that it articulates
the significance of faculty-assured educational outcomes for the benefit of students.
In other words, if executed properly service-learning is not a superficial academic
exercise in which lessons are taught by dental hygiene students with little observed
or learned by them in the process; instead, educational opportunities are
purposively built into their experiences (Figure 11-5).12 Students are challenged to
create unique opportunities for their community partners that will be mutually
beneficial (see Guiding Principles).
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.
• Assist the school nurse in following up with dental referrals.
• Collaborate with local law enforcement officers and students to promote child
safety by performing bite impressions for use in identification of children.
• Assist the community in assessing the adequacy of their community water

fluoridation.
• 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.
Distinguishing Characteristics of Service-Learning

The experiential learning method of service-learning is differentiated from other
experiential learning methods by distinct features. These features are universally
understood as ideals that must be present for an experiential learning experience to
be characterized as service-learning. Essential components of service-learning
provide a structure to discuss, plan, implement, and evaluate the learning
experience.16
The development of objectives for the service-learning experience is a unique
characteristic of this type of experiential learning. A service objective (SO) and a
learning objective (LO) are used to create a service-learning objective (S-LO). The
relationship of the SO, LO, and S-LO, whereby the SO and LO are contained within
the S-LO, is depicted in Figure 11-6.
FIG 11-6 Relationship of the service objective (SO), learning objective (LO), and
service-learning objective (S-LO).
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).
The process of service-learning uses a structured format that follows a sequence

of necessary steps in the process. The full impact of experiential learning will not be
realized if the community-based service-learning experience does not follow this
structure (Figure 11-11). Leaving out or re-arranging any one or more phases of the
service-learning project will reduce the learning value. These steps are described in
the following sections.
FIG 11-11 Steps in the Service-Learning Process.
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.
Mutual Objective Formation

Collaboration is also involved in the development of the S-LOs, as illustrated by the
process of mutual objective formation. The expectation of equally balanced interests
is a classic feature of service-learning.8 Achieving this balance for all interested
parties requires committed attention not only to the service-learning steps, but also
to deliberately implementing each step correctly. The effort involved in honoring
the collaborative process of developing the SOs, LOs, and S-LOs will serve to build
a close working relationship between the community partner and the dental hygiene
students. Box 11-3 illustrates this process.
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.
• The planning for the service-learning program can now proceed.
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 carefully; use I messages rather than they or them messages.
• Speak specifically; avoid generalizations.
• Focus on quality interaction; accept personal responsibility and trust others to do

the same.
• Avoid adversarial vocabulary.
• 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.
• Be quiet; reflect, process, and reduce tension within the conversation.
• Let go of the need to be right; share your perspective without trying to convince
others.
Dental hygiene faculty members are instrumental in assisting students to connect

the course objectives with the actual experience by posing critical questions.
Questions must be carefully constructed with the objectives in mind. The purpose of
the reflection is to understand and appreciate the connection between the course
content, dental public health issues, and the sociocultural environment in which they
exist. The goal is to assist the student in identifying and remembering how his or
her perspectives were challenged and enhanced and how the experience affected his
or her lifetime learning journey.19-21 Ideas for incorporating reflection can come
through brainstorming activities, ideas from the Internet, and reading the literature
(Box 11-5).
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.
• Have senior students present experiences to junior students at roundtable

discussions.
• Incorporate audiovisuals into any reflection method.
• Guide students in journaling the connections, challenges, context, and continuity of

the service-learning experience.
• Create a website to highlight the continuous nature of the program's service-

learning efforts.
• Develop an evaluation instrument to be implemented in future service-learning

programs.
• Publish an article in a dental hygiene newsletter or journal.
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).
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.”
• “I actually got to participate in an orientation presentation made by my faculty to a

room of school teachers and administrators. They asked me about my training
and what I thought I could help their children learn.”
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.”
• “Even though service-learning is a balanced approach to teaching and learning, I

still think that the dental hygiene students got the most from the experience. I
listened deeply to my peers and every one of them stated that they learned so
much about their selected course objectives.”
• “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.”
• “Not once did our lesson plan remain the same.”
• “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.”
Summative Evaluation Comments from Students

• “At first we didn't understand why we needed to write a summary report to the
principal and school nurse, but it turned out to be a fun project because we
completed it as a class project. The final document was spectacular. Since we
conducted pre- and posttests, we were able to include descriptive data and graphs,
and we printed the report letter using color ink cartridges. The final report was
impressive.”
• “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.

Endorsements from reputable organizations and expert panels position future oral
health professionals as key members of ICP teams.1,4 IPE is a teaching pedagogy that
promotes ICP among different health professions students (see earlier in chapter).
As defined in Chapter 2, ICP “happens when multiple health workers from different
professional backgrounds work together with patients, families, carers and
communities to deliver the highest quality of care.”4
The movement to position oral health as an integral part of overall health is
supported by research, which suggests that higher education health professions
programs incorporate IPE into their curricula through collaboration.1,4,11 ICP
requires health professionals to enter the workforce ready to integrate into teams of
mixed healthcare professionals for the purpose of cooperating to achieve the best
health outcomes for patients and communities.23 The literature has numerous
examples of IPE in which service-learning is used as the experiential learning
model.23-30 Several international and national health initiatives and organizations
have addressed the need to integrate oral health professionals into interdisciplinary
community-based strategies for comprehensive health outcomes (Box 11-6).
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
• Association of State & Territorial Dental Directors
• National Maternal and Child Oral Health Resource Center
• World Health Organization, Oral Health Programme
• American Dental Education Association
• Interprofessional Education Collaborative Expert Panel
• Community Campus Partnership for Health
• American Dental Hygienists' Association

Interprofessional Collaborative Practice and
Service-Learning
A classic and notable example demonstrating ICP using service-learning with health
professions students from multiple health disciplines was implemented by a group
of educational researchers in the 1990s.18 In this instance, a multiprofessional team
of students were taught by a multiprofessional group of faculty. The disciplines
included dental hygiene, nursing, dietetics, psychology, social work, and physician
assistants. The course was conducted weekly for a full academic term with a
primary goal of familiarizing students with different populations, educational
processes, and professions. Essentially, health professions students representing
various disciplines learned about each other's professions, practiced team building
exercises, learned about the public health approach to health care, and worked
together in the design and implementation of an interprofessional collaborative
project to experience an interdisciplinary team approach to solving health problems.
The coursework and exercises led to service-learning projects that were
implemented to meet the public health needs of their own community.18
A more recent interdisciplinary collaborative project demonstrated that dental
hygiene students and physical therapy students successfully collaborated to apply
their joint knowledge in an interdisciplinary learning environment.24 In this instance,
the students provided their discipline-specific professional services to each other.
The physical therapy students received a thorough oral examination by the dental
hygiene students, and the dental hygiene students received a thorough physical
therapy assessment. The students reported that they experienced heightened
meaningful learning and self-confidence from this interdisciplinary experience.
Results showed that the course objectives were met and the students felt engaged as a
result of working in a real-life situation while also learning about each other's
health profession.24
Clearly, service-learning is the experiential learning model of choice for a host
of new ICP initiatives throughout the nation. Student experiences in three distinct
models of IPE in relation to ICP have been reviewed in Florida, Washington, and
Chicago.23 Each of these three models included a diverse combination of health
professions students, including dentistry, medicine, pharmacy, nursing, social work,
public health, physical therapy, psychology, nutrition, and veterinary medicine. In
some cases, ICP is becoming the standard for teamwork in health care, and some
programs are instituting this type of ICP as a requirement in the curriculum. Each of
the models included a didactic portion, a community experience, and
interprofessional involvement.23
An ideal framework is afforded by service-learning to provide health professions
students with the opportunity to experience ICP while still in school.23 Such
experiences are critical to the process of preparing them with the mind-set and skills
needed to move into ICP upon graduation and entry into the healthcare
workforce.25,26 Exposing students to service-learning in combination with IPE and
ICP has the potential to assist today's dental hygiene graduates in transitioning
seamlessly into the role of a collaborative practitioner prepared to impact the
public's oral health challenges.1,4,28
Interprofessional Strategies in Service-Learning

One of the goals for this chapter is to illustrate how the use of service-learning in
the dental hygiene curriculum can be implemented to prepare graduates for the
team-oriented approach in planning, developing, and delivering relevant oral health
messages and providing community-based oral health services. The narrow focus
on discipline-specific employment settings for health professionals, including oral
health professionals, is changing.1,4 National indicators have clearly pointed to the
need for a transformation from discipline-specific practice to interprofessional
practice to bring about better health outcomes.28 This includes the dental hygiene
profession, which is evolving in its delivery systems.1 Emergent models of
delivering oral health (see Chapter 2) will necessitate oral health professionals who
are capable of integrating into the growing interprofessional teamwork landscape
of healthcare delivery.
Dental hygienists will be in a primary position to address the public's oral health
issues within the existing and emerging scope of practice.1,4 Nurses, physical
therapists, physician assistants, respiratory therapists, and other healthcare
professionals will also graduate capable of working in their discipline's scope of
practice, but none will be able to stay abreast of the combined knowledge that each
discipline produces, and which all patients will need. Thus a crucial need exists and
will continue to grow for fully functional interprofessional healthcare teams.1,4 Five
values and five principles have been suggested as necessary for students, existing
healthcare institutions, and health professions educational institutions to prepare for
effective interprofessional collaborative teamwork (Box 11-7).3 Each of these
values and principles can be incorporated into interprofessional service-learning
experiences, as clearly demonstrated by real-world examples.3
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
• Measurable processes and outcomes
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
• Student acknowledgment/agreement before participation
• Confidentiality and Health Information Portability and Accountability Act (HIPAA)

compliance agreement
• Special insurance policies
• Policies/procedures
• Contact information
• Emergency procedures
• Background checks
• Student misconduct
• Travel, transportation, and parking
• Approval of lesson plan
• Storage of personal items
• Orientation checklist
• Assessment and evaluation procedures and documentation
• 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).
FIG 11-12 Dental hygiene students provide screening, training in self-assessment,

and education about oral and pharyngeal cancer (OPC) and the need for regular
screening for OPC in a service-learning project completed in collaboration with a
local community dental clinic and the Oral Cancer Foundation. (Photograph courtesy
Leticia Silva, Deandrea Doddy, and Afua Ampem.)
In addition, service-learning also provides a form of role-play through which

dental hygiene students can safely explore issues of access, health equity, and
disparities in populations. Clearly, constructing service-learning projects can be
instrumental in learning more deeply about public health issues, such as those
identified in local and national local community health assessments.14,34-36 Through
service-learning dental hygiene students can increase their public health knowledge,
social awareness, and teamwork potential, as well as improve the oral health of their
local communities.14,34,36
Public Health Resources

Various public health resources are important to public health practice (see Box 11-
10). Integrating these resources into service-learning and other community oral
health projects will provide additional application of learning about the resources
themselves and about the public health process. Use of reputable and national
resources adds a dimension of consistency to community oral health projects and a
standard measure for assessing the success of course and service-learning project
objectives as well as program objectives when working in the community after
graduation. These and additional resources are listed in the Additional Resources
and References of this and other chapters, along with their URLs for easy access. In
addition, Appendix A lists professional and community organizations, and
Appendix D has a list of government resources, all of which can be helpful in
planning and designing service-learning and other community oral health projects.
ox 11-10
B
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).
• Encourages use of information by individuals, groups, and organizations to

improve the community's health; contains ideas about how others have used this
resource to improve the health of their communities.
• Provides common, measurable standards by which to evaluate success in meeting

the national oral health objectives; these standards can be implemented easily in
service-learning lesson plans and service projects.
State and Local Oral Health Programs
• Website search of one's own state's health department to learn about the state's
public health and oral health infrastructure and capacity (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.
• Provides consumer information through which residents can access information to

help them find a dental home, learn about services available, or learn about oral
health topics.
• Has water fluoridation status and information for the state.
• May provide opportunities for professionals, consumers, and teachers to request

educational materials, possibly at low cost or free of charge to professionals for
training purposes and for one's own service-learning projects.
Association of State & Territorial Dental Directors (ASTDD)

• A national dental public health organization whose membership includes each of
the state directors for oral health, representing a strong governmental presence
regarding issues, core functions, and best practices for community oral health
practice.
• Central location to access a myriad of resources to assist in community-based

initiatives, including program development (see Chapter 3 and 6).
• 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.
National Oral Health Surveillance System (NOHSS)

• Collection of specific oral health data and information from every state, compiled
to monitor changes in the oral health indicators over time (see Chapters 4 and 5).
• 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).
National Maternal and Child Oral Health Resource Center (OHRC)

• Supports health professionals, program administrators, educators, policymakers,
and others with the goal of improving oral health services for infants, children,
adolescents, and their families.
• 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.
• Interconnected and collaborates with countless organizations, including federal,

state, and local agencies; national and state organizations and associations; and
foundations.
• Located at Georgetown University in Washington, DC and funded by the Maternal

and Child Health Bureau of the U.S. Department of Health and Human Services
(DHHS) Health Resources and Services Administration (HRSA).
Centers for Disease Control and Prevention (CDC)

• The nation's major health promotion agency responsible for monitoring,
protecting, and improving the public's health.
• Conducts critical science related to epidemiology, provides surveillance, delivers

health information, operates laboratory systems, and is involved in response-
readiness activities.
• 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.
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.
2. Locate the oral health LHI and record it.
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.
• Which of the BSS surveys could you integrate into your

service-learning project? How?
• What would be a benefit of a team of dental hygiene

students actually conducting a screening?
• What would be the benefits of teaching a group of school
teachers or nurses to conduct a BSS survey?
7. Search for the NOHSS website and click on State Profiles. Click on your own
state or a state of interest, and review the data. Think about how you can use this data
in a service-learning project. Record your thoughts and share them 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.
Set B. Service-Learning Objectives Exercises

Exercise 1 presents an opportunity for you to practice writing SOs, LOs, and S-LOs.
Read the following statement and finish the exercise by combining the SO with the
LO to create an S-LO.
A first-year dental hygiene student enrolled in a dental radiology course has a
dialogue with a high school anatomy teacher about how he or she might connect
one of the student's academic course objectives (“Identify moderate to severe
interproximal dental decay from bitewing images”) with the expressed need of the
high school teacher's course objectives (“I want you to show them what decay looks
like on the inside of a tooth and how much of the tooth's surface has to be removed”).
Although the SO and the LO are provided for you in this scenario, clearly identify
each of the following by recording them:
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.
Exercise 3 is a dental radiology service-learning assignment. This is more

comprehensive in that you will practice designing a service-learning experience.
You will have the unique opportunity to “experience” service-learning from the
development stage. In this way, you will be better prepared for your real-world
service-learning project with a community partner. Following is a scenario in which
you will be coached through a service-learning practice writing session. Read
through the assignment, and then complete all the practice steps.
You are a first-year dental hygiene student enrolled in Dental Radiology. Your
faculty has reviewed the course requirements and assignments with the class. Your
instructor provided examples of previous students' work so that you could better
understand the assignments. You recently scored pretty high on a pop quiz covering
the course requirements in which you were tested on the course LOs, reading
schedule, assignments, grading components, and the overall schedule. As
homework, your instructor asked the class to review the assignment purpose and
directions, review the examples of previous students' work (or online examples),
and come to class with prepared questions.
Assignment Purpose: To supplement the didactic and laboratory experiences
with experiential learning, dental hygiene students will develop and implement a
Dental Radiology service-learning lesson plan for elementary school children.
Directions: Pair up with one other student to complete the assignment. Before
you begin, you will need to research and define the following terms. As you
progress with this assignment, your definition will take on greater clarity. Your
final definitions should be in your own words, using real examples, and each term
should be defined using at least 100 words. (Hint: Use this chapter and the glossary
to define these terms. You will also find definitions on the Internet by searching key
words such as “define service-learning,” and you can use the list of resources at the
end of this chapter.)
1. Service-Learning
2. Learning objective
3. Service objective
4. Service-learning objective
Now follow these three steps to develop one S-LO.
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.
3. Compare and contrast traditional imaging with digital imaging.
4. Apply critical thinking procedures to modify techniques for special

circumstances.
5. Produce various imaging surveys on a mannequin (dummy used for exposure of

radiographs) at the required proficiency using principles of interproximal,
paralleling, and bisecting techniques.
6. Demonstrate proficient ability to use panoramic radiographic equipment.
7. Acknowledge errors in technique and processing, suggest multiple remedies, and

identify and take corrective action.
8. Define and utilize new terminology.
Anatomy
1. Describe the normal radiographic appearance of teeth and the supporting
structures.
2. Identify anatomic structures on bitewing, periapical, and panoramic images.
3. Demonstrate competency in the process of anatomic evaluation.
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.
4. Discuss the appearance of trauma, lesions, and other disturbances.
5. Systematically interpret and present radiographic findings.
Record your LO (academic course objective).
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).
Exercise 4 consists of practice developing measurable service-learning in Table

11-3. This exercise will increase your ability to write more meaningful objectives.
You will practice writing objectives that are more specific in that the outcomes can
be measured against the stated program activities. Chapter 6 included a discussion
of how to write measurable objectives. This information will be incorporated into
writing quantifiable (measurable) S-LOs. In this instance, not only will you develop
LOs and S-LOs, you will also include a performance verb, condition, and criterion
for each of the S-LOs. The first one has been completed for you as an example.
Your instructor may have you complete additional activities for increased
proficiency and comfort with this skill.
TABLE 11-3
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:
Set C: Service-Learning Lesson Plan Development

Exercises
Exercise 1 will provide you with the opportunity to develop a complete service-
learning lesson plan. (See Figure 11-13 for the template for this exercise.) For the
purpose of this exercise, a lesson plan is defined as a comprehensive sketch of what
is planned for a teaching situation. It is comprehensive in that it is very detailed, to
the point that if someone had to take your place, he or she could teach your lesson
from the outline of the plan. On the other hand, it is referred to as a sketch because it
does not include an exact account of dialog (words) that will be used to teach the
lesson. In essence, it may be useful to think of a lesson plan as a roadmap for how to
get from point A to point B. In this digital age it is probably more applicable to
think of a lesson plan as an electronic application that will plan your entire itinerary
including the time required for each of your desired pursuits along the way such as
meal detours, entertainment, lodging, weather forecasts, and so on.
FIG 11-13 A service-learning lesson plan template.
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.
2. In small groups, brainstorm ideas for service-learning opportunities in relation to

the selected course objective.
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.
6. Complete the steps required to develop a service-learning project by using those

instructions in the chapter section entitled Stages of Service-Learning.
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.
10. In a small group, create a checklist of strategies to avoid risk management

issues. Use the list in Box 11-10, and combine the various strategies to form one
service-learning risk management agreement.
competencies:
Core Competencies
C.3
Use critical thinking skills and comprehensive problem-solving to identify oral
C.8
organizations.
C.10
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.

HP.1
CM.1
CM.2
CM.3
CM.6
Evaluate the outcomes of community-based programs and plan for future activities.
CM.7
Professional Growth and Development

PGD.1
Pursue career opportunities within health care, industry, education, research, and
other roles as they evolve for the dental hygienist.
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
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Team-Based Health Care (Discussion Paper). The National Academies,
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17. Eyler J, Giles DE. Where's the Learning in Service-Learning?. Jossey-Bass:
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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.
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learning: A framework. Teach High Educ. 2013;18(4):401–413;
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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–
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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
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[(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]
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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.
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
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.
5. Read directions and questions carefully.
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.
10. Look for the “best” answer to a multiple-choice question;

frequently several will seem correct, but one is the best.
11. Use process of elimination to answer multiple-choice items.

Start by eliminating the answers that are obviously not
correct, and then focus on the remaining choices to select the
best answer.
12. If you are unsure of the right answer, use logical clues that
help you figure it out:
a. A repeated word or concept in both the question and

answer can indicate the correct response
b. Length of the correct response: often the longest answer of

a multiple-choice question is the correct one
c. A similarity in alternatives: you can eliminate similar

answers
d. Direct opposite of responses: you can eliminate

contradictory answers or complete opposites to the
question
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.
1. Which of the following describes the Stages of Change Theory?
a. An example of ways to influence changes in public policy
b. A means of assessing a person's readiness to change and

adopt behaviors that lead to a healthy lifestyle
c. A model that includes key concepts such as reciprocal

determination, observational learning, and reinforcement
d. A way to directly assess how susceptible to periodontitis a

patient perceives oneself to be
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.
2. Which of the following is an example of the tailoring technique that is used in

formulating an individual's oral health plan?
a. Highlighting one or two messages that might apply to your

patient
b. Using photographs of American Indian women for posters

in the Indian Health Service clinic
c. Providing three individualized recommendations based on

risk factors identified during a personal risk assessment
d. Asking a group whether they prefer a video, slides, or a

demonstration
The correct answer is c. This answer uses a similar idea—the concept of

individualization—even if one does not connect risk with tailoring. Answer
choices b and d can be eliminated because they are opposites of the question stem,
referring to a group rather than an individual. Answer choice a uses the vague
term might, making it a less feasible answer than answer choice c.
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
c. Research poster 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.
4. Which of the following strategies would ensure the highest retention of

information about oral cancer in a group of adults?
a. Distributing a booklet about oral cancer for them to read
b. Using a multimedia presentation
c. Demonstrating an oral cancer examination, followed by a

discussion and a return demonstration of the oral cancer
self-examination
d. Watching a video together, followed by discussion
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
Major Are as (3) Assoc iate d Subje c ts (13)

Scientific basis for dental hygiene practice Anatomic Science
Microbiology & Immunology
Pathology
Pharmacology
Physiology, Biochemistry & Nutrition
Provision of clinical dental hygiene services Management of Dental Hygiene Care
Patient Management
Periodontology
Preventive Agents
Professional Responsibility
Radiology
Supportive Treatment
Community health/research principles Community Oral Health*
*
Some dental hygiene programs have a separate research course; for the purpose of the NBDHE, research
content is folded into community oral health content.
Data from 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 January 13, 2015; Tsai TH, Dixon BL. Setting and validating the pass/fail score for
the NBDHE. J Dent Hyg 2013;87: 90.
In the community health/research principles area of the NBDHE, five community

cases are presented with a series of four or five questions related to each case, for a
total of 24 questions.1 These five testlets include questions that comprehensively
represent the content of community health/research principles. The specific content
of these questions is presented in Table 12-2.
TABLE 12-2
Specific Content of Community Health/Research Principles Questions on
the NBDHE
Conte nt Numbe r of Que stions

Promoting health and preventing disease within groups 6
Participating in community programs: 10
Assessing populations and defining objectives
Designing, implementing, and evaluating programs
Analyz ing scientific literature, understanding statistical concepts, and applying research results 8
Total number of questions 24
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
*The correct answer is c.

Completion:
Purpose and format similar to a question format; instead of requiring a correct
answer to a question, this format requires the correct completion of a concept or
idea
Example:
A public health dental hygienist who meets with city council members to explain the
benefits of fluoridation for the purpose of convincing them to adopt fluoridation
for the community is functioning in which of the following roles?
a. Administrator/manager
b. Advocate
c. Clinician
d. Researcher
*The correct answer is b.

Paired True-False:
Used to test comparisons and contrasts of concepts; consists of a stem with two
statements related to the same topic; includes a standard set of responses applied to
all paired true-false test items
Example:
Inferential statistics are used to describe and summarize data. The t-test is used to
compare three or more mean scores.
c. The first statement is true; the second is false.
d. The first statement is false; the second is true.

Cause-and-Effect:
Used to test the ability to analyze relationships among concepts; stem consists of a
statement and a reason written as a single sentence connected by because; includes a
standard set of responses applied to all paired cause-effect test items
Example:
Results of oral screenings in a comprehensive school program should be explained
to parents because a parent can misinterpret screening results as the findings of a
complete dental examination.
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.
*The correct answer is a.

Negative:
Used in situations where exceptions to general rules or principles exist; stem
includes the word EXCEPT or NOT, capitalized to help examinees; standard
language is applied to all exception test items
Example:
Each of the following EXCEPT one is important when framing a health education
message. Which one is this EXCEPTION?
a. Attempting to connect the message to people's values, beliefs, knowledge, and

emotions
b. Using the same message for all members of the population to ensure consistency
c. Making a message meaningful to the audience by personalizing it
d. Focusing oral health education materials on the specific needs of the audience

Answering Community Case Questions
(Testlets)
When answering the community testlet questions on the NBDHE, you must change
your train of thought from thinking about clinical practice to thinking about
community practice. Recall the definitions from within this text and the comparisons
of private practice and community oral health practice. Your selection of the correct
answer must be what is best for the community as a whole rather than for an
individual. You will be applying the information you have learned in your
community course to a simulated situation in the community.
In most dental hygiene schools students have an opportunity to apply what they
have learned in the community course by conducting projects in the community.
These projects require critical thinking skills to determine the best way to achieve
maximum oral health for the target population the student has chosen to work with.
Studying the “Applying Your Knowledge” features at the end of each chapter in this
textbook is a good way for students to practice their critical thinking skills. Testing
with cases or testlets requires students not only to retrieve knowledge, as in the
stand-alone questions, but also to use critical thinking skills to apply knowledge to
specific situations. Your critical thinking skills are just that—thinking about what
you know. The NBDHE measures your ability to solve problems and make
decisions based on both the knowledge you have acquired in your coursework and
your critical thinking skills.
When you are in a community frame of mind, read carefully through the
community situation described in the testlet. Note the key words and phrases in the
scenario that can guide your thinking through the correct answers. Then begin to
read the questions; remember that the questions refer to the case presented in the
testlet, so you must refer back to the scenario as you answer the associated
questions. The questions are intended to relate only to the case presented; the best
answer is the one related to the information in the case. It is also a good idea to
reread the case one more time after answering the questions to catch any incorrect
answers you may have selected without recalling important data from within the
case.
In general, as you prepare for the NBDHE, try to identify your weak areas and
concentrate your review on them. Do not cram for an examination of this
magnitude. Set aside scheduled time for review, possibly using a calendar to set
aside hours to study weekly. Some people study well in groups. Group studying can
be beneficial because you learn other students' ideas and ways to recall, critically
think about, and apply information. Other students do better alone. It is your choice,
but perhaps you can try a little of both.
Previous NBDHE questions give you practice in test taking and often cover
material that never changes. Alternate your review periods with practice
examinations. Staying calm is important to your psyche. Remember, you will not
know everything. A positive attitude always helps!
Application of Critical Thinking: Sample

Community Oral Health Practice Testlets
The following five testlets are compiled as a practice test in community oral health.
The number and types of questions are similar to what you will encounter on the
NBDHE in the area of community health/research principles. You should be able to
complete these questions in 45 minutes or less to allow about 1 minute each on the
other questions in the first session of the examination.
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
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.
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.
Academy of General Dentistry (AGD)
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
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.
5. Professional Growth and Development (PGD) reflect opportunities that may

increase patients' access to the oral healthcare system or offer ways to influence the
profession and the changing healthcare environment. Dental hygienists must possess
transferable skills (e.g., in communication, problem-solving, and critical thinking)
to take advantage of these opportunities.
Competencies for the Dental Hygiene
Profession
Core Competencies (C)
C.1 Apply a professional code of ethics in all endeavors.
C.2 Adhere to state and federal laws, recommendations, and regulations in the
provision of oral health care.
C.3 Use critical thinking skills and comprehensive problem-solving to identify oral
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.5 Assume responsibility for professional actions and care based on accepted
scientific theories, research, and the accepted standard of care.
C.6 Continuously perform self-assessment for lifelong learning and professional
growth.
C.7 Integrate accepted scientific theories and research into educational, preventive,
and therapeutic oral health services.
C.8 Promote the values of the dental hygiene profession through service-based
organizations.
C.9 Apply quality assurance mechanisms to ensure continuous commitment to
accepted standards of care.
C.10 Communicate effectively with diverse individuals and groups, serving all
persons without discrimination by acknowledging and appreciating diversity.
C.11 Record accurate, consistent, and complete documentation of oral health
services provided.
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 health care providers
to facilitate optimal treatments.
C.14 Manage medical emergencies by using professional judgment, providing life
support, and utilizing required CPR and any specialized training or knowledge.
Health Promotion and Disease Prevention (HP)
HP.1 Promote positive values of overall health and wellness to the public and
HP.2 Respect the goals, values, beliefs, and preferences of all patients.
HP.3 Refer patients who may have physiologic, psychological, or social problems
for comprehensive evaluation.
HP.4 Identify individual and population risk factors, and develop strategies that
promote health-related quality of life.
HP.5 Evaluate factors that can be used to promote patient adherence to disease
prevention or health maintenance strategies.
HP.6 Utilize methods that ensure the health and safety of the patient and the oral
health professional in the delivery of care.
Community Involvement (CM)

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
CM.5 Evaluate reimbursement mechanisms and their effects 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.
Patient Care (PC)

Assessment
PC.1 Systematically collect, analyze, and record diagnostic data on the general, oral,
and psychosocial health status of a variety of patients using methods consistent
with medicolegal principles.
PC.2 Recognize predisposing and etiologic risk factors that require intervention to
prevent disease.
PC.3 Recognize the relationships among systemic disease, medications, and oral
health that impact overall patient care and treatment outcomes.
PC.4 Identify patients at risk for a medical emergency and manage the patient care in
a manner that prevents an emergency.
Dental Hygiene Diagnosis

PC.5 Use patient assessment data, diagnostic technologies, and critical decision
making skills to determine a dental hygiene diagnosis, a component of the dental
diagnosis, to reach conclusions about the patient's dental hygiene care needs.
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.
Professional Growth and Development (PGD)

PGD.1 Pursue career opportunities within health care, industry, education, research,
and other roles as they evolve for the dental hygienist.
PGD.2 Develop practice management and marketing strategies to be used in the
delivery of oral health care.
PGD.3 Access professional and social networks to pursue professional goals.
Source: Competencies for Entry into the Profession of Dental Hygiene. In ADEA
Competencies for Entry into the Allied Dental Professions (As Approved by the
2011 ADEA House of Delegates). J Dental Educ 2015; 79(7):825-26. Available at
http://www.jdentaled.org/content/79/7/822.full.pdf+html?sid=24d3d7e5-0451-4791-
be4f-cf41829ac126. Accessed July 2015.
AP P E N D I X C
Community Partnerships for Oral
Health
Appendix C-1 Potential Community Partners
Patie nts, Clie nts, and Consume rs of Se rvic e s
• Patients and clients • Consumers of services
• Parents and family representatives • Public representatives
• Advocacy groups for patients, clients, and consumers of services • Support groups for patients, clients, and consumers of services
• Advocacy groups for parents and family representatives • Support groups for parents and family representatives
Gove rnme nt Ag e nc ie s and Prog rams
• State, territorial*, and tribal departments of health administrators and • Local health departments (e.g., county and city health officials and staff)
staff (e.g., oral health, maternal and child health, Women, Infants, and • Local human service agency administrators and staff (e.g., programs for
Children [WIC], primary health care, family planning, rural health, individuals with mental illness and mental retardation, developmental and
health disparities, minority health, human immunodeficiency virus acquired disabilities, government hospitals, clinics, and institutions, programs
[HIV], chronic diseases, tobacco control) for individuals with special health care needs [e.g., blind, deaf], elder affairs
• State, territorial*, and tribal human service agency staff and and aging, department of corrections)
administrators (e.g., government hospitals, clinics, and institutions; • Other county and city officials (e.g., working with child care, youth services,
programs for individuals with mental illness and mental retardation; literacy, libraries, elderly and disabled services, public transportation, public
programs for individuals with developmental and acquired disabilities; housing, workforce development)
programs for individuals with special health care needs [e.g., blind, • Environmental health (e.g., community water supervisors or managers related
deaf]; state units on elder affairs and aging; department of corrections) to community water fluoridation)
• Regional council of governments
• Area agencies on aging in local areas
• County extension agencies
Polic ymake rs and Org aniz ations
• U.S. Congress: Senators and representatives • Policy advocates (e.g., Legal Aid, League of United Latin American Citiz ens
• Legislators: State senators and representatives [LULAC], National Association for the Advancement of Colored Persons
• Local government elected officials: County judges, mayors, city [NAACP])
councilors, county commissioners • Policy institutes (e.g., Georgetown University, Robert Wood Johnson
Foundation, Kaiser Permanente, Pew Research Center)
Community Org aniz ations
• Advocacy organiz ations for clients and consumers of services • Local representatives active in collaborative service programs with health and
• Advocacy organiz ations for children and adults with disabilities, HIV, human service agencies that specifically address key issues (e.g., community
cancer, or who are homeless planning)
• United Way, American Cancer Society, Diabetes Association, March of • Service organiz ations for vulnerable population groups (e.g., literacy, elderly
Dimes, Easter Seals, Mental Health Association, Success by 6, Healthy and disabled services, youth services, veterans, women, public transportation,
Mothers/Healthy Babies Coalition, League of Women Voters, public housing, workforce development, child care, food banks, homeless
Association for Retarded Citiz ens (ARC), United Cerebral Palsy, shelters, migrant and seasonal farm workers)
American Red Cross, Urban League, American Association of Retired • Administrators and staff for programs and supportive services, including
Persons (AARP) Alz heimer's facilities and care, assisted living, programs for assistive
• Community action agencies technology and disability aids, eldercare agencies, geriatric and professional care
• Senior nutrition services and sites managers, home care services, home maintenance and chore services, hospice
• Early childhood intervention organiz ations care, insurance programs (e.g., long-term care, Medicaid, Medicare supplement,
• National, state, and local information and resource (I&R) networks: advantage, and drug planning), medical equipment and medical alert programs,
community information and resource centers such as organiz ation- nursing homes, assisted living centers, retirement communities that provide
coordinating nonemergency 3-1-1 telephone number call centers for healthcare, senior healthcare and house call doctors, and veterans' benefits
government services; organiz ations coordinating 2-1-1 telephone consultants
number help lines with the United Way and information and referral • Corporation for National and Community Service, AmeriCorps, Senior Corps,
agencies in states and local communities; organiz ations coordinating Learn and Serve America, Volunteers in Service to America (VISTA), Youth
toll-free hotlines (e.g., state Maternal and Child Health [MCH] Agency Service Corps, and City Year
Title V toll-free hotline; aging and disability information and referral • Business leaders (see later section)
support centers) • Unions and organiz ed labor
• Representatives of consumer and regional advisory groups • Civic organiz ations: Junior League, Rotary International, Kiwanis, Lions
• Religious organiz ations Club, Elks
• Faith-based organiz ations (e.g., Catholic Charities, Salvation Army) • Youth groups: Boys and Girls Clubs, YMCA, YWCA, Big Brothers/Big
• Community centers and neighborhood associations Sisters, Special Olympics
• State and local coalitions; collaborations; initiatives; outreach staff; and • Media: International, national, state, and local media, including newspapers,
community-based organiz ations and advocacy organiz ations for oral television, radio, magaz ines/journals, Internet, websites, blogs, social media,
health, public health issues, and access to health care (e.g., insuring social networking pages, Facebook, Twitter, Flickr, and YouTube
children and adults; the uninsured; vulnerable groups)
• Foundations and corporate giving programs: international, national,
state, and local community grant makers and philanthropy sector
administrators and staff
Educ ation-Re late d Org aniz ations and Groups
• Regional education service centers • Parent-Teacher Associations/Organiz ations
• Local school districts and boards: Superintendents, principals, teachers, • Parenting education programs
school nurses, school social workers, parent liaisons • Adult education and literacy programs
• Local child development and child care grantees and Head Start grantees • Home school programs
and delegate agencies (e.g., Head Start executive directors, Head Start • Employment and vocational education
health coordinators) • Education-related unions
• Fraternities and sororities
He alth and Human Se rvic e Provide rs, Groups, Org aniz ations, and Assoc iations
• Health systems, hospitals and clinics (e.g., rural and community, • Physicians, pediatricians, family physicians, and physician assistants
public, nonprofit, private, children's hospitals, Department of Veterans • Nurses, nurse practitioners, and nurse midwives
Affairs hospitals and clinics, county hospital districts) • Speech pathologists
• Community health centers • Dieticians
• Safety-net health and oral health programs: Community dental clinics, • Nursing home administrators
nonprofit dental clinics • Early childhood early intervention providers
• Maternal and Child Health Programs • Social workers, care coordinators, and case managers
• State and local health professional associations • Health educators, community health workers, community health advisors, lay
• Dentists, dental hygienists, and dental assistants health advocates, promotores/promotoras, outreach educators, community
health representatives, peer health promoters, peer health educators, and patient
navigators
Third-Party Paye rs
• Health plans • Program established by the 2010 Patient Protection and Affordable Care Act
• Dental insurers • Health insurance programs and special initiatives reaching out to people with
• Managed care organiz ations disabilities, veterans and military personnel, families, children, young adults,
• Health maintenance organiz ations (HMOs) seniors, early retirees, individuals living in rural areas, Hispanics/Latinos,
• Employers providing dental insurance coverage African Americans, Asian Americans and Pacific Islanders, American Indian
• Employers not providing dental insurance coverage and Alaska Natives, small businesses, employers, women, and lesbian,
• Medicaid; Children's Health Insurance Program (CHIP) bisexual, gay, and transgender (LBGT) communities
• Health insurance coverage high-risk pools, preexisting condition
insurance plans, and health insurance exchanges
Hig he r and Profe ssional Educ ation
• Universities and colleges • Schools of social work
• Dental, dental hygiene, dental therapist, and dental assisting schools • Schools of public policy and health administration
• Nursing schools • Schools for speech pathology
• Medical schools • Schools for dietetics
• Allied health schools (e.g., occupational therapy, physical therapy)
• Schools of public health
Busine ss Org aniz ations and Re tail Outle ts
• Airlines • Delicatessens and specialty and ethnic food stores
• Banks • Health clubs
• Beauty and barber shops • Insurance companies
• Chambers of Commerce (e.g., Women Chamber of Commerce, Hispanic • Shopping malls
Chamber of Commerce) • Maternity stores
• Computer companies and stores • Movie theaters
• Grocery stores
*
Territorial agencies and organizations include the following territories and jurisdictions: District of Columbia;
Pacific-Basin territories and jurisdictions: Territory of American Samoa, Territory of Guam, Republic of the
Marshall Islands, Federated States of Micronesia, Commonwealth of the Northern Mariana Islands, and
Republic of Palau; and Eastern territories and jurisdictions: Commonwealth of Puerto Rico and U.S. Virgin
Islands. Tribal agencies and organizations include the following: American Indian/Alaska Native tribally
designated organizations; Alaska Native Health Corporations; Urban Indian Health Organizations.
Appendix C-2 Oral Health Coalition
Framework
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.
Administration on Aging (AOA)
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
HIV/AIDS, Human immunodeficiency virus/acquired immunodeficiency disease; STD, sexually transmitted

disease.
Appendix D-4 Examples of Primary Data
Collection Tasks
Planning
• Determine scope and objectives • Plan and develop data collection and entry process (manual collection or direct data entry into personal computer or a
• Prepare protocols describing mobile device, also known as handheld device, handheld computer, palmtop computer, or personal digital assistant
assessment plan [PDA])
• Select data collection methods • Translate data collection instruments
• Establish criteria • Gain approval of data collection instruments from Institutional Review Board
• Determine sampling methods and • Pilot-test consent form and data collection instruments
processes • Revise consent form and data collection instruments
• Obtain approval of authorities • Obtain approval of revised consent form and data collection instruments from Institutional Review Board
• Plan for personnel and physical • Draw sample
arrangements • Plan fieldwork and scheduling
• Plan for data analysis phase • Purchase and organiz e supplies
(recording, managing, and • Initiate contact with data collection sites (work through established community networks or organiz ational
analyz ing data) structures)
• Plan for data reporting phase • Organiz e logistics for data collection, including travel and site requirements
• Prepare budget • Train field team
• Develop timetable of main • Calibrate field team
activities and responsible staff • Implement pilot test of assessment
• Plan for referral process (for
clinical findings detected in health
survey)
• Plan and develop consent form
• Translate consent form
• Gain approval of consent form
from Institutional Review Board
• Plan and develop data collection
instruments
• Develop data collection protocols
• Plan data entry processes
• Plan quality assurance processes
for data collection
• Plan and develop training
materials for field team
Imple me nting
• Contact and recruit participants • Analyz e data
• Gain consent of participants • Maintain quality assurance processes
• Record data • Summariz e findings
• Manage data • Report findings
AP P E N D I X E
Selected Oral Conditions and Factors
Influencing Oral Health That Can Be
Assessed in Oral Health Surveys
ORAL CONDITIONS OR FACTORS VARIABLES THAT CAN BE ASSESSED
Clinical treatment needs • Dental service needed by type of care (e.g., prevention, restorations, extractions,
crowns)
• Treatment urgency
Craniofacial anomalies, including developmental anomalies • Cleft lip or cleft palate
• Craniofacial anomalies
• Oral malformations
Dental caries • Coronal caries
• Early childhood caries
• DMF
• Gross loss of tooth structure
• Pulpal involvement
• Retained roots
• Root caries
• Untreated tooth (dental) decay
• Restoration and Tooth Condition Assessment (RTCA)
• Significant Caries Index (SiC Index): World Health Organiz ation
Dental sealants • Dental sealants on specific teeth (first molars, second molars, primary molars)
Dietary intake • Healthy Eating Index
• Dietary recall and dietary intake questionnaire
• Food frequency questionnaire
• Food choices and dietary patterns
• Bottle feeding practices
Expense and payment source for oral health services • Dental care expenses
• Dental insurance
• Medicaid
Fluoride • Fluoride toothpaste use
• Community water fluoridation
• Fluoride supplements
• Fluoride treatments
Impact of oral health on daily living • Acute pain
• Chronic pain
• Eating (e.g., trouble chewing or eating)
• Lost work, lost school days, activity change as the result of dental problems
• Masticatory function
• Mouth pain
• Orofacial Pain Assessment: Orofacial pain questionnaire and orofacial pain
examination
• Salivary function (e.g., dry mouth, Sjögren's syndrome, xerostomia)
• Speech
• Swallowing
• Temporomandibular dysfunction (TMD)
• Temporomandibular Joint (TMJ) Assessment
Malocclusion • Occlusion and occlusal traits
• Orthodontic treatment needs
• Dental Aesthetics Index (DAI)
Medications • Medications prescribed for dental treatment
Oral and pharyngeal cancer • Receipt of examination to detect oral cancer
• Oral cancer diagnosis
Oral health knowledge, beliefs, opinions, attitudes, practices, behaviors, • Assessments of children, adolescents, and parents
and skills • Assessments of younger and older adults
• Assessments of oral healthcare providers
• Assessments of healthcare providers
• Assessments of community stakeholders and policymakers
Oral healthcare providers • Dental care provider information
• Oral healthcare provider distribution
• Oral healthcare provider training
• Staffing of oral healthcare providers
• Types of healthcare providers seen
Oral healthcare utiliz ation • Access to dental care (e.g., cost, travel time, satisfaction)
• Type of dental provider seen
• Dental services by type (e.g., prevention, restorations, extractions, crowns)
• Emergency dental care (e.g., traumatic injuries)
• Dental care satisfaction
• Frequency of dental visits
• Last dental visit (indicating when)
• Reason for dental visit
• Reason for last dental visit
• First dental visit
• Frequency of dental visits
• Number of dental visits
• Usual source of dental care
• Oral health care during pregnancy
• Centers with oral health services
• State and local dental programs
Orofacial injury • Trauma
• Accident
• National Institute for Dental Research (NIDR) Trauma Index
Perceived oral health status and oral health–related quality of life • Assessment of general oral health status
(OHRQOL) • Global Oral Health Assessment Index (GOHAI)
• Oral Health Impact Profile (OHIP)
• Child Oral Health Quality of Life Questionnaire
Perceived treatment needs • Self-perceived need for dental care
Periodontal diseases • Alveolar bone loss
• Community Periodontal Index (CPI)
• Furcations
• Gingivitis
• Calculus (e.g., subgingival calculus or supragingival calculus)
• Gingival bleeding
• Gingival inflammation
• Loss of attachment
• Periodontal index
• Pocket depth
• Recession
• Tooth mobility
Preventive care • Preventive care by clinician
• Preventive self-care (e.g., oral hygiene)
Primary/permanent dentition • Cleaning
• Oral debris
• Oral Health Index
Soft tissue lesions • Mouth sores
• Oral herpes
• Oral lesions
• Oral ulcers
• Tongue lesions
Temporomandibular disorder (TMD) • Clicking/popping
• Crepitation
• Limited opening and function
• Pain
Tobacco • Cigarettes
• Smokeless tobacco
• Smoking cigars
• Smoking pipes
• Tobacco cessation counseling by dental professionals
Tooth loss/edentulism • Tooth count
• Denture ownership and use
• Missing teeth
• Self-reported dentition status
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
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3/M013735560.pdf [e-ISSN: 2279-0853, p-ISSN: 2279-0861].
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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.
Dental health professional shortage area (dental HPSA) Geographic area or

healthcare facility in which the dentist/dental health professional to population
ratio is low as designated by the Health Resources and Services Administration
(HRSA). HPSAs receive various federal benefits as a result of the designation.
Dental home The ongoing relationship between the oral healthcare provider and
the patient that allows for the delivery of comprehensive, continuously
accessible, coordinated, and family-centered oral health care.
Dental hygiene therapist A dental hygiene-based dental therapist that has advanced
dental therapy training after dental hygiene licensure and extensive dental
hygiene experience; has both a dental hygiene and a dental therapy scope of
practice.
Dental index An abbreviated scale with definite upper and lower limits to measure
the amount or severity of an oral disease or related condition in a population;
both dental indexes and dental indices are used as the plural form.
Dental public health The science and art of preventing and controlling oral
diseases and promoting oral health through organized community efforts.
Dental therapist A midlevel oral health care provider; the advanced dental
therapist has a greater scope of practice and requires less supervision.
Denturist An oral healthcare provider who has direct access to the population to
provide dentures.
Department of Health & Human Services (DHHS) A department of the federal
government presiding over agencies that implement programs to fulfill health
goals, including oral health; primarily provides an infrastructure, research,
surveillance, and funding for programs that are carried out at the state and local
levels.
Dependent variable The variable thought to depend on or to be affected by the
independent variable in an experimental or quasi-experimental study; the
outcome variable of interest.
Descriptive statistics Category of statistics that are used to describe and summarize
data; used to determine information about the sample being studied without
generalizing to the population.
Descriptive study A study in which the characteristics of a population are defined,
providing information about the naturally occurring health status, behavior,
attitudes, or other characteristics of a particular group.
Determinants of health Factors that interact to create circumstances that have a
comprehensive influence on collective and personal well-being with a profound
effect on health; can be classified as social, physical, economic, environmental,
biologic, personal, and behavioral, many of which cannot be controlled by the
individual.
Dichotomous data Categorical data that possess only two categories.
Dietary fluoride supplements Fluoride drops, tablets, or lozenges used as a source
of fluoride to supplement the diet when fluoridated drinking water is not
available.
Diffusion of Innovations Theory A theory or concept that assesses how new ideas,
products, or services spread within a society or to other groups or how
innovations are adopted.
Direct access The 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.
Direct reimbursement The dental hygienist's right to file and be reimbursed for
services directly from third-party payers such as Medicaid or private dental
insurers.
Direct supervision The level of supervision that requires that the dentist be present,
examine the patient to authorize the work to be performed, and check it after.
Discrete data Numeric data with a set of fixed or finite values that can be counted
only in whole numbers.
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit The
federal mandate to provide comprehensive and preventive healthcare services,
including dental, for children under age 21 years who are enrolled in Medicaid.
Early childhood caries (ECC) classification Classification system for categorizing
the severity of dental caries in children aged 71 months and younger (infants
through age 5 years).
Early Head Start Head Start program that serves children from birth to age 3
years.
Eastman Interdental Bleeding Index (EIBI) A dental index used to determine the
extent of interdental inflammation based on bleeding that occurs in response to
inserting a triangular wooden interdental cleaner.
Ecological approach Concerned with the relations of people to one another and the
interactions between people and their physical surroundings, including the
interdependence of people and institutions.
Ecological study An observational study in which existing group-level data, as
opposed to data collected from individuals, are used to relate risk attributes to
health or other outcomes.
Empowerment/empowering Enabling individuals or a community to gain mastery
in and take control of overall decision making about achievement of health for
themselves or their own community.
Environmental factors Physical, sociocultural, sociopolitical, and economic
components that interact with host and agent factors in the multifactorial
Epidemiology The study of the distribution and determinants of health-related states
and events in specified populations and its application to the prevention and
control of health problems.
Essential public health services/essential public health services to promote oral
health A framework that provides guidelines and describes the roles of public
health as applied by many national programs. The ASTDD applied these
essential services to develop a framework and guidelines for the roles of state
oral health programs in their promotion of oral health; used in the development
and evaluation of dental public health activities at the state level and in some
cases at the local level.
Ethics/professional ethics The general science of right and wrong conduct; the
code by which the profession regulates actions and sets standards for its
members, with the recognition that professionals are accountable for their
actions.
Ethnocentrism Judging others by one's own cultural standards based on a belief
that one’s personal cultural group is superior.
Evaluation/evaluate The final step of the prog ram planning or community health
improvement process when outcomes are measured against objectives that were
developed during the earlier planning stage, for the purpose of judging the
effectiveness and efficiency of a program; referred to as summative evaluation.
Evaluation can consist also of formative evaluation undertaken during the
implementation step of the program planning process; use of both summative
and formative evaluation is considered good practice in community health
practice.
Evidence-based decision making Application of a combination of relevant
components to oral healthcare practice: scientific evidence, practitioner's
professional expertise and judgment, patient or community preferences or
values, and circumstances of the situation.
Experiential learning An umbrella term that encompasses various models of
learning in which experience governs the learning process, including reflection
on the experience; critical to learning community oral health concepts and
practice.
Experimental group The sample group of participants in an experimental study that
receives the experimental treatment or intervention.
Experimental study A study intended to discover the effect of a treatment,
procedure, or program in a controlled setting. Experimental studies have the
greatest control and thus provide the highest level of evidence of all study
designs.
Extraneous variable Any confounding (relevant) variable in a study that is not
controlled and can be a source of error in relation to any observed effects in the
study outcomes.
Factorial study An experimental study that simultaneously tests the effect of
multiple factors (independent variables or treatments) on the dependent variable
and includes an assessment of potential interactions among the treatments.
Federal poverty level (FPL) A measure of income level issued annually by the
DHHS and used to determine eligibility for certain programs and benefits;
current FPL amounts can be found at www.hhs.gov.
Federally qualified health center (FQHC) A community health center that serves
an underserved area or population as defined by the Health Resources and
Services Administration; receives federal funding, enhanced reimbursement
from Medicare and Medicaid, and other federal benefits.
Fee-for-service A payment model in which healthcare services are paid for as
itemized in the provider ’s invoice, patients are able to make healthcare decisions
independently, and providers bill for each service separately and have no third-
party restrictions on care provided and fees charged; used to describe individual
out-of-pocket payment for services by uninsured individuals and payment
mechanism in an indemnity insurance plan.
Fee-for-service voucher Means of payment available for limited oral health
services to uninsured individuals who fall outside the eligibility guidelines for
entitlement programs such as Medicaid.
Fluoride mouthrinse program Weekly rinsing with a fluoride mouthrinse by
children, usually in a school setting, in communities that do not have access to
water fluoridation.
Fluoride varnish program Public health prog ram that makes fluoride varnish
available to children in communities that do not have access to water
fluoridation; administered through health department medical clinics or school-
based programs.
Focus group Small number of people (usually between 6 and 12, but typically 8)
brought together with a moderator to discuss a specific topic and produce
qualitative data; useful for the purpose of idea generation in community
assessment or for evaluation of programs, initiatives, or products such as health
messages or communication materials.
Formative evaluation Evaluation mechanisms conducted during the
implementation step of the program planning or community health improvement
process to ensure effectiveness of program processes, procedures, and activities
and to provide an opportunity for adjustment as needed; sometimes referred to
as process evaluation.
Framing health messages A concept that relates to the cues (e.g., sounds, symbols,
words, pictures) that signal how and what to think about a health issue. Gain-
framing a message focuses on what is to be gained by adopting the
recommended health behavior, and loss-framing is the opposite, focusing on the
effect of continuing to practice an unhealthy behavior.
Frequency distribution table A table that shows the frequency or number of times
that values or categories occur in a data distribution.
Frequency polygon A line graph that portrays a distribution of continuous data.
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
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.
Statistical conclusion The conclusion of a research study founded on the statistical

results of the data analysis.
Statistical significance A value that expresses the probability that the results of data
analysis from a given research study could be occurring purely because of
chance.
Status State or condition of a disease or related condition in the population.
Stratified random sampling The use of random selection of study participants
from two or more subdivisions (strata) of the population that possess similar
characteristics; recommended for a heterogeneous population.
Sulcus Bleeding Index (SBI) A complex dental index used to determine the extent of
gingival inflammation based on bleeding that occurs in response to “walking”
the periodontal probe at the base of the sulcus; used primarily in clinical
research trials.
Summative evaluation Evaluation mechanisms conducted during the evaluation
step of the program planning or community health improvement process that
determine the results or outcomes of the program (the change that has occurred
as a result of the program). Objectives form the basis for summative evaluation.
Surveillance The ongoing, systematic collection, analysis, and interpretation of
health-related data needed for the planning, implementation, and evaluation of
public health practice 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.
Oral health surveillance is surveillance in relation to oral health conditions and
related factors.
Surveillance, Epidemiology and End Results Program (SEER) A program of the
National Institute of Health National Cancer Institute that monitors and provides
information on cancer statistics in an effort to reduce the burden of cancer in the
U.S. population.
Systematic review A critical assessment and evaluation of all previously published
research studies that address a particular clinical issue, using a set of specific
criteria to apply an organized, explicit, systematic method of locating,
assembling, and evaluating the body of literature.
Systematic sampling Selection of study participants by including every nth person
from a list or file of the total population.
Tailoring health messages A concept in which specific cues are used to make health
messages meaningful for a specific individual.
Teledentistry The remote provision of dental care, advice, or treatment through the
medium of information technology; can be used for a dentist to remotely
supervise or provide consultation to a dental hygienist or midlevel oral health
provider.
Tertiary literature Sources of information that are a distillation and collection of
primary and secondary sources such as almanacs and dictionaries.
Tertiary prevention Services designed to soften the impact of an ongoing illness
or injury that has lasting effects by helping people manage long-term, often-
complex health problems and injuries (e.g., chronic diseases, permanent
impairments) to improve as much as possible their ability to function, their
quality of life, and their life expectancy.
Theory A set of interrelated concepts, definitions, and propositions that presents a
systematic view of events or situations by specifying relationships among
variables to explain and predict the events or situations.
Third-party payment Payment for healthcare services by someone other than the
patient. The three parties involved are the patient, the provider of the healthcare
service, and the third party, which is the organization that participates in
financing the services rendered such as an insurance company, union, or
government program.
Time series graph A graph that illustrates data points at successive time intervals.
Trend Inclination or general direction in which a health condition is changing or

developing.
t-test A statistical test used to analyze the difference between two sample means.
Type I alpha (α) error Based on statistical results, rejection of the null hypothesis
when it is actually true.
Type II beta (β) error Based on statistical results, acceptance of the null hypothesis
when it is actually false.
Unsupervised practice According to state statute, dental hygienists' right to make
treatment decisions and provide treatment within their scope of practice without
the supervision of a dentist.
Validity The degree to which an assessment measures what it is supposed to or
intended to measure. In research, external validity is the extent to which the
results of a study can be generalized to the population, and internal validity is the
degree to which a causal conclusion is warranted based on the control of
confounding variables and other sources of error.
Variable A characteristic or concept that varies, or differs, within the population
under study.
Variance A numerical value that demonstrates how widely individual scores in a
group vary around the mean; used with interval and ratio data.
Volunteer dental services programs Community oral health programs operated by
professional and nonprofit organizations through which oral health
professionals volunteer to provide oral health services to underserved
populations.
Volunteerism Activity in which individuals provide a service to the community that
is a major benefit for the community; in the educational arena, not necessarily
associated with an academic course.
Washout period The period in a crossover study between the treatments under
study, during which study participants receive no treatment to eliminate the
effects of a previous treatment.
Water Fluoridation Reporting System (WFRS) An online tool managed by the
CDC to track the level of fluoride in local water supplies; is the basis for
national surveillance reports of the status of community water fluoridation in the
nation.
Web-based presentation The use of computer technology to deliver an online
professional presentation of a topic on the web; can involve one or more
speakers and connection to the audience via phone lines or computer audio.
WIC (Special Supplemental Nutrition Prog ram for Women, Infants, and
Children) A federal program that provides grants to states to fund local
programs that provide supplemental foods, healthcare referrals, and nutrition
education for low-income pregnant, breastfeeding, and nonbreastfeeding
postpartum women, and to infants and children up to age 5 years who are found
to be at nutritional risk; includes nutrition education related to oral health.
Wilcoxon signed-rank test A nonparametric statistic to test the difference between
two related or paired data sets using the median as the basis for comparison.
World Health Organization (WHO) An international health organization with the
primary role of directing and coordinating international health within the United
Nations' system; primarily focused on serving the needs of developing
countries.
Index
Page numbers followed by “f” indicate figures, “b” indicate boxes, and “t” indicate
tables.
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
dental care financing in the U.S, 119–124
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
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
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
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
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
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
ADT, 26
CDHC, 28
clinician, 31–33
educator, 33–34
manager, 35–36
researcher, 35
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
ADT, 26
CDHC, 28
clinician, 31–33
educator, 33–34
manager, 35–36
researcher, 35
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
status and trends of, 129
success of, 131b
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
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
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
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
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
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
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
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
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
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
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
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
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
Health Belief Model, 212–213, 213t
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
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
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
Orientation, 271
comments, 273b
Orofacial injuries
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
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
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
dental insurance coverage and, 119
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
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
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
strategies of, 210–211
theories of, 211–216, 211f, 212t
community level, 211f, 213–216
interpersonal level of, 211f, 213
intrapersonal level of, 211f, 212–213
levels of influence of, 211f, 212t
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
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
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
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
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 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
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
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
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
interpersonal level of, 211f, 213
intrapersonal level of, 211f, 212–213
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
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

Christine French Beatty - Community Oral Health Practice For The Dental Hygienist (2017) - 2

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Christine French Beatty - Community Oral Health Practice For The Dental Hygienist (2017) - 2

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Community

Oral Health Practice for

CHRISTINE FRENCH BEATTY, RDH,

Chapter 1 People's Health

Health, Public Health, and Dental Public Health

The Public Health Problem and the Public Health Solution

Role of Government in Public Health

Future of Dental Public Health

Applying Your Knowledge

Dental Hygiene Competencies

Chapter 2 Careers in Public Health for the Dental Hygienist

Community Oral Health Practice as a Career

Future Trends for Dental Hygienists in Public Health

Interprofessional Collaborative Practice

Careers in Public Health

Applying Your Knowledge

Dental Hygiene Competencies

Chapter 3 Assessment for Community Oral Health Program Planning

Public Health Practice

Assessment: a Core Public Health Function

Overview of Epidemiology: Population-Based Study of Health

The Community Health Program Planning Process

Applying Your Knowledge

Dental Hygiene Competencies

Health Assessment: Essential in Monitoring Community Health

Oral Health Surveillance Systems

Measuring Oral Health and Its Determinants in Populations

Future Considerations for Oral Health Surveillance

Applying Your Knowledge

Dental Hygiene Competencies

Chapter 5 Population Health

Part One: Oral Health Status and Trends

Status and Trends of Specific Oral Conditions in the U.S.

Applying Your Knowledge

Dental Hygiene Competencies

Improving Oral Health in the Community

National, State, and Local Programs: Role of the Health Department

Program Planning Process

Primary Prevention Programs: Fluorides, Sealants, Oral Health Education

School-Based Oral Health Programs

Secondary and Tertiary Oral Health Prevention Programs

Applying Your Knowledge

Dental Hygiene Competencies

Chapter 7 Applied Research

Using Research to Answer Questions

The Scientific Method and Development of a Research Question

General Methods of Research

Presentation of the Data and Data Analysis

Analysis of the Literature

Applying Your Knowledge

Chapter 8 Health Promotion and Health Communication

Health Communication and Health Information Technology

Resources for Professional Development

Applying Your Knowledge

Dental Hygiene Competencies

Chapter 9 Social Responsibility

Social Responsibility and Professional Ethics

Health Care: a Privilege or a Right?

Government Role in Healthcare Delivery

Patient Responsibility and Patient Confidentiality

Health Care: a Comprehensive Approach

Applying Your Knowledge

Chapter 10 Cultural Competence