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Milestones in Public
Health: Chapter 9
Lectures for Medical and
Clinical Education
January 2011
Describe the history of dentistry in becoming a
profession
Discuss the impact of major innovations in
dental health
Describe major oral diseases
Explain the impact of fluoridation on oral
health
Describe the impact of dental sealants on oral
health
Identify health disparities in oral health
2
1. Looking Back
2. Milestones in Dental Innovation
3. Oral Health and Public Health
4. The Major Oral Diseases
5. Looking Ahead: Oral Health Disparities
3
Looking Back
The Earliest known dentist, Hesi-Re, lived in Egypt around 2600
BC, where ancient skulls have been found with small holes in the
jaw-bone, possibly representing efforts to alleviate the pressure
of abscesses, secondary complications of dental caries
Royalty in ancient Egypt, who had a diet rich in carbohydrates,
show an 80% caries rate, while lower class ancient Egyptians had
a very low caries rate due to lower carbohydrate consumption
Dentistry was a part of medicine in ancient Mesopotamia. The
code of Hammurabi (1900 BC) reveals that the government
regulated the medical profession (including dentistry) as far back
as 2500 BC
Pfizer Inc. (2006). Chapter 9: Oral health: Looking back. In Milestones
in public health : Accomplishments in public health over the last 100
year. (p.171). New York, NY: Pfizer Inc.
5
Historically, scientists, educators, and practitioners in the
health field have disconnected the mouth from the rest
of the body. As a result of the Maryland legislature’s
unwillingness to incorporate dentistry as a department
at the University of Maryland medical school due to
attendant costs, dentistry did not become a medical
specialty, but rather its own discipline
Dr. Chapin A. Harris, considered the father of American
dental sciences, along with Dr. Horace H. Hayden, co-
founded the Baltimore College of Dental Surgery, the
world's first dental college, in 1840. Between 1840 and
1867, nine more freestanding dental schools were
founded using the Baltimore model
6
In 1867, Harvard established the Harvard School of
Dental Medicine in association with the
Massachusetts General Hospital, becoming the first
university-affiliated dental school
By 1870, 85% of the 8,000 practicing dentists in the
U.S .had trained under preceptors, or declared
themselves as dentists, while only 15% had
graduated from dental schools
According to the Bills of Mortality, dental infections
and complications represented a leading cause of
death during this time
Pfizer Inc. (2006). Chapter 9: Oral health: Looking back. In Milestones
in public health : Accomplishments in public health over the last 100
year. (p.169). New York, NY: Pfizer Inc.
7
With the advent of more dental schools in the U.S. in the
late 1800’s, fewer dentists employed the preceptorship
model for their education, and dental school graduates
began to dominate the ranks of their profession
By the mid 1920’s, less than 3% of practicing dentists
had trained under preceptorship arrangements
The 1926 Gies Report advocated that incoming dental
students should have at least two years of university
education in addition to instruction on the basic biology
of oral structure and the pathology of oral facial disease
Pfizer Inc. (2006). Chapter 9: Oral health: Looking back. In Milestones
in public health : Accomplishments in public health over the last 100
year. (p.170). New York, NY: Pfizer Inc.
8
According to Dr. Allan Formicola, president of the
William J. Gies Foundation, the field of dentistry moved
closer to becoming an oral specialty of medicine as a
result of the Gies Report
– The report established stricter accreditation standards and
admission requirements to dental schools
– This “higher bar” raised the caliber of and quality of dental
students and education, and led to a new respect for dentistry
Dougherty, M. (2003, March 26). A biochemist who lead dental history: William Gies'
1926 report on dental education
is still relevant today. In VIVO: Columbia University Health Sciences, 2(6). Retrieved
June 13, 2010 from http://cumc.columbia.edu/publications/in-
vivo/Vol2_Iss06_mar26_03/medical-history.html
9
However, dental schools and dental societies continued
to operate separately from medical schools and
societies, and subsequently many health care
professionals were never fully educated on the impact of
oral disease on overall health
Pfizer Inc. (2006). Chapter 9: Oral health: Looking back. In Milestones
in public health : Accomplishments in public health over the last 100
year. (p.169). New York, NY: Pfizer Inc.
10
The dental health profession includes:
– Dentists, dental hygienists, dental assistants, and
dental laboratory technicians
There are nine dental specialties
– Dental public health, endontics, oral and maxillofacial
surgery, oral pathology, orthodontics, pediatric
dentistry, periodontics, prosthodontics, and radiology
11
Milestones in Dental
Innovation
While significant improvements in preventive
dentistry and oral health have occurred since
dentistry became a profession in 1839, presently,
the silent epidemic of tooth decay
disproportionately affects the:
– uninsured, inner-city and rural, low-income,
developmentally disabled, homebound, and homeless
populations
Pfizer Inc. (2006). Chapter 9: Oral health: Looking back. In Milestones
in public health : Accomplishments in public health over the last 100
year. (p.170). New York, NY: Pfizer Inc.
13
Toothbrushes
– Chewsticks, the first toothbrushes, borrowed
from the Chinese and from Babylonians
– Tooth brushing became a daily routine after
World War II
– Rejection rate of draftees during World War II
due to oral health had been so high that
standards had been lowered to meet targets
14
Toothpaste
– Origins of toothpaste can be traced back to
ancient India and China as far back as 500 BC.
In the 19th century toothpaste more similar to
what we know today was developed
– Procter and Gamble introduced fluoride in
toothpaste in 1956, which is necessary to
prevent tooth decay
– Without fluoride, toothpaste can help prevent
gum disease but not tooth decay
15
Novocain
– Developed in 1905 by Alfred Einhorn as an
analgesic substitute for cocaine in 1905. The trade
name Novocain comes from a combination of the
Latin word "novus," meaning "new," plus "cocaine"
Dental Floss
– Silk thread floss developed by Levi Spear Parmly in
1815 and patented by Johnson and Johnson in
1898
– Dr. Charles C. Bass (a physician) developed nylon
floss and promoted its use during WW II
Mouth Rinses and High Speed Drill
16
Oral Health and Public
Health
“Oral diseases are a neglected epidemic in our
country, and the oral health disparities of the
underserved are shameful. We need to reconnect
the mouth to the rest of the body.”
Dr. Myron Allukian
former director of Oral Health
Boston Public Health Commission
18
In spite of these milestones in dental
innovations, presently, poor oral health
continues to exist as a silent epidemic,
where underserved populations
disproportionately suffer from major and
often preventable oral diseases, which
results in great societal costs
19
The Major Dental
Diseases
The most common chronic disease among
children 5 to 17 years – five times more
common than asthma
Bacteria occur normally in the mouth
Plaque begins to build up on teeth within 20
minutes after eating (the time when most
bacterial activity occurs). If this plaque is
not removed thoroughly and routinely,
tooth decay will begin and flourish
National Institute of Dental and Craniofacial Research. (2010). Oral health in America: A report of the Surgeon
General (executive summary). Retrieved 6/13/2010 from
http://www.nidcr.nih.gov/DataStatistics/SurgeonGeneral/Report/ExecutiveSummary.htm
21
“The acids in plaque dissolve the enamel surface of
the tooth and create holes in the tooth (cavities).
Cavities are usually painless until they grow very
large and affect nerves or cause a tooth fracture.
If left untreated, a tooth abscess can develop.
Untreated tooth decay also destroys the internal
structures of the tooth (pulp) and ultimately
causes the loss of the tooth.”
MedlinePlus. (2010). Dental cavities: Cavities are holes, or structural
damage, in the teeth. Retrieved 6/13/2010 from
http://www.nlm.nih.gov/medlineplus/ency/article/001055.htm
22
MedlinePlus.(2010). Tooth abscess [Online image]. Retrieved 8/26/2008
from http://www.nlm.nih.gov/medlineplus/ency/imagepages/9979.htm
23
Early childhood caries (ECC), also
referred to as baby bottle tooth decay,
stems from sweetened liquids that
cling to the infants’ teeth
ECC often occurs when a baby is
regularly given a bottle with sugary
liquid at bedtime or nap-time, most
often affects the upper front teeth, and
can cause severe tooth decay
Although a preventable disease, ECC is
National Library of Medicine. Baby bottle tooth decay
prevalent in low-income families, and [Online image].
Retrieved June 13, 2010 from
can cost as much as $6,000 per child to http://www.nlm.nih.gov/medlineplus/mobileimages/ency/f
treat (as general anesthesia may be ullsize/9090_xlfs.png
required)
24
Good oral hygiene consists of:
– Undergoing regular professional teeth cleaning every 6
months, brushing at least twice a day, flossing at least
daily, and having x-rays done on a yearly basis
– Eating chewy, sticky foods (such as dried fruit or candy)
as part of a meal rather than as a snack, and brushing
the teeth or rinsing the mouth with water after eating
these foods
– Minimizing snacking, which creates a constant supply of
acid in the mouth
– Avoiding constant sipping of sugary drinks or frequent
sucking on candy and mints
MedlinePlus. (2010). Tooth abscess in Dental cavities: Cavities are
holes, or structural damage, in the teeth. Retrieved 6/13/2008 from
http://www.nlm.nih.gov/medlineplus/ency/article/001055.htm
25
Dental sealants, thin plastic-like coating
applied to the chewing surfaces of the
molars can prevent cavities, as they block
the accumulation of plaque in the deep
grooves on vulnerable surfaces
While sealants are generally applied on
teeth of children, shortly after the molars
erupt, older individuals may also benefit
from their use MedlinePlus. (2010). Tooth abscess in Dental cavities: Cavities are
holes, or structural damage, in the teeth. Retrieved 6/13/2008 from
http://www.nlm.nih.gov/medlineplus/ency/article/001055.htm
26
Fluoride is often recommended to protect against
dental caries as studies have shown that people who
ingest fluoride in their drinking water or by fluoride
supplements have fewer dental caries. Fluoride
protects the enamel against the action of acids
“Topical fluoride is also recommended to protect
the surface of the teeth. This may include a fluoride
toothpaste or mouthwash. Many dentists include
application of topical fluoride solutions (applied to a
localized area of the teeth) as part of routine visit"
MedlinePlus. (2010). Tooth abscess in Dental cavities: Cavities are
holes, or structural damage, in the teeth. Retrieved 6/13/2008 from
http://www.nlm.nih.gov/medlineplus/ency/article/001055.htm
27
“Community water fluoridation has been
ranked one of 10 great public health
achievements in the 20th century”
Fluoride occurs naturally in all drinking water in
varying concentrations, according to geological
features
In 1931, Dr. Frederick S. McKay, proved that
naturally occurring fluoride in the water supply
could inhibit dental caries
Centers for Disease Control and Prevention (n.d.) Preventing Chronic Diseases
Invetsing Wisely in Health - Preventing Dental Caries. Retrieved 8/26/2008 from
http://www.dental.ufl.edu/Patients/Files/PreventingDentalCaries.pdf
Pfizer Inc. (2006). Chapter 9: Oral health: Case study. In Milestones in public health :
Accomplishments in public health over the last 100 year. (pp.176-178). New York, NY: Pfizer
Inc.
28
Dr. McKay collaborated with Dr. H. Treandly, Dean of
the U.S .Public Health Service, to identify an
adjusted fluoridation standard that would have the
benefit of reducing dental caries while avoiding
tooth discoloration
Drs. McKay and Treandly concluded that the water
fluoride standard should be one part per million.
Several subsequent studies proved that this
standard provided optimum dental caries protection
with minimum staining of the teeth
Pfizer Inc. (2006). Chapter 9: Oral health. In Milestones in public health
: Accomplishments in public health over the last 100 year. (p. 178).
New York, NY: Pfizer Inc.
29
In 1945, Grand Rapids, Michigan became the first
city in the world to adjust its fluoride concentration
to the new adjusted fluoride standard
In 1950, the U.S. Public Health Service
recommended community water fluoridation as a
public health measure
By the early 1980’s, epidemiologic studies revealed
that the prevalence of caries was decreasing
throughout the U.S.
Pfizer Inc. (2006). Chapter 9: Oral health. In Milestones in public
health : Accomplishments in public health over the last 100 year.
(pp. 178-179). New York, NY: Pfizer Inc.
30
In 2005, 170 million people in the U.S. lived in
fluoridated communities, including about 10 million
who lived in communities with naturally fluoridated
water supplies
The majority of communities (91%) fluoridate
administratively through local or state government
In 2005, an additional 30-40 million people were
estimated to live without public water supplies,
depending on sources such as natural springs or
drilled wells
Pfizer Inc. (2006). Chapter 9: Oral health. In Milestones in public
health : Accomplishments in public health over the last 100 year.
(p. 179). New York, NY: Pfizer Inc.
31
Yet, community water fluoridation remains
controversial to some people who oppose
any form of government intervention and
regard fluoridation as forced medication
and violation of personal freedom
– In 2002 and 2004, 26 communities across the
U.S. voted in referenda for fluoridation
Pfizer Inc. (2006). Chapter 9: Oral health. In Milestones in public
health : Accomplishments in public health over the last 100 year.
(p. 180). New York, NY: Pfizer Inc.
32
66% of individuals on public water
systems— more than 162 million people —
receive community water fluoridation
“Community water fluoridation effectively
prevents dental caries in communities with
varying disease prevalence
– ”Children in communities with water
fluoridation experienced 29% fewer cavities”
Centers for Disease Control and Prevention. (n.d.). Preventing Chronic Diseases Invetsing Wisely in Health - Preventing
Dental Caries. Retrieved August 26, 2008 from http://www.dental.ufl.edu/Patients/Files/PreventingDentalCaries.pdf
33
MedlinePlus. (2009). Medical Encyclopedia, Gingivitis [Online image].
Retrieved August 26,2008 from http://www.nlm.nih.gov/medlineplus/ency/imagepages/1136.htm
34
Localized infection or inflammation of the soft
tissues characterized by swelling and bleeding of the
gums
Bacteria in plaque around the teeth release enzymes
(collagenases) that can erode the gum tissues.
The inflamed gums swell, recede, bleed easily, and
can loosen from the teeth
Good oral hygiene is the best prevention against
gingivitis because it removes the plaque that causes
the disorder
MedlinePlus. (2010). Gingivitis is inflammation of the gums (gingiva).
Retrieved 6/13/2010 from http://www.nlm.nih.gov/medlineplus/ency/article/001056.htm
35
Peridontitis
– Also an infection of the soft tissues, involves
the supporting alveolar bone around teeth with
loss of peridontal attachment
– Prevalence increases with age and the
condition disproportionately affects
immunosuppressed individuals (e.g. HIV/AIDS)
36
Source (n.d.): Courtesy of Sonny Johansson, MD, PhD [image].
37
Oral cancer includes cancers of the mouth
and the pharynx, part of the throat
– About two-thirds of oral cancers occur in the
mouth and about one-third are found in the
pharynx
An estimated 35,000 Americans will be
diagnosed this year and approximately
7,500 deaths will occur from the disease
National Institute of Dental and Craniofacial Research. (2010). Oral cancer. Retrieved 5/15/2009
from http://www.nidcr.nih.gov/OralHealth/Topics/OralCancer/OralCancer.htm
38
Risk factors include:
– Male gender
– Alcohol and tobacco use
– Age over 40 years old
– For lip cancer, sun exposure is a risk factor
39
The majority of oral cancers are preventable
75% of oral cancers are related to tobacco
use, alcohol use, or both
Of all cancers, oral and pharyngeal cancers
show the largest disparity in five-year
survival rates between whites (56%) and
African-Americans (36%)
40
The vast majority of oral cancers are
squamous cell carcinomas
Oral leukoplakia requires follow-up with
biopsies as it may be a precursor of
squamous cell carcinoma
41
Source (1980): Courtesy of Jan Hirsch, MD, PhD., [image].
42
Looking Ahead: Oral
Health Disparities
“There are profound and consequential
health oral health disparities within the U.S.
population”
“The burden of oral diseases and conditions
is disproportionately borne by individuals
with low socioeconomic status at each life
stage and by those who are vulnerable
because of poor general health”
US. Department of Health and Human Services. (2003). National call To action to promote
oral health: A public-private partnership under the leadership of The Office of the Surgeon
General . (No. 03-5303). Rockville, MD: National Institutes of Health
44
“Differences in the incidence, prevalence,
mortality, and burden of diseases and other
health conditions that exist among specific
population groups…”
National Institutes of Health, US Department of Health and Human Services
”Differences in the incidence or prevalence of
disease disability, or illness. These differences
can be among racial/ethnic groups,
socioeconomic groupings, gender groups, or
other groupings”
LaVeist, T. A. (2005). Minority Populations and Health, An Introduction to Health
Disparities in the United States. San Francisco, CA: Jossey-Bass A Wiley
45
According to the Surgeon General:
– Poor children suffer twice as much dental caries
as their more affluent peers
– Children living below the poverty line (annual
income of $17,000 for a family of four) have
more severe and untreated tooth decay
US. Department of Health and Human Services. (2003). National call To action to
promote oral health: A public-private partnership under the leadership of The Office of
the Surgeon General . (No. 03-5303). Rockville, MD: National Institutes of Health
46
The major factors that determine oral and general
health and well-being are:
• Individual biology and genetics
• Environment, including its physical and socioeconomic aspects
• Personal behaviors and lifestyle
• Access to care
• Organization of health care
“These factors interact over the life span and
determine the health of individuals, population
groups, communities – from neighborhoods to
nations” US. Department of Health and Human Services. (2003). National call To action to
promote oral health: A public-private partnership under the leadership of The Office of
the Surgeon General . (No. 03-5303). Rockville, MD: National Institutes of Health
47
Living and working conditions
may include:
• Psychosocial factors
• Employment status and
occupational factors
• Socioeconomic status (income,
education, occupation)
• The natural and builtc
environments
• Public health services
Over the life span • Health care services
SOURCE: The Future of the Public’s
Health (IOM, 2003)
NOTES: Adapted from Dahlgren and
Whitehead, 1991.
The dotted lines denote interaction effects
between and among the various levels of
health determinants (Worthman, 1999).
48
“Access to care makes a difference. A complex set of
factors underlies access to care and includes the
need to have an informed public and policymakers,
integrated and culturally competent programs, and
resources to pay and reimburse for the care. Among
other factors, the availability of insurance increases
access to care”
“Federal and state assistance programs for selected
oral health services exist; however, the scope of
services is severely limited, and their
reimbursement level for oral health services is low
compared to the usual fee for care”
US. Department of Health and Human Services. (2003). National call To action to
promote oral health: A public-private partnership under the leadership of The Office
of the Surgeon General . (No. 03-5303). Rockville, MD: National Institutes of Health
49
”Medical insurance is a strong predictor of
access to dental care. Uninsured children are
2.5 times less likely than insured children to
receive dental care. Children from families
without dental insurance are 3 times more
likely to have dental needs than children with
either public or private insurance. For each
child without medical insurance, there are at
least 2.6 children without dental insurance.”
US. Department of Health and Human Services. (2003). National call To action to
promote oral health: A public-private partnership under the leadership of The Office
of the Surgeon General . (No. 03-5303). Rockville, MD: National Institutes of Health
50
Medicaid is available only to certain low-
income individuals and families who fit into
an eligibility group that is recognized by
federal and state law
Medicaid is a state-administered program
and each state sets its own guidelines
regarding eligibility and services
Centers for Medicare & Medicaid Services. (2010). Overview Medicaid program -
general information. Retrieved 6/13/2010 from http://www.cms.gov/MedicaidGenInfo/
51
Medicaid has not been able to fill the gap in
providing dental care to poor children.
Fewer than one in five Medicaid-covered
children received a single dental visit in a
recent year-long study period
US. Department of Health and Human Services. (2003). National call To action to
promote oral health: A public-private partnership under the leadership of The Office
of the Surgeon General . (No. 03-5303). Rockville, MD: National Institutes of Health
52
”Increased public-private partnerships are
needed to educate the public, to educate
health professionals, to conduct research, and
to provide health care services and programs.
These partnerships can build and strengthen
cross-disciplinary, culturally competent,
community-based, and community-wide
efforts and demonstration programs to expand
initiatives for health promotion and disease
prevention.” US. Department of Health and Human Services. (2003). National call To action to
promote oral health: A public-private partnership under the leadership of The Office
of the Surgeon General . (No. 03-5303). Rockville, MD: National Institutes of Health
53
Crest Healthy Smiles 2010
– Campaign addressing tooth decay in children
– Initiated by Proctor and Gamble in partnership with
American Dental Association, Boys and Girls Clubs
of America, and the American Academy of
Dentsitry
– Aims to reach 50 million children through: full
service dental clinics at Boys and Girls Clubs, oral
health instruction, and preventive services
provided by dental students in schools
Pfizer Inc. (2006). Chapter 9: Oral health: Looking back. In Milestones
in public health : Accomplishments in public health over the last 100
year. (p.186). New York, NY: Pfizer Inc.
54
Case Western Sealant Program
– Case Western dental students apply sealants to
the teeth of 15,000 second and sixth graders in
Cleveland Public Schools every year
Pfizer Inc. (2006). Chapter 9: Oral health: Looking back. In Milestones
in public health : Accomplishments in public health over the last 100
year. (p.187). New York, NY: Pfizer Inc.
55
Public health measures such as community
water fluoridation and school-based dental
sealant programs play an important role in
addressing the neglected epidemic of oral
disease
Government support of dental health
infrastructure through expanded dental
insurance coverage, in addition to the creation
of more public private partnerships may also
improve the oral health of Americans
56
