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A Children’s Dental Program for American Indians
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Mobile u n it used by dentists who pioneered in the Indian Health Service. Home was a bedroll; dental clinic was the shade of a tree. Extraction was the most frequently rendered service. Itinerant ac tiv ity with use of portable equipment exists only in Alaska now where teams travel by boat or plane to remote villages between “ freeze-up” in the fall and "break-up” in the spring.
A c h i l d r e n ’s d e n t a l p r o g r a m f o r A m e r i c a n I n d i a n s
Joseph A bram ow itz, DDS, MPH, Bethesda, Md
A dental health program carried out for many years among American Indians, Eskimos, and Aleuts may offer guidelines for setting up a national program fo r children. Because dental resources may never be p le n tifu l in relation to the need, the Service has established program priorities and methods de signed to do the most good in the shortest time. An incremental care system including preventive den tistry is followed, beginning with the youngest children available. The Service designed its own c lin ic s and equipment, supports training, re search, and development, employs increasing num bers of dental assistants, and is com m itted to en couraging com m unity participation in program planning.
T he A m erican D ental A ssociation H ouse o f D ele gates, at its annual session in N ovem ber 1965 called for the developm ent o f a national dental program for children. A year later at the annual session in Dallas, the H ouse adopted a specific
program and gave as its objective: “ to m ake the benefits of an organized program o f dental health education, preventive dentistry and dental care available to all children, particularly the needy and underprivileged.” 1 T o initiate this program , the H ouse o f D elegates recom m ended a series o f pilot or exploratory program s to study “the co m plex problem s o f adm inistration at local, state and national levels, the available supply o f dental p e r sonnel and its distribution throughout the country, the provisions for adequate financing and the solu tion o f m any other problem s involved in providing dental services on an unprecedented basis.” T he Public H ealth Service Indian H ealth Ser vice developed and has carried out for m any years a children’s dental health program for A m erican Indians, Eskim os, and Aleuts. T his program has m et problem s sim ilar to those that may be expect ed in the general population. C onsequently, it m ight well serve as a large scale pilot project to be studied by those who will develop the national dental health program for children. 395
Two house trailers like this, outfitted with old dental equipment, were put into service in the thirties when the dentist-to-patient ratio in the IHS was about 12:260,000.
H isto ry of In d ia n H e a lth D e n ta l P ro g ra m A dental pro g ram 2 for Indians began in 1913 with the assignm ent o f five dentists to travel am ong the reservations. D ental needs were overw helm ing and the dentists could provide little m ore than ex tractions. In those early years roads were usually either prim itive o r nonexistent. T ravel was often by horseback w ith the shade o f a tree serving as a clinic and a bedroll as a home. T he great cultural differences that existed between non-Indians and the tribes, com bined with the prim itive facilities and w orking conditions, required Spartan q u ali ties th at w ere found in only a few dentists. A fter 1932, the program began its slow shift from extraction services to corrective services for children and tow ard prevention through educa tion. D uring 1934, when there were 12 dentists attem pting to serve about 260,000 Indians, the first two m obile clinics were put to use. T hese in efficient units consisted of sm all house trailers co n taining old dental equipm ent. In the late forties, several program s for topical application o f fluoride solution to the teeth were initiated. M ost o f the available equipm ent con sisted of hand-m e-dow ns from oth er governm ent agencies. In 1951, a center was initiated for training In dian wom en to becom e dental assistants. D uring 1955 the Indian H ealth Program was transferred from the D epartm ent o f the Interior, B ureau o f In dian A ffairs, to the D epartm ent o f H ealth, E du ca tion, and W elfare, Public H ealth Service. A t th at tim e the program had 46 dentists and 22 assistants o p eratin g in one-chair clinics in schools, hospital basem ents, converted garages, or anyw here that 396 ■ JADA, Vol. 81, August 1970
equipm ent could be placed. D uring this period, the increm ental care approach was begun. F o r about the next ten years extensive efforts were m ade to increase m anpow er, upgrade the facili ties, and im prove the quality and efficiency of the program .
T h e p e o p le Today 403,500 Indians, Eskim os, and A leuts m ake up the service population o f the Indian H ealth Service. T hese people live in circum stances th at differ from those of any other population group in the U nited States. They are geographical ly and culturally isolated on 250 reservations, m ost o f which are west o f the M ississippi, and in hundreds of villages in Alaska. W ith few exceptions, these people live in co n ditions o f abject poverty. T he average fam ily o f five or six lives in a one- or two-room house w ith out running w ater or waste disposal facilities. In m ost households, the income is less than $1,500 per year.3 Indian and A laska native hom es are often con structed of brush, m ud, canvas, or other local m a terials available at no cost. A bout 50 % of reserva tion Indians m ust haul their w ater, m any for dis tances of a m ile o r m ore. Dom estic w ater use is frequently only 1 to 3 gallons per person per day as com pared with 150 gallons for the average A m erican.4 In general, Indians and A laska natives have m aintained their traditional language, religion, values, and social organizations. They are not fa m iliar with m odern health theories and do not u n derstand the scientific bases o f illness and tre a t m ent.3
Dental task force in early days of IHS had to have courage and robust health as well as a dental degree.
M ost Indian people gain facility with English w ords. H ow ever, m any exhibit difficulties in grasping and accepting health know ledge reg u lar ly expressed in English. M any still attrib u te illness to som e type o f im balance between m an and both natural and supernatural forces. T his belief is u su ally rooted in the various religious system s o f the people.5 G enerally, where a religious in terp reta tion o f illness exists, treatm ent o r preventive a c tion by ritual m eans is prescribed. In other in stances, a herbalist m ay be called for needed ser vices. F requently patients first consult with re li gious healers or herbalists before seeking out the doctor. C ertain traditional social practices am ong some tribes cause health facility m anagem ent problem s. T he cultural requirem ent th at an Indian be accom panied by a friend or relative while w aiting in the o u tp atien t departm ent causes traffic and noise problem s and, possibly, risk o f infection. Sim ilar problem s are created by the cultural requirem ent th at a relative or group o f relatives be n ear the hospitalized patient. T his pattern, general th ro u g h out the plains and the Southwest, is som etim es re flected in refusal of the sick to enter or rem ain in a hospital unless provisions are m ade to have re la tives n ear at hand, visiting hours notw ithstanding.5
T h e p ro b le m The incidence o f dental disease does not vary a p preciably from th at o f the non-Indian people liv ing in the sam e geographical regions. H ow ever, Indians and A laska natives live predom inantly in isolated areas w here private dental care is not available. Few o f them w ould be able to afford p ri
vate practice services even if such services w ere available. The accum ulated neglect, oral hygiene status, changing dietary patterns involving in creased use o f refined sugars, isolation, and, in re cent years, an increasing aw areness and conse quent dem and for dental care, have all contributed to a massive burden on existing dental resources.2 T ransportation also is a m ajor problem , both for the Indians and A laska natives needing health ser vices and for the health personnel providing these services. M any patients m ust travel long distances over prim itive roads and difficult terrain to reach hospitals, clinics, and health centers. T he very ill or those needing em ergency treatm ent m ust be transported by am bulance o r airplane, som etim es hundreds o f m iles.3 T he goal o f the Indian dental health program is to elevate the oral health status o f Indians, E sk i mos, and A leuts to the highest possible level. Fifty-six percent of these people are 19 years o f age or younger; the birth rate is about twice th a t o f the general population. T hese two factors, in addition to an increasing recognition by the Indians o f the need for dental services, are m aking an im pact on the Indian H ealth Service dental program by p ro ducing a vastly increased burden on the existing resources.6 T he dental clinics in hospitals, health centers, and health stations are located near the largest accessible populations.2 D ental care is still not available to m any for geographic reasons. T he num ber o f facilities, dentists, and dental assistants is not sufficient for the jo b at hand. It would be unrealistic to believe that the Indian H ealth Service will ever have an adequate am ount o f dental resources to m eet the potential dem and for dental care. To m ake m ost efficient use o f its Abramowitz: DENTAL PROGRAM FOR AMERICAN INDIANS m 397
Classroom instruction in oral health is an essential part of the pro gram. Here a young dental officer tel Is schoolchildren about tooth care.
lim ited resources, the Service uses p rogram p rio ri ties and m ethods designed to do the m ost good in the shortest tim e. It also has designed its own clin ics and equipm ent and em ployed increasing num bers o f dental assistants for m axim um efficiency. T raining, research, and developm ent also c o n tri b ute to the effectiveness o f the program . In ad d i tion, a com puterized data system was developed and is currently in use for the planning and evalu ation o f the program .
T h e p ro g ra m T o ensure that a long-range im provem ent in the dental health level of Indians and A laska N atives actually does occur, a system o f age and service prio rities is follow ed. In the age-priority system, preschool children receive prim ary attention; schoolchildren are next, beginning with the young est, and so on. W ithin the service priorities, em er gency c are for all patients, regardless o f age, takes precedence. O th er services are given in the follow ing order: preventive care, corrective care, and re habilitative care. E m phasis is placed on providing the m ost essen tial d ental c are for the age groups w ith highest priority. T hese services are concentrated on the young because the m ajor o ral diseases can best 398 ■ JADA, Vol. 81, August 1970
be prevented o r arrested at an early stage. Large num bers o f children are treated so that a new gen eration is now growing up w ithout the severe, chronic dental disability and loss o f teeth common am ong the adult population. A t present, the older age groups receive little m ore than emergency care, because providing routine services for them w ould require the full use o f all available program resources to m eet the im m ediate need o f a small proportion o f the population w ithout decreasing the future w orkload. An increm ental care program is carried out starting with the youngest children available. U n til greater num bers o f preschool children are brought to the clinics, dentists are concentrating th eir efforts on the first grade, then adding the second, third, and successive grades as the academ ic year progresses. C linical experience in the In d i an H ealth Service7 has confirm ed the findings of other studies,8-9 nam ely th at patients previously treated require little tim e to m aintain since only the conditions which have developed since the last exam ination need treatm ent. Services have been gradually extended to m ore and m ore grades so that, at present, all except the first grade stu dents in m any schools have been placed on a m ain tenance level. If tim e perm its after all students and preschool children have reached this level, routine care for adults is provided, starting with the young
est adult age groups. T he latter groups are usually recent high school graduates who have been placed on a m aintenance level while in school.6 T he prevention o f dental disease plays a m ajor role. I t is a w ritten policy th at every available child 19 years o f age o r less receives a topical ap plication o f fluoride annually. A p rogram for the issuance o f dietary fluorides in the form o f tablets o r drops has been inaugu rated to provide the benefits o f ingested sodium fluoride until fluoridated drinking w ater is avail able. M uch o f the success of this effort depends on the physician’s acceptance o f the procedure since he is m ost likely to see the child aged three or less. In addition to the topical application and diet supplem ents o f fluoride, the preventive program also em phasizes the fluoridation of com m unity w ater supplies w herever new w ater systems are in stalled o r old systems can be renovated. T h e health education program is an im portant facet o f the preventive program . T he Service em phasizes the im portance o f oral hygiene, effect of diet, and th e im portance o f regular dental care through classroom instruction and conferences w ith school teachers and various tribal and com m unity organizations. M ost of this work is p e r form ed by dental officers, dental assistants, health educators, and other Indian H ealth Service staff. P reventive periodontic and orthodontic services are also provided to children. In the corrective program , th e restoration of carious teeth c o n sumes a m ajor am ount o f the available time. T he prosthetic replacem ent o f teeth is a m inim al effort because the resources are so limited. G reater b en e fit can be gained from using the resources for p re vention and restorations, thereby helping to p re vent som e o f the need for dentures in the future.
R e so u rc e s T he Indian H ealth Service currently em ploys 138 dentists, including 15 who are in adm inistration o r full-tim e specialty training. T he clinicians have an average o f 1.5 highly trained dental assistants each. A b o u t 9 5 % o f these girls are Indians or A laska N atives. In addition to perform ing their regular duties as assistants, they frequently act as interpreters. T here are small isolated groups o f people for whom it is im practical to provide fixed clinics such as those m aintained in the hospitals, health cen ters, and health stations, and for whom private practitioners are unavailable. To reach these p a
tients, the Service uses 13 m obile dental units. T h e older dental trailers have only one operatory b u t the m ost recent ones have two. A t their best, however, these m obile clinics are not as efficient as perm anent facilities and are used only w hen other m eans o f providing services are n o t avail able. Itinerant activity with use o f portable equip m ent exists only in A laska. T here are few roads, so dental team s are required to travel by b o at o r airplane to the villages. Itin eran t service is lim ited to that p a rt of the school year between “ freeze-up” in the fall and “ break-up” in the spring. To carry out a successful dental program on these trips, it is essential to m aintain good relations with the schoolteachers, store proprietor, postm aster, and village council. These people generally have m uch influence over the affairs o f the village and are in terested in the w elfare o f the people. In addition to the direct services program , the Service contracts with about 200 private p rac ti tioners to provide dental services. A bout 15% o f the total dental program is carried out through this m echanism.
T ra in in g T he training efforts o f the Indian H ealth Program are designed to bring together the desires of the potential dental trainees with the specific needs o f the Service. Each year four dental officers are p ro vided long-term training leading to a specialty d e gree in public health, periodontics, orthodontics, pedodontics, or oral surgery. A n intram ural dental public health residency is also available. T he Indian H ealth Service operates dental as sistant training program s at the dental training centers at B righam C ity, U tah; Law rence, K ansas; and M t Edgecum be, A laska. A bout 25 Indian and A laska N ative dental assistants are trained each year. In addition to their im portance in providing dental services, em ploym ent o f these assistants adds to the economic base o f the Indian com m uni ties. Tw o o f the training centers are accredited by the Council on D ental E ducation o f the A m erican D ental A ssociation and the th ird is seeking accred itation. A lthough the graduates o f these schools have a high level o f com petence, the dentists m ust m ake enlightened use o f assistants so this com pe tence will not be wasted. A t the three training centers, a one-week course in efficient clinic m anagem ent is given to every dentist em ployed by the Indian H ealth Service. Abramowitz: DENTAL PROGRAM FOR AMERICAN INDIANS ■ 399
About 25 Indian and Alaska Native dental assis tants are trained each year in three accredited or about-to-be accredited centers. Their employ ment adds to the dental manpower and to the economic base of the community. Clinic facilities are designed by IHS to make efficient use of available manpower according to four-handed dentistry procedures. Little brother watches this procedure.
Dental assistant demonstrates art of toothbrushing to young patients as mother looks on. Children have firs t priority in the IHS program designed to eradicate chronic dental disability and loss of teeth com mon among adults.
400 ■ JADA, Vol. 81, August 1970
Each n ew dentist and his dental assistants receive this tra in in g as a team. In a recent evaluation of the p ro g ra m ,10 it was determ ined th at th e week of train in g increases the efficiency o f the dental team by 13% and the effect continues for at least 12 m onths. W ithin three m onths the increase in ser vices p ro v id ed offsets the cost o f the training. T he d en tal officers also p articipate in extram u ral sh o rt courses in oral pathology, oral surgery, research design, periodontics, preventive dentis try, an d prosthetics. T he Indian H ealth Service it self tra in s some dentists in dental public health, epidem iology, and program planning to im prove their com petencies in com m unity dentistry. T h e In d ia n H ealth Service also has dental in tern tra in in g program s a t three o f its m edical cen ters. T h ey are designed to increase the technical skills o f th e young dentist to m eet the needs o f the Service. Som e o f the dental officers are given support for th eir attendance at national and state dental association conventions. A num ber o f officers also atte n d the annual jo in t m eeting of the P u b lic H ealth Service C linical Society and C om m is sioned O fficers A ssociation.
R e s e a r c h a n d d e v e lo p m e n t A research and developm ent program has been initiated to help solve problem s related to the d e livery o f dental services. A study was conducted o f the q u ality o f dental restorations m ade by dental assistants w ith expanded functions.11 I t was found th at th ere w as no significant difference in quality betw een C lass II alloy restorations m ad e by the dentists a n d dental assistants in the study. A n ex tensive new study is currently under way to re a s sess the q u ality o f restorations done by dental as sistants. T h e study will also determ ine the d iffer ence in th e quantity and in the types of services provided w hen the functions o f dental auxiliaries are expanded. In addition, a cost-benefit analysis will be c a rrie d out to determ ine the m ost efficient ratio o f d en tal auxiliaries to dentists when the auxiliaries practice their new functions. T he d en tal program o f the Indian H ealth S er vice has developed a com puterized systems ap proach to th e determ ination o f required resources. F o r exam ple, by use of the population ch aracter istics and epidem iology o f a specific location, the system tells the m anager how m any dentists, d en tal assistants, and operatories are needed. By use o f this m eth o d ,7 a m aster resource p lan will be d e
veloped th at will specify, for the total Indian p o p ulation by location, the requirem ents in m an power and facilities to m eet the total potential ef fective dem and for dental services. A quality im provem ent program is currently in an early developm ent stage. I t will identify m ea surem ents o f quality and m ethods for collecting the data. R ealistic optim um levels o f quality and current levels o f quality will be determ ined. The m ethods for elevating the quality to the optim um levels will then be im plem ented. These steps will be followed for im proving the quality o f the com m unity program and care provided the patient. Standard clinic plans have been developed for various num bers o f general and specialty o p era tories. These standards are designed to m ake the m ost efficient possible use o f the available m an power according to the newest procedures in fourhanded dentistry. T he process of developm ent in cluded testing clinical designs and revising them accordingly. T here is an ongoing evaluation of dental equipm ent for its operating characteristics, efficiency, ease of m aintenance, and adaptability to the clinic designs. A n oral health classroom idea has been devel oped and is being tested.4 T his unique m ethod of m aking schoolchildren available for dental care uses a room in the health facility. A n entire class of schoolchildren, with th eir teacher, are brought to the dental clinic for a dental health field trip. D uring this trip they receive preventive and c o r rective care and while they are waiting for care, they receive dental health education.
C o m m u n ity p a r tic ip a tio n T he Indian H ealth Service is fully com m itted to encouraging and increasing Indian and A laska N a tive participation in planning, operating, and eval uating the program . M eaningful participation by the Indian people in the decision-m aking p ro cess enhances the effectiveness o f the program and expedites im provem ent o f the people’s health. It also increases the concern o f the Indian people for an effective health program to m eet their needs. This partnership prom otes self-help activities th at im prove health and related services. T he tribes are encouraged to structure their health councils or other organizational units in a form com patible w ith th eir com m unities. T he Ser vice is less concerned with the organizational structure than with the involvem ent and p artic ip a tion o f the people. Abramowitz: DENTAL PROGRAM FOR AMERICAN INDIANS ■ 401
Mobile clinics, less efficient than permanent facilities, are used only for small, isolated groups of people remote from hospitals or health centers. Twelve units, most of them containing two operatories, are now in service.
T h e com m unities p articipate in the d eterm in a tio n o f nontechnical priorities, clinic hours, and the location and construction o f health facilities. In addition, the tribes assist with the developm ent of the program plan, budget and program evalua tion, and coordination o f their health plan with o th er program s to m ake up a com prehensive plan for th eir com m unity. They assist the Service unit directo r in th e orientation o f new personnel, p ro vide guidance to the Service in th e resolution o f com plaints, and keep inform ed on the goals, o b jectives, accom plishm ents, and program plans o f the Indian H ealth Program . A n o th er form o f participation exists w here the people actually provide services th at help facili tate th eir health program . A n exam ple is the labor provided to help construct sanitation facilities. In som e com m unities, the tribes arrange for tran sp o r tatio n for patients, thereby helping to solve a m a jo r problem in the delivery o f services. If p articip atio n is to be m eaningful and success ful, it m ust be carried out by an inform ed com m unity. Some tribes are reluctant to p articipate b e cause they believe th a t their lack of know ledge or background for m aking decisions and giving a d vice on health m atters m ight actually retard their health program . W hen adequate procedures for orienting and training these people have been c ar ried out, their decisions are found to be sound and constructive. 402 ■ JADA, Vol. 81, August 1970
In discussion o f specific item s with the com m u nity representatives who are faced with m aking decisions, the Service provides facts o f a technical nature. F o r exam ple, the n atu re o f a health p ro b lem and the proposed program are explained and alternatives are presented. T he benefits, problem s, and risks involved in the proposed program and the alternatives are discussed, along w ith their rel ative chances for success in helping to reduce the health problem. Com m unity involvem ent may be the key to a successful health program . The recipients of the program should feel that it is their program rather than that of the health agency. It is carried out in accordance w ith the people’s wishes and require m ents as seen by them. T he Indian H ealth Service is the instrum ent for providing services th a t are planned, conducted, and evaluated in cooperation with the recipient groups.
P la n n in g A health program m ust be constantly appraised for success in m eeting objectives. T his appraisal, in the Indian H ealth Service, is carried out form al ly against a w ritten plan. T his plan is used in bu d get justification, as a guide to program im plem en tation, and as an orientation docum ent for new personnel. The planning process identifies the
problem s, determ ines the objectives, describes the m ethods th at will be used to m eet the objectives, and establishes a base for evaluation. E ach phase is quantified for a specific p eriod of time. T he long-range goal is expressed as the greatest im provem ent th at can be expected w ith the c u r ren t state o f the art and with an anticipated realis tic use pattern. It specifies the condition o f the ta r get group th at will exist when the Service has done its jo b at an optim um level. All planning is direct ed tow ard m eeting the goal. T he health problem s that m ust be overcom e to reach the goal are determ ined by the analysis o f data. T he m agnitude o f the health problem s is ex pressed in term s o f conditions of people. Program d ata and resource needs are not included because they reflect the agency’s effort and requirem ents. In the next phase, the objectives are established. They are quantified statem ents relative to the re duction o f each problem and are expressed as the degree of reduction o f the problem during a sp e cific p erio d o f time. O bjectives relate to the target population an d not to the Service’s efforts. T he causes o f the health problem s and the fac tors relating to them are then determ ined. A ction can only be taken against causes and factors. In the next phase, plans o f action by the Service are determ ined. T o develop a plan o f action, we study alternate program approaches, including cost benefit analy sis considerations. T he best com bination o f activi ties designed to m eet the objectives is selected. T hese actions are also quantified and designated for a specific period o f time. T h e required resources and budget are d eter m ined according to the needs expressed in the plan o f action. A s a result, the budgetary needs re flect the p o tential change in the health status. This process allows for the developm ent o f a p erfo r m ance budget. It tells the budget exam iners th at for a given num ber of dollars, a specific degree of im provem ent in the health status will occur.
D ata s y s te m A com puterized system o f d ata collection, p ro cessing, and analysis was recently instituted. Both epidem iologic and service d ata are provided for the Service, the adm inistrative area, the facility location, and also by dentist. T he system provides accurate and tim ely data fo r program planning at all levels of the organization. Program evaluation is carried o u t by the analysis of these data.
In developing this system, we first considered w hat the data needs w ere for com prehensive evalu ation of the program . T he d ata needs w ere m odi fied slightly by the determ ination o f w hat data w ere actually collectible in the Indian H ealth Ser vice by know n technology. T he m ethod o f data collection was w orked out and a p atient record form was instituted that related precisely to a m ark-sense form. T he inform ation was p u t on tape and processed by a com puter. T he printouts su p ply all the statistical needs of each level of the o r ganization. T he old system, which was carried out m an u al ly, took a great am ount o f tim e that should have been spent treating patients. D aily, m onthly, q u a r terly, and annual sum m aries w ere kept individu ally for each age group and repeated for each level o f the organization. It is estim ated th at with the cu rren t system, only 15 seconds o f staff tim e are used p e r patient visit to fill out the m ark-sense form . T he rest is done by the m achines. T here has been a 90% decrease in dental staff tim e spent in processing the reporting form s and a notable d e crease in the num ber o f errors. T here has also been a trem endous im provem ent in the ability to evalu ate a program because accurate, pertinent, and cu rren t statistics are a t hand in a usable form.
D e n ta l p ro g ra m e v a lu a tio n Program evaluation is both an ongoing and p e ri odic activity for changes in health status and for activities of the dental program . T he process in cludes determ ination o f w hether the resources w ere used efficiently and w hether they w ere actu ally used as specified in the plan. T he plan o f action is then studied to determ ine to w hat degree it was carried out and if it had the expected effect on the objectives. A determ ination is m ade o f how close the program cam e to m eet ing its objectives and if the objectives helped re duce the health problem s and thereby reach the goal o f the Indian H ealth Service. Im portant indi cators o f progress are epidem iologic d ata presen t ed on a trend basis. T he average total o f decayed, missing, and filled teeth per person (D M F rate) for children 6-17 years o f age rose for ten years to 1965 (Table 1). T here was a leveling off in 1966 and a sharp rise in 1967. It leveled off once again in 1968. These d ata resulted from the exam ination o f 47,520 ch il dren in 1957. T he num ber of children exam ined increased annually to 81,399 in 1968. T he inAbramowitz: DENTAL PROGRAM FOR AMERICAN INDIANS ■ 403
60
T a b le l ■ Average number DMF teeth amongchildren 6 to 17 years old, fiscal years 1957 through 1968.
Filledteeth Missingteeth 00
->
-----------------------1----------------------- 1----------------------- 1------------------------>— 1957 1958 1959 1960 1961
1962
1963
1964
1065
19«
1967
— -I ---------------------------- 1---------------------------------1--------------------------------- 1 ----------------------------------1_________________ 1_________________ L _ 1968
Table2 ■ Ratioof teeth restored to teeth extracted by Indian Health Service dentists, fiscal years 1957 through 1968.
1957
1958
1959
1960
1961
1962
1963
19«
iimimia MaleDebris Indices ■■MI■FemaleDebris Indices ■■■HMMaleCalculus Indices ■■ ■ ■FemaleCalculus Indices
DEBRIS &CALCULUS INDICES
2.0---------------------------------
Table 3 ■ Debris and calculus index per patient examined by age group and sex for fiscal year 1968.
Table 4 ■ Periodontal disease per person examined, by age group, for fiscal year 1968.
404 ■ JADA, Vol. 81, August 1970
AGE
PERCENT 10
All Ages Under 5 5-9 10-14 15- 19 20-24 25-34 35-44 45-54 55-64 65-74 75+
20
30
40
60
60
70
80
90
|0 0
22.8 12.5 51.6 5 4 .1 43.5 I 1.5
8.6 6.7 5.5 5.1 3.7 2.3
Table 5 ■ Percentage of dental services provided, of total services required by Indian population, for fiscal year 1968.
creasing trend in the D M F rate m ay possibly be due to the greater ability of the Indian people to travel to the source of sweets as a result of road im provem ents. A nother possible reason is the q u al ity of dental officers and exam inations. It appears probable that the rise in 1967 was due to the in troduction of the new d ata system with the accom panying requirem ents for a m ore precise oral ex am ination. D uring the same period the decayed teeth com ponent rem ained about th e sam e w hereas the filled teeth com ponent rose considerably. The missing teeth com ponent dropped only slightly but the tooth fatality rate (M /D M F) dropped sharply. T he beneficial aspects o f this inform ation are seen in the trend o f the ratio of extracted teeth to restored teeth. It w ent from 1:1.31 in 1957 to 1: 3.34 in 1968 (T able 2). T he oral hygiene index com ponents are used to m easure the status o f debris and calculus in the In dian population. E xam ination o f 124,677 patients showed that the debris score rises sharply in the 5 to 9 age group and drops steadily to the 15 to 19 age group. It then rises to the 55 to 64 age group, levels off, and drops sharply at the oldest ages (Table 3). T he calculus score shows an increase to the 55 to 64 age group and then drops. A periodontal evaluation of 129,093 people dem onstrated th at the num ber o f patients with no periodontal disease drops steadily to age 45 to 54 and then rises. Incipient periodontal disease rises som ew hat to age 20 to 24 and then continuously drops off. T he num ber of people with overt d is ease rises from age 10 to 14 to age 35 to 44 and then rem ains constant (Table 4). O f the total required services during 1968,
2 2 .8 % were provided to the Indian population o f 399,000. M ost o f this treatm ent was given to the 81,399 school-age children (Table 5). A b o u t 90% of all children exam ined were given topical ap p li cations o f fluoride. Eleven percent o f the p o pula tion consum ed fluoridated water. T he productivity of the dentist has increased steadily and sharply since 1962, because o f ex panded and im proved use of dental assistants, m ore efficient equipm ent and clinic layouts, spe cial training efforts, and an organized approach to providing preventive and restorative dental ser vices to children. This kind of program develop m ent is essential to a com prehensive children’s dental program for the general public in view of the anticipated shortage o f dentists.
Doctor Abramowitz is chief, dental services branch, Indian Health Service, Health Services and Mental Health Adminis tration, Public Health Service, HEW. 7915 Eastern Ave, S il ver Spring, Md 20910.
1. American Dental Association. Dental health program for children. Chicago, American Dental Association, 1966. 2. US Department of Health, Education, and Welfare, Pub lic Health Service. The dental health program for American Indians, EskimosandAleuts, 1967. PHS Publication no. 1585. 3. US Department of Health, Education, and Welfare, Pub lic Health Service. The Indian health program of the US Pub lic Health Service, 1966. PHS Publication no. 1026. 4. US Department of Health, Education, and Welfare, Pub lic Health Service, Division of Indian Health. Report on the conference w ith theCouncil on Federal Dental Services of the American Dental Association. Washington, DC, 1967. 5. US Department of Health, Education, and Welfare, Pub lic Health Service, Division of Indian Health. The Indian health program. 6. US Department of Health, Education, and Welfare, Pub lic Health Service. Dental services for American Indians and Alaska Natives; annual report fiscal year 1968, 1969. Wash ington, DC, PHS Publication no. 1870, 1969. 7. US Department of Health, Education, and Welfare, Pub lic Health Service, Indian Health Service. Dental resources criteria and program requirements for the Indian Health Ser vice. 1969. 8. US Department of Health, Education, and Welfare, Pub lic Health Service, Division of Dental Public Health and Re sources. Report on dental program of the ILWU-PMA: the first three years. Washington, DC, Government Printing Of fice, 1962. 9. Young, W.O., and Pelton, W.J. Planning a dental prepay ment program for children in an area of low caries prevalence. JADA 53:38 July 1956. 10. McClellan, T.E., and Cox, J.L. Description and evalua tion of dentist-dental assistant team training in efficient den tal practice management. JADA 76:548 March 1968. 11. Abramowitz, J. Expanded functions for dental assis tants: a preliminary study. JADA 72:386 Feb 1966.
Abramowitz: DENTAL PROGRAM FOR AMERICAN INDIANS ■ 405
Mobile u n it used by dentists who pioneered in the Indian Health Service. Home was a bedroll; dental clinic was the shade of a tree. Extraction was the most frequently rendered service. Itinerant ac tiv ity with use of portable equipment exists only in Alaska now where teams travel by boat or plane to remote villages between “ freeze-up” in the fall and "break-up” in the spring.
A c h i l d r e n ’s d e n t a l p r o g r a m f o r A m e r i c a n I n d i a n s
Joseph A bram ow itz, DDS, MPH, Bethesda, Md
A dental health program carried out for many years among American Indians, Eskimos, and Aleuts may offer guidelines for setting up a national program fo r children. Because dental resources may never be p le n tifu l in relation to the need, the Service has established program priorities and methods de signed to do the most good in the shortest time. An incremental care system including preventive den tistry is followed, beginning with the youngest children available. The Service designed its own c lin ic s and equipment, supports training, re search, and development, employs increasing num bers of dental assistants, and is com m itted to en couraging com m unity participation in program planning.
T he A m erican D ental A ssociation H ouse o f D ele gates, at its annual session in N ovem ber 1965 called for the developm ent o f a national dental program for children. A year later at the annual session in Dallas, the H ouse adopted a specific
program and gave as its objective: “ to m ake the benefits of an organized program o f dental health education, preventive dentistry and dental care available to all children, particularly the needy and underprivileged.” 1 T o initiate this program , the H ouse o f D elegates recom m ended a series o f pilot or exploratory program s to study “the co m plex problem s o f adm inistration at local, state and national levels, the available supply o f dental p e r sonnel and its distribution throughout the country, the provisions for adequate financing and the solu tion o f m any other problem s involved in providing dental services on an unprecedented basis.” T he Public H ealth Service Indian H ealth Ser vice developed and has carried out for m any years a children’s dental health program for A m erican Indians, Eskim os, and Aleuts. T his program has m et problem s sim ilar to those that may be expect ed in the general population. C onsequently, it m ight well serve as a large scale pilot project to be studied by those who will develop the national dental health program for children. 395
Two house trailers like this, outfitted with old dental equipment, were put into service in the thirties when the dentist-to-patient ratio in the IHS was about 12:260,000.
H isto ry of In d ia n H e a lth D e n ta l P ro g ra m A dental pro g ram 2 for Indians began in 1913 with the assignm ent o f five dentists to travel am ong the reservations. D ental needs were overw helm ing and the dentists could provide little m ore than ex tractions. In those early years roads were usually either prim itive o r nonexistent. T ravel was often by horseback w ith the shade o f a tree serving as a clinic and a bedroll as a home. T he great cultural differences that existed between non-Indians and the tribes, com bined with the prim itive facilities and w orking conditions, required Spartan q u ali ties th at w ere found in only a few dentists. A fter 1932, the program began its slow shift from extraction services to corrective services for children and tow ard prevention through educa tion. D uring 1934, when there were 12 dentists attem pting to serve about 260,000 Indians, the first two m obile clinics were put to use. T hese in efficient units consisted of sm all house trailers co n taining old dental equipm ent. In the late forties, several program s for topical application o f fluoride solution to the teeth were initiated. M ost o f the available equipm ent con sisted of hand-m e-dow ns from oth er governm ent agencies. In 1951, a center was initiated for training In dian wom en to becom e dental assistants. D uring 1955 the Indian H ealth Program was transferred from the D epartm ent o f the Interior, B ureau o f In dian A ffairs, to the D epartm ent o f H ealth, E du ca tion, and W elfare, Public H ealth Service. A t th at tim e the program had 46 dentists and 22 assistants o p eratin g in one-chair clinics in schools, hospital basem ents, converted garages, or anyw here that 396 ■ JADA, Vol. 81, August 1970
equipm ent could be placed. D uring this period, the increm ental care approach was begun. F o r about the next ten years extensive efforts were m ade to increase m anpow er, upgrade the facili ties, and im prove the quality and efficiency of the program .
T h e p e o p le Today 403,500 Indians, Eskim os, and A leuts m ake up the service population o f the Indian H ealth Service. T hese people live in circum stances th at differ from those of any other population group in the U nited States. They are geographical ly and culturally isolated on 250 reservations, m ost o f which are west o f the M ississippi, and in hundreds of villages in Alaska. W ith few exceptions, these people live in co n ditions o f abject poverty. T he average fam ily o f five or six lives in a one- or two-room house w ith out running w ater or waste disposal facilities. In m ost households, the income is less than $1,500 per year.3 Indian and A laska native hom es are often con structed of brush, m ud, canvas, or other local m a terials available at no cost. A bout 50 % of reserva tion Indians m ust haul their w ater, m any for dis tances of a m ile o r m ore. Dom estic w ater use is frequently only 1 to 3 gallons per person per day as com pared with 150 gallons for the average A m erican.4 In general, Indians and A laska natives have m aintained their traditional language, religion, values, and social organizations. They are not fa m iliar with m odern health theories and do not u n derstand the scientific bases o f illness and tre a t m ent.3
Dental task force in early days of IHS had to have courage and robust health as well as a dental degree.
M ost Indian people gain facility with English w ords. H ow ever, m any exhibit difficulties in grasping and accepting health know ledge reg u lar ly expressed in English. M any still attrib u te illness to som e type o f im balance between m an and both natural and supernatural forces. T his belief is u su ally rooted in the various religious system s o f the people.5 G enerally, where a religious in terp reta tion o f illness exists, treatm ent o r preventive a c tion by ritual m eans is prescribed. In other in stances, a herbalist m ay be called for needed ser vices. F requently patients first consult with re li gious healers or herbalists before seeking out the doctor. C ertain traditional social practices am ong some tribes cause health facility m anagem ent problem s. T he cultural requirem ent th at an Indian be accom panied by a friend or relative while w aiting in the o u tp atien t departm ent causes traffic and noise problem s and, possibly, risk o f infection. Sim ilar problem s are created by the cultural requirem ent th at a relative or group o f relatives be n ear the hospitalized patient. T his pattern, general th ro u g h out the plains and the Southwest, is som etim es re flected in refusal of the sick to enter or rem ain in a hospital unless provisions are m ade to have re la tives n ear at hand, visiting hours notw ithstanding.5
T h e p ro b le m The incidence o f dental disease does not vary a p preciably from th at o f the non-Indian people liv ing in the sam e geographical regions. H ow ever, Indians and A laska natives live predom inantly in isolated areas w here private dental care is not available. Few o f them w ould be able to afford p ri
vate practice services even if such services w ere available. The accum ulated neglect, oral hygiene status, changing dietary patterns involving in creased use o f refined sugars, isolation, and, in re cent years, an increasing aw areness and conse quent dem and for dental care, have all contributed to a massive burden on existing dental resources.2 T ransportation also is a m ajor problem , both for the Indians and A laska natives needing health ser vices and for the health personnel providing these services. M any patients m ust travel long distances over prim itive roads and difficult terrain to reach hospitals, clinics, and health centers. T he very ill or those needing em ergency treatm ent m ust be transported by am bulance o r airplane, som etim es hundreds o f m iles.3 T he goal o f the Indian dental health program is to elevate the oral health status o f Indians, E sk i mos, and A leuts to the highest possible level. Fifty-six percent of these people are 19 years o f age or younger; the birth rate is about twice th a t o f the general population. T hese two factors, in addition to an increasing recognition by the Indians o f the need for dental services, are m aking an im pact on the Indian H ealth Service dental program by p ro ducing a vastly increased burden on the existing resources.6 T he dental clinics in hospitals, health centers, and health stations are located near the largest accessible populations.2 D ental care is still not available to m any for geographic reasons. T he num ber o f facilities, dentists, and dental assistants is not sufficient for the jo b at hand. It would be unrealistic to believe that the Indian H ealth Service will ever have an adequate am ount o f dental resources to m eet the potential dem and for dental care. To m ake m ost efficient use o f its Abramowitz: DENTAL PROGRAM FOR AMERICAN INDIANS m 397
Classroom instruction in oral health is an essential part of the pro gram. Here a young dental officer tel Is schoolchildren about tooth care.
lim ited resources, the Service uses p rogram p rio ri ties and m ethods designed to do the m ost good in the shortest tim e. It also has designed its own clin ics and equipm ent and em ployed increasing num bers o f dental assistants for m axim um efficiency. T raining, research, and developm ent also c o n tri b ute to the effectiveness o f the program . In ad d i tion, a com puterized data system was developed and is currently in use for the planning and evalu ation o f the program .
T h e p ro g ra m T o ensure that a long-range im provem ent in the dental health level of Indians and A laska N atives actually does occur, a system o f age and service prio rities is follow ed. In the age-priority system, preschool children receive prim ary attention; schoolchildren are next, beginning with the young est, and so on. W ithin the service priorities, em er gency c are for all patients, regardless o f age, takes precedence. O th er services are given in the follow ing order: preventive care, corrective care, and re habilitative care. E m phasis is placed on providing the m ost essen tial d ental c are for the age groups w ith highest priority. T hese services are concentrated on the young because the m ajor o ral diseases can best 398 ■ JADA, Vol. 81, August 1970
be prevented o r arrested at an early stage. Large num bers o f children are treated so that a new gen eration is now growing up w ithout the severe, chronic dental disability and loss o f teeth common am ong the adult population. A t present, the older age groups receive little m ore than emergency care, because providing routine services for them w ould require the full use o f all available program resources to m eet the im m ediate need o f a small proportion o f the population w ithout decreasing the future w orkload. An increm ental care program is carried out starting with the youngest children available. U n til greater num bers o f preschool children are brought to the clinics, dentists are concentrating th eir efforts on the first grade, then adding the second, third, and successive grades as the academ ic year progresses. C linical experience in the In d i an H ealth Service7 has confirm ed the findings of other studies,8-9 nam ely th at patients previously treated require little tim e to m aintain since only the conditions which have developed since the last exam ination need treatm ent. Services have been gradually extended to m ore and m ore grades so that, at present, all except the first grade stu dents in m any schools have been placed on a m ain tenance level. If tim e perm its after all students and preschool children have reached this level, routine care for adults is provided, starting with the young
est adult age groups. T he latter groups are usually recent high school graduates who have been placed on a m aintenance level while in school.6 T he prevention o f dental disease plays a m ajor role. I t is a w ritten policy th at every available child 19 years o f age o r less receives a topical ap plication o f fluoride annually. A p rogram for the issuance o f dietary fluorides in the form o f tablets o r drops has been inaugu rated to provide the benefits o f ingested sodium fluoride until fluoridated drinking w ater is avail able. M uch o f the success of this effort depends on the physician’s acceptance o f the procedure since he is m ost likely to see the child aged three or less. In addition to the topical application and diet supplem ents o f fluoride, the preventive program also em phasizes the fluoridation of com m unity w ater supplies w herever new w ater systems are in stalled o r old systems can be renovated. T h e health education program is an im portant facet o f the preventive program . T he Service em phasizes the im portance o f oral hygiene, effect of diet, and th e im portance o f regular dental care through classroom instruction and conferences w ith school teachers and various tribal and com m unity organizations. M ost of this work is p e r form ed by dental officers, dental assistants, health educators, and other Indian H ealth Service staff. P reventive periodontic and orthodontic services are also provided to children. In the corrective program , th e restoration of carious teeth c o n sumes a m ajor am ount o f the available time. T he prosthetic replacem ent o f teeth is a m inim al effort because the resources are so limited. G reater b en e fit can be gained from using the resources for p re vention and restorations, thereby helping to p re vent som e o f the need for dentures in the future.
R e so u rc e s T he Indian H ealth Service currently em ploys 138 dentists, including 15 who are in adm inistration o r full-tim e specialty training. T he clinicians have an average o f 1.5 highly trained dental assistants each. A b o u t 9 5 % o f these girls are Indians or A laska N atives. In addition to perform ing their regular duties as assistants, they frequently act as interpreters. T here are small isolated groups o f people for whom it is im practical to provide fixed clinics such as those m aintained in the hospitals, health cen ters, and health stations, and for whom private practitioners are unavailable. To reach these p a
tients, the Service uses 13 m obile dental units. T h e older dental trailers have only one operatory b u t the m ost recent ones have two. A t their best, however, these m obile clinics are not as efficient as perm anent facilities and are used only w hen other m eans o f providing services are n o t avail able. Itinerant activity with use o f portable equip m ent exists only in A laska. T here are few roads, so dental team s are required to travel by b o at o r airplane to the villages. Itin eran t service is lim ited to that p a rt of the school year between “ freeze-up” in the fall and “ break-up” in the spring. To carry out a successful dental program on these trips, it is essential to m aintain good relations with the schoolteachers, store proprietor, postm aster, and village council. These people generally have m uch influence over the affairs o f the village and are in terested in the w elfare o f the people. In addition to the direct services program , the Service contracts with about 200 private p rac ti tioners to provide dental services. A bout 15% o f the total dental program is carried out through this m echanism.
T ra in in g T he training efforts o f the Indian H ealth Program are designed to bring together the desires of the potential dental trainees with the specific needs o f the Service. Each year four dental officers are p ro vided long-term training leading to a specialty d e gree in public health, periodontics, orthodontics, pedodontics, or oral surgery. A n intram ural dental public health residency is also available. T he Indian H ealth Service operates dental as sistant training program s at the dental training centers at B righam C ity, U tah; Law rence, K ansas; and M t Edgecum be, A laska. A bout 25 Indian and A laska N ative dental assistants are trained each year. In addition to their im portance in providing dental services, em ploym ent o f these assistants adds to the economic base o f the Indian com m uni ties. Tw o o f the training centers are accredited by the Council on D ental E ducation o f the A m erican D ental A ssociation and the th ird is seeking accred itation. A lthough the graduates o f these schools have a high level o f com petence, the dentists m ust m ake enlightened use o f assistants so this com pe tence will not be wasted. A t the three training centers, a one-week course in efficient clinic m anagem ent is given to every dentist em ployed by the Indian H ealth Service. Abramowitz: DENTAL PROGRAM FOR AMERICAN INDIANS ■ 399
About 25 Indian and Alaska Native dental assis tants are trained each year in three accredited or about-to-be accredited centers. Their employ ment adds to the dental manpower and to the economic base of the community. Clinic facilities are designed by IHS to make efficient use of available manpower according to four-handed dentistry procedures. Little brother watches this procedure.
Dental assistant demonstrates art of toothbrushing to young patients as mother looks on. Children have firs t priority in the IHS program designed to eradicate chronic dental disability and loss of teeth com mon among adults.
400 ■ JADA, Vol. 81, August 1970
Each n ew dentist and his dental assistants receive this tra in in g as a team. In a recent evaluation of the p ro g ra m ,10 it was determ ined th at th e week of train in g increases the efficiency o f the dental team by 13% and the effect continues for at least 12 m onths. W ithin three m onths the increase in ser vices p ro v id ed offsets the cost o f the training. T he d en tal officers also p articipate in extram u ral sh o rt courses in oral pathology, oral surgery, research design, periodontics, preventive dentis try, an d prosthetics. T he Indian H ealth Service it self tra in s some dentists in dental public health, epidem iology, and program planning to im prove their com petencies in com m unity dentistry. T h e In d ia n H ealth Service also has dental in tern tra in in g program s a t three o f its m edical cen ters. T h ey are designed to increase the technical skills o f th e young dentist to m eet the needs o f the Service. Som e o f the dental officers are given support for th eir attendance at national and state dental association conventions. A num ber o f officers also atte n d the annual jo in t m eeting of the P u b lic H ealth Service C linical Society and C om m is sioned O fficers A ssociation.
R e s e a r c h a n d d e v e lo p m e n t A research and developm ent program has been initiated to help solve problem s related to the d e livery o f dental services. A study was conducted o f the q u ality o f dental restorations m ade by dental assistants w ith expanded functions.11 I t was found th at th ere w as no significant difference in quality betw een C lass II alloy restorations m ad e by the dentists a n d dental assistants in the study. A n ex tensive new study is currently under way to re a s sess the q u ality o f restorations done by dental as sistants. T h e study will also determ ine the d iffer ence in th e quantity and in the types of services provided w hen the functions o f dental auxiliaries are expanded. In addition, a cost-benefit analysis will be c a rrie d out to determ ine the m ost efficient ratio o f d en tal auxiliaries to dentists when the auxiliaries practice their new functions. T he d en tal program o f the Indian H ealth S er vice has developed a com puterized systems ap proach to th e determ ination o f required resources. F o r exam ple, by use of the population ch aracter istics and epidem iology o f a specific location, the system tells the m anager how m any dentists, d en tal assistants, and operatories are needed. By use o f this m eth o d ,7 a m aster resource p lan will be d e
veloped th at will specify, for the total Indian p o p ulation by location, the requirem ents in m an power and facilities to m eet the total potential ef fective dem and for dental services. A quality im provem ent program is currently in an early developm ent stage. I t will identify m ea surem ents o f quality and m ethods for collecting the data. R ealistic optim um levels o f quality and current levels o f quality will be determ ined. The m ethods for elevating the quality to the optim um levels will then be im plem ented. These steps will be followed for im proving the quality o f the com m unity program and care provided the patient. Standard clinic plans have been developed for various num bers o f general and specialty o p era tories. These standards are designed to m ake the m ost efficient possible use o f the available m an power according to the newest procedures in fourhanded dentistry. T he process of developm ent in cluded testing clinical designs and revising them accordingly. T here is an ongoing evaluation of dental equipm ent for its operating characteristics, efficiency, ease of m aintenance, and adaptability to the clinic designs. A n oral health classroom idea has been devel oped and is being tested.4 T his unique m ethod of m aking schoolchildren available for dental care uses a room in the health facility. A n entire class of schoolchildren, with th eir teacher, are brought to the dental clinic for a dental health field trip. D uring this trip they receive preventive and c o r rective care and while they are waiting for care, they receive dental health education.
C o m m u n ity p a r tic ip a tio n T he Indian H ealth Service is fully com m itted to encouraging and increasing Indian and A laska N a tive participation in planning, operating, and eval uating the program . M eaningful participation by the Indian people in the decision-m aking p ro cess enhances the effectiveness o f the program and expedites im provem ent o f the people’s health. It also increases the concern o f the Indian people for an effective health program to m eet their needs. This partnership prom otes self-help activities th at im prove health and related services. T he tribes are encouraged to structure their health councils or other organizational units in a form com patible w ith th eir com m unities. T he Ser vice is less concerned with the organizational structure than with the involvem ent and p artic ip a tion o f the people. Abramowitz: DENTAL PROGRAM FOR AMERICAN INDIANS ■ 401
Mobile clinics, less efficient than permanent facilities, are used only for small, isolated groups of people remote from hospitals or health centers. Twelve units, most of them containing two operatories, are now in service.
T h e com m unities p articipate in the d eterm in a tio n o f nontechnical priorities, clinic hours, and the location and construction o f health facilities. In addition, the tribes assist with the developm ent of the program plan, budget and program evalua tion, and coordination o f their health plan with o th er program s to m ake up a com prehensive plan for th eir com m unity. They assist the Service unit directo r in th e orientation o f new personnel, p ro vide guidance to the Service in th e resolution o f com plaints, and keep inform ed on the goals, o b jectives, accom plishm ents, and program plans o f the Indian H ealth Program . A n o th er form o f participation exists w here the people actually provide services th at help facili tate th eir health program . A n exam ple is the labor provided to help construct sanitation facilities. In som e com m unities, the tribes arrange for tran sp o r tatio n for patients, thereby helping to solve a m a jo r problem in the delivery o f services. If p articip atio n is to be m eaningful and success ful, it m ust be carried out by an inform ed com m unity. Some tribes are reluctant to p articipate b e cause they believe th a t their lack of know ledge or background for m aking decisions and giving a d vice on health m atters m ight actually retard their health program . W hen adequate procedures for orienting and training these people have been c ar ried out, their decisions are found to be sound and constructive. 402 ■ JADA, Vol. 81, August 1970
In discussion o f specific item s with the com m u nity representatives who are faced with m aking decisions, the Service provides facts o f a technical nature. F o r exam ple, the n atu re o f a health p ro b lem and the proposed program are explained and alternatives are presented. T he benefits, problem s, and risks involved in the proposed program and the alternatives are discussed, along w ith their rel ative chances for success in helping to reduce the health problem. Com m unity involvem ent may be the key to a successful health program . The recipients of the program should feel that it is their program rather than that of the health agency. It is carried out in accordance w ith the people’s wishes and require m ents as seen by them. T he Indian H ealth Service is the instrum ent for providing services th a t are planned, conducted, and evaluated in cooperation with the recipient groups.
P la n n in g A health program m ust be constantly appraised for success in m eeting objectives. T his appraisal, in the Indian H ealth Service, is carried out form al ly against a w ritten plan. T his plan is used in bu d get justification, as a guide to program im plem en tation, and as an orientation docum ent for new personnel. The planning process identifies the
problem s, determ ines the objectives, describes the m ethods th at will be used to m eet the objectives, and establishes a base for evaluation. E ach phase is quantified for a specific p eriod of time. T he long-range goal is expressed as the greatest im provem ent th at can be expected w ith the c u r ren t state o f the art and with an anticipated realis tic use pattern. It specifies the condition o f the ta r get group th at will exist when the Service has done its jo b at an optim um level. All planning is direct ed tow ard m eeting the goal. T he health problem s that m ust be overcom e to reach the goal are determ ined by the analysis o f data. T he m agnitude o f the health problem s is ex pressed in term s o f conditions of people. Program d ata and resource needs are not included because they reflect the agency’s effort and requirem ents. In the next phase, the objectives are established. They are quantified statem ents relative to the re duction o f each problem and are expressed as the degree of reduction o f the problem during a sp e cific p erio d o f time. O bjectives relate to the target population an d not to the Service’s efforts. T he causes o f the health problem s and the fac tors relating to them are then determ ined. A ction can only be taken against causes and factors. In the next phase, plans o f action by the Service are determ ined. T o develop a plan o f action, we study alternate program approaches, including cost benefit analy sis considerations. T he best com bination o f activi ties designed to m eet the objectives is selected. T hese actions are also quantified and designated for a specific period o f time. T h e required resources and budget are d eter m ined according to the needs expressed in the plan o f action. A s a result, the budgetary needs re flect the p o tential change in the health status. This process allows for the developm ent o f a p erfo r m ance budget. It tells the budget exam iners th at for a given num ber of dollars, a specific degree of im provem ent in the health status will occur.
D ata s y s te m A com puterized system o f d ata collection, p ro cessing, and analysis was recently instituted. Both epidem iologic and service d ata are provided for the Service, the adm inistrative area, the facility location, and also by dentist. T he system provides accurate and tim ely data fo r program planning at all levels of the organization. Program evaluation is carried o u t by the analysis of these data.
In developing this system, we first considered w hat the data needs w ere for com prehensive evalu ation of the program . T he d ata needs w ere m odi fied slightly by the determ ination o f w hat data w ere actually collectible in the Indian H ealth Ser vice by know n technology. T he m ethod o f data collection was w orked out and a p atient record form was instituted that related precisely to a m ark-sense form. T he inform ation was p u t on tape and processed by a com puter. T he printouts su p ply all the statistical needs of each level of the o r ganization. T he old system, which was carried out m an u al ly, took a great am ount o f tim e that should have been spent treating patients. D aily, m onthly, q u a r terly, and annual sum m aries w ere kept individu ally for each age group and repeated for each level o f the organization. It is estim ated th at with the cu rren t system, only 15 seconds o f staff tim e are used p e r patient visit to fill out the m ark-sense form . T he rest is done by the m achines. T here has been a 90% decrease in dental staff tim e spent in processing the reporting form s and a notable d e crease in the num ber o f errors. T here has also been a trem endous im provem ent in the ability to evalu ate a program because accurate, pertinent, and cu rren t statistics are a t hand in a usable form.
D e n ta l p ro g ra m e v a lu a tio n Program evaluation is both an ongoing and p e ri odic activity for changes in health status and for activities of the dental program . T he process in cludes determ ination o f w hether the resources w ere used efficiently and w hether they w ere actu ally used as specified in the plan. T he plan o f action is then studied to determ ine to w hat degree it was carried out and if it had the expected effect on the objectives. A determ ination is m ade o f how close the program cam e to m eet ing its objectives and if the objectives helped re duce the health problem s and thereby reach the goal o f the Indian H ealth Service. Im portant indi cators o f progress are epidem iologic d ata presen t ed on a trend basis. T he average total o f decayed, missing, and filled teeth per person (D M F rate) for children 6-17 years o f age rose for ten years to 1965 (Table 1). T here was a leveling off in 1966 and a sharp rise in 1967. It leveled off once again in 1968. These d ata resulted from the exam ination o f 47,520 ch il dren in 1957. T he num ber of children exam ined increased annually to 81,399 in 1968. T he inAbramowitz: DENTAL PROGRAM FOR AMERICAN INDIANS ■ 403
60
T a b le l ■ Average number DMF teeth amongchildren 6 to 17 years old, fiscal years 1957 through 1968.
Filledteeth Missingteeth 00
->
-----------------------1----------------------- 1----------------------- 1------------------------>— 1957 1958 1959 1960 1961
1962
1963
1964
1065
19«
1967
— -I ---------------------------- 1---------------------------------1--------------------------------- 1 ----------------------------------1_________________ 1_________________ L _ 1968
Table2 ■ Ratioof teeth restored to teeth extracted by Indian Health Service dentists, fiscal years 1957 through 1968.
1957
1958
1959
1960
1961
1962
1963
19«
iimimia MaleDebris Indices ■■MI■FemaleDebris Indices ■■■HMMaleCalculus Indices ■■ ■ ■FemaleCalculus Indices
DEBRIS &CALCULUS INDICES
2.0---------------------------------
Table 3 ■ Debris and calculus index per patient examined by age group and sex for fiscal year 1968.
Table 4 ■ Periodontal disease per person examined, by age group, for fiscal year 1968.
404 ■ JADA, Vol. 81, August 1970
AGE
PERCENT 10
All Ages Under 5 5-9 10-14 15- 19 20-24 25-34 35-44 45-54 55-64 65-74 75+
20
30
40
60
60
70
80
90
|0 0
22.8 12.5 51.6 5 4 .1 43.5 I 1.5
8.6 6.7 5.5 5.1 3.7 2.3
Table 5 ■ Percentage of dental services provided, of total services required by Indian population, for fiscal year 1968.
creasing trend in the D M F rate m ay possibly be due to the greater ability of the Indian people to travel to the source of sweets as a result of road im provem ents. A nother possible reason is the q u al ity of dental officers and exam inations. It appears probable that the rise in 1967 was due to the in troduction of the new d ata system with the accom panying requirem ents for a m ore precise oral ex am ination. D uring the same period the decayed teeth com ponent rem ained about th e sam e w hereas the filled teeth com ponent rose considerably. The missing teeth com ponent dropped only slightly but the tooth fatality rate (M /D M F) dropped sharply. T he beneficial aspects o f this inform ation are seen in the trend o f the ratio of extracted teeth to restored teeth. It w ent from 1:1.31 in 1957 to 1: 3.34 in 1968 (T able 2). T he oral hygiene index com ponents are used to m easure the status o f debris and calculus in the In dian population. E xam ination o f 124,677 patients showed that the debris score rises sharply in the 5 to 9 age group and drops steadily to the 15 to 19 age group. It then rises to the 55 to 64 age group, levels off, and drops sharply at the oldest ages (Table 3). T he calculus score shows an increase to the 55 to 64 age group and then drops. A periodontal evaluation of 129,093 people dem onstrated th at the num ber o f patients with no periodontal disease drops steadily to age 45 to 54 and then rises. Incipient periodontal disease rises som ew hat to age 20 to 24 and then continuously drops off. T he num ber of people with overt d is ease rises from age 10 to 14 to age 35 to 44 and then rem ains constant (Table 4). O f the total required services during 1968,
2 2 .8 % were provided to the Indian population o f 399,000. M ost o f this treatm ent was given to the 81,399 school-age children (Table 5). A b o u t 90% of all children exam ined were given topical ap p li cations o f fluoride. Eleven percent o f the p o pula tion consum ed fluoridated water. T he productivity of the dentist has increased steadily and sharply since 1962, because o f ex panded and im proved use of dental assistants, m ore efficient equipm ent and clinic layouts, spe cial training efforts, and an organized approach to providing preventive and restorative dental ser vices to children. This kind of program develop m ent is essential to a com prehensive children’s dental program for the general public in view of the anticipated shortage o f dentists.
Doctor Abramowitz is chief, dental services branch, Indian Health Service, Health Services and Mental Health Adminis tration, Public Health Service, HEW. 7915 Eastern Ave, S il ver Spring, Md 20910.
1. American Dental Association. Dental health program for children. Chicago, American Dental Association, 1966. 2. US Department of Health, Education, and Welfare, Pub lic Health Service. The dental health program for American Indians, EskimosandAleuts, 1967. PHS Publication no. 1585. 3. US Department of Health, Education, and Welfare, Pub lic Health Service. The Indian health program of the US Pub lic Health Service, 1966. PHS Publication no. 1026. 4. US Department of Health, Education, and Welfare, Pub lic Health Service, Division of Indian Health. Report on the conference w ith theCouncil on Federal Dental Services of the American Dental Association. Washington, DC, 1967. 5. US Department of Health, Education, and Welfare, Pub lic Health Service, Division of Indian Health. The Indian health program. 6. US Department of Health, Education, and Welfare, Pub lic Health Service. Dental services for American Indians and Alaska Natives; annual report fiscal year 1968, 1969. Wash ington, DC, PHS Publication no. 1870, 1969. 7. US Department of Health, Education, and Welfare, Pub lic Health Service, Indian Health Service. Dental resources criteria and program requirements for the Indian Health Ser vice. 1969. 8. US Department of Health, Education, and Welfare, Pub lic Health Service, Division of Dental Public Health and Re sources. Report on dental program of the ILWU-PMA: the first three years. Washington, DC, Government Printing Of fice, 1962. 9. Young, W.O., and Pelton, W.J. Planning a dental prepay ment program for children in an area of low caries prevalence. JADA 53:38 July 1956. 10. McClellan, T.E., and Cox, J.L. Description and evalua tion of dentist-dental assistant team training in efficient den tal practice management. JADA 76:548 March 1968. 11. Abramowitz, J. Expanded functions for dental assis tants: a preliminary study. JADA 72:386 Feb 1966.
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