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An Effective Dental Division in the Public Health Department
S EVENTH N A T IO N A L D EN T A L H EA LT H C O N F E R E N C E . . . V O L U M E 54, F EB R U A RY 1957 • 173
Education projects are planned by the Philadelphia Mouth Hygiene Association and the United Cerebral Palsy Associa tion of Philadelphia. Anovel andeffectivemethodforstudy ing a problem was conceived by Dr. Wisan. A Mock Trial Investigation of PhiladelphiaDental Health Programs for Children was given by the Philadelphia Society of Dentistry for Children in col laborationwiththeCouncil. It was set up in courtroom fashion, with a presiding judge, attorney for the commonwealth, attorney for the advisory committee and a jury representing a home and school association, the Health and Welfare Council, a high school principal, the di rector of medical services of the Board of Public Education, a pediatrician, and deans of bothPhiladelphiadental schools, among others. Also, there were witnesses, representative authorities in hospital, school and public health dental agencies and even a clerk of the court. Excellent newspaper reviews were ob servedonthefollowingday—“Panel calls dental programs for city children inade quate” and“aninquiryintodental health programs was heldlast night and a‘jury’ found them grossly inadequate.” The linage securedwas about thebest todate. This presentation has enumerated many activities which normally should
require abudget of $5,000. However, be causeof thecoordinationandcooperation of the various agencies, this has been ac complished with $300 for the first year andwith anincrease to $720 for the sec ond year. Some few of the projects and the sums required are: the Health Fair —$200 (an amount which will have to be increased) ; summer-session scholar ship for the Workshop on CommunitySchool HealthEducationat TempleUni versity—$70; aspecial printingof Views, publication of the Philadelphia Depart ment of Health and dedicated to Phila delphia dentistry—close to $300, includ ing mailing to the county membership; publicity expenses incidental to hospital seminars—$75 (this, too, must require more money as the plandevelops) ; mail ing of minutes to Council members— $100; funds for sending Council repre sentatives to study hospital facilities and programs in other cities—to be de termined, and fund for a television edu cation project—to be determined. It is unfair to expect individuals to give of their time, energy andfinances to subsidize so worthy a program as that which dentistry has accepted as its re sponsibility. Adequate budgetary allow ances shouldbeprovidedbythe local and state dental societies for this most im portant phase of dental health activities.
A N E F F E C T IV E D E N T A L D IV IS IO N IN T H E P U B L IC H E A L T H D E P A R T M E N T
John W. Stone, D.D.S., M .P.H ., Austin, Texas
The first dental programestablishedby a health department on a state-wide basis was in North Carolina in 19I8.1 Un fortunately, other states were slowto fol lowthepatternthus created. Most of the early programs arose as the direct result of theinterest andactivityof dental prac titioners and dental societies who recog
nized the urgent need for broad, state wideprograms directedtowardthe eradi cation, or at least theamelioration, of the dental diseases andtheir sequelae. Form erly, p u b lic health d e n tis try section, M ic h ig a n D e p a rtm e n t o f H e a lth ; a t present, d ire c to r, d e n ta l d iv is io n , Texas D e p a rtm e n t o f H e a lth . I. G e rrie , N . F. Dental p u b lic hea lth. J .A .D .A . 40:750 June 1950.
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The flirtation and courtship of den tistry with public health has extended throughthegreaterpart of acenturyand aquarter, but the matrimonial unionhas had a comparatively short hectic history. The consummation of the union of den tistry and public health ona nation-wide scale was hastened during 1935 when through the Social Security Act the fed eral government made funds available to the states to operate dental programs.2It has been since 1935 that dentistry in public health has become a recognized profession—recognizedbyorganizedden tistry, by official public health, and by the public as well. Distrust and alarm, with the attendant cries of “this is socialized dentistry” and “this is not public health,” have greeted the marriage in various areas and at various times. At other times andinother areas, or perhaps even inthe same areas, the joining together of dentistry and publichealthhas beenhailed as asignifi cant step along the pathway of progress. The fluoridation of communal water sup pliesisanactivitywhichhascausedglow ingsuperlatives tobeheapedondentistry in public health. An example of these statements is that “fluoridation is the greatest advance inthepractice of public health that has occurred during the last onehundredyears.” A controversy has raged regarding the designation for dentistry and public health; whether it should be “dental public health,” “public health dentistry,” or “public dental health.” Persons ac tively engaged in the field of dentistry in public health considered the problemof a name during a recent workshop at the University of Michigan.3 It was de termined by those assembled that “den tal public health” was the most accurate descriptive termof all those reviewed. It isthepurposeof this presentationto consider the factors that are significant in the determination of the effectiveness of the division of dental public health in the department of health. The factors
to be considered are the basic organiza tional pattern for a health department’s dental division, its proper function and responsibilities, its development of a pro gram and budget, its relations with the dental society, with the public and pri vate agencies interested in health, and with the United States Public Health Service and other federal units. B A S IC O R G A N IZ A T IO N A L P A T T E R N
Inasmuch as the organization of dental divisions in departments of health will vary fromlevel to level of public health activity, andfromorganizationtoorgani zation on the same level, there is no single “correct” or even “common” basic organizational pattern that will fit every dental division. There are, however, cer tain fundamental principles of organiza tion which are applicable, to some de gree, ineachinstance. The basic organizational pattern for statehealthdepartments will be reviewed in order that a more detailed considera tion may be given to the importance of the organizational pattern of the dental division. The comparatively small num ber of local health departments having dental programs and the great variation in their organization, operation, and function make it impossible to give more than a passing glance to these programs at this time. It must be emphasized, how ever, thatit isat thelevel of thelocal pro gram, the level of application, that den tal public health programs reach the public. It is at the level of application that results may be expected and ob tained. There are two general types of basic organizational patternsutilizedbydepart ments of health—the horizontal and the vertical. 2. Pelton, W . J. Federal aid in public health den tistry. J.A.D.A. 30:570 A p ril 1943. 3. University of Michigan, School of Public Health. Fourth workshop on dental public health, University of Michigan, Ann A rbor, A p ril 2-6, 1956. Unpublished.
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The horizontal pattern is, as the name implies, one in which there may be any number of units operating under the di rect supervisionandcontrol of the execu tive officer of the state health depart ment.4 It is apparent that the horizontal structurecouldbecome unwieldyinthose instances in which there are an excessive number of units reporting to the health officer. The definition of what constitutes an excessive number would have to be determined by the executive ability of eachhealth officer, and not by any state ment of generalities. The vertical organizational pattern may be characterized as having a hier archy and being scalar or pyramidal in structure; that is, where the lines of authority and responsibility run upward and downward through several levels with a broad functional base at the bot tom and a single executive head at the apex.5 On November 11, 1953, the governing council of the American Public Health Association adopted as an official state ment a report prepared by the Subcom mittee on State and Local Health Ad ministration entitled “The State Health Department—Services and Responsibili ties.” The report contained many laud able recommendations concerning the organization and the reorganization of state health departments. Primarily, the recommendations were directed toward the reduction of the wasteful operations which may appear in the day-to-day function of an organization the size of a state health department, or to increase the efficient and economical operations of thestatehealthdepartment. The scalar orpyramidal organizational structurewas the basic organizational pattern recom mended bythe subcommittee to the state healthdepartments. It was recommended that there be established a limited num ber of major units which would report directly to the executive officer of the health department. All of the sub-units having similar areas of activity andfunc
tion would be grouped together into a major unit. The proposal for major units tends to break down, however, in that there is no delineation of what constitutes similar areas of activity and function; nor is there any description of what constitutes alimited number of major units. The Council on Dental Health of the American Dental Association, during its conference in 1951,6 studied the dental administration in state health depart ments. It was noted at that time that the reorganization of several state health departments had resulted in the down grading of the dental division to the third or even the fourth administra tive level belowthe health officer. These changes had developed as the result of recommendations of representatives of the American Public Health Associa tion, administrative advisers of the U. S. Public Health Service, and consultants from schools of public health. Almost without exception these changes were made, or are being made, without con sulting the dental profession in the states involved. In 1950, the House of Delegates of the American Dental Association recom mended that dentistry be included as a basic health service of the health depart ment, andthat the dental unit be staffed with qualifiedpersonnel. In an editorial7 in the July 1951 issue of t h e
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it was stated that those who would re duce dentistry to a secondary position apparently labor under the false assump tion that dentistry can function best as a subsection of one of the medical di4. A m e ric a n Dental A s s o c ia tio n , C o u n c il on Dental H e a lth . Dental a d m in is tra tio n in sta te h e a lth ' d e p a rt m ents. J .A .D .A . 43:61 J u ly 1951. 5. H a nlon, J. J . Principles o f p u b lic hea lth a d m in is tra tio n , ed. 2. St. Louis, C . V. M osby C o ., 1955. 6. A m e ric a n Dental A s s o c ia tio n , C o u n c il on Dental H e a lth . Dental a d m in is tra tio n in state health d e p a rt m ents: re p o rt o f 1951 c onference. J .A .D .A . 43:489 O c t. 1951. 7. D e ntistry's p o s itio n in m o d e rn p u b lic hea lth d e p a rtm e n t. E d ito ria l. J .A .D .A . 43:86 J u ly 1951.
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visions. It has been pointed out many times that dentistry is not asubsection of medicine, or a subsection of any other profession for that matter. History shows that decadencc has always set in whenever or wherever dental education or dental practice has been brought under the supervision and control of authoritative non-dental administration. T he reason is not far to seek. It lies in the associated lack of the special dental qualifications and concern which would enable such administration to judge the values and practical significance of the special therapeutic procedure involved in the com prehensive dental art. Physicians, with few exceptions, have always demonstrated notable lack of genuine interest in dental health care.8
Dentistry is an entity withinitself, and as a profession it is concerned with one of the largest single health problems that confronts, humanity. The dental public health unit functions most effectively as anindependent unit of thehealthdepart ment workinginfull cooperationwithall the other units of the department, and administeredby a qualified dental officer who is directly responsible to the health officer. PER SO N N EL
To paraphrase the recommendations of the House of Delegates of the American Dental Associationin 1950, “In order for the dental unit to be able to function as a basic health service of the health de partment, it must be staffed by qualified personnel.” Realistically, the number and the pro fessional background of the members of the staff should be determined by the breadth and scope of the oral health problems in the state. Unfortunately, however, in this day of enlightenment and progress there remain several dental units of state health departments that have a staff consisting of a director or supervisor, as thesituationmaybe, and a secretary. Dental public healthhas expandedbe yond the boundaries that were known in 1935, andtodaythe talents of manytypes
of professional persons are needed to man aneffective dental division. Dentists anddental hygienists especiallytrainedin public health, sometimes dentists and dental hygienists having an interest in the clinical aspect of public health prac tice, health educators, public health ad ministrators, psychologists and others are to be found working in various dental units inthenation. In general, thefactors which designate a dentist as being a qualified director apply equally well to the other persons on the staff of thedental unit. “Much of the success of the director of a program of dental publichealthwill dependonhis capacity to establish favorable public re lations and to organize cooperative efforts.”9 Public and professional relations and cooperative effort are the key to success in almost every endeavor in which man engages. The cooperative efforts of the members of the staff of the dental unit run the gamut from intraunit projects, through joint action on the part of two or more divisions of the department of health to community-wide or state-wide programs involvingthe representatives of many professional and nonprofessional organizations. At one time the public health dentist primarily was concerned with the dental problems of children. The old axiom“an ounce of prevention is worth a pound of cure” was thesole theme of almost every dental program. With the advent of fluoridation of communal water supplies, and with the constant increase in the number of communities instituting this procedure, thedental administratorshave the opportunity to initiate programs in aspects other than those related directly todental caries. It is essential that the director and the 8. Carr, M. W . Dentistry—an agency ofhealth service. New York, Commonwealth Fund, 1946. 9. American Public Health Association. Proposed re port on educational qualifications of public health dentists. Am. J . Pub. Health 42:188 Feb. 1952.
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members of thestaff of the dental unit be able to function as dental consultants to nondental public health organizations, both official and nonofficial, and to pro vide specialized assistance to dental organizations andtoprivatepractitioners. In addition to intelligent and effective participation in general public health work and administration, the public healthdentist must assumethespecialized tasksincident toadental healthprogram. He should keep informed regarding the latest developments in dental research in order that he may serve as a consultant for oral diagnosis. The publichealthden tist must be capable of preparing and initiating plans for the dental phases of new health programs, including the de termination of the facilities necessary for their operation. Other responsibilities of the public health dentist maybe the pro vision of professional advice in develop ingandsupplyingauthentic andeffective dental health educational material, as well asinstructioninsounddental health practice to groups of public health workers, teachers, and others. He may be called on to institute dental research projects which have public health impli cations and to coordinate the public efforts of avarietyof agencies, official and nonofficial, that deal with dental health. He also must be capable of developing specialized indexes and records for measuring and appraising the efficacy of dental health activities.9 The personnel of an effective dental division will have a broad insight into social trends as they affect, or will affect, the practice of dentistry, and should in terpret these trends to the practicing profession. They must learn howto pre pare policies and budgets for an increas ingvarietyof programs. After someexpe rience with the operation of these programs, they will need to evaluate them. All of these activities, and others, growout of the special problems of ad ministrationof theprogressivedental unit inthedepartment of public health.
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The shift from the point of view in whichthe individual patient is the center of professional consideration to the com munity as the center of interest is not accomplished overnight. The technics andattitudes evolvedduringthedevelop ment of apublic healthdentist are based on the same factors that have been learned by other professions and by per sonnel of other fields of endeavor when they have dealt with the community rather than with individuals. Standards for professional proficiency and educational background for the per sonnel on the staff provide an assurance that the health department will have an effective dental division, but the prob lems of recruiting personnel aremanifold and varied. It must be recognized that the stature of the profession is going to be judged by the stature of the people who meet the public. To the recruiting officer, the members of the dental profession appear to con stitute one of the most militantly indi vidualistic groups to be found anywhere. There are only a few dentists who are attracted by the fixed annual income found in public health and who are at tracted by working for someone else. There are several other factors which complicate recruitment, but they hinge on one or the other of these two factors, or theyaresoindividual that they donot fit any particular pattern. The Bureauof EconomicResearchand Statistics of the American Dental Asso ciationhas publishedperiodically acom pilation of information concerning the practice of dentistry in the United States.10The informationispresentedac cording to the individual states and ac cording to the geographic regions. A comparisonof theaverageannual income for the dentists in a particular region withthe annual income for the dentist in 10. A m e ric a n Dental A s s o c ia tio n , Bureau o f Econom ic Research and S ta tistics. Facts a b o u t states fo r the d e n tis t seeking a lo c a tio n . C h ic a g o , A m e ric a n Dental A s so c ia tio n , 1955.
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public health in the same region reveals that the income for one is almost identi cal with the income for the other.11 Dentists, as others, are reluctant to in vest the necessary additional time in graduate school when the financial re turn will be no more than average, and when the initiation of the income is de layed by the period expended on the graduate work, usually a year or longer. Public health administrators and budget directors are beginning to recognize that in order to secure dental public health specialists they are going to have to pro vide a commensurate specialist salary. The recognitionof this situationhasbeen slow in coming, but it is coming never theless. An increase inthesalaries for the positions in dental public health, or the rewriting of the specifications to secure the benefits of additional tangible salary, or both, will remove one of the major obstacles to recruiting excellent person nel. To secure such recognition is a re sponsibility of organized dentistry. The working-for-someone-else aspect of the practice of dental public health does make certain demands. It demands a willingness of personnel to accept di rection and criticism, but it does not entail prostitution of professional rights and privileges. The shift of emphasis from the individual as a patient to the community as a patient, the basic differ ence between private practice and the practice of dental public health, discloses a problemof tremendous magnitude. Its magnitude is such that it is humanly, as well ashumanely, impossiblefor one per son to meet every aspect of the problem singlehanded. It becomes apparent that the teamapproach is the logical method for attacking the dental health problem of the community. The teamapproach may be defined as work done by a number of associates who subordinate personal prominence to the efficiency of the whole. Hence the necessityforbeingwillingtoaccept direc tion determines the success or failure of
programs of dental publichealth. The fixed annual income which has been established at an adequate level throughthe efforts of organized dentistry has the advantage of allowing the re cipient to plana budget for expenditures for theyear. The annual income and ex penditures of a private practitioner may fluctuate from year to year to such an extent that abudget isnot nearlyasprac ticable, even in many instances is some what meaningless andabsurd. Whentheteamapproachandthefixed annual income arereviewedthoughtfully, and when these factors are coupled with the benefits of paid vacations, sick leave, and all of the other factors so common to civil service and merit systems, the problems of recruitment of personnel for the positions in dental public health be ginto pale andfade away. F U N C T IO N A N D R E S P O N S IB IL IT Y OF
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E. G. McGavran,12 dean of the School of Public Health of the University of North Carolina, suggests that a working definition of public health include those activities of a team of persons of the health service professions working to gether asequalstodiagnoseandtreat the healthneeds of thebodypolitic. This definition says in essence that the jobof publichealthis to diagnose acom munity’s health needs and then to treat them. To progress a step further, the function and responsibility of the dental publichealthunit istodiagnoseandtreat the dental health needs of the com munity. The dynamic nature of public health, coupled with the fact that it is account able to the taxpayers, requires that there be a plan or programfor every segment 11. Dental hea lth personnel salary ranges. Bui. A m . A . Pub. H e a lth Den. 15:24 A u g . 1955. 12. M c G a v ra n , E. G . W h a t is p u b lic h e a lth . Fourth w o rksho p on d e n ta l p u b lic health, U n ive rsity o f M ic h i gan , A p r il 2-6, 1956.
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of activity. The successivephases of plan ning a program can be enumerated as follows: 1. Determination of specific problems or needs. 2. Delineation of long-term, inter mediate andshort-termobjectives. 3. Assessment of resourcesavailableor obtainable for the conduct of the pro gram. 4. Selection of the methods or ac tivities to be used to gain the objectives. 5. Continuous or periodic evaluation of achievement or progress toward the goals. 6. Redirection of the program when indicated by shifts in circumstances. 7. Evaluationof final results.13 The tripartite division of the objec tives (long-range, intermediate, and short-range) of the programis a logical progression from the general to the specific. The long-range objectives are those conditions to be attained in the ideal society and stated simply as the complete eradication of an undesirable entity from the experience of the com munity. It issuperfluous topoint out that there can be no expectation of attaining the long-range objectives of a program promptly, despite the expenditure of every effort in that direction. The inter mediate objectives are those included within the long-range which are attain ablewithinaknownorpredictableperiod of time, usuallyabout 10or 20 years. The short-range objectives are the specific ac tivities to be completed in a specified period of time, usually the one or two year period of the organization. Methods for the attainment of the short-range ob jectives may be included in the program as aids to evaluation. The functional areas of activity of the dental division may be divided into sev eral overlapping segments. If the dental divisionis to be effective in the diagnosis andtreatment of theoral healthneeds of the community, there first must be a recognition of the existence of a problem
or need and then a determination of the extent of the problem. Upon thecomple tion of the collection and summarization of the essential information will depend thedeterminationof thepossiblemethods bywhichtheoral healthproblemmaybe reduced or removed. The tools available to the public health dentist are dental health education, prevention, remedia tion, evaluationandresearch. These tools may be usedsingly or in combination, as indicated, to attain the desiredobjectives of the dental division. The factors in the determinationof an effective dental division whichhave been considered thus far are important, but their importance is overshadowed by the relationship which exists, or should exist, between the dental division and the den tal profession. Only whenthedental pro fession provides the dental division with strongandconstant support will theden tal division be capable of functioning in aneffective manner. The effective dental division is a resource for the dental pro fession and for the community to utilize in the programs for the improvement of the oral healthof the population andthe enhancement of the prestige of the pro fession. Modern dental public health arose as the direct result of the activities of dental practitioners and dental societies. After many disappointing experiences, the pro fession recognized the need for facilities and personnel to assemble the informa tion essential for the proper planning, initiation, and operation of dental activi ties in the community. By utilizing the methods of statistical appraisal, the personnel of the dental divisionare able to estimate not only the magnitude and the distribution of oral disease, but gaina notionof the methods availabletoreduceoreliminatethesecon-
13. U n ive rsity o f M ic h ig a n , School o f P u b lic H e a lth . Proceedings o f th e firs t n a tio n a l confe re n c e on^evalu atio n in p u b lic hea lth . A n n A rb o r, M ic h ., U n iv e rs ity Pub lic a tio n Services, 1955.
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ditions. This statement is not to be in terpreted to mean that the personnel in dental public health are in possession of some occult power which enables them to decipher the cabalistic signs and sym bols so common to statistical procedures —it is intended merely to point out the importance of this, the newest, specialty within the dental profession. The dental division of the department of public health provides an excellent medium for disseminating to the com munity factual information concerning good oral health. The combination of the dental society andthedental divisionrepresentsamajor segment of the health service professions in the community. The department of healthis anofficial governmental agency andthushas aresponsibilitytothepublic. The dental society is a group of profes sional people who are interested in all phases of health problems in the com munity, but they are particularly inter ested in the specialized areas of the oral problems of thepeopleof thecommunity. The dental society, likethedental division of the department of public health, ulti mately is responsible to the people. The dental divisionserves as aresource for dental health educational material. The private practitioner may seek and secure assistance fromthe dental division in providing individual patients with up-to-date information concerning oral health. The dental divisionis a clearing house for information and for learning methods for effective presentation of the information. Dental health education programs for the community often are beyond the purviewof the private prac titioner. When confronted with the problem of educating the community regarding the advantages of early and regular dental care, for instance, many dentists would be at a loss as to where to begin. It is the responsibility of the public health dentist to be acquainted with the resources of mass media within the community and to be capable of se
lecting those for the practitioner which will be most effective. The dental division provides services not available elsewhere, or those services which are prohibitively expensive when operated on an individual basis, but are well within the realm of reasonableness when operated on a community-wide basis for the dental profession by the dental division. An excellent example is the laboratory services for counts of acidogenic organisms in the saliva pro vided by the dental division in several states. There are other areas in which thedental divisioncanprovide assistance totheprofession, but it seemsappropriate to consider what assistance the dental societycanprovideto the dental division. One of the primary factors to be con sidered in the planning of any program for the improvement of thedental health of thecommunityis the determinationof the number and the distribution of the dental personnel who will be available tobring the programto a successful con clusion. The dental society can provide the dental division with this up-to-date information. Such information is not available fromany other reliable source. Other assistance which organized den tistryshouldprovide to the dental unit is in the attainment of proper administra tive and budget recognition for the unit andtoassist intheconduct andoperation of surveys to determine the state of oral health in the local communities. BUDGET
Every act perform ed for the prom otion of public health involves an expenditure o f money, w hether it be for supplies, for transpor tation, or for salaries o f personnel. In fact, the very nature and extensiveness of the public health program are determined in the final analysis by the amount of funds available for its con du ct.5
There are three primary sources of funds for the operation of programs of dental public health. They are tax-sup portedstateand local,agencies having an
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interest in health, and federal agencies having similar interests. State and local appropriations for pro grams of dental public healthmaybecat egorical; that is, limited to one activity, or maybe apart of general healthfunds. The positionof the dental unit inthe ad ministrative hierarchy oftentimes deter mines the ease or difficulty with which funds are obtained. The federal funds which have been used for dental programs have been, for the most part, derived from the general health grants given by the Public Health Service to the states and territories. The Children’s Bureau provides funds to the states throughgrants toprograms for ma ternal and child health andprograms for services for crippled children.2 The pattern established at the time of the enactment of the Social Security Act in 1935 wherebyfederal funds weremade available to states for the operation of programs in dental public health is still followedinmanystates. Publichealthad ministrators and budget directors have not felt compelled to modify the budget ary position of the dental division from one supported almost entirely by federal funds to one supported largely by state appropriations. Is it not logical to askthe reasonfor the continuation of this status quo? Could the answer lie in the nearly universal distributionof oral diseases and their lack of drama and popular appeal when compared with some of the other areas of activity of public health? Could it be that the dental profession has been lax in making clear to the public and to public health administrators the true im portanceof the oral diseases as related to health, andthe methods available for the amelioration of these conditions or their complete eradication? Those units pri marily supported by federal funds are in a precarious position indeed, for a major reduction in federal funds by the next Congress could cause the discontinuation of the oral health programs with little or no warning.
It wouldbeprudent for all persons and organizations interested in the continued progress of the programof dental public healthtoexpresstheirwishesinamanner whichwill bringabout thedesiredchange in budgetary position and support. Or ganizeddentistryat all levels—local, state, and national—has bemoaned the failure of the dental divisions to attain the de sired budgetary position in the hierarchy of the health department, but in many instances that hasbeentheextent of their efforts to correct the situation. All seg ments of the dental profession should work together to demonstrate the impor tance of acomprehensiveoral healthpro gramorientedrealisticallyto theneeds of the population to be served. A dental division can be effective only when financial support for the program is fromthe taxpayers whomit serves. The relation which exists between the dental divisionof thestate department of health, the United States Public Health Service, and the Children’sBureauis one of mutual cooperation and assistance. Just as there are some procedures which are uneconomical or unfeasible for the privatepractitionertoprovideforhimself, there are certain procedures which are beyondthe scopeof activityof the dental divisioninthe statedepartment of health but arewithintheareaof activityof these dental units of the federal services. The Public Health Servicehas dental consult ants who are stationed in each of its re gions, or in an adjacent region, who are available for consultation to the states on the receipt of a request for such services. The dental division of the state depart ment of health provides information and cooperation to the regional consultant in all phases of the activity of dental public health. These facilities should be utilized by the practicing profession. SU M M A R Y
In summary, then, the activities which now constitute dental public health are
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not new-—they have evolved during the past century and a quarter. The dental divisionis a functional unit withinthe administrative structure of the department of health. Organizeddentistry has recommended that the dental pro grambe one of the basic health services of the state department of health. The dental divisionhas athree-fold re sponsibility to discharge: a responsibility to the dental profession, a responsibility tothepublichealthagency, andarespon sibility to the population served. The areas of activity include those which af ford an indication of the extent of the problems, a notion of the most useful methodfor the reductionof the problem, andameans for the determinationof the effectiveness of theprogram. Thescopeandtheextentoftheprogram of thedental divisionwill bedirectlypro
portional to the amount of funds which aremade available for its operation. It is obvious that themost important factor in the determination of the effectiveness of the dental division of the department of public health is the relationship which exists betweenthedental divisionandthe dental profession. Modern dental public health arose as the direct result of the activities of the members of the dental profession. The dental division of the statedepartment of healthis the result of thejoiningtogetherof organizeddentistry and official public health. It must not be forgotten that the cooperative support and assistance provided by these, the parent organizations, will determine the effectiveness of the dental division in its efforts to improve the healthof the com munity by the improvement of the com munity’s dental health.
G R A N T S -IN -A ID IN F E D E R A L -S T A T E D E N T A L P U B L IC H E A L T H P R O G R A M R E L A T IO N S H IP S
Norman F. Gerrie, D.D.S.,
Forthepast 38 yearsfederal grants-in-aid have been utilized for public health pur poses by state and local units of govern ment.1The historical development of the grant-in-aid principle as ameans of pro vidingfinancial assistancetogovernments with limited financial resources has been considered in detail by many students of public health administration.1'5 A current list of identifiable health grants would include those for maternal and child health and crippled children’s services derived fromTitle V of the So cial SecurityAct; thegrants administered by the Public Health Service for the fol lowingpurposes: general health services; venereal diseasecontrol; tuberculosiscon trol; cancer control; mental health; hos pital survey and construction; heart dis ease control; poliomyelitis vaccine dis
Washington, D. C.
tribution, and the basic support grants of the Office of Vocational Rehabilita tion. It is generally acknowledged that the grants-in-aid have been highly effective instimulatingthe state and local governA ssistant c h ie f Service.
d e n ta l
o ffic e r,
U.
S.
P u blic
H e alth
1. M ou n tin , Joseph W ., and G re v e , C liffo r d H . Role o f g ra n ts -in -a id in fin a n c in g p u b lic hea lth pro g ra m s. P u blic H e a lth B ulletin 303. W a s h in g to n , D. C ., G o v e rn m e n t P rin tin g O ffic e , 1949. 2. W h ite House C o nfe ren ce on C h ild H e a lth and P ro te c tio n . Public^ hea lth o rg a n iz a tio n ; section II. P u b lic health service and a d m in is tra tio n . New York, C e n tu ry C o ., 1932. 3. M o u n tin , Joseph W . F ina ncing local ices— fe d e ra l p a r tic ip a tio n . Pub. H e a lth O c t. 1952.
hea lth serv Rep. 67:944
4. H a nlon, J . J . P rincip les o f p u b lic health a d m in is tra tio n , e d . 2. St. Louis, C . V. M osby C o ., 1955. 5. M ou n tin , Joseph W .; H a nkla, Em ily, and Druzina, G e o rg e B. Ten years o f fe d e ra l g ra n ts -in -a id fo r p u b lic hea lth, 1936-1946. P ublic H e a lth B u lle tin 300. W a s h in g to n , D. C ., G o v e rn m e n t P rin tin g O ffic e , 1951.
Education projects are planned by the Philadelphia Mouth Hygiene Association and the United Cerebral Palsy Associa tion of Philadelphia. Anovel andeffectivemethodforstudy ing a problem was conceived by Dr. Wisan. A Mock Trial Investigation of PhiladelphiaDental Health Programs for Children was given by the Philadelphia Society of Dentistry for Children in col laborationwiththeCouncil. It was set up in courtroom fashion, with a presiding judge, attorney for the commonwealth, attorney for the advisory committee and a jury representing a home and school association, the Health and Welfare Council, a high school principal, the di rector of medical services of the Board of Public Education, a pediatrician, and deans of bothPhiladelphiadental schools, among others. Also, there were witnesses, representative authorities in hospital, school and public health dental agencies and even a clerk of the court. Excellent newspaper reviews were ob servedonthefollowingday—“Panel calls dental programs for city children inade quate” and“aninquiryintodental health programs was heldlast night and a‘jury’ found them grossly inadequate.” The linage securedwas about thebest todate. This presentation has enumerated many activities which normally should
require abudget of $5,000. However, be causeof thecoordinationandcooperation of the various agencies, this has been ac complished with $300 for the first year andwith anincrease to $720 for the sec ond year. Some few of the projects and the sums required are: the Health Fair —$200 (an amount which will have to be increased) ; summer-session scholar ship for the Workshop on CommunitySchool HealthEducationat TempleUni versity—$70; aspecial printingof Views, publication of the Philadelphia Depart ment of Health and dedicated to Phila delphia dentistry—close to $300, includ ing mailing to the county membership; publicity expenses incidental to hospital seminars—$75 (this, too, must require more money as the plandevelops) ; mail ing of minutes to Council members— $100; funds for sending Council repre sentatives to study hospital facilities and programs in other cities—to be de termined, and fund for a television edu cation project—to be determined. It is unfair to expect individuals to give of their time, energy andfinances to subsidize so worthy a program as that which dentistry has accepted as its re sponsibility. Adequate budgetary allow ances shouldbeprovidedbythe local and state dental societies for this most im portant phase of dental health activities.
A N E F F E C T IV E D E N T A L D IV IS IO N IN T H E P U B L IC H E A L T H D E P A R T M E N T
John W. Stone, D.D.S., M .P.H ., Austin, Texas
The first dental programestablishedby a health department on a state-wide basis was in North Carolina in 19I8.1 Un fortunately, other states were slowto fol lowthepatternthus created. Most of the early programs arose as the direct result of theinterest andactivityof dental prac titioners and dental societies who recog
nized the urgent need for broad, state wideprograms directedtowardthe eradi cation, or at least theamelioration, of the dental diseases andtheir sequelae. Form erly, p u b lic health d e n tis try section, M ic h ig a n D e p a rtm e n t o f H e a lth ; a t present, d ire c to r, d e n ta l d iv is io n , Texas D e p a rtm e n t o f H e a lth . I. G e rrie , N . F. Dental p u b lic hea lth. J .A .D .A . 40:750 June 1950.
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The flirtation and courtship of den tistry with public health has extended throughthegreaterpart of acenturyand aquarter, but the matrimonial unionhas had a comparatively short hectic history. The consummation of the union of den tistry and public health ona nation-wide scale was hastened during 1935 when through the Social Security Act the fed eral government made funds available to the states to operate dental programs.2It has been since 1935 that dentistry in public health has become a recognized profession—recognizedbyorganizedden tistry, by official public health, and by the public as well. Distrust and alarm, with the attendant cries of “this is socialized dentistry” and “this is not public health,” have greeted the marriage in various areas and at various times. At other times andinother areas, or perhaps even inthe same areas, the joining together of dentistry and publichealthhas beenhailed as asignifi cant step along the pathway of progress. The fluoridation of communal water sup pliesisanactivitywhichhascausedglow ingsuperlatives tobeheapedondentistry in public health. An example of these statements is that “fluoridation is the greatest advance inthepractice of public health that has occurred during the last onehundredyears.” A controversy has raged regarding the designation for dentistry and public health; whether it should be “dental public health,” “public health dentistry,” or “public dental health.” Persons ac tively engaged in the field of dentistry in public health considered the problemof a name during a recent workshop at the University of Michigan.3 It was de termined by those assembled that “den tal public health” was the most accurate descriptive termof all those reviewed. It isthepurposeof this presentationto consider the factors that are significant in the determination of the effectiveness of the division of dental public health in the department of health. The factors
to be considered are the basic organiza tional pattern for a health department’s dental division, its proper function and responsibilities, its development of a pro gram and budget, its relations with the dental society, with the public and pri vate agencies interested in health, and with the United States Public Health Service and other federal units. B A S IC O R G A N IZ A T IO N A L P A T T E R N
Inasmuch as the organization of dental divisions in departments of health will vary fromlevel to level of public health activity, andfromorganizationtoorgani zation on the same level, there is no single “correct” or even “common” basic organizational pattern that will fit every dental division. There are, however, cer tain fundamental principles of organiza tion which are applicable, to some de gree, ineachinstance. The basic organizational pattern for statehealthdepartments will be reviewed in order that a more detailed considera tion may be given to the importance of the organizational pattern of the dental division. The comparatively small num ber of local health departments having dental programs and the great variation in their organization, operation, and function make it impossible to give more than a passing glance to these programs at this time. It must be emphasized, how ever, thatit isat thelevel of thelocal pro gram, the level of application, that den tal public health programs reach the public. It is at the level of application that results may be expected and ob tained. There are two general types of basic organizational patternsutilizedbydepart ments of health—the horizontal and the vertical. 2. Pelton, W . J. Federal aid in public health den tistry. J.A.D.A. 30:570 A p ril 1943. 3. University of Michigan, School of Public Health. Fourth workshop on dental public health, University of Michigan, Ann A rbor, A p ril 2-6, 1956. Unpublished.
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The horizontal pattern is, as the name implies, one in which there may be any number of units operating under the di rect supervisionandcontrol of the execu tive officer of the state health depart ment.4 It is apparent that the horizontal structurecouldbecome unwieldyinthose instances in which there are an excessive number of units reporting to the health officer. The definition of what constitutes an excessive number would have to be determined by the executive ability of eachhealth officer, and not by any state ment of generalities. The vertical organizational pattern may be characterized as having a hier archy and being scalar or pyramidal in structure; that is, where the lines of authority and responsibility run upward and downward through several levels with a broad functional base at the bot tom and a single executive head at the apex.5 On November 11, 1953, the governing council of the American Public Health Association adopted as an official state ment a report prepared by the Subcom mittee on State and Local Health Ad ministration entitled “The State Health Department—Services and Responsibili ties.” The report contained many laud able recommendations concerning the organization and the reorganization of state health departments. Primarily, the recommendations were directed toward the reduction of the wasteful operations which may appear in the day-to-day function of an organization the size of a state health department, or to increase the efficient and economical operations of thestatehealthdepartment. The scalar orpyramidal organizational structurewas the basic organizational pattern recom mended bythe subcommittee to the state healthdepartments. It was recommended that there be established a limited num ber of major units which would report directly to the executive officer of the health department. All of the sub-units having similar areas of activity andfunc
tion would be grouped together into a major unit. The proposal for major units tends to break down, however, in that there is no delineation of what constitutes similar areas of activity and function; nor is there any description of what constitutes alimited number of major units. The Council on Dental Health of the American Dental Association, during its conference in 1951,6 studied the dental administration in state health depart ments. It was noted at that time that the reorganization of several state health departments had resulted in the down grading of the dental division to the third or even the fourth administra tive level belowthe health officer. These changes had developed as the result of recommendations of representatives of the American Public Health Associa tion, administrative advisers of the U. S. Public Health Service, and consultants from schools of public health. Almost without exception these changes were made, or are being made, without con sulting the dental profession in the states involved. In 1950, the House of Delegates of the American Dental Association recom mended that dentistry be included as a basic health service of the health depart ment, andthat the dental unit be staffed with qualifiedpersonnel. In an editorial7 in the July 1951 issue of t h e
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A S S O C IA T IO N ,
it was stated that those who would re duce dentistry to a secondary position apparently labor under the false assump tion that dentistry can function best as a subsection of one of the medical di4. A m e ric a n Dental A s s o c ia tio n , C o u n c il on Dental H e a lth . Dental a d m in is tra tio n in sta te h e a lth ' d e p a rt m ents. J .A .D .A . 43:61 J u ly 1951. 5. H a nlon, J. J . Principles o f p u b lic hea lth a d m in is tra tio n , ed. 2. St. Louis, C . V. M osby C o ., 1955. 6. A m e ric a n Dental A s s o c ia tio n , C o u n c il on Dental H e a lth . Dental a d m in is tra tio n in state health d e p a rt m ents: re p o rt o f 1951 c onference. J .A .D .A . 43:489 O c t. 1951. 7. D e ntistry's p o s itio n in m o d e rn p u b lic hea lth d e p a rtm e n t. E d ito ria l. J .A .D .A . 43:86 J u ly 1951.
176 • THE J O U R N A L O F THE A M E R IC A N D EN T A L A S S O C IA T IO N
visions. It has been pointed out many times that dentistry is not asubsection of medicine, or a subsection of any other profession for that matter. History shows that decadencc has always set in whenever or wherever dental education or dental practice has been brought under the supervision and control of authoritative non-dental administration. T he reason is not far to seek. It lies in the associated lack of the special dental qualifications and concern which would enable such administration to judge the values and practical significance of the special therapeutic procedure involved in the com prehensive dental art. Physicians, with few exceptions, have always demonstrated notable lack of genuine interest in dental health care.8
Dentistry is an entity withinitself, and as a profession it is concerned with one of the largest single health problems that confronts, humanity. The dental public health unit functions most effectively as anindependent unit of thehealthdepart ment workinginfull cooperationwithall the other units of the department, and administeredby a qualified dental officer who is directly responsible to the health officer. PER SO N N EL
To paraphrase the recommendations of the House of Delegates of the American Dental Associationin 1950, “In order for the dental unit to be able to function as a basic health service of the health de partment, it must be staffed by qualified personnel.” Realistically, the number and the pro fessional background of the members of the staff should be determined by the breadth and scope of the oral health problems in the state. Unfortunately, however, in this day of enlightenment and progress there remain several dental units of state health departments that have a staff consisting of a director or supervisor, as thesituationmaybe, and a secretary. Dental public healthhas expandedbe yond the boundaries that were known in 1935, andtodaythe talents of manytypes
of professional persons are needed to man aneffective dental division. Dentists anddental hygienists especiallytrainedin public health, sometimes dentists and dental hygienists having an interest in the clinical aspect of public health prac tice, health educators, public health ad ministrators, psychologists and others are to be found working in various dental units inthenation. In general, thefactors which designate a dentist as being a qualified director apply equally well to the other persons on the staff of thedental unit. “Much of the success of the director of a program of dental publichealthwill dependonhis capacity to establish favorable public re lations and to organize cooperative efforts.”9 Public and professional relations and cooperative effort are the key to success in almost every endeavor in which man engages. The cooperative efforts of the members of the staff of the dental unit run the gamut from intraunit projects, through joint action on the part of two or more divisions of the department of health to community-wide or state-wide programs involvingthe representatives of many professional and nonprofessional organizations. At one time the public health dentist primarily was concerned with the dental problems of children. The old axiom“an ounce of prevention is worth a pound of cure” was thesole theme of almost every dental program. With the advent of fluoridation of communal water supplies, and with the constant increase in the number of communities instituting this procedure, thedental administratorshave the opportunity to initiate programs in aspects other than those related directly todental caries. It is essential that the director and the 8. Carr, M. W . Dentistry—an agency ofhealth service. New York, Commonwealth Fund, 1946. 9. American Public Health Association. Proposed re port on educational qualifications of public health dentists. Am. J . Pub. Health 42:188 Feb. 1952.
SEVENTH N A T IO N A L D EN T A L H EA LT H C O N F E R E N C E
members of thestaff of the dental unit be able to function as dental consultants to nondental public health organizations, both official and nonofficial, and to pro vide specialized assistance to dental organizations andtoprivatepractitioners. In addition to intelligent and effective participation in general public health work and administration, the public healthdentist must assumethespecialized tasksincident toadental healthprogram. He should keep informed regarding the latest developments in dental research in order that he may serve as a consultant for oral diagnosis. The publichealthden tist must be capable of preparing and initiating plans for the dental phases of new health programs, including the de termination of the facilities necessary for their operation. Other responsibilities of the public health dentist maybe the pro vision of professional advice in develop ingandsupplyingauthentic andeffective dental health educational material, as well asinstructioninsounddental health practice to groups of public health workers, teachers, and others. He may be called on to institute dental research projects which have public health impli cations and to coordinate the public efforts of avarietyof agencies, official and nonofficial, that deal with dental health. He also must be capable of developing specialized indexes and records for measuring and appraising the efficacy of dental health activities.9 The personnel of an effective dental division will have a broad insight into social trends as they affect, or will affect, the practice of dentistry, and should in terpret these trends to the practicing profession. They must learn howto pre pare policies and budgets for an increas ingvarietyof programs. After someexpe rience with the operation of these programs, they will need to evaluate them. All of these activities, and others, growout of the special problems of ad ministrationof theprogressivedental unit inthedepartment of public health.
V O L U M E 54, FEBRU ARY 1957 • 177
The shift from the point of view in whichthe individual patient is the center of professional consideration to the com munity as the center of interest is not accomplished overnight. The technics andattitudes evolvedduringthedevelop ment of apublic healthdentist are based on the same factors that have been learned by other professions and by per sonnel of other fields of endeavor when they have dealt with the community rather than with individuals. Standards for professional proficiency and educational background for the per sonnel on the staff provide an assurance that the health department will have an effective dental division, but the prob lems of recruiting personnel aremanifold and varied. It must be recognized that the stature of the profession is going to be judged by the stature of the people who meet the public. To the recruiting officer, the members of the dental profession appear to con stitute one of the most militantly indi vidualistic groups to be found anywhere. There are only a few dentists who are attracted by the fixed annual income found in public health and who are at tracted by working for someone else. There are several other factors which complicate recruitment, but they hinge on one or the other of these two factors, or theyaresoindividual that they donot fit any particular pattern. The Bureauof EconomicResearchand Statistics of the American Dental Asso ciationhas publishedperiodically acom pilation of information concerning the practice of dentistry in the United States.10The informationispresentedac cording to the individual states and ac cording to the geographic regions. A comparisonof theaverageannual income for the dentists in a particular region withthe annual income for the dentist in 10. A m e ric a n Dental A s s o c ia tio n , Bureau o f Econom ic Research and S ta tistics. Facts a b o u t states fo r the d e n tis t seeking a lo c a tio n . C h ic a g o , A m e ric a n Dental A s so c ia tio n , 1955.
178 • THE J O U R N A L O F T H E A M E R IC A N D EN T A L A S S O C IA T IO N
public health in the same region reveals that the income for one is almost identi cal with the income for the other.11 Dentists, as others, are reluctant to in vest the necessary additional time in graduate school when the financial re turn will be no more than average, and when the initiation of the income is de layed by the period expended on the graduate work, usually a year or longer. Public health administrators and budget directors are beginning to recognize that in order to secure dental public health specialists they are going to have to pro vide a commensurate specialist salary. The recognitionof this situationhasbeen slow in coming, but it is coming never theless. An increase inthesalaries for the positions in dental public health, or the rewriting of the specifications to secure the benefits of additional tangible salary, or both, will remove one of the major obstacles to recruiting excellent person nel. To secure such recognition is a re sponsibility of organized dentistry. The working-for-someone-else aspect of the practice of dental public health does make certain demands. It demands a willingness of personnel to accept di rection and criticism, but it does not entail prostitution of professional rights and privileges. The shift of emphasis from the individual as a patient to the community as a patient, the basic differ ence between private practice and the practice of dental public health, discloses a problemof tremendous magnitude. Its magnitude is such that it is humanly, as well ashumanely, impossiblefor one per son to meet every aspect of the problem singlehanded. It becomes apparent that the teamapproach is the logical method for attacking the dental health problem of the community. The teamapproach may be defined as work done by a number of associates who subordinate personal prominence to the efficiency of the whole. Hence the necessityforbeingwillingtoaccept direc tion determines the success or failure of
programs of dental publichealth. The fixed annual income which has been established at an adequate level throughthe efforts of organized dentistry has the advantage of allowing the re cipient to plana budget for expenditures for theyear. The annual income and ex penditures of a private practitioner may fluctuate from year to year to such an extent that abudget isnot nearlyasprac ticable, even in many instances is some what meaningless andabsurd. Whentheteamapproachandthefixed annual income arereviewedthoughtfully, and when these factors are coupled with the benefits of paid vacations, sick leave, and all of the other factors so common to civil service and merit systems, the problems of recruitment of personnel for the positions in dental public health be ginto pale andfade away. F U N C T IO N A N D R E S P O N S IB IL IT Y OF
DEN TAL
D IV IS IO N
E. G. McGavran,12 dean of the School of Public Health of the University of North Carolina, suggests that a working definition of public health include those activities of a team of persons of the health service professions working to gether asequalstodiagnoseandtreat the healthneeds of thebodypolitic. This definition says in essence that the jobof publichealthis to diagnose acom munity’s health needs and then to treat them. To progress a step further, the function and responsibility of the dental publichealthunit istodiagnoseandtreat the dental health needs of the com munity. The dynamic nature of public health, coupled with the fact that it is account able to the taxpayers, requires that there be a plan or programfor every segment 11. Dental hea lth personnel salary ranges. Bui. A m . A . Pub. H e a lth Den. 15:24 A u g . 1955. 12. M c G a v ra n , E. G . W h a t is p u b lic h e a lth . Fourth w o rksho p on d e n ta l p u b lic health, U n ive rsity o f M ic h i gan , A p r il 2-6, 1956.
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of activity. The successivephases of plan ning a program can be enumerated as follows: 1. Determination of specific problems or needs. 2. Delineation of long-term, inter mediate andshort-termobjectives. 3. Assessment of resourcesavailableor obtainable for the conduct of the pro gram. 4. Selection of the methods or ac tivities to be used to gain the objectives. 5. Continuous or periodic evaluation of achievement or progress toward the goals. 6. Redirection of the program when indicated by shifts in circumstances. 7. Evaluationof final results.13 The tripartite division of the objec tives (long-range, intermediate, and short-range) of the programis a logical progression from the general to the specific. The long-range objectives are those conditions to be attained in the ideal society and stated simply as the complete eradication of an undesirable entity from the experience of the com munity. It issuperfluous topoint out that there can be no expectation of attaining the long-range objectives of a program promptly, despite the expenditure of every effort in that direction. The inter mediate objectives are those included within the long-range which are attain ablewithinaknownorpredictableperiod of time, usuallyabout 10or 20 years. The short-range objectives are the specific ac tivities to be completed in a specified period of time, usually the one or two year period of the organization. Methods for the attainment of the short-range ob jectives may be included in the program as aids to evaluation. The functional areas of activity of the dental division may be divided into sev eral overlapping segments. If the dental divisionis to be effective in the diagnosis andtreatment of theoral healthneeds of the community, there first must be a recognition of the existence of a problem
or need and then a determination of the extent of the problem. Upon thecomple tion of the collection and summarization of the essential information will depend thedeterminationof thepossiblemethods bywhichtheoral healthproblemmaybe reduced or removed. The tools available to the public health dentist are dental health education, prevention, remedia tion, evaluationandresearch. These tools may be usedsingly or in combination, as indicated, to attain the desiredobjectives of the dental division. The factors in the determinationof an effective dental division whichhave been considered thus far are important, but their importance is overshadowed by the relationship which exists, or should exist, between the dental division and the den tal profession. Only whenthedental pro fession provides the dental division with strongandconstant support will theden tal division be capable of functioning in aneffective manner. The effective dental division is a resource for the dental pro fession and for the community to utilize in the programs for the improvement of the oral healthof the population andthe enhancement of the prestige of the pro fession. Modern dental public health arose as the direct result of the activities of dental practitioners and dental societies. After many disappointing experiences, the pro fession recognized the need for facilities and personnel to assemble the informa tion essential for the proper planning, initiation, and operation of dental activi ties in the community. By utilizing the methods of statistical appraisal, the personnel of the dental divisionare able to estimate not only the magnitude and the distribution of oral disease, but gaina notionof the methods availabletoreduceoreliminatethesecon-
13. U n ive rsity o f M ic h ig a n , School o f P u b lic H e a lth . Proceedings o f th e firs t n a tio n a l confe re n c e on^evalu atio n in p u b lic hea lth . A n n A rb o r, M ic h ., U n iv e rs ity Pub lic a tio n Services, 1955.
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ditions. This statement is not to be in terpreted to mean that the personnel in dental public health are in possession of some occult power which enables them to decipher the cabalistic signs and sym bols so common to statistical procedures —it is intended merely to point out the importance of this, the newest, specialty within the dental profession. The dental division of the department of public health provides an excellent medium for disseminating to the com munity factual information concerning good oral health. The combination of the dental society andthedental divisionrepresentsamajor segment of the health service professions in the community. The department of healthis anofficial governmental agency andthushas aresponsibilitytothepublic. The dental society is a group of profes sional people who are interested in all phases of health problems in the com munity, but they are particularly inter ested in the specialized areas of the oral problems of thepeopleof thecommunity. The dental society, likethedental division of the department of public health, ulti mately is responsible to the people. The dental divisionserves as aresource for dental health educational material. The private practitioner may seek and secure assistance fromthe dental division in providing individual patients with up-to-date information concerning oral health. The dental divisionis a clearing house for information and for learning methods for effective presentation of the information. Dental health education programs for the community often are beyond the purviewof the private prac titioner. When confronted with the problem of educating the community regarding the advantages of early and regular dental care, for instance, many dentists would be at a loss as to where to begin. It is the responsibility of the public health dentist to be acquainted with the resources of mass media within the community and to be capable of se
lecting those for the practitioner which will be most effective. The dental division provides services not available elsewhere, or those services which are prohibitively expensive when operated on an individual basis, but are well within the realm of reasonableness when operated on a community-wide basis for the dental profession by the dental division. An excellent example is the laboratory services for counts of acidogenic organisms in the saliva pro vided by the dental division in several states. There are other areas in which thedental divisioncanprovide assistance totheprofession, but it seemsappropriate to consider what assistance the dental societycanprovideto the dental division. One of the primary factors to be con sidered in the planning of any program for the improvement of thedental health of thecommunityis the determinationof the number and the distribution of the dental personnel who will be available tobring the programto a successful con clusion. The dental society can provide the dental division with this up-to-date information. Such information is not available fromany other reliable source. Other assistance which organized den tistryshouldprovide to the dental unit is in the attainment of proper administra tive and budget recognition for the unit andtoassist intheconduct andoperation of surveys to determine the state of oral health in the local communities. BUDGET
Every act perform ed for the prom otion of public health involves an expenditure o f money, w hether it be for supplies, for transpor tation, or for salaries o f personnel. In fact, the very nature and extensiveness of the public health program are determined in the final analysis by the amount of funds available for its con du ct.5
There are three primary sources of funds for the operation of programs of dental public health. They are tax-sup portedstateand local,agencies having an
SEVEN T H N A T IO N A L D EN T A L H EA LT H C O N F E R E N C E . . . V O L U M E 54, FEBR U A RY 1957 • 181
interest in health, and federal agencies having similar interests. State and local appropriations for pro grams of dental public healthmaybecat egorical; that is, limited to one activity, or maybe apart of general healthfunds. The positionof the dental unit inthe ad ministrative hierarchy oftentimes deter mines the ease or difficulty with which funds are obtained. The federal funds which have been used for dental programs have been, for the most part, derived from the general health grants given by the Public Health Service to the states and territories. The Children’s Bureau provides funds to the states throughgrants toprograms for ma ternal and child health andprograms for services for crippled children.2 The pattern established at the time of the enactment of the Social Security Act in 1935 wherebyfederal funds weremade available to states for the operation of programs in dental public health is still followedinmanystates. Publichealthad ministrators and budget directors have not felt compelled to modify the budget ary position of the dental division from one supported almost entirely by federal funds to one supported largely by state appropriations. Is it not logical to askthe reasonfor the continuation of this status quo? Could the answer lie in the nearly universal distributionof oral diseases and their lack of drama and popular appeal when compared with some of the other areas of activity of public health? Could it be that the dental profession has been lax in making clear to the public and to public health administrators the true im portanceof the oral diseases as related to health, andthe methods available for the amelioration of these conditions or their complete eradication? Those units pri marily supported by federal funds are in a precarious position indeed, for a major reduction in federal funds by the next Congress could cause the discontinuation of the oral health programs with little or no warning.
It wouldbeprudent for all persons and organizations interested in the continued progress of the programof dental public healthtoexpresstheirwishesinamanner whichwill bringabout thedesiredchange in budgetary position and support. Or ganizeddentistryat all levels—local, state, and national—has bemoaned the failure of the dental divisions to attain the de sired budgetary position in the hierarchy of the health department, but in many instances that hasbeentheextent of their efforts to correct the situation. All seg ments of the dental profession should work together to demonstrate the impor tance of acomprehensiveoral healthpro gramorientedrealisticallyto theneeds of the population to be served. A dental division can be effective only when financial support for the program is fromthe taxpayers whomit serves. The relation which exists between the dental divisionof thestate department of health, the United States Public Health Service, and the Children’sBureauis one of mutual cooperation and assistance. Just as there are some procedures which are uneconomical or unfeasible for the privatepractitionertoprovideforhimself, there are certain procedures which are beyondthe scopeof activityof the dental divisioninthe statedepartment of health but arewithintheareaof activityof these dental units of the federal services. The Public Health Servicehas dental consult ants who are stationed in each of its re gions, or in an adjacent region, who are available for consultation to the states on the receipt of a request for such services. The dental division of the state depart ment of health provides information and cooperation to the regional consultant in all phases of the activity of dental public health. These facilities should be utilized by the practicing profession. SU M M A R Y
In summary, then, the activities which now constitute dental public health are
182 • THE J O U R N A L O F T H E A M E R IC A N D EN T A L A S S O C IA T IO N
not new-—they have evolved during the past century and a quarter. The dental divisionis a functional unit withinthe administrative structure of the department of health. Organizeddentistry has recommended that the dental pro grambe one of the basic health services of the state department of health. The dental divisionhas athree-fold re sponsibility to discharge: a responsibility to the dental profession, a responsibility tothepublichealthagency, andarespon sibility to the population served. The areas of activity include those which af ford an indication of the extent of the problems, a notion of the most useful methodfor the reductionof the problem, andameans for the determinationof the effectiveness of theprogram. Thescopeandtheextentoftheprogram of thedental divisionwill bedirectlypro
portional to the amount of funds which aremade available for its operation. It is obvious that themost important factor in the determination of the effectiveness of the dental division of the department of public health is the relationship which exists betweenthedental divisionandthe dental profession. Modern dental public health arose as the direct result of the activities of the members of the dental profession. The dental division of the statedepartment of healthis the result of thejoiningtogetherof organizeddentistry and official public health. It must not be forgotten that the cooperative support and assistance provided by these, the parent organizations, will determine the effectiveness of the dental division in its efforts to improve the healthof the com munity by the improvement of the com munity’s dental health.
G R A N T S -IN -A ID IN F E D E R A L -S T A T E D E N T A L P U B L IC H E A L T H P R O G R A M R E L A T IO N S H IP S
Norman F. Gerrie, D.D.S.,
Forthepast 38 yearsfederal grants-in-aid have been utilized for public health pur poses by state and local units of govern ment.1The historical development of the grant-in-aid principle as ameans of pro vidingfinancial assistancetogovernments with limited financial resources has been considered in detail by many students of public health administration.1'5 A current list of identifiable health grants would include those for maternal and child health and crippled children’s services derived fromTitle V of the So cial SecurityAct; thegrants administered by the Public Health Service for the fol lowingpurposes: general health services; venereal diseasecontrol; tuberculosiscon trol; cancer control; mental health; hos pital survey and construction; heart dis ease control; poliomyelitis vaccine dis
Washington, D. C.
tribution, and the basic support grants of the Office of Vocational Rehabilita tion. It is generally acknowledged that the grants-in-aid have been highly effective instimulatingthe state and local governA ssistant c h ie f Service.
d e n ta l
o ffic e r,
U.
S.
P u blic
H e alth
1. M ou n tin , Joseph W ., and G re v e , C liffo r d H . Role o f g ra n ts -in -a id in fin a n c in g p u b lic hea lth pro g ra m s. P u blic H e a lth B ulletin 303. W a s h in g to n , D. C ., G o v e rn m e n t P rin tin g O ffic e , 1949. 2. W h ite House C o nfe ren ce on C h ild H e a lth and P ro te c tio n . Public^ hea lth o rg a n iz a tio n ; section II. P u b lic health service and a d m in is tra tio n . New York, C e n tu ry C o ., 1932. 3. M o u n tin , Joseph W . F ina ncing local ices— fe d e ra l p a r tic ip a tio n . Pub. H e a lth O c t. 1952.
hea lth serv Rep. 67:944
4. H a nlon, J . J . P rincip les o f p u b lic health a d m in is tra tio n , e d . 2. St. Louis, C . V. M osby C o ., 1955. 5. M ou n tin , Joseph W .; H a nkla, Em ily, and Druzina, G e o rg e B. Ten years o f fe d e ra l g ra n ts -in -a id fo r p u b lic hea lth, 1936-1946. P ublic H e a lth B u lle tin 300. W a s h in g to n , D. C ., G o v e rn m e n t P rin tin g O ffic e , 1951.