Dental Public Health Practice: Improving the Oral Health of California Communities

ABSTRACT

Background

Dental public health (DPH) is a specialty of dentistry that serves the community as a patient rather than the individual. It requires broad knowledge and skills in preventing and controlling oral diseases, planning and administering programs, applied research, surveillance and evaluation, financing, and providing dental care. This article aims to outline DPH practice, emphasizing its role in improving the oral health of communities, and highlight professional training pathways in this field.

Methods

We used the Ten Essential Public Health Services framework to illustrate DPH practice. The Association of State and Territorial Dental Directors (ASTDD) provides guidance to state and local health programs for promoting oral health policies and programs at the population or community level. In addition, we presented the education and training pathways for becoming a DPH specialist and identified opportunities for all dental practitioners.

Results

This paper outlines real-world examples how DPH practitioners have contributed to improving the oral health of Californians. The opportunities to practice both in the public health and private sectors and the collaboration with academia are highlighted. Examples throughout the paper such as the collaborative effort in San Francisco to address high tooth decay rates in children and its contribution to the statewide policy illustrate the opportunity for practicing dentists to improve community oral health and overall health with a DPH mind-set.

Conclusions

Improving the oral health of Californians requires competent dental public health and clinical practitioners. It is essential to have robust education and training programs with a community focus that offers multiple pathways.

KEYWORDS:

• Dental public health
• community dentistry
• oral health

Background

Dental public health (DPH) is defined as “ … the science and art of preventing and controlling dental disease and promoting dental health through organized community efforts. It is that form of dental practice which serves the community as a patient rather than the individual. It is concerned with the dental education of the public, with applied dental research, and with the administration of group dental care programs as well as the prevention and control of dental disease on a community basis.”¹ DPH practitioners work in governmental, non-governmental, and academic sectors to improve the health of communities.

In the 20th century, the average lifespan of persons in the United States (US) lengthened mainly because of public health efforts such as control of infectious diseases through improved sanitation and clean water, vaccination, safer and healthier foods, family planning, recognition of tobacco use as a health hazard, and technological advances.² DPH gained prominence during World War II because one of the primary reasons for rejecting army recruits was failure to meet the minimum standard of having at least 12 teeth.³ Therefore, controlling tooth decay in children through organized community efforts by promoting oral hygiene and topical fluorides in school settings, providing fluoridated water, and promoting healthy habits like toothbrushing became the focus of dental public health. Because many Americans have limited access to dental care, gap-filling programs have also been implemented at the community level to address the needs of children, adolescents, adults, and the elderly. In the mid-70s, the focus shifted to addressing risk factors like tobacco for controlling chronic diseases. The enactment of the Affordable Care Act has led to unprecedented changes in the US healthcare system and the emergence of the concept of population health. It is defined as “the health of a population as measured by health status indicators and as influenced by social, economic, and physical environments, personal health practices, individual capacity and coping skills, human biology, early childhood development and health services.”⁴ This is a recognition that the health of individuals depends on where people live, work, and play.

Practice of Dental Public Health

State and local health departments are responsible for providing public health protections and services specific to their community’s needs. These are best described in the Ten Essential Public Health Services framework. The 10 Essential Public Health Services (10-EPHS) framework was originally released in 1994 and updated in 2020 to include equity at the center (Figure 1).⁵ According to this framework, “to achieve equity, the Essential Public Health Services actively promote policies, systems, and overall community conditions that enable optimal health for all and seek to remove systemic and structural barriers that have resulted in health inequities. Such barriers include poverty, racism, gender discrimination, ableism, and other forms of oppression. Everyone should have a fair and just opportunity to achieve optimal health and well-being.”⁵ The Association of State and Territorial Dental Directors (ASTDD) has used this framework to provide guidance to state and local health programs for promoting oral health policies and programs at the population or community level.⁶ The frameworks are organized in the three core functions of public health: assessment, policy development and assurance (Figure 1).

Figure 1. Essential Public Health Services⁵ and Related Examples in California.

The 10 Essential Public Health Services, Public Health National Center for Innovations and de Beaumont Foundation, September 2020, https://phnci.org/uploads/resource-files/EPHS-English.pdf.

DPH practitioners also work in non-governmental settings such as academia, research, hospital dentistry, federally qualified health centers (FQHCs), dental practices, health plans, corporate sectors, and foundations. They conduct research and evaluation studies, direct educational programs, manage projects, direct safety net dental care, and advocate for policy and resources.

The following section provides examples to illustrate how DPH practitioners working in governmental, non-governmental, and academic settings contribute to these essential public health services and make communities healthier.

Essential Public Health Services to Promote Health and Oral Health

Assessment

Assess and Monitor the population’s Oral Health Status, Factors That Influence Oral Health, and Community Needs and Assets

The California State Department of Public Health document, Status of Oral Health in California: Oral Disease Burden and Prevention 2017, illustrates the assessment function. This is a comprehensive review of oral health and disease in the state. It served as a foundation for the Oral Health Program in the California Department of Public Health and the establishment of a new state oral health plan for California. The purpose of the report is to provide an overview of California’s oral health status and capacity to address the disease burden in the state. This report summarizes the most recent data that describe oral health status, disparities, risk and protective factors, and dental services in California.⁷

Investigate, Diagnose and Address Oral Health Problems and Hazards Affecting the Population

The San Francisco Children’s Dental Health Committee, a group of dedicated professionals with two decades of experience working together, prioritized the development of school-based oral health surveillance to address oral health problems. Only after the San Francisco Dental Society (SFDS) offered to provide the workforce to conduct the screenings, the San Francisco Department of Public Health (SFDPH) was able to implement an annual kindergarten dental screening program for San Francisco’s public schools to identify children with immediate dental needs and enable public health assessment. SFDPH, in collaboration with SFDS, the National Dental Association, and the San Francisco Unified School District (SFUSD), began providing dental screening in 2000 to all kindergarten children attending SFUSD schools.⁸ The data gathered from the screening was used to assess and monitor the oral health status of kindergartners and identify associated disparities in oral health outcomes and the causes of the high prevalence of tooth decay.⁹ By promoting early dental visits, fluoride varnish applications, tooth brushing, and care coordination, the prevalence of tooth decay and untreated tooth decay declined substantially. It led to a statewide law (AB 1433) that created a kindergarten oral health assessment requirement for children attending public schools.¹⁰ This policy has served as a model for all counties to identify children with tooth decay and link them to sources of dental care.

Policy Development

Communicate Effectively to Inform and Educate People About Oral Health and Influencing Factors and Educate/Empower Them to Achieve and Maintain Optimal Oral Health

In 2015, the San Francisco Kindergarten screening data revealing caries disparities by Zip Code were shared at community briefings to inform, educate, and empower the community about this significant health problem. Briefings were held in the three neighborhoods with the highest caries prevalence and included community health leaders, school administrators, local policymakers, grassroots community members, and the media.⁸ A direct outcome was the creation of children’s oral health task forces in each of the three neighborhoods to foster community development and take collective action against dental caries that was disproportionately afflicting their children.

Mobilize Community Partners to Leverage Resources and Advocate For/Act on Oral Health Issues

The California Oral Health Plan 2018–2028 recognized that language, race/ethnicity, cultural values, transportation, and lack of dental benefit coverage present barriers to accessing dental care.¹¹ Therefore, it recommended utilizing community health workers (CHW) to improve access to oral health information and services.

The CHW Section of the American Public Health Association (APHA) has adopted the following definition of a community health worker: “A community health worker is a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. This trusting relationship enables the worker to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. A community health worker also builds individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support and advocacy.”¹²

In July 2022, the Centers for Medicare & Medicaid Services (CMS) approved California’s Medicaid State Plan Amendment (SPA 22–0001) to add CHW services as a preventive service.¹³ The California Partnership for Oral Health Plan has convened an ad hoc Community Health Worker Workgroup to bring together partners and stakeholders to leverage the community health worker benefit for oral health.¹⁴

Develop, Champion and Implement Policies, Laws and Systematic Plans That Support State and Community Oral Health Efforts

The California Children’s Dental Disease Prevention Program (CCDDPP) (Health and Safety Code 104,770–104825) was established in 1979 to fund local agencies for comprehensive dental disease prevention efforts. The mission of the CCDDPP was to assure, promote, and protect the oral health of California’s school-aged children. It was designed to increase their oral health awareness, knowledge, and self-responsibility by developing positive, lifelong oral health behaviors and to improve access to primary preventive services such as topical fluoride and dental sealants. The program was focused on children who were otherwise unlikely to receive preventive services. The criterion was based on the proportion of free and reduced-price school lunch program enrollment for each participating school. Based on the Community Preventive Services Task Force (CPSTF) recommendation, the Office of Oral Health has identified school sealant programs as the best approach to prevent tooth decay in school children.^15,16 All 61 local health jurisdictions or their partners currently have the Proposition 56 Tobacco Tax Initiative funds to implement school-linked/based programs. This complements the Kindergarten Oral Health Assessment requirement (AB 1433) to link children to a source of dental care.¹⁰

Review, Educate About and Enforce Laws and Regulations That Promote Oral Health and Ensure Safe Oral Health Practices

California led the nation’s fight against the COVID-19 pandemic with early public health measures that saved lives. The COVID-19 response included guidelines for the healthcare industry and practitioners. The Office of Oral Health staff worked collaboratively with State, local and national agencies, and organizations, including the California Dental Association, to help achieve no COVID outbreaks in California dental offices during the pandemic. This included the development of state guidelines for providing (resuming) dental care, guidance for non-aerosol procedures, conducting a survey to assess local oral health program capacity to address community dental needs, and handling Personal Protective Equipment questions.¹⁷ The California Dental Association developed resources and tools for practitioners.¹⁸ These collaborative efforts continue and have been sustained and strengthened to maintain the public’s high level of confidence in the safety of dental offices.

Assurance

Reduce Barriers to Care and Assure Access to and Use of Personal and Population-Based Oral Health Services

It is widely recognized that good oral health habits and timely dental care protect a person’s health before and during pregnancy and can reduce the transmission of dental caries-causing bacteria from mothers to their children. Further, studies show that the mother’s oral health status profoundly influences oral health outcomes in children.¹⁹ However, utilization of dental services during pregnancy is low and disparities persist. Walton-Haynes et al. reported that only 43.9% of California people with a live birth had a dental visit during their pregnancy in 2017 and 2018.²⁰

National and state efforts to increase dental utilization include programs, policies, resources, and training. The California Dental Association Foundation and the American College of Obstetricians and Gynecologists, District IX, developed the Perinatal Oral Health Practice Guidelines in 2010.²¹ The federal Maternal and Child Health (MCH) Services Block Grant (Title V of the Social Security Act) has established performance measures regarding preventive dental visits.²² The ASTDD has compiled a Best Practice Approach Report to help achieve successful outcomes.²³ The Medi-Cal Dental Program’s Smile, California campaign has developed educational materials for pregnant people in California.²⁴ Further, demonstration programs such as the federal MCH Bureau-funded Perinatal and Infant Oral Health Quality Improvement (PIOHQI) Initiative have produced strategies to reduce oral disease in pregnant people and infants at high risk for oral disease by increasing access to and utilization of oral health care. California’s PIOHQI pilot project in Sonoma County successfully improved the utilization of oral health care through an integrated approach.²⁵

Assure an Adequate, Culturally Competent, and Skilled Public and Private Oral Health Workforce

According to the Commission on Dental Accreditation (CODA), the specialized accrediting agency recognized by the US Department of Education, dental education programs must make available opportunities and encourage students to engage in service-learning experiences and/or community-based learning experiences. CODA recognizes service-learning experiences and/or community-based learning experiences as essential to developing a culturally competent oral healthcare workforce. Further, it states, “The interaction and treatment of diverse populations in a community-based clinical environment adds a special dimension to clinical learning experience and engenders a life-long appreciation for the value of community service.”²⁶ To support such community-based education, the California Department of Public Health’s Office of Oral Health funds all seven dental schools in collaboration with the California Dental Association Foundation. Dental schools partner with providers in underserved communities to create opportunities for dental students and residents to rotate through these clinical facilities to train skilled and culturally competent dental practitioners.

Improve and Innovate Dental Public Health Functions Through Ongoing Evaluation, Research and Continuous Quality Improvement

The Smile Keepers Dental Program (SKDP) is a preventive program in Tuolumne County. In its 29^th year of service, SKDP provides services in all Tuolumne County Schools and preschool programs for approximately 4,800 children annually. Services include education, dental screenings, fluoride varnish applications, and referrals for families needing dental care.²⁷ However, tracking referral closure i.e., closing the referral loop through communication that the services have been provided, has been a problem because of the paper-based system. This led to the search for and implementation of an electronic referral management system to link patients to providers and improve access to dental care.

To further improve its services, SKDP collaborated with the University of California San Francisco School of Dentistry (UCSF SoD) to provide a training opportunity for dental public health and pediatric dentistry residents. The UCSF SoD, in collaboration with SKDP, opened a Virtual Dental Home at Tenaya Elementary in Groveland. Such demonstration programs serve as laboratories for researching interventions and evaluating programs.

Build and Maintain a Strong Organizational Infrastructure for Dental Public Health

State Oral Health Programs (SOHP) have the potential to significantly contribute to improving population health, controlling healthcare costs, and eliminating disparities. These include the Guide to Community Preventive Services recommended community water fluoridation and school sealant programs. According to the ASTDD, a successful SOHP must have diversified resources that include funding for state and local evidence-based programs, a forward-thinking leader, and a complement of staff, consultants, and partners with proficiency in the ASTDD Competencies for SOHPs. In addition, it should include one or more broad-based partnerships or coalitions, valid data (oral health status and other) for evaluation, high-quality oral health surveillance, a state oral health plan with implementation strategies, and evidence-based programs and policies. The California Department of Public Health reestablished the state oral health program in 2015. With Proposition 56 Tobacco Tax Initiative funding, the Office of Oral Health has built the capacity to administer a statewide program incorporating the ASTDD guidelines. Funds are provided to 61 Local Health Jurisdictions to implement the California Oral Health Plan 2018–2028 strategies.¹¹ The California Oral Health Technical Assistance Center (COHTAC) residing at UCSF was established to provide technical assistance to local oral health programs.²⁸

The following section describes pathways to develop knowledge, skills and competency to pursue advanced education in DPH.

Dental Public Health Education and Training Overview

Dental public health (DPH) is a distinctive dental specialization focused on preventing and managing dental diseases in the community while promoting dental health through community-driven initiatives. DPH is one of the 12 specialties in dentistry recognized by the American Dental Association since 1950.²⁹ In the US, there are currently 15 DPH postgraduate programs accredited by the CODA (Table 1).³⁰ The American Board of Dental Public Health (ABDPH) is the certifying board of the DPH specialty,³¹ and the American Association of Public Health Dentistry (AAPHD) is the sponsoring agency.³² All residency programs are designed to prepare trainees to take the ABDPH board exam to become certified as a DPH diplomate, which is a requirement for some career opportunities in DPH.³³

Table 1. List of US Dental Public Health Residency Program.

Dental Public Health Residency Program
A.T. Still University
Boston University Goldman School of Dental Medicine
Case Western Reserve University
Centers for Disease Control and Prevention
Harvard School of Dental Medicine
Jacobi Medical Center Dental Public Health Residency Program
National Institute of Dental and Craniofacial Research
New York State Dental Public Health Residency Program at the Eastman Institute for Oral Health
North Carolina Division of Public Health
The Maurice H. Kornberg School of Dentistry at Temple University
UNLV School of Dental Medicine
UT Health San Antonio
Texas A&M School of Dentistry
The University of Iowa College of Dentistry
University of California San Francisco School of Dentistry

Program Format

There are multiple program formats related to duration and degree/certificate conferred. Most programs offer standalone DPH training over 1–2 years. These require a Master of Public Health (MPH) degree, or a comparable degree approved by the ABDPH and lead to a DPH certificate or master’s degree.^31,32 However, some programs offer MPH education as part of their two-year DPH program or, in some cases, a joint MPH-DPH program between two institutions. The only program in California, UCSF offers both a one-year standalone DPH certificate program and a joint two-year interdisciplinary MPH-DPH program with the UC Berkeley School of Public Health. The first year is dedicated to the MPH, followed by the second year, DPH training. Candidates’ qualifications for this joint program are evaluated by both schools for admission.³⁴ There are also more extensive 3-year DPH programs that include a concentration on a clinical discipline (geriatrics, special needs, and pediatric dentistry)³⁵ or research.³⁶

Settings and Focus Areas

Most DPH residency programs are based in academic settings, the majority of which are dental schools. Other programs are located at federal agencies such as the Center for Disease Control and Prevention (CDC), state or local health departments, and hospitals (Figure 2). Programs based in academic settings tend to be more structured while programs in governmental settings provide real-world experiential training.³⁷

Figure 2. Dental Public Health Residency Program settings and examples.

Modes of Learning Delivery

Many DPH residency programs offer flexibility by incorporating various modes of learning to accommodate student life demands and priorities. They are structured as either a two-year part-time or 1–2-year full-time program. Some programs may be entirely remote or distance-learning while others may offer just some courses that allow for virtual or online participation. Some programs employ a blended learning approach that combines synchronous and asynchronous learning. Synchronous learning incorporates real-time interactions (e.g., live lectures, seminars, discussions, and collaborative activities) and engagement with instructors and peers. Asynchronous learning includes access to prerecorded lectures, online discussion forums, study materials, and assignments, which affords flexibility to trainees to manage the learning process at their own pace. All these options enable individuals to pursue advanced training in dental public health without disrupting existing commitments.

Training Components and Curriculum

Unlike other dental specialty training programs, DPH programs have no clinical component. Instead, there is significant emphasis on the 10 DPH core competencies. (Table 2).³⁸

Table 2. Dental public health core competencies updated by the American Board of Dental Public Health, 2016.

Dental Public Health Residency Program
(1) Manage oral health programs for population health.
(2) Evaluate systems of care that impact oral health.
(3) Demonstrate ethical decision-making in the practice of dental public health.
(4) Design surveillance systems to measure oral health status and its determinants.
(5) Communicate on oral and public health issues.
(6) Lead collaborations on oral and public health issues.
(7) Advocate for public health policy, legislation, and regulations to protect and promote the public’s oral health and overall health.
(8) Critically appraise evidence to address oral and public health issues for individuals and populations.
(9) Conduct research to address oral and public health problems.
(10) Integrate the social determinants of health into dental public health practice.

There is wide variability in curriculum among programs, but common elements include didactic courses aligned with core competencies, supervised field site experiences, and 1–2 projects according to the ABDPH guidelines (one of which must demonstrate analytical and statistical proficiency).³¹

Residents often collaborate closely with local health departments or their local oral health programs to conduct one or more of their required projects. These are mutually beneficial experiences as they are usually identified by the health department as an important area of focus/need while fulfilling a program requirement for the resident. Furthermore, these types of projects often have a direct community health impact or inform local public health decisions, which provides a real-world and rewarding experience for the resident. DPH residency projects cover a wide array of topics such as improving access to oral health care in rural areas, increasing Medi-Cal dental services utilization, building capacity among non-dental health professionals, and evaluating school-based dental programs.

Pathway to DPH Specialization

Dentists, whether trained in the US or abroad, may apply for DPH residency programs through the ADEA-PASS system³⁹ or directly via the program itself. Enrollment capacity ranges from 1 to 6 trainees. Candidates can access a list of all DPH programs with contact information on the AAPHD website.²⁹ Each program has its own admissions process, which may include the submission of supplemental materials related to their dental degree, proof of passing related exams, and English language proficiency test results. Programs select qualified candidates by evaluating their application documents and conducting interviews to assess their qualifications, motivation for pursuing DPH, knowledge of the field, critical thinking and problem-solving, communication skills, self-confidence, and ethics and integrity.

Career Opportunities

The comprehensive and holistic training provided by DPH programs prepares graduates for diverse career opportunities. They will have the knowledge and skillset to perform a variety of job functions in multiple sectors.^37,40 Within academia, DPH graduates are well-poised for faculty positions in academic institutions to teach not only in the DPH field but also in public health, leveraging their MPH and DPH knowledge. They can also focus on research, write grants, collaborate with other team scientists, and collaborate with community partners (e.g., practicing dentists) to conduct community-based participatory oral health-related research. A recent survey of 157 active and life time member DPH diplomates showed that 70% of respondents reported currently working in academia and 34% of diplomates practiced in community settings, including clinic or hospital, and nonprofit organizations, showing how trained DPH specialists distributed across various sectors incorporate their acquired knowledge and skillset.³³

Within the public sector, DPH graduates can contribute to government or community-based organizations by leading, planning, implementing and evaluating oral health programs and policies that improve equitable access to oral health services. The knowledge and expertise they obtain during training make them valuable assets as leaders, directors, or consultants in local and state health departments, and other nonprofit research, policy development, and advocacy organizations.

In healthcare, DPH specialists could lead and oversee community dental clinics such as federally qualified health centers (FQHCs), contributing to oral health improvement strategies at the community level, ensuring high-quality data collection and analyses, and quality assurance. If DPH graduates hold a valid license in the state where they practice, they can also provide patient care with a DPH mind-set, actively working to improve the oral health status of the communities they serve.^37,40

The Future of DPH

The AAPHD Council on Practice asserts that to move forward the field of dental public health, efforts should focus on oral health inequities, comprehensive dental care models and systems, oral health promotion, and social and policy changes.⁴¹ This serves as a guide for dental public health specialists in planning and prioritizing initiatives and projects. However, a successful future in dental public health will depend on the work and participation of many beyond this specialty, including dental practitioners in the private sector.

Dentists play a critical role in supporting community-based oral health programs, contributing to the overall health and well-being of their local communities. Here are some ways in which dentists can make an important impact:

1. Improving access: Dentists can make dental care more accessible to their patients, including those with limited financial means or special health care needs. Accepting Medicaid, offering flexible payment plans, or creating an inclusive environment for all patients helps ensure that everyone receives necessary dental care.

2. Providing dental services in collaboration with local organizations: Dentists can collaborate with local oral health programs and schools to provide free school-based screening, receive dental referrals from screening events, and participate in community outreach events.

3. Mentorship: Dentists can help build up the next generation of dental professionals by providing mentorship and guidance to aspiring dentists and dental hygienists, especially those from underrepresented minority groups.

4. Advocacy: Dentists can become advocates for policies that support community-based oral health initiatives. This may involve engaging with local and state governments to secure funding, resources, and legislation that promotes equitable access to dental care.

5. Practice-based research: Dentists can collaborate with DPH researchers in collecting oral health data from their patients to be analyzed in local institutions to advance the science of improving oral health.

Conclusion

Dental public health is a specialty of dentistry that serves the community as a patient rather than the individual. The Ten Essential Public Health Services framework and the examples illustrate DPH practice. Improving the oral health of Californians requires competent dental public health and clinical practitioners. It is essential to have robust education and training programs with a community focus that offers multiple pathways.

Disclosure statement

The findings and conclusions in this report are those of the authors and do not necessarily represent the views or opinions of the California Department of Public Health, the California Health and Human Services Agency, and the University of California San Francisco. Authors have no conflict of interest to declare.

Additional information

Notes on contributors

Jayanth Kumar

Jayanth Kumar, DDS, MPH, is the state dental director at the Office of Oral Health, Center for Healthy Communities, California Department of Public Health.

Sepideh Banava

Sepideh Banava, DDS, MSc, MPH is the assistant professor and deputy director of the Dental Public Health Residency Program, Department of Preventive and Restorative Dental Sciences at the University of California San Francisco School of Dentistry

Lisa Berens

Lisa Berens, DDS, MPH, is professor and chair of the Division of Oral Epidemiology and Dental Public Health, Department of Preventive and Restorative Dental Sciences at the University of California San Francisco School of Dentistry

Lynn Walton-Haynes

Lynn Walton-Haynes, DDS, MPH, is the dental program consultant at the Office of Oral Health, Center for Healthy Communities, California Department of Public Health